In this section :

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 this program to ensure caregivers and home care 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 wellbeing. Home care 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) to identify “at risk” caregivers. Home care 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. The program was piloted in multiple settings – urban, rural, suburban and inner city – and rolled out to the entire Edmonton Zone from late 2019. 

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]). Tier 3 provides a self-management approach to wellbeing, supporting and connecting caregivers to a comprehensive suite of resources and tools. The program was 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 Local Health Integration Network. 

Connect: @CBIHealth and @KatMcQueenOT and @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: 
• Wait times for home care services, referral to services 
• Caregiver distress 
• Death at home/not in hospital 
• Patient/population reach indicator: Paediatric 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 Paediatric Patients 

Through this program, the Children’s Hospital of Eastern Ontario’s (CHEO) intensive care unit addressed the length of stays and admission rates by improving home care services for paediatric patients so they can remain at home. The program was funded by the Local Health Integration Network (LHIN) and modelled on 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 paediatric respiratory specialist offered home visits as needed for complex respiratory patients – addressing home equipment issues and creating a more seamless transition between patients and hospital teams. The program team also delivered 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: CHEO

Connect: @CHEO 

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

Team lead: Amelie DesLauriers, Social Worker-System Navigator 

Patient/family representative: Lillian Kitchen; Teresa MacMillan 

Senior officer/director: Michele Hynes, Director; 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 the Children’s Hospital of Eastern Ontario (CHEO) 

Navigator Program 

Parents of children and youth with medical complexities experience many challenges when caring for their child. Among the highest concerns are the effects on parents’ physical and mental health, and their increased social isolation.   
The Navigator Program helps to address critical gaps in supports and connections, and promote social and emotional health, for these families.

Two Parent Navigators help families to socialize, share ideas and connect with others, through workshops, wellness and social events, social media, and supporting them during admissions and clinic visits. In addition, a System Navigator can help families with needs beyond social isolation to navigate the complex care system, by finding resources and through one-on-one counselling, family counselling and workshops. Parents decide what their goals are and meet with Parent Navigators and/or System Navigators depending on their needs. 

Learn more: CHEO Navigator Program 
Connect: @CHEO 

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, 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 

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

The H.O.P.E. Model addresses 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 clients’ use 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. 

Learn more: The Hope Initiative

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 worked to integrate and enhance three of its regional chronic obstructive pulmonary disease (COPD) related programs: lung health, community-based pulmonary rehab and primary care outreach for seniors. The aim of integrating these programs was to improve early screening of COPD, enhance appropriate referral and care, and identify patients requiring palliative care supports. The team targeted four key areas for improvement to increase access, with the goal being 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: ConnectWell 

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). 

Learn more: McGill University Health Centre  

Connect: @cusm_muhc   

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 designed a quality measurement framework and performance monitoring process for home care within Alberta. They identified quality measures/key performance indicators (KPIs) and developed a reporting process to drive quality and measure progress. The team established accountability for quality in a consistent, standardized and transparent way which supports collaboration and sharing. 

Learn more: Alberta Health Services Continuing Care Quality 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 was 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 could access housing assistance or purchase a meal during their visit. Seniors who were homebound had home visits to integrate them into a social services program, helping them to stay at home. C3 Nurse Practitioners and other team members saw seniors in their home for both ongoing primary care and urgent care requests. Both of these types of visits contributed to seniors’ ability to stay at home, which decreased the number of non-urgent visits to emergency rooms, avoided hospitalizations and potentially decreased 911 calls for non-emergency concerns. 

Learn more: Sage 

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. 
• 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 was a robust service for patients who were on a complex medication regime, had compliance issues, were non-mobile and/or required additional assistance. It was an innovative initiative under the Wellness/Naz pharmacies located in Vancouver, Surrey and Langley, British Columbia. The team facilitated care transitions from the hospital to the client’s home as well as supporting older adults to stay healthy at home, therefore reducing emergency and primary practitioners' visits. The service supported clients around their immediate and long-term medication needs, wellness checks and reducing social isolation. The Wellness Campus’s innovative services helped clients with medication compliance such as insulin administration, daily injections and smart medication dispensation, as well as case managing and facilitating GP consultations to keep clients at home. 

Learn more: Wellness Pharmacy