BY ADELLE LARMOUR

One of the deepest needs of a human being is the need to belong.

This philosophy was the driving force behind the formation of an interdisciplinary team that provides community-based psychogeriatric consultation services for seniors in northeastern Ontario transitioning from the Northeast Mental Health Centre to long-term care homes and other accommodations.

Under the auspices of the Seniors’ Mental Health Program (SMHP) at the Northeast Mental Health Centre in North Bay, the team serves communities from Huntsville to Attawapiskat and Mattawa to Sault Ste. Marie.

The team includes the services of psychiatry, medicine, nursing, social work, occupational therapy and recreation therapy with the support of a regional outreach manager and support staff.

It evolved out of the need to create a smoother transition for seniors with mental health problems who were discharged from hospital to long-term care facilities or back home.
Today, the unit is comprised of 34 beds with one ward (13 beds) specializing in dementia care. Geriatric patients are referred from nursing homes, long-term care facilities or hospitals in their respective communities. The list of ailments varies from middle to end-stage dementia, schizophrenia, depression, or other behavioural problems.

Once admitted, patients are assessed and prepared for transfer back to their place of residence within their community. The entire team is involved with their return, easing potential bumps or problems along the way.

“They are prepared for discharge upon admission,” said Sharon Langley, SMHP’s psychogeriatric social worker.

Of course, this wasn’t always the case. Prior to the establishment of the team, transitions were few and far between, according to Dr. Emilia Hlusek, a 32-year veteran psychiatrist at the hospital.

Stigma
Prior to 1992, the SMHP/Psychogeriatric Unit was a 75-bed unit consisting of one female and two male wards. The patients were “highly stigmatized” and often grew old within the walls of the psychiatric hospital, said Langley.

At the same time, long-term care homes lacked the funding and resources to manage dementia or difficult behaviour. Thus, there was apprehension to admit these types of patients.

By 1992, a provincial mandate to reform mental health was initiated. Its goal was to remove the stigma around psychiatric wards by returning patients to the community. Staff within long-term care facilities required education in dementia and mental health care. As well, a network of community resources had to be developed.

Placement Co-ordination Services (PCS) worked through the Home Care program, now the Community Care Access Centre (CCAC). This agency managed the wait list, performed the patient’s initial assessment and determined who went into nursing homes.

“There needed to be a strong community partnership between placement, nursing homes and our Seniors program,” Langley said.

Hlusek, who was medical director at the time the program started, took it upon herself to follow patients from hospital to the nursing home.

“Continuity for patients was important, so I followed them to make sure they stayed there,” she said.

Soon, the number of referrals for Hlusek mushroomed. Sandy Bolton, a registered nurse and PCS co-ordinator, suggested that the hospital hold a bed for two weeks while the patient was transitioning to a nursing home. During this trial period, a report would be written, possibly flagging any problems that arose.

“If, for example, the person wasn’t taking his or her medication, we would provide help to solve the problem because we knew the patient,” Langley explained.

The nursing homes were very receptive to this collaborative effort because the vacant bed served as an assurance that if something happened, the patient could return to the hospital.

“Even though we discharged a bed after two weeks, we would still offer services on a consultation basis,” Langley said.

As the concept of using “many players” evolved, those chosen became whoever best met the interests of the patient, resulting in a multidisciplinary team of professionals from within the inpatient staff at the hospital, as it is today. By 1997, the team was fully functional.

“We used internal resources to do external work, so it took a few years to gel,” Langley said. “Now, it has evolved to a point that the nursing homes expect the transition, and they are more trained in dementia care today.”

Monitoring
As well, community programs are in place for patients who may require more intense monitoring.

“It can be very traumatic for a patient to transfer from one environment to another,” Langley said, explaining the social impacts of moving from a certain culture within the hospital to another type of culture in a long-term care home.

Hlusek recounted a story about a woman who found the transition so distressing that she walked through a glass door in order to be returned to the hospital. This occurred before the program began.

As transition became the norm, patients’ families have become more involved and open minded about nursing-home placements.

“Often, families preferred the care here, because there were concerns the care would be less or the move would be too disruptive,” Langley said.

Now, family members are more involved and are invited to attend admission and progress conferences, where expectations are set out. They are encouraged to tour the facility and even attend social events, creating more transparency. Nursing home staff are also encouraged to attend patient conferences and express concerns, if any.

During the last four years, a follow-up survey on transitions has been sent to every family and nursing home. Overall, feedback has been positive, but constructive criticism is also taken seriously and discussed amongst team members.

Today, the transition team continues to work with families, long-term care staff and patients.