Expanding Patient-Centred In-Home Physiotherapy Services to Support a Range of Patient Needs and Goals

Transcription

1 Expanding Patient-Centred In-Home Physiotherapy Services to Support a Range of Patient Needs and Goals Central East CCAC Mississauga Halton CCAC Central West CCAC

2 Physiotherapy Reform The report, Living Longer, Living Well (Sinha 2012), promotes improved mobility for seniors to help them live safely and independently at home as long as possible. In response, the Ministry of Health and Long-Term Care launched an initiative to reform PT services including in-home PT services. CCACs: $33 million in annualized funding to expand the provision of in-home physiotherapy services to 60,000 seniors/other patients and clear the physiotherapy wait list Falls Prevention and Exercise Classes: $10 million to provide exercise and falls prevention classes Others: PT Clinics, Long Term Care Home and Primary Care Services

3 Transition from OHIP funded Physiotherapy Services Initial Priorities during the Transition Period Eliminating waiting lists for in-home physiotherapy. Identifying and transitioning patients receiving OHIP-funded physiotherapy (ended on August 21 st, 2013). Streaming to appropriate services In-home physiotherapy Exercise classes Falls prevention Other services Magnitude of the Transition CCACs and SPOs successfully collaborated to transition over 32,000 patients in over 1,000 sites across the province, bringing 23,300 on to care over a four month period.

4 Assumptions prior to the transition Additional needs Patients needing long-term support to maintain function and prevent decline Goal-oriented Physiotherapy Patients who really need PSS services OHIP In-home Physiotherapy CSS Exercise Classes People who need referrals to other services (e.g., pain management) People needing 1:1 help to access classes CSS Falls Prevention

5 Physiotherapy Advisory Panel Recommendations In June of 2013, an advisory panel was established to review the literature and recommend evidence-informed practices to support the development of new, patient-centred models of care. Led by Cathy Hecimovich (CEO of Central West CCAC), membership included experts from geriatrics, the rehabilitation sector and the physiotherapy profession along with CCAC and OACCAC representatives. Recommended a number of evidence-informed innovations including: support for an expansion of PT scope of practice in home care, integration of physiotherapist support personnel, focus on outcome-focused service delivery to serve the needs of different in-home physiotherapy patient groupings, self-management models. To operationalize the recommendations and support the needs of this new population, a provincial working group came together to develop the PT service delivery model of care.

6 In-Home Physiotherapy Service Delivery Model In-Home Physiotherapy Stream 1: Rehabilitation Goal: Improve & Restore Independent Function Stream 2: Restorative Goal: Restore Optimal Function Stream 3: Maintenance Goal: Maintain & Prevent Decline in Function

7 Patient-Centred, Evidence- Informed Care Operationalization of the model of care for PT: expands the capacity of in-home PT service delivery to address a range of patient needs and goals (rehabilitation, restorative and maintenance). reinforces outcome-focused care delivery. brings province-wide consistency to the delivery of in-home physiotherapy services while allowing for local variation. enables the health care system to better support seniors to live as safely and independently as possible. Ongoing work: CCAC sites continue to engage locally with SPOs and retirement home operators to operationalize the recommendations. OACCAC and CCACs continue to engage with provincial associations: ORCA, OCSA, OHCA, APACTS. Implementation and testing continues: based on local needs and conditions, each CCAC is choosing to implement recommendations according to those needs.

8 Site Perspectives Physiotherapy Reform and Physiotherapy Transition in Central East CCAC Laszlo Cifra Program Director, Integrated Care, CE CCAC Michelle Nurse Director, Contracts and Relationships, CE CCAC Implementing the New Physiotherapy Model: Successes, Challenges & Key Learnings in Mississauga Halton CCAC Carey Lucki Program Manager, Patient Care, MH CCAC Physiotherapy and Exercise and Falls Prevention Program in Central West CCAC Kimberley Floyd Director of Client Services, CW CCAC

9 Physiotherapy Reform and Physiotherapy Transition Phase 1, 2 and 3 Central East CCAC

10 Our Task Soft Landing for patients Transitioning of 4000 Patients from Designated Physiotherapy Clinics (DPC) to CCAC Ensuring Service Provider human resource capacity 10

11 Phase I - Approach Initiation of a Physiotherapy Steering Committee Seconded an Internal Physiotherapist to provide expert advice to the steering committee Early engagement of Service Provider Organizations (SPO) Early engagement of Retirement Homes (RH) and Congregate Setting Administrators Introduction of Physiotherapy Assistants (PTA s) early in the transition 11

12 Phase I - Approach, cont d Obtained patient lists from RH s and existing DPC providers Assigned patients to SPO based on predetermined cluster care assignments SPO assessment completed for each patient Received recommendations from SPO regarding patient s transition plan exercise and falls prevention classes continue with restorative care (up to 8 weeks) 12

13 Phase I - Approach, cont d Registered all patients in CHRIS Authorized services based on the SPO recommendation 13

14 Phase I - Results, cont d Physiotherapy Reform Statistics 3972 patients received from the DPCs and registered with CECCAC 3290 patients received treatment from CECCAC 2270 referrals to exercise and Falls Prevention Programs 104 patients removed from Physiotherapy waitlist 14

15 Phase I - Results Who Did We Serve? PT Reform Patient Age Distribution 15

16 Phase I - Results, cont d Who Did We Serve? PT Reform Profile (Existing CECCAC Patients) Client Care Model Distribution 16

17 Phase I - What We Spent Physiotherapy Reform Weekly spend peaked w/o September at $137,679 Total 3972 Patients 17

18 Phase II - SPO Engagement Utilizing data from Phase I What is the future going to look like Service Levels Agreement by all SPO to utilize standardize assessment tools Functional Assessment Matrix was developed 3 restorative streams based on functional abilities assessments 18

19 Gait Phase II - Community Based Assessment Measures Timed Up and Go (TUG) 50 Ft Walking Test Dynamic Gait Pain Visual Analog Scale (VAS) Strength Manual Muscle Testing 19

20 Phase II - Community Based Assessment Measures cont d Balance Functional Reach BERG Tinetti Other Elderly Mobility Scale (EMS) Disabilities of the Arm, Shoulder and Hand (DASH) Barthel Physical Performance Test (PPT) 20

21 Phase II - Initial Restorative Streams Stream A Up to 12 Weeks 3 PT/9PTA visits CHRIS Stream 2 Stream B up to 24 weeks 7 PT/17 PTA CHRIS Stream 3A/B Stream C up to 32 weeks 10 PT/25 PTA CHRIS Stream 3A/B 21

22 Phase II - Functional Indicators (FI) Chart 22

23 Phase II - What We Spent - Transition Weekly spend peaked w/o December at $18K Total 420 Patients (298 Maintain, 122 Restore) 23

24 Phase II - Lessons Learned Most patients did not require the full 32 weeks of service to meet their goals Physiotherapists were not utilizing all of the assessment tools Outcomes collected in existing Care Coordinator assessment tools need to be aligned with the new physiotherapy model 24

25 Phase II Refining the Model Reduced the number of measurement tools used from 12 to 8 TUG, Dynamic Gait VAS Berg, Tinetti MMT EMS, DASH Aligned the streams with the Provincial restorative streams 25

26 Phase III - Updated FI Chart Tool Options PT Stream 2 Restore to Optimal Up to 16 weeks (1 assessment + 6PT/12PTA) PT Stream 3 Gait Pain Balance Strength Other TUG Berg Dynamic Gait Tinetti/Gait TUG: Dynamic Gait: VAS (Vis ual Ana log Scal e) VAS: 1-5 Berg: Tinetti/Gait: greater than or equal to 22+ MMT (Man ual Musc le Testi ng) MMT: 3-5 Elderly Mobility Scale DASH (Disabilities of the Arm, Shoulder and Hand) Elderly Mobility Scale: 12+ DASH: Self Management Goal (Patient s own goal) A) Maintain PT/PTA Up to 24 weeks (1 assessment + 8PT/22PTA) A) Maintain PT/PSW (requires PSW service already in place) TUG: 30+ Dynamic Gait: 13 or lower VAS: 6-10 Berg: 28 or lower Tinetti/Gait: 21 or less MMT: 1-2 Elderly Mobility Scale: Under 11 or less DASH: 50+ Up to 24 weeks (1 assessment + 8PT/17PTA) 26

27 Phase III Refining the Model Process For Admitting New Patients 27

28 Phase III - Restorative Physiotherapy Eligibility - RAI HC 28

29 Phase III - What We Spent Physiotherapy Streams Includes All PT streams Weekly spend peaked w/o March At $44,326 29

30 Phase III - Total Spend 30

31 Phase III Lessons Learned CECCAC evaluated the sustainability of the Phase III Model Significant financial pressure to meet the target of 6664 additional patients within our budget PT/PTA is a viable model for community based therapy service The change from acute to restorative model of care is a lengthy process for care coordinators and service providers alike 31

32 Phase III (IV) In collaboration with our SPO we are refining our eligibility criteria Stream 2 eligibility Post acute physiotherapy Stroke, risk for falls 2 Physiotherapists and 6 PTA visits Stream 3B 2 Physiotherapist visits to assess for PSW supported activation/maintenance 32

33 Personal Support Services (PSS) Organization Engagement Stream 3B Invited our PSS organizations to assist with the development of the activation program Physiotherapy agencies agreed to develop a standing and sitting activation program appropriate for Personal Support Worker (PSW) supervision Transfer vs delegation of care to PSW 33

34 Next Steps Finalize the standing and sitting activation program Re-educate Care Coordinators and SPO in the new program Set up train the trainer modules for sustainability 34

35 Questions 35

36 Implementing the New Physiotherapy Model: Successes, Challenges & Key Learnings Carey Lucki Mississauga Halton CCAC 36

37 Mississauga Halton CCAC Ontario s 4 th largest CCAC Serve more than 41,000 patients annually (2012/2013 data) 2 nd fastest growing population of seniors in Canada (projected 32.2% increase in seniors aged 75-84; 71% increase in seniors aged 85+) Highly diverse area (43.2% cultural diversity) One of Canada s fastest growing populations (15% by 2014) Mississauga Halton CCAC 37

38 Mississauga Halton CCAC Serve the municipalities of south Etobicoke, Halton Hills, Mississauga, Oakville and Milton. Over 1.1 million people in the region. We cover ~ 900 square kilometers with a mix of urban/rural composition. Mississauga Halton CCAC 38

39 Strategic Plan Quality Community Care Outcomes Focused Patient Care Implementing and sustaining the necessary infrastructure, processes, care models and practices to ensure the delivery of safe, effective, evidence-based and high-quality care to every patient, every day. Rehabilitation Programming Mississauga Halton CCAC

40 MH CCAC Rehabilitation Initiatives Physiotherapy Model of Care (POC) November 2013 Home Independence Program December 2013 Rapid Recovery January 2014 Hips/Knees OBPs/Regional Work February 2014 Stroke Program April 2014 Mississauga Halton CCAC

41 Org wide All streams All SPOs PT Journey PT Reform Transition of 5400 patients August 2013 Phase 1 Launch of PT Model Mid November 2013 Phase 2 Launch of PT Model April 2013? Query Phase 3 Fall 2014 (4+ months) Data collection/metrics Focus Groups Care Coordinators/SPOs Other POC sites, external stakeholders Mississauga Halton CCAC 41

42 Physiotherapy New Streams of Care Stream 1 Improve and Rehabilitate to Independent Function Org wide All streams All SPOs Stream 2 Assess and Restore Optimal Function (slower stream rehab) Stream 3 A/B Maintain and Prevent Decline in Function Mississauga Halton CCAC 42

43 Phase days LOS (3 months) Up to 12 PT visits It is expected that PT goals are met in Stream 1. If client is slow and/or not progressing towards goal achievement, consider moving to Stream Days LOS (2 months) PT and PTA visits *PTA cannot be entered in CHRIS; enter all visits as PT in CHRIS 9 10 month LOS PT and PTA visits or PT and PSW (training to supervisor) or *PTA cannot be entered in CHRIS; enter all visits as PT in CHRIS 0-14 days (2 3 PT visits) CSR completed by SPO -Assessment (goals, teaching, self-management) -Expected LOS -Identification of other service needs days (3 6 PT visits) D/C or progress to Interval days (2-3 PT visits) D/C or consider Stream 3 Revised January 20th, 2014 MH CCAC 0-60 days 3-4 PT visits as required to monitor progress *CC has discretion to add more PT if necessary* 1-3 PTA visits per week D/C or consider Stream 3 if necessary Tip: PTA or PSW? PTA: Focused intervention. May involve specific stretching, more complicated exercises, some modalities (i.e., accutens) Up to 3-4 PT visits as required to train PTA and monitor progress *CC has discretion to add more PT if necessary* 1-2 PTA visits per week PSW: Exercises are maintenance in nature, easily incorporated into the care plan. Gentle movement, ROM or walking small distances. Up to 3-4 PT visits as required to train and monitor progress *CC has discretion to add more PT if necessary* Add PSW time as follows: For cluster care sites, add additional units 15 or 30 mins (Enter as 1.25 or 1.50 in CHRIS) For in home - Care coordinator has discretion to allow 30 mins -1 hour extra PSW per week to accommodate PT programme. Alternatively, it can be built into existing PSW allotment. Mississauga Halton CCAC 43

44 Comparison Physiotherapy Previous Model New Model Length of Stay 3-4 weeks weeks Visits 2 or 3 visits visits Service Plan Use of other services Discharge Disposition Assessment Consultation PT PT/PSW Goals met Assessment Treatment Consultation PT/PTA PT/PSW Goals met Type of Service Generic Specific to population/need Mississauga Halton CCAC 44

45 Key Assumptions Patients would begin at Stream 1 and progress through subsequent streams if required Physiotherapists would determine total number of visits required and length of stay Physiotherapists would identify the need for PTA involvement and provide oversight and direction as to PTA service Physiotherapists would continue to work with PSW as in traditional models; PSWs could now begin exercise programming as part of their care plans Mississauga Halton CCAC 45

46 Metrics November 2013 March 2014 Units per patient Stream Stream Stream 3A 7.5 Stream 3B 2.9 Average 4.0 Length of stay Stream days Stream days Stream 3A days Stream 3B 37 days Average days Stream distribution Stream 1 53% Stream 2 30% Stream 3A 12% Stream 3B 5% Mississauga Halton CCAC 46

47 Metrics # of patients 5,082 7,537 Cost per patient $ $ Units 21,139 30,320 Units per patient Length of stay 30 days days Mississauga Halton CCAC 47

48 Findings Beginning all patients in Stream 1 did not always correlate with patient need and right care PT utilization did not change significantly (remained at 4 units per patient on average) Transition from 2-3 visit consultation model to a broader, expanded role of PT which focuses on establishing SMART goals and the provision of treatment over a longer period of time PSW incorporation of exercise programming PSW allocation Prescriptive PT/PTA visits did not always correlate with patient need and right care PT/PTA new relationships Mississauga Halton CCAC 48

49 November February 2014 PT/PTA Breakdown PT PTA PT PTA PT PTA PT1 PT2 PT3A Mississauga Halton CCAC 49

50 Challenges Competing demands (Accreditation, DMS, other rehab programs) Unforeseen events (Red Cross Strike) Holidays Hospital surges Referral Coding Mississauga Halton CCAC 50

51 Successes The benefits to our patients with these PT Streams is immeasurable if it allows patients to be more active and safer in their home and community, and for some it allows them to stay in their home rather than have to contemplate a move to a RH or LTCF. I like the structure of each stream, goal expectations are known, it is not restrictive in length, clients could start in Stream 1 and progress through to Stream 2 or 3 if as per PT professional judgment/discussion with CCAC that, ongoing therapy would benefit patient. I also like that the frequency authorization is standard for all Access ordering the service, because it equalizes services for all, rather than I think they should receive 2 visits and some other Access CCs think 1 visit is enough. Mississauga Halton CCAC 51

52 Phase 2 - Changes Model/framework remained the same Reinforced use of the RAI-CA rehab algorithm at intake CC chooses stream; subject to change based on initial clinical PT assessment Visit frequency/length of stay was modified Removed the prescriptive PT/PTA visit specifications Revised the PT/PSW service plan Revised the PSR/CSR Reinforced the use of SMART goals Implemented the reporting of clinical outcome measures pre/post test scores Mississauga Halton CCAC 52

53 Description Stream 1 Rehabilitate to Independence MH CCAC Physiotherapy Streams Guideline Stream 2 Restore to Optimal Stream 3A Maintain & Prevent Decline Stream 3B Maintain & Prevent Decline CHRIS Referral Code PT1 Rehab to Independence PT2 Restore to Optimal PT3A Maintain PT/PTA PT3B Maintain PT/PSW Clinical Presentation Eligibility Criteria Patients who have a specific, focused need and predictable treatment/rehabilitation journey Specific, focused assessment and treatment in the following areas: Orthopaedic (fractures) Neurological (MS, Parkinson s) Respiratory (COPD) Musculoskeletal/Exercise (postsurgery, post injury/fall) EXCLUSION: OBP hips/knees Stroke program Rapid Recovery Patients who may have a specific, focused need and predictable treatment/rehabilitation journey but will take longer to meet goals (slower stream rehab) Generally slower stream rehabilitation Frail, older adults Functional loss is reversible (capacity to improve) Patients who present with acute or chronic gait deficit, balance deficit, reduced functional strength resulting in functional decline in ability to perform ADLs 2 or more comorbidities with complicating factors 2 or more falls in last 6 months Decline in ability to independently perform 1 or more ADLs in last 6 months Deconditioning (as a result of hospital stay or exacerbation of a chronic condition) Need to prevent further decline PTA criteria: -patient is expected to have ongoing changes but condition is stable and pain is controlled -PT is delegating program to PTA and continuing to supervise the PTA -evidence based program is recommended and expected to be stable over a period of time (3 wks) Patients who present with acute or chronic gait deficit, balance deficit, reduced functional strength resulting in functional decline in ability to perform ADLs 2 or more comorbidities with complicating factors 2 or more falls in last 6 months Decline in ability to independently perform 1 or more ADLs in last 6 months Deconditioning (as a result of hospital stay or exacerbation of a chronic condition) Need to prevent further decline PSW criteria: -patient is stable, not changing, long term mtce -PSW may be doing a walking program -recommendations from PT are not required on an ongoing basis -PT transfers skill to PS Supervisor/PSW -PT will discharge once skills are transferred Mississauga Halton CCAC 53

54 ACCESS At A Glance CC determines eligibility for CCAC physiotherapy service RAI-CA is completed. Rehab algorithm is calculated (see below, next page) Rehab algorithm score is 1-2 Patient can safely attend an outpatient class or program without hardship YES Refer to outpatient PT, falls prevention, exercise classes, clinics *if classes cannot accommodate patient due to wait listing, place on Stream 1 NO RAI CA rehab algorithm score is 3+ Determine PT Stream based on algorithm and clinical judgement. Assign referral to SPO. Add referral code in CHRIS Stream 3B Stream 1 Referral Code: PT1 Rehab to Independence RAI-CA rehab algorithm = 3 SRC = 92 Service Plan: Block of 8 PT visits LOS: 8 weeks Stream 2 Referral Code: PT2 Restore to Optimal RAI-CA rehab algorithm = 4 SRC = 93 Service Plan: Block of 12 PT visits (combination of PT/PTA - PT will determine how much PTA) Stream 3A Referral Code: PT3A Maintain & Prevent RAI-CA rehab algorithm = 4/5 SRC = 93/94 Service Plan: Block of 12 PT visits (combination of PT/PTA PT will determine how much PTA) Referral Code: PT3B Maintain & Prevent RAI-CA rehab algorithm = 4/5 SRC = 93/94 Service Plan: Block of 4 PT visits (combination of PT/PSW) PT will determine if PSW can be used for exercise programming and communicate with Community CC. PT will likely discharge after 8 weeks LOS: 8 weeks PT will need to revise PED after 8 weeks with community CC. LOS: 8 weeks PT will need to revise PED after 8 weeks with community CC. LOS: 8 weeks. PT will need to revise PED after 8 weeks with community CC and/or discharge. Mississauga Halton CCAC 54

55 Successes Bi weekly meetings with 4 contracted rehab SPO agencies Best Practice Rehabilitation Committee Frontline CC roadshows and team meetings Identified Care Coordinator rehab champions per team THP/HHS/CVH road shows allied health and patient navigators/discharge planners Formed a outcome based metrics committee to further inform: % patients per stream Cost/utilization Clinical outcome measures Patient satisfaction Discharge disposition referral to exercise classes/falls prevention classes, CSS Intranet Mississauga Halton CCAC 55

56 PT Models of Care 56

57 Where are we? Phase 2 launch April 2014 Change management curve is moving upwards with acceptance, experimentation, and integration Costs are on the rise ~ 21% more per month Stream breakdown: Stream 1 30% Stream 2 46% Stream 3A 10% Stream 3B 14% Clinical outcome measures - too early to analyze Metrics analysis PSW engagement Mississauga Halton CCAC 57

58 Questions Mississauga Halton CCAC 58

59 Central West CCAC Physiotherapy and Exercise and Falls Prevention Program Kimberley Floyd Central West CCAC June 9, 2014

60 Overall Vision: To Develop a Sustainable Physiotherapy / Exercise and Falls Prevention Program in the Central West Region

61 Execution of PT Reform in Central West LHIN Allowing for continuity of care between in-home physiotherapy and exercise and falls prevention with CCAC implementing and overseeing both streams Developing a flexible, streamlined and innovative delivery model that blends exercise and falls prevention classes to optimize available resources and maximize outreach to seniors

62 Physiotherapy Continuum Consistent service provider treats patient within neighbourhood approach to care (congregate setting and in home/community settings) Patient progresses through streams that meet their presenting needs within safe and effective transition between streams with no gaps in service or redundancy in assessments and treatment Execution of recommended PT streams across all service providers supported by exercise and falls prevention classes as an extension of any one on one in home stream Care offered across continuum close to home in neighbourhood locations across the LHIN

63 Exercise and Falls Prevention Classes Implementing a combined Exercise and Falls Prevention education service delivery model Ensuring continuity of care Optimizing available resources and maximizing outreach to seniors through innovative model of care All classes are replicated in congregate and community settings including specialized classes sensitive to community needs (mental health, culture and disease specific)

64 Exercise and Falls Prevention Model Each class has a blended approach of exercise and falls prevention built into every class Classes run 48 weeks a year Overseen by regulated health care professional PTA runs the class under a supervision model by the PT Congregate settings and Community Based classes are supported by this model Building of strong community partnerships for community sites including Recreation and Parks departments, municipalities, primary care practices and other community settings Self management and chronic disease management education components built in through interprofessional team based organized sessions

65 Commitments of PT Model Committed presence of therapy team in congregate settings to integrate into the inter-professional team Consistent team of therapists working within each congregate setting Provide a continuum of care with in home Physiotherapy and exercise and falls prevention classes with PT and PTA model Communication/documentation within congregate settings Support in falls prevention programs in Retirement Homes as per Retirement Home Act Timeliness of interventions (reduce waste in the process or unnecessary bureaucratic steps) Main elements of model replicated across all locations Model transferable to in home focus

66 Lessons Learned Communication: Process is required for weekly established meetings between PT care team and Retirement Home PT and PTA of class and in home therapy must be supported to case conference Oversight: Supervision Model is imperative between PT and PTA PT needs to have professional accountability for whole model Appropriate compensation must be offered to support program oversight, supervision, care planning and participation in falls prevention programming Standardizing quality metrics across continuum that is evidenced based Intake Process: Needs to be seamless and real time Encourage therapist and congregate setting to forward a referral and then receive immediate authorization to assess patient (supports transition from hospital to home as one example)

67 Logistics Screening Processes to recommend class best suited to the needs of the senior and to support service outcomes by regulated health care professional Seniors registered in desired classes (location and time convenience) in order to maximize consistent attendance in classes Attendance monitored for all class settings (congregate and community locations in order to provide CSS sector statistics) Care Coordinators attached to congregate and community sites as points of contact and patient level care planning and system navigation Strengthened collaborative care planning that extends beyond PT reform (proactive service planning opportunities)

68 Five Pillars of Ideal Continuum of Care Continuity of Care Team (PT, PTA and Care Coordinator) Proactive Communication Approaches in Congregate Settings PT and PTA Integrated into Care Team in Congregate Setting Documentation Practices that Support Interprofessional Care Planning Seamless and Timely Access to Service

69 Retirement Home Partnership Collaborative service planning around falls prevention which includes monitoring and reporting of falls Informing program design Commitment of regular engagement re refinement of model Established planning days to ensure development of quality outcomes Satisfaction of model is continually explored based on the above practices CCAC Managers aligned with all congregate settings in order to escalate any issues in real time

70 Benefits Seniors are navigated to appropriate health services by leveraging existing system structure of CCAC Utilize centralized function to implementation and navigation that ensures efficiencies and better quality in providing services and monitoring of service providers One stop source of information for program options for seniors and other stakeholders Reduced delay in access to services

71 Benefits Continued Individualized plan of care for seniors involved in services from a care team who is proactively meeting their needs Preventative approach to educating on the multi factoral elements of falls prevention by leveraging use of interprofessional resources in neighbourhoods Evaluation and outcome measurement is strengthened as a critical mass of locations exist with a consistent approach to the model of care Sharing of best practices to create a Community of Practice among providers in Central West LHIN

72 Questions Kimberley Floyd Director of Client Services, Central West CCAC ext

73 For More Information Laszlo Cifra Program Director, Integrated Care, CE CCAC x 5558 laszlo.cifra@ce.ccac-ont.ca Michelle Nurse Director, Contracts and Relationships, CE CCAC x 5247 Michelle.Nurse@ce.ccac-ont.ca Carey Lucki Program Manager, Patient Care, MH CCAC carey.lucki@mh.ccac-ont.ca Kimberley Floyd Director of Client Services, Central West CCAC ext Kimberley.floyd@cw.ccac-ont.ca