Team profiles :

Golden Health Care Management inc.

At a Glance   

Region: Saskatchewan

Setting: Rural

EAIP program principle(s): 

• Access to specialized healthcare services 
• Access to social and community supports 
• Access to system navigation and support 

Implementation (new, spread, and/or expand):   

• Spread 

Team Profile  

The organization leading this initiative is Golden Health Care Management Inc. (GHC) in collaboration with representatives from the University of Saskatchewan and the Saskatchewan Health Authority (SHA), alongside interdisciplinary staff, and family partners. Geriatricians and Nurse Practitioners provide mentorship and advisory support to the team, as well as a health economist and a nursing informatics specialist. Additionally, a Métis community-based researcher and various community connectors/relationship builders offer valuable support to the team. 

Community

• This initiative is being piloted in Diamond House, a personal care home located in Warman, Saskatchewan. 
• Warman is a small city located approximately 20 kilometers north of Saskatoon, in central Saskatchewan. With a growing population of around 12,000, Warman has a diverse demographic with a significant number of adults aged 65 and older, approximately 15% of individuals living in Warman are 65 and older.  
• The community serves as a catchment area for other rural and remote communities, including surrounding First Nations and Métis communities.   

Program Focus 

Program Description  

• GHC is currently piloting 30 alternate-level care beds within Diamond House in Warman, in partnership SHA, as part of the STEPS (Short Term Enablement and Planning Suites) program. The significance of the STEPS initiative lies in its provision of transitional care outside the acute care hospital setting, supporting care to be delivered closer to home. Where possible, the STEPS program supports older adults to regain health and transition back to the community delaying entry to long-term care. The STEPS approach aligns with the principles of quality care, ensuring that individuals receive the right care, in the right place, at the right time. Simultaneously, the Nav-CARE project is being piloted within GHC (Diamond House), offering support to STEPS participants and their family caregivers in making informed decisions regarding transitions and accessing supportive care services closer to home following discharge. 

Implementation Approach: 

• Cultural Integration: As GHC engages with the community, they aim to identify ways to integrate culturally specific care into their programming.    
• Integration of SK Nav-CARE: By collaborating with the SK Nav-Care volunteer program, individuals identified as candidates for the alternate-level care spaces, along with their families, will receive personalized support in developing transition plans and identifying goals throughout their continuum of care journey. The SK Nav-CARE coordinator will serve as a liaison between participants, families, and the SHA/GHC, ensuring seamless communication and coordination of care. 
• Utilizing Team CarePal: GHC will utilize the Team CarePal App to enhance collaboration among care teams as individuals transition from acute care settings to their home of choice through the STEPS program.  
• Facilitating Opening Conversations: As individuals move into the alternate-level care spaces, GHC will hold opening conversation sessions, focusing on abilitation (focusing on the person and their strengths and identified goals) and relationship-building, to actively engage participants in their care journey, promote improved health outcomes, and recognize caregiver roles within a supportive care environment.