 Ottawa – When Cathy Maclure visits Georgette Connolly during a routine check-in, she finds her watching a soap opera. Pretty Boy, her blue budgie, makes it vocally clear he is present. With a smile, Georgette invites Cathy in to her small, tidy, one-bedroom apartment that is filled with warmth, from the hand-made curtains her daughter sewed and a framed picture of the East coast painted by her granddaughter, to the many photos of family, past and present, that surround her.
As a Case Manager for the Champlain Community Care Access Centre (CCAC), Cathy is checking on the state of Georgette’s health, which is not 100 percent. She has chronic back problems, diabetes, and balance issues – but she is able to live at home thanks in part to the Aging in Place Program (AIP), and that keeps her happy.
“I grew up just down the street from here,” says Georgette, who will be 91 in February. “And I walk with my walker to the hairdresser, just over there, under the bridge. Even in the winter. I am very thankful for this program. I can’t imagine being anywhere else but here. This is my home, where my heart is, where I want to be.”
AIP was created in 2007 in response to a growing need for an integrated mix of services for seniors living in select Ottawa Community Housing (OCH) Apartments. At that time, the top five OCH buildings with the highest Emergency Room (ER) and hospitalization rates were chosen for the program. The goal with the new program was to reduce ER visits and hospitalization of its elderly population and provide support to clients to live healthier lives, so they could remain safely in their homes for a longer period of time. The project has expanded to include 11 OCH buildings in Ottawa.
In each AIP-designated building, services include Outreach and Intervention, Health Promotion and Education, Nurse Practitioner Primary Care Outreach, Targeted Enhanced Services and Targeted Rapid Response. An AIP Community Support Outreach Coordinator and Champlain CCAC Case Manager have offices at the 11 buildings. They have become expert in prioritization and time management; not to mention in matters of the heart and kindness.
“You never know what the day will bring,” says Cathy, a Champlain CCAC Case Manager and registered nurse for three OCH buildings, including Georgette’s. “I plan my day, but sometimes I need to react to emergencies or walk-in requests. My current case-load is approximately 90 patients. I set Georgette up with occupational therapy services, which recommended help twice a week from a personal support worker, with bathing and cleaning. I also assigned her a physiotherapist to assist her in obtaining the proper walker for her mobility needs. Other patients may need more or less, depending on their mental and physical health.”
George Kong, the AIP Community Support Outreach Coordinator with Ottawa West Community Support for two of the same OCH buildings, works closely with Cathy to coordinate additional supports needed such as Meals on Wheels, home support services, transportation and foot care.
“It’s not just about medical services,” says George, who also translates documents into Mandarin and Cantonese for their Asian clients and always ensures that the freezer is stocked with healthy frozen foods for residents who may not be well enough to cook. “It’s also about getting them out of their isolation and encouraging stimulating outings and events. Our workshops provide information on anything from falls prevention to coping with stress and mental wellness. And events like bingo keep them socialized.”
Four years after its inception, AIP continues to work towards reducing the number of elderly patients in OCH building who use the ER. For example, ambulance transfers to ERs went from 757 in 2008-2009 to 640 in 2010-2011. Data also shows a slowing turnover rate in AIP buildings, which demonstrates that residents are truly “aging at home.”
“These results show AIP is effective,” says Gilles Lanteigne, CEO of the Champlain CCAC. “We are very pleased with the positive impact this program has had on the elderly patient population in these 11 buildings.”
An hour after Cathy checks on Georgette, she hurries to meet George in another client’s apartment. She quickly makes her way to the second building, which is linked via a tunnel. George is there already with the Champlain CCAC nurse practitioner, Dianne Beaudry, who is consulting with the family. George is translating Cantonese and Cathy joins a conversation about how to best provide basic services, such as help with bathing and cleaning the apartment, which are twice a day on a daily basis for this man. After 30 minutes in the apartment, the three leave and discuss the case knowing they have done the best they can.
Aging in Place (AIP) is a partnership between the Champlain Community Care Access Centre, Ottawa Housing Corporation and Ottawa West Community Services. The AIP buildings are located in Ottawa at: 160 Charlotte St., 1455 Clementine Blvd., 865 Gladstone Ave., 616 Kirkwood Ave., 31 McEwen Ave., 445 Richmond Rd., 280 Rochester St., 395 Somerset St., 800 St. Laurent Blvd., 540 Thomson St. and 1041 Wellington St.
The program is funded by the Ministry of Health and Long Term Care and the Champlain Local Health Integration Network and works in partnership with community organizations such as the United Way, Seniors Impact Council, City of Ottawa, the Glebe Centre, Centre de Services Guigue, Good Companions and The Kings Daughter’s Dinner Wagon Meals on Wheels.
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Services provided and organized by the Aging in Place Program
Medical Services:
- Needs Assessment of client’s health problems/concerns as referred by client, client’s family/friend, or health/community agency
- Crisis Intervention – financial crisis, hoarding, bed bugs, cockroaches, addictions, mental illness, aggressive behaviors, elder abuse, health crisis, end-of-life, and bereavement
- Assessment and application to Long-Term Care (Nursing Homes)
- Going Home Program (GHP) – assists residents returning from hospital by providing nursing care, personal care, home care, and Meals On Wheels (MOW) to help their recovery
Seminars / Workshops:
- Falls Prevention
- Beat the Heat
- Oral Hygiene, Smoking Cessation
- Healthy Cooking, Food Nutrition / Safety / Storage
- Coping with Stress, Mental Wellness
- Diabetes, Heart & Stroke, Osteoporosis, Alzheimer & Dementia
Health Services:
- Blood Pressure and Pulse Rate, Glucose Testing, and Health Support Clinic
- Annual Flu Shots
Health and Wellness Fairs:
- Health information and services from various health / social agencies and service providers
Client Walk-In Services:
- Need health or social services information and referrals – services in the community or provided by other community agencies
- Need a family doctor, medical specialist or medical clinic
- Need transportation to medical appointments
- Need translation of letters, calling for medical appointments, housing repairs
- Essential Help Social Support (E.H.S.S.) application for financial assistance for eye-glasses, dental work, hearing aid, assisted devices etc.
- Need someone to talk with regarding their concerns/issues
Enhanced / Value-Added Services:
- Nurse Practitioner visits and assessment
- Homemaking/Housekeeping
- Foot Care Services
- Meals distribution (Meals On Wheels) and Meals Fest
- Van outing to shopping, festivals & events, picnics, city tours, provincial parks
- Partnership with Ottawa Community Housing (OCH) to promote a safe, secure, and healthy environment
- Partnership with Tenant Association/Circle to promote healthy living and social & cultural activities
- Partnership with health/community agencies for any health resources/activities that are beneficial to the residents in the AIP Buildings
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