On any given day across our vast region, the North East CCAC provides care and support to 15,000 individuals at home, in school or in the community. There are many different paths to CCAC care, but each and every one involves a CCAC Access Care Coordinator. In 2014-2015, our Access teams transitioned close to 34,000 people – that's almost 100 patients a day – from hospital to home, or onto CCAC care from the community.
Talking to that many people every day about their care needs offers a great opportunity to examine what you are doing well, and what you can do to enhance the patient experience. Our Access teams have utilized this frontline expertise to develop innovative ways to ease each patient's journey as they transition between care venues. How are we doing?
For one, we are reducing wait times by working with existing assessments and referral information, for example, from Long-Term Care Homes, which means our patients don't have to tell their stories twice (or more!). This makes the development of an individualized service plan a much more pleasant experience for the patient.
Our triage teams are working together regionally, using human resources in other branches to provide coverage during extended hours to meet priority patient needs. Managers are working regionally to assist each other in monitoring Access queues to troubleshoot when necessary and ensure our targets around referral to assessment times are being met (with success, we are pleased to report).
In larger centres across the North East, our CCAC Access Teams are located in hospitals, where they work collaboratively with their acute care colleagues to ensure a smooth transition for patients requiring home care services following a stay in hospital. Last year alone, our Access Teams received almost 14,000 in-patient referrals, and worked with another 11,000 patients who were previously under CCAC care and needed their home care services resumed after an acute care episode.
In many cases, patients can be assessed for home care services while still in the emergency department (ED), helping to avoid an unnecessary hospital admission. At the Sault Area Hospital for example, CCAC Care Coordinator Sunnie Robertson collaborates daily with the hospital's Geriatric Emergency Management (GEM) nurse. Using the new e-Notification system, Sunnie knows immediately when a CCAC patient has arrived in the emergency department. By informing the ED team of the CCAC services currently in place, serving as a resource to re-evaluate patient needs and providing counsel to family members and caregivers, Sunnie plays an important role in the decision around whether a patient needs to be admitted to hospital or discharged with CCAC support in the home. In 2014-2015, over 2500 ED referrals were coordinated by CCAC Access teams across the region.
Outside of hospital to home transitions, many of our patients come to us through community referrals – approximately 10,000 per year. Community Access teams are skilled in identifying each individual's health care needs, in consultation with family, friends and other informal sources of information. Research has shown that we are maintaining increasingly complex patients in home, helping them to live as independently as possible and avoiding unnecessary trips to hospital.
The North East Community Care Access Centre will continue its efforts to expedite referrals from both hospital and community to ensure patients and their families receive the care they need, in the right place, at the right time.
The CCAC's Sunnie Robertson, ED Care Coordinator and Elizabeth Dionisi, Access Team Assistant, work as a team with Heather Koskela, SAH GEM nurse, and Maureen Lowe, SAH ED Supervisor to ease patients' transitions from hospital to home