Janice Paul and Heather Higgs - crncc

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Referral Guidelines‣ Frequent user of the emergency department‣ Recent hospital admission(90 days) <strong>and</strong>/or ED visit (30 days)‣ Complexity of needs(number <strong>and</strong>/or type of support required)‣ Socially isolated
Referral Guidelines (cont’d)‣ Resistant to assistance or support‣ Ability to access services is limited due to financialreasons‣ Language or cultural barrier‣ MD or RN concern about ability to follow through withrecommendations‣ Caregiver burden, lack of caregiver support or long-distance caregiver
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 and 12: Intensive Geriatric Service Worker(
Page 13: IGSW Goals - Healthy, Happy,Safe
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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