Roy sits on the edge of the bed, gently taking Tamara’s hand as he recounts their love story. They knew each other through church for years, and had once attended the symphony together with a mutual friend. So when Roy found himself with an extra ticket one night, he decided to invite Tamara. “We went and thoroughly enjoyed it. Afterwards we talked for hours. We found out then that we were soul mates.”

Shortly after they were married in 2002, Tamara’s health began to decline: she lost most of her vision, and experienced decreased mobility as a result. She also started to show signs of memory loss. Unable to care for Tamara on his own, Roy immediately knew to contact the

CCAC for help. He had used their services before, when his first wife was diagnosed with Alzheimer’s. “The ability to have support of various types is invaluable,” he says. “In a crisis, I always know where I can go. I’ve never had a refusal, and I was always able to get advice and encouragement.”

Never leaving Tamara’s side, a devoted Roy speaks proudly of her many achievements. She was born in Russia in 1922 to a prominent family. When the political climate become too dangerous for her well-to-do relatives, they immigrated to Canada using the Mennonite underground. Sadly, her father passed away soon after. To help support her struggling mother, Tamara started working as soon as

she graduated high school. She eventually landed a job as an accountant for Waterloo College, beginning a long and successful career at what would become Wilfred Laurier University.

Tamara organized the school’s finances so efficiently that the budget had a surplus for 18 consecutive years. “She was called the wizard,” Roy relates. After just a few years, she was promoted to Vice-President and upon retirement, received an Honorary Doctorate for her service to the school. She was also granted the Order of Canada.

Tamara has been confined to her bed after a fall last year twisted both of her knees. The CCAC of fered more support and physiotherapy, and a personal support worker now looks after Tamara four days a week. A fighter all her life, Tamara now faces what might be her biggest challenge. And yet, Roy is confident her well-being is in good hands: “With the CCAC, you’re never alone. No matter what comes up, you have help.”

STAFF NEWSLETTER

WATERLOO WELLINGTON COMMUNITY CARE ACCESS CENTRE May 2014

 

COMMITTED TO QUALITY, EVIDENCE-BASED, PERSON CENTRED CARE

Mak ing a D i f fe rence

“In a crisis, I always know where I can go. I’ve never

had a refusal, and I was always able to get advice

and encouragement."

Message from the CEO

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Gordon Milak, CEO 

Deborah Szczepko, with CEO Gordon 

Milak. Szczepko, a Specialist with Franklin 

Covey, presented a lively interac ve 

session en tled “The one thing that 

changes everything – Trust.” Many of the 

principles she introduced will be reinforced 

during upcoming team mee ngs.  

Dr. Chris Perlman, University of 

Waterloo, and Andrea Mar n, Senior 

Director Pa ent Services. In conversa on 

with Mar n, Perlman shared his 

perspec ves on the value of the InterRAI 

tools. Dr. Perlman reminded us that “The 

assessment tool is part of the care 

process. It’s a conversa on starter.”  

Dr. Joe Lee, Chair and Lead Physician, Centre for 

Family Medicine Family Health Team, and Gloria 

Cardoso, Senior Director Performance and 

Partnerships. Dr. Lee talked about the importance of 

the partnership between community and primary 

care, and offered this advice: “Keep doing the great 

work you’re doing, keeping in mind what’s in the best 

interest of the people we all serve. O en the best way 

to do that is to work with the other health 

professionals who are also involved. Remember that 

we are all on the same team.”   

Peggy Grall.  In a moving presenta on, Grall shared her experiences as a caregiver for her husband Graydon, who 

passed away last fall, and her perspec ves on the care team that supported her husband and family. “In the end, 

people make all the difference,” Grall said. “Your humanity is all you have to give and it’s all you need. Who you are 

and who you are willing to be is what makes the difference. “  

Working Together, Growing Together

Now that spring has finally taken hold, the gardeners among us are joyfully getting their hands dirty again. (I’m not a gardener myself, but I admire the

dedication and enjoy the results!) One of the delights of this month is the glorious burst of apple blossoms.

Every gardener knows that apple trees must be nurtured carefully. They must be watered, fed, and pruned to help them grow stronger. That’s because during the growing season, they will face adversity, in the form of disease, insects, and drought. Yet each apple tree has a single-minded focus from the moment it comes back to life in the spring– to produce fruit in the fall.

The CCAC and the teams within it and across provider agencies are living organisms too. Like the apple trees, we have a single purpose – to deliver outstanding care,

every person, every day. Like the apple trees, we sometimes face adversity. But the fruit of our combined labours is captured in the story of Roy and Tamara, the CCAC clients who were featured in a recent series on home care produced by CTV and whose story is told in this newsletter.

On May 1, many of you gathered for a day of fellowship, learning and reflection. The theme, “Working Together, Growing Together,” spoke to our relationships with individual patients and families, with one another within the CCAC, and with our care providers and as a health system from primary care to long-term care. Throughout the day we were nourished by new knowledge, perspectives and understanding.

My thanks to the organizing committee, who brought us together for this wonderful shared experience. To those of you who stayed behind to meet the needs of our patients and partners, my heartfelt thanks. Over the next year we will continue to work and grow together, focusing on supporting one another and our patients and families to produce the fruit of independence and wellness.

Working Together, Growing Together: All Staff Conference May 1st

 3 3 

IT Team Improves Response to Service Interruptions When you’ve got a problem with your computer, you feel like it can’t be fixed too soon. Fortunately for CCAC employees, the IT team provides exceptional service, solving even the most complex problems quickly.

Every time you contact IT with an issue or question, it becomes a “ticket.” IT has service level agreements (SLAs) – commitments for how long it will take to resolve each issue -- based on the urgency of the ticket, ranging from low to high. A high urgency ticket, for example, should be resolved within four hours. When the SLA time is surpassed without a solution, it is considered a “breach.”

During 2013-2014, the total number of tickets grew from 3500 to 3700, an increase of 6%. Yet breaches d e c r e a s e d d r a m a t i c a l l y across the board. For example in the high category, the rate of breaches dropped from 12% in 2012-2013, to just 6% in 2013-2014. Similarly, medium tickets dropped from 15% to 6%. The new “User High” category introducing during 2013-2014, which promises that IT will contact the user within 30 minutes, has had no breaches.

Burns is delighted that results are just as good for hospital sites as they are for the organization as a whole. “Hospitals are a far more complex environment,” he says. “Our system is sitting on the hospital’s network and there are lots of other moving parts.” Yet there were only two breaches out of 31 tickets across all seven hospital locations.

So what is the secret of IT’s success? “I have a marvelous team, with the ability to stop and turn on a dime,” Burns says. “The IT team takes support failures in the organization very seriously. They work hard to ensure everyone has all the tools available to be successful in their role.”

eShift Launched, International Visitors Welcomed In April the Waterloo Wellington CCAC launched eShift, an innovative shift nursing approach to providing enhanced care for end-of-life patients.

eShift allows more patients to stay at home longer or choose to die at home. Specially trained personal support workers provide care at the bedside, connected through technology to a directing Registered Nurse. The eShift model has been shown to reduce ER visits and hospital readmissions, improve symptom management, prevent caregiver burnout and strengthen collaboration within the care team.

“eShift is part of the array of end-of-life choices,” says Heather Nicolson-Morrison, the CCAC’s Integrated Hospice Palliative Care Lead. “This is about using technology to enable patients to die comfortably at home and ensure that families don’t have to worry about something happening that they can’t cope with. It means that a nurse can be at the bedside (virtually) of four patients anywhere in the region, so access is equitable no matter where you live.”

Charlotte Koso, Director Program Development & Innovation with Red Cross Care Partners, says Waterloo-Wellington was a good place to introduce the model. “This region has always stood out in the province in terms of palliative care,” she says. “Patients have been served very well. Now with eShift, more patients will have an easier end-of-life experience and perhaps avoid hospital admission or ER visits in the final weeks of life.”

 4 4 

Care Coordinators Reflect on Changing Roles

“I would just like to say a great big “THANK‐YOU” for giving the staff that wonderful opportunity to take part in such 

an extraordinary  staff mee ng!  I  feel with all  the changes  the organiza on has gone  through and  s ll are going 

through, it really gave us a reminder of what we represent every day and how we truly do make a difference in the 

community and to one another! I can’t thank‐you enough for the guest speakers they were absolutely amazing!  

‐ Michele Quigley 

“We have to meet people where they are, be person-centered, and then be very, very creative in helping them achieve their goals.” That’s Melissa Grenier, talking about her work as an Care Coordinator with the North Wellington Health Link in-home team.

Health Links is a new philosophy of care focused on patients with multiple, complex conditions. Health Links bring together hospital, primary care, long-term care, community support services and the CCAC to work as a team, ensuring that patients receive better, more coordinated care. “Health Links is about having everyone involved in a person’s care working together and communicating around the client’s care,” says Saide Haddad, a CCAC care coordinator who is working with the Guelph Health Link.

Grenier, a Registered Nurse, has worked in a wide variety of settings, from the ICU to long-term care. She’s bringing all her skills and knowledge to bear to meet the needs of the complex patients she works with. She notes that 65% of referrals are people with mental health and

addiction issues. “And most of them are also dealing with food, housing and financial insecurity and family dynamics challenges, too.”

These patients call for a different approach to care coordination, Grenier says. When a referral comes in, usually from a family physician, she visits the patient at home, spending time to understand both their medical and social challenges. Often, it’s system navigation, rather than contracted services, that is needed most. “It’s about making connections to the appropriate community service, so the patient can be a participant in his or her own care and feel safe and comfortable at home,” she says. “I’m trying to prevent crises, by making the right community connections.” Grenier works as part of an in-home complex care team that also includes community outreach workers who work closely with patients to help them access the right services.

Working with this population has reinforced Grenier’s focus on person-centered care. She remembers one client with diabetes who said her goal was to learn to belly-dance. Grenier was surprised at first but soon saw that dancing would be a good form of exercise. “I got her hooked up with a belly-dancing class and now she’s managing her blood sugar better.”

Nancy Worton, a care coordinator with the Cambridge and North

Dumfries Health Link in-home team, has been a care coordinator for 15 years. She too is practicing care coordination in new ways. “I work closely with the family physicians and the rest of the team,” she says. “We meet weekly to review our patients and determine who is most appropriate to do the home visit or follow-up. We have the opportunity to discuss difficult situations and get input from various sources.”

Like Grenier, Worton says a person-centered approach is critical. “We sometimes get into thinking we know what these people need, but when you step back and look at it from a holistic perspective, we really have to consider what their goals are.” Since the team became fully operational in March, Worton says several patients have avoided emergency room visits. When she checked up on one man, he told her that he was going to an exerc ise program and was determined to lose weight. “I could tell, just from the tone of his voice, that he was really happy about himself.”

"Health Links is about everyone involved in a person’s care working

together and communicating around the client’s care.”