Success Story: Mental Health Service Delivery for Marginalized Elderly/Frail Populations

Dr. Jeanine Marshall knew that elderly and frail populations with substance use and/or mental health issues were sometimes falling between the gaps of adult mental health services and geriatric psychiatry. As a result, these patients were being seen disproportionately by the Emergency Room teams and in the inpatient setting, rather than having a community-based service. Seeing these patients in the community would not only help prevent the need for hospitalization, it would also facilitate patients’ discharge back into the community, drawing together a support network for their ongoing care.

Supported by a grant from the South Island MSA’s Facility Engagement funding, Dr. Marshall and her colleagues organized a series of meetings between Adult Mental Health, Geriatric Psychiatry, Consultation Liaison Psychiatry, and Seniors Outreach Team clinicians to discuss the current pathways for care for this population and brainstorm more innovative ways of service delivery.

These meetings helped start a conversation around challenges to the current model of care and how to improve the collaboration across disciplines. In Dr. Marshall’s words, “We are a tough crowd to gather together so bringing us into the same room to discuss our common patients was pretty great”. They determined that, before any changes to care pathways were made, they should have an accurate picture of the current situation. They established a series of data points and inclusion criteria that they will use to measure their patient population’s experience of care both prospectively and retrospectively.

They are currently drafting a Phase 2 application which will enable them to conduct this data collection and analysis. We wish them success in this next crucial phase of the project!


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