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!