St. Joseph’s Health Centre Guelph (SJHCG) is the lead organization for specialized geriatric services and Behavioural Supports Ontario (BSO) in the Waterloo Wellington region, and has been formally recognized with a SAGE award for its delivery of outstanding care to older adults.

Regional Geriatric Outreach Services operate through SJHCG and include the Nurse Led Outreach Team (NLOT), BSO, and Geriatric Clinical Intake and Specialized Geriatric Services (SGS). These programs aim to support the elderly in reaching their optimal health and quality of life. They also consider the role of caregivers and provide education and support for those caring for an older person managing complex health conditions.

Nurse Led Outreach Team (NLOT)

The NLOT provides support to all Long Term Care Homes (LTCHs) within the Waterloo Wellington Local Health Integration Network (WWLHIN) to ensure timely access to high quality care and to decrease the number of avoidable resident transfers to hospital emergency departments.

The team consists of 3 full time registered nurses and 1 full-time nurse practitioner. Through education, group and individual coaching, policy and procedure development, quality initiatives, and direct clinical support, the NLOT works with staff, physicians, and residents in LTCHs to increase capacity and improve processes.

The goals of the NLOT program are to:

  • reduce transfers to the emergency department and hospital admissions for conditions that can be treated in the LTCH, and
  • reduce the hospital length of stay for residents who can be safely transferred back to the LTCH with the appropriate supports.

NLOT support is available 8:30 am – 4:30 pm, Monday to Friday.

Contact

NLOT can be contacted directly by LTCHs or through WWLHIN Home & Community Care Coordinators.

Behavioural Supports Ontario (BSO)

The BSO initiative was created to enhance services and supports in managing responsive or expressive behaviours that are often associated with dementia, mental health, and/or addiction. These behaviours may include verbal or physical aggression, agitation, or wandering.

In Waterloo Wellington, the Community Responsive Behaviour Team (CRBT) at SJHCG, funded through the BSO initiative, includes 3 social workers, 2 recreation therapists, 2 occupational therapists, and 1 BSO addictions registered nurse.

As part of their role, CRBT clinicians:

  • share assessment and develop care plan information with an individual’s broader care team (i.e. Home Care, physicians, specialized geriatric services),
  • assist with service coordination,
  • advocate in the community,
  • provide support during transitions (i.e. moving to long term care, introducing personal support worker services), and
  • provide support to caregivers (i.e. education about behaviours, why a behaviour may be occurring, related symptoms, new ways to manage behaviours, reducing risks associated with behaviours, etc.)

To Make a Referral

In the Waterloo Wellington Local Health Integrated Network (WWLHIN), the CRBT is an integrated extension of specialized geriatric services and works closely with the primary care practitioner or geriatric specialist. It is preferred that a thorough geriatric assessment is completed and pharmacotherapy reviewed/optimized, prior to CRBT involvement.

Referrals can be made by healthcare professionals by faxing the Specialized Geriatric Services Referral Form to the Geriatric Services Clinical Intake Service at 1-888-205-1491.

Specialized Geriatric Services Clinical Intake

Timely access to community-based specialized geriatric assessments is important for seniors managing complex health conditions. To improve access to care, SJHCG, the Waterloo Wellington Local Health Integration Network (WWLHIN), the Canadian Mental Health Association Waterloo Wellington (CMHAWW), and the Home and Community Care division of the WWLHIN have collaborated to create a centralized geriatric clinical intake service for the region.

Funded by BSO, the clinical intake team includes a registered nurse, occupational therapist, social worker and clinical intake coordinator who manage and triage client referrals for geriatric medicine, geriatric psychiatry, SGS mental health outreach, intensive geriatric service workers and memory clinics.

By streamlining client information and making it more easily available to geriatricians, this centralized service works as part of a coordinated care system to:

  • improve communication between health care providers,
  • improve the care experience for clients and their families/caregivers,
  • increase clients’ access to care,
  • support client transitions from hospital to community, and
  • ensure more timely care for clients.

To Make a Referral

Referrals can be made by healthcare professionals by faxing the Specialized Geriatric Services Referral Form to the Geriatric Services Clinical Intake Service at 1-888-205-1491.