CSR Plan Summary of Initiatives and Objectives
In support of a public engagement process completed in Spring 2011, these videos were produced to introduce each of the clinical topics.
Clinical Lead Dr. John Puxty, who also serves as Chief of Staff at Providence Care, has been working with a team of experts to develop a plan on how to improve restorative services for our region’s most elderly and vulnerable.
Please find the initiatives with the appropriate objective to follow, below:
High Risk Screening
To implement a common high risk screening process to be used at all sites and community partners. This process will alert care teams (in any setting including hospitals, Community Care Access Centre (CCAC), acute care, restorative care or community care) that their patient/client requires further assessment or a review/guide of current care plans. The completion of either of these actions could uncover the patient/client’s need for supportive services or enhancement of current supportive services and treatment delivery for individuals at risk.
This will lead to better targeting and coordination of a service delivery plan both inside and outside hospital (primary care and community). It will also guide development of innovative new services such as quick response multidisciplinary ambulatory assessments for high-risk individuals presenting to urgent care and ED within South East Ontario.
Community Hub-Integrated Community Assessment Referral Team (ICART)
To provide an integrated community assessment and referral team (CCAC and Community Support Services-CSS care coordinators) in response to the High Risk Screening process (see above) and serve as an information and referral resource for health professionals so that they are able to locate supportive services for their patient/client.
The team will use patient/client information system with an up-to-date service database that details the health and support services available throughout the LHIN, including those not funded through the LHIN.
Roles and expectations of the various sectors will be understood broadly to enhance communication and appropriate referrals. Referral processes for all services will be detailed and referrals may be facilitated on behalf of the health professional as indicated. Additional assessment will be performed (using modified Inter-RAI, for example) by a CSS or CCAC care coordinator when required.
Other Restorative Programs
To provide standardized programs outside formal settings.The provision of slow-stream rehabilitation will be established as a role within Complex Continuing Care (CCC) throughout the LHIN. Best practice programs that are currently in place throughout the LHIN will be expanded and maintained. Potential restorative components within other CCC streams (complex medical, respite and end-of-life will be explored). Additionally, opportunities for introduction of convalescent beds within LTC will be explored and restorative models for care will be enhanced and reinforced in both community and LTC.
- Develop regional standardized program (admission criteria and referral processes) for access to restorative care in CCC, LTC and Community;
- Identify, and implement where lacking, the necessary linkages across the continuum e.g., slow stream rehab with formal rehab and other services in LTC and community.
Reducing Avoidable Loss of Function
To ensure that preventable loss of function during hospitalization individuals is reduced. This will include best practice protocols being implemented throughout the LHIN and support the creation of senior- friendly environments in hospital.
Senior friendly hospital principles will be endorsed by all institutions and action plans developed consistent with the Provincial Senior Friendly Hospital Framework and recent survey of all hospitals in South East Ontario. This includes:
- Organizational Support;
- Processes of Care;
- Emotional and Behavioural Environment;
- Ethics in Clinical Care and Research;
- Physical Environment.