Seniors Health Clinic   at
Bridgeland Seniors Health Clinic
Connect Care Specialty: Geriatric Medicine
Connect Care Department: CGY CBSC SENIORS HEALTH CL
Estimated time to routine appointment: Within 3 months
Alberta Health Services - Calgary Zone
SERVICE DESCRIPTION
Offers assessment, diagnoses and development of treatment plans for older adults with complex health issues.This service provides a team based approach for multidisciplinary, consultative advice on the assessment,diagnosis and development of treatment management plans of adults age 65 or older with issues relating to medical complexity, frailty and chronic disease, functional decline, cognitive impairment, dementia or falls. Referrals for advice on dementia managment challenges, complex chronic disease managment, decline in functional status, delirium, disrptive behavior, fraility, frequency of falls; pre-op evaluation; reveiw of complex medicaition issues.
Offers assessment, diagnoses and development of treatment plans for older adults with complex health issues.This service provides a team based approach for multidisciplinary, consultative advice on the assessment,diagnosis and development of treatment management plans of adults age 65 or older with issues relating to medical complexity, frailty and chronic disease, functional decline, cognitive impairment, dementia or falls. Referrals for advice on dementia managment challenges, complex chronic disease managment, decline in functional status, delirium, disrptive behavior, fraility, frequency of falls; pre-op evaluation; reveiw of complex medicaition issues.
ROUTINE REFERRAL PROCESS
All referrals are managed through the Senior's Health One Line Referral Service. Please note that we no longer accept referrals directly from Home Care. All referrals must come through an MD, ideally the family physician.

Connect Care Users: Use the Ambulatory Referral Order to the respective specialty in Connect Care. 

Geriatric Medicine Pre-Operative Clinic Referral : Please see Eligibility Requirements

Physicians and clinical support staff - Ask a Geriatric Medicine specialist non-urgent questions through eReferral Advice Request. For more information, go online.

For all Cognitive assessment referrals we require the Family Physician to complete the clinical pathway outlined in the Cognitive Impairment Guideline by the AMA Toward Optimized Practice program.
All referrals are managed through the Senior's Health One Line Referral Service. Please note that we no longer accept referrals directly from Home Care. All referrals must come through an MD, ideally the family physician.

Connect Care Users: Use the Ambulatory Referral Order to the respective specialty in Connect Care. 

Geriatric Medicine Pre-Operative Clinic Referral : Please see Eligibility Requirements

Physicians and clinical support staff - Ask a Geriatric Medicine specialist non-urgent questions through eReferral Advice Request. For more information, go online.

For all Cognitive assessment referrals we require the Family Physician to complete the clinical pathway outlined in the Cognitive Impairment Guideline by the AMA Toward Optimized Practice program.
URGENT REFERRAL PROCESS
  • Recent or sub-acute decline in function
  • Multiple falls in a short period of time
  • Rapid decline in cognition
  • Recent or sub-acute decline in function
  • Multiple falls in a short period of time
  • Rapid decline in cognition
EMERGENCY REFERRAL PROCESS
The following reasons for referral are considered Emergent, send/go to emergency for same day assessment;
  • Acute confusion (delirium)
  • Disruptive behavior in the setting of dementia
  • New onset immobility
The following reasons for referral are considered Emergent, send/go to emergency for same day assessment;
  • Acute confusion (delirium)
  • Disruptive behavior in the setting of dementia
  • New onset immobility
ELIGIBILITY REQUIREMENTS
Inclusions criteria:
  • Age 65 or older with complex medical issues
FOR GERIATRIC MEDICINE PRE-OPERATIVE CLINIC 
  • Indicate if Surgery Date is known and Urgency
  • Elective high-risk surgery (postoperative inpatient stay anticipated)
  • Cognitive and/or Physical frailty present (defined as):
    • History of dementia or mild cognitive impairment (MCI) or previous delirium AND/OR
    • Suspected but undiagnosed memory impairment or cognitive impairment AND/OR
    • Receives home care or lives in assisted living/long term care facility or meets criteria for frailty based on a pre-operative scoring system.
  • Difficult decision making (concerns with capacity to consent or uncertainty about intervention)
Exclusions criteria:
  • Currently referred or being followed by another service for the same issue unless clear goals provided for geriatric assessment
  • Capacity assessment 
  • Medical-legal assessments
  • Primary reason for the consult is to help transition patient to facility living. (Send referral to Home Care 403-943-1930 or fax at 403-943-1602)
  • Patient is actively abusing substances (Send to: Community Geriatric Mental Health Services. Phone 403-955-6155 Fax 403-955-6169)
  • Third party assessments (Immigration assessments, WCB assessments, fitness to work, placement issues, co-signatures for PD & EPOA)
  • Cognitive assessment of clients < 65 (Send to : Neurosciences Cognitive Assessment Clinic. Phone: 403-944-4406 Fax: 403-944-8228)
  • Primary mental health issues (Send to: Community Geriatric Mental Health Services. Phone 403-955-6155 Fax 403-955-6169)
  • Moderate and severe BPSD  - Behavioral & Psychological Symptoms of Dementia. (Send to: Access Mental Health. Phone 403-943-1500)
  • The primary reason for referral is management of chronic pain
  • Requests to assume/provide primary care
  • Additional opinions on an issue without a clear indication as to why a geriatric assessment is specifically needed
  • Patients living outside the Calgary Zone who have access to Specialized Geriatric Services within their zone
Inclusions criteria:
  • Age 65 or older with complex medical issues
FOR GERIATRIC MEDICINE PRE-OPERATIVE CLINIC 
  • Indicate if Surgery Date is known and Urgency
  • Elective high-risk surgery (postoperative inpatient stay anticipated)
  • Cognitive and/or Physical frailty present (defined as):
    • History of dementia or mild cognitive impairment (MCI) or previous delirium AND/OR
    • Suspected but undiagnosed memory impairment or cognitive impairment AND/OR
    • Receives home care or lives in assisted living/long term care facility or meets criteria for frailty based on a pre-operative scoring system.
  • Difficult decision making (concerns with capacity to consent or uncertainty about intervention)
Exclusions criteria:
  • Currently referred or being followed by another service for the same issue unless clear goals provided for geriatric assessment
  • Capacity assessment 
  • Medical-legal assessments
  • Primary reason for the consult is to help transition patient to facility living. (Send referral to Home Care 403-943-1930 or fax at 403-943-1602)
  • Patient is actively abusing substances (Send to: Community Geriatric Mental Health Services. Phone 403-955-6155 Fax 403-955-6169)
  • Third party assessments (Immigration assessments, WCB assessments, fitness to work, placement issues, co-signatures for PD & EPOA)
  • Cognitive assessment of clients < 65 (Send to : Neurosciences Cognitive Assessment Clinic. Phone: 403-944-4406 Fax: 403-944-8228)
  • Primary mental health issues (Send to: Community Geriatric Mental Health Services. Phone 403-955-6155 Fax 403-955-6169)
  • Moderate and severe BPSD  - Behavioral & Psychological Symptoms of Dementia. (Send to: Access Mental Health. Phone 403-943-1500)
  • The primary reason for referral is management of chronic pain
  • Requests to assume/provide primary care
  • Additional opinions on an issue without a clear indication as to why a geriatric assessment is specifically needed
  • Patients living outside the Calgary Zone who have access to Specialized Geriatric Services within their zone
ADDITIONAL SERVICE DETAILS
All referrals are managed through the Senior's Health One Line Referral Service - 403-955-1514 (fax).

This service provides a team based approach for interdisciplinary/multidisciplinary, consultative advice on the diagnosis and management of frail adults age 65 or older with issues relating to medical complexity, chronic disease, medications, functional decline, cognitive impairment, dementia or falls.

Patient Instructions;

Please bring the following to your appointment:
  • Your Alberta Health Care Card
  • Put all medications you have in the house in a plastic bag, even the ones bought in a drug store (vitamins) and not prescribed by your doctor.
  • If you use a blisterpack/dosette, bring in the one you are currently using.
  • Eye Glasses (if you wear them)
  • Hearing-aid (if you own one)
  • Cane or walker (should you use one or both, bring along)
  • Alberta Health Services is a scent-free environment, please no perfume or cologne
The appointment will take approximately two (2) hours to allow for a comprehensive assessment and thorough physical examination to be done.  It would be helpful for our team to have input from a family member if one can accompany you to this appointment.
All referrals are managed through the Senior's Health One Line Referral Service - 403-955-1514 (fax).

This service provides a team based approach for interdisciplinary/multidisciplinary, consultative advice on the diagnosis and management of frail adults age 65 or older with issues relating to medical complexity, chronic disease, medications, functional decline, cognitive impairment, dementia or falls.

Patient Instructions;

Please bring the following to your appointment:
  • Your Alberta Health Care Card
  • Put all medications you have in the house in a plastic bag, even the ones bought in a drug store (vitamins) and not prescribed by your doctor.
  • If you use a blisterpack/dosette, bring in the one you are currently using.
  • Eye Glasses (if you wear them)
  • Hearing-aid (if you own one)
  • Cane or walker (should you use one or both, bring along)
  • Alberta Health Services is a scent-free environment, please no perfume or cologne
The appointment will take approximately two (2) hours to allow for a comprehensive assessment and thorough physical examination to be done.  It would be helpful for our team to have input from a family member if one can accompany you to this appointment.
COMMUNICATION PROCESS
  • Communication of referral receipt to referral source will occur within 7 calendar days.
  • Communication of appointment details or wait list status to patient and referral source will occur within 14 calendar days.
  • Communication of initial appointment outcomes to referral source will occur within 30 calendar days.
 
PHONE
403-955-1500
403-955-1525 (Seniors Health One Line Referral)
FAX
403-955-1514 (Referral Fax)
REFERRAL FAX
403-955-1514
REFERRAL FORM
Please identify any patients who, due to their dementia, might be prone to forget or cancel appointments? This will allow our schedulers to understand and accommodate their needs more effectively, without declining their referrals due to misunderstandings. Please indicate an alternate contact under "if patient is unable to book their own appointment" to facilitate booking. 

Senior's Health & Geriatric Medicine Referral Form
Please identify any patients who, due to their dementia, might be prone to forget or cancel appointments? This will allow our schedulers to understand and accommodate their needs more effectively, without declining their referrals due to misunderstandings. Please indicate an alternate contact under "if patient is unable to book their own appointment" to facilitate booking. 

Senior's Health & Geriatric Medicine Referral Form
REFERRAL RESOURCES
eReferral Advice Request
CLICK + TO VIEW REFERRAL GUIDELINES
+-
Routine Reason for Referral
Access Targets convey the clinically appropriate timeframe patients should be seen within, by reason for referral and priority level.
Access Target
Required Information/Investigations
Timing
Additional Details
+-
Advice on dementia management challenges
If presentation meets the diagnostic criteria for Alzheimer's Disease, and there are no complicating diagnostic or management issues associated, we will not accept the referral.Alzheimer's Disease:1) Typical Symptoms: Insidious onset and gradual progression of a dementia with prominent and early deficits of memory and learnings2) Cognitive Testing: Evidence of episodic memory loss (e.g. impaired delayed recall) plus at least one other cognitive domain3)Behavioural Symptoms: Apathy and depressive symptoms common early in the disease4)Neurological Examinations: Initially unremarkable
 
Current
For a rapidly progressive dementia, please describe the cognitive or functional decline noted on a day to day basis. Note Alzheimer's typically declines 1-2 points in the MMSE per year.
 
Current
Provide a clear description of the management challenges you would like addressed.
 
Current
Describe medical complexity impacting dementia and/or its management.
 
Current
Provide all initial work-up completed and what diagnostic uncertainty question you would like to have answered.
 
Current
CBCElectrolytes CalciumBlood GlucoseCreatinineAlbuminVitamin B12TSH
 
Within 12 months
Current medication list
 
Current
For further information for cognitive impairment see: https://actt.albertadoctors.org/CPGs/Lists/CPGDocumentList/Cognitive%20Impairment%20Summary.pdf
+-
Complex chronic disease management
More than 3 medical issues or difficulty managing complex/multiple chronic diseases
 
Within 12 months
Goals or clear reason for referral
 
Current
Current medication list
 
Within 6 months
Past relevant medical information and diagnostics
 
Within 6 months
Consults from other specialists pertinent to the referral if not on Netcare. If on Netcare, please indicate on referral.
 
Last 2-3 years
Cognitive testing results
 
Last 2-3 years
CBCElectrolytes CalciumBlood GlucoseCreatinineAlbuminVitamin B12TSH
 
Within 12 months
+-
Decline in functional status
Functional decline
 
past 3-6 months
Goals or clear reason for referral
 
Current
Past relevant medical information and diagnostics
 
Within 6 months
Current medication list
 
Within 6 months
Cognitive testing results
 
Last 2-3 years
Consults from other specialists pertinent to the referral if not on Netcare.If on Netcare, please indicate on referral.
 
Last 2-3 years
CBCElectrolytes CalciumBlood GlucoseCreatinineAlbuminVitamin B12TSH
 
Within 12 months
+-
Frailty
Please complete the Clinical Frailty Scale and if under 4, referral will not be accepted
 
Current
Goals or clear reason for referral
 
Current
Current medication list
 
Within 6 months
Past relevant medical information and diagnostics
 
Within 6 months
Consults from other specialists pertinent to the referral if not on Netcare. If on Netcare, please indicate on referral.
 
Last 2-3 years
Cognitive testing results
 
Last 2-3 years
CBCElectrolytes CalciumBlood GlucoseCreatinineAlbuminVitamin B12TSH
 
Within 12 months
Clinical Frailty Scale
Vulnerable (4) to Severely Frail (7) is the targeted population for frailty.
+-
Frequency of falls
If the issue is falls related to frailty please see frailty criteria above.
 
Current
Goals or clear reason for referral
 
Current
Current medication list
 
Within 6 months
Past relevant medical information and diagnostics
 
Within 6 months
Consults from other specialists pertinent to the referral if not on Netcare. If on Netcare, please indicate on referral.
 
Last 2-3 years
Cognitive testing results
 
Last 2-3 years
CBCElectrolytes CalciumBlood GlucoseCreatinineAlbuminVitamin B12TSH
 
Within 12 months
Please see Calgary Fall Prevention Clinic at Bridgeland Seniors Health Centre on Alberta Referral Directory for more information.
+-
Planned telephone contact
Goals or clear reason for referral
 
Current
Request for the referring physician to speak with a Geriatrician for specific advise or where it is unclear whether to refer a client to the clinic.  Please check the ‘Geriatrician to Referring Physician Telephone Consultation’ box on the Seniors Health Clinic Referral form and we will contact your office to book the phone call.
+-
Pre-op evaluation
Current medication list including over the counter medications
 
Current
Past relevant medical information and diagnostics
 
Within 6 months
Pre-op Geriatric Assessments
+-
Review of complex medication issues
Goals or clear reason for referral
 
Current
Current medication list including over the counter medications
 
Current
Past relevant medical information and diagnostics
 
Within 6 months
Consults from other specialists pertinent to the referral if not on Netcare. If on Netcare, please indicate on referral.
 
Last 2-3 years
Cognitive testing results
 
Last 2-3 years
CBCElectrolytes CalciumBlood GlucoseCreatinineAlbuminVitamin B12TSH
 
Within 12 months
+-
Emergent Reason for Referral
Additional Details
+-
Delirium
Active confusion (Delirium) is considered Emergent, patient should be sent/go to emergency for same day assessment.
+-
Disruptive behavior
Disruptive behavior in the setting of dementia is considered Emergent, patient should be sent/go to emergency for same day assessment.
PATIENT APPOINTMENT INFORMATION
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Print
 
MISSED APPOINTMENT GUIDELINES

If a Cancellation of appointment is required, our Clinic requires a MINIMUM of ONE WEEK's notice please.

If a patient cancels on short notice (less than 24 hours) or misses an appointment completely on 2 consecutive occasions, the referral will be closed and the referring physician notified that a re-referral is required.

If a Cancellation of appointment is required, our Clinic requires a MINIMUM of ONE WEEK's notice please.

If a patient cancels on short notice (less than 24 hours) or misses an appointment completely on 2 consecutive occasions, the referral will be closed and the referring physician notified that a re-referral is required.

 
HOURS OF OPERATION
Monday: 8:00 am - 4:00 pm
Tuesday: 8:00 am - 4:00 pm
Wednesday: 8:00 am - 4:00 pm
Thursday: 8:00 am - 4:00 pm
Friday: 8:00 am - 4:00 pm
   
 
ADDRESS
1070 McDougall Road NE
Calgary Alberta
T2E 7Z2
PATIENT APPOINTMENT INSTRUCTIONS
 
DIRECTIONS
Directions will be provided at time of appointment booking.
Directions will be provided at time of appointment booking.
 
PHONE
403-955-1500
403-955-1525 (Seniors Health One Line Referral)
 
PARKING INSTRUCTIONS
Instructions will be provided at time of appointment booking.
Instructions will be provided at time of appointment booking.
 
EMAIL
VIRTUAL APPOINTMENT INFORMATION
 
PARKING MAP
Instructions will be provided at time of appointment booking.
Instructions will be provided at time of appointment booking.
 
WHEELCHAIR ACCESSIBILITY
Yes

The primary purpose of the All Locations list is to let the user easily access any location of a healthcare service without going back to the main search screen.

The locations listed have 3 background colors:
  • Green means the healthcare service@location has referral information attached to it.
  • Brown means the healthcare service@location never had referral information attached to it, or it has unpublished referral information.
  • Red means
    • IA changed the healthcare service@location's status to something other than Current
    • It was deleted if it is an ARD healthcare service@location.
Green  and Brown are always at the top of the list. These are the Healthcare Service@Locations with the status of Current.
The Red list at the bottom consists of non-current Healthcare Service@locations that once had Published referral information in the ARD.
If the referral information was never published in ARD the Healthcare Service@location will not show in the Red list.

The secondary purpose of the All Locations list is to allow ARD Administrators to recover (copy) referral information from the non-current Healthcare Service@Locations to ones that are current.

Common Scenario:
A Healthcare Service moves from one location to another. In this case the IA Healthcare Service@Location record will be made defunct (non-current) and a new Healthcare Service@Location record will be created with a current status. In this scenario the captured referral guidelines in ARD can become "orphaned" as they are not attached to any current IA healthcare service.

Categories of non-current or orphaned referral guidelines: INDIVIDUAL and COMMON.
The REFERRAL GUIDELINES section of the profile has the prefix INDIVIDUAL or COMMON to help you choose the method below when transferring referral guidelines from a non-current Healthcare Service@Location to a current healthcare service@location.

Individual referral process
  1. Click on a non-current (Red) Healthcare Service@Location at the bottom of the All Locations list.
  2. The non-current referral info is displayed with the link Copy this Referral Process to another Healthcare Service@Location link on the upper right hand corner. Click on the copy link.
  3. Choose a current location (Green or Brown) from the All Locations list. This will be the Healthcare Service@Location you are pasting the referral info into.
  4. The system will display the Edit Referral Info screen populated with the referral info from the non-current Healthcare Service@Location you viewed in the first step.
  5. Click Save and the referral info is transferred from the non-current Healthcare Service@Location to the current one.
  6. Repeat these steps for each Healthcare Service@Location that needs attention.

Common referral process - 2 sub cases.
Case 1: At least 1 current Healthcare Service@Location with common referral info is with current status for this healthcare service; One or more Healthcare Healthcare Service@Locations where replaced by new one.
  1. Click on any current Healthcare Service@Location whether it has referral info (Green) or not (Brown).
  2. The healthcare service location opens in the Edit Referral Info screen populated with the current common referral info.
  3. Save it. 
  4. All locations will be updated with the common referral information, including all the locations that don't have referral info yet (Brown). The non-current referrals (Red) will also be updated.
Case 2:  All Healthcare Healthcare Service@Locations for a healthcare service are set to a non-current status and replaced by new ones. In this case there is no current additional referral info to copy from, so the only alternative is to pick up the non-current common referral process (Red). Follow the steps described in the section Individual Referral Process above to copy/paste the non-current common referral info to the current healthcare service locations.
Generally we want to replicate current common referral info to new or replaced healthcare service locations. We only resort to copying non-current common referral info if there is no other option.

Remember: Some fields can be location specific with the common referral process:
Parking Instructions, Directions, Parking Map, Wait Time, Referral Phone or Referral Fax.
To update these items you have to edit each Healthcare Service@Location separately.

ADDITONAL NOTES:
  • The info icon after the All Locations drop down will be visible to ARD Administrators.
  • The system doesn't allow you to copy referral information from one non-current Healthcare Service@Location to another.

 

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