ANNUAL REPORT. Delivering High Quality, Integrated and Consistent Home and Community Care

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1 ANNUAL REPORT Delivering High Quality, Integrated and Consistent Home and Community Care

2 I ve been fortunate to work with some wonderful people through the WWCCAC. When I ve needed support, they have always been there. Sandy Warley

3 MESSAGE FROM BOARD CHAIR & CEO was an exciting year for the Waterloo Wellington Community Care Access Centre (WWCCAC). The Bringing Care Home (Gail Donner) Report re-ignited the discussion on home and community care and identified key areas for sector improvement. The Ministry s Patients First proposal that followed reaffirmed our shared vision of what home and community care could be, and confirmed that we were well on our way in planning and implementing key initiatives that will create greater integration between health care partners, greater consistency in care and a better patient experience initiatives that include our new neighbourhood model for delivering care. In the fall of 2015, WWCCAC Board of Directors, its senior leadership team, staff, and health care and community partners refreshed WWCCAC s strategic plan to closely align with the Ministry s vision for home and community care, as well as the Bringing Care Home Report, the Price-Baker Report and the Waterloo Wellington Local Health Integration Network Integrated Health Services Plan. The resulting strategic plan sets out 5 key priorities that will support the delivery of outstanding care and service, every person, every day, now and throughout the transition. In addition to changes to the sector, we also saw changes within our community. Last year we saw an increase in demand for services, specifically a 120% increase in the number of patients managing a complex health condition and a 52% increase in the number of patients managing a chronic health condition. Through the commitment and dedication of staff and our health care partners, WWCCAC met that demand and made it possible for more people to access care and remain safely in their home, which is where they want to be. On behalf of the Board of Directors and the Senior Leadership Team, we would like to thank patients and families, our community partners and WWCCAC staff for your ongoing support. We are proud of the work we did to support the modernization of home and community care in our region and we look forward to continuing to support this exciting transformation. Brian Cowan Board Chair Dale Clement CEO Annual Report 3

4 ABOUT WATERLOO WELLINGTON CCAC The Waterloo Wellington CCAC supports those living in our community with injury, illness or disability. We help them navigate an often complicated health care system, assess and identify their support needs, connect them to the appropriate services and advocate on their behalf. As always, our goal is to help people reach their optimal health at home which is where they ve told us they want to be. VISION: Outstanding care and service every person, every day MISSION: Partnering to provide equitable access to high quality, individualized, coordinated care in the home and community VALUES: Person-Centred Compassionate Responsive Accountable Leadership These five core values define who we are and how we work. They are imbedded in our Internal Compass and every member of our team demonstrates their commitment to these core values in their everyday activities. We refer to these guiding principles when making decisions, delivering care and service, and in interactions with patients, carers and partners Annual Report

5 YEAR IN REVIEW Supporting the Modernization of Home and Community Care In , WWCCAC refreshed its strategic plan in collaboration with the Board, staff and community leaders. Our strategic plan closely aligns with the Ministry s vision for home and community care, The Bringing Care Home (Gail Donner) Report, and the Price-Baker Report, as well as the Waterloo Wellington Local Health Integration Network s Integrated Health Services Plan. It sets out five key priorities for the organization: Outstanding Service Delivery, Inspired People and Culture, Effective Partnerships and Relationships, Performance Excellence, and Communication and Engagement. COMMUNICATION AND ENGAGEMENT OUTSTANDING SERVICE DELIVERY INSPIRED PEOPLE AND CULTURE EFFECTIVE PARTNERSHIPS AND RELATIONSHIPS These priorities are the cornerstone of our work and focus on delivering outstanding care and service, every person, every day. PERFORMANCE EXCELLENCE Annual Report 5

6 A Neighbourhood Approach to Delivering Care Our efforts this past year have focused on building the foundation for the modernization of home and community care. In collaboration with service provider organizations and staff, we developed our unique neighbourhood approach to delivering care. This new approach defines distinct neighbourhoods across Waterloo Wellington region which allows us greater ability to collaborate with care providers, family physicians and local resources in each neighbourhood and work with them as a team across disciplines. This innovative, team-based approach will enable greater communication, collaboration and consistency in care, and will provide the foundation for the transformation of home and community care in our region. At the core of this work are patients and improving the patient experience. Enhanced Rehabilitation in the Home This past year, WWCCAC implemented its Rapid Recovery Therapy Pilot program a 30 day intensive in-home therapy program aimed at helping patients leave hospital sooner to complete their rehabilitation in their own home. The pilot program provides daily therapy (one visit per day) for the first seven days, and then up to 10 additional visits over the next three weeks. Preliminary findings show that patients were able to safely return home an average of eight days sooner than their expected hospital discharge date. This program supports better patient flow across the health care system and allows patients to increase their functional independence in the comfort of their own home Annual Report

7 THE PATIENTS WE SUPPORT 120% increase in the number of patients served with complex health needs 52% increase in the number of patients served with chronic health needs 58% Senior (65+) 27% Adult (19-64) 15% Child (-19) People served by age group Annual Report 7

8 Expanding Access to Specialized Nursing Care WWCCAC opened its fifth Community Nursing Clinic in the Minto Rural Health Centre, making specialized nursing care even more accessible to our communities. Patients referred to one of our clinics can receive ambulatory nursing care, including wound care, intramuscular or subcutaneous injections, catheter removal and/or re-insertion, and intravenous therapy. There are many benefits for patients to receive care through a CCAC nursing clinic. Patients have quick and easy access to nursing services and can schedule appointments at their convenience - no waiting at home or visiting the Emergency Department for care. Getting out into the community supports independence, and provides an opportunity to socially interact with others. Expanding our ambulatory nursing clinics also creates capacity for our in-home community nursing teams by supporting those patients who are unable to leave their home to access nursing care. Last year, WWCCAC expanded its Wound Care Program with the recruitment of a Clinical Nurse Specialist and Nurse Practitioner, both with advanced wound care education and experience. These specialized roles enable greater collaboration with physician wound care specialists and primary care physicians in our region, and provide patients with increased access to best practice wound care assessment and treatment. On any given day, WWCCAC supports 18,000 people in our region Delivered nursing care to 4,777 patients in Community Clinics AN INCREASE OF 1,250 compared to year prior Annual Report

9 IMPROVING QUALITY OF LIFE FOR THOSE WITH ADVANCED WOUNDS From left to right: Sue Starling (WWCCAC Wound Coordinator/Wound Specialist), Siane Burgess (RN), Peter Wilson (patient), and Betty Pasca (RPN) Meet Peter Wilson For more than two years, Peter suffered from stubborn and complex Venous Leg Ulcers on each leg, making it difficult to walk. For two years, I was in pain every day and had trouble walking. More and more, I felt isolated from my friends and family says Peter. Peter was referred to WWCCACs Community Nursing Clinic where his care team implemented the Venus Leg Pathway - best practice care to treat Peter s wounds. WWCCAC. This is a critical first step in the Venus Leg Pathway because wounds can have many causes and the type of wound dictates the care plan. Peter s care included a holistic comprehensive clinical history and physical examination, followed by an Ankle Brachial Pressure Index (ABPI) test a test that measures blood flow and requires nurses to have advanced knowledge and speciality in leg ulcer management to ensure an accurate diagnosis. At our Community Nursing Clinic, the specialized team of nurses began with a lower leg assessment to determine if the wound was in fact a venous ulcer or if it was caused by arterial disease says Sue Starling, Wound Coordinator/Wound Specialist, Once the lower leg assessment and ABPI are completed, the treatment included obtaining a medical order from a physician to start compression wrapping of the legs. High compression therapy is considered best practice for venous leg ulcers Annual Report 9

10 Over time, and once the wounds were almost healed, the wound specialist made the appropriate arrangements for Peter to be fitted for compression stockings which support healthy blood flow to the affected area with the goal of preventing recurrence a gold standard practice in wound care. Peter s care team also included an occupational therapist to help Peter learn to apply and remove the compression stockings and a Personal Support Worker to assist with his personal care. Peter s wounds were extremely stubborn. As one would heal, another ulcer would re-occur. It took a lot of time and patience for the wounds to heal, but Peter and his team did not give up. Provided more than 2.5M visits/hours of service an increase of 400,000 visits/hours of service compared to year prior Peter was so determined to heal having him on board was key to a successful outcome says Michelle Currie, Clinical ParaMed Supervisor and Wound Care Specialist. It takes a multidisciplinary team, including the patient, in order to successfully heal a wound. Today, Peter s wounds have healed and although he must continue to wear his compression stockings to manage this chronic condition, he says life is much more enjoyable. The nurses at the clinic really went above and beyond for me. says Peter. I m thrilled to be able to go swimming again, at the local YMCA and at the lake. It s been years since I ve been able to do that life is good fun again. Delivered more than 1.7M Personal Support Worker (PSW) hours of service AN INCREASE OF 168,000 compared to year prior Annual Report

11 THANK YOU TD BANK! Children who may have trouble with fine and gross motor skills and sensory skill development will benefit from TD Bank s generous $20,000 donation. The donation, which is enabling the screening of more than 800 children on a waitlist for school-based occupational therapy, will help those children who struggle with printing, writing, managing things like their backpack, jackets, toileting, washing hands or difficulty developing coping skills to manage noise levels and other classroom stimulants. Regardless of their challenge, we know that these young years are critical in building the confidence of a child and play a key role in their ability to succeed in school and build relationships with peers which is why this initiative is so important. says Martina Rozsa, Senior Director Operations, Waterloo Wellington CCAC. In WWCCAC serviced more than 38,000 people in the Waterloo Wellington Region, 15% of which were children Annual Report 11

12 SEAMLESS TRANSITIONS FOR PATIENTS Hospital Discharge WWCCAC advanced the integration of CCAC staff with hospital discharge planning teams. WWCCAC has achieved one of the highest levels of integration with hospital partners in the province. For patients, this means a seamless transition from hospital to home and an overall better patient experience. Home First Intensive Services WWCCAC streamlined our Home First Intensive Services program to support patients to transition from hospital to their most appropriate destination, as quickly as possible. These process improvements have contributed to the Waterloo Wellington Local Health Integration Network s (WWLHIN) Alternate Level of Care (ALC) rate which is the second best in the province. Supported close to 14,000 people to make the transition from HOSPITAL TO HOME Supported more than 2,000 people to make the transition to LONG-TERM CARE Annual Report

13 WWCCAC s STROKE TEAM RECEIVES AWARD The work of our Stroke Team was recognized at the Ontario Association of Community Care Access Centre s Achieving Excellence Together conference. The Team Award recognized the work done to build positive relationships between Care Coordinators, hospitals, external service providers, and community-based stroke services; partners across the continuum of care that enable the delivery of best-practice stroke care to Waterloo Wellington Region. that provide stroke support services or resources, such as the YMCA and Stroke Recovery Canada, have also been formalized. The community providers collaborate with the Community Stroke Team through the Waterloo Wellington Community Stroke Advisory Committee, which meets regularly to share resources and critically review the patient journey across the program. The Community Stroke Program integrates designated care coordinators, both in hospital and in the community, using a consolidated service provider model to create community stroke teams that work together to design and deliver services according to the patient s specific requirements. The team includes occupational therapists, physiotherapists, rehab assistants, dieticians, social workers, and speech and language pathologists who work closely together and with each patient to reach individual goals and begin the integration back into the community and everyday life. of WWCCAC patients who rated the services they received and individuals who provided care as GOOD, VERY GOOD OR EXCELLENT Throughout the process, patients and families also play an integral role on the team, helping to define goals based on what is important to the patient and their family. As one Care Coordinator puts it, We re looking at whatever the patient considers a meaningful task. If that patient s goal is to get out and walk the dog, that s what we re going to focus on. Through the Community Stroke Program, connections with community agencies Connected 3,739 people in our community to a physician including 243 SYRIAN REFUGEES Annual Report 13

14 RECOGNIZING OUR COMMUNITY HEROES Caregivers in our community are the Congratulations to each of the 145 unsung backbone of home and community care and heroes from across Waterloo Wellington heroes to so many. Each year we recognize region and thank you for your hard work, their dedication and tireless efforts in dedication and compassion. supporting those living with illness, injury or disability so they can remain safely in the home, which is where they want to be Annual Report

15 FINANCIALS Statement of Operations 12 months ending March 31, in Millions March 2016 March 2015 REVENUE Net MOHLTC/LHIN Funding Other Revenue NET EXPENSES Patient Care Administration Balance Sheet 12 months ending March 31, in Millions March 2016 March 2015 ASSETS Current Assests Capital Assets LIABILITIES Current Liabilities Long-term Fund Balances Annual Report 15

16 Waterloo Office: 141 Weber Street South Waterloo ON N2J 2A9 For residents of the Region of Waterloo: For residents of Guelph, Wellington County and the Township of Southgate: wwccac.org Funding for the WWCCAC is provided by the Waterloo Wellington Local Health Integration Network (WWLHIN)