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Improving the seniors’ transition from hospital to the community: a case for intensive geriatric service workers

Published online by Cambridge University Press:  26 July 2016

Carrie A. McAiney ,
Loretta M. Hillier ,
Janice Paul ,
Jane McKinnon Wilson ,
Anna Tersigni Phelan ,
Fred Wagner  and
Sheli O'Connor
Carrie A. McAiney*
Affiliation:
Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada Seniors Mental Health Research and Evaluation, St. Joseph's Healthcare Hamilton, West 5th Campus, 100 West 5th Street, Rm G102, Hamilton, Ontario, Canada
Loretta M. Hillier
Affiliation:
Specialized Geriatric Services, St. Joseph's Health Care London, London, Ontario, Canada Aging, Rehabilitation & Geriatric Care Research Centre of the Lawson Health Research Institute, 801 Commissioners Road East, London, Ontario, Canada
Janice Paul
Affiliation:
Canadian Mental Health Association Waterloo Wellington Dufferin Branch, 147 Delhi Street, Guelph, Ontario, Canada
Jane McKinnon Wilson
Affiliation:
Canadian Mental Health Association Waterloo Wellington Dufferin Branch, 147 Delhi Street, Guelph, Ontario, Canada
Anna Tersigni Phelan
Affiliation:
Canadian Mental Health Association Waterloo Wellington Dufferin Branch, 147 Delhi Street, Guelph, Ontario, Canada
Fred Wagner
Affiliation:
Canadian Mental Health Association Waterloo Wellington Dufferin Branch, 67 King Street East, Kitchener, Ontario, Canada
Sheli O'Connor
Affiliation:
Canadian Mental Health Association Waterloo Wellington Dufferin Branch, 147 Delhi Street, Guelph, Ontario, Canada
*
Correspondence should be addressed to: Dr. Carrie A. McAiney, Department of Psychiatry & Behavioural Neurosciences, McMaster University; Seniors Mental Health Research and Evaluation, St. Joseph's Healthcare Hamilton, West 5th Campus, 100 West 5th Street, Rm G102, Hamilton, Ontario, L8N 3K7, Canada. Phone: 905-522-1155 ext.36722. Email: [email protected].
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Abstract

Background:

Limited continuity of care, poor communication between healthcare providers, and ineffective self-management are barriers to recovery as seniors transition back to the community following an Emergency Department (ED) visit or hospitalization. The intensive geriatric service worker (IGSW) role is a new service developed in southern Ontario, Canada to address gaps for seniors transitioning home from acute care to prevent rehospitalization and premature institutionalization through the provision of intensive support and follow-up to ensure adherence to care plans, facilitate communication with care providers, and promote self-management. This study describes the IGSW role and provides preliminary evidence of its impact on clients, caregivers and the broader health system.

Methods:

This mixed methods evaluation included a chart audit of all clients served, tracking of the achievement of goals for IGSW involvement, and interviews with clients and caregivers and other key informants.

Results:

During the study period, 632 clients were served. Rates of goal achievement ranged from 25%–87% and in cases where achieved, the extent of IGSW involvement mostly exceeded recommendations. IGSWs were credited with improving adherence with treatment recommendations, increasing awareness and use of community services, and improving self-management, which potentially reduced ED visits and hospitalizations and delayed institutionalization.

Conclusions:

The IGSW role has the potential to improve supports for seniors and facilitate more appropriate use of health system resources, and represents a promising mechanism for improving the integration and coordination of care across health sectors.

Keywords

seniorstransitional carecommunity careadherence
Type
Research Article
Information
International Psychogeriatrics , Volume 29 , Issue 1 , January 2017 , pp. 149 - 163
Copyright
Copyright © International Psychogeriatric Association 2016 

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