Community Care Access Centres Your Connection to Community Health Services and Long Term Care

1. Community Care Access Centres Your Connection to Community Health Services and Long Term Care October 30, 2006 Val Armstrong, CCAC Simcoe County

2. What is Community Care? • health care and support services provided in the home, school, workplace, or other community setting • a range of services and supports for people of all ages • intended to optimize the individual’s health and independence • information and referral to health care resources

3. What is Long Term Care? • the provision of residential and health and support care services in the non-hospital setting • offered in “Long Term Care Homes” also known as Nursing Homes and Homes for the Aged • For individuals who need • Higher levels of daily personal care • Availability of 24 hour nursing care • Availability of 24 hour supervision or a secure environment • regulated by the Ministry of Health and Long Term Care

4. Community Care Access Centres Across the Province Presently 43 CCACs in Ontario • Regional or county boundaries e.g. Durham Access to Care CCAC Simcoe County As of January 1, 2007 • 14 CCACs across the province with same boundaries as 14 LHIN areas e.g Central West CCAC North Simcoe Muskoka CCAC

5. What are Community Care Access Centres (CCACs)? CCACs are government agencies that • are a single point of information and referral to all community health care services • works with the individual and their family to determine and coordinate needed services and supports • Arrange for and authorize the admission of individuals into a Long term care home • Partner with other health and community support services to improve the system of care for all clients and their caregivers

6. Community Care Access Centres Core Business

7. Information and Referral Case Management Access to Long Term Care Homes Long stay Short stay Convalescent care Community Nursing Personal Support services (personal support and caregiver relief) Therapies including: Physiotherapy Occupational Therapy Speech Therapy Social Work Nutritional Support Medical Equipment and Supplies Access to Adult Day programs What Services Do CCACs Provide?

8. Who Can Receive CCACSC Services? Eligible Clients include . . . • any Simcoe County resident with a valid OHIP Card • children who need health services to live at home and/or attend school • people who require in-home health services before and after being hospitalized • people who need long term therapeutic or personal support • older people needing assistance to remain in their homes or gain access to Long Term Care Facilities

9. How Can Someone Become a CCAC Client? CCACs takes referrals from . . . • family doctors and specialists • hospitals • therapists and other community health care workers • other community agencies – health care or otherwise • family members, friends, and neighbours • and • directly from the person who needs the help

10. How Does the CCACSC Deliver These Services? • Childrens’ – for children requiring school and home-based care • Acute Medical/Surgical – for people going home from the hospital after surgery or acute medical care or being treated at home • Medically Complex – for people with a significant medical condition or event and an unpredictable outcome

11. Programs Provided • Cognitive Impairment – for people dealing with dementia, brain injuries, developmental disabilities, etc. • Adult Continuing Care – for adults under 75 with lengthy recovery support needs due to a physical disability or chronic illness • Senior Continuing Care – for adults over 75 with chronic illness or disability, frail elderly

12. Case Management as a System Navigator • Focus is on supporting clients and their caregivers • Establish an ongoing relationship with the client and family based on trust and respect, understanding and supportive of their needs. • Completes a comprehensive assessment and facilitates the implementation of a comprehensive client service plan that meets the needs of both the client and family • Provide planned client/caregiver education, counselling, linkages to other community supports and long term planning.

13. Collaborative Community Initiatives • To partner with other health and community support services to improve the system of care for clients and their caregivers • Community partnerships with • Acute care hospitals • Community mental health services • Alzheimer Societies • Attendant Care Services • Adult day Programs • Developmental service agencies • Hospices • Community networks e.g. Dementia Network, End of Life Network

14. Case Scenerio • Mrs R. who has dementia and Mr. R • Mr. R. as primary caregiver expresses concerns about wife’s behaviours • Calls the CCACSC and a referrals is made to the CCAC Cognitive Program • Home Visit by Program CM • Comprehensive assessment completed • Review of Welcome package including community support information

15. Role of Case Manager Following assessment, Program Case Manager will: • Assess readiness for services • Explore with Mr. and Mrs. R what other service they may already be accessing • Educate Mr. and Mrs. R. to other service options • Provide initial counselling and education re disease process • Develop a comprehensive service plan including referral/linkage to a basket of services provided by CCAC and other community agencies

16. A Comprehensive Plan of Care In-Home Services • Cognitive Assessment and Care Management Service (OT) • Assistance with personal care • Caregiver relief Long Term Care Services • Short Stay respite • Access to adult day program • Long term care placement

17. A Comprehensive Plan of Care Specialized Geriatric Services • Cognitive Assessment and Support Services Referral to other community services • Alzheimer respite program • Alzheimer Society • Supportive counselling • Caregiver support groups • Education

18. Ongoing Support • Ongoing education and counselling throughout the progression of the disease • Advocacy • Long Term Care Planning • Changes in client service plan to meet changing needs