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Visions Journal

A reminder that this article from our magazine Visions was published more than 1 year ago. It is here for reference only. Some information in it may no longer be current. It also represents the point of the view of the author only. See the author box at the bottom of the article for more about the contributor.

Elderly Outreach Service

A Community Mental Health Program for Seniors

Giuseppe (Joe) Scaletta, MSW

Reprinted from "Seniors' Mental Health" issue of Visions Journal, 2002, No. 15, pp.37-38

The Elderly Outreach Service (EOS) is an interdisciplinary community mental health program for seniors that started as part of the Victoria Health Project in 1989. The Victoria Health Project started with a commitment by the government of British Columbia to dedicate $4 million in each of two years to develop services for the elderly in the region. EOS was one of 11 successful proposals out of the 113 submissions generated by the call for proposals.

The program serves the Greater Victoria area of BC including the southern gulf islands, Salt Spring, Galiano, North and South Pender, Mayne and Saturna — a region where about 19% of the population is over 65 years of age. The EOS provides comprehensive, coordinated, and prompt interdisciplinary assessment, consultation and short-term treatment to individuals aged 65 and older experiencing a late-onset mental health problem. In its fourteenth year, the program has responded to over 9,000 referrals of seniors experiencing mental health problems. EOS was the first program of its type in BC and was the model for similar programs in over 50 communities in the province.

Education to seniors — and to both formal and informal caregivers — is an integral part of the program mandate (see the article by Irene Barnes, above). Team members have presented hundreds of educational sessions over the years. With the Alzheimer’s Society, the program has initiated and co-sponsored six conferences on dementia care. The program has also acted as a training centre for professionals by hosting many student practicum placements from universities in BC and other provinces. In addition, EOS staff have presented our use of Goal Attainment Scaling (GAS) to many mental health programs in Edmonton, seven of which adopted the use of GAS following the presentation. Clinically, Goal Attainment Scaling is used to track outcomes in service provision and show that clinicians are meeting clinical goals set for/with clients.

Program team disciplines include:

Geriatric Psychiatry 0.9
General Practice Physician 1.8
Nursing 4
Social Work 2
Occupational Therapy 1
Psychology 1
Neuropsychology 1
Admin. Support 2.6
  14.3 FTEs*
*Full-time Equivalents

Community linkages are vital to the work of the program. Linkages have been proactively established with hospital-based programs, not-for-profit agencies such as the Alzheimer’s Society, long-term care services and any service that works with seniors. Some community initiatives include the establishment of a dementia-specific day centre, development of a video library on seniors’ mental health issues, the presentation of numerous educational sessions for formal and informal care providers, as well as the co-hosting of six conferences on dementia care. In a survey of referral agents, over 90% of respondents indicated that they were satisfied or very satisfied with the program.

Ongoing quality improvement is an important part of the program. All cases are presented at interdisciplinary clinical meetings to ensure that each client has the benefit of an interdisciplinary assessment. Other quality improvement measures include tracking service delivery to ensure equitable access to the service by each region.

EOS has an open referral process. About half of the referrals to the program come directly from family physicians. Another 25% to 30% come from long-term care and facility care staff. The program has two intake/clinical meetings a week at which new referrals are discussed and assigned, where clinicians do case presentations on clients recently accepted into the program. Each client has a clinical assessment by one of the team members. Depending on client need, more than one discipline may be involved in completing the team assessment. The results of the team assessment are then sent to the client’s family physician and long-term care facility if a person resides in one. Care plans and treatment goals are agreed on during clinical meetings using the Goal Attainment Scaling format. The team uses a case management approach, with each client having one case manager on the team who is primarily responsible for assessment and follow-up within the program.

2001 Referral Stats

Total referrals = 794

Age Range Female Male Total Percentage
Under 65 11 7 18 2%
65-74 70 39 109 14%
75-84 272 101 373 47%
85+ 208 86 294 37%
Total 561 249 794 100%


Cases closed during 2001 590
Total cases open during 1991 905
Average length of stay 137 days
Cases open @ Dec. 31, 2001 315

EOS was surveyed and accredited by the Canadian Council on Health Services Accreditation in November 1996 as a Ministry of Health Mental Health program, and in February 2000 as part of the Capital Health Region accreditation.

The trend for the program over the past several years is that it is seeing an older population and an increasing number of people with dementia.

Recent Developments

With the regionalization of health care that has taken place over the past several years, there were new opportunities for collaboration and development of services, and a review of psychogeriatric services in the region was undertaken. The result was the development of a geriatric psychiatry continuum of care, encompassing community outreach mental health services to seniors (EOS), an outreach substance abuse program for seniors (VISTA) and two inpatient services: a 25- bed geriatric psychiatry assessment and treatment unit and a 36-bed behaviour stabilization unit. Clients are able to move within this continuum as their care needs require and also have access to long-term care services in their home.

About the author
Joe is the Coordinator of the Elderly Outreach Service for the Vancouver Island Health Authority (South Island).

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