Enhanced funding, a new approach and a heightened sense of teamwork resulted in some impressive improvements in physiotherapy wait times over the past 12 months. According to Clinical Services Manager, Stephanie Chevrette, the time patients are waiting for in-home physiotherapy services has improved by 61% and the total number of patients waiting for service has dropped by 71%.
"When patients are seen faster, it helps reduce the risk of at home injuries and assists on their path to independence," says Stephanie. "I'm very proud of the entire team."
For patients who have been prescribed multiple medications, keeping track of the correct doses and frequency is not only a challenge, the risk of errors can be life-threatening.
"Not taking medication correctly can definitely affect a patient's management of a chronic illness or recovery from an acute episode," says Lily Petrus, Management Lead for medication safety. In 2013-2014, the North East CCAC took steps to address this patient safety issue by implementing medication reconciliation. Today, it is incorporated in a number of CCAC roles – from care coordinators to rapid response nurses, from nurse practitioners to nurses contracted with CCAC service provider organizations – and is a key component in a patient's care plan.
"The reconciliation process begins with reviewing the medication the patient is taking and comparing it to the current medication list obtained from the patient's physician or pharmacist," Lily adds. "Education is also provided to help patients take their medication safely on an ongoing basis."
The Patient-Managed Care Program empowers patients and family members to be active partners in defining their health care needs and how they will be met.
"This pilot project gives patients control over their personal support services," says Project Manager Mark Richards. "Who delivers the care, when it happens, and what is done during the visit are all managed directly by the individual receiving the care.
This program is an important first step toward a true patient-centred health care system." The North East CCAC has three patients currently enrolled in the pilot program in the Sudbury area.
A new Primary Palliative Care Team in North Bay is working with a small group of palliative patients and their families to develop a more comfortable integration care plan. The pilot project takes a multi-disciplinary approach, with care coordinators, palliative nurse practitioners and registered nurses, personal support providers and therapists all working together to provide specialized supports for palliative patients. The successful model is now being implemented in Sudbury and Sault Ste. Marie. In 2014-2015, the North East CCAC provided care to 1435 palliative patients and those needing end-of-life care and support. Of those, 158 patients were able to die with dignity at home.
Assess and Restore
Funded for the past two years, the Assess and Restore program provides necessary equipment and/or home renovations to allow patients to live safely in their homes and maintain independence for as long as possible. The benefits of the program are not all physical, however, with patients experiencing huge improvements in their emotional and mental wellbeing. "I have witnessed more than a few tears of joy during this process," explains Occupational Therapist Nathan Laakso.
"While we may take something as simple as stepping outside to get the mail for granted, adding an exterior ramp for a wheelchair bound patient translates to freedom and independence." While applicants did not have to be on care with the CCAC to access the program, the funding was time-limited, ending March 31, 2015.
In communities across the North East, many family members take on the responsibility of providing day-to-day care for their loved one. According to Placement Admission Coordinator, Janic Feth, when patients who need 24/7 support are placed into long-term care homes, it not only provides relief for the primary caregiver, it helps them feel like a family member again.
"It's a similar situation for patients who need long-term care but are residing in hospital – we know we are improving their quality of life by placing them in a more appropriate, homelike environment," says Janic. But long-term care is not the only solution for patients and families requiring extra support.
"By offering such placement services as Short Stay Respite, Convalescent Care, and Assisted Living, we are maintaining patients in their home longer and decreasing the likelihood of hospital admissions," adds Janic.
Excellence in Dementia Care
In 2014, three representatives from the North East CCAC embarked on a weeklong study tour to the Netherlands at the invitation of Windesheim University in the provincial capital of Zwolle. Focused on case management excellence for people with dementia and their families, the ultimate goal of the research project was to create an international community of practice of researchers and care coordinators.
"This was practical research," says Care Coordinator Nathalie Bureau, one of the CCAC reps on the tour.
"I brought home a number of tips and tools that are helping our Care Coordination team take a more holistic approach to care for dementia patients and their families."
e-Notification is an award-winning initiative that, as the name suggests, electronically notifies the hospital and the CCAC when a CCAC patient presents at the emergency department, is admitted to hospital or is discharged. Operational 24/7, 7 days a week, the e-Notification tool gives hospital staff access to CCAC patient records so they can review what services the patient has been receiving at home. In turn, CCAC staff can decide if enhanced services can assist the patient to return home without being admitted to hospital, or if CCAC services need to be put on hold during a hospital stay or resumed after discharge. As of March 2015, North East CCAC has implemented e-Notification at 24 hospitals across the North East.
"This project has seen an unprecedented level of cooperation among partners for the benefit of our patients," states Peter Taylor, e-Notification Steering Committee Chair, and North East CCAC's Director of Business Solutions. "e-Notification enables patients to experience smoother transitions, faster discharges, fewer readmissions to hospital, and better follow-up care." The e-Notification Integration project was awarded the System Partnership Award at the 2015 OACCAC Awards for Excellence and selected team members have been invited to present at the Canadian Home Care Association's International Home Care Summit in Ottawa in November 2015.
Health Partner Gateway
Health Partner Gateway (HPG) is a web-based program which allows the North East CCAC and its primary care partners to securely exchange a patient's health information, allowing for enhanced communication, less duplication of service and overall better patient care. As of March 2015, 28 Primary Care organizations (Family Health Teams, Nurse Practitioner clinics, etc.) across the North East were accessing HPG. A number of these partners were also using the new "Automated Report Subscription" feature that generates a detailed report of what CCAC services the patient is currently accessing to help the primary care provider get a more fulsome picture of that patient's health status at any given time.
Resource Matching and Referral (RMR) is an electronic information and referral system that matches patients to the earliest available health care services that best meets their needs. Once identified, an electronic referral (e-Referral) directs the patient to that health professional or facility and recommends the type and level of care required.
"The project has seen health partners working actively together to ensure the right information is received at the right time so that even more benefits for our patients can be achieved," explains CCAC Project Lead, Karen Lacelle. Adds CCAC Triage Care Coordinator, Sherri Wuorinen:
"We have opened up the dialogue between our front line staff and our referral partners which will ultimately be a win-win for the patient." Now operational in seven hospitals across the North East, the plan is to introduce the e-Referral system to an additional 18 hospitals in 2015-2016.
HEALTH CARE PARTNERS
Primary Care Link
It seems simple, but connecting physicians with Community Care Coordinators and CCAC Managers in all regions of the North East can be a challenge. But establishing this primary care link is essential to quality patient care. After a concentrated effort in 2014-2015, the CCAC has successfully developed formal connections with all Family Health Teams, Community Health Centres and North East Specialized Geriatric Services. "Linking Care Coordinators with our primary care providers has promoted a seamless approach to wrapping care around our patients," explains Manager Christine Barbeau. "The development of this relationship has truly opened the lines of communication, which ultimately results in improved outcomes and value for our patients."
Hospital Integrated Discharge Planning
In an ongoing effort to improve the experience of patients transitioning from hospital to home, the North East CCAC and its hospital partners continued to promote the
Home First Philosophy. Simply put, the
Home First Philosophy focuses on keeping patients – specifically seniors and adults with complex needs – safe in their homes for as long as possible with support.
"The success behind the Integrated Discharge Program at Health Sciences North is the commitment of both CCAC and hospital staff to work together as one team," explains Manager Colleen Cleroux.
"The patient doesn't care where you work - they just want a seamless transition between hospital and home." This year, the CCAC supported 18,000 patients to return or to a home or to short stay rehab and convalescent care setting.
Community Response by EMS
The Community Referrals by Emergency Medical Services (CREMS) initiative is a long title for a valuable new program that is providing a safety net of sorts for individuals at risk in the community. The program empowers EMS Paramedics to refer directly to the CCAC on behalf of patients they encounter during the course of their daily work.
"In many cases, paramedics are the first to recognize the need for help and through the CREMS program they have become one of the primary links connecting patients to much needed support services to keep them home, healthy and safe," states Denise Charbonneau, CCAC Care Coordinator and Lead for the CREMS project in North Bay. The CREMS project is now operational in all communities across the North East.