title: Improving the seniors' transition from hospital to the community: a case for intensive geriatric service workers.
abstract: Limited continuity of care, poor communication between healthcare providers, and ineffective self-management are barriers to recovery as seniors transition back to the community following an Emergency Department (ED) visit or hospitalization. The intensive geriatric service worker (IGSW) role is a new service developed in southern Ontario, Canada to address gaps for seniors transitioning home from acute care to prevent rehospitalization and premature institutionalization through the provision of intensive support and follow-up to ensure adherence to care plans, facilitate communication with care providers, and promote self-management. This study describes the IGSW role and provides preliminary evidence of its impact on clients, caregivers and the broader health system.
  
  
  
  This mixed methods evaluation included a chart audit of all clients served, tracking of the achievement of goals for IGSW involvement, and interviews with clients and caregivers and other key informants.
  
  
  
  During the study period, 632 clients were served. Rates of goal achievement ranged from 25%-87% and in cases where achieved, the extent of IGSW involvement mostly exceeded recommendations. IGSWs were credited with improving adherence with treatment recommendations, increasing awareness and use of community services, and improving self-management, which potentially reduced ED visits and hospitalizations and delayed institutionalization.
  
  
  
  The IGSW role has the potential to improve supports for seniors and facilitate more appropriate use of health system resources, and represents a promising mechanism for improving the integration and coordination of care across health sectors.
authors.affiliation: Department of Psychiatry & Behavioural Neurosciences,McMaster University,Hamilton,Ontario,Canada.
authors.forename: Carrie A
authors.initials: CA
authors.lastname: McAiney
authors.affiliation: Specialized Geriatric Services,St. Joseph's Health Care London,London,Ontario,Canada.
authors.forename: Loretta M
authors.initials: LM
authors.lastname: Hillier
authors.affiliation: Canadian Mental Health Association Waterloo Wellington Dufferin Branch,147 Delhi Street,Guelph,Ontario,Canada.
authors.forename: Janice
authors.initials: J
authors.lastname: Paul
authors.affiliation: Canadian Mental Health Association Waterloo Wellington Dufferin Branch,147 Delhi Street,Guelph,Ontario,Canada.
authors.forename: Jane
authors.initials: J
authors.lastname: McKinnon Wilson
authors.affiliation: Canadian Mental Health Association Waterloo Wellington Dufferin Branch,147 Delhi Street,Guelph,Ontario,Canada.
authors.forename: Anna
authors.initials: A
authors.lastname: Tersigni Phelan
authors.affiliation: Canadian Mental Health Association Waterloo Wellington Dufferin Branch,67 King Street East,Kitchener,Ontario,Canada.
authors.forename: Fred
authors.initials: F
authors.lastname: Wagner
authors.affiliation: Canadian Mental Health Association Waterloo Wellington Dufferin Branch,147 Delhi Street,Guelph,Ontario,Canada.
authors.forename: Sheli
authors.initials: S
authors.lastname: O'Connor
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003142:Communication; D003153:Community Health Services / Q000592:standards*; D005260:Female; D005853:Geriatrics; D006760:Hospitalization; D006801:Humans; D007326:Institutionalization; D007407:Interviews as Topic; D008297:Male; D009864:Ontario; D010349:Patient Compliance; D024382:Professional Role; D000069341:Transitional Care / Q000592:standards*; D000078329:Workforce
keywords: adherence; community care; seniors; transitional care