House call

Winnipeg Health Region staff members are able to visit seniors in their own homes, thanks to a program that is being called the best in Canada

Laurel Rose examines client Margaret Johnston
Laurel Rose examines client Margaret Johnston
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What is GPAT?

Winnipeg Health Region
Wave, May / June 2011

Margaret Johnston sits in the tidy living room of her St. James apartment and quietly ponders the suggestion for a moment.

At issue is whether the 89-yearold woman with the quick smile and sparkling eyes should start taking a new kind of medication. Laurel Rose, a Winnipeg Health Region clinician who has just completed a home assessment on Johnston, thinks a change in prescriptions might be in order.

"Mrs. Johnston, you remember when we talked about asking your doctor about a new medication?" Rose asks. "The medication might make you feel better."

Rose also suggests that Johnston might want to think about purchasing her medications in a bubble pack, which would lessen the chance of her mixing up her meds. "It would look like this," Rose says showing Johnston an example of the plastic packaging designed to better organize the storage of medications. "Remember, your doctor contacted us and asked us to see you. She wants to make sure you are taking your medications correctly."

After thinking about it for a bit, Johnston tells Rose she'll talk to her doctor about the change in medication. The unfamiliar bubble pack, however, is another issue. She explains to Rose that she has always kept track of her medication through a checklist on a kitchen counter, and doesn't think it is a good idea to change her practice at this time. "This is the way I have been doing it for many years. I think my system works well," she says.

Rose doesn't push the issue too hard. After all, the goal here is to make sure Johnston has a good system for taking her medications, not to force her into using one that she is uncomfortable with. But she does manage to secure a promise from Johnston that she will talk over the bubble pack idea with her pharmacist.

Discussions like this one happen every day in Winnipeg, and with good reason. Health experts say that many seniors are prone to mixing their medications or taking the wrong amounts, actions which could result in a trip to the emergency department. Taking action to ensure seniors track their medications properly not only protects the individual, it eliminates potential trips to the hospital.

That's one reason why the Winnipeg Health Region created the Geriatric Program Assessment Team (GPAT) program, but it is not the only one. Under the initiative, GPAT team members such as Rose do visit at-risk seniors to ensure they are taking their medication properly. But they're also there to assess the overall health and well-being of clients and to determine whether they require support from various programs and services, such as home care or Meals on Wheels.

The initiative is just one of several innovative programs the Region has developed in recent years to help seniors live safely and independently in their own homes for as long as possible. In doing so, the Region is working to achieve two goals: to help keep seniors healthy, and to control costs by reducing visits to the emergency department and delaying placement in a personal care home.

Under the program, the Region has established six GPATs, one for each of the city's main hospital emergency departments. Each team includes two or three clinicians - nurses, physiotherapists, or occupational therapists, or social workers and a geriatrician - and is responsible for covering a specific geographic area.

In any given year, the program receives about 2,500 referrals, mostly from doctors or family members who are concerned about a loved one, but also from people in the community who come into contact with at-risk seniors, including police officers, social workers, bank managers, relatives, friends and neighbours. Seniors who end up in the emergency department because of an injury or another health issue may also be referred to GPAT.

Marlene Graceffo, Rehabilitation and Geriatrics Regional Manager, oversees the GPAT program for the Region. She says the program is unique in Canada because it operates in hospitals as well as the community. "There's no other team like ours, to my knowledge," she says.

And the program does appear to be paying dividends. According to an internal audit completed in March 2008 by the Manitoba Centre for Health Policy, overuse of medication was lower in Winnipeg than any other part of the province, and "the Centre felt that may be because of our program," she says.

The GPAT program has caught the attention of others. It recently received a Leading Practice designation from Accreditation Canada, the organization responsible for reviewing health-care practices across the country. In order to receive the designation, the program had to be adaptable and innovative, as well as client- and family-centred. "It's a great honour," Graceffo says of the designation. "Saskatoon, Edmonton and Calgary have shown interest and requested information about our program to use in their communities."

In many ways, Johnston is a typical GPAT client. She was referred to the program by her doctor who wanted to be assured she was taking all of her medications properly. But in addition to addressing medication issues, Rose also checked Johnston's blood pressure, listened to her heart and assessed her memory. She also took time to make sure Johnston was able to get around safely by assessing her ability to walk around her home and use the stairs.

Rose says working with seniors is extremely rewarding. "I have been doing this job for nearly 10 years. I love it. It's the best job I have ever had," she says. "Here, my scope of practice is wider. I see people where it matters the most to them - at home. When they want to stay there, they are totally involved."

Each year, GPAT will visit about 2,000 seniors like Johnston. Some of the clients visited may need additional support, such as home-care services. Others may have trouble keeping track of their medication or meeting basic needs, such as keeping food in the house or eating regularly.

Many GPAT clients may not have seen a physician in a long time. "They may have trouble getting out and have missed appointments," explains Graceffo.

The program has an open referral process, which enables clinicians to connect older adults more promptly to the services and programs they need without having to see a physician first. "Of course, we encourage physician visits, but many seniors just need to be connected with the right resources to support them in remaining in their home," she says.

A complete assessment during a visit can take about 90 minutes. When that is complete, the GPAT clinician reviews client cases with a geriatrician who is part of the team, and recommendations are made to the family physician. Suggestions might include adding a bath seat or grab bars in the bathroom, reorganizing cords so they won't trip, having someone remind them about taking their medications, or a referral to home-care services for personal care and home management services.

"Maybe they should no longer be using the stove. Maybe they should now only use the microwave to prepare food and have their stove disabled, or have meals delivered by Meals on Wheels. Maybe they could move the bed to the main level so they don't have to use the stairs so much. We are looking at things like this always," Graceffo says.

Prior to the GPAT program, it was usually up to the primary care physician to refer a client to home care services for assistance with personal and household management or to day hospital programs that offer numerous health care professional interventions and therapies. But not everyone had a family doctor. "Many people were falling through the cracks," says Graceffo.

The GPAT program is always looking for ways to enhance the level of service it delivers. A recent program evaluation, for example, focused on the risk assessments done with clients experiencing cognitive impairment or memory loss. During their visits, GPAT clinicians will assess a client's cognition, considering whether the person is at risk of becoming lost or a driving risk. The clinician will determine if the client knows what to do in the event of an emergency or if nutrition, kitchen safety, medication, or financial management are concerns.

The client's support system also enters the picture when contemplating risk. In addition, environmental concerns that place the client at risk of falling are an integral portion of the home assessment.

Preparations are underway for the next evaluation which may focus on reducing the risk of falls for frail, elderly clients.

For an aging population with complex geriatric issues that are not met by other health care resources, GPAT can provide assistance in navigating the health care system and guide client's to living safely and independently for as long as possible.

Liz Katynski is a Winnipeg writer.

Wave: May / June 2011

About Wave

Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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