mary centre model mary centre model. mission statement mary centre delivers integrated supports and...
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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<C and MCSS to ensure the program continues to grow and meet the needs of the ageing population in Peel