Keep Calm and Care On: Providing Person Centred Psychogeriatric Supports

in the Community

Presentation to West Toronto Human Services and Justice Coordinating Committee November 19, 2015

Debra Walko, Director of Seniors Services, LOFT

Mission

�To help people achieve their optimal health and

well-being in the com

munity, LO

FT offers unw

avering support and hope. We serve people

living with com

plex mental health, addictions,

cognitive and physical health challenges, offering a range of services and housing delivered in the com

munity. Through innovation, investm

ent, expertise and collaboration w

e respond to changing needs in our diverse com

munity.

�LO

FT is a values-driven organization with a deep belief that each person has the

ability to grow and change and that each person deserves the opportunity to do

so. LOFT em

braces the individual needs and aspirations of each client and encourages the developm

ent of comm

unities of mutual support w

ithin our program

s to enable each client to attain his or her potential. �

LOFT takes risks to reach out to those m

ost in need, including people with

multiple challenges w

ho are often considered hard-to-serve and too often fall through the cracks as a result. W

e believe we m

ake our best contribution to the comm

unity w

hen we not only continue to provide our core services, but also identify gaps in

existing services and develop programs to reach out to people w

ho cannot get the help they need.

�The LO

FT Name: LO

FT stands for “Leap of Faith Together“. Our nam

e refers to our philosophy of taking risks and reaching out in response to unm

et and emerging

needs. It also refers to the leap of faith our clients take when they join our program

s and take the risk of believing that things can im

prove for them, and that recovery is

possible.

Seniors Services �

LOFT S

eniors Services has been a leader for

more than 30 years, providing specialized,

comm

unity-based housing and support services to vulnerable and at-risk seniors w

ith complex

challenges including mental or physical health

issues, addictions, behavioural challenges, dem

entia, absence of family support, social

isolation, cultural dislocation and poverty.

Seniors Services �

LOFT has 13 m

odels of service providing 24 hour supportive housing, Transitional S

upportive Housing, S

upported Housing,

Psychogeriatric C

ase Managem

ent and B

ehavioural Support S

ervices that support older adults and seniors in Toronto, York R

egion and the South S

imcoe area of O

ntario. �

Supporting over 1500 seniors and older adults

living with com

plex mental health, addiction,

psychosocial and physical health challenges.

Who do our Seniors Services Support ?

�O

lder Adults &

Seniors – “55ish” and older

who are:

�living w

ith mental health and/or addiction challenges.

�considered “high risk”

�very culturally diverse

�diverse on m

any other levels. �

extremely socially isolated.

�experiencing serious housing challenges or hom

elessness �

experiencing elder abuse. �

have had involvement w

ith the legal system.

�are open to support but w

ere having a very difficult time navigating the

“system”.

�experiencing responsive behaviours

�living w

ith complex psychosocial and physical health challenges

Where LO

FT Provides S

ervices

�P

rovide Service in Toronto C

entral LHIN

(#7) and Central LH

IN (#8)

Where LO

FT Provides S

ervices

�Toronto, York R

egion and South S

imcoe areas

of Ontario

�P

rovide services in underserved areas such as S

outh Sim

coe �

Provide S

eniors Services in at risk

comm

unities in Toronto: �

Jane/Finch �

Weston – M

ount Dennis

�P

arkdale �

Yonge/Church C

orridor

Dunn Avenue/Spencer

Supportive Housing Services

College View

Supportive Housing Shoreham

Current Toronto Comm

unity Housing Sites –

Individual Intensive Support for 400+ Residents M

ount Dennis

Arleta

100 High Park

61 Pelham Park

St. Anne’s Place

John Gibson

House

Bradford House

LOFT O

wned Sites – 250 Residents

Simon

Apartm

ents

Types of LOFT Seniors Supports & Services

�A

ssisted Living for High R

isk Seniors

�24 hour P

SW

Support

�S

cheduled & U

nscheduled Services

�C

are Coordination

�O

n Site &

Hub and S

poke Model

�S

upportive Housing for S

eniors �

24 hour on site PS

W S

upport �

Scheduled and U

nscheduled Services

�C

are Coordination

�S

upported Housing S

ervices �

Psychogeriatric C

ase Managem

ent/Care C

oordination Housing S

upport and P

SW

Support

�S

cheduled and unscheduled service �

Com

munity D

evelopment

Types of LOFT Seniors Supports & Services

�Transitional H

ousing & S

upport �

Em

bedded in our existing Supportive H

ousing Hubs so receive those

services �

58 Older A

dult and Seniors annually return to the com

munity from

A

lternative Level of Care B

eds and the Em

ergency Departm

ent

�P

sychogeriatric Case M

anagement

�Intensive C

ase Managem

ent/Care C

oordination �

In our housing sites and the comm

unity

�B

ehavioural Support S

ervices �

Mobile S

upport Teams that support older adults/seniors and their

caregivers in the comm

unity and long term care

�P

roviding knowledge exchange, supports w

ith transition, peer coaching �

Creation, testing and im

plementation of behavioural support plans

�“B

ehaviour has Meaning”

LOFT’s Seniors’ Services

�

Services provided include : �¾

Care Coordination �¾

Personal Care

- ¾ Ethno Cultural Services

�¾

Medication Rem

inders - ¾

Dining Services �¾

Meal Preparation

- ¾

Crisis Intervention �¾

Emergency Response

- ¾ Affordable Housing

�¾

Escorts to Appointments

- ¾ Psychogeriatric Case M

anagement

�¾

Care Giver Relief

- ¾ Reintegration/Transitional Housing

�¾

Essential Housekeeping - ¾

Behavioural Support Services �¾

Laundry �¾

Social Recreational/ Acitvation Activities

BEHAVIOURAL SUPPO

RTS ONTARIO

(BSO

)

BSO

is not a new service; rather, it is a province-w

ide value-based and evidence-inform

ed catalyst for change or a trigger for the realignm

ent of existing services.

�B

SO creates a system

that ensures people are treated w

ith dignity and respect in an environment that supports

safety for all, and is based on high quality and evidence-inform

ed care and practices.

�B

SO provides clients w

ith the right care, in the right place and at the right tim

e.

BSO Fram

ework

Value Statement

“I am m

ore than my behaviour.

Learn W

ho I Was,

Understand W

ho I am and

Treat M

e with D

ignity and Respect.”

Central LH

IN Value S

tatement

Behavioural Support Services – 1000 clients annually

Service Components of the Team

s

Direct Client Service Behaviour Support Plans

Peer to peer coaching and m

entoring of Staff/caregivers

Liaising and building on the W

ork of existing Outreach Team

s

Supports with Transitions to ensure

Optim

um use of behavioural supports

ie LTCH to Behaviour Support Unit, Hospital to LTCH etc.

BSO Pillars

Integrated Service, Know

ledgeable Capacity Building, System

Coordination

Functions of the BSS- MST

�Link to Existing Crisis Services �

Urgent and tim

ely �

24/7 - after hours

�Transitional Support �

Sm

ooth hand-off\clear accountability �

Com

munication

�S

ystem navigation

�Transition

�S

upport �

Building linkages

�

In-home behavioural support

�Instrum

ental support – in-the-mom

ent – coaching and mentoring role

�H

ands-on, on-site �

Instrumental practical supports

�C

oaching �

Support to caregivers

BSS Transition Support

Behavioural Support Plans

�BSS-M

ST uses the follow

ing evidence-based/best practice approaches for developm

ent of individualized B

ehavioural Support P

lans: �

P.I.E.C

.E.S

./U-First!

�G

entle Persuasive A

pproaches for Dem

entia C

are (GPA

) �

Montessori M

ethods for Dem

entia �

Applied B

ehavioural Analysis (A

BA

)

How can w

e achieve this? �

By w

orking in a person centred/recovery framew

ork �

Having experience and expertise in both m

ental health and addictions and seniors physical health supports

�U

sing evidence based practices �

Working in a client centred, collaborative care

coordination model

�S

upporting the “whole person” as they w

ork toward

their goals and life journey. �

Using com

mon assessm

ent tools �

Working w

ith people where they are “at”

�C

reativity and Flexibility within the funding fram

ework

�C

onstant Quality Im

provement w

ork

“The Shades of Grey”

�S

o the best approach is not purely from a

mental health perspective or a physical

health/aging perspective. �

It blends both perspectives and this creates “grey” areas for the individual, their fam

ily and their supports

�K

nowledgeable navigating and effectively

supporting individuals through this grey area is the key!

The “Grey” A

reas……

. �

The impact of capacity for decision m

aking on choice and control

�C

are model vs. a support m

odel �

Stigm

a of mental illness, aging and m

ental illness and aging

�E

xpertise, knowledge and experience needed for

assessment of risk from

both a mental

health/addiction and complex physical health

perspective �

Know

ledge, understanding and support with the

impact m

ental health and physical health have on each other.

�W

orking between each of the silos and the current

cultures of support

How

do we N

egotiate the “Grey”?

�Maintain a belief in H

ope and the strengths each person possesses

�Work w

ithin a Care C

oordination Model

�Create system

responses as they are ultim

ately best for the individual �C

ollaborative approaches with supports

doing what they do best

�Formal partnerships w

ith MO

U’s:

�R

egional Mental H

ealth Centre’s

�H

ospitals �

Municipal H

ousing �

Com

munity C

are Access C

entre

In Summ

ary �

We believe as service providers that w

e have a responsibility to develop supports and services that m

eet the needs of seniors living w

ith mental health and addiction challenges.

�E

ffective services will be able to navigate those grey areas in a

client centred way w

hile managing risk and safety

�P

erson centred approaches must be incorporated into seniors

services support individuals in their own journey.

�It isn’t alw

ays about the funding �

System approaches and solutions creates better health care and

lower costs – benefitting everyone…

…

Contact Information

Debra W

alko D

irector of Seniors’ Services 416-259-7117

dwalko@

loftcs.org