Edmonton Home Living - Care of the Elderly

The team provides specialized geriatric consultation services for complex frail seniors in Home Living.

COE coverage is provided to Home Living clients as a limited and concentrated resource. The COEs are assigned specific to geographic location, with part-time on-site availability. This varies per Home Living network office. The COE is a consult service and does not assume the role of the most responsible health care provider (MRHP).

• Consultation on complex clients
• Attendance at home care team or client / family conferences
• Attendance at Home Care client case reviews
• Home visits to homebound Home Care clients who requires an assessment
• Home Care clinic visits for complex / geriatric assessments
• Provides support for post-acute discharged clients presenting with geriatric syndromes

Indications for COE Referral

• Multiple co-morbidities and presentation of geriatric syndromes (aging, dementia, depression, delirium, incontinence, vertigo, falls, failure to thrive, neglect and abuse, sleep disruption, polypharmacy)
• Exhibits unexplained decline in cognition (acute or gradual)
• Dementia requiring support for care planning and medical intervention
• Challenging and/or unmanaged responsive behaviors (gradual onset)
• Assessment to support determination of capacity
• Unexplained decline in function from baseline daily activities (gradual onset)
• Unmanaged safety concerns
• Medication optimization (cannot be only reason for referral)
• Significant caregiver stress, no caregiver (cannot be only reason for referral)
• Transitions of care and/or support with decisions related to relocation to higher level of care, acute care or rehabilitative care
• Chronic and / or neuropathic pain in the older adult