Cognitive Assessment, Treatment and Services Map – Ottawa Region
Primary Care Practice
Patient presents with, or at high risk for, cognitive impairment
Complete cognitive assessment or screening in the primary care setting, as appropriate
(Consider primary care initiatives focused on cognition)
Need further diagnostic assessment or treatment?
No
Consider
community
services1 for
patient & family
Yes
Consider what geriatric service is most appropriate for your patient
Regional Geriatric Program 2
Cognitive problems, possible MCI or dementia +/functional/safety/driving concerns + other
medical or geriatric issues and > 65 yrs old
• Geriatric Assessment & Outreach Teams
• Geriatric Day Hospital
• Geriatric Clinics
Bruyere Memory Clinic 2
•Mild and atypical cognitive symptoms
• Possible Mild Cognitive Impairment
(MCI) or early dementia
•No age restriction (usually >45 yrs old)
Geriatric Psychiatry 2
•Primarily psychiatric +/- behavioural issues and > 65 yrs old
•Alzheimer's Dementia or FTD with behavioural or psychological
symptoms and <65 yrs old (GPCSO only)
•Geriatric Psychiatry Community Services Ottawa (Living at
home or in Retirement Home)
• Royal Ottawa Mental Health Centre (Living in LTC Home)
1Community
2 Geriatric
Services: Contact information and details
Services : Contact information and details
October 2014
Specialized Geriatric Services – Ottawa
Regional Geriatric Program:
Geriatric Assessment Outreach Teams/Day Hospitals/Clinics
Memory Disorder Clinic
East Geriatric Assessment Outreach Team
* For Patients EAST of Bronson Ave & Ottawa River
West Geriatric Assessment Outreach Team
* For Patients WEST of Bronson Ave & Ottawa River
75 Bruyere Street, Room 261Y, Ottawa
***Physician referral needed***
Telephone: 613-562-6362
Fax: 613-562-6373
Telephone: 613-721-0041
Fax: 613-820-6659
The main focus is on diagnostic assessment of dementia (mild, moderate or severe) and
concomitant medical problems in patients over age 65. There is also an emphasis on
multidisciplinary assessment and management of associated issues such as functional
dependency, safety, driving concerns, caregiver stress, education needs, community
services, and future planning.
Geriatric Assessment Outreach Teams provide in-home comprehensive screening with
triage to geriatric day hospitals (3) for geriatric physician assessment and full
multidisciplinary team assessment or to outpatient clinics (3) for geriatric physician
assessment.
Telephone: 613-562-6322
Fax: 613-562-6013
The main focus of the clinic is the early diagnosis of dementia (mild to moderate) and
diagnosis of atypical forms of dementia.
Age cut off is 45 years though exceptions to this are made under certain circumstances.
Typically patients function at a reasonably independent level and do not have significant,
active psychiatric conditions. Exclusions include cognitive change secondary to recent head
injury or stroke, or neurological disorders that typically include cognitive change such as MS
or PD.
The team is made up of Neurology, Medicine, Neuropsychology, and Nursing.
Referral to is appropriate for patients requiring complete dementia work-up.
Patients with common geriatric problems not suffering from dementia are also assessed
and treated.
Royal Mental Health Centre
1145 Carling Ave, Ottawa
***Physician referral needed***
Geriatric Community Services of Ottawa
Telephone: 613-722-6521 x 6507
Fax: 613-798-2999
75 Bruyere Street, Room 127Y, Ottawa
***Physician referrals needed***
Telephone: 613-562-9777
Fax: 613-562-0259
This program offers services to meet the full range of mental health needs of persons 65
years of age and older. This includes patients suffering from dementia with concurrent
depression, psychosis or associated behavioural problems which are assessed and treated by
a bilingual, multidisciplinary team. Services offered are:
The main focus of GPCSO is to provide bilingual services to persons 65 years of age and
older with mental health problems including dementia and to persons less than 65 years of
age who have been diagnosed with Alzheimer or fronto-temporal dementia, complicated by
behavioural or psychological symptoms.
The Outpatient Clinic: it is an inter-professional consultation providing psychiatric
expertise to primary care physicians.
Case managers will work with the person and family/caregiver in their homes providing
assessment, counselling, and behavioural management. There is also emphasis on
management of associated issues such as functional dependency, safety, caregiver stress,
driving, education needs, community services, and future planning. In addition, capacity
assessments for personal care/property are available for a fee.
The Outreach Service: provides consultative and educational services to most long-term
care homes. A psychiatrist and nurse work collaboratively to support staff, residents and
families in the long-term care home.
The : provides inter-professional care for persons who require urgent and intensive
treatment, but can safely live in the community.
Geriatric Psychiatry Inpatient Service: provides 43 specialized beds for treatment of
complex psychiatric illnesses that require inpatient care. ( and Specialized Inpatient Service
are available as determined by the initial Outpatient or Outreach Consultation)
Geriatric psychiatry consults are available upon request to treat concomitant depression,
behavioural problems, or other psychiatric problems. This may include doing a home visit, if
appropriate.
Community Services - Ottawa
Community Support Services
(CSS)
REFERRAL INFORMATION
• Available to seniors who are 65+, as well
as caregivers
• OHIP is not mandatory
• Services are provided by agencies located
throughout the City of Ottawa
• Will assist clients to be healthy and
independent in the comfort of their own
home
• Referrals accepted from the client, family
members, friends or other members of the
community
Champlain Community Care
Access Centre (CCAC)
REFERRAL INFORMATION
• No age limit/requirement
• Require OHIP card and client consent
• Intake assessment is by telephone
• Provide as much info as possible on
referral regarding urgency of client needs,
best methods to contact client, or what
approach works with this client
• Important to note on referral if another
professional can assist to set up the first
meeting if client is difficult to reach by
phone or if they are likely to refuse
services over the phone
• In some cases, not able to do intake
assessment over phone, and CCAC may
determine that a home assessment by a
community Care Coordinator would be
appropriate
• Referrals from client, caregiver, physician,
other health care provider
613-688-1768
www.ocsc.ca
SERVICE DESCRIPTION
• Core services are available to clients
including but not limited to Meals on
Wheels, Transportation, Adult Day
Program, Support to Caregivers and
Respite/Personal Support Services
• Agencies may/will initiate a telephone
assessment followed up by a home visit,
depending on the needs of the client
• Referrals to order community resources are
often part of the service delivery in other to
ensure that clients’ needs are met.
613-745-5525
healthcareathome.ca/champlain
SERVICE DESCRIPTION
• Comprehensive in-home assessment
• Use of standardized, validated tool to
assist with assessment (RAI-HC)
• Coordination of care plan which can
involve CCAC Services such as personal
support services, nurse, occupational
therapist, physiotherapist, social worker,
nutritionist, speech language therapist,
Rapid Response Nurse
• Referral to other services such as Adult
Day Programs, Assisted Living Services
for High Risk Seniors, application to Long
Term Care Homes as well as referrals to
other community partners
• Assist with linkage to a Primary Care
Practitioners (GP, NP)
First Link- Alzheimer Society of
Ottawa and Renfrew County
REFERRAL INFORMATION
• Direct referrals from physicians and
other health care professionals using the
online referral form , phone or fax
• Self referrals from patients, family or
friends
Primary Care Outreach (PCO)
REFERRAL INFORMATION
Seniors:
• Over 65 with priority to seniors over 75
who are isolated, living on a low income
and have inadequate caregiver support
• At risk of cognitive and functional
decline, who are presenting to emergency
more frequently than the average senior
• Have had more than 2 falls in the last 3
months
• Have limited support and need
accompaniment
to
specialist
appointments; may have difficulty in
keeping appointments and have missed
important medical appointments
• Need support in navigating the health
care system to access services and may
need a primary care provider
• Referrals from client, family members or
friends and health care providers
613-523-4004
www.alzheimer-ottawa-rc.org
SERVICE DESCRIPTION
• First Link services include access to a
progressive learning series, ongoing one
on one support, and access to support
groups.
• The learning series includes: Next Steps
for Families, Care Essentials, Options for
Care, and Care in the Later Stages. Each
course builds upon the other to provide a
comprehensive overview of dementia,
coping strategies, planning for future care,
resources and support systems.
1-844-PCO-5115
www.seochc.on.ca
SERVICE DESCRIPTION
• Clients will receive home visits from a
Registered Nurse (RN) and/or a
Community Health Worker (CHW)
• Services include response to immediate
needs, monitoring and support for care
plans, individual health information,
advice and education, screening for
environmental/safety
risks
and
mobilization
• RNs provide for early intervention,
assessment, monitoring and support for
implementation of care plans established
by the primary care provider
• The CHWs coordinate and link people
with supports and services in the
community
See Champlain Healthline Primary Care Geriatric Desktop for a list community services organized by need (ie: Driving testing centres, Respite, Adult Day Programs etc.)