Halton Geriatric Mental Health Outreach Program

By: Hgmhop  09-12-2011
Keywords: Mental Health

Client & Families

Referrals are received directly by the clinical office via fax to: 905-681-8628, using the standard Referral Form. Submission of an incomplete referral form can delay the service delivery process. If there are any questions about who the program serves, what we do and/or how to access the program, please contact the program office directly for assistance by calling: 905-681- 8233 or 1-866-429-7677 (toll free).

  • Provide orientation and clarity regarding who we are, what we do and how we do it.
  • Determine program eligibility; clarify presenting problems; clarify referral and/or client expectations of GMHOP; determine clinical priority for GMHOP services based on telephone contact.
  • Where appropriate, to provide interim strategies or actions that may assist the referral source/caregivers/client to better understand and/or help with the presenting problem (i.e. clinical investigations, behavioural documentation, linkages to support services, follow up with family physician, crisis support options etc).

This initial point of contact follows a standard format and gathers screening information related to changes in the referred senior's: physical & mental health, functional issues, environmental issues, behavioural issues, presence of possible risk factors, family and caregiver situation, and current formal and informal supports and services. The information received by fax and over the phone will guide our service response - urgent, moderate, wait list. The case priority determines the time frame in which a case manager will see the client for an initial face-to-face assessment. Clients, designated others and/or referral sources are asked to contact the program if the situation changes or if there are any questions following the initial telephone screen.

We work in partnership with family physicians and others. Responsibility for delivering primary health care to the senior rests with the family physician or alternative primary care provider, community agencies and long-term care facilities. Our consulting physicians work in a shared care fashion and make recommendations to primary care physicians and others. Following the assessment and collaborative development of a plan, a clinical note is forwarded to the primary care provider and others as indicated, for consideration and implementation of the recommendations.

Outreach service and intervention may also include providing education on seniors mental health to caregivers, healthcare providers and family members. Seniors with mental health and addiction difficulties often benefit greatly when they, their family members, caregivers and/or healthcare providers are well-informed about mental health, and available services, treatments and supports.

We work collaboratively with our care partners in the assessment, treatment and intervention phases of service. It is our goal to broaden and/or strengthen the client's network of support, stabilize the presenting issue and hopefully enhance the quality of life for the senior and their family/caregivers.

It is our goal to stabilize the presenting issue, optimize available resources to enhance the quality of life for the senior and their family/caregivers. This may be done through a variety of approaches/interventions which may include investigations, health teaching, counseling, behavioural strategies, medications, education, and linkages to appropriate community supports. The average length of stay on the program is 8-9 months however this is very individualized.

Our program views 'discharge' as positive outcome as it reflects that through partnership, and systematic assessment and intervention, the presenting problem(s) have stabilized, resources have been optimized and the situation has been improved. Seniors, families and referral sources are reassured that if the situation changes in the future individuals can be re-referred to our program- we are just a phone call away.

Providers & System

To improve quality of care, we provide education and support to existing and future health care providers.

Education and Community Development
Through community development initiatives, in consultation and through partnerships, we strive to be a resource to front line and primary care health and social services, building community capacity to serve seniors with complex mental health and/or addiction problems.

PsychoGeriatric Resource Consultant
Complimentary to the case management staff are the services of the Psychogeriatric Resource Consultants (PRC). The Psychogeriatric Resource Consultant (PRC):

  • provides advice and support to staff caring for persons with dementia and cognitive/mental health needs;
  • develops an ongoing relationship with area long-term care home and community systems;
  • acts as a consultant, educator and network builder.

Keywords: Mental Health