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Mary Centre Model
Mission Statement Mary Centre delivers integrated supports and services and creates new opportunities for the benefit of the developmentally challenged, their families and the community in which they live Values Dignity – of whole person Integrity – treat people with respect Focus on Individual – coordination of services Responsibility – to individual, family, & community
Mary Centre 1988 - Founded by parents with older adults to ensure good quality care based on Catholic Values Focus on seniors with Developmental Challenges 25 years supporting individuals with Developmental Challenges 75% of individuals supported by Mary Centre are over 50 years of age Mary Centre offers a holistic approach to support by looking at the person in all aspects of life
Programs • • • Residential Group Homes all homes are wheelchair accessible Supported in Independent Living Community Support Integrated Seniors Program Transition and Long Term Care Program Alzheimer’s/ Dementia Day Program Parish Outreach Volunteer Adult Day Programs
THE PARTNERSHIP A representative from the Residential Services Committee approached the region re placement of some of their clients with complex medical care needs into long term care. There appeared to be a natural fit between LTC and the DS sector. To support people with intellectual disabilities to lead enriched and meaningful lives in LTC in partnership with their families and community
THE STEERING COMMITTEE Five Developmental Services Agencies The CCAC The Ministry of Health and Long Term Care The Ministry of Community and Social Services Representatives from the Region of Peel Struck a committee to further examine this partnership. The group meets monthly
THE PLAN The plan was to complete the successful transition of 10 individuals with Developmental Disabilities and complex health challenges from the community into Malton Village Long Term Care home A proposal was developed and forwarded to the MCSS provided funding for this project Much discussion took place regarding our philosophies of care/ differences and similarities A Coordinator was hired from the DS sector
APPLICATION & REVIEW PROCESS Applications are received from CCAC Applications are reviewed Project Coordinator meets with potential clients and their current service providers (case workers) Tours provided
Reason for Program Developing circles of support within the long term care setting Sharing skills sets and individual’s history with Health Care staff Creating positive changes to the individual’s lifestyle by helping to maintain life skills or offering the opportunity to develop new skills Working with staff to meet the social and emotional needs of the individual and ensuring that participation is not used to simply pass time
STAFF EDUCATION A series of in-services were provided to staff of LTC homes to: - Inform them of the Project (2005 – 2006) - Provide sensitivity training and awareness of Developmental Disabilities - Educate on Personal Outcome Measures (PC) Within the developmental sector, personal outcome measures have become the vehicle for the discussion of what people expect from services and supports they receive. These are compared to the Long Term Care Resident Bill of Rights.
ADMISSIONS 7 applications made Average was 56 (69, 56, 55, 52, and 50) 5 approved - major diagnosis Developmental Challenge and deteriorating health 4 residents admitted to regular health units, another located in a more secure unit Most of these clients had been supported by the DS sector for most of their lives
LIFE AT MALTON VILLAGE 5 individuals who moved into Malton Village LTC all reported to have adjusted well They developed new relationships with other residents and staff, said it “felt like home” They actively participated in centre wide activities and programs 1 Resident assists with mail delivery and running the Village Shop to meet her interests Some of these residents remain independent with visits to the local mall, bank or community groups
MCSS CWR Facilities Iniative 2006 MCSS identifies individuals who require long term care support Family tours Malton Village and agrees to placement Malton Village willing to accommodate Mary Centre agrees to provide the support Previously developed relationship with Malton Village is renewed.
One Residential Setting to Another Transition across sectors from one residential setting to another requires a coordinated approach to planning that is not limited to placement. Attitude change and relationship building are keys to enabling knowledge, action and progress.
HOME TO HOME TRANSITION PROCESS • Lived independently in community • Resides in own home, group home or apartment • Physical and Mental Health deteriorates • Transition and Long Term Care worker supports through transition to LTC (continuous and seamless) • Help LTC staff to support with information • Individual is supported to adjust to new setting
How we do what we do Mary Centre is committed to accomplishing this through: ◦ Collaboration between the Developmental Services, Health Care and Seniors Services; ◦ Creating new evidence-based approaches to planning and service delivery; ◦ Focusing on innovative and creative models of support.
Clarified Roles Long Term Care Home provides: Medical Care Personal Care Mary Centre provides: Ongoing support to enhance opportunities for integration and interaction with the other residents Ongoing family involvement in the lives of the individuals Ongoing community involvement and inclusion to enhance the life of the individual and maintain existing relationships.
Transition into Long Term Care
Transition and LTC Support Workers All support workers must obtain a Vulnerable Persons Police Check Support workers are trained in the following: ◦ Non-violent Crisis Prevention Intervention ◦ First Aid and CPR Other training sessions offered for Mary Centre staff include: ◦ Working with families ◦ Protecting the vulnerable ◦ Documentation ◦ Gentle Persuasive Approach ◦ Montessori-based programming
Role of the Support Worker • • • To support individual to participate in activities of interest within the facility To work with facility staff in meeting the social and emotional needs of the individual To help develop networks of support and friendship within the long term setting To maintain community and family connections To work as part of the team in LTC home.
Role of the Support Worker To ensure goal setting is a collaboration with client, family members, long term care and support agency To assist in implementing behaviour management protocols and modelling protocols to LTC staff To access community resources to better enhance the individual's quality of life
Personal Support Plan A Personal Support Plan (PSP) is developed annually for each individual addressing the 10 areas of life. The PSP outlines individualized goals; what has been achieved and what will be worked on over the year Staff complete a quarterly report to document the progress made in meeting their PSP goals Personal Support Plans are completed jointly with the team from Long Term Care homes, the individual and their family and presented at the Care Conference
Qualities of the Partnership • Collaboration to meet the needs of persons with Developmental Disability • Responsive supports • Continuity in supports between sectors • Shared resources • Shared knowledge and understanding between sectors • Provide an enhanced quality of life • Person focused service • Seamless support model
Community Supporters Ministry of Community and Social Service Community Living Mississauga Brampton Caledon Community Living Family Services of Peel Christian Horizons Peel Behavioural Services Malton Village Leisure World Care Centres
Community Partners Mary Centre has worked to develop meaningful partnerships with: ◦ Alzheimer’s Society ◦ Community Care Access Centres ◦ Behaviour Supports Ontario ◦ Behaviour Training Services ◦ Peel Services for Seniors ◦ Ontario Collation for Seniors ◦ Long Term Care homes in Peel
Community Referrals Community Living Agencies – Group Homes Family Members Community Care Access Centers Hospitals Long Term Care Homes Family Services
Overview of the Program We currently provide support to 29 individuals in 13 different LTC facilities in the region of Peel Eligibility: ◦ Residents of the region of Peel with a Developmental Disability ◦ Individuals who currently reside in Long Term Care (LTC) or are planning to move into a LTC home
Life in Long Term Care ü ü ü Support continued community involvement and participation Support the continuation of social skills development Modify programming to meet individual needs, skills, and interests Provide opportunities to develop new friendships Encourage ongoing communication between the individual, LTC staff, and the individual’s family
SOME UNANTICIPATED ISSUES Capacity and consent Behavioral challenges Finances and managing finances Lack of family support/involvement for some clients Individuals/Family refused LTC space Individuals transferred out of long term care and left at hospitals.
Working Partnerships Behaviour supports are a vital part of the ongoing success of the partnership Mary Centre has worked closely with the Behaviour Therapist for the DS sector to support individuals and provide in-service training for LTC staff We work closely with the Community Mental Health Dual Diagnosis services Using the appeal process to gain access to a LTC placement
Preliminary Best Practices Dispelling myths about persons with Developmental Challenge and LTC Providing information on the transition process Generating information for individuals, their families and support workers about LTC Ongoing liaison between sectors to enable both systems to build upon new learning. Learning from each other on how to identify and support the unique needs of the individual with a Developmental Challenge in LTC
BENEFITS • Seamless transition from community to LTC through planning and support from Transitional Support Worker prior to move • Staff in Long Term Care home’s have gained skills through the Transitional Support Worker • LTC staff are comfortable approaching the worker when they have a question • The Transition & LTC worker has become part of the team in the LTC home
BENEFITS • Having an on-going liaison between sectors to enable both systems to learn from each other • Developing a LTC referral protocol for individuals with developmental disabilities • Continuation of involvement from the community agencies for a transition period • Further enhancing the relationship with LTC and providing an opportunity for others to receive support
SUCCESSES Ø 3 Individuals inappropriately placed in long term care have now been integrated back to the community to appropriate residential placements Ø Connections with 12 other long term care homes in Peel have been developed Ø MCSS and other service providers support Mary Centre Long Term Care Initiative Ø We are currently recognized and consulted regarding placement and support for individuals with Developmental Challenges by the CCAC’s, Alzheimer’s Society, Long Term Care providers and Psychogeriatric Resource Consultants
TIPS For CONNECTING Determine who the most important contact is within the LTC home. (Director, Social Worker etc. ) Set up a meeting to discuss what you have to offer (your giving them something at no cost to them!) Use your connections with community partners or other LTC Homes as reference. Don’t get discouraged if you get “NO” check with other LTC homes in your area.
Developmental Services Ontario The DSO came into effect July 1, 2011 under the Ministry of Community and Social Services The DSO is now the central point of access Referrals still come from LTC homes but must then go through the DSO
Future Direction Identify inappropriately placed individuals for re-referral back to community (currently 8 individuals aged 18 - 35) Continue to work with community partners and DSO to facilitate a seamless transition of individuals into long term care. Secure ongoing funding from MOH<C and MCSS to ensure the program continues to grow and meet the needs of the ageing population in Peel