Wellness, Independence & Quality of Life in Aging

Who We Serve

Target population

The North Simcoe Muskoka Specialized Geriatric Services (NSM SGS) program supports frail seniors in the North Simcoe Muskoka region and their caregivers.

Who is a Frail Senior?

While most seniors live healthy and active lives, some become frail, facing complex health problems putting them at risk of losing their independence. This can increase the risk of Emergency Department visits, hospital admissions and/or being placed prematurely in a long-term care home.
These seniors can have multiple chronic medical conditions as well as geriatric syndromes like dementia, depression, falls, weakness and other issues. This complex presentation can complicate accurate assessment, diagnosis and treatment. Often there are social situations at play which impact the senior’s home situation or caregiver supports. This can further complicate care. A frail senior is sometimes like a house of cards …. pull one card out and things start falling apart!

Where is the North Simcoe Muskoka Region

The North Simcoe Muskoka region encompasses the District of Muskoka, most of the County of Simcoe and a portion of Grey County. The NSM LHIN is divided for planning purposes into 5 sub-regions: Barrie and Area, Couchiching, Muskoka, North Simcoe and South Georgian Bay.

Existing Services

Initial work of the NSM SGS program has been focused on the redesign of the North Simcoe Muskoka Behaviour Support System (BSS).  Over time, additional services and programs will be added.

North Simcoe Muskoka Behaviour Support System

Originally established in 2012 through the Behaviour Supports Ontario initiative, initial redesign of the NSM BSS team began in 2017.  Redesign is focused on moving from several different resources and teams to a single integrated team.

Target Population 

The NSM BSS team serves older adults with cognitive impairment and responsive behaviours in the NSM region and their caregivers.

Of note:
  • Cognitive impairment and the associated responsive behavior(s) can be due to mental health, addictions, dementia and/or other neurological or cognitive disorders.
  • Responsive behaviours are an individual's actions, gestures and/or words in response to a real or perceived stimulus. Examples can include: hitting, kicking, rummaging, resistance to care, wandering, exit seeking, sexually responsive behaviour, etc. For more information see the BSS team's standard definitions 
  • There is no specific age limit as the process of aging may occur in any of the following five dimensions: chronological, biological, psychological, social and developmental.

Team Members

The NSM BSS team supports seniors across the continuum of care, with the greatest resources being based on long-term care homes.Team members include:
 

  • BSS Manager
  • BSS Physician Lead (Geriatric Psychiatrist)
  • Psychogeriatric Resource Consultants
  • Psychometrist and Behaviour Support Specialists
  • Registered Nurses and Registered Practice Nurses
  • Social Workers
  • Occupational Therapy
  • Unregulated health care providers eg. Personal Support Workers.
  • If you or your loved one have questions about your care, speak with your family doctor.

Services Provided

The BSS team provides support in the assessment and management of responsive behaviours. During the assessment, the team attempts to identify the factors causing the behaviour(s) which can include underlying health conditions, factors in the environment and the approach of caregivers. Once the assessment is complete, the team works with the senior, their caregivers and health care providers to develop a plan of care to reduce or eliminate the behaviour, optimize safety, support the caregiver and improve health care outcomes.  The focus is on first trying to improve the behaviours through non-pharmacological approaches to care.  A variety of research and best practices are used by the BSS team in the care of the senior.  A key role of the BSS team also includes role-modelling and sharing information with caregivers and health care provider partners so that, together, we can improve care across the system

How to Access the Service

If you or your loved one have questions about your care, speak with your family doctor

Additional Information

North Simcoe Muskoka Behaviour Support System