champlain ccac dementia initiative - hssontario.ca posters...champlain ccac dementia initiative...
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Champlain CCAC Dementia Initiative
Client Care Model: Complex Seniors Team
Focusing on:
Enhancing independence / Preventing deterioration
Improving client outcomes and quality of life
Delaying long term care institutionalization
Reducing avoidable ER visits and hospitalization
Increasing links with partners; Care Coordinators are more
specialized in their knowledge of dementia and resources
available to those clients
Intensive care coordination
Using RAI HC Data in a Different Way
Use the Resident Assessment Instrument Home Care (RAI HC) data to assist with
identification of clients who may benefit from referral to specialized geriatric services
Partnering with Regional Geriatric Program of Eastern Ontario (RGPEO) the RAI HC
was reviewed and key questions were identified that indicated further follow up would
be beneficial
Analysis of samples of clients based on key questions in the RAI HC led to the use of
specific Client Assessment Protocols (CAPs)
An average client may trigger 10 CAPs, and most clients trigger at least three
Development of a Dementia Report:
A client report using RAI data was created to assist Care Coordinators to
identify clients who might benefit from follow up (implementation Oct 2012)
Clients will appear on the report if:
Specific CAPS are triggered:
Cognition
Depression and Anxiety
Over age of 55
The RAI HC was completed within last
40 days (this ensures a dynamic report
to reflect the most current clients)
Other information is included in the report to assist the Care Coordinator in determining
when to refer the client to specialized geriatric services
Goal of report:
Increase Care Coordinator΄s awareness and referrals to specialized geriatric services
Identify and refer clients earlier in the disease process which is essential to provide
clients and families with the latest medication and treatment options
The report allows the option of sending an auto-populated letter to the family physician
Connect with Family Physicians
If the Care Coordinator makes a referral to specialized geriatric
services, a letter can be sent to the Family Physician
The letter provides Family Physicians with valuable information
about their dementia patients gained from the Care Coordinator’s
home assessment and RAI HC:
All CAPS triggered, Cognitive Performance Score (with MMSE
equivalent), number of falls in last 3 months, number of ER
visits in last 3 months, CCAC active services
The Family Physicians will also be informed about specialized
geriatric services that are available in Champlain and a referral
will be made if applicable
The letter is followed up by a phone call to confirm if
assessment is required
Family Physicians
have the option of
returning a simple
survey indicating
if the information
was helpful
Dementia Tool Kit and Education Plan
Information about dementia specific resources and services
within Champlain are centrally located on the Champlain CCAC
intranet
Created to enable Care Coordinators to increase their knowledge
base in order to better assist dementia clients and their families
Care Coordinators on the Complex Team have been supported to
attend the RGPEO Geriatric Education Series— a five day intensive
learning program
Care Coordinators have been supported to complete the RNAO
eLearning modules: Delirium, Dementia, Depression
141 Care Coordinators completed all modules by April 2013
The Dementia Tool Kit has been accessed over 1,000 times in the
last 7 months
Sophie Parisien, Director, Care Coordination, Champlain Community Care Access Centre (CCAC)
Anne MacDonald, Manager, Care Coordination, Champlain Community Care Access Centre (CCAC)
“Our Business Intelligence Team has done an excellent job of using data and technology to create an easy method
(a letter) for Care Coordinators to share valuable RAI HC information with Family Physicians. While currently
focusing on dementia we envision expanding our initiative to include other populations and conditions.”
Sophie Parisien, Director, Care Coordination, Champlain Community Care Access Centre (CCAC)
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See www.champlainccac.ca News and Events for this poster
Future Direction: