Shining the spotlight on the PHC IGSI Education Series

Geriatric nurse Wendy Evans has become a valuable resource for the town of Innisfail, Alberta, since she started working at the Wolf Creek Primary Care Network in September 2017. (The Wolf Creek PCN spans the communities of Innisfail, Sylvan Lake, Lacombe, Ponoka and Rimbey.)

Evans conducts comprehensive geriatric screening in the Innisfail medical clinics to diagnose frailty, both physical and cognitive. Her work means people with dementia, and their care partners, can increase their chances of getting the treatment and services they need before a crisis situation arises. It’s a much-needed service in the town south of Red Deer, where 21.5 per cent of the population is over the age of 65, compared to 12.3 per cent provincially.

“People are very good when it comes to supporting people who have physical needs, but when it comes to those with cognitive needs, it’s a very different challenge that is tough for individuals and their families,” Evans says.

Improved screening and geriatric assessments at the Innisfail medical clinic reflect efforts to improve care for those living in the community with cognitive impairment or a diagnosis of dementia. Action planning around the work being done in Innisfail is also part of a collaboration with the Primary Health Care Integrated Geriatric Services Initiative, or PHC IGSI (a long acronym pronounced fig-see by those involved), which aims to provide ongoing support to those living with dementia and other geriatric syndromes in Alberta’s Central Zone. The work out of Innisfail is just one of many exciting projects in several Central Zone communities that have partnered with PHC IGSI.

Funded by an Alberta Health grant, PHC IGSI began in 2015 as a demonstration project. It is a partnership between the Primary Care Networks (PCNs) of Wolf Creek, Big Country, Provost, Red Deer and Wainwright, and Alberta Health Services’ Seniors Health Strategic Clinical Network, the Primary Health Care Integration Network, and the Alzheimer Society of Alberta and Northwest Territories to better support those living with dementia or other geriatric syndromes.

“There are many stories of people ending up in emergency, or maybe earlier placement than required, because they need community supports and those supports are lacking,” says Charlene Knudsen, a St. Albert-based AHS practice lead for the Seniors Health Strategic Clinical Network who co-leads PHC IGSI with her colleague, Sharon Hamlin, from Provincial Primary Health Care. “We hope to show that this program is supporting people well in their community.”

A large component of the PHC IGSI has been education around the complex topic of dementia care. In 2015, an AHS Seniors Health Strategic Clinical Network survey found that, “38 per cent of family physicians responding … felt that they did not have the necessary training or skills in the area of recognizing and providing care to people living with dementia.”

To address this gap in training and knowledge, the PHC IGSI team has hosted three day-long dementia-care workshops for participating PCNs and their community partners. The workshops were designed to “mirror the journey of the person living with dementia,” says Knudsen. There were between around 90 and 120 primary health-care workers at each workshop, including doctors, nurses, social workers, pharmacists, members of the Alzheimer Society of Alberta and Northwest Territories, home-care case workers, and Family and Community Support Services employees.

During the first workshop, held in Red Deer in June 2017, participants looked at timely recognition of dementia, diagnostic tools and how to put early supports in place. Laurie Grande, regional lead for client services at the Alzheimer Society of Alberta and Northwest Territories, presented at the event. Her talk centred on how important it is to connect people living with dementia with both the services in their community, such as those offered by the Alzheimer Society, as well as more traditional supports offered through the health-care system.

“Historically, community supports have worked independently of the health-care system,” says Grande. “When you’re looking at a more integrated approach, I think you’re more likely to have impactful outcomes if [support] is more coordinated and people are able to access information in the early stages. Being proactive is very important.”

During the second workshop, held in Red Deer in December 2017, participants looked at managing in more difficult times as dementia progresses. This day’s learnings were based on the Geriatric 5Ms model of dementia care, in which care providers create a plan based on: Mind (cognition and mood), Mobility, Medications, Multi-complexity (including other factors such as financial needs and other chronic health conditions), and Matters Most (such as a person’s desire to remain in their own home or remain independent as long as possible).

The final workshop, held in Lacombe in May 2018, looked at late-life support for dementia and frailty, including palliative care and pain management. “It was a great day learning about what other communities are doing to support their clients and families living with dementia in end stages,” says Lori Watts, a registered nurse with the Red Deer PNC who attended the workshop in Lacombe. “We can all learn from each other, having those difficult conversations about end-of-life care and how we need to de-professionalize dying.”

In addition to developing and offering these workshops, Knudsen and her team are also supporting the community teams who are participating in PHC IGSI to achieve their locally defined goals.

“It’s not a top-down approach,” Knudsen says. “We’re not coming in and saying, ‘This is what you have to do.’ And that’s working out really well.”

The Wolf Creek PCN geriatric-screening program in Innisfail, which started last September, is one of the grassroots PHC IGSI projects. Another PHC IGSI-supported project is the new Elder Care Assessment Clinic based out of the Red Deer PCN. In Drumheller, the PCN has developed a partnership with the community mental health nurse to refer people with cognitive changes for further assessment. Results of a community needs assessment of Kneehill County communities (Three Hills, Trochu, Acme, Carbon, Linden, Torrinton, Huxley, Swalwell and Wimborne) identified a need for support for care partners of those living with dementia. This led to the Alzheimer Society of Alberta and Northwest Territories establishing a support group in the village of Linden.

Laurie Grande of the Alzheimer Society sees rural projects, like the one in Linden, as particularly invaluable. “I think it’s critically important to build capacity there,” she says. “Many people who live in those rural areas are not able to come into the city centres to access the support and education they need. Collaboration and integration is essential in order to provide more comprehensive services in all communities. In addition to the medical support in managing dementia, community supports can make a significant impact in helping people to live well in the community.”

While the initial phase of the Central Zone PHC IGSI pilot project will wrap up with a final evaluation report on the project due in December 2018, Knudsen would like to see the initiative expanded across the province in order to improve the journey for people in the community living with dementia and their families.

“The more we can provide knowledge and education, and the more people who are actively involved in trying to make changes, the bigger difference we’ll make.” [ ]

You can access the resources offered at the educational workshops online at albertahealthservices.ca/scns/Page13526.aspx.