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South West CCAC




The Home First philosophy

an Access to Care initiative

What is Access to Care?



The Access to Care project is led by the South West LHIN and the South West CCAC in partnership with Hospitals and Community Support Service Agencies. It 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 to make living arrangements and care choices in a comfortable place with all of the information and supports that they require. 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. The success of this approach will be measured, primarily by the number of days that patients have to wait in hospital for the most appropriate type of care.
 


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 across the South West LHIN.

They include: 

  1. Home First
  2. Assisted Living, Supportive Housing, and Adult Day Programs (AL/SH/ADP)
  3. Complex Continuing Care and Rehabilitation (CCC/Rehab). 



Visit Access to Care on the South West LHIN web site for more information.

Home First

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 CCAC 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 CCAC care coordinator and modified, as needed, to fully support the patient. Patients also receive ongoing support from their CCAC 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 CCAC Intensive Care Coordinators; service hours decrease as patient's health improves
  • Patients recuperate at home while making decisions about remaining in their homes, alternative CCAC care plans, community supports or Long-Term Care

To learn more, read the Home First Fact Sheet.



Watch this video to hear about one patient's experience with the Home First program.

Home First Year in Review - 2015

The Home First program is showing remarkable results. The number of patients waiting in hospital to go to long-term care has decreased significantly and many Home First patients are able to stay at home with regular CCAC services. Read the Home First Financial Impact Report 2015.

Highlights from the review:



 

The number of patients designated ALC-LTC in hospitals that have implemented Home First is decreasing. 



The graph indicates when each hospital initiated Home First.

 

  

Additionally, we are seeing rises in the:

  • complexity of those admitted to LTC with high or very high MAPLe scores

  • number of individuals being supported with robust service plans in the community
  • complexity of care needed by those receiving care through the South West CCAC


Home First One-year Impact Analysis

As many as 800 people a month are supported at home rather than in hospital thanks to the home first approach. Learn more about the impact Home Home First has had on patients, hospitals and the health-care system since it was implemented in the South West.