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: