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Working together for our most fragile citizens

For the past two years, the North East CCAC (CCAC) and North East Specialized Geriatric Services (NESGS) have been working collaboratively to develop and support their community partnership.

"We have an important mutual goal – the best possible community care for our geriatric patients. The best way to do this is to establish a combined care model and work towards that goal from the same page," explains North East CCAC Manager, Care Coordination, Marta Milks.

What this means is that the North East CCAC and NESGS have committed to a partnership that strives to ensure that the most appropriate medical and community supports are accessed for our most fragile geriatric population allowing them to age in place for as long as possible.

As the integration continues a North East CCAC Complex Care Coordinator is now working from NESGS, dedicated to a growing portion of the mutually serviced population of Complex patients. CCAC Care Coordinator Valerie Chabot attends weekly NESGS case conferencing meetings and maintains close contact and open communication with NESGS staff.

"Working with the geriatric specialists from NESGS helps me expand my knowledge and skills, which I can then apply while working with my frail geriatric patients. In turn, I am a resource to them as to what CCAC services are available and how to connect their patients with these services. This exchange is really great for patients," says Chabot.

Recently, the two agencies have been involved in extensive working sessions, with the focus on promoting information sharing and planning.  

Patients benefit by having to undergo fewer assessments, as NESGS specialists and CCAC staff are able to coordinate visits, reducing fatigue and frustration for both patients and caregivers. Sharing information also increases the opportunities to monitor health and progress of patients.

In one recent case, for example, the CCAC was able to identify that a cognitively impaired frail elderly patient of the NESGS and CCAC had been hospitalized. In being able to share this information with NESGS, both teams were able to work with hospital staff and the physician to share information about the current care plan. This ensured there was a good understanding as to the work that had already taken place between NESGS and the family, what medications had been prescribed to the patient, and what supports and services were already in place or would be available upon discharge.

Chabot, an experienced community care coordinator who has worked extensively with geriatric patients, applauds the partnership and its benefits for all involved, especially for the patients who simply wish to stay in their homes as long as possible.

"This is truly the proverbial win-win-win. We want to reduce the risk of Emergency Department visits and hospitalizations for our frail geriatric patients, and provide the best chance for a discharge home when we cannot avoid it. If we can keep some of these frail elderly patients safe in their homes and delay or avoid an admission to a long-term care home, then we will all have achieved success. That's a goal worth working towards."