With a service area the size of Germany, the humble telephone is a very efficient and effective communication tool for the North East CCAC. In fact, almost every assessment begins with a phone conversation between an individual seeking support for themselves or a loved one and a regulated health professional who will coordinate that care. Anyone – a physician or other care provider, family member, or individual – can make a referral to the North East CCAC by calling 310-2222 (no area code required). Let's follow "Mary" through the process.
Once the referral is received, an Access Care Coordinator will contact Mary directly by phone and through a series of standardized questions, they will discuss her health condition, care requirements and the types of services that would be available to support Mary at home. Together, they will build an individualized care plan, a "basket of services" if you will, to help meet Mary's care needs. If Mary's needs aren't urgent, an in home assessment visit may be scheduled to develop the care plan.
Of course, there are times when a telephone assessment is not appropriate. For example, an individual may have cognitive or communication challenges that inhibit their ability to actively participate in a telephone conversation. These could include hearing loss, speech or linguistic impairments, mental health challenges, or simply the lack of a knowledgeable "substitute decision maker" who could participate in a preliminary discussion. In the majority of these cases, a Care Coordinator would schedule a home visit and with the individual's consent, involve other family members or caregivers in the assessment as appropriate.
Another key care transition involving the CCAC assessment process is when patients are moving from hospital to home. In many of the larger hospitals in the North East, our Care Coordinators are on site and work closely with the multidisciplinary discharge teams to assess patients who may require CCAC services to help them transition safely and resume their normal activities once home. In smaller communities, the hospital would initiate the referral to the CCAC.
Let's bring "Mary" back to our story.
After an unfortunate fall, and a brief stay in hospital, Mary is being discharged with IV antibiotics to treat her leg wound. The hospital discharge team refers Mary to the CCAC, and an Access Care Coordinator will contact Mary, typically by phone, to discuss her needs. Finding her to be otherwise healthy, the Care Coordinator develops a service plan that includes wound care and administration of her IV medications. A visit(s) by the appropriate service provider is scheduled, Mary receives her care, and once her wound is healed or no longer requires nursing support, she is discharged from CCAC services.
In contrast, Mary's hospital roommate "Ann" is being discharged from hospital after a flare up with her chronic illness. Ann has had cognitive and mental health impairments since youth, is diabetic, and uses a wheelchair. Her mother is elderly with health issues of her own and needs help to provide the care Ann will require when she returns home. In this instance, while the Access Care Coordinator will discuss Ann's care with her mother and set up the initial services required to transition her from hospital to home, a Community Care Coordinator will schedule a home visit to develop a more comprehensive, long-term care plan.
Not all individuals referred to the CCAC require the level of care that we provide in the home. On these occasions, our team can suggest and provide information to callers on alternate health programs or resources that would better meet their needs, and if requested, can link them directly by phone to the appropriate community service.
So now you know the ABCs of assessment at the North East CCAC. In an environment of limited resources, increasing patient volumes, and geographical challenges, the telephone remains a vital communications tool to establish and maintain connections with patients across our vast region.