Circle of Community Care

1. Circle of Community Care Providing the Community with Care November 2006

2. The role of the CCAC • To promote and optimize personal health by simplifying access and managing care across the health system by working with our clients and partners, to make the best use of home and community resources. • The CCAC provides: • Access to community health services • Coordination of placement and respite needs • Information services about informal health and social resources

3. To be eligible you must have: A valid Ontario Health Number Requirements that cannot be met on an outpatient basis A condition that can be adequately treated at home with the services available from the CCAC Family or friends who are willing and able to assist the client with the treatment program as required A reasonable expectation that service intervention will result in progress towards established outcome/goals Who is Eligible

4. Miscellaneous Information • Program is provincially funded by the Ministry of Health and Long Term Care (MoHLTC) • Clients may self refer or be referred by physicians, family and friends, other community agencies, hospital or other CCAC’s • Services are delivered at home, work, clinics, schools, retirement homes and in some cases LTC facilities

5. Case Management • Case Managers: • Determine eligibility for services, develop a service plan in consultation with the client and decide which CCAC services would best allow the client to meet their goals • Continuously assess the client’s needs, goals and ajusts services accordingly. • Initiate referrals to informal health and social community resources • Work from the main office, hospitals and satellite offices

6. Client Service Representatives(CSRs) • Client Service Representatives • Are responsible for providing a broad range of client service support, administrative and clerical assistance to the CCAC Professional staff, clients and families, service providers and the general public . • Take medical supplies orders over the phone • Action voice mail messages for Case Managers • Order services using a rotation list. • Action placement documents. • Provide information for existing clients

7. Bayshore Bayshore ParaMed ParaMed St - Elizabeth St - Elizabeth Carefor Carefor WeCare PSS Visit Nursing WeCare Bayshore Dietetics Shift Nursing ParaMed ParaMed St - Elizabeth Carefor Case Managers Carefor WeCare Client ( Caregiver / Family ) Social Work Physiotherapy CommuniCare COTA COTA Carefor Carefor Medical Supplies and Occupational Equipment Therapy CommuniCare COTA Speech Carefor Language Therapy Canada Care Desjardins Medigas OMS CommuniCare

8. Personal Support Services • Personal Support Workers: • Are an integral part of the Interdisciplinary Health Team • Are unregulated health care workers • Provide services to clients who require assistance with personal care and routine activities of daily living

9. Personal Support Workers • Personal Support Workers can be taught to perform delegated tasks when it is part of the client’s personal daily routine. • The delegation of tasks follows the recommendation of the College of Nurses of Ontario : Working with Unregulated Workers. • Examples of Delegated Tasks: Apply lotion, perform exercises, G-tube and ostomy care.

10. Visit Nursing • RN/RPN’s: • Assess the client and the families’ needs • Develop a plan of care in conjunction with the client • Provide direct care and teach the client with a focus on self care in order to reduce and discharge • Consult and communicate with the health care team regarding the client’s needs and condition

11. Shift nursing • RN/RPN: • Provide nursing care to medically fragile clients of all ages requiring continuous nursing interventions and care • Care is provided to the client and the family. • Most shift nursing services are for the pediatric and palliative population

12. Physiotherapy • Physiotherapists • Assess the client’s mobility, and suggest exercises and activities to promote healing, strength building and independence. • Assess equipment needs that are required to optimize independance and initiate funding for the equipment through ADP or other community resources. • Play a key role in pain management, energy conservation and muscle strengthening. • Teach Personal Support Workers exercises that the client requires in his/her daily routine. • Play an important role in the schools in assessing the student’s mobility abilities, focusing on safety and efficiencies in order for the student to to participate in all school activities.

13. Occupational Therapy • Occupational Therapists: • Assist people to live a more productive life by providing aids/tips to perform every day tasks. Ex: wheelchairs, feeding issues, home safety. • Assist clients to continue to live in the community, through suggestions about home modifications, cognitive retraining, energy conservation. • Will evaluate for specialized equipment and initiate funding through ADP or other community resources. • In the schools they assist students with fine and gross motor difficulties by assessing special equipment required and teaching the appropriate use to school staff and families.

14. Speech Language Pathology • Speech Language Pathologists: • Assess and identify the strengths and limitations of the client in terms of communication and provide recommendations in order to achieve a functional level of communication. • Address the communication challenges in the school setting that impact cognitive and social functioning and academic development.

15. Social Work • Social Workers: • Assist clients in developing, retaining and enhancing their psychosocial functioning. • Act as a facilitator for clients dealing with difficult issues such as mental health, resource issues, caregiver burnout, etc. • Provide education, counselling to client and family, collaborate with CCAC community organizations.

16. Dietetics • Dietitians: • Assess and optimize nutritional status • Provide assistance with the management of therapeutic diets, enteral tube feeds and swallowing disorders • Teach and develop client/caregivers skills and knowledge to facilitate self care

17. Equipment and Supplies • The right equipment and supplies are critical to healing successfully at home. The CCAC provides equipment and supplies to maximize the care of the client • For eligible clients, the CCAC provides equipment/supplies related to the care being delivered. Equipment is only rented on a short term basis. If the client continues to require the equipment after this period of time it is their responsibility to assume the rental costs or purchase the equipment • Supplies are ordered to ensure a 2 week inventory only in the client’s home • Catalogues are available that outline the supplies and equipment authorized by the CCAC

18. Communication throughout the health care team • Constant communication between the Case Manager and the Service Provider is the key to success to ensure the provision of the right service at the right time to CCAC clients. • Frequent updates on the client status are important to initiate changes in the service plan that reflect the client’s needs and goals.