Improving Seniors’ Care in the Kalyna Country Primary Care Network

Project Lead

Brian Match, Executive Director, Kalyna Country PCN

Brian Match, Executive Director, Kalyna Country PCN.

In collaboration with St. Joseph’s General Hospital, Vegreville, Alberta Health Services (AHS) Vermillion Health Centre, AHS Viking Health Centre and Extendicare.

Rationale

The Kalyna County Primary Care Network (KCPCN) serves a large geriatric population with complex needs who require access to a variety of supports in order to maintain independence and wellness. The KCPCN wanted to know how effectively the current Geriatric Assessment Program (GAP) model was serving these seniors and whether it created the collaborations needed for professionals to share knowledge and coordinate appropriate referrals.

At the Kalyna Country Primary Care Network (PCN), a comprehensive evaluation of the Care of the Elderly Geriatric Assessment Program (GAP) model was needed to understand how these resource intensive assessments were impacting seniors and their health. Having inter-professionals working collaboratively at each site within Kalyna Country PCN was desired.

The goal was to create inter-professional teams to work directly with seniors in each community to provide health education, happiness basics classes, blood pressure and foot clinics.

Project Summary

Kalyna Country is located in east central Alberta, including Vegreville, Vermillion, Viking, Killam, and Tofield. First, a full report on the evaluation of the GAP program was completed. Secondly, Collaborative Teams were developed from within the PCN.

The evaluation assessed the reach and effectiveness of the current GAP model and the effectiveness of care plan interventions on patient functioning and patient health outcomes. It is also looking at identifying and addressing gaps in knowledge regarding geriatric conditions and care.

For each Collaborative Team, a project manager was hired to survey professionals providing senior services and to work closely with Community Development in each of the different communities in Kalyna Country. Working directly with seniors, where seniors meet is proving to be effective. Workshops were conducted throughout the funding on topics such as “understanding dementia”, and “compassion fatigue”.

Deliverables

  1. GAP Evaluation report
  2. An online seniors directory; a great local resource and template for other PCNs.
  3. Collaborative Team products: action plans, Successes and Challenges charts, Professional Education (eg. Understanding Dementia, and Compassion Fatique workshops)

impact and Ultimate Success

The collaborative teams developed in Vegreville and Viking have increased the efficiency and effectiveness of care for seniors. Service providers are familiar with each other and coordinate care more effectively.  This model could be spread beyond Kalyna Country, potentially throughout the province.

Access the Kalyna Country Directory of Seniors Services.   This resource has increased the number of referrals and use of existing programs and services with less duplication.

The Compassion Fatigue workshops were extremely successful in part because they were chosen and planned for with Health Professionals and seniors themselves. For small rural communities the attendance was high (Viking a population of 800 had over 150 people attend). Virtually everyone in a community is caring for someone.

The GAP analysis helped improve the Geriatric Assessment Program at the Kalyna Country PCN to better fit the needs of Family Practitioners and seniors.

For future vision, Kalyna is now looking at bringing teams in its’ various communities together to support each other and decrease the referrals for Geriatric Assessments. How can we become more of a community of support to seniors? A Community Coordinator has been hired by the PCN whose role will be to work with these teams to help us reach this goal.