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Mobilizing the Community to Serve Seniors

Partners in Care… Living in the Moment. Mobilizing the Community to Serve Seniors. Mon. March 5, 2007 Eleanor Stelmack, OTReg(MB). Seniors Health Resource Teams.

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Mobilizing the Community to Serve Seniors

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  1. Partners in Care… Living in the Moment Mobilizing the Community to Serve Seniors Mon. March 5, 2007 Eleanor Stelmack, OTReg(MB)

  2. Seniors Health Resource Teams • As a program started in 1999 to address the growing seniors population and to look at alternative ways of delivering health care for older adults. • Currently, there are Teams in 3 community areas-River East, St.-James Assiniboia, and Downtown. • Team composed of a nurse and an allied health professional (OT or Dietitian). • Part of Support Service to Seniors

  3. Support Services to Seniors: Philosophy • Aging is a normal developmental process. • Human beings need peers with whom they can interact and who are available as a source of encouragement and support. • Adults have the right to have a voice in determining matters in which they have a vital interest.

  4. Support Services to Seniors: Principles • Focus on a holistic approach. • Reduce barriers to improve and/or maintain health status. • Foster social and physical environments that support health and independence. • Promote optimal well being through life-long learning. • Increase health promotion to prevent and/or postpone disabilities, distress, discomfort, disease and preventable injury. • Increase capacity of seniors to have meaningful control over their health and well being.

  5. Support Services to Seniors: Population Served • Individuals 55 years and older • Average age is between 75 and 80 years • Well to frail and “at risk” older persons

  6. Support Services to Seniors: Mandate • To promote a range of coordinated, accessible and affordable, community-based services that focus on promoting health, independence and well being for older persons in Winnipeg.

  7. Support Services to Seniors: Who Are We • Direct service provided through Seniors Health Resource Teams. • Granted Agencies and Programs • Congregate Meal Programs • Community Resource Councils • Seniors Centres • Tenant Resource Programs • Rupert’s Land Caregiver Services

  8. Support Services to Seniors: Who Are We(Continued) • Creative Retirement Manitoba • Meals on Wheels of Winnipeg • Manitoba Association of Multipurpose Senior Centres • Medication Information Line for the Elderly(MILE) • University of Manitoba-2 dental programs (Home Dental & Deer Lodge Centre • Canadian Institute of the Blind • *Services vary by community area.

  9. Support Service to Seniors: Community Development • Using a community development approach: • See seniors mobilize • Identify the gap • Take social action • Work with seniors at a grassroots level • Various services act as a resource

  10. Support Services to Seniors: Community Development • Using the population health framework to work collectively in developing and implementing services based on the determinants of health(not all health care services, however, provide personal supports).

  11. Seniors Health Resource Team: Program Goal • To enable seniors to live independently in a health conducive community by providing primary health care, health promotion, illness and injury prevention and chronic disease management that promotes optimum quality of life.

  12. Seniors Health Resource Teams: Accessing Services • Provide services where seniors live, work and play. • RE and SJ have their offices in Senior Centres. • Outreach is often creative. • Banks, flu clinics, walking programs, etc. • Word of mouth has become an effective strategy as well.

  13. Seniors Health Resource Teams: Individual and Personal Service • Often attend on a “lost lead”-I.e. Blood pressure clinic. • Mood and Memory checkups are well-attended. • Health assessment with a focus on health promotion(falls risk, osteoporosis risk, depression questions, incontinence, medication review) and chronic disease management.

  14. Seniors Health Resource Team- Health Edu-tainment • Prescription for Health After 50: Aging with Zest & Vitality • Tips to Keep Your Mind Alert • Take Control of Your Stress • Memory Tips: The Skit

  15. Seniors Health Resource Team: Chronic Disease Management • Living with Alzheimers’ Support Group • In-Block Activity Program • “Because We Care” Carer’s Lunch • Grief Support • And since no man(or woman) is an island; Diabetes education and support, Osteoporosis Support Group, Visually Impaired Coffee Group, Meniere’s Support Group and others.

  16. Seniors Health Resource Team: Partners in Care • First and foremost, the person with dementia and their primary carer. • For the person with dementia, appropriate assessment-GPAT, family Dr., Memory Clinic. Also, the issue of whether their medical needs are being addressed. • For the person with dementia, are they safe-Alzheimers Society Wandering Registry, medication setup, cooking. • For the person with dementia, what is their quality of life like.

  17. Seniors Health Resource Team: Care for the Carer • Living with Alzheimers’ Support Group • “Because We Care” Carers Lunch • Individual Support and Counselling • Grief Support • Reintegration into the Community

  18. Seniors Health Resource Team: Community Development • Daughter called SHRT looking for services and supports for 75 year old mother with Alzheimer’s Disease. Father is primary carer. • Father was given info to connect with the Living with Alzheimer’s Support group and In-Block Activity Program(Rupert’s Land Caregiver Services). • Father also experiencing health difficulties particularly with OA. SHRT did Home Visit.

  19. Seniors Health Resource Team- Case Example • Recommendations from home visit: equipment and home modifications-equipment supplier • Several questions around medications and herbals arose-MILE • Arthritis Education & Support Group for Dad-Arthritis Society • Community Walking Program for Mom and inclusive in community events -Active Living Committee

  20. Seniors Health Resource Team- Case Example • Ongoing health support through SHRT clinics issues: skin, thrush, questions about medications, Advanced health care directives, Enduring Power of Attorney, Wandering Registry, diet and nutrition, exercise, respite. • Referral to Home Care for bath and dressing assist for mom. Respite-Adult Day Program-Respite. • Individual counselling through Age & Opportunity for Dad to help deal his feelings(frustration, guilt, anger).

  21. Seniors Health Resource Team- Case Example • Mom placed in PCH • Dad had knee surgery; unable to drive. Connected with Rides for Seniors through River East Council for Seniors. • Dad given support in reconnecting with the community. Became a member of Good Neighbours Senior Centre. • Reconnect at death.

  22. Seniors Health Resource Team: Comments from the Client(Dad) • “I don’t know how I would have coped without your support. There were days I wanted to strangle her, she could be so frustrating. Just to know that there was someone that I could call and that something good would happen kept me sane.”

  23. Seniors Health Resource Team- Integrating and Working Together • Interconnect with our partners on an ongoing basis • Partner on projects I.e. research and working group • Creates an awareness of one anothers’ resources • Links seniors to appropriate resources

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