Team 290 fondazione dignis olanda


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Convegno 19.10.2011 a Biella

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Team 290 fondazione dignis olanda

  1. 1. Convegno Famiglia e Alzheimer 19 ottobre 2011, Biella Team290 Contents• What is team290• How does it work? Case Management by team290 1
  2. 2. Convegno Famiglia e Alzheimer 19 ottobre 2011, BiellaTasks and objectives Team290• Diagnostics – Early medical diagnosis (of dementia and related problems) – Care diagnostics (???? Wat is hier de intentie)• Guidance, treatment, and support by Case Management• Objectives: – Prevent overload of carers (family, spouse, children etc.) – Retain an optimal quality of life for both patient and carer Composition Team290• Team co-ordinator• Case managers – Nurse, specialised in community psychiatry (SPV) – Nurse + Social Worker• Physician – Geriatrician and/or psychiatrist• Psychologist• Team support and administration 2
  3. 3. Convegno Famiglia e Alzheimer 19 ottobre 2011, Biella Intake by team290• Registration by GP/specialist – Medical status – Blood tests, was the NHG-protocol applied? – Assign case manager and physician – Urgency indication – Home visit within 2 weeks• Or by – Nursing home, CIZ, home care organisation, MJD, family, friends etc. Intake Team290 (cont’d)• Intake by the case manager – Anamnesis/hetero anamnesis – Identify burden to carer – Physical condition and medication – Preliminary medical diagnosis – Identify required care (care diagnosis) – Way forward (medical examinations, treatment and support plan etc)• Intake by geriatrician – Medical anamnesis – Physical examination (to exclude physical causes) – Psycho geriatrical examination – Medication – File review – Likely medical diagnosis 3
  4. 4. Convegno Famiglia e Alzheimer 19 ottobre 2011, Biella Intake team290 (cont’d)• Neuropsychological assessment by psychologist• Assessment of cognitive abilities – Type and severity of the dementia – Advice to carer • How to manage behaviour • What is still possible? • Subsequent assessments • Adjustments to living environment needed? (day care, nursing home etc.) • * Neuropsychologisch onderzoek Intake Team290 (cont’d)• Diagnosis review (multidisciplinary team) – Agree on diagnosis – Classification according to DSM IV – Define treatment plan – Progress/evaluation meetings schedule• Feed back session – Diagnosis and treatment plan explained to patient/client and family/carer• Medical report – Written report to GP and/or specialist 4
  5. 5. Convegno Famiglia e Alzheimer 19 ottobre 2011, Biella Implementation team290• Case manager (tasks and responsibilities) – Implement treatment plan and control progress – Manage care requirements – Educate and advise carer – Active support and guidance – Mediation – Medication administration control – How to deal with behavioural changes – Crisis management Other Services team290• Outpatient clinic for medication – Physician – Psychologists• Discussion groups – Patient/client – Carers• Consultation – Nursery homes – Clinical lessons/Case studies (??) – Lectures to carers 5
  6. 6. Convegno Famiglia e Alzheimer 19 ottobre 2011, Biella Strengths Team290• Co-ordination – Hospitals, CIZ, nursing homes, day care• Broad competence and skills spectrum – Mental health care, nursing homes, home care• Integrated approach: diagnostics, treatment, guidance and support• Easy access• Widely appreciated and supported Thank you for your attention Any Questions? 6