CARING ALONG THE WAY
Annual Report to the Community 2014/2015 OUR Outstanding care—every person, everyday Vision
To deliver a seamless experience through the health OUR Mission system for people in our diverse communities, providing equitable access, individualized care coordination and quality health care.
• Treating everyone with respect, empathy, fairness and integrity; OUR Values • Fostering initiative, innovation, unity, and continuous improvement in what we do; • Actively seeking and supporting collaborative care partnerships so that clients experience integrated care; • Being client focused, open, culturally sensitive and responsive, and accountable in our relationships and all we do; • Remaining committed to our mission, vision, values and the communities and people we serve.
ACCESS We help people access and navigate community-based services.
OUR QUALITY CARE We listen to and collaborate with our clients to deliver innovative high-quality care plans that effectively and safely meet their needs. STRATEGIC INFORMATION We generate and share information that drives safe and effective client care across the health system, influences system decision making, and guides improved quality DIRECTIONS of care.
COLLABORATION We inspire strong relationships, effective collaboration and meaningful communication with our system partners, service providers and the public.
PEOPLE We are a people oriented organization that values the individual capabilities, strengths and contributions of others.
STEWARDSHIP As stewards of public funds and public trust, we deliver value for money.
ACCOUNTABILITY We strive for transparency and continuous improvement in everything we do. Profile Land mass extends from White River in the Hudson Bay East to the Manitoba border in the West, to James Bay and Hudson Bay in the north and LEGEND Fort Severn to the United States border in the South. Communities In total the North West CCAC covers an area Roads Hospital of 458,010 square kilometres - approximately NWCCAC Office 47% of the Province of Ontario.
Bearskin Lake Sachigo Lake
Kitchenuhmaykoosib Wapekeka Muskrat Dam Kasabonika Lake The North West CCAC is a Wawakapewin Sandy Lake community-based, independent health Kee-Way-Win Kingfisher Lake Webequie Deer Lake Weagamow Lake care agency funded by the Ministry of Wunnumin Lake Health and Long-Term Care through North Spirit Lake About Manitoba Poplar Hill MacDowell Lake Lansdowne House the North West Local Health Integration Pikangikum the Network. Cat Lake Pickle Lake Fort Hope The role of the North West CCAC in Red Lake North West Ontario’s health care system is to ensure Slate Falls New Osnaburgh people receive the right care, in the right Ear Falls Savant Lake Armstrong CCAC place, at the right time. We connect Whitedog Lac Seul Aroland Nakina thousands of people each year with the Sioux Lookout Kenora Lake Longlac care they need at home, at school, or in Vermillion Bay Dryden Gull Bay Nipigon Geraldton Ignace the community by: Caramat
Rainy River Manitouwadge Assessing individuals referred to the Nipigon Lake Helen Emo Rainy Lake Dawson Pays Plat North West CCAC and arranging for Terrace Bay Fort Frances Atikokan Schreiber Marathon health and personal support services Oliver Paipoonge Pic Mobert such as nursing, rehabilitation and Thunder Bay
supportive equipment in their homes; Minnesota Lake Superior Managing assessments to Long-Term Care in our region and supporting individuals and families throughout the process; Helping individuals navigate the health care system by acting as a vital link to health care services, support and resources.
Area Population approx. 231,000 (based on 2011 census)
Number of Clients Served 14,783 Number of Hospitals in the District 13 Number of Long-Term Care Homes in the District 24 Health care can bring many journeys and this year we have chosen to highlight a few that people may experience when they receive services from the North West Community Care Access Centre.
The nature of our business is to arrange services and connect people to the care they require and are eligible for, which is often during the time when people are most A Message vulnerable. The system can be a complex one and we continually place the client, caregiver and family at the forefront of care. As per our organizational values, we from strive to walk with the person and their family and listen to their story, as opposed to telling them what they need. The examples in this report highlight some of those stories and the different programs we offer as we continue to grow. It provides a the picture of our core business, the care coordination, from the Coordinator’s point of view.
Our year has been energy packed as we responded to the Ontario Auditor Board Chair General’s Office requests for information and evidence in their survey of the CCAC sector. Throughout this year the Board invested time to receive education on the and Enterprise Risk Management Framework. These processes and tools regarding risk management will assist the Board in having the proper conversations at Board CEO meetings and assist in guiding the North West CCAC strategy. The Client Services and Quality Committee of the Board has approved our Quality Improvement Plan which you will find posted on the public website. Other performance information such as, Long Term-Care Home waitlists, nursing and personal support wait times, and waitlist for long stay programs can also be viewed on our public website. Every year, as a publicly funded organization, we are under a great deal of scrutiny to ensure the funds allocated to our organization are spent where they create the most value to the people we serve. With that in mind, we have continued to work on building system capacity with our health care partners and to support people in their homes.
Information is power and moving forward this year, our goal is to invest more time in determining how best we can better engage people, families and caregivers in the care plans and learning what adds value to the services.
We recognize the importance of our staff, the contracted service providers and the collaboration we have with our health care partners, including the North West LHIN. We continually welcome and appreciate any feedback to make the care better for the people who receive our services in Northwestern Ontario.
Tuija Puiras, CEO Brad Coslett, Chair
Senior Leadership Team (at March, 2015) Tuija Puiras, Chief Executive Officer Senior Christy McClelland, Senior Director, Corporate Services Leadership Paula Donylyk, Senior Director, Community Care Chris Houle, Director, Finance & Information Management Chrysta Burns, Senior Manager, Human Resources Ian Ritchie, Director, Community Care Kathryn Hughes, Director, Community Care Nicole Brown, Senior Manager, Community Care Cheryl D’Angelo, Director, Community Care Kathy Bevilacqua, Executive Assistant Jennifer Wintermans, Manager, Communications, Privacy & Projects
Our employees completed 12,093 visits with people to talk about what services they need to be as independent as possible. Our employees By the connected 3,321 people to a primary On any given day there care provider. were 4,902 people Numbers receiving services from the North West CCAC
Our employees helped 629 people Our employees helped Our employees helped access a Long-Term 4,744 people return 2,289 children by setting Care Home home after a hospital up the services they need stay. to go to school every day. The Board of Directors represent Board Member Title Term communities across Northwestern Board Ontario and generously volunteer their R. Bradley Coslett Chair September 2012 – June 2015 time. Jim Restall Vice-Chair June 2013 – June 2016 The Board of Directors is responsible Andrew Bishop Treasurer June 2014 – June 2017 of Directors for overseeing financial viability, Hal Fjeldsted Director June 2014 – April 2015 executive performance, strategic Cindy Jarvela Director June 2013 - June 2016 goals, and ensuring the achievement Sandra Leonetti Director June 2014 – June 2017 and of high quality care provided by the Eric Long Director December 2014 – June 2016 North West CCAC. R. Barry McBain Director September 2012 – June 2015 Board Meetings are open to the public Shelley Peirce Director September 2012 – June 2015 and past minutes and Board member Shelby Poletti Director December 2014 – June 2017 Committees profiles are available at Elaine Scott Powell Director September 2013 – June 2016 www.healthcareathome.ca/northwest Rob Stinchcombe Director September 2012 – June 2015 of the
Board Client Services & Quality Committee Finance Committee Cindy Jarvela, Committee Chair Andrew Bishop, Committee Chair Barry McBain Barry McBain Elaine Scott Powell Sandra Leonetti Shelley Peirce Bradley Coslett (ex-officio) Victor Chapais Eric Long Human Resources Committee Karen Bazilewich Bradley Coslett, Committee Chair Rob Stinchcombe Jim Restall Bradley Coslett (ex-officio) Andrew Bishop Barry McBain Governance Committee Jim Restall, Committee Chair Risk Management & Audit Committee Barry McBain Rob Stinchcombe, Committee Chair Hal Fjeldsted Barry McBain Rob Stinchcombe Shelley Peirce Cindy Jarvela Andrew Bishop Bradley Coslett (ex-officio) Bradley Coslett (ex-officio)
(from left to right) Elaine Scott Powell, Andrew Bishop, Jim Restall, Bradley Coslett, Tuija Puiras, Eric Long, Shelley Peirce, Cindy Jarvela, Shelby Poletti Making the journey better by connecting the right care...
Jeremy is a 38 year old with multiple health conditions and has been a participant in the Thunder Bay Health Link program for over six months. Prior to joining Thunder Bay Health Link, Jeremy had made frequent trips to the emergency room. Now he connects with the Health Link Enhanced Care Team Clinic (ECTC) and has been able to cut down on his trips to the emergency room. The Health Link Enhanced Care Team sees him quickly and addresses his needs. Support provided by the team is beneficial and the experience has been invaluable. He appreciates the care and encouragement he receives from his Health Coach. “She Health Links helps keep me on track and she gives me advice on going to college, getting my driver’s license, quitting smoking, and then sometimes she’s just there to talk.” The entire program has helped Jeremy realize that there is more to his health and well-being than what can be treated by a primary care provider. “There’s a lot of things that can make a person healthier and it doesn’t always have to do with medication or illness. Sometimes just getting a better job makes you feel better, or moving into a house instead of an apartment building.” The Health Links team is proud of the work they have been doing in helping participants take ownership of their health care plan and to meet their health care goals. “Everyone with multiple illnesses should be part of Health Links,” Jeremy said. “I think the program is great and they should be looking at making it accessible to more people with ailments that need that helping hand.”
The Health Link team has been successfully working with participants to:
• gain access to primary care. • find housing. • decrease isolation. • help find funding programs to deal with high utility bills. • improve the quality of their diet. • assist them in returning to school. • help provide transportation solutions. • provide tools and support to quit smoking. Care at the right time in the journey of life...
The Palliative COPD/CHF Program (PCCP) is a program that changes the way the health care system works for people who are living with end-stage Chronic Obstructive Pulmonary Disease or Congestive Heart Failure.
Early palliative services have been shown to prolong life, decrease the cost of care, and increase overall quality of life for patients. All of these results can be achieved in conjunction with standard care. Six months ago, Barbara was taken to hospital by ambulance. The initial diagnosis gave her only 48 hours to survive and at that time she was moved to a hospice setting. Palliative Care Fortunately, her condition stabilized and, she was provided an invitation to join PCCP. She was seen by a member of the PCCP team where services were arranged that would allow Barbara to move to her daughter’s home.
Barbara’s daughter is a strong supporter of the PCCP. As a nurse, she has a deep understanding of how the program benefits the health care system and the support that it has provided to her mother. “I don’t think she’d be with us if we didn’t have this program.” Barbara and her family appreciated that care was brought to them in the home; they did not have to go to the hospital to see a doctor or receive care.
Melora Serediuk is an RN and Community Care Coordinator for the program and states, “our goal for the project is to try to bring the health care to them when they need it and hopefully be able to fulfil their wishes to stay home for as long as they can.”
The North West CCAC’s ability to move quickly and treat the patient in the home has made a big difference in hospital admissions and ER visits. Thirteen visits to ER and nineteen admissions to hospital in Thunder Bay have been avoided in the first four months of this program. Patients can be referred to the program by the hospital, primary care provider or other community agencies as long as they meet eligibility criteria.
Through the dedicated support of her family and the PCCP, Barbara has become stronger each day. She was able to move into an assisted living facility and is now looking towards an apartment as an independent and capable individual. Our Bringing Care to the journey... Contracted When someone calls the North West CCAC for the first time, they are usually unsure of the exact resources they will need to meet their specific needs or those of a family member. Upon Service receiving the call, a Community Care Coordinator will listen and assess their needs, and make a plan to provide the assistance they require. Providers “We go into the home to do an assessment,” says Melissa Costanzo, Community Care Coordinator. “We get a sense of their needs and what sort of care we can provide.” A Care Plan is developed based on that first assessment and this outlines the steps that will be taken to ensure the client’s needs will be met. “The Care Plan is unique to each person and we can make changes to it as needed. It’s important to be proactive and update the client’s needs before it turns into a crisis,” says Melissa. One of the strongest skills a Community Care Coordinator should possess is the ability to form good Coordinating relationships with clients. “I find there is a trust that develops. I let them know they can call me anytime, even if they don’t have services. I also make sure they know that they can call me if the Care situation changes and they need to change their service plan.” An important element in supporting the client involves forming a strong relationship with the family. Community Care Coordinators must communicate to ensure they have the support needed to cooperate in taking care of the client. Community Care Coordinators will check in with the client to see how things are going and to be sure their needs are being met. They often become the point of contact for any health-related questions the client or their family might have, and helping people navigate the health care sector is part of the job that many families find invaluable. “Getting them to think about the future is important, but it’s not easy for the family to do. Topics like Long-Term Care can be difficult and part of my role is to give them the information they need to make an informed decision.” Even after a Care Coordinator’s role with a client is complete, the client and their family know that the Coordinator is always there to accept another call and help them in any way to ensure they have the help and support that they need. Our Contracted Service Providers 2014/2015 Our • Atikokan General Hospital: Physiotherapy, Occupational Therapy, Nutrition • Bayshore Home Health: Nursing, Personal Support & Homemaking Contracted • Creative Therapy Associates: Occupational Therapy, Speech Language Pathology • Dryden Regional Health Centre: Physiotherapy, Occupational Therapy, Nutrition Service • Firefly: Speech Language Pathology, Physiotherapy • Manitouwadge General Hospital: Nursing Providers • New Hope Speech Language Pathology Services: Speech Language Pathology • Northwestern Independent Living Services Inc.: Personal Support & Homemaking • Partners in Rehab: Physiotherapy, Occupational Therapy, Speech Language Pathology • Red Cross Care Partners: Personal Support & Homemaking *Corporate name changed to CarePartners Oct.2014 • Revera Health Services: Nursing, Personal Support & Homemaking, Nutrition • Riverside Health Care Facilities Inc.: Nutrition • Saint Elizabeth Health Care: Nursing, Personal Support & Homemaking • Sean Sloan: Physiotherapy • Shoppers Drug Mart Inc.: Medical Supplies and Equipment • Superior Speech Services: Speech Language Pathology • Superior Therapy Services: Occupational Therapy • Trout Forest Physical Therapy: Physiotherapy • Victorian Order of Nurses: Nursing, Personal Support & Homemaking, Social Work
Care Coordination Information and Referral Long-Term Care Placement School Health Support Services In-Home Services: Nursing, Personal Support / Homemaking, Occupational Therapy, Physiotherapy, Nutrition, Social Work,Speech Language Pathology Our Programs Medical Supplies and Equipment Mental Health and Addictions Nurses and Services Access to Adult Day Programs Access to Supportive Housing Nurse Practitioners Palliative Pain & Symptom Management Medically Fragile Program Rapid Response Nurses System Navigator NICE Fund (Network of Individualized Community Enhancement) Health Care Connect Chronic Disease Prevention and Management Home Medication Review Program Telehomecare PCCP (Palliative COPD/CHF Program) Health Links
Revenue An Overview of our Financials
North West Local Health Expenditures Integration Network 97.6%
Ministry of Health and Long- Term Care 2.1%
Interest and Other Income 0.3%
Allocation of Services
Client Services Expenditures
Looking forward to continuing the journey...
During 2014/2015 the North West CCAC Board continued to develop the Risk organization’s Enterprise Risk Management program. The focus of this work was to develop Risk Governance skills and tools for the Board of Directors to Management assist in understanding existing and emerging risks. The implementation of Risk Governance will assist the Board of Directors to understand how risk can both guide strategy development and impact its achievement. Through the use of this program, the Board of Directors will have additional tools and techniques to focus on decision-making and, resources to benefit both our clients and the health system.
We look forward to further implementing the Enterprise Risk Management Framework and strengthening the risk culture throughout the organization.
The North West CCAC recognizes the importance that caregivers and family bring to the healthcare journey. The coming year will provide opportunity to further develop the involvement of caregivers and families to make our programs and services even better. Family and Our involvement in the accreditation program provided through Accreditation Canada Caregivers will assist us in our commitment to improving the quality and safety of our services and ensure that clients, families and caregivers are always a big part of the care plan. Thunder Bay (Head Office) Kenora 961 Alloy Drive 35 Wolsley Street, Suite #3 Thunder Bay, ON P7B 5Z8 Kenora, ON P9N 0H8 Tel: 1 807 345 7339 Tel: 1 807 467 4757 Toll-free: 1 800 626 5406 Toll-free: 1 877 661 6621
Atikokan Marathon 120 Dorothy Street 26 Peninsula Road Box 1438 Box 1559 Atikokan, ON P0T 1C0 Marathon, ON P0T 2E0 Tel: 1 807 597 2159 Tel: 1 807 229 8627 Toll-free: 1 877 661 6621 Toll-free: 1 866 449 3313
Dryden Rainy River 6 – 61 King Street 113 – 4th Street Dryden, ON P8N 1B7 Box 457 Tel: 1 807 223 5948 Rainy River, ON P0W 1L0 Toll-free: 1 877 661 6621 Tel: 1 807 852 3955 Toll-free: 1 877 661 6621 Fort Frances 110 Victoria Avenue Red Lake Fort Frances, ON P9A 2B7 200A Howey Street Tel: 1 807 274 8561 Box 219 Toll-free: 1 877 661 6621 Red Lake, ON P0V 2M0 Tel: 1 807 727 3455 Geraldton Toll-free: 1 877 661 6621 510 Hogarth Avenue West Geraldton, ON P0T 1M0 Sioux Lookout Tel: 1 807 854 2292 37 Front Street Toll-free: 1 866 449 2424 Box 657 Sioux Lookout, ON P8T 1B1 Nipigon Tel: 1 807 737 2349 125 Hogan Road Toll-free: 1 877 661 6621 Box 37 Nipigon, ON P0T 2J0 The North West Community Care Access Tel: 1 807 887 5862 Centre is funded by the Government of
Ontario through the North West Local Health Visit us online at: Integration Network. www.healthcareathome.ca/northwest
Disponible en français. Copies of this Report can be obtained from the North West Community Care Access Centre Head Office in Thunder Bay or as a pdf from the website at www.healthcareathome.ca/northwest