Community Care Services Promoting Independence Mount Sinai Geriatrics Institute Thursday June

Transcription

1 Community Care Services Promoting Independence 2013 Mount Sinai Geriatrics Institute Thursday June

2 Presentation Outline Part 1 Care Plan Review Carmelina Marziliano MSW, RSW Social Worker Mt Sinai Hospital Part 2 Linking to the community Stacey Pustowka BSW, RSW Social Worker Housecalls 2 2

3 Admission criteria for ACE admission Patients 65 years and older with an acute medical illness plus any 3 or more of the following: Recent decline in functional abilities Recent change in cognition or abilities Problems common to older adults (eg: falls, dehydration, urinary /fecal incontinence, acute and / or chronic pain, adverse drug reactions, delirium) Complex social issues Identification of Seniors at Risk (ISAR) score >2 on ED assessment 3 3

4 Assessment process in hospital Upon admission, automatic referral orders go in for Occupational Therapy, Physiotherapy and Social Work to see patient. Initial screens are done in order to uncover early concerns regarding discharge back to community or rehabilitation center. By early identification, concerns can be explored and incorporated into care plans as goals for durable discharge plans. Communication between medical and allied team members is crucial so that all working with patient and their family on the same goals as the patient and family. 4 5

5 Assessment process in hospital Areas that are explored: Living arrangement: How was everything going at home before coming to hospital? Did you feel there were any gaps in your care Are there stairs that you have to manage (inside or outside the home) Did you already receive help from CCAC or other community agencies prior to coming to hospital Family Structure: Do you have immediate family? I s there anyone else you would consider to be important in your life? Do you have a Power of Attorney document for personal care and /or finances At Home: Were you walking independently? Did you use a cane or walker? Do you have any equipment in the bathroom? 5 6

6 Alice - Care Planning Education and support to Alice and her common law spouse Family meeting to discuss medical status, future planning Facilitator of application to: rehabilitation units (if deconditioned) behavioural units (if needs more intervention to stabilize the behaviours) BSOT Community Support Outreach Team, Convalescent Care (while delirium clears) Link to Reitman Center Referral to CCAC to reinstate previous PSW support and assess for increased support (COPD/CHF Self Management Support) Link to Community Social Worker for continuity and link to community 6 9

7 Alice in the Community

8 Community Care Services Promoting Independence

9 SPRINT Senior Care Services Adult Day Services Community Dining Dementia Care Residence Health and Wellness House Calls In-Home Services Meals on Wheels Social Work Supportive Housing Transportation Volunteer Services

10 10 House Calls Interdisciplinary Mobile Team Home-Based Geriatric Primary Care Team Team Members Physicians Physiotherapist Occupations Therapist Rehab Assistant Nurse Practitioner Administrative Data Analyst Social Worker Team and Intake Coordinator 10

11 Interdisciplinary Teams Client- centered approach and better outcomes for clients Team members have complimentary skills Comprehensive care plans

12 12 House Calls Goals Support and Maintain Independence at Home for Clients and Caregivers Prevent Emergency Department Visits and Hospitalizations Prevent Premature Move to Nursing Homes 12

13 13 Continuity Theory Strengths- Assessment Maintain same behaviors Maintain same personalities Stay active Client Community services support independence Maintain same relationships 13

14 14 Alice over Time 2012 Linked with CCAC, and Community Supports Alice assigned POA documents to Alice Future Care Wishes and Advance Directives Discussed Judy linked with caregivers groups 2013 New Diagnosis of Alzheimer s Behavioral Problems Caregiver stress and caregiver isolation Where to move next? 14

15 Social Work Reassessment for New Care Plan 15 InterRAI CHA Assessment Cognitive Testing (Referral to Occupational Therapist) Alice s Perception of her Situation Caregiver s Needs Strengths Assessment Service Review and Linkage Future Care Planning 15

16 16 Judies Caregiving Duties Increased demand for ongoing daily help with ADL s (activities of daily living) Judy now making all financial decisions that directly affect them both Judy providing more emotional support to Alice Judy researching future care options 16

17 17 Social Embarrassment and Social Isolation Preoccupation with inconsequential matters Arguing loudly in public Loss in inhibitions Personality changes 17

18 Some Strategies Judy has learned arguing and trying to reason doesn t help Judy has learned being distracting and agreeable helps Despite the behaviors, Judy still loves Alice

19 Referrals: Occupational Therapist and Baycrest Community Behavior Support Outreach Team 19 In-service at Adult Day Services Caregiver education and support Comprehensive care plan 19

20 20 Profile of Judy Primary caregiver Increased knowledge of disease process No history of mental health problems. Insight of caregiver stress Adequate support network Wants to stay as close to Alice as possible Member of LGBT community 20

21 21 Judy s Worry List Moving My role as a caregiver? Changes in role and separation Will a move mean moving back into the closet? Rethinking downsizing to a condo? Does Alice need a nursing home? How much will it cost? Will new health care professional recognize my relationship with Alice What will happen to me if I get sick? What happens if I die? How long can I cope? Alice s increasing dependence Physical and emotional intimacy How can I imagine the future as a single person, as a single lesbian? 21

22 Demonstrating Cultural Competency 22 Learning the language Alice uses to describe her relationship with Judy Assessing past experiences of oppression/homophobia Reviewing institution s or agency s multicultural policy and practices Staff Training 22

23 23 Ewart Angus SPRINT Homes Consists of 6 floors Well seniors live in market rental apartments on the first three floors Seniors with dementia live on the 4 and 5 floor (secure units) * Ewart Angus is owned by Ewart Angus Homes Inc, a private not for profit organization

24 24 Programming/Philosophy of Care Respect for lifelong routines Meaningful, practical activities help the resident remain involved and active Individualized care programs Health and Wellness, Activation, and Outings Culturally Competent

25 25 Caregivers: Family, Friends and Volunteers The needs of family members are recognized and supported Family members, friends and volunteers significantly enrich the programming Families and friends are welcome to visit anytime and participate in as much or as little

26 Ewart Angus SPRINT Homes 26 6 th floor

27 Gardening at Ewart Angus SPRINT Homes

28 28 Benefits Prevent premature institutionalization Fosters independence, self-esteem and self confidence High quality of life for residents Significantly decrease caregiver stress Supports family relationships LGBT-friendly

29 Working Together: Referrals, 29 Consults, Discharge Planning Mount Sinai Hospital Community Care Access Centre SPRINT Senior Care and House Calls Reitman Centre Mount Sinai Baycrest Community Behavior Support Outreach Team 29

30 30 Alice s Careplan House Calls Alice attends Adult Day Services Ongoing behavioral assessment Linkages to services Imminent move to Ewart Angus Home SPRINT Home 30

31 31 Judy s Careplan Attendance at monthly caregivers group Judy uses SPRINT Senior Care programs Ongoing Systems Navigation Imminent move to first floor of Ewart Angus Home 31

32 Contact Information CNAP : Community Navigation and Access Program Ewart Angus SPRINT Homes: House Calls:

33 33 SPRINT Senior Care 140 Merton Street, Second Floor Toronto, ON M4S 1A Presented by: Stacey Pustowka Social Worker, BSW, RSW House Calls Team 33