on aSolidFoundation Building Innovation Celebrating 40Years ofService: Annual Report 2015 -2016

Foundation

Foundation

Foundation Contents

40th Anniversary Greetings...... 1 – 5 Carefirst 40th Anniversary & Milestone Achievement...... 6 – 8 Mission & Values...... 9 Strategic Plan 2016 – 2021...... 10 – 11 2015 / 2016 Report from the President & Chief Executive Officer...... 12 – 13 Board of Governance...... 14 2015 / 2016 Financial Report...... 15 2015 / 2016 Balance Scorecard...... 16 2015 / 2016 Service Statistics...... 17 Carefirst One-Stop Multi-Services Centre ...... 18 – 19 Carefirst INTEGRATE Model...... 20 2015 / 2016 Service Highlights...... 21 - 30 The Carefirst Family – Carefirst Family Health Team...... 31 – 36 – Carefirst Foundation...... 37 – 40 Donors ...... 41 – 42 Acknowledgement...... 43 – 45 2015 / 2016 Activities Highlights in Photo...... 46 – 49

Carefirst Seniors & Community Services Centre One-Stop Multi-Services Centre Adult Day Centre / 300 Silver Star Blvd., Scarborough, Ontario M1V 0G2 Scarborough Health Management Centre Tel: 416-502-2323 Fax: 416-502-2382 17 – 19 Glen Watford Drive Email: [email protected] Scarborough, Ontario M1S 2B7 Tel: 416-649-1212 Fax: 416-649-0014 Carefirst Family Health Team & Email: [email protected] Carefirst Specialist Clinic (Scarborough Site) 300 Silver Star Blvd., 2/F South Toronto Office / Scarborough, Ontario M1V 0G2 Helena Lam Community Services Tel: 416-502-2029 479 Dundas Street West, Toronto, Ontario M5T 1H1 Tel: 416-585-2013 Fax: 416-585-2892 Carefirst Family Health Team (Richmond Hill Site) Email: [email protected] 420 Highway 7 East, Suite 27, Richmond Hill Ontario L4B 3K2 York Region Richmond Hill One-Stop Tel: 905-695-1133 Fax: 905-695-0826 Access Multi-Services Centre / Email: [email protected] Ip Fu Ling Fung Adult Day Centre 9893 Leslie Street, Richmond Hill, Ontario L4B 3Y3 Carefirst Specialist Clinic(Richmond Hill Site) Tel: 905-780-9646 Fax: 905-780-9045 420 Highway 7 East, Suite 206 Email: [email protected] Richmond Hill, Ontario Tel: 905-695-0901 Mississauga Community Services Centre 1051 Eglinton Ave. West, Mississauga York Region Community Services Centre Ontario L5V 2W3 420 Highway 7 East, Suite 104A, Richmond Hill Tel: 905-270-9988 Ontario L4B 3K2 Email: [email protected] Tel: 905-771-3700 the Governor General

Congratulatory Message from

1 the Prime Minister

Congratulatory Message from

2 the Premier

Congratulatory Message from

the Minister of Health and Long-Term Care

Congratulatory Message from

3 the Minister Responsible for Seniors Affairs

Congratulatory Message from

the Mayor of Toronto

Congratulatory Message from

4 the Mayor of Markham

Congratulatory Message from

the Mayor of Richmond Hill

Congratulatory Message from

5 1976 Started Chinese meals-on-wheels service in 1989 Opened the Scarborough Branch Office to serve 1999 Opened the York Region Community Service 2004 Achieved the first 3-year accreditation for 2004- Chinatown, Toronto with a $1,000 operating the City of Scarborough. Centre and Adult Day Care Centre in Richmond 2007 by the Canadian Council on Health Services budget. In 1978 Founded the Chinese Meals- Hill; approved as a member agency of United Accreditation (presently known as Accreditation Renamed as the Chinese Seniors Support on-Wheels and Mutual Aid Association. 1992 Way of York Region. Canada). Services Association to reflect the expanding 1980 Changed to Chinese Seniors Home service scope and geographic coverage. 2000 Launched an agency renaming campaign Launched the only Chinese Elder Abuse Helpline Support Services Association, services grew and adopted a new agency name as in Toronto. Renamed as the Chinese Seniors Support from single meals-on-wheels service to a range 1992 Carefirst Seniors & Community Services Services Association to reflect the expanding 2005 Granted $1 million capital funding by the Town of home support services. Association. service scope and geographic coverage. of Richmond Hill for “Carefirst York Region One- 1985 Incorporated as a non-profit charitable 2001 Collaborated with The Scarborough Hospital’s stop Multi-Services Centre” in Richmond Hill. Started the first Supportive Housing Services in organization. 1995 Regional Dialysis Centre to pioneer the Peritoneal the Alexandra Park Seniors Apartments at 91 Dialysis Social Day Centre for the chronic renal Approved as a member of the United Way of Augusta Ave in Toronto. 1986 patients at Carefirst. Greater Toronto (presently known as United Opened the second Supportive Housing Service Way of Toronto); adopted the new agency name 1997 2002 Extended services to Mississauga and was in Tam O’Shanter Seniors Apartments and Toronto Chinese Seniors Home Support approved as a member agency of United Way of started an Adult Day Service in Scarborough. Services Association. Peel Region.

Reminiscing Carefirst’s Historic Milestone Development

2006 Launched the Stanford Model Chronic Disease 2010 Approved licence by the Ministry of Training, 2013 Received approval of $12 million loan from Self-Management Program. Colleges and Universities for the operation of Infrastructure Ontario for construction of the Carefirst Vocational Training Centre. “Carefirst One-Stop Multi-Services Centre”. 2007Celebrating Funded by the Ministry of Health 40th and Long - Anniversary for Carefirst in 2016 Term Care for the operation of Carefirst Family 2011 Received $ 500,000 from the Ontario Trillium Held Ground Breaking Ceremony for the building Health Team (Richmond Hill site) and opened Foundation - Community Capital Fund towards of the Centre for tomorrow: “Carefirst One-Stop the Carefirst York Region Specialist Consultation the building of the One Stop Access Multi Multi-Services Centre”. 2015 Completed construction of capital project and Service Centre in Richmond Hill. Services Centre in Scarborough. 2014 Opened another Adult Day Program in operating from “Carefirst One-Stop Multi- Services Centre” 2009 Won 2009 Health Innovation Finalist Award 2012 Study Tour to On Lok Lifeways, San Francisco, Scarborough, a total of 3 Adult Day Program Centres (2 in Scarborough and 1 in Richmond from the Ministry of Health and Long Term U.S. and adoption of the On Lok PACE Model of Received Health and Wellness Award from 2016 Hill). 2016 Care for the innovative project: Chronic Kidney Care at Carefirst. European Healthcare Design Congress for the Disease Early Identification and Outreach innovative architectural design of “Carefirst Program, jointly launched with the Scarborough One-Stop Multi-Services Centre”. Regional Renal Dialysis Program.

6 7

1976 2016 Carefirst 40th Anniversary

Chinese Meals on Wheels Services – housed by 20th Anniversary Celebration 30th Anniversary Celebration. the University Settlement House

Received Capital Funding from Town of Richmond Hill to set up the “Carefirst York Region One-Stop Multi-Services Centre” in Renaming Campaign in Year 2000 – new agency name: Carefirst Seniors & Community Services Association 2007 Chinese Seniors Home Support Services with a basement office loaned by Toronto City Home Tenant Association at 36A Baldwin Street, Toronto

Official Launching of Capital Campaign for Carefirst One-Stop Multi-Services Centre in Scarborough in 2012

Carefirst One-Stop Multi-Services Centre Ground Breaking Ceremony in 2013

Celebrating 40 years of serving the community

Grand Opening of Carefirst One- Stop Multi-Services Centre in 2016

8 Carefirst Seniors & Community Services Association

Mission Statement

Our mission is to ensure that seniors and others in need of services, living in Toronto and surrounding areas, enjoy a high quality of life in their communities. We strive to maximize their well-being through a range of social, health care, and supportive services planned and delivered through an integrated model of care. We will ensure that a comprehensive range of services are delivered by an effective team of professionals and volunteers. We will achieve the above mission by: • Delivering client-centred services that reflect an integrated model of care. • Providing top quality & culturally relevant social, health care, & support services to our clients. • Ensuring a professional and caring attitude in all our client relationships. • Achieving optimal wellness levels in our clients by encouraging them to participate as actively as possible in their communities. • Promoting in the broader community an awareness of our clients’ needs for social, health care & support services. • Advocating to government, voluntary and private sectors on issues relating to policies and programs that affect our clients.

VISION & VALUES

Carefirst will be a leader in providing comprehensive, responsive and client-focused programs to seniors and others in need of services in the Greater Toronto and surrounding areas.

• Client-and-Family-Centred Service - Respect client and family’s right to co-design and participate in discussion making about service utilization, their health and wellness. • Quality Services - Provide and promote excellence in service through its quality standards and best practices. • Responsiveness to Diverse Community Needs - Respect diversity within the community through the provision of culturally and linguistically sensitive services. • Respect for Staff - Value the contribution of all employees by making every effort to meet their professional needs. • Integrated Care Approach - Consider the needs and well-being of clients, families and caregivers by using an inclusive, holistic service approach. • Professional Care - Provide services in a professional manner, ensuring that programs are delivered by qualified and competent staff.

9 Carefirst Strategic Plan 2016 - 2021

I. Context

The new 2016 – 2021 strategic plan was developed at an important moment in Carefirst’s history. In October 2015 Carefirst moved into its long planned new quarters. The building on Silver Star Blvd. was conceptualized, designed and built by the Carefirst community. This innovative Multi- Services Centre was the culmination of a decade of planning and fund-raising. Its opening marks a new era for Carefirst. This Strategic Plan reflects the vision that underlies the development of a Multi-Services Centre that can provide an exemplary Integrated Model of Care based on the successful PACE model replicated extensively in the United States.

II. Strategic Planning process

Carefirst’s strategic plan is the result of a very thorough assessment, consultation, analysis and discussion process led by our Strategic Planning Working Group consisting of an external consultant, Board and staff members with the involvement of all relevant stakeholders. From the deliberations and consultations throughout the planning process, a number of strategic imperatives were identified and prioritized.

Strategic Imperatives

Imperative #1: Develop a New Carefirst Business Model based on the PACE Model for Promotion of Integrated Care

• Establish through performance indicators that the PACE based model implemented by Carefirst is capable of meeting the MOHLTC expectations for high-quality, cost effective integrated community-based care.

• Promote the new Carefirst Business Model as a publicly recognized integrated care model that works in Ontario, specified in terms of key ingredients and evidenced based outcomes.

Imperative #2: Promote Organizational Health as the Greatest Opportunity for Improvement and Competitive Advantage

• Demonstrate that Carefirst cares for its staff’s work-life balance and HR communications as much as it does for its clients, through adapting leading- edge human resources, policies and practices.

• Build a robust succession planning program that emphasises current talent development and increases the availability of experienced and capable employees to meet future leadership needs.

10 Carefirst Strategic Plan 2016 - 2021

Imperative #3: Develop a Comprehensive and Effective Marketing & Rebranding Strategy for Carefirst and Its Services

• Reinforce Carefirst’s positioning in the home and community care sector by leveraging the new business model.

• Establish Carefirst as a leader in innovative home care practices amongst clients, funders and other service providers.

Imperative #4: Diversify and Broaden the Revenue Base to Enhance Organization’s Capacity

• Seek business partnerships to complement and augment the resource base so as to enhance Carefirst’s capacity and efficiency in service delivery.

• Develop social productive enterprises that are relevant within Carefirst’s mandate and jurisdictions to broaden the funding sources as well the service scopes for the benefit of clients and caregivers.

Imperative #5: Expand Development of Strategic Alliance and Selective Partnering to Enhance Social Impact

• Develop a matrix of strategic alliances and collaborative service partnerships to enhance the development of integrated care.

• Explore and open new forms of partnerships to gain access to new service opportunities.

11 2015/2016 Report from President and Chief Executive Officer

2015/2016 earmarked significant milestone developments for Carefirst. It celebrates 40 years of service for the community, and Carefirst enters a new era with the launch of its own newly built “Carefirst One-Stop Multi-Services Centre”. The investment in constructing the new Centre demonstrates the organization’s commitment to further developing better coordinated home and community care, actively collaborating with service partners to improve the implementations of seamlessly integrated social and health care, as well as becoming adaptable to the changing needs of the community and the transforming healthcare sector.

Throughout this annual report you will find highlights of our innovative service developments and strengthened community partnerships to advance integrated care for all. Some of our key accomplishments are described below:

• Developing New Five Year Strategic Plan 2016-2021: This strategic plan was developed at an important moment in Carefirst’s history as Carefirst celebrates its 40th anniversary and begins a new era of operating from its innovative multi-services centre. This strategic plan reflects the vision underlying the development of a Multi-Services Centre providing an exemplary Integrated Model of care based on the successful PACE model replicated extensively in the United States. Led by Professor Sheila Neysmith, Board Member of Carefirst, and supported by Don Pollock, external consultant with the Management Advisory Services, the Strategic Planning Working Group had undertaken a well-thought-out engagement of stakeholders in the planning process. Carefirst’s new strategic plan is the result of a very thorough engagement, assessment, consultation, analysis and discussion process in partnership with stakeholders, clients and families, whose input was incorporated. The new strategic plan shall provide a solid foundation to guide Carefirst’s future organizational growth.

• Attaining Architectural Design Award and Relocation to State-of-the-Art Carefirst One-Stop Multi-Services Centre: Construction was completed for the Carefirst One-Stop Multi-Services Centre in the fall of 2015. Since then, Carefirst has successfully taken over and moved into the building, located at 300 Silver Star Boulevard. It has been busy but exciting to settle into a new home, a dream decades in the making. Alongside Montgomery Sisam Architects, Carefirst received the Health and Wellness Award at the 2016 European Healthcare Design Congress, held in London, U.K. The outstanding architectural design of the facility supports easy one- stop access to Carefirst’s integrative and comprehensive services all under one roof.

• Celebrating 40th Anniversary and Grand Opening of New Centre: On June 17, 2016, Carefirst celebrated its 40th anniversary and official grand opening of its own remarkable centre. Over 500 guests supported and attended, including dignitaries, government officials, service agencies, hospitals, CCACs, supporters, donors, friends, and community members. We had the honor of receiving greetings from Hon. Kathleen Wynne, Premier of Ontario; Hon. Michael Chan, Minister of

12 2015/2016 Report from President and Chief Executive Officer

International Trade; MPP Soo Wong; City Councillors; Deborah Hammons, CEO of Central East LHIN; and Thomas Chanzy, Vice-President, Public Affairs of the Ontario Trillium Foundation. We also received a keynote message from Dr. Samir Sinha, Director of Geriatrics at Mount Sinai and the University Health Network Hospitals, Expert Lead for Ontario’s Seniors Strategy and Medical & Health Advisor for Carefirst Seniors and Community Services Association.

• Commencing Operation of the Transitional Care Centre: Along with the opening of the new Centre, operations at the Carefirst Transitional Care Centre also officially commenced in November 2015. The 30-bed short stay respite care centre at the Carefirst One-Stop Multi-Services Centre launched its operations by phases, with an intake of 10 clients per phase. By May 2016, Phase 1 has been completed, and the collaboration with Scarborough Hospital kicked off in the same month with hospital patients transferred to this unique and innovative facility for short recuperation. Patients are then transitioned back to their own homes or homes of destination. The transitional care arrangement not only addresses the issue of bed blockage in hospitals, patients are also all able to return home safely, as patients and families often take advantage of the tail end services provided by Carefirst, including home care, Chronic Disease Management and various social services. Client satisfaction rate has averaged at 90%.

• Preparing for 2017 Accreditation Survey: In 2013, Carefirst was accredited by Accreditation Canada with exemplary standing for four years. For this year, the organization has started the preparation process for the next accreditation, which on-site survey will take place in June 2017. To uphold the true value of client- and-family-centred care, a Client and Family Advisory Council was struck in 2016. Working in partnership and collaborating with the Client and Family Advisory Council allows Carefirst to incorporate the client and families’ perspectives and inputs into the development of the organization on all aspects, including client service delivery, policies and procedures.

Carefirst looks forward to deepening engagement with our community service users, including caregivers and families. This year’s incredible achievements and cherished opportunities could not have been made possible without the passion, hard work, and dedication of our Honorary Advisors, Board of Directors, staff, volunteers, service partners and stakeholders. We would also like to express our heartfelt gratitude toward the generous support of our funders and donors. As always, Carefirst continuously strives to provide quality and comprehensive services to meet the essential and changing needs of the community.

Sunny Ho Helen Leung President Chief Executive Officer

13 Carefirst Seniors & Community Services Association

Honorary Advisory Council Board of Directors 2015 – 2016 Chair President Irene So Sunny Ho

Fundraising & Immediate Past President Finance Management Advisor Genevieve Wong Stanley Kwan Executive Vice-President Charles Poon Michael Wong Medical & Health Advisor Treasurer Dr. Samir K. Sinha Olivia Mui Social Work Advisor Secretary Dr. Ka Tat Tsang Janet Lee Media & Community Relations Advisor Committee Vice President Patrick Fong Building Maintenance Committee Michael Wong Service Quality & Safety Committee Dr. Sandra Tam

Directors Senior Management Team Kwan Chan Chief Executive Officer Dr. Joseph Chien Helen Leung Kingson Lee Finance Controller & IT Director James Meloche Edmund Kwan Dr. Sheila Neysmith Dr. Paul Ng Senior Program Director Ian Po Germaine Lee Dr. Paul Tam Acting Senior Program Director Dr. George Wu Alice Mui

Nominees for 2016 – 2017 Director of Development & Board of Directors Communication Edith Lam Kwan Chan – Re-elect Kingson Lee – Re-elect Program Director Dr. Sandra Tam – Re-elect Lesley Krempulec Dr. Sheila Neysmith – Relect Program Director

Paul Fong Nancy Leung

14 2015/2016 Financial Report Carefirst Seniors and Community Services Association This is a condensed financial report. A full copy of the 2015 / 2016 Audited Financial Report reported by Financial Report Audited A full copy of the 2015 / 2016 report. This is a condensed financial Office (416-502-2323) Administration Thornton is available at Carefirst’s our auditor Grant

15 2015-2016 Balanced Scorecards

Outcome Measure of Accomplished Strategies and Objectives

• 98% clients satisfied with Community • 339 complex care needs clients Support Services, e.g. Client Intervention participated in INTEGRATE model of care and Assistance, Beareavement Services, (approx. 5% of total 6,780 clients served) etc. (based on random sampling of 100 • 95% staffs and 100% Board Members clients) particpated in new Strategic Plan • 95% client satisfied withAssisted Living Development (2016-2021) Services (441 clients surveyed) • 0% Sentinel Incident • 98% client satisfaction in Infection • Set up new “Client and Family Advisory Control/Personal Protective Equipment Council” of Home Care Services (477 clients surveyed) • Relocation and operation from new “Carefirst’s One-Stop Multi-Services • 45% service units Centre” since October 2015 increase in Exercise on & Bus cti ine & Falls Prevention fa e Ma ss is c n P (Total service t en ag r a ri e o unit: 260,046 S e m c t p e n x e s attendance) e n s i E l t

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n L responses) t • 24% increase in • 96% staffs satisfied with the government training they need to do the job and supportive grants well (174 total staff responses) • 8% increase in restricted reserve funds • 570 participations in 27 professional (designated for capital project) development courses in Demential • 43% increase in total agency donation Care, Palliative Care, Transfer Skills, and with total proceeds of $664,409 (majority Infection Control of which went to support capital • 21 Carefirst delegates, including a Board campaign) Member and 2 reps from The Scarborough • 90% operating budget expensed on direct Hospital, particpated in the 2nd study client services tour to On Lok Lifeways, U.S. Model, San Francisco in July 2015

16 2015/2016 Service Statistics

2015-2016 Service Statistics

2015 - 2016 Volunteer Hours (Total: 77,682 hours)

17 Carefirst One-Stop Multi-Services Centre

Carefirst One-Stop Multi-Services Centre, located at 300 Silver Star Blvd., Scarborough, facilitates accessibility and mobility for people with various special and health care needs. It is an one-stop access to integrated medical and social care. The Centre promotes population health, enhances patient and client’s experience, provides recreational and social space to promote wellness and integration and provides integrated care services for seniors (On Lok Model of Care). European Healthcare Design Awards 2016 Designed by Montgomery Sisam Architects, the Carefirst One-stop Multi-Services Centre won the Highly Recommended Award in the category of Design for Health & Wellness. Helen Leung, CEO of Carefirst Seniors (left), Alice Liang, Principal of Montgomery Sisam Architects, Canada (middle); Liz Paslawsky, Lead Judge of Full Operation Design for Health & Wellness June, 2016 Award (right).

Moved In Oct, 2015

Construction Ground Level 3rd Level Completed • Wellness Centre • Transitional Care Centre July, 2015 • Teaching Kitchen 4th Level • Vocational Training Centre • Central Administration, Finance, • Library, Computer and Cyber HR, IT, Home Care service Centre coordination • 70,000 sq. ft. • Courtyard Garden

• 4-storey building with 5 Lower Level 2nd Level • Social and Recreation Centre levels including lower level • Carefirst Family Health Team- • Community Support Services Primary Health Care Centre • $20 million building cost, Centre • Specialist clinics including cost of the land • Volunteer Development and • Chronic Disease Management Training Centre • Construction duration: 20 and Prevent Centre months • Adult Day Centre • Ontario Telemedicine Network- Virtual Care Centre • Rehabilitation Centre Ground-breaking Ceremony Client Feedback: Nov 6, 2013 “Easy access to medical care and other services under one roof.” Establishment of “An uplifting environment, I enjoy coming to the Carefirst Foundation Centre for interest and exercise classes!” 2006

18 Carefirst One-Stop Multi-Services Centre

19 Carefirst INTEGRATE Model

9 Key Dimensions:

I nter-disciplinary care • Multi-disciplinary intervention, i.e. physicians, nurses, social workers, physiotherapist, occupational therapists and frontline workers (PSWs), are involved in joint care planning and intervention N avigation • A care coordinator works with participants/caregivers/families throughout the process (engagement, assessment, care planning, implementation, monitoring, and evaluation) to improve access to health care and social services through case management T eam-based practice • A group of health care professionals with complementary skills work with participants/ families toward a common purpose, with agreed upon performance goals, and approaches, e.g. coordinated care planning, for which they hold themselves mutually accountable E lectronic health record (EHR) • A real-time, digital version of participants’ charts and records make available information instantly and securely to authorized users • A virtual platform for inter/intra-net communication insures care coordination and monitoring G rounded in care coordination hubs • ADP centres are “health homes” to coordinate visiting home-based and centred -based programs/services R esources coordination • Development of an integrated care pathway which specifies elements of care detailed in local protocols, the foreseen sequence of events, and expected patient progress over time • Integration of home and community based services • Arrangement of an inter-organizational network through vertical & horizontal integration A ccessibility • One portal entry to a circle, and continuum, of health care, social/community care and housing/transitional care services • Care close to home and on-site service delivery, e.g. assisted living and ADPs T imeliness • Care services delivered and intervention occurring at the right suitable time E ngagement • Engagement and involvement of all relevant sectors - primary care, community care, acute care, rehabilitation, public health, housing, and government support to make the integration model of care a success • Client-and-family-centred care – program development in partnership with clients/families and incorporations of inputs from them

20 2015/2016 Service Highlights

Adult Day Program • Carefirst’s three ADPs in Richmond Hill and Scarborough look after 425 different individuals a year. • With the expansion of our integrated care approach, more seniors in our ADP’s are receiving additional health services, such as mobile geriatric assessment and intervention, regular physiotherapy care and health monitoring services. • Caregiver support groups offered family members and cares for emotion or education needs. • In partnership with The Scarborough Hospital, the ADP has expanded our program to accommodate the medical needs for those on peritoneal dialysis.

Changes/challenges • Coordinating transportation to and from the programs and the cost of the programs. • Introducing portable GPS systems for improved safety and to keep a safe eye on those at risk for wandering away from the centre - staffs and families give two thumbs up! • While managing complex frail seniors, the ADP continually strives to make our environment safer while maintaining a client’s dignity and independence. − Increased Occupational Therapy assessments for client’s mobility equipment, falls assessments at home and physical safety at each ADP site; − Improved access to other health professionals (i.e., geriatrician, nurse practitioner, pharmacist, nurse, social worker) to better monitor health conditions and preventable falls; − Implemented GPS and other systems for assisting those with wandering behaviours.

Our newest ADP has been growing steadily in attendance.

“The Nostalgic Librarian” the books and look at Farsi magazines. When he returned to ADP, he presented as calm and contented. The staff also developed Mr. F has been a client of the ADP for 5 months.He has Dementia a number-code and had Mr. F help to “code” books, organize and presents with some inappropriate “responsive behaviours”, pamphlets and fill envelopes for mail-outs. He also helps to set including pacing, exit-seeking, agitation and aggression. His tables at lunch and straightens up chairs at the end of the day. Staff children who are in school did not have the resources to care for have also learnt some Farsi to maximize communication. Since him at home. At admission, the ADP staff really wanted to help but using his own language and providing Mr. F with tasks that helped struggled to manage his behaviours until they used the Montessori him to fulfill his previous role and feel like he is contributing to the approach to analyze the situation. They looked at his background program, his undesirable responsive behaviours drastically reduced. and learned that he used to be a librarian. He thought the ADP was a He has even allowed his sense of humour to come out and jokes library and he was responsible for overseeing it. This explained the with the staff. He enjoys his time at the “library” every day, which pacing and the agitation when the room became noisy. provides his family with much-needed respite. Staff responded by taking him to the library on the ground floor when it was too noisy in the ADP. In the library, he would organize

21 2015/2016 Service Highlights

Assisted Living Services • Assisted Living Services (ALS) addresses the needs of high-risks seniors to enable seniors to remain at home independently with personal support and homemaking services on a 24/7 basis. As a result, the percentage of hospital admissions and ER visits were significantly reduced and the program was effective in preventing premature LTCH admission among clients. • Two main challenges encountered this year pertained to scheduling: − Difficulties in locating and scheduling Personal Support orkersW (PSWs) to provide short but frequent or unscheduled visits to clients due to distant travelling in Richmond Hill and York Region; − Fewer PSWs willing to work full time in the York region.

Client Satisfaction Report 3% 92% 95% 2014-2015 2015-2016

# of client responded to survey 376 441

Positive client Experience also referred Mrs. Lee to other programs, such as Diabetes Education Program and Falls Prevention Program, that deemed beneficial Mrs. Lee was a client of the Assisted Living program since August according to her condition. Both Mrs. Lee and her daughter reported 2015. Prior to admission, she had a fall that fractured her left ankle. that these programs were helpful and informative. Mrs. Lee had not As a result, she was not able to walk independently with continuous fallen since admission to the Assisted Living program. In December pain in her ankle. Mrs. Lee was also at high risk for falls as she had 2015, the care coordinator received a call from them, requesting to multiple “minor” falls in the months prior to admission. Following reduce services to one hour weekly instead and allow other clients a thorough care planning session with Mrs. Lee and her daughter, who are more in need of services to use these resources, as Mrs. it was agreed that Mrs. Lee would receive two hours of services Lee’s condition had improved. They also expressed gratitude and weekly, focusing on assisting with transferring, exercising, psycho- thanked the care coordinator and PSW for all the help and support. social support, as well as some light cleaning. The care coordinator

Home Care Services • Home Care (HC) Services is a Community Care Access Centre (CCAC) subcontracted service through Central East, Central and Toronto Central, which provides individuals with personal care and homemaking services to maintain/improve their quality of life. With the input of clients and families, all clients have an assessment and individualized care plan developed to meet their needs. The services are delivered by PSWs under the supervision of nurses and supported by client coordinators. • Total of 251,897 hours of Home Care Services provided in 2015-2016, which represents a 6% increase, as compared to last year. • Toronto Enterprise Fund (United Way initiative) is a unique funding partnership with United Way Toronto, the City of Toronto, the Ontario Ministry of Community & Social Services, and the Homelessness Partnering Strategy, a federal government program administered by the City of Toronto. The TEF was established in 2000 to support the implementation of social enterprises that provide transitional or permanent employment, or training leading to employment, for people who are marginalized. Carefirst supports and trains people living in the communities that encounter severe barrier to employment.

22 2015/2016 Service Highlights

Home Care Services (Cont’d)

Highlights of the Year • There is minimal turnover for the Home Care Department in 2015-16, arising from our staff who are caring and supportive to clients. Carefirst’s pool of PSWs has a great combination of skills to help and support our clients’ needs. • “ ” - Carefirst’s PSW, Lucy Lu Yao, received the prestigious, Hero at Home Award from Toronto Central CCAC. The award was given to care providers who showed compassion and family/client centred approach in the care provided.

Direct quote from the nomination: Client Satisfaction Report “Lu Lucy is a PSW. Lucy is nominated by a homebound client for her work, and especially for Lucy’s going above and beyond in providing personal care, and homemaking 16% services for the clients.” Punctuality 80% 96% Hero at Home 18% “On behalf of my family and myself, thank-you for all the Infection Control/ PPE wonderful care that your staff provided for my husband over 80% 98% the past year. I was overwhelmed by the care my husband Year 2014-2015 2015-2016 has received. Carefirst’s staffs were all my husband’s Florence Nightingale.” —Barbara Smith # of client responded 477 477 to survey Supportive Housing Program • Situation and background of individual clients are assessed by Program Manager and Client Service Coordinators to make recommendations best suitable for clients. Coordinated care plans are then worked out with inputs from clients, caregivers, and staffs. On-going review of care plan is also undertaken to incorporate the changing condition(s) of client.

• In 2015-2016, 124 coordinated care plans were reviewed and updated.

• In addition to on-site services provided by Supportive Housing Program, 56% of the clients are referred to different departments, e.g. Adult Day Program and Chronic Disease Management Program, aiming to benefit clients with the total all-rounded care offered by Carefirst.

• Support to caregiver is also part of the total care: • 149 support and counselling sessions were provided for caregivers. • 30 caregivers were given training, information and education.

• Staff training is important for enhancement of work knowledge and skill: • All PSWs of Supportive Housing attended the Palliative Care training. • Other training sessions were also taken to ensure that quality care was provided to clients.

23 2015/2016 Service Highlights

Chronic Disease Management Program (CDMP)

CDMP is a cluster of carefully designed programs to help those with chronic health conditions including: • Cardiovascular • Frailty • Diabetics • COPD (Chronic Obstructive Pulmonary Disease) • Obesity • Rehabilitation after hospitalization • Mobile care to sites and homes within Central East LHIN Highlights for 2015-2016:

• Carefirst’s Geriatric Assessment and Intervention Network (GAIN) entered into its second year in providing care to complex care, to frail seniors. • Carefirst’s Community Cardiovascular Rehabilitation (CVR) program welcomes the addition of a physiotherapist to complement the nursing and kinesiology team. • The mobile Tele-Ophthalmology (TOP) to screen diabetic clients expanded its catchment area from Scarborough to the Durham area in an effort to reach out to more individuals. • Carefirst’s Enhanced Recovery Program (ERP) combined this year with our new Transitional Care Centre to better reach those who require rehabilitation to go back home independently and safely. • Carefirst’s inter-professional team provided professional and clinical support to the clients referred by other Carefirst programs/services, demonstrating the power of a unique integrated care approach.

The “Happy” COPD Client – Mr. L.

“My dad will be 90 years old in November. When he had a heart attack 14 years ago, we also found out about the emphysema because he was a heavy smoker for 30 years. Although he quitted smoking in his 50s, his lungs were damaged. For the last 14 years, dad had been in relatively good health until the December last year, when he got the flu virus. I took him to visit the respirologist and he was still fine but suddenly became very sick and was admitted to Sunnybrook Hospital for COPD exacerbation. Soon after he was discharged, he was readmitted for aspiration pneumonia and then readmitted again for chest pain. Dad was in and out of hospital almost on a weekly basis. His weight dropped quickly from 123 lbs to 106 lbs within three months. When the respirologist suggested that dad should come to Carefirst to join the COPD rehab program, I wasn’t sure because he was very weak. However, I decided if the doctor thinks that this is the last thing that dad should try, I would support it. COPD staffs at Carefirst would remember that when I first brought dad in, CCAC and I were talking about palliative care for him. When you look at my dad today, he doesn’t look palliative. Medication is still the same, the only difference is dad has joined this weekly COPD Rehab Program. It is the best that we can ask for. This program has given us hope, it has provided both mental and physical stimulation for dad and he is getting stronger every week.

24 2015/2016 Service Highlights

Community Support Services

“I was angry, scared, feeling isolated and lonely. I was so independent as I managed to support myself with a part- desperate that I have nowhere to stay and go. I have been time job. I learnt how to interact and communicate with helping and supporting my children for all my life, but now my children differently. Hopefully, I could have my own they become a stranger to me. They yelled at me and space soon.” asked me to leave…..…….With the continuous support ~ Ms. Z., 68-years-old service user of and assistance of Carefirst, now, I felt more positive and Community Support Services.

The Community Support Services are programs/services assisting seniors and others in need of the services to access appropriate services, whether provided by Carefirst or other community agencies. Through these services, seniors and needy individuals are able to lead an independent life in a safer, better supported and more comfortable environment.

The programs have adopted the use of InterRAI Preliminary Screener and InterRAI CHA common assessment tool to identify the seniors’ individual care needs and service goals. They were provided with client-and- family-centred intervention and support services, including case management, ongoing assessment and service navigation.

The basket of Community Support Services includes Crisis Intervention and Assistance, Friendly Visiting and Telephone Reassurance/Security Check, Escort & Interpretation, Information and Referral, Bereavement Counseling, and Elder Abuse Prevention and Intervention. Achieved Impactful Outcomes:

Offered over 550 seniors/ over 985 intake Provided over 6,500 caregivers with information on assessments or reassessments information and referrals senior housing, seniors benefits, for high risk seniors who through telephone and/or face- aging at home community encountering significant life to-face drop-ins enquiries. resources, and integrate care.

• Outreached to over 3000 seniors/caregivers residing in Toronto, York Region and Mississauga areas to equip them with elder abuse education through 48 workshops, 4 symposiums, and 7 support groups. • Actively engaged 136 bereaved service users to join the Bereavement Network for ongoing peer mutual support to deal with the loss of loved ones. The network members have volunteered to help planning and implementing periodic social activities and trainings to promote friendship and mutual support within the Network.

Program Effectiveness: Client-centred Care: Accessibility

95% 93% 93% 100% 96.5%

95% clients 93% participants had 93% bereaved 100% clients reported 96.5% clients increased strengthened coping better understanding clients increased active participation in usage of community abilities and problem of elder abuse and and strengthened the assessment and resources by overcoming solving skills in daily enhanced sense of the social support intervention process language and cultural functioning self- protection and network barriers that prevent them safety from accessing community support services.

25 2015/2016 Service Highlights

Community Exercise & Falls Prevention Program

Funded by Ministry of Health & Long Term Care through the Central East, Central and Toronto Central LHINs. Seniors’ exercise classes focus on improving and maintaining functional performance through strength and balance to prevent injury and falls. Falls prevention classes provide seniors with instruction on how to reduce the risk of falling.

492 classes of exercise and falls Locations - prevention classes from downtown Toronto, 130 sites - delivered. Scarborough, North York, including retirement homes, Thornhill to most of York community centres, libraries, Region and south Simcoe community agencies, The program has County. Welcome Centres, Toronto helped approximately Community Housing, 5,000 seniors York Housing, private to stay healthy, For adults condominiums and places of physically active and worship. independent in the 65+ community.

The exercise classes vary in their pace and type, including tai chi practice, qigong/breathing “I joined the exercise class more practice, line dance, chair-yoga and the standard than 1.5 years; I found the classes chair-based exercise. are very helpful. My health conditions improved a lot.” • The program has demonstrated its ~ Ada Leung effectiveness in promoting overall health and wellness, as well as in “I am diabetic, my sugar level mobilizing seniors to encourage the is well kept. It maintains at same in their peers. As reflected in the a healthy level and is under client satisfaction survey conducted in controlled.” ~ Tony Yuen September 2015:

• 81% of the seniors surveyed had noticed “It’s a wonderful program and helps me a lot especially my back improvement in their overall physical pain. The instructors are very function, e.g. walk longer distances than professional and patient.” before

• 99% continue to participate in the program and will also be recommending the classes to family and friends

26 2015/2016 Service Highlights

The Wellness Club

The Wellness Club, which has a membership of 2,502 members, provides various social and recreational activities, fitness programs and educational workshops to promote and help the club members to stay healthy, active and well-connected with the community. It also paves the way for the retirees, baby boomers to contribute meaningfully to programs as volunteer instructors, speakers and peer leaders.

• The Club utilizes experience and skills of volunteers to plan programming/ activities for their peer group. They also help in recruitment, implementation and evaluation of activities.

• Pooling together resources of four service teams (Wellness, ADP, SHS and Volunteer) to implement a client-centred half-day program.

• Rolled out a year-round falls prevention education campaign: delivered 17 education workshops for seniors (391 participants) and 6 education workshops for caregivers (201 participants).

The client satisfaction survey in Sep 2015 reflects:

96% 97% 97% 94%

are more engaged felt happier felt better both rated excellent in and interactive with physical and overall experience others mental well being participating in the Wellness Club Program

Christine Chau’s Story – in pursuing her interest and self-discovery For Christine Chau, knitting was more than a simple with a group of peers from similar walks of life and from hobby. It was a passion and an outlet for her to express similar backgrounds. Christine has also found a sense her feelings and emotions. She originally began knitting of community and acceptance, friendship and support. when she was very young, but because she led a busy life she was unable to practice this passion as often as Christine is now happily enjoying her life in a way she she would have liked. After her retirement, she began never thought possible and is continuously developing her search for a knitting class that would fulfill her new interests. The impact that Carefirst has on a senior’s needs. life is immeasurable, and in the case of Christine Chau, we can see firsthand the improvement that Carefirst She fell in love with the knitting program! It was can make in terms of seniors’ social lives, well-being affordable, allowed her to pursue her passion for and interpersonal relationships. knitting, and allowed her to share her life experiences

27 2015/2016 Service Highlights

Transportation Services • Transportation is a vital service for frail and homebound seniors to stay connected with the community as well as to maintain their quality independent community living.

Toronto

Close to 40,000 transportation trips With a fleet of 12 With a team of 17 dedicated paid drivers, were provided to needy clients in the vehicles. as well as 10 volunteer drivers using Greater Toronto Areas. their own vehicles.

• The transportation program is committed to the implementation of integrated care model within Carefirst. The team has worked closely with Carefirst’s all service departments year round in transporting frail seniors to attend adult day programs, hemodialysis treatment, rehabilitation programs, medical appointments, as well as transporting discharged patients from hospital to home. Transportation staff members also participate in the team-rounds to contribute to client’s care planning.

• Carefirst has to subsidize the transportation program annually despite it receives funding from the government, for the purpose to meet the high demand for transportation services. The program needs to operate in a financially sustainable manner so that it does not become a financial burden to the organization. Last year, the team adopted the “LEAN” approach to review and streamline the service organization and routings, so we are able to sustain the program and continue to offer the transportation service to support clients attending essential programs.

“Without Carefirst’s transportation service, I won’t be able “Being a caregiver is not easy, my family and I sincerely to enjoy the time at the Adult Day Program. Thank you thank the whole transportation team for all the support very much!” you have given us.” ~ Ms. M.H. Cheng. ~ Mr. & Mrs. H.C. Ho, family member of transportation service user.

Volunteer Development & Coordination Some of the volunteers The program recruits individuals from all walks of life as volunteers to play surveyed that: an active role in the delivery of volunteer services that will both support our community and improve our society.

agreed their Highlights for 2015-2016 94% skills are utilized • The program actively engaged the veteran volunteers in developing “Volunteer Training Programs” with contents where their skills and expertise are best utilized. agreed they had • The program also provides a platform for the volunteers having made a the same interests/hobbies to meet regularly for sharing and 90% difference in the socialize. The hobbies clubs (Photography, Folk Dance, First Aid community and Calligraphy) would not made possible without the devotion of time and skills of some volunteers who play an important role in planning and leading the clubs activities. agreed the volunteer work • Has a pool of 717 volunteers capable in communicating in 97% was rewarding Chinese (Cantonese/Mandarin/other dialects), English, French, Vietnamese and South Asian Language (Tamil, Punjabi, Hindi) to support Carefirst’s diverse clientele.

28 Carefirst Transitional Care Centre

An OPTION to Transition from Hospital to Home, Caregiver Relief and Waiting for Admission to Alternate Level of Living Placement

“We were told of Carefirst’s Transitional Care Centre to his needs, the physiotherapy was intensive and while he was recovering from the effects of having extensive, the food nutritious and thus contributing to cancer surgery at The Scarborough General Hospital. healing, and the atmosphere isl very supportive. I would He was not ready to return home, but was not able like to express our appreciation of the excellent care to continue staying in the hospital surgical floor. Your that my husband received while staying at your facility. facility proved to be the right place for my husband to I would like to recommend Carefirst to any patient, recuperate back to normal living and possibly return especially in the process of adjusting to independence to his home. The staff team was very accommodating after a hospital stay.” ~ Caregiver MS

A newly established service at the new facility, Carefirst One-Stop Multi-Services Centre, consisting of 30 beds, aiming to provide an environment promoting exceptional recovery, respite care and also simultaneously enriching the quality of life for individuals who are in need.

Specially designed and available for individuals for the following purposes:

• Recuperating from surgical procedures or medical conditions • Relieving caregivers who need a short break • Waiting for admission into long term care home facility

Achieved Impactful Outcomes

• Since its inception from November 23, 2015 untill the end of July 2016, received over 413 phone enquires and/or visits. • Served a total of 82 individuals with 59.8% female and 40.2% male. • Improved health condition with 84% of the program participants felt recuperated and stronger during their stay at the facility. • Enhanced caregiver support/Reduced caregiver stress with 95.6% of the program participants/families felt better supported.

Received Overwhelming Patient Experience

Physical Environment: Overall Experience: expressed that the physical 92% expressed that I received 100% comfort of the transitional 92% good/very good/ excellent quality care centre is good/very good/ of care in my stay. excellent.

29 Carefirst Vocational Training Centre

• Licensed by the Ministry of Training, Colleges and Universities (MTCU). • Registered as a Private Career College under the Private Career Colleges Act, 2005. • Obtained another maximum of the three-year accreditation from Ontario Community Support Association Personal Support Worker Education Program Accreditation (PEPA) in June this year.

2015/2016 Program Highlights:

PSW Certificate Program • The PSW Certificate rainingT Program prepares graduates to provide supportive care to individuals across the lifespan, including clients experiencing cognitive impairment, physical disability and mental health challenges, by assisting them with their activities of daily living. Last year, the team worked diligently to review and redesign the training curriculum to meet the new compliance requirements set by the MTCU. • The redesigned training curriculum with licenced course hours, to 650 hours were approved by the Ministry that it meets the new compliance requirements for the new Ministry of Training, Colleges and Universities Personal Support Worker Training Standard, 2014. The new curriculum will be rolled out in 2016 Fall Semester. • Accreditation by OCSA PEPA indicates Carefirst’s PSW Certificate Training Program has attained the standards in both contents and program organization. • Thanks to the partner training organizations: Tendercare Living Centre, Mon Sheong Long Term Care Centre, St Paul’s L’Amoreaux Community Centre, TransCare Community Support Services, Scarborough Centre for Healthy Communities, and Participation House for supporting the PSW student practicum placements. Under the coaching and mentoring of experienced supervisors from the partner agencies during the practicum, the students are able to gain valuable work related experience.

Comments from OCSA PEPA surveyor: “Program staffs are dedicated and strive to provide training that will ensure graduates from the PSW Certificate Training Program will provide quality care services. The program is supported by a well-established infrastructure with resources available to students and instructors.” Lead Instructor Debbie Mancini (Front R2) and PSW students.

Future Development Carefirst Vocational Training Centre is actively exploring to expand the training programs to include caregiver education and food service programs to meet the needs of the community.

30 Foundation Carefirst Family Health Team 2015-2016 Annual Report Carefirst Family Health Team (FHT) continues to be busy enrolling and serving patients on a Carefirst Family Health Team daily basis, to develop our services in alignment with the Ministry of Health and Long Term Care (MOHLTC) Bill 210, Patients First Act, 2016 to Strengthen Patients-Centered Health Care in Ontario. For 2015/2016, Carefirst FHT has been working its goals to ensure that patients receive integrated, accessible high quality care by planning Carefirst Family Health Team (FHT) continues to bean developing programs and services. In consultation with t busy enrolling and serving patients onhe Local Health Integrated Networks, other a daily basis, to develop our services in alignment with the Ministrycommunity stakeholders and upholding the patient and family of Health and Long Term Care (MOHLTC)-centred care approach. Bill 210, Patients First Act, 2016 to Strengthen Patients-CentredQuality Improvement Engagement Health Care in Ontario. For 2015/2016, Carefirst FHT has been working its goals to ensure that patients receiveCarefirst Family Health Team’s Board and staff have dedicated the past year to quality improvements integrated, accessible high quality care by planning . In our an developing programs and services. In consultationquality improvement engagement, we have been working in partnership with: with the Local Health Integrated Networks, other community stakeholders and upholding the patient and family-centred care approach. ♦ Health Quality Ontario (HQO) Quality Improvement Engagement ♦ Institute for Clinical Evaluative Services (ICES) ♦ Association of Family Health Teams Ontario (AFHTO) Carefirst Family Health Team’s Board and staff have dedicated the past year to quality improvements. In our quality improvement engagement, we have been working♦ College of Family Physicians (O in partnership with:CFP)

• Health Quality Ontario (HQO) • Institute for Clinical Evaluative Services (ICES) • Association of Family Health Teams Ontario (AFHTO) Keeping track major key performance indicators:• College of Family Physicians (OCFP) Keeping track major key performance indicators: ♦ Cancer Screening (pap test, mammography and colorectal cancer screening) ♦ Diabetes management (HbA1C, LDL and retinal testing) • Cancer Screening (pap test, mammography and colorectal ♦cancer Other health services utilization (emergency visits and hospital screening) re-admissions)

• Diabetes management (HbA1C, LDL and retinal testing) We continue to identify patients who are due or overdue for cancer screening and have developed a reminder • Other health services utilization (emergency visits and hospitalprocess to recall patients for follow re-admissions) -ups tests or referrals. We have implemented change ideas by developing We continue to identify patients who are due or overdueprocess maps to identify gaps, encourage each physician within the team to register and sign up for their Cancer for cancer screening and have developed a reminder process to recall patients for follow-ups tests or referrals.Care Ontario Screening Activity Report (SAR) to find out the patients’ screening status, and also use the Electronic We have implemented change ideas by developing process maps to identify gaps, encourage each physicianMedical Records (EMR) to screen eligible patient within the team to register ands so that the team can regularly review the baseline and set sign up for their Cancer Care Ontario Screening Activity Report (SAR) toimprovement targets. find out the patients’ screening status, and also use the Electronic Medical Records (EMR) to screen eligible patients so that the team can regularly review the Carefirst FHT Key Performance Indicators 2015/2016 baseline and set improvement targets.

Diabetes Care Comprehensive Management - Diabetes Education Program DEP

Diabetes is one of the most complex diseases and can be challenging to manage for many patients. The Carefirst Diabetes Team has been working tremendously hard and continues to identify and take concrete measures to improve and provide ongoing care for diabetic patients, who are referred to Carefirst FHT DEP from more than 300 FHT’s internal physicians and external community 78.8% practitioners on a regular basis. patients have had their LDL cholesterol78.8% test. (Provincial For 2015/2016, like in previous years, the Carefirst DEP served up to 2,000 patients have had their LDL diabetic patients and have screened patients to prevent complications from average = 67.1%) cholesterol test. (Provincial diabetes such as retinopathy and neuropathy through foot screens. The team average = 67.1%) has very satisfactory results by using the EMR and International Classification of Disease (ICD-9) codes to develop diabetes registry. The team uses the national guidelines and diabetes flow sheet tool to ensure 341 or 51.3% that we keep track of diabetic patients and to make sure that the front desk enrolled FHT patients with staff, RN’s, SW, physicians and those who are involved in the care of the diabetes341 orhad their51.3% HbA1C patients provide the care that patients need. enrolled testFHT done. patients with diabetes had their HbA1C test done. 32 Carefirst Family Health Team

Adoption of OntarioMD’s Hospital Report Management System (HRM)

The Carefirst Family Health team has signed up with OntarioMD’s Hospital Report Management System (HRM) that provides direct access to hospital reports for the purpose of timely information and notification on discharged patients who have been hospitalized or for those who routinely visit the hospitals.

• FHT staff will ensure that patients return to the clinic to see physicians in follow-up upon discharge within 7 days.

New Carefirst FHT—Scarborough Clinic and Integrated Coordination of Patients Care

Carefirst FHT’s patients, in particular seniors, have incredible opportunity to receive “wrap around coordinated multi-disciplinary care” through the adapted PACE model at Carefirst FHT. In October 2015, Carefirst FHT-Scarborough Clinic moved into the newly built Carefirst Seniors’ One-Stop Multi Access Centre where patients and their caregivers could receive a one-stop access to a basket of community support services: home care, meals on wheels, transportation, adult day care and also can be admitted to the transitional care unit when needed, all under one roof. This new Scarborough site provides not only family medicine care but also on site specialist access for the convenience of the FHT patients.

Seeking Accreditation The official accreditation survey date is October 3 - 5th, 2016. Why be Accredited? Carefirst FHT embraces the process of accreditation, which is an ongoing organizational journey that strengthens quality improvement efforts already underway. The benefits of accreditation include the ability to: 1. Assess services and find out where to focus improvement efforts 2. Develop standardized processes to improve efficiency and reduce costs 3. Mitigate risk and support the uptake of best practices 4. Build a culture of quality, safety, and excellence 5. Identify leading and commendable practices 6. Publicly promote the commitment to offer safe, high-quality services 7. Maintain and measure a Healthy Work Place Environment 8. Embed a Continuous Quality Improvement framework

Carefirst FHT continues to strive to provide quality care for patients, clients and families in the coming year. We plan to incorporate the accreditation standards to improve communication and safety within the FHT, so as to take the FHT’s operation to an overall higher level in efficiency and efficacy.

33 Carefirst Family Health Team

Carefirst Family Health Team – 2 services sites (located in Richmond Hill & Scarborough) to provide quality care for patients, clients and families

Carefirst Family Health Team Scarborough Clinic located on 2/F of Carefirst One-Stop Multi-Services Centre where patients can easily receive a one-stop access to a basket of community support services under one roof

Providing culturally and linguistically services

Specialized Programs & Services

Diabetes Education / Nutrition Counselling Physiotherapy Services

1634 Carefirst Family Health Team

Board of Directors 2015 – 2016 President Dr. Paul Tam Treasurer Winter Ng

Directors Dr. Chi Mong Chow Rahim Ismail Doreen Tai Foundation Nominees for 2016 – 2017 Board of Directors 2016 - 2017 Dr. Paul Tam - Re-elect Rahim Ismail - Re-elect

Senior Management Team

Chief Executive Officer Helen Leung Lead Physician Dr. Christina Lee Acting Director of Patient Care Services Louise Poon Administrative Lead Myrtle Robichaud

Family Physician Team Specialist Physician Team Dr. Christina Lee (Lead Physician) Dr. Gabriel Chan Gastroenterologist and Hepatologist Dr. Eugene Kwong Dr. John Chan Psychiatrist Dr. Polly Lam (Locum) Dr. Alice Cheng Endocrinologist Dr. Amy Lau (until August., 2016) Dr. Chi Ming Chow Cardiologist Dr. Nabil Moharib (until January, 2016) Dr. Jiang Optometrist Dr. Philip Sin Dr. Ying Lu Ophthalmologist Dr. A. Srinivasan Dr. Denise Tam Nephrologist Dr. S. K. Tong (until July, 2016) Dr. Melissa Tong Ophthalmologist Dr. Lesley Wu Dr. Gunjan Vador General Internist Dr. Sean Wang Dr. Albert Yeung Allergist & Immunologist Dr. Albert Yeung (until July, 2016) Shirley Cheung Chiropodist Dr. Lihua Zhuang Dr. S.K. Tong Eye Doctor

35 2015/2016 Financial Report Carefirst Family Health Team This is a condensed financial report. A full copy of the 2015 / 2016 Audited Financial Report reported by Financial Report Audited A full copy of the 2015 / 2016 report. This is a condensed financial Office (416-502-2323) Administration Thornton is available at Carefirst’s our auditor Grant

1636 n Foundatio Carefirst Foundation 2015-2016 Annual Report

Carefirst Foundation

About Carefirst Foundation • Registered as a charitable non-profit organization (charitable organization #83974 4943 RR0001) • Fundraises for Carefirst Seniors and Community Services Association and other organizations with similar objectives – to provide stable and quality community services for those in need. • Since its inauguration in October 2006, the Foundation’s Board has developed a strategic plan to realize its commitment to Carefirst Seniors and Community Services Association’s captial development of the “One-Stop Multi-Services Centre”, which combines social, medical and recreational services for the community in Scarborough.

2015/2016 Program Highlights • Under the leadership of the Foundation Board and the Capital Campaign Committee, Carefirst achieved the Phase One fundraising target of $6 million for the development of the “One-Stop Multi-Services Centre” last year. • The official grand opening and open house of the Carefirst One-Stop Multi-Services Centre, was held on June 17, 2016. The event showcased the new Centre as an inclusive care coordination hub, and brought together over 500 guests, including dignitaries, government officials, service partners, community stakeholders, supporters and friends. Major donor, the Fu’s family, and other donors and supporters were recognized and acknowledged at this memorable and celebrative occasion.

The fundraising activities organized To support the advancement of the last year included: Carefirst One-Stop Multi-Services Centre, donors can still participate in the Room • ‘Carefirst eek’W – a week-long event Naming and Furniture Naming Campaign comprising a Radio-Telethon for the support of further development • Mini-Open House of the “One-Stop Multi-Services Centre”. • Community Health Fair Donors can choose their preferred areas • Young at Heart Charity Gala or furniture items for honoring their loved • Charity Walk for Health one. Alternatively, a wish list is available • Mother’s Day Celebration with the most needed items in supporting • Carefirst first Charity Golfournament T the centre’s service delivery.

Carefirst Foundation would like to express its heartfelt gratitude to donors and supporters for designating Carefirst Foundation as their events’ beneficiaries. Special appreciation goes to: • Buddha’s Light International Association • Toronto Elegant Lions Club • Jenny Wong Beauty Institute • Power 7 Team • Toronto Chinese Road Bike Club • MiTV • Mr. & Mrs. Fred Kwan & Mimi Chau • Mr. and Mrs. Peter Choy

38

2015/2016 Financial Report Carefirst Foundation This is a condensed financial report. A full copy of the 2015 / 2016 Audited Financial Report reported by Financial Report Audited A full copy of the 2015 / 2016 report. This is a condensed financial Office (416-502-2323) Administration Thornton is available at Carefirst’s our auditor Grant

39

Carefirst Foundation

Honorary Advisors n Irene So Stanley Kwan

Honorary Members Benjamin Fu Samuel Tan Dr. Ying Lu Anna Yip

John Man Alex Yuan Foundatio

Board of Directors 2015 – 2016 Chair Ian Po Vice Chair Jason Chiu Treasurer Peter Choy Secretary Stephanie Ho Directors Maggie Deng* Sunny Ho Matthew Wan Kevin Fu Wilson Lam Michael Wong Ambrose Fung Shirley Ng Philip Ho Linda Tam* *Resigned during the term

Nominees for 2016 – 2017 Board of Directors Stephanie Ho – Re-elect Cathy Li Philip Ho – Re-elect Allan Sum Matthew Wan – Re-elect Ben Luong Yan Liu Will Sung

Senior Management Team Chief Executive Officer Helen Leung Finance Controller & IT Director Edmund Kwan Director of Development & Communication Edith Lam

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Donors

SPECIAL TRIBUTE Carefirst & Carefirst Foundation would like to extend our heartfelt gratitude to the following supports who have donated / raised $10,000 and more to Carefirst in 2015 / 2016

AstraZeneca Canada Inc. S.C.C.O. Management Inc. Fu, Benjamin W. EFES Management Ltd Torce Financial Group Inc. Fu, George Fontana Development Ltd Toronto Chinese Road Bike Club Orfi, Peri Fu's Borchun Property Management Ltd. Po, Ian International Buddhist Progress Society Mimi Chau & Frank Kwan Seng, K.H. Of Toronto Choy, Peter & Isabella Wong, Susan Foon Chim Power 7 Team Chung, Kim Yick, Jok Leung Senghwa Trading Inc. Chung, Sigrid

Our heartfelt thanks to all donors and supporters, with special recognition to contribution of $500 or more to Carefirst & Carefirst Foundation (April 2015 – June 2016) INDIVIDUAL DONORS Au Yeung, Eric Kuen Dr. Hong, Collin Dr. Sinha, Samir Bassi, Harmesh Kam, Michelle So, Irene Baylatry, Duc Ko, Kam Szeto, Allen Chan, Miranda Kwan, Thomas Dr. Tam, Paul Dr. Chang, Iris Kwan, Wong Sze Dr. Tam, Sandra Chao, Chih Jun Lai, William Wan, Matthew Chau, Mei Lan Mimi Lam, Edith Wong, Arnold & Diana Cheng, Kenneth Lam, Ray Wong, Bernice See Kai Cheng, Paul Law, Edmund Yick Tak Wong, Chris Cheung, Yuki Sau Fun Lee, Barbara Wong, Christina Dr. Chien, Joseph Lee, Kingson Wong, Ford Chiu, Simon, Hon-Sheung Leung, Helen Wong, Gordon Chung, Kim Leung, Rosie Lok Sze Wong, Justina Wai Sum Chung, Sigrid Leung, Stephen Wong, Kevin Dr. Choy, Ping Fun Loo, Whiteler Wong, Michael Chan Yuk Chung, Kim Ma, YingYing Wong, Susan Foon Chim Chung, Sigrid Min, Jeffrey Wong, Teresa K DiMenna, Ping Mui, Anita Wong, Yuen Ming Fan, Liling Mui, Olivia Dr. Wu, George Fok, Kenneth Hoi Wai Orfi, Peri Wu, Patrick Fu, Benjamin W. Dr. Neysmith, Sheila Yeung, Philip Kai Kwong Fu, George Dr. Ng, Paul Yick, Jok Leung Fung, Ambrose Ng, Shirley Yip, Anna Fung, Edmund Ng, Winter Yu Iu, Shui Hung Fung, Johnny Ngai, Moira Dr. Yuan, Alex Habra, Anthony Nguyen, Catherine Late Mrs. Sun Po Chu Memorial Fund Ho, David Po, Ian Late Mr. KK Kwan Memorial Fund Ho, Douglas Seto, Wendy Late Mr. Chup Yan Lee Memorial Fund Ho, Ling Seng, K.H. Ho, Stephanie Sie, Patsy Shuk-Wah Ho, Sunny Siegal, Marissa

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Donors

Our heartfelt thanks to all donors and supporters, with special recognition to contribution of $500 or more to Carefirst & Carefirst Foundation (April 2015 – June 2016)

CORPORATE DONORS Landstars 360 Realty Inc. Brokerage Mackenzie Financial Corporation 2333162 Ontario Inc Magna International Inc. 3T Financial Services Inc Mandarin Holidays Advanced Physiotherapy & Rehabilitation Centre Manulife Financial Alpex Prime Inc Metcalfe, Blainery & Burns LLP ARK Group Construction & Development Inc. MiTV AstraZeneca Canada Inc. Montgomery Sisam Architects Inc. Bayview Hill Pharmacy Mount Pleasant Group of Cemeteries Best Deal Graphics & Printing Inc. Neo City Café BrokerTeam Holdings Inc. On Care Pharmacy Ltd Brookfield Multiplex Construction Canada Ltd Peter B. Choy & Associates Canadian Chinese Line Dance Association Poon & Ho LLP CB Ross Partners RBC CFMC Pharmacy Ltd RBC Global Asset Management CHC Technology Inc. RESCO Mortgage Investment Corporation CIBC S.C.C.O. Management Inc. Clear Tone Hearing Centre Scarborough Nephrologists Cops & Community Charity Event Senghwa Trading Inc. csr eco solutions Sun & Partners Professional Corporation CW Broup Swismond Jewelery International Inc. Dr Eric Hui Dentistry Prof Corp Tam & Ting Medicine Professional Corporation Dupak Inc TD Bank Group Dyamond Co. Ltd. The Scarborough Hospital Dynamic Security & Telephone Systems Corporation The Toronto Cathay Lions Club EFES Management Ltd The Toronto Paragon Lions Club Fontana Development Ltd Torce Financial Group Inc. Forward Signs Toronto Chinese Road Bike Club Fu's Borchun Property Management Ltd. Toronto Elegant Lions Club Heart & Stroke Foundation of Ontario Toronto Heart Centre Highland Feather Manufacturing Inc. Toronto Hyundai Homelife Gold Pacific Realty Inc. Town of Richmond Hill Hong Kei Fitness & Dance Club Trillium Sleep Centre Hong Kong Economic & Trade Office V Can Construction Inc HSBC Bank Canada Wah Lung Labels Canada Inc. International Buddhist Progress Society Of Toronto Walton Capital Management Inc. Jenny Wong Beauty Institute Willow Springs Winery (2010) Limited J.S. Cheng & Partners Inc. Kingstec Technologies Inc.

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Acknowledgements

Carefirst would like to extend our heartfelt thanks to the following funders, community organizations, business corporations and individuals for their contributions and support. Funders City of Toronto Community Partnership and Investment Program Local Health Integration Network, Central East – Community Services Grant Program Local Health Integration Network, Toronto Central Community Care Access Centre, Central Ontario Ministry of Health & Long-Term Care Community Care Access Centre, Central East Ontario Seniors Secretariat Community Care Access Centre, Toronto Central Ontario Trillium Foundation Employment and Social Development Canada – New Horizons United Way of Peel Region for Seniors Program United Way Toronto and York Region Local Health Integration Network, Central

Community Organizations

105 Gibson Centre Community Home Assistance to the Seniors (CHATS) Accreditation Canada Community Legal Clinic of York Region Agincourt Library Coral Place Alzheimer Society of Ontario Creditvale Mills Alzheimer Society of Peel Cummer Park Community Centre Alzheimer Society of Toronto Dancepooh Team Alzheimer Society of York Region Dixon Hall Neighbourhood Services Bayview Hill Community Centre Elder Abuse Ontario Bridle Trail Baptist Church FCCM Cultural Centre Bridletowne Park Church Fife House Campaign and Community Engagement Viral Hepatitis Care George Brown College Network (VIRCAN) Goldhawk Dance Group Canada Revenue Agency Greater Toronto Chinese Christian Churches Council Canadian Chinese Health Qigong Organization Health Canada Canadian Chinese Line Dance Association Heart & Stroke Foundation of Ontario Canadian Diabetes Association Hong Fook Mental Health Association Canadian Mental Health Association Hosanna Evangelical Free Church Canadian Patient Safety Institute Hospices Association of Ontario Caring for Aging Relatives Group (CARG) Hous ing York Inc. Catholic Family Services Peel-Dufferin Joyful Christian Church Centre for Addiction and Mental Health L’Amoreaux Community & Recreation Centre Centre for Education and Training Ladies Leisure Club Centre for Immigration and Community Services (CICS) Langstaff Community Centre Chinese Canadian Community Service Centre Lumacare Chinese Canadian Line Dance Association Mackenzie Health Richmond Hill Hospital Chinese Caregiver Network Management Advisory Services Chinese Family Services of Ontario (CFSO) Markham Chinese Baptist Church Chinese Inter-agency Network (CIN) Markham Chinese Presbyterian Church Chinese Social Service Network-York (CSSN-YR) Markham Federation of Filipino Canadians Circle of Care Markham Free Methodist Church City of Markham Markham Missionary Church City of Toronto - Parks & Recreation Department Markham Stouffville Hospital CNIB (Vision Loss) Markham Wesley Community Services Centre Coalition of Agencies and Seniors Serving Immigrant Seniors McConaghy Seniors Centre Community Care Information Management McNicoll Manor

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Acknowledgements

Community Organizations

Mill Brook Place St. John Ambulance Milliken Mills Community Centre St. Paul’s L’Amoreaux Centre Ministry of Labour St. Stephen’s Community House Mississauga Chinese Presbyterian Church Steeles L’Amoreaux Strength in Partnership Mississauga Fire & Emergency Services Stouffville Library Mitchell Field Community Recreation Centre Tendercare Living Centre Momiji Health Care Association The Canadian Hearing Society Mon Sheong Long Term Care Centre The Credit Valley & Trillium Health Centre Mount Sinai Hospital The Scarborough Hospital New Unionville Home Society The Wellness Centre, Mount Sinai Hospital North Toronto Chinese Alliance Church Toronto Centre for Liver Disease UHN – Toronto General Hospital North York Central Library Toronto Chinese Baptist Church North York Elder Abuse Network Toronto Chinese Community Church North York General Hospital Toronto Community Housing Corporation Oak Ridges Community Centre Toronto Fire Services Ontario Community Health Coalition Toronto Housing Connections Ontario Community Support Association Toronto Police 42 Division Ontario Network for the Prevention of Elder Abuse (ONPEA) Toronto Public Libraries Ontario Service Safety Alliance (OSSA) Toronto Rehabilitation Centre Ontario Telemedicine Network (OTN) Town of Richmond Hill Peel Chinese Inter-Agency Network(PCIAN) Transcare Community Support Services Peel Elder Abuse Prevention Network(PEAPN) University of Toronto Peel Regional Police Vaughan Community Health Centre Polycultural Immigrant & Community Services Vaughan Health Care Centre Prevention of El der Abuse of York Region VHA Home Health Care Public Health Agency of Canada Volunteer Canada Quality Improvement and Innovation Partnership Volunteer Toronto Rainbow Team Welcome Center Vaughan Regent Park Community Health Centre Welcome Centre Markham North Region of Peel Welcome Centre Markham South Revenue Canada Welcome Centre Newmarket Richmond Hill Chinese Baptist Church Welcome Centre Richmond Hill Rouge Valley Hospital Wellness Club Committee Ryerson University West Neighbourhood House Scarborough Centre for Healthy Communities Winnie Wang Line Dance Group Scarborough Diabetes Network Workplace Safety & Insurance Board (WSIB) Scarborough Elder Abuse Network Xin Tian Di Senior Association Scarborough Housing Help Centre Yee Hong Centre For Geriatric Care Scarborough Nephrologists York Region Chinese Health Initiative Network (YRCHIN) Seniors Tai Chi Enthusiasts of Markham York Region Transit Service Canada York Regional Police Social Services Network YWCA Toronto Southlake Regional Health Centre SPRINT Senior Care St. Christopher Chinese Anglican Church St. Christopher House St. Elizabeth's Anglican Church

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Acknowledgements

Business Corporations and Individuals

A1 Chinese Radio HSBC Bank Canada, Willowdale Branch Primo Chiropractic and Physiotherapy Altima Wellness Centre Jenny Wong Beauty School Royal Bank of Canada Bayview Hill Pharmacy Market Village Sheraton Parkway Toronto North Hotel Carson Wing Tsun Academy Ming Pao Daily Newspaper Sing Tao Daily Newspaper Chartwell Place MiTV Star-3 Group Circa Towers Mobility Matters Sunny C Ho – Barrister, Solicitor & Notary Edmund Pharmacy Mount Pleasant Group of Cemeteries Today Commercial News Eva Mak Solicitor North American Weekly Times Toronto Chinese Music School Fairchild Radio Novo Peak Health Toronto Pearson International Airport Fairchild Television OMNI 2 UNI shows System Focuspoint Optical Philips Lifeline Unionville Hearing Centre Guardian Pharmacy Pierre-Yves Wong

Au, Yvonne Ho, Macie Xiaomei Luk, Catherine Tsui, Jacky Au-Yeung, Eric Ho, Peon Ma, Kit Yee Wan, Linda Chan, Emily Hoang, Linda Mak, Julie Wong, Andrew Chan, Michael Jiao, Peng Miu, Raymond Wong, Anson Chawla, Dr. Radhika Keung, Alan Mo, Cathy Wong, Bernard Chen, Guochan Ko, Michelle Ng, Smile Wong, Man Kuen Chen, Sandy Kong, Peggy Pollock, Don Wong, Margaret Chen, Yue Yue Kwok, Dr. Jason Poon, Dr Teresa Wong, Teresa Cheung, Hon Tai Lai, Thomas Poon, Joanne Wong, Vincent Chiu, Dr. Alan Lam, Rev. Karl Ramasamy, Sathia Yee, Maria Chiu, Kenneth Lam, Tin Chor Rawlins, Julian Yiu, Wing Mui Choi, Dr. Christina Lau, Joanna Shan, Ji Qing Yip, Leslie Chow, Edmund Lau, Linda Siu, Lolita Yu, Winnie Chow, Henry Law, Edmund Sum, Steve Yuen, Jason Fung, Daryl Lee, Mabel Tang, Cecilia Yung, Peter Fung, Patricia Leung, Solon Tang, Jun Wei Zhu, Suki Fung, Phyllis Li, Mien-Chen To, Dr. Charlene Ho, Kwong Yee Ling, Andrew Tong, Bobo

Special acknowledgement to the following volunteers who have contributed over 200 service hours in 2015 – 2016

Au, Susanna Hung, James Shun Wan Leung, Shiu Hong Tam, Kai Yuen Chan, Alice Ko, Jimi Leung, Yee Ling Tang, Andrew Chan, Anny Wing Kit Kong, Doreen Fung Luen Li, Ella Ting, Gloria Chan, Francis Kui Tuen Kung, Christina Lo, Janny Chin Ying Tse, Karen Ching Wai Chan, Michael Kwok Siu Kwok, Irene Lo, Winnie Tung, Jennia Cheng, Hoi Fai Kwong, Belinda Wing Ng, Teresa U, Anissa Cheng, Jason Chung Ling Lam, Jack Tak Fai Rosario, Mario Wong, Angela Kuen Cheng, Peggy Suk Ling Lau, May Hing Shaw, William Wong, Daisy Mo Dak Ho, Hilda Lee, Kenneth Kam Wing Shum, Peter Chung Leung

45 2015 ~ 2016 Activities Highlights

Carefirst Seniors Services, Carefirst Foundation and Carefirst Family Health Team Board Directors and the dignitaries at the 2015 Annual General Meeting.

Celebrating the building completion of the Carefirst One-Stop Multi-Services Centre

Celebrating 40 years of serving the community

Carefirst Board Directors and the dignitaries at Carefirst 2016 Young at Heart Charity Gala.

Carefirst One-Stop Carefirst Board of Governance at 2015 Christmas Multi-Services Centre Party and Volunteer Recognition Dinner Open House

Delegates from Agency for Integrated Care (AIC) Singapore visiting Carefirst to learn about Carefirst’s Integrated Model of Care Carefirst One-Stop Multi-Services Grand Opening

46 2015 ~ 2016 Activities Highlights Carefirst One-Stop Multi-Services Centre Grand Opening Highlights

(L to R) Carefirst Board Directors Shirley Ng, Michael Wong, Over 500 guests supported and attended the Carefirst Thomas Chanzy of Ontario Trillium Foundation, Carefirst One-Stop Multi-Services Centre Grand Opening Foundation Chair Ian Po, Hon. Michael Chan, Hon. Advisory Ceremony Chair Irene So, former Carefirst Board Director Alan Liu, Director Stephanie Ho.

(L to R) Thomas Chanzy of Ontario Trillium Foundation, Hon. Michael Chan, MPP Soo Wong present recognition plaque to Sunny Ho

Special recognition from Carefirst and Carefirst Foundation to the Fu’s Family for their staunch support towards the development of Carefirst One-Stop Multi- Services Centre.

Glenn Chan, President of Buddha’s (L to R) Dr. Ying Lu, Dr. Samir Sinha, Light International Association Professor Paul Williams, Helen Leung, Toronto (L2), Ven. Yung Ku, Abbess of Carefirst CEO, and representatives Fo Guang Shan Temple(R3), Stanley from The Scarborough Hospital Kwan, Hon. Chair, Carefirst Capital Campaign Campaign(R3) , at the Plaque Presentation Ceremony

47 2015 ~ 2016 Activities Highlights

Peter Choy (Foundation Treasurer), and Sunny Ho (President) presenting recognition plaque to Billy Law and members of Toronto Chinese Road Bike Club for organizing “Ride for Carefirst” Event. (L to R) Ian Po, (Foundation Chair), Irene So, (Carefirst Honorary Advisor Council Chair), and Stephanie Ho, (Foundation Secretary) at Carefirst’s first Charity Golf Tournament in celebrating Carefirst 40th Anniversary.

Stephanie Ho (Foundation Secretary), and Sunny Ho (Carefirst President), and Markham Mayor Scarpitti, receiving donation from Fred Kwan & Mimi Chau (R1 & 2)while celebrating their 30th Wedding Anniversary. Dr. Joseph Chien (L3), Carefirst Board Director, and Helen Leung, CEO, receiving support from AstraZeneca Michael Wong (Executive VP), Canada towards Carefirst Community Chronic Obstructive Sunny Ho (President), Ian Po Pulmonary Disease (COPD) Rehabilitation Program (Foundation Chair), Janet Lee (Secretary), Amanda Yeung Collucci, Markham Councillor, presenting recognition plaque to Abby Lee, renowned artist from China, for supporting Carefirst Mother’s Day Dinner.

Peter Choy (Foundation Treasurer), Sunny Ho (Carefirst Board President), Ian Po (Foundation Chair) and team participated in Scotia Waterfront Marathon to fundraise for Carefirst.

Carefirst Annual Radio Telethon Carefirst Charity Walk for Health.

48 2015 ~ 2016 Activities Highlights

Community Health Fair

Community Exercise Class Carefirst Ladies Leisure Club celebrating Mother’s Day with seniors

Energetic Youth Volunteer Team Dedicated volunteers receiving long service awards

Professional Staff Teams with different ethnic culture background and linguistic skills

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