Treat at Home Treat at Home (An Aging at Home Program) 1 - - PowerPoint PPT Presentation

Treat at Home Treat at Home

(An Aging at Home Program)

Promoting mental health, one mind at a time

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Purpose Purpose

• To serve seniors in their homes who

i t li i l d require assessment, clinical and supportive monitoring, intensive home d li f t l h lth d i delivery of mental health and primary care services in order to prevent unnecessary f ER d i ti t f iliti use of ER and inpatient facilities.

Promoting mental health, one mind at a time

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Two Foci Two Foci

• Service delivery to clients.
• Development of a psychogeriatric network.

Promoting mental health, one mind at a time

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Target Population for Service Target Population for Service

1. Seniors experiencing mental health problems or mental illness mental illness. 2. Individuals with serious mental illness experiencing accelerated aging (55+)

Target Population for Network

Service providers working with either of the above Service providers working with either of the above populations.

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Key Learnings Key Learnings

• This population is significantly more fragile and complex than
• riginally thought (complex physical health and addictions in
• riginally thought (complex physical health and addictions in

addition to mental health).

• Caregiver health is often compromised as well.

C ti t i iti l b t ti t il

• Connections to primary care are critical but sometimes not easily

available.

• Polypharmacy requiring medication management and support is a

i ifi t i significant issue.

• Hoarding is a problem for a few clients and uses significant services.

Promoting mental health, one mind at a time

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Service Delivery Service Delivery

Program achievements

• 84 clients served (November to March 31) (prorated

target of 55) f f

• By end of first quarter 2011:
• 78 clients served (ahead of target).
• 30+ ER visits hospitalizations prior to TAH;
• 30+ ER visits hospitalizations prior to TAH;

decreased to 5.

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Implementation Process Implementation Process

• Deciding to Partner analysis completed by Senior Management.
• Operations and Senior Management team meetings established
• Operations and Senior Management team meetings established.
• Developed an MOU (organizational) and a service agreement

(operational)

• Developed a Terms of Reference for the psychogeriatric network

Developed a Terms of Reference for the psychogeriatric network.

Promoting mental health, one mind at a time

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Ch ll Challenges

• Ongoing recruitment and issues Community Support Sector and Mental

Health Sector track visits differently.

• Definition of visits are constantly changing – a work in progress at

provincial level. B k t i t i t

• Brokerage case management versus intensive case management.
• Highly complex clients with often few appropriate or receptive referral

sources.

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Effectiveness Effectiveness

• Exceeding range of revised target number of clients

seen.

• Established benchmarks for face to face visits
• Cost per unit of service $212.00

benchmarks as per Health Care Indicator Tool (HIT):

• benchmarks as per Health Care Indicator Tool (HIT):

$58.93 to $155.47

• Cost per client $1,622.00

p ,

• benchmarks as per HIT: $2,838.52 to $4,531.82
• 4% administrative costs budgeted.

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Client Feedback Client Feedback

1. 90% agreed the worker respected their rights. 2 84% d t th i th th ht th 2. 84% agreed got the services they thought they needed. 3. 79% agreed they were able to see a worker when they 3. 79% agreed they were able to see a worker when they needed to. 4. 69% agreed their mental health and physical health d t (l k f t l h lth) needs were met (lack of awareness re mental health). 5. 59% agreed their worker connected them to other programs and services.

Promoting mental health, one mind at a time

programs and services.

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Critical Success Factors Critical Success Factors

• Established common benchmarks
• Strong infrastructure to ensure clinical soundness

g

• Client was central to all agencies
• An effort made to always have decision makers for all agencies

present present

• Ongoing communication for clarity at all levels
• Recently ensured front line staff meet regularly as an “intake team”.

R i it d t i d

• Revisit mandate as required.
• Involvement of Sheridan Elder Research Centre and survey of

caregivers.

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Linkages and Partnerships g p

• CMHA/Peel
• CANES
• Reconnect
• William Osler Psychogeriatic Team
• Malton Neighbourhood Services
• Headwaters Health Centre
• Peel Regional Police
• Members of the Psychogeriatic Network
• Wise Elephant Health Team
• Caledon Community Service
• CW- CCAC
• St. Elizabeth Peel Crisis Services

g

• Service Canada
• India Rainbow
• WOHC
• PAARC

P l S i Li k

• Richview Residence
• Peel Elder Abuse Prevention Network
• Trellis Health Care
• Spectra Support Services
• Peel Senior Link
• CAMH
• Rexdale CHC

Promoting mental health, one mind at a time

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Development of the Central West Development of the Central West Psychogeriatric Network

21 b f lti l t

• 21 members from multiple sectors.
• Terms of Reference completed.
• Sheridan Elder Research Center enhancing the Aging
• Sheridan Elder Research Center enhancing the Aging

Mental Health and Addictions Tool Kit as an educational tool for all network providers.

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