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Intensive Geriatric Service Worker (IGSW)

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Intensive Geriatric Service Worker (IGSW) Janice Paul WW IGSW Lead Heather Higgs - WW IGSW Thursday, August 12, 2010 GiiC Outline Setting the stage integrated ... – PowerPoint PPT presentation

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Title: Intensive Geriatric Service Worker (IGSW)


1
Intensive Geriatric Service Worker (IGSW)
  • Janice Paul WW IGSW Lead
  • Heather Higgs - WW IGSW
  • Thursday, August 12, 2010
  • GiiC

2
Outline
  • Setting the stage integrated system of care
  • Intensive Geriatric Service Worker (IGSW)
  • Case Review

3
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

4
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
    effectflows across the continuum

5
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

6
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

7
Guiding Principles Continued.
  • Cost Effective best care at optimal cost
    recognizing benefits of volunteerism, local
    community responses
  • Results Oriented results defined and measured

8
Seniors Services Flow
Dr. John Yang
9
Design Principles
  • 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

10
Intensive Geriatric Service Workers (IGSW)
11
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 seniors care.
  • For the senior who is reluctant to accept any
    supports, the IGSW can help pave the way for
    other services in the community

12
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

13
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

14
IGSW GoalsHEALTHY, HAPPY, SAFE
15
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

16
Referral Guidelines contd
  • 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

17
Who can refer a patient to an IGSW?
  • GEM Nurses
  • Geriatric Clinical Nurse Specialists
  • in Acute Care
  • Specialized Geriatric Services

18
Hospital
Community
19
IGSW Statistics
20
IGSW Statistics
Min age 48 Max age 98 Average age 80
21
IGSW Statistics
22
IGSW Statistics
23
IGSW Statistics
24
IGSW Qualifications
  • Recruitment- IGSWs cross-section of academic
    preparation
  • Gerontology
  • Rec therapy
  • Social Work
  • Pastoral Care
  • Psychology
  • Social Services
  • Geriatric experience within the team
  • Community support
  • Long-term care
  • Mental Health
  • Community Ministry
  • Retirement Home
  • Day Program
  • Private Home care
  • Acute Care
  • Rehab
  • Language, ethnicity, culture
  • German, Italian, Dutch, French, Mennonite

25
Keys to Success
  • 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

26
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

27
An IGSW Success Story
28
Case Review
  • The Role of an IGSW

29
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
    1100am.

30
SMART Goals
  • Obtain Family Doctor
  • Have Hearing Tested
  • Arrange Transportation
  • Lifeline
  • Encourage use of walker instead of shopping cart

31
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

32
Initial Visit cont.
  • Blood sugar monitor and sharps 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

33
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.

34
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.

35
Daughter
  • Through phone call with the niece found out that
    client does not have a daughter.
  • Called clients sister to confirm. Sister states
    that daughter is a drinking buddy and it is a
    relationship theyve 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.

36
Whats 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

37
Whats 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 hadnt seen since 2002.
    New family doctor obtained
  • Now has walker and bath chair
  • IGSW visits weekly in addition to accompanying to
    any medical appointments

38
Whats 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 1st time in 5 years.
  • Visited optometrist, cataracts diagnosed, should
    have had them removed 5 years ago only sees
    movement
  • Ophthalmologist appointment arranged

39
Bumps along the road
  • Missed initial Geriatricians appointment (mixed
    up appointment time so wasnt at home when I
    arrived to take him).
  • Sweater went missing at the same time as the
    social workers 1st visit. He is convinced she
    stole it and wouldnt 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.

40
Successes
  • 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 Ive 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.

41
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

42
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

43
Questions
44
Contact Information
  • Janice Paul Intensive Geriatric Service Worker
    Lead
  • 519-576-2333 x 277, cell 519-400-8176,
    jpaul_at_trellis.on.ca
  • Heather Higgs Intensive Geriatric Service
    Worker
  • hhiggs_at_trellis.on.ca
  • Jane McKinnon Wilson Waterloo Wellington
    Geriatric Systems Coordinator jmckinnon_at_trellis.o
    n.ca
  • Maria Boyes- GEM Clinical Resource Consultant
    mboyes_at_cmh.org
  • Carrie McAiney Lead Evaluator
    mcaineyc_at_mcmaster.ca
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