link people diagnosed with dementia to support, information and services that can help. assist caregivers of people with dementia by linking them to services as early as possible in the disease process. BENEFITS FROM PARTICIPATING IN FIRST LINK People

with dementia will have increased health information enabling them to make informed decisions about their health care needs. People with dementia and their caregivers will have

more information about dementia, health services and non-medical community services. BENEFITS FROM PARTICIPATING IN FIRST LINK Caregivers have will

increased knowledge, skills and confidence. be encouraged to develop self care strategies. FIRST LINK REFERRAL RESOURCES To First Link Referral

by physicians and other health care professionals, diagnostic and treatment services and community service providers. Self referral by the person with dementia or their family. FIRST LINK REFERRAL RESOURCES To Other Services The

Alzheimer Society will provide information about primary health and community-based non-medical services. Alzheimer Society services such as Safely Home - the Alzheimer Wandering Registry. FIRST LINK SUPPORT SERVICES The Alzheimer Society provides

phone conversations personal appointments support groups for people with dementia caregivers in person and distance telephone groups FIRST LINK INFORMATION SERVICES Alzheimer

Society services include Print material Website Information sessions Caregiving: Building Your Team Caregiving with Confidence

is your link to Help for Today and Hope for Tomorrow Serving People with Dementia Click to edit Master Winnipeg Regional Health Authority (WRHA): GERIATRIC MENTAL HEALTH TEAMS

Why Change? Improve Access Reduce Duplication Develop linkages Improve system efficiency Bed Capacity SITE PAST

FUTURE Bethania Mennonite Personal Care Home 9 behavioural treatment 10 PCH Cottage Deer Lodge Centre

12 assessment & rehab 0 assessment & rehab 36 dementia care personal 47 specialized dementia care Riverview Health Centre

10 behavioural treatment 60 dementia care personal care & behavioural care 10 Acquired Brain Injury Rehab 60 dementia/behavioural care Seven Oaks General Hospital

19 Geriatric Psychiatry 19 Geriatric Psychiatry Geriatric Mental Health Service Delivery Model: June 1st, 2006 6 teams- 6 catchments Service to PCH & Community Geriatric Psychiatrist on each team 1 Central Intake Consistent response to referrals Data Entry done daily- retrieval/ stats

Geriatric Mental Health Service Delivery Model: Information Sheet for public 65 or older with 1st onset Mental Illness 65 or older with history of Mental Illness-disease and aging process- GMH service 65 or younger with behaviour/MH symptoms or cognitive issues related to aging

Geriatric Mental Health (GMH): CENTRAL INTAKE GMH & GPAT DLC - 8:00 a.m.-4:00 p.m. Phone: 982-0140 or Fax: 982-0144 Open Referral Process- phone/ fax/ mail GMH Referral Form

GMH Intake: Database Flag entry- if known to GMH or GPAT & eventually DH Based

on client address- faxed to appropriate team the same day GMH Teams:

River East & Transcona (ARE) St. James-Assiniboia/Assiniboine South (DLC) River Heights/Fort Garry (RHC) St. Boniface/St. Vital (Tache) Inkster/Seven Oaks (1050 Leila) Point Douglas/Downtown (DLC) Each team consists of 2 clinicians + Geriatric Psychiatrist. GMH Service: Provide

timely geriatric mental health assessment Recommendations (Geriatric Psych.) Short-term intervention Connect with service to clients in the Community or recommend care in Personal Care Homes Response Times: GOAL: Not

a Crisis Response Team Non-Urgent contact- 3 days, visit in 10 days Urgent contact-1 day, visit in 3 days Clinician contact made to determine level of risk/ appropriate service & schedule appointment Weekly Team Reviews: Team

Reviews scheduled with Geriatric Psychiatrist -discussion of cases Care Planning/ problem-solving/ resources Case Closure: when linked with services required when issues stabilized/ improve when admitted to hospital-not expected to return

Winnipeg Regional Health Authority (WRHA): Geriatric Program Assessment Teams (GPAT): Geriatric Program Assessment Teams (GPAT): Outreach program within the WRHA

Rehab & Geriatrics Program Developed in 1999 & modeled from Ottawa/Carlton Geriatric Outreach Teams Started with 2 teams of 3 clinicians in each team then grew to 5 teams of 3 GPAT (contd)

Each clinician receives 12 weeks of specialized geriatric training This enables each clinician to complete a medically based multidimensional assessment in the clients home assessing the following: physical, functional, cognitive, emotional, psychosocial,

mobility, GI/GU, safety, polypharmacy. GPAT Emergency Room (ER) Involvement In Aug. 04 ER Task force made recommendations about GPAT as follows: GPAT clinicians will have a standard approach in

assessment process in all ERs in Wpg. to improve care to geriatric clients GPAT clinicians will prioritize the ER in their caseload GPAT will refer directly to Home Care to decrease wait times for clients services in the community GPAT response to ER Task Force Restructured 5 teams to 6 to service 6 ERs in Wpg. in mid Nov. 04 Researched database information on clients over age 65 in the community and in Personal Care Homes in 12 community areas

Developed new catchment boundaries for 6 teams with no additional resourcessome 2 & 3 person teams with Geriatrician Geriatric Program Assessment Teams (GPAT): There are 6 teams across the city of Winnipeg

Concordia Deer Lodge Center Health Science Center Riverview St. Boniface Seven Oaks Hospital

Each Team consists of 2-3 disciplines and a Geriatrician + .6 float BN, BPT, BOT, BSW GPAT: contd After the clinician has completed the assessment they review with the

Geriatrician and team. Clinicians will make referral to community resources & recommendations to family MD with geriatrician input. GOALS To ensure the right care, in the right place at the right time. Maintain functional ability in their home Partner with community caregivers for

management to prevent hospital admission (Home Care, Day Hospital, Age and Opportunity friendly visitor, CNIB) GOALS (Contd) Facilitate the transfer of appropriate clients to geriatric medicine and rehab units. Assist

in-patient teams with the discharge planning of complex, frail, elderly (ER). Provide care management/ follow-up, short term intervention POPULATION SERVED The frailest, at-risk elderly, 65+ years.

Complex health concerns affecting their ability to function. Geriatric Issues: mobility, ADL problems, Toileting, Confusion, Depression, Social Support, Medication problems REFERRALS

Open Referral Process: Anyone can refer to our service: Family member, friend, bank manager, Home Care, caregiver, & physicians, etc. To refer to GPAT, either call the Central Intake Line at 982-0140 or fax Central Intake Form to 982-0144.

Contacts: Marlene Graceffo, Rehab & Geriatrics Regional Manager 831-2537 Lois Stewart-Archer, Geriatric Mental Health Regional CNS 831-2179 Jill Moats, Rehab & Geriatrics Regional Educator 831-2150 Questions

PRIME A Health Centre for Seniors Who does PRIME serve? Targets community-dwelling seniors who are: Not functioning well in the community At risk of institutionalization Wish to remain in the community

PRIME Goals Maintain seniors in the community 2. Enhance care coordination and service delivery for the frail elderly 33 Personal care home placement 33 Hospital/Emergency use 1. PRIME Umbrella of Care Case Manager

Day Centre Primary Health Clinic After hours support Inpatient beds Day Centre Transportation Personal care/ grooming/ personal laundry Recreational and social activities Rehabilitation /exercises Health promotion activities

Lunch meal Primary Health Clinic Transfer of care to PRIME physician Coordination of on-site & off-site appointments Medications provided weekly After hours support Evening

and weekend nurse Home visits and telephone response Provincial Health Contact Centre Facilitate Access to Inpatient Beds Treatment Intensive rehabilitation Emergency respite Assessment

Program Model & Outcomes Modelled on Edmonton CHOICE and U.S.A. PACE Edmonton CHOICE results: emergency visits reduced by 62.9% inpatient days reduced by 70% ambulance claims reduced by 51.5% Edmonton Outcomes (contd) High

participant & family satisfaction Maintained health status of participants Slowing of health decline Improved quality of life Support community living PRIME A Health Centre for Seniors Judy Ahrens-Townsend Regional Manager Phone: 831-2192

Email: [email protected]

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