Intensive Geriatric Service Worker (IGSW) Janice Paul WW IGSW
Lead Heather Higgs - WW IGSW Thursday, August 12, 2010 GiiC Slide 2
Outline Setting the stage integrated system of care Intensive
Geriatric Service Worker (IGSW) Case Review Slide 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 Slide 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 Slide 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 Slide 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 Slide 7 Guiding
Principles Continued. Cost Effective; best care at optimal cost
recognizing benefits of volunteerism, local community responses
Results Oriented: results defined and measured Slide 8 Seniors
Services Flow Dr. John Yang Slide 9 Design Principles 1) Process
capable of meeting need and demand 2) Process will deliver client
value and demonstrate outcomes 3) Robust and Reliable 4) Uses and
Improves Existing Infrastructure 5) Clearly defined operations that
can be enabled with information technology. 6) Improves flow by
minimizing all types of waste and by creating pull 7) Has positive
impact on system goals Slide 10 Intensive Geriatric Service Workers
(IGSW) Slide 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 Slide 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 Slide 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 Slide 14 IGSW Goals HEALTHY, HAPPY, SAFE Slide 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 Slide 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 Slide
17 Who can refer a patient to an IGSW? GEM Nurses Geriatric
Clinical Nurse Specialists in Acute Care Specialized Geriatric
Services Slide 18 Referral Process Seniors in need ED Assessment
GEM and CCAC CCAC central Database AdmitHome IGSW Required
Community SGS: Geriatric Medicine Psychogeriatric CARE PLAN
IMPLEMENTED Service Order request to Trellis Hospital Community
Slide 19 IGSW Statistics Slide 20 Min age: 48Max age: 98Average
age: 80 Slide 21 IGSW Statistics Slide 22 Slide 23 Slide 24
Recruitment- IGSWs cross-section of academic preparation:
Gerontology Gerontology Rec therapy Rec therapy Social Work Social
Work Pastoral Care Pastoral Care Psychology Psychology Social
Services Social Services Geriatric experience within the team:
Community support Community support Long-term care Long-term care
Mental Health Mental Health Community Ministry Community Ministry
Retirement Home Retirement Home Day Program Day Program Private
Home care Private Home care Acute Care Acute Care Rehab Rehab
Language, ethnicity, culture German, Italian, Dutch, French,
Mennonite German, Italian, Dutch, French, Mennonite IGSW
Qualifications Slide 25 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 Keys to Success Slide 26 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 Slide 27 An IGSW Success
Story Slide 28 Case Review The Role of an IGSW Slide 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
11:00am. Slide 30 SMART Goals Obtain Family Doctor Have Hearing
Tested Arrange Transportation Lifeline Encourage use of walker
instead of shopping cart Slide 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 Slide 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 Slide
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.
Slide 34 Family Client stated his niece had recently visited and
brought food (later found out that was 1 st 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. Slide 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. Slide 36 Whats
Been done 1 st 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 Slide 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 Slide 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 1
st time in 5 years. Visited optometrist, cataracts diagnosed,
should have had them removed 5 years ago only sees movement
Ophthalmologist appointment arranged Slide 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 1 st 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. Slide 40
Successes He is now medically stable Cognition is improving Called
my voice mail for the 1 st time ever and left an appropriate
message Was able to use buzzer for controlled entry at his
apartment for the 1 st 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. Slide 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 Slide 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 Slide
43 Questions Slide 44 Contact Information Janice Paul Intensive
Geriatric Service Worker Lead: 519-576-2333 x 277, cell
519-400-8176, [email protected] [email protected] Heather Higgs
Intensive Geriatric Service Worker [email protected] Jane
McKinnon Wilson Waterloo Wellington Geriatric Systems Coordinator:
[email protected] [email protected] Maria Boyes- GEM
Clinical Resource Consultant: [email protected] [email protected] Carrie
McAiney Lead Evaluator: [email protected]
[email protected]
