NURS 1002H Lecture 3: Interprofessional Collaboration for a Comprehensive
Geriatric Assessment
1. Identify community services to support older adults in community and
institutional settings.
Intersectoral Collaboration to Support Older Adults:
• Social networks – when speaking with an older adult, find out who
comes to visit them in their home, what/who makes them happy?
• Primary Health Care – do they have one? When they move into an
institutional place, is there one available there?
• Private Business (pharmacies and labs) – can be private or public? If
you have money, you can just hire someone directly.
• Transportation – approx. $100 down to about $20 for patient taxi travel
• Community Support Services – fundraisers and more.
• Hospital
• Supportive or Assistive Housing – partially funded from Peterborough
housing services
• Home Care (private and non-profit) – ex. Victoria nurses and homecare
cooperatives
Rockwood Clinical Frailty Scale:
- Need to know what services are provided at what stage
Principles of the Canada Health Act (1984):
Principle Mandate
Operate on nonprofit basis through public
Public administration
authority
Comprehensiveness Cover medically necessary services
Universality Free of discrimination
Coverage across Canada for insured
Portability
residents
Reasonable access, regardless of ability to
Accessibility
pay
Evolution of the Canadian Health Care System:
- The federal government:
o Sets and administers national principles
o Assists in financing of health care services through transfer
payments
o Delivers health services for Indigenous people, veterans, federal
inmates, and Royal Canadian Mounted Police, armed forces
o Provides national policy and programming to promote health and
prevent disease
- Provincial and territorial governments:
o Develop and administer their own health care insurance plans
OHIP
o Manage, finance, and plan insurable health care services and
delivery, in alignment with CHA principles Ontario Health –
physicians can directly go through OHIP and will reimburse
private physicians, some long term care, some programs, etc.
o Determine organization and location of hospitals or long-term
care facilities; employ health providers in various specialties; and
determine amount of money dedicated to health care services
o Reimburse physician and hospital costs and some rehabilitation
and long-term care services, usually on the basis of co-payments
with individual users
Settings for Care: Transitioning Health Care System to Ontario Health Teams:
Local – Regional Peterborough Ontario Health Team: Steering Committee:
• Alzheimer Society Peterborough – non-profit organizations who will
support and education and most are free of charge
• Canadian Mental Health Association, HKPR – transfer payments and
provide in home and group support
• Care Partners
• City of Peterborough, Social Services Division
• Community Care Peterborough – community support service that deals
with transportation, they fundraise as well
• Curve Lake First Nation – get some funding from feds and some
directly from the province
• Hiawatha First Nation – same
• Hospice Peterborough – palliative care, on site and outreach
• Long-Term Care/Retirement Home Representative
• Patient & Family Representative – real life patients for every long-term
care facility
• Peterborough Family Health Team – cluster of primary care and family
health organizations. Provide pharmacists, nutritionists, etc.
• Peterborough Paramedics – wellness checks and drive to houses for
checks
• Peterborough Public Health – health protection, promotion and
enforcement
• Peterborough Regional Health Centre – handle health inspections like
checking water supply and more
• Primary Care
• VON
2. Documentation and communication across settings for collaborative
care.
- Professional jurisdiction: Regulated Health Professions Act,
Ontario1991
- Who provides what care?
- Who pays them?
- Who ensures they are safe to provide care?
- Who can they share your information with?
- How can a person get to see them?
Documentation:
- Concepts:
o Standardized instruments for care outcomes and evaluation are
integral to the consistent determination of the needs and the
health and wellness status of older adults, as well as appropriate
funding.
o Documenting the patient’s status and needs is a key
responsibility of the nurse.
o Nurses have a responsibility to protect patient confidentiality at
all times, both in spoken communication and in the clinical
record
- Examples:
o Recall Person Centred Language
o Resident Assessment Instrument (RAI)
o Subjective, Objective Assessment Plan Intervention and
Evaluation
o Or Point Click Care or other EMRs
o Consent to share personal health information
o Comprehensive Geriatric Assessment
Common health concerns in each setting:
- Home:
o Injuries (51% 2018)
o chronic obstructive pulmonary disease
o heart failure
o knee and hip arthritis requiring replacements
o pneumonia
o myocardial infarction
o Diabetes complications
- Hospital:
o Functional decline
o Malnutrition
o Falls
o New-onset incontinence
o Pressure ulcers
o Delirium
o Medication interactions and adverse effects
Canadian Frailty Network:
Comprehensive Geriatric Assessment Framework:
• Medical Surgical History
• Functional History
• Social History
• Physical Assessment
• Falls
• Sleep
• Pain
• Nutrition
• Polypharmacy
• Continence
• Cognition
• Mood
