Dementia Pathway Group Visit

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Dementia Pathway Group Visit
A Shared Journey
Vicky Bach, RN, BScN, MSN Clinical Nurse
Specialist, Acute Geriatrics Abbotsford/Mission
Hospitals vicky.bach_at_fraserhealth.ca
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Seniors Clinic, Abbotsford

• Client centered multidisciplinary approach
• Older adults living in community
• independently or in assisted living
• Geriatric assessments at clinic or home visit

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Services provided include

• Geriatric medicine
• Dementia Care Pathway
• Group sessions/education
• Geriatric assessment

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Some numbers

• As of January 2009 452 active patients
• 145 men / 307 women
• Average age range 51 100
• Average age 81
• Referral sources include
• Home Health
• Family MD
• Self
• ER

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Shared Medical Appointments/ Group Visits
Journal of the American Geriatric Society,
2006, 54, 1937-1942 Cleveland Journal of
Medicine, 2004, 71(5), 369 - 377
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Benefits and successes of SMA/Group Visits

• Instill hope
• Add universality
• Share information / dispel anxiety
• Support

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Seniors Clinic Dementia Group Visit

• Structure initiated by physicians/coordinator
• Group visits fit with Chronic Disease Model
• Patients drawn from physician patient group
• 1st and 3rd Thursday/month
• Usually 2 patients / 2 caregivers

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Visit Structure

• 1.5 hours
• Overview of the visit
• MMSE screening (in private) Health Check
• Caregiver screening
• Group Visit checklist in group
• IADL review
• ADL review
• Safety checklist

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• Changes/concerns including behaviour,
• mood, sleep, appetite, pain,
• falls, ED visits
• Health Improvement Plan
• Appointment for next visit
• Evaluation
• Invitation for Alzheimers Society
• group meeting
• 4th Tuesday/month
• 1.5 hours

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Findings

• Not just the score
• This is real
• Sharing frustrations
• Optimum size
• Caregiver time alone