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How We Care: Programs and Initiatives

2013-2014 Annual Report

Care Coordinators are the pillars of home and community care. These health care professionals—nurses, social workers, occupational therapists and others—provide an essential role by working directly with patients and families to identify their needs and determine what matters to them.

Champlain CCAC Care Coordinators work in hospitals and emergency departments, with family physicians, in schools, with community agencies, and long‐term care homes across the region. Increasingly, they are using their specialized skills to identify high-needs patients earlier, so they get the right level of care and support in the most appropriate place.

Our team of therapists provide a range of services and supports to people of all ages including speech language therapy, physiotherapy, social work, and occupational therapy.


Making Decisions about Long-Term Care

We assist clients and their families in exploring long-term care options. Our highly knowledgeable professionals assess specific care needs when people are no longer able to safely stay at home. In 2013-14, the Champlain CCAC began publishing wait lists on its website for Long-Term Care Homes across the region.


Care for Seniors in the Community

We work closely with community support services to connect seniors with care in the community such as Meals on Wheels, Adult Day Programs and Respite. Our award-winning Elder Mediation program supports those caring for people with dementia.

Learn more about resources in the community here »


Helping Patients after a Hospital Stay

We work closely with the 19 hospitals in the Champlain region to explore every opportunity for patients to stay at home before considering other options. Our Care Coordinators help patients as they move between different health providers, services and settings to address their changing health care needs.


Care in the Schools

Our Pediatric Team coordinates in-school access to a wide range of professional health care services, including nursing, occupational therapy, physiotherapy, speech and language, and dietetics. In addition to delivering care during school visits, practitioners train school personnel and may provide required medical supplies, dressings and equipment for care. Our Mental Health and Addictions Nurses program help children and youth transition back to school and get the support they need.


Specialized Nursing Programs

Nursing care is an important part of our overall healthcare system. The Champlain CCAC recognizes that some people need specialized care in certain situations, where specially selected and trained nurses can make a meaningful difference to their recovery and well-being.


Rapid Response Nurses

In 2013-14, our team of Rapid Response Nurses helped over 887 adult patients to transition from hospital to home—helping to reduce hospital re-admissions and avoidable emergency department visits across the Champlain region.

These highly skilled registered nurses support patients with complex medical needs—frail adults, seniors and children—who are in need of specialized nursing care, by providing ongoing medical assessments during the first 30 days after hospital discharge.

Two Pediatric Rapid Response Nurses are currently part of a pilot program with CHEO, helping to provide safe transitions for children as they are discharged from hospital.

Learn more about Champlain CCAC's Rapid Response Nursing Program 


Mental Health and Addictions Nurses

Champlain CCAC's dedicated Mental Health and Addictions Nurses provide supports and services to children and youth in eight district school boards across the region. The nurses help students and their families by:

  • Meeting with students one-on-one in school or at home
  • Providing mental health and addictions education
  • Medication monitoring and support
  • Linking students to services in the community
  • Connecting with family doctors and schools

Our Mental Health and Addictions Nurses focus on the success of students, helping them to thrive at school, remain in school, or successfully transition back to school after being in hospital. 

Learn more about Champlain CCAC's Mental Health and Addictions Nurses Program


Champlain Regional Palliative Consultation Team

As patients approach the end of their lives, many want to be at home surrounded by family and friends. The Regional Palliative Consultation Team connects, supports and cares for patients who have a life-limiting illness in the Champlain region.

A partnership with Bruyère Continuing Care, this inter-professional consultant team includes physicians, Champlain CCAC nurse practitioners, advanced practice nurses, and nurse specialists with expertise in palliative care.  

Our nurses enhance the care team's ability to support even the most complex palliative care patients, so that they can continue to live with dignity, as comfortably as possible, in their own homes.

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