Home and Community Care at the Champlain LHIN Towards a person-centred health care system Presenter: Kevin Babulic Director, Champlain LHIN - Home and Community Care
Outline Who is the Champlain LHIN-Home and Community Care? Who does Home and Community Care serve? What are the services Home and Community Care provides? Long Term Care (LTC) What s new / what s changed List of resources How do I access Home and Community Care? 2
Introduction The Champlain Local Health Integration Network s (LHIN) mandate is to ensure health services are well-organized, appropriately funded, and meet the health needs of the 1.3 million residents who call this region home. We work with and fund roughly 120 health service providers that offer about 240 health programs in hospitals, community support services, mental health and addiction service agencies, community health centres, and long-term care homes. As of May 24, 2017, the Champlain LHIN also delivers home and community care services. 3
Home and Community Care at a glance 18,000 square kilometres 4
Connecting people of all ages Champlain LHIN Home and Community Care: Our patient-care coordination teams help develop care plans for people of all ages, focused on maintaining independence and dignity at home and in their community. Provides services to facilitate care of patients to remain safe and independent at home Connects patients to resources available in the community Assesses and determines eligibility for long-term care, respite care, adult day programs, assisted living services for high risk seniors Helps find primary care 5
Working Together for Quality Care Long Term Care Champlain LHIN Informal Caregivers: family, neighbours, volunteers Community Support Services 6
Our People: Professional, Qualified and Caring Champlain LHIN - Home and Community Care staff are dedicated nurses, therapists and other health care professionals. We work directly with patients in: hospitals schools doctor s offices communities and at home 7
Our Presence in the Community H H H H H H H H H H H H H H H Long Term Care Homes H Hospice Care H Community Support Services Community Health Centres H Hospitals Family Health Teams
What does the Care Coordinator do? Provides essential care coordination/case management service Assesses patients to determine care needs (using provincially-mandated standardized assessment and screening tools) Monitors each patient s care plan Helps patients connect with various care and services May be located in hospitals, in the community or in primary care practices 9
Our services Care coordination Nursing Personal support Physiotherapy Occupational therapy Nutritional counselling Speech therapy Social work Medical supplies and equipment Respite care Information and Referral 10
Specialized Services Palliative Nurse Practitioners Rapid Response Nurses Mental Health and Addictions Nurses Wound Care Specialists Palliative Care Team School Health Support Services Pediatric Care Placement Coordination Services Long-Term Care, Assisted Living Geriatric Assessment 11
Profile: Higher Needs Patients Common characteristics of higher needs/complex patients: Unstable medical conditions Frequent hospitalizations, visits to emergency Need help with personal care, daily activities At high risk for institutionalization Caregiver burnout is common 23 % of our patients are over 85 14% Of our patients are under the age of 21 62% of our complex/ chronic patients have high care needs 12
Who does Home and Community Care serve? Mary s Story Mary is 87 years old. She lives with her husband, John, who is struggling to meet her increasing care needs. Requires daily assistance with personal care, meal prep and housework. Taking medication for multiple chronic conditions. Confused and is finding difficult to express herself. Wants to stay home but is at high risk for institutionalization. 13
Home and Community Care Connects People: to other Services, Support and Resources in the Community Champlain LHIN working with Community Support Services (CSS) agencies to ease patient transitions and coordinate care Patients assessed as lower needs are often referred to partners such as: Adult day programs Caregiver support groups Friendly visits Hospice care Housekeeping and home maintenance Meal delivery and community dining Rehabilitation Supportive housing Transportation services 14
Long-Term Care Champlain LHIN Care Coordinators help: Inform patients and caregivers about their Long-Term Care LTC options Ensure each patient s specific care and lifestyle needs can be met in a Long-Term Care Home Determine the best place for them to receive care should Long-Term Care not fit their needs Determine the best place to receive care should LTC not fit the needs Placement to Long-Term Care from hospital has decreased from 50% in 2011 to ~ 30% currently 15
Steps in the LTC Process Referral Assessment Eligibility Capacity Evaluation Consent Counseling Choice Waitlist and admission I had no idea about them [nursing homes] and didn t want to know. I didn t think about them until I had to. Long Term Care: How the System Works 16
Retirement Homes are different Long Term Care Homes Legislated by the Ministry of Health and Long Term Care Nursing care is provided by OHIP Access to admission only through the LHIN Waitlists vary depending on supply and demand. Some homes have short waitlists, others are very long. Need to meet Provincial standard eligibility criteria (Care Coordinator assessment) Monthly costs ~$1950-$2400 (subsidized if not able to afford) Retirement Home Private / Landlord-Tenant Act legislation Limited Regulation Negotiated between the client and the retirement home. Costs and services vary. Anyone can make arrangements for admission with the home Usually no waitlist No standard set of eligibility, determined by each individual home Monthly costs vary widely.
What s changed: Sub regions Access Respite Palliative Changes Health Links Patient and Family Advisory Counsel
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Our mission to build a coordinated, integrated and accountable health system for people where and when they need it requires an approach that reflects the needs of local residents. 1. Patient Centered: Engage patients/clients and caregivers to ensure that services in each sub-region meets the needs of its population. Why Sub-Regions? 2. Coordinated Care and Accessible Services: Enhance coordination of services. This will improve access, simplify navigation and smooth transitions of care. 3. Comprehensive Care: Better leverage local community resources and knowledge. 4. Quality: Focus on population health needs and address health equity. Enhance local accountability for population health and performance along the continuum of care. 33
1. Sub-regions are not mini-lhins, but rather local planning areas. Administrative infrastructure is minimal. What Sub-Regions are Not 2. Sub-regions in no way create barriers to care for patients. People have always received care in different places and this will continue. 3. Sub-regions are not intended to organize everything. Some services are organized provincially, regionally and some at the very local level (e.g. within a municipality). Sub-regions will serve as the focal point for integrated health service planning and delivery 34
Improving Access to Home Care for People with Complex Health Conditions LHIN Care Coordinators and management have been aligned to sub-regions Decrease waitlists for Personal Support Worker and Allied Health Closer alignment with Community Support Service sector to improve transitions and minimize duplication of assessments 35
Respite - Caregiver Distress Program Goal: To relieve caregiver strain, reduce caregiver burden and avoid burnout. Launched 2017 Based on feedback best practice guidance both internationally and locally and feedback from caregivers and family What's different: Services are focused on the needs of the caregiver Flexibility in scheduling, respite hours to best meet caregiver s needs. Hours are allocated in 3 month blocks, to facilitate custom scheduling Caregivers can opt to schedule hours however best meets their needs or plan a combination of visits and shifts.
The Regional Palliative Consultation Team The Regional Palliative Consultation Team connects, supports and cares for patients who have a life-limiting illness in the Champlain region. Our nurses help people and families understand their options and provide support.
Medical Assistance In Dying (MAiD) The Champlain LHIN will work with the doctor or nurse practitioner to coordinate the procedure in the patient s home, which may include arranging for a nurse to be present, sending equipment and supplies, and ensuring all the documents are completed before the procedure can also educate the patient and their loved ones and make sure they are prepared for what to expect, during and after the procedure can also help find additional support in the community if it s needed
Health Links Approach to Care Health Links is a patient-centered approach to care that focuses on enhancing and coordinating the care for patients living with multiple chronic conditions and complex needs. The Health Links approach: enables patients and their caregivers to be full partners in their own care brings together the care team to support the patient to achieve their goals 39
Coordinating all the services and supports that a person with multiple health conditions requires. That s the idea behind the Health Links approach. The primary care provider, home and community care organizations, specialists and other community partners as well as the patient and caregivers work with a Health Links care coordinator. Together, they develop one coordinated care plan that focuses on the patient s goals and what is important to them. The goal is to improve the quality of care and the health care experience for those who use the health system the most. And the Health Links approach will reduce unnecessary hospital admissions and emergency department visits.
Who is eligible? Target population Identified sub-groups Important considerations People living with four or more complex or chronic conditions People who are Facing mental health and addictions challenges Palliative Frail Frequent users of health services (e.g. emergency departments, hospital admissions) Economic characteristics (e.g. low income, unemployment) Social determinants (e.g. challenges with housing, social isolation, language) Judgment of clinicians working with patients
How do I access HealthLinks? Anyone a family doctor, care provider, friend, family, caregiver or even a patient - can identify someone who fits the Health Link criteria. Providers: Complete the Health Links Identification Form and fax it to the central number. A Health Links care coordinator in your area will follow-up with you. Patients & Families: Talk to your family doctor, nurse practitioner or other health care provider to see if the Health Links approach is right for you or your loved one. You can also contact the Health Links Manager in your area.
Patient and Family Advisory Committee The Patient and Family Advisory Committee (PFAC) will work with the LHIN to: Support creative engagement and inclusion of patients and caregivers in system improvement within the Champlain LHIN. Provide advice on recommendations about health care access or service delivery improvements from the patient and/or family caregiver perspective. Work with the LHIN CEO, LHIN staff, service providers and partners on strategies and practical ideas for improving patient care, and caregiver recognition and support.
To access our services Patients must have a valid Ontario Health Card Referral by a physician, family member or friend or self-referral Referral by a community agency, hospital, emergency department or another LHIN Patient consent required if referred by a second or third party 44
Other resources on Champlainhealthline.ca 47
Contacting the Champlain LHIN One provincial number: 310-2222 Automatically connects you to a bilingual Information & Referral Specialist healthcareathome.ca 48
Thank you 49