North and South: Integration Case Studies from the Community Health Sector Part 3 SPEAKERS – Thursday, June 25 th , 2015 Jeanie Joaquin CEO, Scarborough Centre for Healthy Communities On Scarborough's Palliative Care Community Team Annette Katajamki, Executive Director, CMHA Sault Ste Marie On Learning from the Algoma Anchor Agency Experience Presented by Community Health Ontario
About Community Health Ontario The strategic partnership of Community Health Ontario believes that the sustainability of Ontario’s health care system depends on our ability to keep Ontarians healthy and avoid the need for more costly care models. We envision strong community-based services that are integrated, coordinated, efficient and better able to partner, focus on the social determinants of health and are coordinated with the long-term care and acute care systems.
Integration Resources Website An online repository of resources designed to help community health organizations survive and thrive in the world of integration pressures and opportunities. www.integrationresources.ca
Scarborough's Palliative Care Community Team Jeanie Joaquin CEO, Scarborough Centre for Healthy Communities
Building a Collaborative Model of Care Scarborough’s Palliative Community Care Team
Overview of Scarborough
Overview of Scarborough • Scarborough is 187 km2 with a public transportation system that was last updated in 1985 • Population is over 600,000 residents • Over half of the population of Scarborough was born outside of Canada (58%) • 9% of Scarborough identify as First Nations, Metis, or Aboriginal (highest in GTA) • In the 1980s, Scarborough had one of the highest median household incomes ($64,129) of all the former cities. By 2006, Scarborough is home to 6 of the 13 Neighbourhood Investment Areas in Toronto. • NIAs have higher than average concentrations of low income earners and higher than average populations of individuals who are considered at-risk, such as new immigrants, visible minorities and lone parent families
Overview of Scarborough • Scarborough has a slightly higher percentage of youth than other parts of Toronto, with youth unemployment in at an all-time high of 18.1%, with marginalized youth likely having even higher unemployment rates • Over 14% of Scarborough’s population are seniors aged 65 years and over. By 2016, seniors will account for 16% of the population: by 2021 they will account for 18%. 82% of seniors have one or more chronic progressive health conditions, 43% have three or more. • 43% of low-income people live in high rise units. Most of the buildings are more than 40 years old, energy inefficient, plagued with pests, and many are reported to be in disrepair. • There are 28 Toronto Community Housing Corporation communities in Scarborough. • Amongst the towers, along Highway 2 (Kingston Road), many of Toronto’s most marginalized residents live in the motels
Where we started • History of fragmented HPC services in Scarborough many gaps in community care • 90% of people say they want to die at home • 75% actually die in institutions even higher for those over 65 years of age
Partners of Scarborough PCCT • Scarborough Centre for Healthy Communities – Lead • Central East CCAC • The Scarborough Hospital • Rouge Valley Health System • Temmy Latner Centre for Palliative Care • Yee Hong Centre for Geriatric Care • Carefirst Seniors and Community Services • East GTA Family Health Team • Providence Healthcare
Background • March 2014 the Scarborough Hospice Palliative Care (HPC) Integration Project was launched with goals to: – Explore integration opportunities among the existing Scarborough HPC providers – Improve accessibility to quality palliative care ensuring the right patient is in the right bed at the right time – Develop an integrated and centrally coordinated HPC model – Establish service criteria based on appropriate service level intensity across the healthcare providers (hospital and community providers) – Increase the public and care providers awareness related to HPC – Ensure the opportunity for advanced End of Life Advanced Care Planning during the early disease trajectories is incorporated in the service model.
Method • SWOT analysis • Process review • Current state analysis of clinical and non-clinical services • Experience based co-design approach • Two-day Value Stream Mapping (VSM) – Development of framework future state – Captured patient and caregiver experiences – Engaged care providers & volunteers – Captured stories
Goal A model of integrated palliative care services that is inclusive of the centralized navigation system within the community that links patients and care givers to HPC services within the continuum including the introduction of a System Navigator Role and a Palliative Provider Outreach Team.
Scarborough Integrated HPC Model • 6 baskets of services across the continuum of care • Builds on existing services • System navigator as connector • Wrap around care – Client and family – From diagnosis to end of life – Provides variety & choice Right care, right time, right place
Where are we now • Building the team – recruiting and hiring the Navigators and Medical Secretary • Focus on transitioning patients from hospital who wish to die at home. • Soft launch started May 26 th with one unit at one hospital – spread planned after 4 week trial and evaluation to other units and hospital sites within Scarborough • Linking/coordinating with Health Links – Piloting the Coordinated Care Plan and Consent • Cultivating physician support • Leveraging and building on discharge options algorithm • Continue to work closely with the Palliative Care Network at a local and LHIN level
Where are we going? • Respecting Scarborough residents and their caregivers wishes to die at home, with dignity, support and respect • 24 x 7 support to clients and caregivers • Serving 200 patients by 2016 • Piloting and implementing provincial process of Coordinated Care Plan in collaboration with Scarborough Health Links • Being recognized by both patients and providers as a Palliative Hub in Scarborough community • Providing holistic care approach (Bereavement, Respite, Hospice and Palliative) • Following up patients as early as possible in their disease trajectory in cooperation with chronic disease management
Keys to Success • Support from Senior Leadership from all partners • Broad engagement • Availability of intensified PSW and nursing support right after discharge from hospital by staff trained in hospice palliative care • Timely referral of palliative patients to PCCT • Building relationships and trust with hospital physicians and Most Responsible Physician (Palliative Care MD) • Increase awareness on available palliative community services for primary and secondary palliative patients
On Learning from the Algoma Anchor Agency Experience Annette Katajamaki Executive Director, Canadian Mental Health Association, Sault Ste Marie
The Integration of Mental Health & Addictions Services in Algoma Annette Katajamaki, Executive Director
Context of Integration in Algoma Population Algoma – 115,000 Population Sault Ste. Marie – 75,000 Budget 2009/10 Community Mental Health - $8.8 million Addictions - $5.6 million Total - $14.4 million 40% goes to Sault Area Hospital Range of budgets $61,548 - $5,745.952 13 different organizations with over 100 programs/services
Agora Group delivers “Together” report • Seven options are laid out in the report • Agora Report recommends Option #7 – the creation of an Anchor Agency for the entire District of Algoma • This is not an option that was put forward at any point during the study – it appeared in the document as the recommended option
Why one agency? No central point for: – Service or system monitoring and evaluation – Accountability for the system – Planning – Additional resource acquisition – Consumer engagement – Sharing system information – Entry – Human resource recruitment and support – Negotiation and bridge-building with other sectors
Agencies involved NE LHIN Board passes resolution to integrate the funded mental health and addictions programs/services of the following (13) agencies: • Lady Dunn Health Centre • Algoma Family Services • Algoma Public Health • Anishnabie Naadmaagi Gamig Substance Abuse Treatment Centre • Breton House • Canadian Mental Health Association • Counselling Centre of East Algoma • Ken Brown Recovery Home • North Shore Community Support Services • Phoenix Rising • St. Joseph’s General Hospital • Sault Area Hospital • Women in Crisis
Proposed Integration Budget Year 1/2 • Facilitator and supports $150,000 • Legal and investigative auditing 50,000 • Buy-out for management staff 300,000 • Team building 50,000 • Leasing adjustment costs 60,000 • Salary equalization 100,000 • Staff costs (ED, supports, sr. staff) 150,000 • Sites location/commissioning 200,000 • Other 150,000 • Total $1,210,000
Recommend
More recommend
