Transcript Mobilizing the Community to Serve Seniors

Partners in Care…
Living in the Moment
Mobilizing the Community to
Serve Seniors
Mon. March 5, 2007
Eleanor Stelmack, OTReg(MB)
Seniors Health Resource Teams
As a program started in 1999 to address the growing
seniors population and to look at alternative ways of
delivering health care for older adults.
Currently, there are Teams in 3 community areas-River
East, St.-James Assiniboia, and Downtown.
Team composed of a nurse and an allied health
professional (OT or Dietitian).
Part of Support Service to Seniors
Support Services to Seniors:
Philosophy
Aging is a normal developmental process.
Human beings need peers with whom they can interact
and who are available as a source of encouragement and
support.
Adults have the right to have a voice in determining
matters in which they have a vital interest.
Support Services to Seniors:
Principles
Focus on a holistic approach.
Reduce barriers to improve and/or maintain health status.
Foster social and physical environments that support
health and independence.
Promote optimal well being through life-long learning.
Increase health promotion to prevent and/or postpone
disabilities, distress, discomfort, disease and preventable
injury.
Increase capacity of seniors to have meaningful control
over their health and well being.
Support Services to Seniors:
Population Served
Individuals 55 years and older
Average age is between 75 and 80 years
Well to frail and “at risk” older persons
Support Services to Seniors:
Mandate
To promote a range of coordinated,
accessible and affordable, community-based
services that focus on promoting health,
independence and well being for older
persons in Winnipeg.
Support Services to Seniors:
Who Are We
Direct service provided through Seniors Health Resource
Teams.
Granted Agencies and Programs
Congregate Meal Programs
Community Resource Councils
Seniors Centres
Tenant Resource Programs
Rupert’s Land Caregiver Services
Support Services to Seniors:
Who Are We(Continued)
Creative Retirement Manitoba
Meals on Wheels of Winnipeg
Manitoba Association of Multipurpose Senior
Centres
Medication Information Line for the
Elderly(MILE)
University of Manitoba-2 dental programs (Home
Dental & Deer Lodge Centre
Canadian Institute of the Blind
*Services vary by community area.
Support Service to Seniors:
Community Development
Using a community development approach:
See seniors mobilize
Identify the gap
Take social action
Work with seniors at a grassroots level
Various services act as a resource
Support Services to Seniors:
Community Development
Using the population health framework
to work collectively in developing and
implementing services based on the
determinants of health(not all health care
services, however, provide personal
supports).
Seniors Health Resource Team:
Program Goal
To enable seniors to live independently in
a health conducive community by
providing primary health care, health
promotion, illness and injury prevention
and chronic disease management that
promotes optimum quality of life.
Seniors Health Resource Teams:
Accessing Services
Provide services where seniors live, work and play.
RE and SJ have their offices in Senior Centres.
Outreach is often creative.
Banks, flu clinics, walking programs, etc.
Word of mouth has become an effective
strategy as well.
Seniors Health Resource Teams:
Individual and Personal Service
Often attend on a “lost lead”-I.e. Blood pressure
clinic.
Mood and Memory checkups are well-attended.
Health assessment with a focus on health
promotion(falls risk, osteoporosis risk, depression
questions, incontinence, medication review) and
chronic disease management.
Seniors Health Resource TeamHealth Edu-tainment
Prescription for Health After 50:
Aging with Zest & Vitality
Tips to Keep Your Mind Alert
Take Control of Your Stress
Memory Tips: The Skit
Seniors Health Resource Team:
Chronic Disease Management
Living with Alzheimers’ Support Group
In-Block Activity Program
“Because We Care” Carer’s Lunch
Grief Support
And since no man(or woman) is an island;
Diabetes education and support,
Osteoporosis Support Group, Visually
Impaired Coffee Group, Meniere’s Support
Group and others.
Seniors Health Resource Team:
Partners in Care
First and foremost, the person with dementia
and their primary carer.
For the person with dementia, appropriate
assessment-GPAT, family Dr., Memory Clinic.
Also, the issue of whether their medical needs
are being addressed.
For the person with dementia, are they safeAlzheimers Society Wandering Registry,
medication setup, cooking.
For the person with dementia, what is their
quality of life like.
Seniors Health Resource Team:
Care for the Carer
Living with Alzheimers’ Support Group
“Because We Care” Carers Lunch
Individual Support and Counselling
Grief Support
Reintegration into the Community
Seniors Health Resource Team:
Community Development
Daughter called SHRT looking for services
and supports for 75 year old mother with
Alzheimer’s Disease. Father is primary carer.
Father was given info to connect with the
Living with Alzheimer’s Support group and InBlock Activity Program(Rupert’s Land
Caregiver Services).
Father also experiencing health difficulties
particularly with OA. SHRT did Home Visit.
Seniors Health Resource TeamCase Example
Recommendations from home visit: equipment
and home modifications-equipment supplier
Several questions around medications and
herbals arose-MILE
Arthritis Education & Support Group for DadArthritis Society
Community Walking Program for Mom and
inclusive in community events -Active Living
Committee
Seniors Health Resource TeamCase Example
Ongoing health support through SHRT clinics
issues: skin, thrush, questions about
medications, Advanced health care directives,
Enduring Power of Attorney, Wandering Registry,
diet and nutrition, exercise, respite.
Referral to Home Care for bath and dressing assist
for mom. Respite-Adult Day Program-Respite.
Individual counselling through Age & Opportunity
for Dad to help deal his feelings(frustration, guilt,
anger).
Seniors Health Resource TeamCase Example
Mom placed in PCH
Dad had knee surgery; unable to drive.
Connected with Rides for Seniors through
River East Council for Seniors.
Dad given support in reconnecting with the
community. Became a member of Good
Neighbours Senior Centre.
Reconnect at death.
Seniors Health Resource Team:
Comments from the Client(Dad)
“I don’t know how I would have coped
without your support. There were days I
wanted to strangle her, she could be so
frustrating. Just to know that there was
someone that I could call and that
something good would happen kept me
sane.”
Seniors Health Resource TeamIntegrating and Working Together
Interconnect with our partners on an
ongoing basis
Partner on projects I.e. research and
working group
Creates an awareness of one anothers’
resources
Links seniors to appropriate resources