Central East Community Care Access Centre

Central East Community
Care Access Centre
Outstanding care
every person
every day
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.
Central East CCAC
The
Health
Sectors
of Ontario
Central East CCAC
Central East CCAC Region
The Central East CCAC 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:
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7.
Central East CCAC
Campbellford Branch
Haliburton Branch
Lindsay Branch
Peterborough Branch
Port Hope Branch
Scarborough Branch
Whitby Branch (Head Office)
Our Services
Central East CCAC 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 Central East CCAC
 A range of in-home health care and related
social services and supplies and equipment
 Specialized programs
Central East CCAC
Who can make a referral for service?
Referrals to the Central East CCAC can be made by:
 individuals
 family members
 caregivers
 friends
 physicians
 health care professionals
Central East CCAC
What We Do
Central East CCAC 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.
Central East CCAC
What services are available?
 Care Coordination
Central East CCAC 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
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Nursing
Physiotherapy
Occupational therapy
Speech-language therapy
Social work
Dietetics
Medical supplies and equipment
Personal support (bathing, dressing etc.)
Central East CCAC
HC
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
Central East CCAC
 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
Central East CCAC
 Specialized Programs
The Central East CCAC 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
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Central East CCAC
 Information and Referral
If a patient is not eligible for the services provided by the
Central East CCAC, 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.
Central East CCAC
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.
www.ontario.ca/healthcareconnect
800 445 1822
Once you have joined Health Care Connect, a Central East CCAC
Care Connector will be assigned to help you find a health care
provider in your area.
Central East CCAC
Call: 310-2222 or visit: www.centraleasthealthline.ca
Central East CCAC
Campbellford Branch:
119 Isabella Street, Unit 7
Campbellford ON K0L 1L0
705-653-1005
Port Hope Branch:
151A Rose Glen Road
Port Hope ON L1A 3V6
905-885-6600
Haliburton Branch:
PO Box 793, 13321 Hwy 118
Haliburton ON K0M 1S0
705-457-1600
Scarborough Branch:
100 Consilium Place, 8th Floor
Scarborough ON M1H 3E3
416-750-2444
Chinese Line: 416-701-4806
Lindsay Branch:
370 Kent Street West, Unit 11
Lindsay ON K9V 6G8
705-324-9165
Peterborough Branch:
700 Clonsilla Avenue, Suite 202
Peterborough ON K9J 5Y3
705-743-2212
Whitby Branch:
920 Champlain Court
Whitby ON L1N 6K9
905-430-3308
Toll-free: 1-800-263-3877
TTY Line: 1-877-743-7939
Website: www.ce.ccac-ont.ca
Central East CCAC
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.
Central East CCAC
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.
Central East CCAC
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.
Central East CCAC
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).
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
Behavioral Supports Ontario
Behavioural Supports Ontario (BSO) was first announced by the Ministry of
Health and Long Term Care in August 2011. 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
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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.
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.
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 Central East CCAC 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
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referral form.
Toll free number 1-888-997-9996
Referral fax number 905-444-2544
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
Nurse Practitioners Supporting Team
Averting Transfers (NPSTAT)
 Reducing and preventing avoidable emergency department
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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
Services Available (NPSTAT)
 Diagnose and communicate a diagnosis
 Order prescriptions,laboratory tests, authorize various assistive devices
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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
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.
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.
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:
www.healthylifeworkshop.ca
Central East CCAC
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.
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.
Central East CCAC
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.
Central East CCAC
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.
Central East CCAC Facts and Stats
 The Central East CCAC is one of 14 CCACs in Ontario
 The Central East CCAC, 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 Central East CCAC 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
Central East CCAC
Central East CCAC Facts and Stats
The Central East CCAC 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 2013–2014 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)
Central East CCAC
Central East CCAC Facts and Stats
 There are 9 hospitals operating out of 15 sites within
the Central East region:
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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 Central East CCAC 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
Central East CCAC
Facts and Stats
On an annual basis the Central East CCAC 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 Central East CCAC:
 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
Central East CCAC
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
Central East CCAC