Presentation on theme: "Intensive Geriatric Service Worker (IGSW) Janice Paul – WW IGSW Lead Heather Higgs - WW IGSW Thursday, August 12, 2010 GiiC."— Presentation transcript:
Intensive Geriatric Service Worker (IGSW) Janice Paul – WW IGSW Lead Heather Higgs - WW IGSW Thursday, August 12, 2010 GiiC
Outline Setting the stage – integrated system of care Intensive Geriatric Service Worker (IGSW) Case Review
What is an integrated system? A cohesive, coordinated model of delivering geriatric care Strong partnerships with stakeholders Evidence of improvement in patient outcome measures Capacity building
What does Integration Mean? Integrated team approach to complex issues Linkages across the continuum of care Targeted to high risk seniors Presently initiated: ED, ALC, SGS— “ripple effect”—flows across the continuum
How did We Get to Where We are Today? Health Accord Funding RGP Central – Support Networks Partnerships Environmental Scan Linkage with academic Settings Evaluations Aging at Home Funding
WWGSN Guiding Principles – High Level Senior Centered: services will respond to the need of seniors Community Based and Integrated: within broader health system Equitable: recognize demographic and geographic challenges
Guiding Principles Continued…. Cost Effective; best care at optimal cost recognizing benefits of volunteerism, local community responses Results Oriented: results defined and measured
Design Principles 1) Process capable of meeting need and demand 2) Process will deliver client value and demonstrate outcomes 3) Robust and Reliable 4) Uses and Improves Existing Infrastructure 5) Clearly defined operations that can be enabled with information technology. 6) Improves flow by minimizing all types of waste and by creating “pull” 7) Has positive impact on system goals
IGSW Key Roles “Walk with” the frail, complex senior and/or the family who needs extra help accessing services in the community after discharge home from hospital. Provide timely intensive support, transition and follow-up. Work closely with primary care, specialty care, community support services, and CCAC as partners in the senior’s care. For the senior who is reluctant to accept any supports, the IGSW can help pave the way for other services in the community
IGSWs Can: Accompany the senior to the primary care doctor or specialist appointment Arrange and accompany for a Pharmacy consult Accompany senior to a day program, dining, exercise or other social programs Help link senior with community programs ie. Transportation, social programs Tour Retirement Homes with the senior Coach senior and/or their family to support self management
Client-centred Focus Length of involvement and level of intensity differs for each individual client Remain involved until client is “cemented” into services in the community
Referral Guidelines Frequent user of the emergency department Recent hospital admission (90 days) and/or ED visit (30 days) Complexity of needs (number and/or type of support required) Socially isolated
Referral Guidelines – cont’d Resistant to assistance or support Ability to access services is limited due to financial reasons Language or cultural barrier MD or RN concern about ability to follow through with recommendations Caregiver burden, lack of caregiver support or long-distance caregiver
Who can refer a patient to an IGSW? GEM Nurses Geriatric Clinical Nurse Specialists in Acute Care Specialized Geriatric Services
Referral Process Seniors in need ED Assessment GEM and CCAC CCAC central Database AdmitHome IGSW Required Community SGS: Geriatric Medicine Psychogeriatric CARE PLAN IMPLEMENTED Service Order request to Trellis Hospital Community
Recruitment- IGSWs cross-section of academic preparation: Gerontology Gerontology Rec therapy Rec therapy Social Work Social Work Pastoral Care Pastoral Care Psychology Psychology Social Services Social Services Geriatric experience within the team: Community support Community support Long-term care Long-term care Mental Health Mental Health Community Ministry Community Ministry Retirement Home Retirement Home Day Program Day Program Private Home care Private Home care Acute Care Acute Care Rehab Rehab Language, ethnicity, culture German, Italian, Dutch, French, Mennonite German, Italian, Dutch, French, Mennonite IGSW Qualifications
Focus on SMART (Specific, Measurable, Attainable, Realistic, Time-Measured) Goals Unique role in the home – IGSWs do not “assess” they “do” Roles belong to the system not one agency (Trellis is Lead agency, accountable to WWLHIN) Integrated into Community Support Service Agencies – IGSW offices are within community partner agencies Keys to Success
Strong partnership with CCAC Collaborative approach with GEM Nurses, SGS and Acute Care IGSWs are part of the Circle of Care Process designed to “pull” patients out of hospital and into the community Communication Communication Communication
Case Review 90 year old gentleman presented to the ED with Shortness of Breath GEM Nurse Assessment completed Treated and sent home same day with prescription IGSW appointment arranged for following day at 11:00am.
SMART Goals Obtain Family Doctor Have Hearing Tested Arrange Transportation Lifeline Encourage use of walker instead of shopping cart
Initial Visit Upon initial visit the following was observed: Using his oven to heat his apartment Using a shopping cart and dowel stick as a gait aid Using a lawn chair as a bath chair Fridge completely empty No CCAC or formal supports
Initial Visit cont. Blood sugar monitor and sharp’s disposal in kitchen covered with a thick layer of dust. Client unable to state what they were used for Medication prescribed in the ED was taken improperly. Too many missing. Alcohol on kitchen counter Client expressed paranoid thoughts
Cognitive Concerns Identified by IGSW Client forgot appointment Not orientated to time/day. Unable to state how long he had lived in his apartment Married 4x – unable to name wives or if any are still living Unable to recall family doctor Unable to understand Power of Attorney therefore impossible to ascertain if he had one.
Family Client stated his niece had recently visited and brought food (later found out that was 1 st visit in over a year) Daughter who lived next door who helps with cleaning/laundry Sister lives down the street but has a strained relationship.
Daughter Through phone call with the niece found out that client does not have a daughter. Called client’s sister to confirm. Sister states that “daughter” is a drinking buddy and it is a relationship they’ve tried to discourage for years. Sister freely admits poor relationship with her brother and very limited involvement. Social Work investigated relationship with client and daughter and determined that he has contact with her by choice.
What’s Been done… 1 st call after initial visit back to GEM to discuss findings and new SMART Goals GEM nurse able to arrange appointment with Geriatrician within a few days Thorough medical workup with Geriatrician Diagnosed with dementia, “severely diabetic”, high blood pressure Medication prescribed and put into a blister pak
What’s Been Done… PSW in place in AM for med cueing Nursing in 2x weekly for blood sugar monitoring Meals on Wheels 2x a week Family doctor found – hadn’t seen since 2002. New family doctor obtained Now has walker and bath chair IGSW visits weekly in addition to accompanying to any medical appointments
What’s Been Done… Case Conference held with family Discovered that sister and niece (not the one visiting) are in fact Power of Attorney Family agreed to reconnect Family visited and brought a basket of food for the 1 st time in 5 years. Visited optometrist, cataracts diagnosed, should have had them removed 5 years ago – only sees movement Ophthalmologist appointment arranged
Bumps along the road… Missed initial Geriatrician’s appointment (mixed up appointment time so wasn’t at home when I arrived to take him). Sweater went missing at the same time as the social worker’s 1 st visit. He is convinced she stole it and wouldn’t let her back in. New social worker assigned Cancelled meals, PSW, his medications at different times. I was able to convince him to take them back with changes.
Successes He is now medically stable Cognition is improving – Called my voice mail for the 1 st time ever and left an appropriate message Was able to use buzzer for controlled entry at his apartment for the 1 st time since I’ve met him Geriatrician assessment: Scored the same on his MMSE but had significant improvements in Recall 2 out of 3 vs. 0 out of 3 in January and marked improvement in his clock drawing.
It Takes a Village… Many people working together to provide his care… GEM nurse, Geriatrician, Nurse Practitioner, Family Doctor, Pharmacist CCAC Case Manager, OT, PT, PSW, Social Work, Nursing Community supports IGSW Family
Ongoing Support Family doctor appointments ongoing First visit with Ophthalmologist, now waiting for cataract surgery –he has been medically cleared to have surgery Work to complete initial SMART Goals – after cataract surgery we will see an audiologist. Ongoing support as needed through weekly visits