REPORT ON HEALTH SYSTEM NAVIGATOR MODELS

Transcription

1 REPORT ON HEALTH SYSTEM NAVIGATOR MODELS Prepared for: The Durham Haliburton Kawartha and Pine Ridge & The Simcoe York District Health Councils November 2003 Prepared by: Louise Pope

2 TABLE OF CONTENTS 1. INTRODUCTION PURPOSE OF SEARCH DESCRIPTION OF A PRIMARY NAVIGATOR SCOPE AND ORGANIZATION OF REPORT PRIMARY NAVIGATOR SERVICE MODELS NAVIGATOR MODEL: CANCER CARE NOVA SCOTIA CLIENT/PATIENT ACCESS SERVICES: SASKATOON HEALTH REGION 2.3 CARELINKS PROGRAM: FRASER HEALTH AUTHORITY BRITISH COLUMBIA WINNIPEG INTEGRATED SERVICES INITIATIVE SUMMARY ONTARIO: OPPORTUNTIES FOR PRIMARY NAVIGATION OF THE HEALTH SYTEM INTRODUCTION TO SECTION CANADIAN HOME CARE ASSOCIATION ONTARIO HOME AND COMMUNITY CARE COUNCIL PRIMARY HEALTH CARE REFORM ONTARIO CASE MANAGEMENT IN COMMUNITY CARE ACCESS CENTRES SUMMARY CONCLUDING REMARKS..12 BIBLIOGRAPHY WEB SITES CONTACTS FOR REFERENCE MATERIAL AND SEARCH FOR NAVIGATION SERVICES

3 REPORT ON HEALTH SYSTEM NAVIGATOR MODELS 1. INTRODUCTION 1.1 Purpose of Search The Durham Haliburton Kawartha Pine Ridge and Simcoe York District Health Councils jointly initiated a search for service delivery models that identified a primary navigator of the health system and coordinator of care for the individual consumer in the continuing care and community sector. The consumer groups included: seniors, adults with physical disabilities and/or sensory impairments, children with longer-term health care needs and caregivers. In the Report on Emerging Issues in Continuous Health Care for Long Term Care Populations 1 prepared by the Simcoe York District Health Council the need was identified for a primary navigator. It was highlighted as one of the features necessary to make the health system work well for all long-term care population groups and their caregivers. The purpose of the search was to identify examples of models, strategies and tools that could be used to dialogue with local agencies and Ministry of Health and Long-Term Care on ways to implement the primary navigator features and enhance the ease of navigation. As Dr. Sholom Gluberman in a speech to the Ontario Association of Community Care Access Centers 2 in October 2003 noted aptly and succinctly: Health is Complex To 1960: Health is a state of the individual body. To 1990: Health is primarily a function of environments. Now: Health is primarily a result of the complex interactions between an individual and the various environments. 1.2 Description of a Primary Navigator The planners from the two district health councils in a Consumer/Caregiver Survey 3 described the navigator as knowledgeable of the needs and supports available for the specific populations. The navigator/coordinator plays a role in the coordination of services for the consumer. The navigator/coordinator can be a service provider, parent, 1 SimcoeYork District Health Council (March 2003). Report on Emerging Issues in Continuous Health Care for Long Term Care Populations. Newmarket.p Speech to the Ontario Association of Community Care Access. Centers. 3 SimcoeYork District Health Council (October 2003). Community Consultations for Long-Term Care Consumers, their Families and their Caregivers. 1

4 self, family or friend. Generally the role of the navigator is described to be a consistent contact, personal guide, someone who has or can learn and assemble the information needed and someone to identify possible routes for service and support. The goal of the primary navigator is to enable the consumer and caregiver to make informed decisions about maintaining and improving their own health by providing thorough information with respect to their disease or disability and facilitating timely access to the health and long term cares. The Canadian Report, Investigation and Assessment of the Navigator Role in Meeting the Information, Decisional and Educational Needs of Women with Breast Cancer in Women, 4 conducted a literature search to examine the role of patient navigator and found three major navigator models in the literature. One model had a strong coordination component that was implemented by a nurse or physician. The second model s component was education and information and could be carried out by a volunteer or a professional. The third model was a shared or tacit model involving several professionals. The role of the patient navigator was described as a person who assists patients to get into and through the health system. The navigator informs patients of the various services available, coordinates their care and assists them with decision-making about treatment, care and other issues. The study identified a number of factors to consider when developing a navigator position based on the literature review and interviews with key informants. Elements to take into account included: Job Description role can overlap and duplicate other role Follow-Up Role can overwhelm other resources Resource Allocation can be unrealistic Marketing Plan as important as design and implementation Staffing considerable variation as who did the role and training Training and preparation no formal training program Navigator limitations Availability of resources are key Doing vs. Empowering Empowerment approach has greater long-term payback 1.3 Scope and Organization of Report The search for service delivery models included resource people in community agencies, associations, regional heath authorities, federal and provincial governments and a number of web sites. 4 Health Canada (2002). Investigation and Assessment of the Navigator Role in Meeting the Information, Decisional and Educational Needs of Women with Breast Cancer in Canada.p.i. 2

5 Resource material included a range of sources such as: service providers, reports, newsletters, policies, websites, briefs, research documents, federal, provincial and professional associations. Where possible, resources were personally contacted by telephone and also by to obtain relevant information. Eighty sources were researched. The next section in the report will describe four services that have staff positions that function as primary navigators for consumers and caregiver. Following that section, there will be a discussion of current initiatives on the part of committees and associations exploring the role of the case management in home and community services. At the end of the report there is a list of references providing resource material for further review and exploration 2. PRIMARY NAVIGATOR SERVICE MODELS 2.1 Navigator Model: Cancer Care Nova Scotia Cancer Care Nova Scotia (CCNS) developed and implemented the Patient Navigation Service in partnership with three District Health Authorities. The staff, called Patient Navigators, is located in three hospitals and is part of the district cancer care team. Initially, CCNS received funding for the three positions on a pilot project basis from the Ministry of Health in The positions are now funded by and report to three District Health Authorities. There is a formal link with CCNS because from the onset, the service objectives, goals, policies, education, monitoring and quality improvement of the navigation network were provided by the patient navigation manager at CCNS. Patient Navigation is described in the report Clearing a Path for Patients Evaluation Framework 5 as a client centered outcome-focused case management approach put in place to help health professionals, patients and their families and district health leaders deal more effectively with cancer and the cancer system. The goals of the service are: To ensure cancer patients and their families have information, knowledge and the support they need as they journey through the cancer system. To assist family physicians, surgeons, community base specialists, oncologists and other health professionals provide optimal cancer care to patients. To enhance district health authorities capacity to care and support people with cancer and their caregivers. 5 Cancer Care Nova Scotia (November 2002). Clearing a Path for Patients: Patient Navigation Evaluation Framework. Halifax. p.4. 3

6 The role of the Patient Navigator is one of coordination of services, education to families and to strengthen support to the role of family physicians. Posters, brochures, and a handbook have been developed to publicize the program and a toll free number is provided. The overall message in the publications is that navigators will guide people through the health care maze and help them get information and support. In a meeting with the project manager from CCNS, she indicated that over the eighteen months, that the program has been operating, the three staff members have served 900 patients. Family physicians and/or staff in regional hospitals make most of the referrals. As discussed by the program manager, the physician may call the navigator after the patient learns of the cancer diagnosis. In a lot of instances, the navigator and the physician will meet with the patient within several days to discuss the treatment and programs available. When patients have finished cancer treatments such as radiology and chemotherapy they are linked back to their local community health and social services resources such as homecare, and cancer support groups. As well as helping patients and their families through the health care system, the navigators support family physicians and surgeons, oncologists, community-based specialists and other health professionals by: Participating with the cancer care team in the district health authorities. Educating and preparing the patient for treatment visits. Assisting in the referral of patients to cancer specialists and centers. Acting as a liaison between community-based professionals and provincial cancer care programs. The evaluation report will assess if the patient navigator program has facilitated a positive journey for the patient and their family, provided support for the family physician and other members of the cancer care team, and improved communication and linkages between the ranges of services. 2.2 Client/Patient Access Services: Saskatoon Health Region The Client Patient Access Services (CPAS) is part of the Saskatoon Health Region, an organization that is responsible for services ranging from hospital to primary care to home care services. It provides a single access point for homecare, community support programs, day programs, nursing homes and the quick response program located in hospital emergency departments. The program, staffed by personal care coordinators, may be located in a hospital or in the community depending on local needs. Patient care coordinators are nurses and may have a general caseload, or a specialized caseload, such as people with acquired brain injury or HIV/AIDS. 4

7 The goals of the service are to: Help consumers identify needs, options and choices. Connect consumers with appropriate services. Develop and work with an overall care plan. Provide a system-wide case management service. Patient Care Coordinators determine eligibility and provide access for community based long-term care programs similar to the role of the Case Manager in the Community Care Access Centres. The coordinator primarily does a functional assessment as a part of the intake process. More comprehensive and clinical assessments are completed when a consumer is referred to a specific service such as homecare or a day program. A unique feature of the CPAS program is that coordinators can continue to provide follow-up services with the consumer even if they are referred to services such as homecare or an adult day program. The main role, in this case, would be to act as a link, a guide, and an information source. The staff can also provide follow-up when the consumer moves in and out of hospital or even in situations where the consumer is not eligible for the service or turns down a program. Specific parameters are set up to ensure that the follow-up service is needed and that there is at least one contact a month. The manager of the program described the philosophy of case management as the movement and integration of services with the coordinators working for the system on behalf of the consumers. This program has been in existence for twelve years in Saskatchewan and the overall goal of the CPAS program is to support people through the health care system and to promote integration and coordination of health services in the hospital and community based sector. 2.3 CareLinks Program: Fraser Health Authority British Columbia The Fraser Health Authority developed the Carelinks Program in This organization provides a wide range of services including primary care, hospital services and community care and support. The program provides a community inreach into the hospital through CareLinks client coordinators who work inside the hospital and assess and coordinate the continuing care needs of in-patients when they no longer requiring acute care services and are ready for discharge. The coordinators are the sole access point for the patients entering into the CareLinks program. In addition, coordinators may be located in emergency departments to work at redirecting patients who unnecessarily would be admitted to the hospital. The approach is different from the traditional model in which hospital staff discharge patients and are accountable to the administration. The goal of the program is to effectively coordinate the delivery of health services by improving the links between continuing care and hospital care. The community 5

8 approach to care is started right in the hospital and it is carried on after patients are discharged back to their home or a facility. 6 The focus is on the implementation of a service model that promotes an integrated continuum of care. The role of the Client Coordinator was to assess, coordinate and authorize continuing and community care services for patients ready to leave the hospital. In discussion with a program manager in Chilliwack, she indicated that the coordinators also provide information about resources to the patients and caregivers to assist them in making informed choices. An evaluation 7 of the CareLinks program noted the following outcomes: The program is cost-effective, as there was a saving from the closure of 30 acute care beds less the costs of implementing the program. Clients in the program were more likely to receive services in the community than were non-carelinks clients. A survey of physicians indicated that they were generally satisfied with the discharge process and level of home support. The CareLinks clients reported significantly improved health status compared to patients that did not participate in the program. 2.4 Winnipeg Integrated Services Initiative Three partners Manitoba Health, the Winnipeg Regional Health Authority (WRHA), and Manitoba Family Services and Housing (FSH) signed a Letter of Agreement in June 2001 that started the planning phase toward a system of integrated health and social services and formed the basis of the new Winnipeg Integrated Services Initiative (WISI). Over a two-year period, the partners developed a new Community Access Model. As noted in the report Winnipeg Integrated Services Initiative Conceptual Framework, 8 the model will represent a major shift from a program-based organizational model to an integrated, neighbourhood-based team structure. Community Access Centers will be developed in local communities to bring together existing programs and services and improve access to services such as: Child and Family Services. Children s Special Services. Child Day Care. 6 Simon Fraser Heath Region (October 2000). Evaluation of the Alternate Level of Care Management Initiative (The Carelinks Program). New Westminister.p.3. 7 Health Canada Health Transition Fund Project Fact Sheet BC421. Evaluation of the Alternate Level of Care Management Initiative (The Carelinks Program) Ottawa.p.1. 8 Manitoba Health (July 2003). Winnipeg Integrated Services Initiative: A Conceptual Framework. Winnipeg.p.20. 6

9 Community Mental Health. Employment and Income Assistance. Homecare. Housing. Long Term Care. Primary Care. Public Health. Services to Seniors. Guiding principles have been developed and agreed upon to determine which services will be centralized or decentralized as part of the planning for the implementation of the imitative. Key benefits of the model include 9 : Enhanced access to information about the full range of health and social services available. More convenient and timely access to services at locations closer to home. Simplified information collection and referral processes. More continuous service provision. Coordinated service provision for citizens and families requiring a number of health and social service. One of the unique features is that a consumer contacting the center for the first time will be greeted by a trained service navigator who will assess the presenting need, provide information on services, and connect the person to the most appropriate staff either in the center or in another location. Protocols have been established to guide the case coordination and service planning process depending on whether one or more than one service is delivered. The service navigator role will provide a single access point to a wide range of services as well as information and referral services in a defined geographic area. The intent is that the consumer may receive a range of services from different programs and not face duplicate registration procedures, or unnecessary waiting periods. 2.5 SUMMARY All of the above models have features that are encompassed in the primary navigator role. The roles of the patient navigator, patient care coordinator, client coordinator and service navigator include the functions of: coordination, education, information and referral and single access assessment. The role is more at a systems level with the emphasis on connecting, linking and supporting the consumer in the overall health system rather than to focus on the clinical components and specific service policies. 9 Manitoba Health (July2003). Winnipeg Integrated Services Initiative: A Conceptual Framework. Winnipeg.p.20 7

10 In each of the models, there is a focus on client-centered care and providing support for informed decision-making for the consumer and caregivers. 3. ONTARIO: OPPORTUNTIES FOR PRIMARY NAVIGATION OF THE HEALTH SYSTEM 3.1 Introduction to Section The search also included researching and reviewing reports, briefs, committee recommendations, and calls to the key associations, primary care contacts and the five Community Care Access Centres (CCACs) in the two district health council geographic areas. In this section, the report will briefly identify initiatives, reports, new or proposed programs and models that may provide opportunities for further exploration and development of the primary navigator role for the health system. The list starts with home and community care strategy, moves to the primary care area, and ends with the case management role in Community Care Access Centres in Ontario. 3.2 Canadian Home Care Association The Canadian Home Care Association (CHCA) has 600 members across the country including home care programs, service provider agencies, researchers, educators and consumers. In the report, A Coordinated Community Care Strategy: Essential Elements 10, the CHCA states that home care is unique within our health care system as it can function as a bridge between various settings of care, whether they are in the acute care hospital, the long-term care facility, respite care or the physician s office place. The report notes that the case management function is essential to the well being of the client while serving as the link between positive clinical outcomes, community resources and fiscal accountability. 11 In order to develop the strategy, the CHCA recommends: The case management function is developed within the health care system. The strengths of the Home and Community Care Service Model integrate with Primary Health Care Reform. 10 Canadian HomeCare Association (August 2002). A Coordinated Home and Community Care Strategy Essential Elements. Ottawa. p Ibid.p.2 8

11 3.3 Ontario Home and Community Care Council The Home and Community Care Council is composed of five provincial associations and the Ontario College of Family Physicians. Their definition of home and community care includes a wide range of health care and social support provided for an individual and/or caregiver in their homes, and/or community, by health professional, community and volunteers. The range of services includes: medical, nursing, pharmacy, therapies, community support, volunteer and caregiver support, and equipment and supplies. In a paper 12 dated July 2003, the Council discussed the shared vision for home and community care services and the relationship amongst providers. Included in the vision were elements that pertain directly to the role of the navigator: The public is well informed on how to access home and community care. Structures and processes to facilitate collaboration in home and community care replace the organizational silos, which serve as barriers between components of home and community care within government, and between providers in the community. Patients/clients, family physicians, pharmacist, home and community care providers, and community volunteers, work together as a care team in their communities to ensure co-ordination/integration of care and support. The Ontario Home and Community Care Council has overseen a report that outlines some key projects that could improve client service in the home and community care sector. It will be presenting the report to the Ministry of Health and Long-Term Care. 3.4 Primary Health Care Reform Ontario Primary health care reform includes programs such as Family Health Networks (FHN), the expansion of nurse practitioners, community health centers and health service organizations. The FHN model encourages groups of family doctors and allied health professionals to work together to provide accessible, continuous care to patients who are enrolled in a network. From the viewpoint of the navigator model, the following program goals are supportive and appropriate. They include: improved access for patients, enhanced coordination and continuity of patient care, increased patient and provider satisfaction and a stronger doctor-patient relationship. The Family Care Networks were formally known as Primary Care Networks (PCN). Previous to PCN s, the beginning model of group networks were called the Health Service Organization (HSO). The HSO, which is still in existence, began in the seventies as an alternative payment program for primary care practices. 12 Ontario Home and Community Care Council (July 2003). Toronto. 9

12 Some HSO s received program grant funding for enhanced primary care services for programs such as nutritional counseling, mental health programs, and health promotion programs. In some HSO s, the staff included social workers who have functions that are aligned with the primary navigator model. They receive referrals from the physician for such functions as case coordination, information and referral, monitoring and follow-up. The basket of services outlined for the Family Health Networks 13 composed of functions that promote patient navigation such as: Health assessments initially and periodically. Service Coordination, where possible. Patient education and preventable health. Access to hospital care and coordination. Also the primary care sector proposes a Physician Coordinator Care Model from the Ontario Medical Association section on General and Family Practice. 14 The proposal represents a new payment and delivery model with a bonus incentive for family physicians that take on a coordinated management role for their patients. Physicians could then be compensated for the coordination and management of the patients overall care and supervision of allied health professionals working collaboratively with them. Approval and implementation of this proposal, plus inclusion of service coordination as a function in the FHN, would enhance the features of the primary navigation model. 3.5 Case Management in Community Care Access Centres The Ontario Association of Community Care Access Centres (OACCAC) notes in the report Community Care Access Centres Case Management 15 that CCACs uniquely interact with other parts of the health care system - physicians, hospitals, long-term care facilities and community support agencies. The OACCAC observed that the CCACs are, therefore in a unique position to facilitate integration and information as a neutral broker. Case management is a core service provided by CCACs and the mechanism through which individuals access a range of services. 13 Ontario Ministry of Health and Long-Term Care (March2001). Evaluation of Primary Care Reform Pilots on Ontario Phase 1- Final Report. Toronto. p Petruccelli, E. Physician Co-ordination Model aim to reward GP-FP s providing comprehensive care. Toronto: Ontario Medical Association. 15 Ontario Association of Community Care Access Centres (September 2002). Community Care Access Centres Case Management. Toronto. p.1. 10

13 The report identified a number of case management activities that could be considered part of the Primary Navigator s role including information and referral services and also coordination. Staff who provide Information and referral services are described as knowledgeable in providing information about a wide range of health and support services available in the community and are trained to help clients access services. Coordination involves orchestrating all elements of client care. Reference is also made to coordination as a process that involves planning for future health care needs and establishing linkages to other services to ensure continuity of care for the client. Currently there are ongoing discussions within the CCAC s and the OACCAC concerning the case management functions and roles. The OACCAC is now working on position papers that recognize the need for monitoring and helping the system given the complexity of resources. The concern is that a significant number of long-term care consumers and caregivers are outside of the CCAC system. Entering, negotiating and traveling through the complex components of the health system can be a challenge, particularly for those consumers and caregivers who are not part of the CCAC caseload. 3.6 SUMMARY The initiatives on the part of committees, associations, professional colleges and the provincial governments with respect to home and community care and primary health care have a consistent theme of linkages, coordination, integration, and information services to consumers for informed decision-making. 11

14 4. CONCLUDING REMARKS There is a growing recognition of the need for a primary navigator in the health care system for the individual consumer. Provinces and health care organizations have developed programs and services that incorporate features of the primary navigator that may be emulated. The report has described some existing models that have been in existence for twenty years, such as the Client Patient Access Services in Saskatchewan, and the newest program, the Winnipeg Integrated Services Initiative. Common themes emerged from the literature review and interviews with service providers. The role of the primary navigator is to coordinate and provide information, knowledge and support to the consumer and caregivers. The primary navigator can assist family physicians and other health care professionals in providing continuity and coordination of care. The single access point for services is an integral part of the model. The model is generally implemented under the auspices of regional and district health authorities that provide a single administrative structure and funding source for a wide range of health care services including hospitals, primary care, home care and community support services. The goals of the primary care, home and community care system and the primary navigator role have many features in common. Both can support and inform consumers and caregivers in a coordinated journey through the health care system. This outline of existing models of primary navigation is a beginning planning strategy to implement the role for all long-term care population groups and their caregivers as they access and experience the health system. 12

15 BIBLIOGRAPHY Canadian HomeCare Association (November 2002). A Coordinated Home and Community Care Strategy Essential Elements. Ottawa. Canadian HomeCare Association (January 2003). Universal Home Care Making it a Reality. Ottawa. Canadian Mental Health Association ( June 2003). Access to Mental Health Services: Issues, Barriers and Recommendations for Federal Action. Cancer Care Nova Scotia (November 2002). Clearing a Path for Patients: Patient Navigation Evaluation Framework Halifax. Cancer Care Nova Scotia. Navigating the System: A Guide for Patients, Families and Caregivers. Halifax. CCAC-LTC Priority Project (January 2003). Case Management Initiative Business Model Overview. Community Care Access Center of York Region ( Revised 2002). Overview of Case Management Practice. Newmarket Gluberman,S. ( October 2003). Speech to the Ontario Association of Community Care Access Centres. Haliburton Northumberland and Victoria Access Centre (Revised 2002).The Practice of Case Management at Haliburton, Northumberland and Victoria Access Centre. Lindsay. Health Canada (2002). Investigation and Assessment of the Navigator Role in Meeting the Information, Decisional Needs of Women with Breast Cancer in Canada. Ottawa. Health Canada, Health Transition Fund Project Fact Sheet BC241. Evaluation of the Alternate Level of Care Management Initiative (The Carelinks Program). Ottawa. Hollander, Marcus J.( August 2003). Unfinished Business: The Case for Chronic Home Care Services, A Policy Paper.Victoria B. C. Hollander Analytical Services Ltd. Ontario Association of Community Care Access Centres (September 2003). Community Care Access Centers Case Management. Toronto. Ontario Association of Community Care Access Centres (November 2001). The Case for Community Care Access Center Case Management. Toronto Ontario Case Managers Association, Ontario Community Support Association (2000). Provincial Standards and Guidelines for Case Management Toronto. 13

16 Ontario Home and Community Care Council (October 2003). Background. Toronto Ontario Association of Community Care Access Centres ( September 2003). Community Care Access Centres Case Management. Toronto. Ontario Association of Community Care Access Centres ( November 2001). The Case for Community Care Access Centre Case Management. Toronto Ontario Ministry of Health and Long-Term Care (March 2001). Evaluation of Primary Care Reform Pilots in Ontario. Phase 1- Final Report. Toronto. Manitoba Health (July 2003). Winnipeg Integrated Services Initiative: A Conceptual Framework. Winnipeg. Petruccelli, E. Physician Co-ordination Model aim to reward GP-FP s providing comprehensive care. Toronto: Ontario Medical Association. Prince Edward Island Ministry of Health (2001). Annual Report for the year ending March31,2001. Charlottetown. Simon Fraser Health Region (October 2000). Evaluation of the Alternate Level of Care Management Initiative (The CareLinks Program). British Columbia. Simcoe York District Health Council ( October 2003). Community Consultations for Long-Term Care consumers, their families and their caregivers. Newmarket. Saskatoon Health Region (November 2003). Programs and Services Client/Patient Access Services. Till, James.E. ( May 2003). Evaluation of support groups for women with breast cancer: importance of the navigator role. Abstract Toronto. 14

17 WEB SITES Alberta Health British Columbia Ministry of Health Canadian Association for Community Care Canadian Homecare Association Canadian Palliative Care Association Canadian Policy Research Network Cancer Care Nova Scotia CanChild Centre for Childhood Disability Research McMaster University, Hamilton Centre on Aging University of Victoria Canadian Institute for Health Research Fraser Valley Health Authority Group Health Centre Health Canada Home and Community Care Home and Community Care Evaluation and Research Centre Hollander Analytical Services Ltd. 15

18 Ontario Community Support Association Ontario Association of Community Care Access Centres Ontario Association of Children s Rehabilitation Services Ontario Family Health Network Ontario Medical Association Ontario Ministry of Health and Long-Term Care Ontario Neurotrauma Association Premiers Council on Canadian Health Awareness Saskatoon Health Region. Solidage Research Group Winnipeg Integrated Services Initiative Winnipeg Regional Health Authority 16

19 CONTACTS FOR REFERENCE MATERIAL AND SEARCH FOR NAVIGATION SERVICES Ann Bell, Executive Director Community Care Access Centre-Simcoe County Barrie Cecil Charlebois, Manager Home Care Saskatoon Health Region. Sandra Cook, Patient Navigation Project Manager Cancer Care Nova Scotia Halifax Joan Doran, Associate Executive Director Community Care Access Centre of York Region Newmarket Deborah Egan, Executive Director Community Home Assistance to Seniors ( CHATS) Aurora Sandra Geddes, Manager Health Services Chilliwack Fraser Valley Health Authority Bill Innes, Executive Director Community Care Access Centre of York Region Newmarket Dan Haughey, Director Winnipeg Integrated Services Initiative Nadine Henningsen, Executive Director Canadian HomeCare Association Ottawa Janet Harris, Executive Director Durham Access to Care Whitby Marcus Hollander Hollander Analytical Services Victoria 17

20 Linda Kenny, Director Rehabilitation Service Canadian Paraplegic Association Toronto Patty Lomas, Case Manager Homecare Abbotsford Fraser Valley Health Authority Nora McCabe, HomeCare and Support Manager Queen s Health Region Prince Edward Island Sue Melrose, Manager Client /Patient Access Services Saskatoon Fran O Hara Haliburton, Northumberland and Victoria Access to Care Lindsay Carla Palmer, Executive Director Barrie Community Health Centre Barbara Smith, Registered Social Worker Caroline Medical Group Burlington Georgina White, Policy Advisor Ontario Association of Community Care Access Centres Toronto ACKNOWLEDGMENTS My thanks to the health planners Vicki Coates, Kate Reed and Jeanne Thomas, and also the people I contacted both in Ontario and other provinces. Everyone was most generous in sharing a wealth of information and expertise. A special thank you to Rebbeca Truax for her excellent work as editor of this project. Louise Pope MSW, RSW Barrie, ON. 18