Caring for our Community - LHIN Home and...

1 | WWCCAC 2014–2015 Annual Report

Caring for our Community2014–2015 Annual Report

http://healthcareathome.ca/ww/en


Vision, Mission & ValuesOur VisionOutstanding care – every person, every day.

Our MissionTo deliver a seamless experience through the health system for people in our diverse communities, providing equitable access, individualized care coordination and quality health care.

Our Values • Person-centered• Accountable• Collaborative• Respectful• Innovative

To learn more about the Waterloo Wellington Community Care Access Centre click here.

The Waterloo Wellington Community Care Access Centre is pleased to introduce our first interactive annual report. Many of the stories provide videos where you can meet some of the people we work with in our community.

When you see this symbol click to see how we are impacting the lives of those living with disability, illness or injury.

We also invite you to click on links throughout the document (indicated with an underline) that will lead you to additional information online.

If you are reading a printed copy of this report, you can find all of the videos listed on our YouTube channel, at www.youtube.com/wwccac.

https://www.youtube.com/watch?v=GIqrEDSA0Ek&feature=youtu.be

http://www.youtube.com/wwccac


Message from Board Chair and CEOOn any given day, the WWCCAC supports more than 17,000 people in our region – including children, adults and seniors. That means 1 in 18 people in our community rely on us to 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 provide outstanding care, to every person every day and to help people reach their optimal health, at home which is where you’ve told us you want to be.

As our community continues to grow and age, and as more and more people live with chronic disease, the WWCCAC is playing a critical role in the lives of those living with illness, injury or disability.

Over the past year, we achieved many accomplishments and have made great strides in advancing our strategic plan. We have challenged ourselves to find new and innovative ways to increase access to personalized, high quality, and seamless care, at every stage of the health care journey.

Within our annual report you will read about some of these initiatives, such as our two innovative pilot projects that resulted in more than 1,000 children being taken off the wait list for occupational therapy and speech language pathology, our formalized Quality Improvement Plan that was developed voluntarily to support our

culture of continuous improvement, and our Community Stroke Program that was recognized as a leading practice by Accreditation Canada. You will also hear and read stories from those who rely on the WWCCAC for care.

We are pleased to report that the advances we made over the past year were done with a balanced budget.

Thank you to patients and families, the Waterloo Wellington Local Health Integration Network (LHIN), our care partners and most importantly, our employees and community, for your support and for enabling the work we do at the WWCCAC.

Brian Cowan - Board Chair Dale Clement - CEO


Strategic PrioritiesThe WWCCAC is focused on three key priorities:

1) Personalized Care

2) Safe, High Quality, Evidence-Based Care

3) Seamless Coordinated Care

Each priority reflects our commitment to putting patients and families at the centre of everything we do and aligns with our vision of providing outstanding care – every person, every day.

Looking forward, our organizational goals will align with the Ministry of Health and Long-Term Care’s Patients First: A Roadmap to Strengthen Home and Community Care. Over the coming months, we look forward to engaging our partners and the broader community as we develop our 2016–2020 Strategic Plan.

2014–2015 YEAR IN REVIEW

Personalized CareWe are committed to providing you care when and where it is needed and to support a positive care experience.

ON ANY GIVEN DAYTHE WWCCAC SUPPORTS

1in18PEOPLE IN OUR COMMUNITY

93%OF WWCCAC CLIENTS

SURVEYED REPORTED HAVING APOSITIVE EXPERIENCE

Enabling People with Intense Support Needs to Return Home

You have told us that when you need help, you want it to be timely and in the right place – preferably in your own home. Over the past year, the WWCCAC supported more than 13,000 people in their transition from hospital to home.

As part of the Home First Philosophy, the WWCCAC launched the Home Intensive Services program. This program, which is unique to the WWCCAC, provides patients with intense home support needs, access to enhanced nursing, therapy, and personal support services to enable a seamless transition from hospital to home.


“The Home Intensive Services program provides personalized care to individuals who no longer need and want to be in hospital,” says Martina Rozsa, Senior Director, Patient Services, WWCCAC. “It provides the support they require to return home while they make decisions regarding the next phase of their health care journey.”

This program helps to support the Waterloo Wellington Local Health Integration Network’s (LHIN) focus on reducing hospital Alternative Level of Care (ALC) rates and their focus on providing seamless transitions to care. This past year, the region’s ALC rates were among the lowest in the province.

Over the past year, the WWCCAC’s Home Intensive Services Program enabled 537 people who otherwise would have remained in hospital to return home, which is where they wanted to be.


Improving Access to School-Based Supports

As the demand for school-based rehabilitative care increases, the WWCCAC is committed to finding new and innovative ways to provide students and parents with timely access to services.

In June 2014, the WWCCAC implemented the School Health Support Services pilot project, aimed at increasing access to best-practice speech and language pathology and occupational therapy services.

Speech Language Pathology

Over the course of the 2014–15 school year, 10 clinics ran across the Waterloo and Guelph Wellington Region. Led by Registered Speech Language Pathologists, small groups of children received therapy during one hour evening sessions. These evening group sessions provided parents and caregivers with the unique opportunity to actively participate in their child’s therapy and empowered them with strategies that could be practiced in the home to achieve their child’s specific goals.

Occupational Therapy

This innovative pilot program, which ran across 45 schools in the region, is an integrated and collaborative approach to incorporating occupational therapy into the classroom. Each therapist visited the school for up to one day a month to support students requiring occupational therapy services - working in the classroom to conduct assessments and provide students and teachers with support in real time.

In 2015–16, the WWCCAC is committed to ensuring all children on a wait list for speech language pathology and occupational therapy are screened.

The School Health Support Services pilot project resulted in more than 1,000 students being taken off the wait list for speech language pathology and occupational therapy. Further plans to expand and build on this program are underway.


Partnering with Emergency Medical Services (EMS) to Connect People to Care

Approximately 18 per cent of 911 calls are from those who frequently use the service to support their day-to-day health care needs. Over this past year, the WWCCAC partnered with the Guelph-Wellington Paramedics to launch the Community Paramedicine Referral program, which enables paramedics – who are on the front-line and often first to identify the need for in-home support – to make a referral directly to the WWCCAC.

“Previously, referrals were made through a hospital’s emergency department, regardless of whether or not the individual required emergency care” says Andrea Binkle, Senior Director, Partnership and Performance, WWCCAC. “This new partnership between EMS and the WWCCAC means that people can avoid unnecessary hospital admissions and can access support in a much more effective way.”

Based on the success of the program to date, plans are underway to bring the program to Waterloo Region.

“The commitment of the Paramedics involved, partnerships with organizations like the Waterloo Wellington CCAC, and provincial support has led to the success of this program,” says Shawn Armstrong, General Manager Emergency Services, City of Guelph. “I believe that careful planning and collaboration by all concerned aided our service in addressing the community need and risk in the most timely way.


Meet Ron and his wife KayeWhen Kaye was diagnosed with dementia, Ron initially had no idea how he would manage. After connecting with the WWCCAC, Ron felt confident that Kaye would receive the care she required, and when it came time for Kaye to move into a long-term care home, the WWCCAC was there to support the transition. Although the past few years have been difficult for Ron, he appreciates that the WWCCAC was able to offer the care that he and his wife so desperately needed.

Click the orange play icon to hear Ron’s story

“Without the CCAC, I have no idea where we’d be.” ~ Ron

https://www.youtube.com/watch?v=85auUx-Y44g&feature=youtu.be


ON ANY GIVEN DAYTHE WWCCACSUPPORTS 17,000PEOPLE IN OUR REGION

SUPPORTED MORE THAN

13,000TO MAKE THE TRANSITIONFROM HOSPITAL

TO HOME

Safe, High Quality, Evidence-Based CareWe will deliver safe, high quality, evidence-based care and support safe independence.

Building a Culture of Continuous ImprovementOutstanding care, every person, every day; it’s the cornerstone of everything we do at the WWCCAC. Building on our culture of continuous improvement, we are constantly challenging ourselves to do better and to find new strategies that will support the delivery of safe, high quality, evidence-based care to our community.

In 2014, we voluntarily formalized our Quality Improvement Plan (QIP) which outlines six priority indicators, along with concrete ways that we will achieve our goals. Like other CCACs, our focus will be on reducing the incidence of falls at home, reducing unnecessary emergency department visits and hospital admissions, and improving service wait time for nursing and personal support. We

are also focused on improving the overall patient experience.

The goals we’ve set are ambitious, but we know that our continued focus on these priority indicators will mean better health outcomes and improved quality of life for the patients we serve.


Reducing the Risk of Falls Falls are the leading cause of injury among older adults and the sixth leading cause of death for those over the age of 65.

More and more, home and community care patients are living with complex health issues that can increase the likelihood of having a fall. Over the past year, the WWCCAC has played a key role on the LHIN’s Fall Prevention Steering Committee and has developed an evidence-based, comprehensive Falls Prevention Plan.

For patients who are considered at risk for falls, Care Coordinators and Service Providers work together to provide education around falls prevention and facilitate access to home and community-based gentle exercise programs to improve balance, mobility and reaction time. In the home, they will assess the environment and recommend ways to reduce risk, review a patient’s medication to consider whether it may contribute to a fall, and provide guidance to ensure the patient has appropriate footwear.

The WWCCAC’s Falls Prevention Plan compliments the Community Paramedicine Referral program. For those who call 911 after experiencing a fall and do not require hospitalization, EMS can now make a direct referral to WWCCAC. This direct access means that patients can more effectively access supports that align with our Falls Prevention Plan.

With a strong focus on falls prevention, the WWCCAC aims to reduce the incidents of falls to 29% in 2015–16, which is much lower than the provincial average of 35.3%.

FALLSARE THE LEADING CAUSE OF

INJURYAMONG OLDER ADULTS

ACCOUNTING FOR59% EMERGENCY DEPARTMENT VISITSAND 80% OF HOSPITALIZATIONS

FALLS ARE THE

SIXTHLEADING CAUSE OF DEATHAMONG OLDER ADULTS

EVERY 10 MINUTES IN ONTARIOAT LEAST 1 SENIORVISITS EMERGENCYDUE TO A FALL


New Program Improves Quality of Life for Stroke PatientsIt’s known that continued rehabilitation, done either in the home or through community programs, can make a significant improvement to a stroke patient’s independence and overall quality of life, which is why rehabilitation must extend beyond the walls of a hospital.

To enable the seamless transition from hospital to home and to provide access to specialized services, the WWCCAC developed a Community Stroke Program, in partnership with five hospitals across the region.

At each hospital, a designated WWCCAC Stroke Care Coordinator and community occupational therapist is integrated into the discharge planning process. This collaboration between inpatient and community-based teams enables the development of a transition plan that ensures the in-home supports are in place, and there is no disruption in therapy while the patient transitions back to home.

A specialized Care Coordinator also oversees the coordination of care from a community-based, interdisciplinary team that provides up to three months of in-home intensive rehabilitation, based on best practice guidelines. The stroke team which includes occupational therapists, physiotherapists, rehab assistants, dieticians, social workers, and / or speech language pathologists work closely with each patient to reach individual goals and begin the integration back into the community and everyday life.

After a full year of implementation, the Community Stroke program saw a reduction in stroke mortality, fewer patients requiring long-term care, and improved functional independence for patients. Plans are currently underway to expand the care team to include personal support workers and nurses.

“I’m so proud to live in a country that has programs like the CCAC,” says Wayne Drew, Stroke Survivor. “I’ve been the beneficiary of so much support, and I don’t know where we’d be without it.”

The WWCCAC’s Community Stroke Programwas named as a leading practice by Accreditation Canada, a third party organization that evaluates the quality and safety of health care organizations, and was nominated for the Minister’s Medal – an award honouring exceptional work across the health system.


Advancing Wound Care through Collaboration A complex wound can sometimes take years to heal and can significantly delay the ability to regain independence and quality of life. It can mean frequent visits to a clinic and in some instances, it can lead to amputation and permanent disability.

In 2014, the WWCCAC, in collaboration with system partners, advanced its work in wound care by establishing the Integrated Wound Care Program Council. In partnership with leaders from across the health care system, the Council is working to develop leading practice standards for wound care.

As a result of the work done by the Council last year, the WWCCAC was an early adopter of the evidence-based, Venus Leg Ulcer Care Path. The WWCCAC and its service providers will inform the Program Council on how the implementation of this best practice positively impacts patient outcomes.

“This collaboration between hospitals, long-term care, primary care and community care will help improve a patient’s quality of life,” says Andrea Binkle, Senior Director, Partnership and Performance, WWCCAC “It will also support the delivery of safe, high quality and evidence-based care across the health care system”

In the coming months, work will continue to expand the program to cover other types of wounds.


Meet CraigIn spring of 2014, Craig was involved in a serious car accident, leaving him with two broken legs and multiple fractures to his ribs, sternum, collarbone and hand. After spending several months in a hospital and then a rehabilitation facility, Craig was finally able to come home. Although Craig’s recovery was going well, one of the wounds on his leg simply would not heal, causing him pain and worry that he could lose his leg. The WWCCAC helped Craig receive the care he needed at home, arranging for a wound care team from St. Elizabeth to assist him. Craig attributes his full recovery to the care he received through the WWCCAC.

Click the orange play icon to hear Craig’s story.

“With the help of the CCAC, I can recover faster. If there is the slightest problem down the road, you know they will be there for you.” ~ Craig

https://www.youtube.com/watch?v=-2puqUIagMY&feature=youtu.be


Seamless and Coordinated CareWe will partner for seamless care and leverage information and technology.

Providing Team-based Care in the Home

Patients with multiple, complex medical, psychiatric and/or social conditions require highly personalized support to address their unique needs. For this reason, they frequently turn to a hospital’s busy emergency department for primary care.

Over the past year, the WWCCAC has worked in close collaboration with hospitals, family doctors, community organizations and others throughout Waterloo Wellington Region to develop three In-home Teams that provide personalized support to this vulnerable population.

WWCCAC Care Coordinators are key members of the multi-disciplinary team, working closely with physicians, nurses, nurse practioners, social workers, outreach workers, pharmacists and other healthcare providers, depending on the needs of the individual and the community.

Each team visits the patient in their home, completes an assessment, problem-solves in real time and creates a person-focused, goal-specific care plan that aims to reduce unnecessary admission to hospital and an improved quality of life for the patient.

Since the program began in 2014, the three multi-disciplinary In-home Teams supported 288 patients with complex medical, psychiatric and/or social conditions by providing personalized care right in the home.

The In-home Team project builds off the success of Guelph’s “Primary Care at Home” program which runs in partnership with the Guelph Family Health Team.

SUPPORTED

3,348CLIENTS IN THEIR TRANSITION TO ADULT DAY PROGRAMS, REHABILITATION,COMPLEX CARE, & SUPPORTIVE HOUSING

SUPPORTED

4,732CLIENTS IN THEIR TRANSITION TO LONG-TERM CARE,

RESPITE &CONVALESCENT

CARE


Supporting the Mental Health of Children and Youth

One in five youth suffer from depression, and recent projections suggest this number will increase by 50 per cent by the year 2020.

With more and more children and young adults facing mental health challenges, the WWCCAC, in partnership with the Waterloo and Wellington Region District School Boards, expanded its Mental Health and Addiction Nurses in District School Boards Program (MHAN) to accept referrals from physician specialists who work with children such as pediatricians and child and adolescent psychiatrists.

“Expanding the MHAN program to include referrals from physician specialists means more children and youth will have access to support,” says Becky Mantynen, Patient Services, WWCCAC. “Over the next year, we will continue our focus on building collaborative relationships with other health care providers.”

Mental Health and Addiction Nurses

play a critical role in supporting this

vulnerable population of children

and youth, particularly for those

transitioning out of hospital and

back to school. They provide one-on-

one support in the school and home

environment, help the child and family

manage medications, co-create coping

strategies, provide mental health and

addictions education to teachers and

students, and coordinate community

supports for both the child and

family. In addition, the MHAN nurses

provide families with mental health

system navigation supports, including

collaboration with school board staff,

community mental health agencies, and

the child’s physician.

“Many of the children and youth in this program have attempted suicide at least once,” says Kim Schnarr, Mental Health and Addictions Registered Practical Nurse, WWCCAC. “Families are devastated and anxious because they don’t know how to get the support they need. As their partner and advocate, I’m with them every step of the way.”

Since the program began in 2012, 883 children and youth in the Waterloo Wellington Region have received support through more than 8,000 visits and phone consultations.


Using e-Referral to Deliver Timely and Efficient Care

The WWCCAC uses secure technology to make electronic referrals on behalf of patients to multiple agencies quickly, and can track the status of each referral. The e-Referral system allows for greater system efficiency for community support service providers, and for patients it means timely access to seamless and coordinated care.

Over this past year alone, the WWCCAC worked with community partners to expand this technology to 100 per cent of local long-term care homes and close to 90 per cent of local community support service partners.

“The e-Referral system provides us with a resource to effectively receive and manage referrals to our agency,” says Linda Flemming, Home Services Lead, Community Support Connections. “Having a secure system that supports greater two-way communication and collaboration among service providers means that we can deliver services such as Meals on Wheels, Friendly Visiting, Transportation Services and more, in a timely and efficient way.”

e-Shift: Using Technology to Link Patients and Families with Care

More and more, patients are requesting to receive end-of-life care in the comfort of their home. In order to support families and caregivers who provide this around-the-clock care, the WWCCAC introduced e-Shift,

an innovative program that uses secure, smart phone technology to connect specially trained personal support technicians to a Registered Nurse. The Registered Nurse provides real time, clinical expertise, and manages and directs the patient’s care during the end stage of life. The program also helps families get the respite they need. They can rest knowing their loved one is receiving high quality care at home, where they are most comfortable.


Meet Jo MarieFor the 54 years that they were married, Jo Marie and Tom were inseparable. They enjoyed all of the same activities, such as canoeing, sailing, and being outdoors. They raised four boys together, and even worked in the same industry. In 2011, Tom was diagnosed with cancer. The WWCCAC provided home care services that enabled Tom to continue living at home, side-by-side with his beloved wife.

Click the orange play icon to hear Jo Marie’s story.

“Tom was expected to live for six months but he actually lived for four years. I truly believe he lived for so long because of the good care, the home care, provided for us by the CCACC.” ~ Jo Marie

https://www.youtube.com/watch?v=OHK4QWNFJqo&feature=youtu.be


Recognizing our Community HeroesIn 2014, we launched Heroes in the Home, our community awards program. At our inaugural event, we honoured more than 300 community heroes from Guelph Wellington and Waterloo Region.

The program invites friends, family members, and care recipients to nominate a caregiver to be recognized for their hard work, dedication, and compassion.

Here are just a few of the Community Heroes we recognized:

MarybelleRay nominated his wife, Marybelle. Shortly after they married, Ray was involved in an accident that left him a paraplegic. “This wonderful woman has stuck by me, through thick and thin,” says Ray.

ShelleyShelley is an occupational therapist, who was nominated after going above and beyond to help a patient readjust to life at home after a long stay in a rehabilitation centre. Thanks to Shelley’s assistance, the patient now feels more confident in her home.

RonRon was nominated by his elderly neighbour, Maria. He helps her with household chores and simple repairs around her house. He’s never turned her down. “I was really surprised to be nominated for something like this,” says Ron. “It’s an honour.”


Congratulations to these very special individuals, and to everyone who was recognized as a hero in the home! We truly value the outstanding contribution you make each and every day to our community.

We look forward to celebrating our second annual Heroes in the Home in the fall of 2015.


Financials

Statement of Operations12 months ending March 31, in Millions

March 2015 March 2014

REVENUE

Net MOHLTC/LHIN Funding 130.7 121.8

Other Revenue 1.8 1.9

132.5 123.7

NET EXPENSES

Patient Care 122.5 113.0

Administration 10.0 10.7

132.5 123.7

Balance Sheet12 months ending March 31, in Millions

March 2015 March 2014

ASSETS

Current Assests 12.8 12.4

Capital Assets 0.6 0.6

13.4 13.0

LIABILITIES

Current Liabilities 12.9 12.4

Long-term 0.7 0.7

Fund Balances -0.2 -0.1

13.4 13.0


By the NumbersIn 2014 - 2015, the WWCCAC:

People Served by Age Group

Senior (64+)

56%Adult (19-64)

27%Child (-19)

17%


Personal Support 73.4%Expenditures: $49.1M

Visits/Hours: 1.6M Clients Served: 10,013

Nutrition 0.2%Expenditures: $665.2K

Visits/Hours: 4.8K Clients Served: 1,174

Occupational Therapy 1.73%Expenditures: $4.4M

Visits/Hours: 37.7KClients Served: 10,025

Nursing 21.9%Expenditures: $24.6M Visits/Hours: 477.3K

Clients Served: 14,804

Speech Language Pathology 0.6%Expenditures: $1.4M Visits/Hours: 12.8K Clients Served: 1,996

Physiotherapy 1.94%Expenditures: $4.2M Visits/Hours: 42.3K Clients Served: 8,452

Social Work 0.3%Expenditures: $951.1K Visits/Hours: 6.4K Clients Served: 1,470

Purchased Home Care Services

Waterloo Office:141 Weber Street South Waterloo ON N2J 2A9

For residents of the Region of Waterloo:519 748 2222888 883 3313

For residents of Guelph, Wellington County and the Township of Southgate: 519 823 2550800 265 8338

wwccac.org

Funding for the WWCCAC is provided by the Waterloo Wellington Local Health Integration Network (WWLHIN).

http://www.ccac.org

http://healthcareathome.ca/ww/en

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