WATERLOO WELLINGTON COMMUNITY CARE ACCESS CENTRE

Wayne and Shelley Drew

The moment Wayne Drew woke up

on the morning of March 2nd, he

knew something was wrong. “I had

a massive headache, like I’ve never

experienced before,” he says. His

wife Shelley took him to the

hospital where doctors confirmed

that Wayne had experienced a brain

hemorrhage. The CT scans also

revealed that he had two

aneurysms.

Even though they weren’t sure what

had caused the hemorrhage, Wayne

and Shelley decided to proceed with

clipping the aneurysms in order to

prevent future problems. Due to the

trauma of the surgery and

perhaps the brain hemorrhage,

Wayne suffered two strokes that

paralyzed the left side of his body.

Three and a half weeks after the

surgery, he was transferred from

Grand River Hospital to St. Joseph’s

Rehabilitation Centre, which would

be his home for the next 42 days.

When Wayne first arrived, he

required a lift to transfer him from

his bed to a wheelchair. After weeks

of intensive physiotherapy, he was

back on his feet and ready to come

home.

While at St. Joe’s, Wayne was

placed into a new region-wide

initiative called the Community

Stroke Program, which gives

patients access to a multi-

disciplinary stroke rehab team for

three months following their

discharge from hospital.

“The Community Stroke Program

supported Wayne and his family

with his discharge home from St

Joe’s,” explains Margot McKenzie,

their care coordinator at the CCAC.

“The program helped Wayne meet

his goals and began his integration

back home and into the

community.”

McKenzie set up multiple

appointments for an occupational

therapist to come to their home,

arranged for visits with a speech

and language pathologist, and

assigned a social worker to help

Wayne and Shelley deal with any

behavioural changes. McKenzie met

with them three weeks into the

program to review his progress and

discuss his goals for the final nine

weeks.

“A stroke is a life changing event,”

McKenzie notes. “Wayne and his

family were very excited that he

was home, but they were also

feeling overwhelmed. They really

appreciated the help that they

received, and made full use of the

Community Stroke Program.”

“I’m so proud to live in a country

that has programs like the CCAC,”

says Wayne. “I’ve been the

beneficiary of so much support, and

I don’t know where we’d be without

it.”

Recovery f rom St roke: One Couple’s Journey

th rough the Communi ty S t roke Program

January 2015

wwhealthline.ca Update: Stroke resources now online New resources are now available online to support people who have had a stroke and their caregivers in the

Waterloo Wellington region. Click on the button on the wwhealthline.ca home page, or find them at

www.stroke.wwhealthline.ca or http://www.strokeresources.wwhealthline.ca

wwccac.org

2

Message from Barry Monaghan, Interim CEO

Please join me in welcoming Dale Clement as the new CEO of the Waterloo Wellington

CCAC.

Dale is currently Chief Operating Officer and Clinical Integration Lead at Halton

Healthcare Services in Oakville. She has more than 20 years of experience in the health

care sector, including positions with the Mississauga Halton CCAC, the Hamilton Niagara

Haldimand Brant CCAC, St. Peter’s Health System, and Bayshore Health Care.

2

Innovative Paramedicine Project Launches in Guelph

“Paramedics are the ones who are

in the client’s home during a crisis,

seeing first hand what’s going on.

They see high-risk situations but

until now had no easy way to

connect people with the help that

they need.”

That’s Laurie Hodgkinson, Project

Manager, describing the concept

behind the Guelph-Wellington

Community Paramedicine Project.

She notes that 18% of 911 calls

come from people who have called

before. The CCAC is involved in two

aspects of the project: Paramedic

Referral and the Community Health

Assessment Program (CHAP-EMS).

The Paramedic Referral program

began on November 24th, with

paramedics able to make electronic

referrals to the CCAC for

assessment and help connecting

with health services. In addition to

the usual referral process, a letter

will go to each patient’s primary

care physician notifying them of the

referral and the outcome. EMS will

also receive a report on the

outcome to keep paramedics

informed. Both EMS and the CCAC

will collect data on how the project

is working.

CHAP-EMS will start in January.

Two high-needs seniors buildings

have been selected for the pilot.

Specially-trained paramedics will

set up clinics at which residents can

get a simple health assessment

(blood pressure, blood sugar,

weight, and so on) without leaving

the building. Although the CCAC is

not directly involved in this part of

the project, there will likely be

some re fe r ra l s , and ca re

coordinators can recommend that

CCAC patients living in the buildings

participate.

Hodgkinson is impressed by the

enthusiasm with which Guelph EMS

staff members have embraced the

project. “They are really excited

about this, which makes them a

wonderful group to work with.”

CCAC staff members have also

stepped up, she says, even though

the new referral process involves

several extra steps. “This is all

about working together to connect

patients with the right care at the

right time in the right place.”

Barry Monaghan

Dale Clement

Dale has a proven track record of building strong relationships

and partnerships with stakeholders. She is a champion of

change and transitional management and was a sector leader

in the initial development of the Home First philosophy.

The CCAC is lucky to have Dale, and she is lucky to be joining an organization that has many

strengths. We have a staff dedicated to delivering outstanding care and a leadership team

committed to innovation and excellence. Above all, we have close collaborative relationships

with you, our system partners. I know that Dale will build on these strengths to take this

organization to new heights.

For my part, I thank you for your support during my time as interim CEO, and for the spirit

of cooperation and partnership that animates our regional health system.

3 3

CCACs Publish First Quality Improvement Plans

Hospitals were the first to create and report on Quality Improvement

Plans. Now CCACs are on board. A report published in December

indicated that CCACs are focusing on:

Improving the patient experience

Preventing avoidable emergency department visits and

hospitalizations

Preventing falls

Improving access to service by providing nursing and personal

support within five days

The Waterloo Wellington CCAC plan focuses on understanding

current performance and building a multi-year plan

for improvements.

The Waterloo Wellington LHIN is launching an exciting

new project to improve access to the health system for

residents in our region. “The ultimate vision is that as

patients move through the system they will know what

the next step is, and the people caring for them will

have the information they need to provide excellent

care,” says Rob Forbes, the CCAC’s Senior Director of

Corporate Services. “It may take many years to

achieve, but this is the beginning.”

Forbes says the project is truly regional in scope, and

builds on the 17 integrated regional programs already in

existence. The CCAC is serving as the sponsoring

organization.

Among the guiding principles of the project:

Access will be simple and user-friendly

The system will be built from a resident’s

perspective

Referrals will be simple and easy, with less

duplication

Referrals will be followed up quickly

The referrer will always know the outcome of the

referral

The primary care provider will always know the

outcome of the referral

The provider will receive appropriate information

for the service

As a first step, a consulting firm has been hired to

determine the requirements of the supporting

technology, and begin to develop governance and

communication models. At the same time, hiring is

under way for a Director of Coordinated Access and

project managers, who will be focused on engaging with

system partners as the project goes forward.

Forbes says the project depends on strong partnerships

across the health spectrum. “The model is person-

centered, and the partners are all the providers who

interact with people on a day to day basis. We have to

work together to ensure that patients and families have

the most seamless experience possible.”

Waterloo Wellington Leads with System

Coordinated Access Project

4 4

“Sometimes family members feel they can’t cope with caring for a dying loved one at home, but with the help of

eShift, many can do it. It gives them a huge feeling of accomplishment, a sense that they have given their loved one

a gift.”

That’s Charlotte Koso, Director of Program Development and Innovation with Care Partners, talking about the

innovative eShift program available in Waterloo Wellington. With eShift, specially trained personal support workers

spend extended periods of time, often overnight, caring for palliative patients in their own homes. The workers are

linked by smartphones to a directing nurse, who provides minute-by-minute clinical expertise.

Koso says eShift improves symptom management, so that patients feel comfortable and safe at home. Caregivers are

able to rest, so they’re better able to cope with the stresses of caregiving at the end of life. “What I love about this

program,” says Koso, “is that we’re doing something that makes a real tangible difference for the family and the

patient. As a nurse, that’s very gratifying to see.” Heather Nicolson Morrison, Hospice Palliative Care Lead with the

CCAC, says eShift is also important to the health system. “

Preventing Falls, Saving Lives The Strategy is based on the BEEACH Model, achieving

Behaviour change through:

Education

Equipment

Environment

Activity

Clothing and footwear

Health Management

“Our plan addresses each of these components,” says

Brent Scott, Manager of Quality & Risk Management.

“Right now we’re focusing on activity.” Gentle exercise

programs are a key component because exercise can

improve balance, mobility and reaction time. Scott says

that there are excellent programs available in the region,

eShift Nursing Model Well-Established

According to the recent Auditor-General’s report, 60% of

deaths occur in the hospital, yet many of these deaths could

have been planned to occur at home or in a hospice,” she

says. “eShift, and other programs through the CCAC, make

it possible for more people to get home from hospital and

die comfortably there, or transition to a hospice.”

Nicolson Morrison says anyone can make a referral to eShift

– visiting nurses, CCAC care coordinators, family doctors,

hospital staff or others. “The important thing is to think

about eShift early in the planning, so that patients aren’t

sitting in hospital any longer than necessary. We can

provide even very fragile people with a better quality of life

in their final days.”

Every 10 minutes in Ontario a senior visits

an emergency department because of a fall.

Every 30 minutes, a senior is admitted to

hospital because of a fall.

Falls are the leading cause of injury in older

adults and the sixth leading cause of death.

Cont’d on next page

Recognizing these facts, the CCAC has made falls

prevention one of the measures on its Quality

Improvement Plan, with a goal of reducing the

percentage of adult long-stay patients who record a fall

on their follow-up assessment from the current rate of

36.4% to less than 30% by March 31st, 2016. To

achieve this goal, a comprehensive Falls Prevention

Strategy has been developed.

5

ERL Codes: Prioritizing Care in Emergency Situations

On the morning of December 23rd

2013, Gladys was waiting for the

nurse to arrive to change her

dressing. But overnight an ice

storm had blown through the

province, leaving slippery roads,

fallen branches, and countless

power outages in its wake. Gladys’s

own power was out, leaving the

service provider unable to contact

her.

“Contracted heal th service

providers are sometimes prevented

from keeping their appointments

with patients due to circumstances

beyond their control,” explains

Dana Khan, Director of Patient

Services at the CCAC. “That’s why

we work with all of our patients to

ensure that they have a back-up

plan in the case of an emergency

situation, like last year’s ice storm.”

When care coordinators perform

their assessment of the patient,

they consider the following factors:

Is the patient living with

someone? If not, is he or she

easily reached by friends or

neighbours?

Can services be held off until the

emergency situation is over, or

does the patient require service

every day in order to support

him or her safely at home?

Does the pa t ient need

mechanica l o r e lect r i ca l

equipment to sustain life, and is

professional assistance required

to support the patient?

After answering these questions,

care coordinators assign the patient

an ERL (Emergency Response

Level) code. There are five ERL

codes, ranging from Very High-Risk

(1) to No Risk (5); a subcategory

(T) indicates whether or not the

patient requires assistance with

transportation, in the event the

patient needed to be evacuated

from their home.

Gladys, for example, is Low Risk

(ERL4). She lives alone, but has

friends within walking distance and

she can remain in her setting

without harm for up to five days.

When the power came back on,

Gladys contacted by her nursing

service provider and the missed

appointment was rescheduled for

the following day.

“Particularly with our ERL1 and 2

patients, we need to make sure

that there is a neighbour or

someone that could support them if

a service provider is unable to

reach them,” Khan says. “ERL

coding is a collaborative process

between our care coordinators, our

patients, and our service providers

to ensure that we prioritize people

effectively in a time of emergency.”

5

but they are under-used. As part of the implementation

plan, community partners will be visiting the CCAC to

demonstrate the programs they offer.

Another component of the Strategy is medical review

and modification. Medications can impair judgment,

balance, coordination and alertness. Care coordinators

will be encouraged to make referrals to the Ontario

MedsCheck program or other services.

“Of course we want to reduce falls, because that’s

better for patients and families,” says Scott. “We also

believe what we’re doing will have a positive impact on

the system as a whole.”