The Development of an Integrated Model of Dementia Care in the Community for Low-Income Seniors

More than 8% of Canadians over the age of 65 are estimated to live with a form of dementia. However, the real number is likely higher for older adults living in social housing as they are disproportionately impacted by poverty, social isolation and poor health, which increases their risk of developing dementia. Community service providers care for persons living with dementia across ambulatory care clinics, hospitals, rehabilitation facilities, nursing facilities and in their homes. Movement across the continuum of care is not necessarily linear from home to hospital, with many persons living with dementia facing re-hospitalizations and increased morbidity and mortality with excess healthcare expenditures. To better identify and support older adult tenants at risk for or living with dementia who reside in Toronto Seniors Housing Corporation (TSHC) buildings, Sunnybrook Health Sciences Centre is collaborating with community partners to expand and integrate three initiatives as part of a new 'Dementia Care in the Community' Strategy (DCSS): 1.Community Psychiatric Services for the Elderly providing at-home psychiatric assessments, coordinating referrals to community agencies, and facilitating a bimonthly support group for dementia family caregivers. 2.Sunnybrook's Homebound Seniors Program, providing team-based, at-home care to patients who have difficulty accessing clinics for primary care. 3.Neighborhood Care Team (NCT), a consortium of 11 service providers that focuses on early identification of needs and seamless access to social and health services for TSHC tenants. An implementation science framework is being used to explore the model’s feasibility, appropriateness, acceptability and sustainability. Specifically, we will use the Consolidated Framework for Implementation Research (CFIR) to guide research that supports evidence-based decision-making to optimize the DCSS strategy including qualitative interviews with key interest groups and analyzing health service utilization patterns amount TSHC tenants to determine whether services have become more streamlined and to detail tenant outcomes. The insights gained from these activities will provide recommendations for optimizing and sustaining the DCSS implementation strategy over the long-term. Specifically, the plan is to: 1.Lead the establishment of new policies and procedures to govern the NCT’s expanded work with TSHC. Operating as a “living lab,” Sunnybrook aims to evaluate and implement innovative ways to bridge the gaps between the health and social systems to better coordinate and deliver seamless care to patients living with dementia and their family and professional caregivers. 2.Conceive and implement a novel strategy for identifying TSHC tenants at-risk of and experiencing the early signs and symptoms of cognitive impairment yet not currently supported by the NCT. This augmented and integrated approach to care will enable personalized plans for one-on-one care (e.g., monitoring and managing high-risk or escalating behaviours), and deliver in-home supports (e.g., medication, meals). Education and navigation supports for families and caregivers, including TSHC and community staff and volunteers, who are sometimes the only support for marginalized older adults. Challenges and plans to address the challenges will also be presented. This work has been generously funded by the Slaight Family Foundation

Aged care · Aging in place · Community-based care · Dementia · Health care · Independent living · Integrated care · Service (business · Service provider · Social isolation · Dementia and Cognitive Impairment Research · Geriatric Care and Nursing Homes · Health Policy Implementation Science