INTEGRATED SERVICES

The planning of services must always be linked to the needs, habits, particularities and expectations of our clients. To that effect, it appears that an organizational structure by program is an excellent choice. Such a structure :

At the moment, we have four (4) programs and we are trying to extend this model to the organization, when applicable :

MENTAL HEALTH PROGRAM

2. Philosophy

3. Guiding principles

4. Target clients

5. Coordinator’s role

6. Offered services

7. Services evaluation methods

We give you a brief description of the other three (3) programs :

ELDERLY AND HANDICAPPED ADULT PROGRAM

The psychosocial services, particularly for the elderly, are offered on an integrated basis. That is, whatever the place of residence: Residence, Family-Type Resource, Lodging Centre and Long Term Care Unit, the same social worker ensures the client's follow-up as well as the evaluation of his needs, even during his stay in hospital.

The client therefore does not have to repeat his case history and to familiarize himself with a different social worker when changing environments.

The integration of this service was done in different phases. Initially since 1997, the same social worker ensured the client's follow-up at home and at the hospital, since this year he continues the follow-up in a Family-Type Resources and in a Long Term Lodging Centre. The results are rather conclusive. The woven links between the client give a state of confidence in addition to accelerating certain procedures, for example, hospital discharges. Moreover, for the implicated social worker, the Long Term Care or Family-Type Resource admission procedures have been facilitated.

The integration of the Family-Type Resources and the Day Centre to the home care team (nursing care, social service, home care, etc.) has also brought conclusive results. It is easier to have an overall view, to foresee a more elaborate and rigorous service plan by having access, under the same direction, to these various services offered in any event to a common clientèle.

It also appeared that the inter-mission links were perceived as being reinforced inside the establishment itself. The workers are more sensitive to the client's condition and to the possibilities that are offered to him, in connection with the resources available in the establishment and those which revolve around, that is to say the community organizations: Golden Peak, Pontiac Respite Services and Volunteer Transportation. An overall picture is thus stimulated and encouraged.

REHABILITATION PROGRAM (ALL CLIENTÈLE)

In regards to rehabilitation, the Centre de santé du Pontiac also offers an integration of services but in another form. That is the team of professionals implied (occupational therapist, physiotherapist and respiratory therapist) ensure the intervention in their respective mission, while keeping a close contact with their peers.

Thus, the client goes from the hospital to his home with an automatic hospital rehabilitation referral to the home care rehabilitation services (also covering the FTR) and this way of functionning also applies from the hospital or the home towards the Long Term Lodging Centres.

Moreover, each worker can, in a specific way, ensure a coverage or a replacement in another mission of the establishment (holidays, staff shortage). This brings to the client reassurance in regards to the necessary services and to the worker a versatility out of the ordinary.

Therefore, one sees services revolving around a client and not the reverse. One maximizes quality, accessibility, and the continuity of the service and the speed of response. Of course the client is the big winner but the worker also gains there as much.

PERINATALITY PROGRAM

The obstetrics department at the Pontiac Community Hospital, as well as the perinatal department at the CLSC are two services that have been integrated in the Pontiac community, which co-ordinates various services such as pre, peri and post-natal care.

The integration of these services has enabled us to put into practice these areas of specialities through the CLSC and the Pontiac Community Hospital, which required a merger of all procedures, politics, teaching practices, as well as health care approach.

A common perspective is shared by these two services which is the continuance of services; therefore enabling the follow-ups to be adapted to the needs of the clientele. Referals can be done directly between caseworkers, which is more time efficient and personalized. The nurse from the CLSC can also meet their clientele at the hospital.

The obstetric department has been restructured in order for the CLSC nurse to assist the physician. This approach enabled us to strengthen the tie between physicians and patients.

Certain projects were realized in a common manner, such as: car infant safety inspection campaign, lending of infant car seats (infants weighing less than 20 lbs), an evaluation of the post-partum depression screening tool. Promoting nursing, as well as screening for mothers who are at risk.

With the preoccupation of improving our services we have created a perinatal committee, made up of nurses from the CLSC and Hospital, a physician and also a co-ordinator of the program. They will meet on a monthly basis in order to maintain the quality of services and seek for future development, improvement.