WATERLOO WELLINGTON COMMUNITY CARE ACCESS CENTRE

Spring 2014
Working Together to Reduce ALCs
A recent province-wide ALC report
contained some very good news for
Waterloo Wellington. In December
2013, our LHIN had the lowest ALC
rate in the province, at just 7.3%.
There are many reasons for this
success, but one is the introduction
of Coordinated Bed Access for
rehabilitation, restorative care,
complex continuing care, and most
recently, convalescent care. “We
took a fragmented system with a
myriad
of
processes
and
streamlined it so that all patients
flow down one superhighway,” says
Martina Rozsa, Director of Patient
Services at the CCAC.
“That’s
better for the patient and for the
system.”
Janice MacDonald, Professional
Practice Lead in the Social Work
Department at Guelph General
Hospital, says the change process
worked because of “a good team
approach” and openness on the
part of everyone involved to raise
concerns and solve problems
together. “At the beginning there
were some worries,” she says. “But
we have developed a great
relationship with the CCAC intake
team and everyone is on the same
page.”
During a recent presentation,
Rozsa used the example of “Joe” to
show the benefits of the new
system.
When Joe, 62, suffered a stroke, he
got to hospital quickly and
received
excellent care. But when he
was ready for rehabilitation,
the
p r o ce s s
became
cumbersome. He had to
apply to each rehab facility
separately,
sometimes
facing different eligibility
requirements. The process
was frustrating and timeconsuming.
With
Coordinated
Bed
Access, Joe’s story is quite
different. He has access to
any rehab bed in the
Waterloo Wellington region
with a single application.
“There’s less waiting, less
confusion,
and
less
frustration,” says Rozsa.
“Joe’s chances of a full
recovery are also better.
Hospital beds are available
sooner, easing the pressure
o n
e m e r g e n c y
departments.”
MacDonald
agrees. “This really streamlines the
process – the turnaround time
seems to have shortened, and
patients are getting to the most
appropriate beds to suit their needs
with less delay.”
A daily reporting system ensures
that hospital teams can track their
patients through the process. The
sites receiving these patients
benefit from more appropriate
referrals and a better ability to fill
beds as they become available.
Ongoing
consultation
and
communication ensure that
processes are continuously refined.
Another factor contributing to the
reduction of ALCs is the Home First
approach adopted by the CCAC and
its hospital partners. The CCAC’s
intensive services program makes
it possible for complex patients to
get home from hospital while
waiting to move to long-term care.
Rosza notes that one-quarter of
these patients are able to stay at
home on a reduced care plan.
“Patients are moving through the
system faster,” she says. “By
committing to collaboration and
working closely with our partners,
we’ve been able to make a real
difference.”
WATERLOO WELLINGTON COMMUNITY CARE ACCESS CENTRE Who’s Your Hero?
Message from the CEO
Gordon Milak, CEO Every
day
in
our
communities people go
above and beyond to
provide patients with care
at home.
Personal support workers
become valued members of the family. Nurses provide
skilled and compassionate care. Community volunteers
deliver hot meals and warm smiles. Devoted spouses
provide loving care, 24 hours a day.
Yet this important work is often invisible, and
sometimes under-valued. That’s why we at the CCAC
are launching “Heroes in the Home,” a recognition
program that celebrates the unsung heroes who help to
support our patients and families at home and in the
community.
The concept is simple. Anybody can make a nomination.
You can recognize a care provider, such as a PSW, care
coordinator, nurse, therapist, physician or social
worker. Or you can recognize an informal caregiver – a
devoted family member, generous friend, or committed
community volunteer.
With Heroes in the Home we have an opportunity to
recognize extraordinary individuals. But we also shine a
spotlight on home and community care as a whole. It’s
a chance to step back and think about the important
work we do together, and the impact we have on
thousands of lives. At the CCAC, we know that we can’t
do it without you, our partners. Please join us on
June 25 to celebrate the best of community care.
To nominate a Hero in the Home, click here to go to the
(short and simple!) nomination form.
Nominations are due by May 23, 2014.
Everyone who is nominated will be recognized at a
special celebration at Bingeman’s on June 25.
Funding Announced for Palliative Care
On March 28, the Hon. Liz Sandals and the Waterloo
Wellington LHIN announced $1 million in annual
funding for palliative care at home and residential
settings across the region.
Accreditation Canada has granted the CCAC
the highest level of accreditation
"Accredited with Exemplary Standing."
2 In the photo from left to right: Rosslyn Bentley,
Executive
Director—
Hospice
Wellington;
Albert McIlraith, a caregiver whose poignant letter of
appreciation to the CCAC was quoted at the event;
Joan Fisk, Chair of the Waterloo Wellington LHIN;
Gordon Milak—CCAC CEO; and the Hon. Liz Sandals,
Minister of Education and MPP for Guelph.
2 Join the Debate!
What’s the Buzz?
What should we expect from our health system? How will we come together to meet the needs of patients? How will
we pay for a transformed system? How will we value and care for our informal caregivers? These are some of the
questions explored in a series of four papers published by the Ontario Association of Community Care Access
Centres, Health Comes Home: A Conversation about the Future of Care. Some of the key issues are
summarized at an interactive website, moreandless.ca, which also offers an opportunity to share your ideas for the
future of health care on Facebook or Twitter.
Community Stroke
Engagement
On February 20, the CCAC held a stroke engagement
session
with
community
partners,
hospitals,
community agencies and stroke survivors. The full-day
event was part of a project to implement best practice
in the provision of in-home therapy for patients who
have had a stroke and aren’t able to attend group
therapy programs.
The CCAC project team shared the new model of care
with those in attendance, and asked survivors for
advice on evaluating the program. “We want to
understand what really matters to them, and then
design a unique patient satisfaction survey based on
their insights,” says Arsalan Afzal, Planning Manager
with the CCAC. “The day was very successful. We see
it as the beginning of an ongoing partnership with
stroke survivors.” Afzal says there will be more
engagement sessions in the future.
CCAC Quality Report
Published
How We Care, the 2012-2013 CCAC Quality Report,
was published in March and is now available online at
http://www.wwccac.org/HowWeCare
Among the highlights:
 Last year, CCACs helped more than 650,000 people
receive care in homes and communities across
Ontario.
 93% of patients and caregivers surveyed said they
had a positive experience with the care they received
from the CCAC.
New Website Launched
The CCAC has a revamped website designed to make it
easy for all stakeholders to find the information they
need. A key component of the new site is the Partners
page
(http://healthcareathome.ca/ww/en/Partners).
Check it out and let us know what you think!
SMART About Staying
Active
Seniors Maintaining Active Roles Together (SMART) is a
national, evidence-based program of gentle exercise
and falls prevention. For patients who have been
discharged from physiotherapy but can’t get out to a
group class, the program is offered in-home by
community support services on a referral basis. To find
out more or make a referral, please contact:
Waterloo Region: Community Support Connections,
Meals on Wheels and More: Janis Doran 519 772 8787
Guelph/Wellington County: VON, Kelly Gee
519 323 2330
 CCAC
patients referred from hospital had a
readmission rate to the emergency department of
8.2%, down from 14.3% in 2009.
 Compared to 2009, 18% more patients are going
home from hospital with supports, and 37% fewer
people are going to long-term care homes.
 Half of patients with complex care needs referred
through hospital had their first service visit within
one day, and 90% of these patients had their first
service visit within five days.
3 3 Better Care, Link by Link
Health Links are developing across the region
“We are all committed to being patientcentered and holistic,” says Sylvia
Scott, a clinical manager with the
Guelph Family Health Team. “We
started by asking patients about their
experience and then wrapped care
around their needs.” Saide Haddad, a
CCAC care coordinator who is working
with the Guelph Health Link, adds,
“We’ve done a good job of building
relationships and trust among the
multiple sectors. We’re learning what
each other does and how best to share
information and reduce duplication.”
Gladys is 83. After a busy career as an administrative
assistant, she spent many years as a dedicated
community volunteer. Over the years, Gladys has had
to live with several chronic health problems. Recently
she had a fall and her daughter took her to the
Emergency Department. Although she was unhurt, she
still felt dizzy.
Fortunately, Gladys is a Guelph Health Link passport
holder. When Gladys was identified as a Health Link
“candidate,” she was asked to participate in a “What
Matters to Me” interview. A nurse and a social worker
met with her to hear her story and develop her
passport. The passport means that her needs are
understood by everybody involved in her care, and she
doesn’t have to re-tell her story everywhere she goes.
Gladys’s team checks in regularly with her, and can call
a meeting of the whole care team if issues arise.
The Guelph Health Link has also introduced other
tactics, including integrated care plans, joint CCAC and
primary care home visits, and a single “go-to” person
for each patient. More than 200 patients already have
Health Link passports, and the initiative is expanding
rapidly. Health Links are also under way in North
Wellington, Kitchener Waterloo and surrounding areas,
and Cambridge North Dumfries, with each one
developing a similar approach.
4 It helps that Guelph has just one
hospital and most family doctors
belong to the FHT. But the Health Link
team also reached out to mental health
services, first responders, social assistance, the police
and other community partners. “We’re trying to
support patients in ways that link together the various
providers in the community,” says Jennifer Mackie,
Health Links Coordinator for the Guelph Family Health
Team. “Ultimately, we want to enable them to stay in
their homes and have the best possible quality of life.”
After her fall, Gladys and her daughter attended a
“roundtable” meeting with her pharmacist, CCAC care
coordinator, a hospice coordinator, a nurse, a social
worker and her family physician. Together they
developed a plan that included medical tests and
assessments, a transportation service, an Adult Day
Program, a volunteer companion, and caregiver
support for her daughter. Gladys was delighted with
the meeting, saying she felt very well cared for.
“Health Links are about having everyone involved in a
person’s care working together and communicating
with one another,” says Haddad. “Ultimately it’s a team
with everyone collaborating to create a seamless
experience for the patient with complex needs moving
through the system.”
To learn more about how Health Links work, visit
http://www.health.gov.on.ca/en/pro/programs/
transformation/community.aspx
4