Janice Paul and Heather Higgs - crncc

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Key Roles: IGSWs‣ To implement care plans from GEM Nurses, acute carehealth team (including hospital CCAC Case Manager), orSpecialized Geriatric Services‣ To provide timely intensive support, transition <strong>and</strong> follow-up with primary care, specialty care & communitysupport services‣ To support person-centered self-directed care (i.e.,coach seniors <strong>and</strong> caregivers)
IGSW Goals – Healthy, Happy,Safe
Page 1 and 2: Facilitating Integration fromthe Co
Page 3 and 4: What is an integrated system?‣ A
Page 5 and 6: How did We Get to Where We are‣ H
Page 7 and 8: Guiding Principles Continued….‣
Page 9 and 10: Integrated Services for SeniorsDr.
Page 11: Intensive Geriatric Service Worker(
Page 15 and 16: Referral Guidelines (cont’d)‣ R
Page 17 and 18: Secure Web Portal for GEMreferrals
Page 19 and 20: IGSW Qualifications‣ Recruitment-
Page 21 and 22: Case ReviewED Presentation:‣ 87 y
Page 23 and 24: PLANAfter the GEM assessment, it wa
Page 25 and 26: Home in the Community‣ Client see
Page 27 and 28: To date‣ Arranged for Meals on Wh
Page 29 and 30: Currently‣ Using walker‣ Now se
Page 31 and 32: Ongoing involvement:‣ Accompanied
Page 33 and 34: Waterloo WellingtonIntegrated Servi
Page 35 and 36: IGSW ActivitiesActivities Percent (
Page 37 and 38: Referral Sources250208Numbe er of R
Page 39 and 40: Client CharacteristicsAge• Mean
Page 41 and 42: IGSW: Other ImpactsImpacts as a res
Page 43 and 44: Summary of the Ways in Which the IG
Page 45 and 46: IGSW: Other ImpactsDo you think the
Page 47 and 48: Selected Quotes“IGSW has gotten m
Page 49 and 50: Lessons Learned: IGSWsFacilitating
Page 51 and 52: Lessons Learned: IGSWsChallenges:
Page 53: Contact Information‣ Janice Paul

Janice Paul and Heather Higgs - crncc

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