Transcript Intensive Geriatric Service Worker

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
 Case
Geriatric Service Worker (IGSW)
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
Senior’s Services Flow
Dr. John Yang
Design Principles
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Process capable of meeting need and demand
Process will deliver client value and
demonstrate outcomes
Robust and Reliable
Uses and Improves Existing Infrastructure
Clearly defined operations that can be enabled
with information technology.
Improves flow by minimizing all types of waste
and by creating “pull”
Has positive impact on system goals
Intensive Geriatric
Service Workers
(IGSW)
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.
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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.
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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:
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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
IGSW Goals
HEALTHY, HAPPY, SAFE
Referral Guidelines

Frequent user of the
emergency department

Recent hospital admission
(90 days) and/or ED visit
(30 days)
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Complexity of needs
(number and/or type of support required)
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Socially isolated
Referral Guidelines – cont’d
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Resistant to assistance or support
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Ability to access services is limited due
to financial reasons
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Language or cultural barrier
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MD or RN concern about ability to
follow through with recommendations
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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
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Specialized Geriatric Services
Referral Process
CCAC central
Database
Seniors in need
Community
ED
SGS: Geriatric Medicine
Psychogeriatric
Assessment
GEM and CCAC
Hospital
Admit
Home
IGSW Required
Service Order request to
Trellis
CARE PLAN IMPLEMENTED
Community
IGSW Statistics
Clients by Gender
Male
36%
Female
Male
Female
64%
IGSW Statistics
Clients By Age Range
10%
5%
<65 years old
37%
65-79 years old
80-89 years old
90+ years old
48%
Min age: 48
Max age: 98
Average age: 80
IGSW Statistics
Clients by Area - Waterloo Wellington
Centre/North
Wellington
Guelph/East
Wellington
Centre/North Wellington
Rural Waterloo
Region
Rural Waterloo Region
Kitchener
Waterloo
Kitchener
Cambridge/North
Dumfries
Cambridge/North Dumfries
Guelph/East Wellington
Waterloo
IGSW Statistics
Clients by Living Arrangement
With Spouse and
others
4%
With adult child
14%
With adult child
With Spouse
25%
Non-Relatives
7%
Non-Relatives
Alone
With Spouse
Alone
50%
With Spouse and others
140
120
100
80
60
40
20
0
Reason for referral
Social Isolation
Service Access
Limited due to
Finances
Resistant to
Service/Support
Recent hospital
and/or ED visit
MD/RN Concern
Recommendation
Follow Through
Frequent User of
Emergency Dept
Culture/Languag
e is a Barrier
Complex Needs
Caregiver
burden/lack of
support/distance
IGSW Statistics
Guidelines for Referral
IGSW Qualifications
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Recruitment- IGSWs cross-section of academic preparation:
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Geriatric experience within the team:
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Gerontology
Rec therapy
Social Work
Pastoral Care
Psychology
Social Services
Community support
Long-term care
Mental Health
Community Ministry
Retirement Home
Day Program
Private Home care
Acute Care
Rehab
Language, ethnicity, culture
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German, Italian, Dutch, French, Mennonite
Keys to Success
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Focus on SMART (Specific, Measurable, Attainable,
Realistic, Time-Measured) Goals
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Unique role in the home –
IGSWs do not “assess” they “do”
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Roles belong to the system not one agency (Trellis is
Lead agency, accountable to WWLHIN)
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Integrated into Community Support Service Agencies –
IGSW offices are within community partner agencies
Keys to Success
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Strong partnership with CCAC
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Collaborative approach with GEM Nurses, SGS and
Acute Care
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IGSWs are part of the Circle of Care
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Process designed to “pull” patients out of hospital and
into the community
 Communication
Communication
Communication
An IGSW Success Story…
Case Review
The Role of an IGSW
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
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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
1st 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
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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…
 1st
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…
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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…
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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 1st 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 1st 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.
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Successes
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He is now medically stable
 Cognition is improving – Called my voice mail for
the 1st time ever and left an appropriate
message
 Was able to use buzzer for controlled entry at
his apartment for the 1st 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
Questions
Contact Information

Janice Paul –Intensive Geriatric Service Worker Lead:
519-576-2333 x 277, cell 519-400-8176, [email protected]

Heather Higgs – Intensive Geriatric Service Worker
[email protected]

Jane McKinnon Wilson –Waterloo Wellington Geriatric Systems
Coordinator: [email protected]

Maria Boyes- GEM Clinical Resource Consultant: [email protected]
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Carrie McAiney – Lead Evaluator: [email protected]