General information
This page is for partners who are participating in or who wish to participate in the initiative to identify seniors age 75 and over who need help maintaining their independence.
Click here to consult the page for users.
Description
The Centre intégré de santé et de services sociaux (CISSS) de la Montérégie-Ouest, in collaboration with community organizations and various community partners, has set up a project to identify seniors age 75 and over who need help maintaining their independence.
Information for partners
This initiative would not have been possible without the invaluable cooperation of our community partners!
The identification of these senior citizens is a collective responsibility of the various public, private, and community partners who are directly concerned by the practice of identifying seniors with a loss of autonomy, namely the CISSS/CIUSSS and its local community services centres (CLSC), hospitals and outpatient clinics, family medicine groups (FMGs), medical clinics, social economy domestic aid enterprises (EÉSAD), private seniors’ residences, community organizations, community pharmacies, and several other partners. [1]
The CISSS de la Montérégie-Ouest promotes the “My Home, My Choice” case-finding program with support from several community partners. In fact, this initiative is made possible thanks to our various partners, who hand out the pamphlet/questionnaire to the target clientele during their activities, and who return the completed forms to the case-finding teams according to the terms agreed upon with the Soutien à l’autonomie des personnes âgées (SAPA) program [Support program for the autonomy of seniors].
Our partners include FMGs, community pharmacies, emergency departments, private seniors’ residences, EÉSADs, community organizations, police departments and fire stations, to name just a few.
It is important that our partners quickly send the completed forms to the case-finding teams so that the latter can identify the users to be contacted and assess the targeted individuals’ needs in terms of autonomy and well-being.
[1]reference to come
Our partners’ responsibilities
- Inform their staff about the “My Home, My Choice” case-finding program for seniors age 75 and over.
- Allow their staff to attend an information session on the promotional pamphlet containing the PRISMA-7 case-finding tool. [2]
- Distribute the case-finding pamphlet to people age 75 and over during activities.
- Quickly send the completed questionnaires to the case-finding teams according to the terms agreed upon with the SAPA program.
- Promote “My Home, My Choice” to their staff and during community activities.
[2]PRISMA-7 Questionnaire, Version 2012. Michel Raîche, Réjean Hébert and Marie-France Dubois, Centre d’expertise en santé de Sherbrooke.
Case-finding tool
The CISSS de la Montérégie-Ouest has designed a case-finding pamphlet containing the PRISMA-7 questionnaire, which our partners hand out to the target clientele. Once filled out, the questionnaire part of the pamphlet is returned to our case-finding teams so they can follow up with the clientele that meet certain criteria.
PRISMA-7 is recognized as a case-finding tool of choice by the Ministère de la Santé et des Services sociaux (MSSS). It includes 7 “yes” or “no” questions used to identify people at risk of moderate-to-severe loss of autonomy who are not known to the health and social services network. It helps to identify vulnerable individuals before their loss of autonomy becomes too advanced, so they can be referred for closer assessment to determine the care and services needed for their condition.
The PRISMA-7 questionnaire can be filled out by the person themselves, or by a caregiver, healthcare professional, or volunteer, if the person requires assistance.
Case-finding teams
There are two case-finding teams at the CISSS de la Montérégie-Ouest. One operates in the Haut-Saint-Laurent (HSL) and Jardins Roussillon (JR) (CLSC Châteauguay, CLSC Jardin-du-Québec, CLSC Kateri) sectors, and the other in the Salaberry-de-Valleyfield and Vaudreuil-Soulanges sectors.
Each team is made up of home care professionals who are supported by volunteers. The volunteers receive specific training related to seniors and on the various community resources available. The first contact is a telephone call with the seniors who meet certain criteria. The teams meet at least twice a month.
The teams contact all users who are not known to home care services and who are identified as positive by the PRISMA-7. Users who live in a long-term care facility (CHSLD) or an intermediate resource are not contacted because they are already part of the health and social services network.
During the phone call, the case-finding team asks detailed questions about certain risk factors. Users are informed of the services available in the community and referred to home care as needed; in some cases, a follow-up call is made six months later to make sure the user’s condition is still stable.
Specific data are tracked periodically across the organization in order to obtain an overview of the initiative and gauge its impact.
Become a partner
To become a partner in this case-finding initiative, email us at reperagecmcmc@ssss.gouv.qc.ca.
Reference documents for partners
- Pamphlet (pending)
- Vidéo (pending)
- Annual activity report (pending)
- PRISMA-7 questionnaire user guide (available in french only)