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Friendly to SeniorsDecember 3, 2012
New Models of Care
• Health Sciences North and North East Community Care Access Centre developing and introducing new models of care for seniors
• These new models of care focus on Care Transitions – which means helping patients transition across the continuum of care
• Goal is to transcend “silos” created by different institutions, care providers, models of practice, etc.
• In keeping with provincial health policy direction
Ontario’s Action Plan For Health Care
LHIN System Imperatives
North East LHIN Priorities
By 2016, the North East LHIN will:
Recognize language and culture and enhance access to care
Improve access to high quality primary care for residents of North East Ontario
Improve navigation
North East LHIN IHSP Summary, 2013 – 2016
Enhance Care Coordination and
Transitions to Improve the Patient Experience
Increase Primary Care Coordination
Make Mental Health and Substance Abuse
Treatment Services More Accessible
Target the Needs of Special Population
Groups – Aboriginal and Francophone
Priorities are enabled by…Electronic Health Record Opportunities Realignment and System Transformation Recruitment and Retention of Health Human Resources
Enhance mental health & substance abuse services
Improve access and quality through greater service coordination
Expand system realignment initiatives in each hospital HUB to improve access and assist in improved navigation for consumers and families
Review and improve client transitions between service providers along the continuum of care
Increase the integration of primary care within the broader continuum of care
Build community treatment capacity to provide alternate options for consumers and families and decrease pressure on hospital sector
Enhance targeted service capacity where required
Continue to engage and collaborate with primary care providers in the North East
Work with health sectors, ministries and governments to develop integrated approaches to support individuals with complex issues not easily supported by any one sector
Keeping Ontario Healthy Faster Access and a Stronger Link to Family Health Care
Right Care, Right Time, Right Place
Enhance Access to Primary Care Enhance Coordination & Transitions of Care for Targeted Populations
Implement Evidence Based Practice to Drive Quality and Safety
Holding the Gains
Expand access to transportation for Aboriginal population
HSN/North East CCAC Friendly to Seniors Initiatives
– Rapid Response Nurses– Telehomecare– Complex Diabetes Clinic – COPD Clinic– Geriatric Day Hospital– Geriatric Emergency (GEM)– ED Outreach– Nurse Practitioner – Palliative– Nurse Practitioner – Complex
Geriatric– CCAC Complex Care Coordinators
(dementia, geriatric & end-of-life care)
– ACE– HELP– ED CCAC Care Coordinator– Geriatric Recruitment– Chair in Geriatric Research– Patient Advisory Council– Community Engagement– Mobility Clinics– Medication Reconciliation– Primary Care Partnership– Health Care Connect– thehealthline.ca
Care Transitions - Continuum of Care
New models in development:
• Care Transitions/Virtual Ward• Integrated Discharge Planning• Re-Launch of Home First philosophy• PACE (Program of All-inclusive Care for the Elderly)• Autumnwood partnership (25 bed unit)
Initiatives are being evaluated/carefully measured
Functional Assessment Outcome Unit
• FAO Unit at Sudbury Outpatient Centre will close January 2013. Peer Review Report recommended closure in September 2013
• Decision to proceed with closure:– Not optimum care model for seniors– Need to implement sustainable solutions vs. “band-aid” solutions– High cost model of care – stand-alone unit does not allow for cost
efficiencies– Funding will be re-directed towards new senior-friendly initiatives
aimed at keeping seniors living independently in their home– Patients not placed will be moved to Ramsey Lake Health Centre– Of note: FAO patient not the same patient population targeted for
Autumnwood
Role for the Community
No combination of publicly funded services provide 1:1, round the clock ‐ ‐care/supervision at home on an ongoing basis. For clients requiring this level of care/supervision who wish to stay in their own homes, a mix of services funded in a number of different ways is needed.
•North East CCAC•Community Support Services•For-Profit Agencies•Client/Family/Caregiver support and resources
Community Venues of Care
• Personal Home / Apartment• Retirement Home• Complex Continuing Care
- medical complex- short-stay rehab and convalescent care
• Long-Term Care Home- short-stay, respite & convalescent care- long-stay placement
• Hospice
Thank you!