The UCDG is a hospital unit dedicated to the care of people aged 75 and over whose health is unstable and requires complex care. This unit focuses on the comprehensive assessment of frail patients and the implementation of interdisciplinary interventions to optimize their functional abilities. The interventions aim to understand the nature of the problems, assess their reversibility (life-threatening, functional, social), and provide the necessary care to improve patients’ health and independence, with the hope of returning them to their homes. These interventions are carried out in close collaboration with patients, their loved ones, and community services, including home support, family doctors, and pharmacists.

The Intensive Functional Rehabilitation Unit (IFRU) welcomes people aged 65 and over with a geriatric profile and pre-existing frailty who have experienced functional decline due to illness or injury. Our mission is to provide intensive rehabilitation care through two main programs: geriatric rehabilitation for physical health and post-stroke and neurological rehabilitation. These programs aim to improve the overall health of users, restore or maintain their functional abilities, and promote a safe return home.

The URFI has 45 beds spread over two floors: 25 beds for physical health rehabilitation and 20 beds for post-stroke and neurological rehabilitation. In addition to providing care, the URFI is a clinical research and teaching environment affiliated with the University of Montreal. We collaborate with externs, residents in family medicine and geriatrics, and interns from various health disciplines.

Our approach is based on interprofessional collaboration and respect for fundamental values such as respect for the individual, recognition of their abilities, autonomy, and active participation in decisions.

The post-acute-care program has 43 beds for seniors who must be evaluated and then oriented to a place to live adapted to their needs, and for those working on progress, moderate-intensity rehabilitation prior to returning home. The program allows users with a potential for functional recovery to return to optimal autonomy.

The Unit also offers services adapted to people who have had an acute-care episode in hospital and cannot immediately return home, although they receive in-home intensive-care services.

IUGM promotes an interdisciplinary approach, based on the services of various healthcare professionals.

The care team is at the centre of action and the IUGM mission. Its role is essential in several ways, such as evaluating clients’ needs, finding the best possible solutions for care and treatments and for end-of-life accompaniment.

In order to provide quality care to users, collaboration by everyone and interdisciplinary efforts are inseparable.

Users and their loved ones are also partners of the interdisciplinary team. The user’s experience, their needs and expertise regarding their health condition are recognized and combined with the knowledge and skills of the interdisciplinary team.

Customizing care for the person by allowing them to make choices — and respecting them — is primary. The patient-partner concept is an integral element of the IUGM approach, based on respect, involvement, compassion, preservation of human dignity and free will.

IUGM offers outpatient programs that provide a continuum of care and services for the elderly who are becoming less autonomous but whose condition does not require a hospital stay.

Unique in Quebec, the Geriatric Outpatient Centre allows the IUGM to make use of its second- and third-line expertise in geriatric care. These services are designed to support first-line healthcare workers. They are offered via medical referral. The priority is to maintain the elderly at home while carefully monitoring the evolution of their needs and requirements for services.

The outpatient centre includes a day hospital, and five specialized external clinics: for cognition, urinary continence, dysphagia, geriatric evaluation and chronic pain management.

Information

The IUGM Cognition Clinic offers interdisciplinary assessment and long-term therapeutic follow-up, as needed, to geriatric patients with neurocognitive disorders related to Alzheimer’s disease or other similar neurocognitive disorders. As part of a university affiliation, this clinic integrates care, research, and teaching activities.

• Information about the clinic

Services offered

• Diagnostic medical assessment and development of an appropriate treatment plan.
• Long-term specialized follow-up in conjunction with the primary health care network.
• Consultations available in speech therapy, occupational therapy, and psychology.
• Comprehensive geriatric psychiatric and neuropsychological assessments, complementary to services already provided.
• Assessment and support for family caregivers.

Target clientele

Anyone aged 65 and over with cognitive difficulties that may be related to a degenerative process (e.g., memory and language disorders) and who expresses a desire to be evaluated on a long-term basis in a specialized clinic.

Exclusion criteria

Patients whose cognitive disorders are related to one of the following causes are excluded:

• Congenital disorders;
• Intellectual disability and neurodevelopmental disorders;
• Active substance use disorder;
• Chronic unstable psychiatric disorders;
• Neurocognitive disorders secondary to multiple sclerosis, HIV, cerebral anoxia, tumor, or head trauma.

Form

• Consultation request – Cognition clinic
• It is strongly recommended that the form be accompanied by laboratory results, diagnostic tests, especially recent brain imaging, medical notes, or any other information relevant to understanding the issues experienced by the elderly person.

Information

The IUGM urinary continence clinic offers multidisciplinary assessment and therapeutic follow-up to geriatric patients with urinary control problems.

This clinic is part of the IUGM Outpatient Center, which includes a day hospital and specialized clinics for geriatric assessment, cognition, dysphagia, falls, urinary incontinence, and chronic pain management. As part of a university affiliation, this clinic integrates care, research, and teaching activities.

• Information about the clinic

Services offered

• Interdisciplinary clinical assessment of urinary incontinence and its impact on seniors and their loved ones. This assessment includes a nursing assessment and a specific medical examination.
• Additional diagnostic tests, as needed, such as laboratory tests and residual urine assessment (using ultrasound).
• Development of an appropriate treatment plan.
• Specialized long-term education and follow-up.
• Specialized pelvic floor rehabilitation services, as appropriate, by a physical therapist.
• Opportunity to participate in research projects specific to urinary control issues.

Target clientele

Anyone aged 65 and over who suffers from urinary incontinence and wishes to be assessed and monitored by a specialized multidisciplinary team.

Admission criteria

• Have a urinary control problem related to a bladder or pelvic floor disorder, or due to dementia, polypharmacy, or functional problems.

Form

• Consultation request – Urinary continence outpatient clinic

Information

The IUGM Dysphagia Clinic offers interdisciplinary assessment and therapeutic follow-up for geriatric patients with dysphagia.

This clinic is part of the IUGM Outpatient Center, which includes a day hospital and specialized clinics for geriatric assessment, cognition, dysphagia, falls, urinary continence, and chronic pain management. As part of a university affiliation, this clinic integrates care, research, and teaching activities.

• Information about the clinic

Services offered

• Interdisciplinary clinical assessment of dysphagia and its impact on seniors and their loved ones. This assessment may include: medical examination, nursing assessment, evaluation of respiratory function, nutritional status, and peripheral oral mechanism.
• Food trials and observation of the user’s swallowing during meals.
• Additional diagnostic tests, if necessary, such as laboratory tests, videofluoroscopy, endoscopy, etc.

Target clientele

Anyone aged 65 and over. Individuals must have a dysphagia problem and express a desire to be assessed by a specialized interdisciplinary team.

Form

• Consultation request – Outpatient clinic specializing in dysphagia

Information

The IUGM’s Falls and Geriatric Assessment Clinic offers specialized interdisciplinary second- and third-line assessments. This clinic is intended for geriatric patients who show signs of frailty due to several complex geriatric syndromes.

This clinic is part of the IUGM outpatient center, which includes a day hospital and specialized clinics for geriatric assessment, cognition, dysphagia, falls, urinary continence, and chronic pain management. As part of a university affiliation, this clinic integrates care, research, and teaching activities.

Information about the clinic

Services offered

• Geriatric assessment by various health professionals tailored to the user’s needs.
• Medical summary sent to the attending physician and other resources (e.g., medical specialists, CLSCs), if necessary.
• Follow-up and collaboration with the responsible resources to ensure continuity with home care services.
• Rehabilitation at the day hospital, if recommended by IUGM professionals.

Target clientele

Anyone aged 65 or older who is experiencing one or more of the following situations:

• Frequent falls
• One or more complex geriatric syndromes associated with comorbidity requiring the expertise of various specialized professionals
• Has shown signs of frailty for at least three months (e.g., weight loss or memory loss). The person is at high risk or is losing independence in activities of daily living;
• Has already received primary care and services (family doctor and CLSC), but their situation remains problematic;
• Their health condition allows them to come in for two or three days of outpatient care to complete assessments based on the targeted issues.
• They are referred by a treating physician who monitors their treatment and recommendations.

Form

• Consultation request – Falls and geriatric assessment clinic

Services offered

• Interdisciplinary assessment of chronic pain and its impacts.
• Development of an individualized intervention plan.
• Pharmaceutical treatment of pain.
• Referral to appropriate resources for injections, physical therapy, psychological approaches, or other interventions.

Target clientele

• Individuals aged 65 and over with chronic pain that persists despite evaluation and management by their primary care physician.

Form

• Consultation request – Chronic pain management clinic

Services offered

The day hospital is an alternative to hospitalization and allows seniors to access interdisciplinary services while remaining at home. The day hospital has a capacity of 15 people per day.

Clients attend the day hospital twice a week for a fixed period of one to three months, depending on the treatment objectives set by the interdisciplinary team. We provide adapted transportation.

Target clientele

This program is intended for clients who are losing their independence and require comprehensive, temporary care through coordinated interventions for the purposes of treatment, functional rehabilitation, guidance, support, and prevention.

How to access

Clients must be referred to the day hospital by a physician or health professional who attaches a medical prescription to the referral request. In addition, they must reside in one of the following areas: Côte-des-Neiges, Snowdon, Côte-Saint-Luc, Hampstead, Outremont, Town of Mount Royal, and Parc Extension.

For more information

• Day Hospital
  Institut universitaire de gériatrie de Montréal
  4565, chemin Queen-Mary, Montreal (Quebec) H3W 1W5 | Tel. : 514 340-3503 | Fax. : 514 340-2810

Our objectives are to:

• Maintain social skills and break isolation;
• Promote overall health, healthy lifestyles, and prevent the deterioration of biopsychosocial status and deconditioning;
• Maintain and improve functional independence and cognitive abilities;
• Prevent caregiver burnout by offering respite and support;
• Contribute to the choice of home care for the person receiving care and their caregiver.

The BPSD Team supports care teams that are increasingly facing behavioural and psychological symptoms of dementia. Such symptoms have significant impacts, not only on the resident, but also for family-care-givers and staff.

The team fulfills the functions of a third-line geronto-psychiatric specialist team for the Réseau universitaire intégré de santé et de services sociaux de l’Université de Montréal:

• supports local outpatient BPSD teams with highly complex cases;
• offers continuing education programs to local outpatient BPSD teams;
• helps regional agencies ensure professional service coverage to local and regional outpatient BPSD teams, including the implementation of telehealth;
• develops practice guides, intervention tools, and a website with a portal for clinicians;
• participates in the development of training programs;
• plays a leadership role in research development;
• participates in the evaluation of technologies and intervention modes in the BPSD sector.

The BPSD Team also offers specialized internships as well as training conferences and workshops on demand.

The BPSD (behavioural and psychological symptoms of dementia) team has offered teleconsultation and teletraining services since 2011. Services are provided to professionals caring for seniors suffering from dementia. For example, diagnostic help, support for the development of a personalized intervention plan, monitoring of the effectiveness of the proposed intervention plan, support in the evaluation of the need for a protection plan.

The advantage of telehealth is that it provides remote access to specialized geronto-psychiatric resources and specialized follow-up (case discussion, training). Results: Case workers improve their skills and feel less distressed when facing these problems.