mary centre model mary centre model. mission statement mary centre delivers integrated supports and...

Mission Statement Mary Centre delivers integrated supports and servicesand creates new opportunities for the benefit of the developmentally challenged, their families and thecommunity in which they live

ValuesDignity – of whole personIntegrity – treat people with respectFocus on Individual – coordination of servicesResponsibility – to individual, family, & community

1988 - Founded by parents with older adults to ensure good quality care based on Catholic Values

Focus on seniors with Developmental Challenges

25 years supporting individuals with Developmental Challenges

75% of individuals supported by Mary Centre are over 50 years of age

Mary Centre offers a holistic approach to support by looking at the person in all aspects of life

• Residential Group Homes all homes are wheelchair accessible

• Supported in Independent Living • Community Support• Integrated Seniors Program• Transition and Long Term Care Program• Alzheimer’s/ Dementia Day Program• Parish Outreach• Volunteer• Adult Day Programs

A representative from the Residential Services Committee approached the region re placement of some of their clients with complex medical care needs into long term care.

There appeared to be a natural fit between LTC and the DS sector.

To support people with intellectual disabilities to lead enriched and meaningful lives in LTC in partnership with their families and community

Five Developmental Services Agencies The CCAC The Ministry of Health and Long Term Care The Ministry of Community and Social

Services Representatives from the Region of Peel Struck a committee to further examine this partnership. The group meets monthly

The plan was to complete the successful transition of 10 individuals with Developmental Disabilities and complex health challenges from the community into Malton Village Long Term Care home

A proposal was developed and forwarded to the MCSS

MCSS provided funding for this project Much discussion took place regarding our

philosophies of care/ differences and similarities A Coordinator was hired from the DS sector

Applications are received from CCAC Applications are reviewed Project Coordinator meets with potential

clients and their current service providers (case workers)

Tours provided

Developing circles of support within the long term care setting

Sharing skills sets and individual’s history with Health Care staff

Creating positive changes to the individual’s lifestyle by helping to maintain life skills or offering the opportunity to

develop new skills Working with staff to meet the social and emotional needs of the individual and ensuring that participation is not used to simply pass time

A series of in-services were provided to staff of LTC homes to:- Inform them of the Project (2005 – 2006)- Provide sensitivity training and awareness of Developmental Disabilities - Educate on Personal Outcome Measures (PC)

Within the developmental sector, personal outcome measures

have become the vehicle for the discussion of what people expect from services and supports they receive. These are compared to the Long Term Care Resident Bill of Rights.

7 applications made Average age was 56 (69, 56, 55, 52,and 50) 5 approved - major diagnosis Developmental Challenge

and deteriorating health 4 residents admitted to regular health units, another

located in a more secure unit Most of these clients had been supported by the DS

sector for most of their lives

5 individuals who moved into Malton Village LTC all reported to have adjusted well

They developed new relationships with other residents and staff, said it “felt like home”

They actively participated in centre wide activities and programs

1 Resident assists with mail delivery and running the Village Shop to meet her interests

Some of these residents remain independent with visits to the local mall, bank or community groups

MCSS identifies individuals who require long term care support

Family tours Malton Village and agrees to placement

Malton Village willing to accommodate

Mary Centre agrees to provide the support

Previously developed relationship with Malton Village is renewed.

Attitude change and relationship building are keys to enabling knowledge, action and progress.

Transition across sectors from one residential setting to another requires a coordinated approach to planning that is not limited to placement.

• Lived independently in community• Resides in own home, group home or

apartment• Physical and Mental Health deteriorates• Transition and Long Term Care worker

supports through transition to LTC (continuous and seamless)

• Help LTC staff to support with information• Individual is supported to adjust to new setting

HOME TO HOME TRANSITION PROCESS

Mary Centre is committed to accomplishing this through:

◦ Collaboration between the Developmental Services, Health Care and Seniors Services;

◦ Creating new evidence-based approaches to planning and service delivery;

◦ Focusing on innovative and creative models of support. 

Long Term Care Home provides: Medical Care Personal Care

Mary Centre provides: Ongoing support to enhance opportunities for

integration and interaction with the other residents Ongoing family involvement in the lives of the

individuals Ongoing community involvement and inclusion to

enhance the life of the individual and maintain existing relationships.

All support workers must obtain a Vulnerable Persons Police Check

Support workers are trained in the following:◦ Non-violent Crisis Prevention Intervention◦ First Aid and CPR

Other training sessions offered for Mary Centre staff include:◦ Working with families◦ Protecting the vulnerable◦ Documentation◦ Gentle Persuasive Approach ◦ Montessori-based programming

• To support individual to participate in activities of To support individual to participate in activities of interest within the facilityinterest within the facility

• To work with facility staff in meeting the social and To work with facility staff in meeting the social and emotional needs of the individualemotional needs of the individual

• To help develop networks of support and friendship To help develop networks of support and friendship within the long term settingwithin the long term setting

• To maintain community and family connections To maintain community and family connections • To work as part of the team in LTC home.To work as part of the team in LTC home.

To ensure goal setting is a collaboration with client, family members, long term care and support agency

To assist in implementing behaviour management protocols and modelling protocols to LTC staff

To access community resources to better enhance the individual's quality of life

A Personal Support Plan (PSP) is developed annually for each individual addressing the 10 areas of life.

The PSP outlines individualized goals; what has been achieved and what will be worked on over the year

Staff complete a quarterly report to document the progress made in meeting their PSP goals

Personal Support Plans are completed jointly with the team from Long Term Care homes, the individual and their family and presented at the Care Conference

•Collaboration to meet the needs of persons with Developmental Disability•Responsive supports•Continuity in supports between sectors•Shared resources •Shared knowledge and understanding between sectors•Provide an enhanced quality of life •Person focused service•Seamless support model

Ministry of Community and Social Service Community Living Mississauga Brampton Caledon Community Living Family Services of Peel Christian Horizons Peel Behavioural Services Malton Village Leisure World Care Centres

Mary Centre has worked to develop meaningful partnerships with:◦ Alzheimer’s Society◦ Community Care Access Centres ◦ Behaviour Supports Ontario◦ Behaviour Training Services◦ Peel Services for Seniors◦ Ontario Collation for Seniors◦ Long Term Care homes in Peel

Community Living Agencies – Group Homes Family Members Community Care Access Centers Hospitals Long Term Care Homes Family Services

We currently provide support to 29 individuals in 13 different LTC facilities in the region of Peel

Eligibility:

◦ Residents of the region of Peel with a Developmental Disability

◦ Individuals who currently reside in Long Term Care (LTC) or are planning to move into a LTC home

Support continued community involvement and participation

Support the continuation of social skills development

Modify programming to meet individual needs, skills, and interests

Provide opportunities to develop new friendships

Encourage ongoing communication between the individual, LTC staff, and the individual’s family

Capacity and consent

Behavioral challenges

Finances and managing finances

Lack of family support/involvement for some clients

Individuals/Family refused LTC space

Individuals transferred out of long term care and left at hospitals.

Behaviour supports are a vital part of the ongoing success of the partnership

Mary Centre has worked closely with the Behaviour Therapist for the DS sector to support individuals and provide in-service training for LTC staff

We work closely with the Community Mental Health Dual Diagnosis services

Using the appeal process to gain access to a LTC placement

Dispelling myths about persons with Developmental Challenge and LTC

Providing information on the transition process Generating information for individuals, their families

and support workers about LTC Ongoing liaison between sectors to enable both

systems to build upon new learning. Learning from each other on how to identify and

support the unique needs of the individual with a Developmental Challenge in LTC

• Seamless transition from community to LTC through planning and support from Transitional Support Worker prior to move

• Staff in Long Term Care home’s have gained skills through the Transitional Support Worker

• LTC staff are comfortable approaching the worker when they have a question

• The Transition & LTC worker has become part of the team in the LTC home

BENEFITS

• Having an on-going liaison between sectors to enable both systems to learn from each other

• Developing a LTC referral protocol for individuals with developmental disabilities

• Continuation of involvement from the community agencies for a transition period

• Further enhancing the relationship with LTC and providing an opportunity for others to receive support

BENEFITS

SUCCESSES 3 Individuals inappropriately placed in long term care

have now been integrated back to the community to appropriate residential placements

Connections with 12 other long term care homes in Peel have been developed

MCSS and other service providers support Mary Centre Long Term Care Initiative

We are currently recognized and consulted regarding placement and support for individuals with Developmental Challenges by the CCAC’s, Alzheimer’s Society, Long Term Care providers and Psychogeriatric Resource Consultants

Determine who the most important contact is within the LTC home. (Director, Social Worker etc.)

Set up a meeting to discuss what you have to offer (your giving them something at no cost to them!)Use your connections with community partners or other LTC Homes as reference.Don’t get discouraged if you get “NO” check with other LTC homes in your area.

The DSO came into effect July 1, 2011 under the Ministry of Community and Social Services

The DSO is now the central point of access

Referrals still come from LTC homes but must then go through the DSO

Identify inappropriately placed individuals for re-referral back to community (currently 8 individuals aged18- 35)

Continue to work with community partners and DSO to facilitate a seamless transition of individuals into long term care.

Secure ongoing funding from MOH&LTC and MCSS to ensure the program continues to grow and meet the needs of the ageing population in Peel