St. Mary’s opens clinic specializing in complex geriatric patients

October 3rd, 2014

October 1st, 2014

Waterloo Region Record
By Johanna Weidner

KITCHENER — St. Mary’s General Hospital has launched an innovative clinic aimed at providing comprehensive care for frail elderly patients to keep them healthy and out of hospital.

The geriatric medically complex clinic has an interdisciplinary team of geriatricians, nurse practitioners, a clinic nurse specialist in geriatrics, pharmacist and social worker.

“We can look at the whole person,” said geriatrician Dr. Nicole Didyk, physician lead for the clinic, which opened in July. “It really allows us to give the best kind of care.”

That comprehensive approach is ideal for addressing the needs of medically complex geriatric patients, who have a host of chronic health conditions, cognitive decline or dementia, multiple medications, caregiver stress and other difficult symptoms or behaviours.

“Often, they’re so complex it really does take a team,” said nurse practitioner Hellen Jarman.

“Our goal is to optimize their health and well-being to keep them as autonomous and independent as long as possible.”

Patients are referred to the clinic from the emergency department at St. Mary’s or Grand River Hospital or through the region’s specialized geriatric services, with the goal of seeing urgent referrals within three days. Visits may even be done in the patient’s home for those elderly patients who have trouble getting to the clinic.

They also plan to partner with the local Community Care Access Centre, which co-ordinates home care. Followup calls are also common, with the ultimate goal at the clinic to keep the patients healthy at home and avoid emergency department visits and hospital admissions.

“We’re trying to address things before they become a crisis,” Jarman said.

Funding for the one-year test project came from the Ontario Medical Association and Ministry of Health.

Didyk hopes that if they’re able to demonstrate it works, it will get base funding to continue. Ideally, the team would like to see the clinic model spread across the province.

So far, the feedback is good.

“I think people really like the time, the attention and the approach, which is patient-centred,” Didyk said.

Joyce Field, 74, remembers one particular moment during her first visit that impressed her. The Kitchener woman met with several team members at once, and Didyk asked the pharmacist about the dosage of a particular medicine.

“That person became involved immediately and the answer was there,” said Field, who started going to Didyk because she was suffering repeated respiratory issues and complications from thoracic surgery.

“And they were there for the doctor as well, so if she wanted to make a change, she had the answer right away.”

Having the pharmacist review a patient’s medication is often needed, and the social worker can be called on to help with issues like caregiver stress.

“I think the care will only be enhanced by having this team approach,” Didyk said.

jweidner@therecord.com , Twitter: @WeidnerRecord

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