Central East Community Care Access Centre

Transcription

1 Central East Community Care Access Centre Outstanding care every person every day

2 Who are we? The Central East Community Care Access Centre (CECCAC) is one of 14 CCACs that work in communities across Ontario to connect people with quality in-home and community-based health care. We make sure our patients receive the care they need when they need it. We provide information, direct access to qualified care providers and many comprehensive services to help people come home from the hospital sooner or live independently at home longer. Finding and accessing care can sometimes be confusing and complicated. CCACs help people find their way through Ontario s health care system, understand their options and get the highest quality care possible. We help people across their life spans from school children who have special health needs to seniors who need health services at home or access to a long-term care home. Every day in communities across the province nurses, doctors, therapists, personal support workers, care coordinators and many others are working together to provide better quality of care for our patients. The CCACs work as a team along with our health care partners to transform our health care system in order to deliver the health care that people need.

3 The Health Sectors of Ontario

4 Region The shares the same boundaries as the Central East Local Health Integration Network (LHIN), stretching from Victoria Park in Scarborough, north to Algonquin Park in Haliburton County and to Lake Ontario along the southern border. There are seven branch offices: 1. Campbellford Branch 2. Haliburton Branch 3. Lindsay Branch 4. Peterborough Branch 5. Port Hope Branch 6. Scarborough Branch 7. Whitby Branch (Head Office)

5 Our Services services are paid for by the Ministry of Health and Long-Term Care and can include: Linking patients to a wide range of community services not directly provided by the A range of in-home health care and related social services and supplies and equipment Specialized programs

6 Who can make a referral for service? Referrals to the can be made by: individuals family members caregivers friends physicians health care professionals

7 What We Do Care Coordinators are dedicated nurses, occupational therapists, social workers and other health care professionals who work directly with patients in hospitals, doctors offices, communities and at home to ensure that people get the care they need.

8 What services are available? Care Coordination Care Coordinators are regulated health care professionals with specialized knowledge and skills that help assess the patient s needs, assist them in developing a care plan and arrange for the services required. In-Home Nursing Physiotherapy Occupational therapy Speech-language therapy Social work HC Dietetics Medical supplies and equipment Personal support (bathing, dressing etc.)

9 Who is eligible for our service? To be eligible for services, you must have: In-Home Services or Alternate Care Setting (ACS) a valid Ontario Health Card health care needs that cannot be met on an outpatient basis a need for a least one professional or personal support service a medical condition that can be adequately treated in the home or ACS Placement a valid Ontario Health Card be 18 years of age or older a need for either nursing care 24 hours a day, assistance with activities of daily living or on-site supervision or monitoring must have care needs that can be met in a Long-Term Care Home

10 Placement When living independently is no longer possible, the Central East CCAC co-ordinates applications to long-term care homes. The Care Coordinator will: provide information about long-term care determine eligibility for placement provide assistance in the application process HC

11 Specialized Programs The may also offer assessment for and referral to specialized programs geared to specific health needs. Programs include: Acquired Brain Injury Convalescent Care Assisted Living for High Risk Seniors Behavioural Supports Ontario Centre for Complex Diabetes Care Centralized Diabetes Intake Central East LHIN Self-Management Community Palliative Nurse Practitioner Health Care Connect Mental Health and Addiction Nurses Nurse Practitioners Supporting Team Averting Transfers (NPSTAT) Rapid Response Nurses

12 Information and Referral If a patient is not eligible for the services provided by the, our staff will link them to alternate services available in the community. These services may include: some adult day programs meal delivery services transportation assistance assistance with shopping and cleaning Note: You may be required to pay a fee for services provided by a community service agency.

13 Health Care Connect The Health Care Connect program is part of the Ministry of Health and Long-Term Care, and was created to help people who are without a family health care provider to find one. The program identifies doctors or nurse practitioners in your community who are accepting patients and links them to people who are in need of a family health care provider Once you have joined Health Care Connect, a Care Connector will be assigned to help you find a health care provider in your area.

14 Call: or visit:

15 Campbellford Branch: 119 Isabella Street, Unit 7 Campbellford ON K0L 1L Haliburton Branch: PO Box 793, Hwy 118 Haliburton ON K0M 1S Lindsay Branch: 370 Kent Street West, Unit 11 Lindsay ON K9V 6G Peterborough Branch: 700 Clonsilla Avenue, Suite 202 Peterborough ON K9J 5Y Port Hope Branch: 151A Rose Glen Road Port Hope ON L1A 3V Scarborough Branch: 100 Consilium Place, 8th Floor Scarborough ON M1H 3E Chinese Line: Whitby Branch: 920 Champlain Court Whitby ON L1N 6K Toll-free: TTY Line: Website:

16 Children/School Health Support Services The School Health Support Services program provides services to assist students with medical and/or rehabilitation needs that are beyond the range and responsibilities of school staff. Through this program students are able to attend school along with their peers. The Children s In-Home Services provides services to children/youth up to 18 years of age while in their home.

17 Home First Philosophy A philosophy that promotes safe and timely care to meet healthcare needs of patients and families in the most appropriate setting. A partnership among Central East LHIN, hospitals, CECCAC and Community Support Services. A system of people, processes and services to return patients back into the community. Overall tenets of Home First: Every patient admitted to the hospital will be discharged home Decisions about major changes in lifestyle should be made from home, not from hospital.

18 What are the benefits to patients? Patients are in their own home where they want to be. Patients health, independence and well-being are maintained longer. The risk of patients getting a hospital acquired infection is reduced. Patients and caregivers are able to receive the benefit of services offered by CECCAC and community support agencies. Patients and families are able to make life-changing decisions related to future living accommodations from the comfort of their own home returning back into the community.

19 Alternate Care Setting (ACS) Clinics are available for CCAC clients who require nursing care and are ambulatory Clinics are open 8:30 a.m. to 8:30 p.m., 365 days of the year Clients book their own appointment Nursing care provided can include: Wound care/dressing changes, including NWPT Therapy IV Therapy Subcutaneous injections (including any Low Molecular Weight Heparin injections for Deep Vein Thrombosis) Intramuscular injections Central Venous Line flushing, such as PICC, Hickman, Port-a-cath. (Blood draws if in conjunction with PICC Lines) Blood Pressure Monitoring/Cardiac Assessment based on changes in status due to medication adjustments or cardiac assessment Chemo de-accessing (required only after Chemo Clinic is closed) Catheter care; includes catheter changes, nephrostomy care, intermittent catheterization (excludes teaching of self- catheterization).

20 Assisted Living Services for High Risk Seniors The Assisted Living Services for High Risk Seniors, 2011 project in the CE LHIN addresses the needs of high risk seniors who can reside at home but require the availability of personal support, homemaking, security checks and reassurance services on a 24/7 basis. The project will target high risk seniors whose needs cannot be met in a cost effective manner through home and community care services provided solely on a scheduled visitation basis. Assisted Living clients are eligible for combined maximum of 180 hours of personal support, homemaking, and professional services per month, it is the intent of this program that no person shall exceed 90 hours of personal support service per month

21 Behavioral Supports Ontario Behavioural Supports Ontario (BSO) was first announced by the Ministry of Health and Long Term Care in August BSO is a comprehensive system redesign that enables the breakdown of barriers, encourages collaborative work, shares knowledge and fosters partnerships to ensure people are treated with dignity and respect in an environment that supports safety and high quality care. The goal is to enhance the health care services of seniors, their families and caregivers who live and cope with responsive behaviours associated with dementia, mental illness, addictions and other neurological conditions, when they require it and wherever they live whether that be at home, Long-Term Care or in the community. Phase 1 -Long-Term Care Homes (LTCHs) Spread starting within 13 Early Adopter LTCHs and moving to all 68 LTCHs. Phase 2 -Community Spread begin with a few staff within community agencies and spread to all agencies and staff.

22 Centre for Complex Diabetes Care The Ministry of Health and Long-Term Care has provided funding for new Regional Centres for Complex Diabetes Care (CCDC) in the Central East and in other parts of the province. The Central East CCDC has been established in three sites located at Peterborough Regional Health Centre, Lakeridge Health Whitby, and The Scarborough Hospital. When fully operational, the Centre will offer care to patients with diabetes who have complex health issues and support needs beyond what can be provided in a primary care setting or through a Diabetes Education Program (DEP). A typical patient would be one who, because of social, mental health, and/or extensive co-morbidity factors, is not achieving diabetes goals despite his/her caregiver s best efforts. This person would come under the care of a dedicated team at each CCDC site, led by a Nurse Practitioner that draws expertise from a range of professionals including a social worker, nurse, dietician and pharmacist. Appropriate specialists would be consulted when advisable.

23 Centralized Diabetes Intake A more streamlined and integrated service for the intake and referral of patients living with diabetes has been expanded for the Central East region. The Centralized Diabetes Intake, supports the Ontario Diabetes Strategy to improve care for Ontarians living with diabetes. It is anticipated that improved access to diabetes care and services will decrease emergency department visits and hospital admissions for people living with diabetes. The will support intake and patient referrals to existing Diabetes Education Programs and the Central East CCDC. The CCAC has both the mandate and infrastructure to support centralized intake and referrals and can also offer patients help with health system navigation. The Centralized Diabetes Intake has one number to call and a common referral form. Toll free number Referral fax number

24 Community Palliative Nurse Practitioner Program The Community Palliative Nurse Practitioner Program (CPNP) is a program supporting individuals and their families in the community living with a terminal condition. CPNPs have expertise providing palliative care in client's home. What Community Palliative Nurse Practitioners Do: Visit palliative clients in their home while working in partnership with the visiting nursing staff and the health care team Provide an opportunity and support the client s wish to die at home Provide physical, emotional, psychological and spiritual support Serve as a source of education and support for client, family and care providers Help diagnose health problems, provide treatment for pain and other symptoms

25 Nurse Practitioners Supporting Team Averting Transfers (NPSTAT) Reducing and preventing avoidable emergency department transfers of Long-Term Care Home residents Providing acute and episodic care referrals to LTCHs throughout the Central East LHIN Reducing the number of Alternate Level of Care (ALC) days Facilitating and supporting the return of hospitalized residents back to their LTCHs. Providing primary health care services to unattached frail seniors 70+ Building capacity, knowledge and skills of LTCH staff

26 Services Available (NPSTAT) Diagnose and communicate a diagnosis Order prescriptions,laboratory tests, authorize various assistive devices and forms Bladder scans Initiate and order IV solutions and drugs Hypodermoclysis for rehydration Venipuncture Percutaneous draining tubes Central venous access devices (e.g., PICC line) Order diagnostic tests (ECGs, Ultrasonography & X-Ray) Certify Death (Certificate of Death - Form 16) Sharp debridement of wounds Gastrostomy tube (G-Tube) replacement Referrals: OT, PT, RD, SLP, Pharmacist, Social Work, Chaplin, Palliative and Medical Specialists, High Intensity Funding

27 Rapid Response Nurses (RRN) The Rapid Response Nurses will: Provide professional settlement services which includes an in-home visit 24 hours post-acute discharge, medication reconciliation, contact with the primary care provider to provide a health care update, review the course of stay in hospital and discharge summary, and to discuss the plan of care. The RRN would also be responsible for arranging an appointment with the primary care provider so that the client will be seen within five to seven days of discharge from hospital. will collaborate closely with the CCAC Care Coordinators both at the hospital and in the community The RRN will not be utilized as a substitute for our contracted Nursing Providers.

28 Mental Health and Addiction Nurses This program was created to support District School Boards to build capacity to recognize and respond to student mental health and addiction issues. These nurses are an integral part of an interdisciplinary District School Boardbased team of mental health leaders, community mental health workers, and existing District School Board staff that will work together to provide early identification and intervention services and supports to students who have mental health and addiction issues. The focus of the program is to support students transitioning from hospital back to school and to provide education on mental health promotion, resiliency, skill development for the student population where required as identified by the school boards. Referrals for this program are accepted from the hospital, school teams or the school administrators only.

29 Self-Management - Living a Healthy Life The Central East LHIN Self Management Program, Living a Healthy Life offers Self-Management Workshops which empowers people to develop new tools and skills to break the cycle of symptoms that can result from chronic conditions, diabetes or pain. Six consecutive weeks 2 ½ hours per week Peer volunteer lead All materials are supplied Free Family members and caregivers are welcome Workshops are available in English, French, Tamil and Chinese For workshop schedules contact:

30 Choices and Changes Choices & Changes is a workshop created by the Institute for Health Care Communication and accredited by the College of Family Physicians of Canada (CFPC). This workshop is designed to acquaint participants with the literature, theory and techniques for promoting change in health behaviours. By the end of the workshop participants will be able to: Describe the role of the clinician as a facilitator of change Assess patients' conviction and confidence to engage in health behaviour change Describe two skills to influence change in patients' health behaviours Demonstrate two techniques to use in clinical settings to influence change and promote adherence to treatment plans Workshops are offered at no cost to clinicians and are sponsored by the Central East LHIN Self-Management Program. Clinicians who successfully complete the training will be eligible for a certificate and CFPC Mainpro-1 credits.

31 CCAC Vision and Mission Our Vision Outstanding care - every person, every day Our Mission To deliver a seamless experience through the health system for people in our diverse communities, providing equitable access, individualized care coordination and quality health care.

32 On a day-to-day basis, we are: an easy to use gateway to information and high quality health services; an innovator seeking to optimize people's health, well-being and autonomy; an integrator partnering with others to reduce the barriers to access, respect diversity and improve the care experience of people across the health care continuum; an employer of choice who believes in the remarkable capacity of our people to continuously learn and make a difference; an open communicator who promotes positive relationships; and a steward of public resources who is openly accountable and contributes to a sustainable health system.

33 Our Values Caring We relate to each other, to those we serve and to those with whom we work with compassion, respect, integrity and fairness and value the contribution of everyone. Excellence We base our decisions on ethical principles and best available information and our actions on best practice. Centered on the Patient We encourage and promote personal responsibility and informed and participative decision-making. Collaboration We co-ordinate our efforts, working in partnership with colleagues, patients, families, caregivers, providers and the community. Accountable We manage resources responsibly, share performance related information freely, and foster a culture of open communication. Continuous Improvement As a learning organization, we foster a spirit of inquiry, committed to improving understanding and encouraging innovation.

34 Facts and Stats The is one of 14 CCACs in Ontario The, formally established on January 1, 2007, is the result of the alignment of the following predecessor CCACs: Durham Access To Care, Haliburton, Northumberland and Victoria Access Centre, Peterborough Community Access Centre, and Scarborough Community Care Access Centre The has seven branches: Campbellford, Haliburton, Lindsay, Port Hope, Peterborough, Scarborough, and Whitby. Staff members are also located in a number of satellite offices in hospitals, family health teams, physician offices and long-term care centres

35 Facts and Stats The is the: Sixth largest CCAC based on geography covering approximately 16,673 square kilometres Second largest based on a population of approximately 1.6 million people. We serve approximately 37,000 patients on any given day Second largest CCAC based on a budget of approximately $260 million for the fiscal year thereby spending over $700,000 per day (91% contracted client service and care coordination, 5% general admin. 2% IT and 2% plant operations)

36 Facts and Stats There are 9 hospitals operating out of 15 sites within the Central East region: Campbellford Memorial Hospital Haliburton Highlands Health Services Haliburton, Minden Lakeridge Health Corporation Bowmanville, Oshawa, Port Perry, Whitby Northumberland Hills Hospital Peterborough Regional Health Centre Ross Memorial Hospital Rouge Valley Health System Ajax Pickering, Centenary The Scarborough Hospital General Campus and Birchmount Campus Ontario Shores Centre for Mental Health Sciences NOTE: While the Uxbridge site of the Markham Stouffville Hospital is located within the Central East LHIN boundaries and serves patients from this region, the hospital is funded by Central LHIN and therefore does not appear on the hospital list. There are 68 long-term care homes with approx. 10,000 LTC beds 7 Family Health Teams 8 Community Health Centres 9 School Boards (3 shared with Toronto and 1 shared with North Simcoe) and 2 Children s Treatment Centres

37 Facts and Stats On an annual basis the serves: 77,697 unique patients 60,525 in-home patients 11,643 school health support services children 3,804 visits to the outpatient care setting (Alternate Care Settings) On an annual basis the : Assesses 14,000 clients for Long-Term Care Facilitates the placement of 2,700 patients to Long-Term Care Provides 601,141 Nursing visits Provides 218,088 hours of Shift Nursing Provides 42,408 Physiotherapy visits Provides 67,030 Occupational Therapy visits Provides 2,890 Nutrition visits Provides 15,533 Speech visits Provides 4,638 Social Work visits Provides 2,833,282 hours of Personal Support Provides 3,687,646 units of In-Home Service

38 You might turn to the Central East CCAC because: you were recently released from hospital after surgery or a serious illness your neighbour needs a little extra help to manage at home your child needs support of a health professional at home or in school you or someone you know is no longer safe living alone and ready to move into a long-term care home