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Community Innovation to Support Seniors in Crisis at Home

Presenters: Ashnoor Rahim, Woodgreen Community Services Debra Walko, LOFT Community Services

Presentation Overview

1. Articulating the Case for Change

2. Evolution of a Model for Seniors’ Crisis Support

3. Partnership and Governance

4. Measuring the Impact

5. Key Factors for Success

6. Conclusion “Every once in a while, a new

technology, an old problem, and a

big idea turn into an innovation.”

-Dean Kamen

The Case for Change

• Toronto Central Local Health Integration Network (TC LHIN) conducted a review

of seniors’ crisis services in 2015:

• Urgent need for community-based, integrated seniors’ crisis services

• Uneven service levels and “no coverage zones” across City of Toronto

• No standardized bundle of services for seniors who experience a crisis

• Long wait times to access services

Community Response

• WoodGreen, LOFT and Reconnect partnered to create the “Seniors Crisis Line” and

the supporting Seniors Crisis Services Initiative program model

• Model evolved into “Toronto Seniors Helpline” in 2017

• Guiding Principles:

• Shared governance model

• Shared objectives and deliverables

• Common service standards

Client Experience Before Toronto Senior’s Helpline

Multiple Access Points

• Crisis services

• Community support services

• TC LHIN Home and Community Care

Fragmented Care Teams

• No data sharing

• Lack of communication between

community-based providers and

TC LHIN Care Coordinators

Uneven Service Levels

• No standard bundle of services

• Eligibility by postal code

• “No coverage” zones

Inconsistent Service Quality

• Waitlist for access to crisis services

• No standardized tools or practices

• No shared accountability for quality of care

Evolution of Toronto Senior’s Helpline

2008 • Crisis Outreach Services for Seniors program (COSS) is initiated by three community providers

2013

• The Community Navigation and Access Program (CNAP) access point is integrated with TC LHIN Home and Community Care access point

2015 • Seniors Crisis Line (SCL) is launched in response to the increased need for seniors’ crisis services

2016 • SCL and CNAP access points merge, work begins on creating an integrated access hub

2016

• Creation of a single phone number staffed jointly by WoodGreen and TC LHIN to access services from CNAP, SCL and TC LHIN Information and Referral services

2017

• Formal launch of Toronto Seniors Helpline, offering information and referral services, short-term crisis intervention and follow-up case management

Client Experience After Toronto Senior’s Helpline

One Community

Number

Standardized

Assessment Tool Triage to Mobile

Crisis Team

“Warm Transfer” to

Community Services

Information and

Referral Phone-based

Support

Innovative Features of the Model

A generalist staff model with specialized skills sets

Live answer and “warm connections” seven days per week

Standard intake assessments and real-time information sharing within the circle of care

Access to multiple databases, including TC LHIN’s CHRIS database

Access to full continuum of community services, from prevention to crisis management

Shared accountability via service agreements and RM&R-supported referral network

Knowledge exchange and harmonization of protocols, standards and processes

Agreed-on performance monitoring indicators and continuous quality improvement approach

Seniors’ Crisis Services Initiative

Phone-based crisis intervention

Triage to mobile crisis teams

Access to short and medium-term

case management

Emergency overnight respite

Collaboration with Toronto Police

Service Community Officers

Funding Partners: Toronto Central LHIN

Central LHIN

Central East LHIN

Service Partners

Partnership Model

Cross-Sector Partners:

Primary Care Providers, CHCs,

Toronto Police Service, etc.

Shared Governance Model

Service Agreement:

• Shared services

• Roles and responsibilities

Terms of Reference:

• Vision and operational model

• System and policy alignment

• Planning and priorities

• Performance monitoring

and improvement

Steering Committee TC LHIN Home and Community Care,

CNAP, WoodGreen, LOFT, Reconnect

Operations

Committee

Operations

Management

Toronto Central LHIN

Design & Improve

Operational Protocols

• Intake process

• Standardized assessments

• “Warm transfers”

• Referral standards

• Connections to primary care

• Matrix reporting structure

• Core competencies

Measuring Activity Indicators 2015/16 2016/17

# Crisis Calls 2,732 4,733

Total calls (I&R, Access & Navigation, CSS Service

Requests, CCAC Linkages) 4,775 6,403

Short-term crisis services:

# of unique clients referred & assessed

1,430

1,746

# of unique clients served 1,318 1,313

# of mobile team visits 3,802 4,851

Follow-up case management services:

# of unique clients served

222

827

# of mobile team visits 1005 2693

Measuring System Impact - 2016/17

157 seniors were referred

directly from a hospital

Estimated that 1 in 4 referrals

prevented an ED visit In a survey, 50% of seniors said

they would have called 911

“I did not know service like this existed, thank you for your support, you saved my life, I really needed it”.

- Client

“Toronto Seniors Helpline has been a tremendous asset to me. The COSS team is consistently quick to respond, and, in less urgent situations, they are able to make referrals to the appropriate resources, supports and services that can help improve the lives of seniors living in Toronto.”

- Joanna Wright, Community Relations Officer, 54 Division, Toronto Police

“I was phoning a little while back and feeling suicidal. You kept me on the line, and now I’m getting the help I need. You saved my life!” - Client

“This is to say thank you very much for your service, through (staff). I think of myself as a lucky person to have had someone like her working with me, to bring my life and my surroundings back to normal.” - Client

Client and Provider Testimonials

• “Joan and Susan” (Client and Caregiver)

• “Ronald” (Client)

• “Jose” (Caregiver)

Client Stories

Key Factors for Success

Clear target population: Seniors (65+) in TC LHIN

Clear goals for population-level Impact:

1) Provide community-based crisis services

2) Create model for simplified access

Strengths-based team model:

WoodGreen: System leadership

LOFT: PSWs and respite beds

Reconnect: Decision support and IT

Provider accountability agreements

Regional framework for coverage

Collaborative governance

Framework for Aligned Contributions

High Action, Low Alignment

Leaders working actively and

independently to contribute to the

result, but not reaching out to build

relationships with others to achieve

complementary efforts.

High Action, High Alignment

Leaders with resilient relationships

acting on collaborative decisions

and being accountable for

measurably improving results

Low Action, Low Alignment

Leaders observing what is going on

and not engaging in either

relationship-building or taking action

that can contribute to results.

Low Action, High Alignment

Leaders joining with others and

fostering relationships, but not

using the relationships to leverage

contributions to the result.

Source: Raj Chawla and Jolie Bain Pillsbury

Conclusion

Potential for regional or national rollout of common crisis services for seniors.

Need for ongoing integration of community services in hospital-based service planning discussions.

Research opportunity for systems-level evaluation of the integrated seniors crisis service.

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Thank you!

Contact Us: Ashnoor Rahim: ARahim@woodgreen.org

Deb Walko: DWalko@loftcs.org