Priority Health Innovation Challenge Participating Teams
Home and Community Care

Alberta Health Services: Edmonton Zone Home Living, Edmonton, Alberta

Team Lead

Jasneet Parmar, Physician Medical Lead, Home Living and Transitions, AHS EZ Continuing Care

Patient/Family Representative

Brenda Bell

Senior Officer/Director

Anita Murphy

Indicators:

  • Primary Outcome Indicator: Home care services helped the recipient stay at home.
  • Supplementary Outcome Indicators: Caregiver distress.
  • Patient/Population Reach Indicator: All primary caregivers of long-term supportive and maintenance home-care clients.

The Edmonton Zone Enhanced Home Living Supports Pilot Program

Alberta Health Services developed the Edmonton Zone Enhanced Home Living Supports Pilot Program to ensure caregivers and homecare clients with complex chronic conditions have a real choice to remain in their homes in the community and caregivers are supported to sustain care and maintain their own well-being. Homecare staff are educated to provide Caregiver Centered Care. Case managers use the Carer Support Needs Assessment Tool (CSNAT) to complete a person-centered assessment of family caregivers’ support needs and the Caregiver Risk Screen [CRS] is used to identify “at risk” caregivers. Homecare staff help caregivers access the support they need and navigate health and community systems. Enhanced respite care and supports for independent activities of daily living are available for caregivers at high-risk of burnout and/or being unable to sustain caregiving. This program is being piloted in multiple settings: urban, rural, suburban and inner city, and is being rolled out to the entire Edmonton Zone from late 2019.

Learn more: https://www.youtube.com/watch?v=vybuT51KJCk
Connect: @AHS_YEGZone @jatiprin

CBI Home Health Group, Etobicoke, Ontario

Team Lead

Kathleen McQueen, Manager of Clinical Excellence, Therapy

Patient/Family Representative

Curtis Hiemstra

Senior Officer/Director

Omar Aboelala

Indicators:

  • Primary Outcome Indicator: Caregiver distress.
  • Supplementary Outcome Indicators: N/A.
  • Patient/Population Reach Indicator: Caregivers who are all ages.

Care for the Caregiver Program

CBI Health Group, the largest provider of community healthcare services in Canada, has developed the Care for the Caregiver Program – a three-tiered program offering varying levels of support for caregivers. Tier 1 provides referral to the appropriate services or programming. Tier 2 provides caregiver support needs assessment (via the Caregiver Strain Index (CSI)). and Tier 3 provides a selfmanagement approach to well-being, supporting and connecting caregivers to a comprehensive suite of resources and tools. The program has been initiated for caregivers involved in the enhanced palliative program and restorative care program in the South West Local Health Integration Network with plans to spread next to Erie St. Clair LHIN.

Learn more: https://www.youtube.com/watch?v=b_0tQy8ayuw&feature=youtu.be

Connect: @CBIHealthGroup @KatMcQueenOT @OmarAboelelaPT

Children’s Hospital of Eastern Ontario (CHEO), Ottawa, Ontario

Team Lead

Carlie Brown, Case Manager, Home Ventilation Program

Patient/Family Representative

Teresa Macmillan

Senior Officer/Director

Sherri Katz

Indicators:

  • Primary Outcome Indicator: Home care services helped the recipient stay at home.
  • Supplementary Outcome Indicators:
    1. Wait times for home care services, referral to services.
    2. Caregiver distress.
    3. Death at home/not in hospital.
  • Patient/Population Reach Indicator: Pediatric home ventilation patients (age newborn to 18), including tracheostomy dependent and invasive ventilation patients, patients on non-invasive ventilation for life support, complex patients on positive airway pressure devices and patients requiring lung airway clearance devices such as LVR and cough assist. Secondary reach includes caregivers (RN’s, PSW, school staff and family members) via caregiver competency checklists and number of providers trained.

Complex Respiratory Care for Pediatric Patients

The Children’s Hospital of Eastern Ontario’s (CHEO) intensive care unit plans to address the length of stays and admission rates by improving home care services for pediatric patients so they can remain at home. This program is funded by the Local Health Integration Network (LHIN) and modeling the Somerset West complex respiratory care program which has demonstrated success for moving adult patients with complex respiratory needs and technology from the acute care setting back to the community.

A community pediatric respiratory specialist will offer home visits as needed for complex respiratory patients – addressing home equipment issues and creating a more seamless transition between patients and hospital teams. It will also deliver training and education to home care agencies to decrease wait times to home care services and decrease length of stay for inpatients requiring home care services.

Learn more: https://www.cheo.on.ca
Connect: @CHEOhospital

Children’s Hospital of Eastern Ontario (CHEO), Ottawa, Ontario

Team Lead

Amelie DesLauriers, Social Worker-System Navigator

Patient/Family Representative

Lillian Kitchen and Teresa MacMillan

Senior Officer/Director

Michele Hynes, Director and Chantal Krantz, Manager

Indicators:

  • Primary Outcome Indicator: Caregiver Distress
  • Supplementary Outcome Indicators: N/A     
  • Patient/Population Reach Indicator: Parents in the Champlain region experiencing caregiver distress who have children and youth under the age of 18 with medical complexities and are receiving support from CHEO.

Navigator Program

Parents of children and youth with medical complexities (CMC) experience many challenges when caring for their child, directly impacting the social determinants of health. Among the highest concerns are the effects on the physical and mental health of the parent and increased social isolation. Providing early screening and intervention will ensure that families thrive and are supported to provide the best life for themselves and their children.

The Navigator Program is in the final year of a five-year federally funded program to help address critical gaps in supports and connections for parents of children and youth with medical complexities. The program promotes the social and emotional health of families by helping them access peer supports and navigate key services, and providing counselling.

In order to support parents, the Navigator Program has two Parent Navigators and one System Navigator. The two Parent Navigators provide peer support to families who have children and youth with medical complexities, with the goal of providing the families with a means to socialize, share ideas, and connect with others who share their experiences in order to end their isolation and improve their wellbeing. The Parent Navigators do this by organizing workshops, wellness and social events, being present on social media, meeting parents individually or in groups, and supporting parents during admissions and clinic visits.

Families with needs beyond social isolation may also receive services from the System Navigator. The System Navigator helps families navigating the complex care system by finding resources and through one-on-one counselling, family counselling and workshops. With the re-initiation of the System Navigator, more families will be provided services and counselling to help alleviate caregiver distress. Parents decide what their goals are and meet with Parent Navigators and/or System Navigators depending on their needs. The System Navigator will be using a pan theoretical evidence-informed approach, specifically the Feedback Informed Treatment (FIT) approach during counselling. This approach allows clinicians to adjust their treatment approaches based on their clients’ feedback, and to monitor their clients’ progress.

Learn more: https://www.cheo.on.ca
Connect: @CHEOhospital

HOPE Model, SE Health, Ontario

Team Lead

Zayna Khayat

Patient/Family Representative

Randy Filinski

Senior Officer/Director

Zayna Khayat

Indicators:

  • Primary Outcome Indicator: Home Care Services Helped the Recipient Stay at Home
  • Supplementary Outcome Indicators: Wait Times for Home Care Services, Referral to Services, Home Care Services Helped the Recipient Stay at Home, Caregiver Distress, (In)appropriate Move to Long-Term Care, Death at Home/Not in Hospital
  • Patient/Population Reach Indicator: Home care clients in London-Middlesex and Englemount Lawrence Neighbourhoods

H.O.P.E. Model (Home Opportunity People Empowerment)

The H.O.P.E. Model® aims to address many of the gaps identified in the current transactional fee for service model of home care. Through combining both the health and social aspects of clients' lives; H.O.P.E aims to reduce utilization of high cost acute services while delivering a community-based care model whereby nurses provide a more integrated and holistic approach to care. Clients are supported to meet their goals by self-managing teams of nurses that take care of a person's full set of needs, including the majority of care services (nursing, PSW, therapies etc.), care coordination, and connections to both formal and informal care. The empowered teams of nurses work to their full scope to manage complex patients in the community with a lean infrastructure and management backbone.

Connect: https://hopeinitiative.ca/

Lanark Renfrew Health and Community Services, Lanark, Ontario

Team Lead

Christina Dolgowicz, Lung Health Coordinator

Patient/Family Representative

Christine Love

Senior Officer/Director

John Jordan

Indicators:

  • Primary Outcome Indicator: Home care services helped the recipient stay at home.
  • Supplementary Outcome Indicators: N/A.
  • Patient/Population Reach Indicator: Clients over the age of 40 with a diagnosis of chronic obstructive pulmonary disease (COPD).

Lanark Renfrew Lung Health Program

North Lanark Community Health Centre is working to integrate and enhance three regional chronic obstructive pulmonary disease (COPD) related programs currently offered through the North Lanark Community Health Centre: lung health program, community-based pulmonary rehab program and primary care outreach for seniors. The integration of these programs will improve early screening of COPD, enhance appropriate referral and care and identify patients requiring palliative care supports. Four key areas for improvement are targeted to increase access with the goal to keep patients at home:

  • Increasingly early screening and detection for people at risk of COPD.
  • Implementation of a 1-833 phone number to connect patients with a respiratory therapist to manage care from home.
  • Connecting patients to primary care outreach programs and providing education sessions to rehabilitation participants.
  • Early identification of palliative care clients based on specific indicators of decline.

Learn more:
https://www.nlchc.on.ca/PrimaryCare/Lung_Health.html
https://www.youtube.com/watch?v=9OdYWI3qibc
Connect: @christinadolgow

McGill University Health Centre (MUHC), Montreal, Québec

Team Lead

Carolyn Freeman, Chair of the MUHC Clinical Pertinence Coordinating Committee

Patient/Family Representative

Susan Szatmari

Senior Officer/Director

Martine Alfonso

Indicators:

  • Primary Outcome Indicator: Death at home/not in the hospital.
  • Supplementary Outcome Indicators: N/A.
  • Patient/Population Reach Indicator: All stage IV lung cancer patients referred to palliative support within 60 days of initial visit to the MUHC for diagnosis or care.

Integrating Palliative Support as Routine Care for Patients with Stage IV Lung Cancer

The McGill University Health Centre (MUHC) is rolling out a program to integrate early referral to palliative support as part of routine care for all patients with stage IV lung cancer treated at the MUHC. A feasibility study will be undertaken by conducting stakeholder interviews to assess readiness of clinicians and the institution/network and identify preferences of patients and caregivers. The program involves:

  • All patients with stage IV lung cancer presenting at the MUHC will be referred to palliative care within 60 days of initial visit.
  • In order to implement this policy, we plan to organize several focus groups with the various stakeholders including physicians, patients and caregivers, allied health care providers, as well as hospital managers and senior administrative staff.
  • Qualitative data from these focus groups and interviews that will help evaluate feasibility and stakeholder preferences and identify current gaps and areas to target (for example, patient and physician education about end-of-life discussions and need for methodical and transparent recording of advance care directives).

Provincial Seniors Health Team, Alberta Health Services, Alberta

Team Lead

Laurel Stretch

Patient/Family Representative

Judy Brown

Senior Officer/Director

Max Jajszczok

Indicators:

  • Primary Outcome Indicator: Home Care Services Helped the Recipient Stay at Home.
  • Supplementary Outcome Indicators: Caregiver Distress, (In)appropriate Move to Long-Term Care.
  • Patient/Population Reach Indicator: All home care clients in Alberta.

Provincial Seniors Health Project

The Provincial Seniors Health team is designing a quality measurement framework and performance monitoring process for home care within Alberta. This will include identifying quality measures/KPI and developing a reporting process to drive quality and measure progress. Additionally, accountability for quality will be established in a consistent standardized transparent way which supports collaboration and sharing.

Learn more: https://www.albertahealthservices.ca/cc/Page15594.aspx
Connect: continuingcare.quality@ahs.ca

University of Alberta, Calgary, Alberta

Team Lead

Tammy O’Rourke, Nurse Practitioner

Patient/Family Representative

Pearl Todd

Senior Officer/Director

Tammy O’Rourke

Indicators:

  • Primary Outcome Indicator: Home care services helped the recipient stay at home.
  • Supplementary Outcome Indicators: N/A.
  • Patient/Population Reach Indicator: Homebound seniors.

Collaborative Community Care (C3) for Seniors: Health Services @ Sage

Collaborative Community Care (C3) for Seniors: Health Services @ Sage is a senior focused/senior friendly clinic providing all the services that a traditional health team provides, with additional services not typically offered by traditional community primary care teams (for example clients can access housing assistance or purchase a meal during their visit). Home visits are provided to seniors who are homebound as part of an integration into a social services program, helping recipients to stay at home. C3 Nurse Practitioners and other team members see seniors in their home for both ongoing primary care and urgent care requests. Both of these types of visits contribute to the seniors ability to stay at home, decreasing the number of non-urgent visits to emergency rooms, avoiding hospitalizations and potentially decreasing 911 calls for non-emergency concerns.

Learn more: https://www.mysage.ca/at-sage/health-services
Connect: @SageYEG

Wellness Campus, Richmond, British Columbia

Team Lead

Dennis Natembeya 

Patient/Family Representative

Tiara Driedger

Senior Officer/Director

Zahid Merali 

Indicators:

  • Primary Outcome Indicator: Home Care Services Helped the Recipient Stay at Home
  • Supplementary Outcome Indicators: Wait Times for Home Care Services, Referral to Services, Home Care Services Helped the Recipient Stay at Home
  • Patient/Population Reach Indicator: Clients in the community on polypharmacy, discharged from the hospital, GP, or referral from case managers and community health nurses

Naz Wellness Campus

Wellness campus is a robust service to for patients on complex medication regiment, have compliance issues, non-mobile and/or require additional assistance. It is an innovative initiative under the Wellness/Naz pharmacies located in Vancouver, Surrey and Langley, BC. As a team we facilitate care transitions from the hospital to the client’s home as well as supporting seniors into the community to stay healthy at home, therefore, reducing emergency and primary practitioners' visits. We do so by supporting clients around their immediate and long term medication needs, wellness checks, and reducing social isolation. We incorporate innovative services that help clients with medication compliance such as Insulin administration, daily injections, smart medication dispensation (among other services ), case managing, and facilitating GP consultation to keep clients at home.

Connect: https://www.wellpharmacy.com/