Helping More Seniors in the Central East LHIN Get Care They Need at Home Ontario Improving Access to Home and Community Care

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1 Helping More Seniors in the Central East LHIN Get Care They Need at Home Ontario Improving Access to Home and Care NEWS November 25, 2013 Seniors and residents across the Central East LHIN are receiving better access to home care and community supports to help them live independently and at home longer. In the Central East LHIN, Ontario is providing nearly $28 million for new investments so that more seniors and other people with complex conditions can receive expanded community health care services, including mental health supports. In Scarborough, Durham Region, Northumberland County, Peterborough City and County, City of Kawartha Lakes and Haliburton County, these investments build on and enhance existing programs that reduce unnecessary emergency room and hospital readmissions, including: Increasing the number of clients who receive services from the Central East Care Access Centres; Creating six new Geriatric Assessment and Intervention Network (GAIN) Teams where atrisk seniors will be supported at home by multi professional care teams and their primary care physicians; Providing more assisted living services for high-risk seniors, especially from the Chinese and South Asian communities in Scarborough and also for high-risk seniors in Havelock and the surrounding geographic area including Norwood, Lindsay, Campbellford and Cobourg; Increasing the number of frail, elderly clients in existing adult day programs, including a new program for francophone seniors in Oshawa and for seniors at Curve Lake First Nation; Implementing a mental health and addictions strategy and increasing the number of specialized teams supporting mental health clients receiving care in their homes.

2 Improving access to home care and community supports is a key priority of Ontario s Action Plan for Health Care and helps to provide the right care, at the right time, in the right place. This is part of the Ontario government's economic plan to invest in people, invest in infrastructure and support a dynamic and innovative business climate. QUOTES We are investing our health care dollars in services that help residents get the care they need at the right time, in the right place. This means better access to quality and timely care for patients, and especially our seniors. Soo Wong, MPP, Scarborough-Agincourt Investing in programs in our rural communities ensures that seniors are able to receive care close to home. These types of rural health hubs provide access to an integrated basket of services for clients and their caregivers. Jeff Leal, MPP, Peterborough By working together, investments are being made in community-based programs that best meet the needs of our local residents, including people requiring mental health support. This means that seniors, their caregivers, their family and friends can receive services that will keep people in their own homes for as long as possible. Joe Dickson, MPP, Ajax Pickering Providing seniors with more timely access to health care in their homes and communities ensures our health care system works better for everyone, improving access for all who need care, where they need it. Deb Matthews, Minister of Health and Long-Term Care These investments support the many valuable programs in the Central East LHIN that are part of an integrated system of care. We know, from listening to patients and service providers that these programs and services will provide the care that our seniors need to help them live independently in their communities and in their homes. Deborah Hammons, CEO, Central East LHIN

3 QUICK FACTS More than 637,000 people currently receive home care across Ontario. Over the next 20 years, the population of seniors aged 65 and over in Ontario will more than double from 1.9 million today to 4.2 million in LEARN MORE Ontario s Action Plan for Health Care. Ontario s Action Plan for Seniors Dr. Samir Sinha s report Living Longer, Living Well. For more information: Katie Cronin-Wood Communications Lead Central East LHIN ext. 218

4 BACKGROUNDER Ontario is providing an additional $27,827,000 to support the delivery of home care and community services for seniors and better support people with mental health and addiction issues in Scarborough, the Region of Durham, Northumberland County, Peterborough City and County, City of Kawartha Lakes and Haliburton County. These investments are a key part of the province s Action Plan for Health Care, which is providing patients with the right care, at the right time, in the right place. With an overarching aim of First - to enable Central East LHIN residents to spend more time in their homes and their communities - the Central East LHIN is making new investments in high-impact community programs to better support people with complex and long-term medical, physical, social and/or cognitive conditions so that they can maintain their health and avoid being admitted to hospital, or having to move to a long-term care home. Creating these local integrated Systems of Care will provide the additional support required to help more seniors to live independently at home and will reduce home care wait times, as well as increase access to community supports including mental health services. Project Service Provider Project Description 2013/2014 Funding Scarborough Cluster - Syste m of Care - $3,473,142 GAIN (Geriatric Assessment and Intervention Network) Team Carefirst Seniors and Services Association Paired with the hospital GAIN clinics at TSH General and RVHS Centenary, an inter-professional GAIN Team will support patients at home, in the community. Using gerontological best practices, standardized assessments and protocols, $620,000

5 Project Service Provider Project Description 2013/2014 Funding GAIN Team GAIN Enhancement Behavioural Supports Ontario (BSO) St. Paul s L Amoreaux Centre The Scarborough Hospital individualized integrated care plans will be created for high risk seniors who will then be supported by Health Career Case Managers, in partnership with their primary care provider, to navigate the system including access to community programs. Paired with the hospital GAIN clinics at TSH General and RVHS Centenary, an inter-professional GAIN Team will support patients at home, in the community. Using gerontological best practices, standardized assessments and protocols, individualized integrated care plans will be created for high risk seniors who will then be supported by Health Career Case Managers, in partnership with their primary care provider, to navigate the system including access to community programs. BSO staff, with special training in responding to patients with complex and challenging mental health, dementia or other neurological conditions, will work with the GAIN Clinics and GAIN Teams to support care in the community. $620,000 $85,000

6 Project Service Provider Project Description 2013/2014 Funding GAIN Enhancement Behavioural Supports Ontario (BSO) Assisted Living Services for High Risk Seniors (ALS-HRS) Assisted Living Services for High Risk Seniors (ALS-HRS) Rouge Valley Health System Carefirst Seniors and Services Association Yee Hong Centre for Geriatric Care BSO staff, with special training in responding to patients with complex and challenging mental health, dementia or other neurological conditions, will work with the GAIN Clinics and GAIN Teams to support care in the community. Building on previous investments in 2011/12 and 2012/13, Carefirst will support another 45 people a year to maintain their independence and remain in their homes for as long as possible. This will include creating a new ALS-HRS hub in Scarborough that will facilitate access to other health and community supports for new immigrants, low income, high risk non-english speaking Chinese or South Asian seniors. Building on previous investments in 2011/12 and 2012/13, Yee Hong will support another 35 people to maintain their independence and remain in their homes for as long as possible. This will include creating an ALS-HRS program for high risk Chinese seniors with Yee Hong s Scarborough Finch Centre serving as the hub. $85,000 $436,678 $486,830

7 Project Service Provider Project Description 2013/2014 Funding Adult Day Programs (ADP) Adult Day Programs (ADP) Adult Day Programs (ADP) Assertive Treatment Team (ACCT) - Stepped Model of Care Carefirst Seniors and Services Association St. Paul L Amoreaux Centre Yee Hong Centre for Geriatric Care The Scarborough Hospital Recognizing how ADPs support care in the community, this new funding is targeted to frail elderly clients who have complex and long-term medical, physical, social and/or cognitive conditions. With the goal of supporting another 25 clients a year, Carefirst will launch a new ADP aligned with their new ALS-HRS location. Recognizing how ADPs support care in the community, this new funding is targeted to frail elderly clients who have complex and long-term medical, physical, social and/or cognitive conditions and will allow St. Paul L Amoreaux to offer an additional day of service with extended hours for 20 clients a year. Recognizing how ADPs support care in the community, this new funding is targeted to frail elderly clients who have complex and long-term medical, physical, social and/or cognitive conditions and will allow Yee Hong to open a new ADP at their Scarborough Finch Centre for 20 clients a year. More people with serious mental illnesses will receive intensive treatment and psychosocial rehabilitation services in their homes or community settings. Care is provided by a team of mental health $340,668 $71,578 $329,975 $111,563

8 Project Service Provider Project Description 2013/2014 Funding and addictions professionals including nurses, physicians and addictions, vocational and peer support specialists. Assertive Treatment Team (ACCT) - Stepped Model of Care Mental Health and Addictions Housing CMHA Toronto St. Paul L Amoreaux Centre More people with serious mental illnesses will receive intensive treatment and psychosocial rehabilitation services in their homes or community settings. Care is provided by two teams of mental health and addictions professionals including nurses, physicians and addictions, vocational and peer support specialists. Building on their successful Addictions Supportive Housing ASH model, more clients with complex needs will have access to a basket of community services including personal care and homemaking. Clients will also be linked with primary care, including geriatric psychiatry, and will be supported to adopt the healthy development and recovery approaches to care to reduce mental illnesses and addictions in order to be able to secure and maintain housing. $223,125 $62,725

9 Durham Cluster - System of Care - $2,969,027 GAIN Team GAIN Enhancement Behavioural Supports Ontario (BSO) Assisted Living Services for High Risk Seniors (ALS-HRS) Adult Day Programs (ADP) Oshawa Health Centre Lakeridge Health Care Durham Oshawa Senior Citizen Centre Paired with the hospital GAIN clinic at Lakeridge Health Oshawa, an interprofessional GAIN Team will support patients at home, in the community. Using gerontological best practices, standardized assessments and protocols, individualized integrated care plans will be created for high risk seniors who will then be supported by Health Career Case Managers, in partnership with their primary care provider, to navigate the system including access to community programs. BSO staff, with special training in responding to patients with complex and challenging mental health, dementia or other neurological conditions, will work with the GAIN Clinics and GAIN Teams to support care in the community. Building on previous investments in 2011/12 and 2012/13, CCD will support another 55 people a year to maintain their independence and remain in their homes for as long as possible at a new location in Clarington. Recognizing how ADPs support care in the community, this new funding is targeted to frail elderly clients who have complex and long-term medical, physical, social and/or cognitive conditions. With a goal of serving 40 $620,000 $170,000 $691,542 $151,100

10 clients a year, OSCC will serve higher needs clients and provide respite to caregivers. Adult Day Programs (ADP) Assertive Treatment Team (ACCT) - Stepped Model of Care Assertive Treatment Team (ACCT) - Stepped Model of Care Les Centres d Accueil Heritage Ontario Shores Centre for Mental Health Sciences CMHA Durham Building on their successful programs in downtown and northwest Toronto, the LHIN will now establish an accountability agreement with Les Centres d Accueil Heritage to offer ADPs in Oshawa. The programs, which will be delivered in French, will support between 12 and 20 clients a year. More people with serious mental illnesses will receive intensive treatment and psychosocial rehabilitation services in their homes or community settings. Care is provided by a team of mental health and addictions professionals including nurses, physicians and addictions, vocational and peer support specialists. More people with serious mental illnesses will receive intensive treatment and psychosocial rehabilitation services in their homes or community settings. Care is provided by a team of mental health and addictions professionals including nurses, physicians and addictions, vocational and peer support specialists. $60,697 $111,563 $111,563

11 Assertive Treatment Team (ACCT) - Stepped Model of Care Mental Health and Addictions Housing Mental Health and Addictions Housing Rouge Valley Health System Durham Mental Health Services Durham Mental Health Services in partnership with Ontario Shores Centre for Mental Health Sciences More people with serious mental illnesses will receive intensive treatment and psychosocial rehabilitation services in their homes or community settings. Care is provided by a team of mental health and addictions professionals including nurses, physicians and addictions, vocational and peer support specialists. Building on the Recovery model of care, seniors living at home and actively using substances will be provided with in-person or telephone support to be better connected to their community, increase their coping skills and develop strategies that can lead to recovery or reduced harm. By providing enhanced community support services, ongoing psychiatric follow up and outpatient group programming, DMHS and OS will work together to transition four people with serious mental illnesses from the hospital to the community. North East Cluster- Haliburton County/City of Kawartha Lakes System of Care - $1,159,671 Paired with the hospital GAIN clinic at PRHC, an inter-professional GAIN Team will support patients Care at home, in the community in CKL with GAIN City of Kawartha additional outreach to Haliburton Team Lakes County. Using gerontological best practices, standardized assessments and protocols, individualized integrated care plans will be created for high risk $111,563 $577,000 $364,000 $620,000

12 GAIN Enhancement Behavioural Supports Ontario (BSO) Assisted Living Services for High Risk Seniors (ALS-HRS) Adult Day Programs (ADP) Ross Memorial Hospital Care City of Kawartha Lakes Care City of Kawartha Lakes seniors who will then be supported by Health Career Case Managers, in partnership with their primary care provider, to navigate the system including access to community programs. BSO staff, with special training in responding to patients with complex and challenging mental health, dementia or other neurological conditions, will work with the GAIN Clinics and GAIN Teams to support care in the community. CCCKL will support 30 people a year to maintain their independence and remain in their homes for as long as possible. Using their Care Village Housing location as the hub, the ALS-HRS program will serve eligible high risk seniors within a 15 minute radius. Recognizing how ADPs support care in the community, this new funding is targeted to frail elderly clients who have complex and long-term medical, physical, social and/or cognitive conditions and will allow CCCKL to provide dementia-specific programming to another 20 clients a year in their four locations. $85,000 $396,843 $57,828

13 North East Cluster Peterborough City and County System of Care - $1,323,570 GAIN Team GAIN Enhancement Behavioural Supports Ontario (BSO) Assisted Living for High Risk Seniors (ALS-HRS) Peterborough Regional Health Centre Peterborough Regional Health Centre VON Ontario Branch Peterborough Paired with the hospital GAIN clinic at PRHC, an inter-professional GAIN Team will support patients at home, in the community. Using gerontological best practices, standardized assessments and protocols, individualized integrated care plans will be created for high risk seniors who will then be supported by Health Career Case Managers, in partnership with their primary care provider, to navigate the system including access to community programs. BSO staff, with special training in responding to patients with complex and challenging mental health, dementia or other neurological conditions, will work with the GAIN Clinics and GAIN Teams to support care in the community. Building on previous investments in 2011/12 and 2012/13, VON will open a new ALS-HRS hub in Havelock. This rural hub, which will support people to maintain their independence and remain in their homes for as long as possible, will support 45 clients a year in Havelock and the surrounding geographic area including Norwood. $620,000 $85,000 $349,962

14 Adult Day Programs (ADP) Assertive Treatment Team (ACCT) - Stepped Model of Care VON Ontario Branch Peterborough Ontario Shores Building on previous investments, this new funding is targeted to frail elderly clients who have complex and longterm medical, physical, social and/or cognitive conditions. By expanding their existing programs and introducing a new ADP at Curve Lake First Nations, VON will be able to serve an additional 104 clients a year. More people with serious mental illnesses will receive intensive treatment and psychosocial rehabilitation services in their homes or community settings. Care is provided by a team of mental health and addictions professionals including nurses, physicians and addictions, vocational and peer support specialists. North East Cluster Northumberland County System of Care - $988,681 GAIN Team Port Hope Health Centre Paired with the hospital GAIN clinic at PRHC and building on investments made in the Port Hope CHC in 2012/13, the inter-professional GAIN Team model will be introduced to continue to support patients at home, in the community. Using gerontological best practices, standardized assessments and protocols, individualized integrated care plans will be created for high risk seniors who will then be supported by Health Career Case Managers, in partnership with their primary care provider, to navigate the system including access to community programs. $157,045 $111,563 $93,193

15 GAIN Enhancement Behavioural Supports Ontario (BSO) Assisted Living Services for High Risk Seniors (ALS-HRS) Assertive Treatment Team (ACCT) - Stepped Model of Care Port Hope Health Centre VON Ontario Branch Northumberland Northumberland Hills Hospital BSO staff, with special training in responding to patients with complex and challenging mental health, dementia or other neurological conditions, will work with the GAIN Clinics and GAIN Teams to support care in the community. Building on previous investments in 2011/12 and 2012/13, VON will support another 90 clients a year in Campbellford and Cobourg to maintain their independence and remain in their homes for as long as possible. This will include opening new ALS-HRS hubs at Campbellford Memorial Lodge and Cobourg Legion Village. More people with serious mental illnesses will receive intensive treatment and psychosocial rehabilitation services in their homes or community settings. Care is provided by a team of mental health and addictions professionals including nurses, physicians and addictions, vocational and peer support specialists. $85,000 $698,925 $111,563

16 Across all clusters - $18,089,800 CCAC Access to Personal Support Services Central East Care Access Centre Reducing wait times for Personal Support Services for persons with complex needs $6,814,800 CCAC Service Enhancements GAIN Health Career Case Management NPSTAT Central East Care Access Centre Central East Care Access Centre Central East Care Access Centre Reduce Emergency Department wait times and Alternate Level of Care days by continuing to meet the needs of complex care clients from across the Central East LHIN who receive services through personal support hours, nursing and therapy visits Working directly with Primary Care and other clinicians and co-located in the GAIN Clinics, twelve Health Career Case Managers will support clients to navigate the health and social services system. Based on the client s individualized integrated care plan, clients will have direct access to the GAIN community clinics and other LHIN-funded communitybased programs. Ongoing funding to support the NPSTAT program - nurse practitioners supporting teams averting transfers. These nurse-led outreach teams, located across the Central East LHIN, address the health risks of transferring frail seniors to emergency departments for visits by providing treatment in the long-term care home. $9,400,000 $1,250,000 $350,000

17 Implementing a Mental Health and Addictions (MHA) Strategy Ontario Shores Centre for Mental Health Sciences Recruitment of a Central East LHIN Mental Health and Addictions Physician Lead, creating a MHA Strategic Co-ordinating Council and project management for the MHA Strategy $275,000 Total allocated across the Central East LHIN Systems of Care $27,408,889 Amount still to be allocated pending project approvals $418,111

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