Centre de santé et de services sociaux de La Matapédia (QC)

  • Michel Simard, Directeur, Services à la clientèle par intérim, Centre de santé et de services sociaux de La Matapédia, Amqui, Quebec (Interim Director, Client Services)

Intégration des services aux personnes âgées fragilisées : mise à niveau des mesures visant à éviter ou à retarder l'hébergement public

Service Integration for the Frail Elderly: Upgrading Measures Seeking to Avoid or Delay Institutionalization

Despite all the changes instituted since 2007 within our continuum of care for the elderly, the Policy Committee on Residencies of the Matapedia CSSS has noticed that the frail elderly access the pathway to permanent accommodation without all the required services having been delivered to support the senior and their loved ones so that they can stay at home as long as possible. Even though more homecare services have been made available, we have noticed a gap between the range of services offered and what is required for the frail elderly. In other cases, there is a total absence of services used. This situation can be explained by a lack of knowledge on the part of these seniors, and their informal caregivers, of the services available to frail and elderly clients in the service area of the CSSS.

We have attempted to improve skills targeting the clarification of roles and of interdisciplinary teamwork for homecare. We have also integrated case management into a hybrid function, which combines a navigator role for simple files requiring little coordination and a case manager for more complex files requiring greater coordination. We carried out this project by establishing operating procedures for interdisciplinary teams.

In addition, we set up a community flagging program in order to take action further up the line in the continuum of services offered to the elderly. In order to do this, we visited an area of Quebec having already experimented with a community flagging project. We started in an area where we could pilot the project, target partners, conclude formal collaboration agreements and offer training.

Clinical Program Leads in health facilities could benefit from this intervention project. This highly transferable project could have economic and optimization spin-offs as it will enable us to address the growing number of seniors without having to increase the number of public residency spaces. Moreover, this project makes it possible for the client to feel less threatened as homecare is what most concerns both stakeholders and partners.

Finally, this intervention project targets changes needed to support seniors as long as possible and as well as possible in their homes. Quebec homecare policies are well known and support these suggested changes. Also, the Quebec Model (RSIPA) or Integrated Services Network for Seniors suggests changes with a view to optimal integration of the model. This project implies little or no financial investment and applies to places where solid partnerships within communities and municipalities exist.