an Access to Care initiative
What is Access to Care?
The Access to Care project, in partnership with Hospitals and Community Support Service Agencies, is an approach to care in which everyone works together to ensure that those who are at high risk of not returning home after their acute hospital stay have the opportunity to be discharged to their homes.
Two key values of this approach are empowerment of the individual/family in care decisions and equitable access to the right level of care in a timely manner.
In order to accomplish this outcome, there are three distinct initiatives in progress. All of them may impact patient volume and levels of care in organizations.
- Home First
- Assisted Living, Supportive Housing, and Adult Day Programs (AL/SH/ADP)
- Complex Continuing Care and Rehabilitation (CCC/Rehab).
Remaining in hospital after the need for acute care has passed does not contribute to patient recovery. The Home First approach to care is based on the philosophy that when a person enters hospital, everyone will work together to get that person home upon discharge.
While still in hospital, a home care plan is developed to support the patient's
recovery. The plan is developed by the patient (and family), nurses, doctors, therapists, and the patient's Care Coordinator. Once the patient has returned home, care providers may include personal support workers, therapists and nurses. The care plan is closely monitored by a Care Coordinator and modified, as needed, to fully support the patient. Patients also receive ongoing support from their Care Coordinator to help them navigate the health care system and to provide them with information about additional community services that exist (e.g. Assisted Living, Supportive Housing and Adult Day Programs).
This approach to care enables patients and their families to make major life decisions about their futures while in their own homes, with stable health, rather than in hospitals during a medical crisis.
Major elements of the Home First approach include:
- Concentrated and coordinated discharge planning approach
- Individually tailored care plans for clients
- Collaborative care plans are coordinated by Intensive Care Coordinators; service hours decrease as patient's health improves
- Patients recuperate at home while making decisions about remaining in their homes, alternative care plans, community supports or Long-Term Care
Watch this video to hear about one patient's experience with the Home First program.