INITIATIVES TO SUPPORT THIS PRIORITY
What needs to be done in the next three years?
To accomplish these priorities, the Toronto Central LHIN plans to meet the following initiatives over next three years:
Initiative #1
Standardize referral and intake processes to improve the flow of patients to and within community programs.
Actions that will drive this initiative
- Expand the standard intake and referral process throughout community agencies that provide services to seniors.
- Coordinate referrals to community support services in neighbourhoods using the Community Navigation and Access Project model, which enables patients and clients to get all the services they need through one point of access. Hubs will be identified that will provide access to coordinated services to support aging in place and the needs of caregivers.
- Implement Resource Matching and Referral for community services, focusing on supporting clients’ transition from acute, rehabilitation and complex continuing care to community settings and transitions within community programs. Resource Matching and Referral is an electronic referral system that matches clients with the most appropriate service.
Initiative #2
Enhance community based programs and services to support patients at home.
Bringing care home
Funded through the Toronto Central LHIN's Aging at Home Strategy, the House Calls program provides ongoing health care to at-risk seniors right in their own homes. "For many of our patients, House Calls is not a convenience, it's a necessity," says Dr. Mark Nowaczynski, a primary care physician who heads House Calls. Read more.
Actions that will drive this initiative
- Expand and enhance intensive case management programs. These programs promote independence and quality of life by coordinating appropriate services and providing constant support to clients. Enhanced intensive case management services will focus initially on at-risk groups such as frail seniors and clients with addictions. These programs would include ongoing intensive support and flexible packages of community based services to help at-risk populations transition and remain home after a hospital stay.
- Enhance supportive housing services to support newly identified at-risk clients.
- Expand convalescent care to ensure seniors who are transitioning back to their homes and communities are able to function in their daily lives.
Key to the success of Initiative #2 will be greater awareness among physicians, other health professionals and individuals of the type and location of community-based services across the Toronto Central LHIN. The Toronto Central LHIN, together with health service providers and associations, will provide relevant and timely information about local community resources – including the Toronto Central Community Care Access Centre’s Community Care Resources web site and toll free number – to health professionals and community members.
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At Bellwoods Centre, people living with disabilities have the support they need to live more independently in their communities.
Initiative #3
Improve hospital processes to increase capacity in the emergency department.
Actions that will drive this initiative
- Continue to increase efficiency by redesigning hospital processes and ensuring discharge planning is done in the early stage of hospital stays to help people return home or advance to the next level of care sooner.
- Increase efforts to identify high-risk seniors to ensure they receive the appropriate services after they are discharged from hospital.
- Enhance care of seniors within hospitals to increase their ability to transition safely from the hospital and into their community. Examples of enhanced care may include wound prevention and assistance with continence, walking and nutrition.