Complex Health Conditions
Table of Contents:
Expanding Physiotherapy for Seniors and Patients
Behavioural Supports in Ontario Project
Ontario's Seniors Care Strategy
Senior Friendly Hospital
Champlain Model for Senior Care
Integrated Provincial Falls Prevention Framework & Toolkit
Aging at Home
Transitional Care Program
Home First
Residents First
Champlain ED / ALC Steering Committee
Ontario's Seniors Care Strategy
Dr. Samir Sinha, Provincial Lead for Ontario's Seniors Care Strategy, visited the Champlain region on August 21, 2012 to engage with health providers and other stakeholders on seniors' health-care challenges and opportunities.
L-R: Alexa Brewer, Champlain LHIN Board of Directors; Dr. Sinha; and Chantale LeClerc, Champlain LHIN CEO.
Senior Friendly Hospital
Improving the health and wellbeing of seniors in hospital
Seniors are three times more likely to be hospitalized than younger people and receive care in nearly every area of the hospital. A hospital stay can have a major influence on the health and wellbeing of seniors.
However, evidence shows that seniors’ health declines the longer they stay in hospital as a result of complications, lack of activity and infections. This can lead to longer hospital stays and reduce their chances of returning home and regaining their health and independence.
Ontario’s Local Health Integration Networks (LHINs) are leading a Senior Friendly Hospital Strategy – an initiative to improve seniors’ health and prevent their physical and mental decline in hospital. By acting together, hospitals can improve the experience and outcomes of older adults in Ontario hospitals.
The Senior Friendly Hospital Strategy aims to:
- Improve the health, wellbeing and experience of seniors in Ontario hospitals, helping them get back home sooner and healthier.
- Improve seniors’ ability to live independently and stay out of hospital.
- Enhance the value of health care dollars.
- Help reduce alternate level of care by supporting people to transition to the right place of care after a hospital stay.
- Promote quality improvement initiatives that can be included in hospital Quality Improvement Plans as part of Excellent Care for All.
As a first step, each hospital assessed their successful seniors’ initiatives, and identified opportunities for improvement and action. All adult hospitals in Ontario have completed a Senior Friendly Hospital Assessment. Summary reports for each LHIN and a summary provincial report were developed in collaboration with the Regional Geriatric Programs of Ontario.
For a copy of the Champlain LHIN and provincial summary reports as well as an FAQ on the Strategy, please click on the links below:
What’s next?
In the coming year, the LHINs will be working together to address the system-level recommendations contained in the summary reports and will be looking to hospitals to help in the planning of local, regional, and provincial actions to move this strategy forward. LHINs will first focus their efforts on developing a coordinated provincial approach to creating positive change across the three clinical priority areas that were identified in the provincial report: functional decline, delirium, and transitions in care.
By spring 2012, all Ontario hospitals will have senior friendly hospital action plans in place and will start to measure their performance with commonly agreed upon indicators.
Champlain Model for Senior Care
From Prevention to Continuing and Palliative Care, click here to learn more about the Champlain Model for Senior Care and the specific initiatives the Champlain LHIN provides to support this important population.
Integrated Provincial Falls Prevention Framework & Toolkit
Falls reduce quality of life for our seniors, impacting their mobility, health and independence. Fall also cost the Ontario health-care system billions of dollars, resulting in avoidable visits to the Emergency Department, hospitalizations, high Alternate Level of Care rates, and all too often, admission to long-term care homes. Click here for more information.
Aging at Home Strategy
Ontario is investing $1.1 billion over four years in the Aging at Home Strategy in sectors such as community support services; hospitals; Community Care Access Centres; long-term care homes and other sectors. Aging at Home, as initially announced in 2007, is a strategy that provides a continuum of community-based services for seniors and their caregivers to allow them to stay healthy and live independently and with dignity in their homes.
The Aging at Home Strategy also aims to decrease the number of patients who become alternate level of care (ALC) in Ontario hospitals. ALC patients are individuals who are occupying acute care beds in hospitals, but would be better cared for in another setting whether it be their own homes or long-term care homes.
This year, the Champlain LHIN is receiving $9,894,398 to fund local programs that provide health services to seniors in the comfort and dignity of their own home, allowing them to continue leading healthy and independent lives and avoid unnecessary visits to hospitals.
Champlain LHIN Aging at Home Projects
The Aging at Home Directional Plan was developed in 2007, in collaboration with a number of partners across the Champlain LHIN. It guided the Champlain LHIN Aging at Home Strategy towards developing a wide range of services across our region and the continuum of care for seniors. Over the last three years, the Strategy has evolved and a number of projects were. The Champlain LHIN currently funds more than 40 Aging At Home projects
Assisted Living Services for High-Risk Seniors is a safe, affordable and cost effective alternative to Long-Term Care Homes for some. This program is a viable option for seniors who need help with everyday activities and who - without this help - are at risk for losing their independence and choice, in terms of a place of residence. A lack of assisted living services in the homes of these seniors can detract from their health and safety, and force them into inappropriate and more expensive institutional options. Currently there are a number of programs for seniors across Champlain. The Champlain LHIN is funding more programs with the new assisted living services for high risk seniors living in different areas in our region.
The program consists of individual care plans developed to meet the needs of eligible seniors. This includes the provision of personal support worker assistance to seniors in their homes through scheduled and unscheduled visits around the clock. The Care Coordinator will evaluate and revise the care plans, as needed. For example, services could include personal care, medication monitoring, light housekeeping, meal preparation, and security and reassurance checks.
Aging at Home in the News
Assisted Living Programs: Helping Seniors with Physical Disabilities Live Independently
“It’s an effective model for many seniors with disabilities.”
Lucille was hospitalized on a number of occasions for her heart condition, unfortunately leaving her visually-impaired husband Cyrille alone at home. The situation created significant stress for the couple.
But now, thanks to a new bilingual supportive housing program in Rockland, Lucille and Cyrille are receiving the daily services they need to live independently and with dignity in their own community. The program provides help with personal care, meals, light housekeeping and groceries. If needed, clients are reminded to take medications. Support staff is around the clock for all non-medical needs. Care plans are individualized and flexible.
The apartments are built with special equipment such as hand rails; wheelchair-accessible bathrooms and laundry rooms. Technology is also important.“We have a bracelet to call for help,” says Lucille. “It’s very good care.” To promote social activities, the building has a common room where residents meet to play cards or bingo, do puzzles and chat.
“The Assisted Living Program delivers client-focused care, reduces emergency room visits, and improves access to needed services,” says Colette Lavictoire from the Canadian Red Cross. “It’s an effective model for many seniors with disabilities.”
The Assisted Living Program in the Eastern Counties is managed by Canadian Red Cross Community Health Services, the United Counties of Prescott-Russell and Clomatek Enterprises Inc. The supportive services are funded through the Champlain LHIN’s Aging at Home Strategy.
Assisted-Living Services Help Seniors at Home (LHIN Update Feb 2012)
Champlain LHIN Focus on Health Communities – 2010 Report
Going Home and Integrated Falls Program
In 2010/11, a number of Aging at Home programs were started or expanded. Two are highlighted, below.
Aging at Home Programs
Going Home Program
LHINfo Minutes
Champlain LHIN Adds ‘Assisted Living’ Spaces Across the Region
Another Successful Aging at Home Program Gives Seniors What They Want – Independence
Aging at home project transforming health care for seniors in Cornwall & Rockland
Background Documents
MOHLTC Aging at Home News Communiqué
Champlain LHIN Investing in More Care for Seniors and Community Services
Transitional Care Program
The Transitional Care Program (TCP) was created to increase patient flow and capacity within the hospital setting. New beds are implemented on a temporary basis for patients who have experienced a recent decline in their health and daily activities and require care and support while awaiting supportive placement or returning home. The goal of this program is to return individuals to their highest level of independence in the community.
The TCP program has been implemented to support and achieve multiple performance measures for the ED and ALC initiatives. Many initiatives have been implemented by hospitals and other health care providers to provide the most appropriate care in a timely manner. This includes improving access to ED, decrease ALC pressures within the hospital setting and access to home and community services.
Transitional Care Program Framework
Transitional Care Program News Release - Dec 2010
Home First
Home First is an evidence-based, patient-centred, transition management approach that aims to optimize patient care by providing the necessary care to allow high-risk seniors to remain in their home with community supports for as long as possible. If/when acute hospital care is required, Home First aims to support patients (who are in hospital) return home on discharge, prior to assessment for and/or admission to a long-term care home or other appropriate care setting.
For a visual overview of the initiatives we are working on to improve patient flow within our LHIN, click here.
Champlain ED / ALC Steering Committee
The Champlain Emergency Department (ED) / Alternate Level of Care (ALC) Steering Committee provides strategic advice to the Champlain LHIN Senior Management Team to inform decisions related to strategic orientations to ensure positive progress against ED and ALC targets. Specifically, the ED / ALC Steering Committee:
- Provides insight into root causes of ED wait times and ALC pressures
- Provides recommendations related to initiatives that address ED wait times and ALC volumes in the Champlain LHIN
- Champions initiatives that are intended to impact on ED wait times and ALC pressures
- Mobilizes the appropriate individuals and groups to identify solutions to ED / ALC problems or barriers.
Here are the ED / ALC Steering Committee newsletters, providing regular updates and key messages discussed at these meetings.
Winter 2013 (pdf)
Fall 2012 (pdf)
Summer 2012 (pdf)
Feb / Mar 2012 (pdf)
Jan 2012 (pdf)
ED / ALC Newsletter Archives