Toronto Central CCAC • Annual Report • 2015/16

The Toronto Central Community Care Access Centre is a trailblazer in the Ontario healthcare system. Our partnership work in advancing client centred, team based care for our community has changed the lives of thousands and it has created new leading edge models of care that are informing the health care system of tomorrow.

At the heart of our strategies is a genuine desire to partner with our clients in new and different ways. We start by listening to our clients in order to understand what is most important to them and we have worked hard to support our staff to use their compassion and ingenuity to break down the barriers and silos to create everyday miracles in our community. Working side by side with our clients and caregivers to redesign and improve our services has been incredibly insightful, humbling and has inspired us to make the meaningful changes that will make the most difference.

Our continued focus on creating a One Client, One TeamTM model has us working more closely than ever with primary care. Working hand in hand with primary care has taught us that we are much stronger together and that our work together has only just begun. We have also taken integration to new heights as we expand our One Client, One TeamTM model from our palliative clients to include more of our client populations.

As you read through the highlights of our past year serving the people of Toronto, we can assure you that the incredible successes we have marked are direct results of the amazing strength and spirit of our people, a few of whom you’ll meet in these pages. We have sought out strategies to empower staff at all levels to work to their full potential, to challenge the status quo and find optimal client centred solutions. We have been able to innovate because hundreds of individuals have agreed to take risks, and we want to recognize in particular the members of our Board of Directors, who have been consistently courageous in their support of our innovations.

We’re on the cusp of significant change in the Ontario healthcare system. And we look forward to working together with our partners to find new and better ways to make a difference in the lives of our clients.

Stacey Daub Bill Yetman Chief Executive Officer Board Chair

This page: Prince Dumanat works with children and youth as a Mental Health and Addictions Nurse, meeting clients and their families in school or at home. He was nominated for a Toronto Star Nightingale award this year for his exceptional work. On the cover: Kan Cheung is a care coordinator who is both a registered nurse and registered social worker. He is a member of our Urban Health team, providing home care for clients who are precariously housed, in shelters and drop-ins. Rosa Giuliani is a care coordinator with a background as a registered nurse. She was nominated for a Toronto Star Nightingale award for her outstanding work this year.

“ I cannot speak highly enough about the outstanding service I received from my lead nurse and the other members of his team. They were professional, knowledgeable, wise, flexible and personable – and I felt that they cared so much about me – and my physical comfort – and were all so devoted to their work. Indeed, my family and I believe that my excellent progress was, in part, due to the quality of the service provided by the team. In my family’s view we are fortunate to have been served by you, and our faith in Ontario’s health system has been redeemed.”

Toronto Central CCAC client Harold Levy

In the past year we’ve seen

13% more clients with medically complex needs

2 3

22 Toronto Central CCAC partners withservice provider agencies to provide care to our clients

SERVING TORONTO – AT A GLANCE

180,000 calls for local health information and referral

Partnership is in our DNA:WE WORK IN 22 hospitals, 7 emergency departments, 13 family health teams, 37 long-term care homes, 34 community support service agencies, 4 school boards, 16 community health centres

We helped 63,025 people transition from hospital to home*(55% returned to homes outside our LHIN)

We helped

77,683 clients this year

4% INCREASE We cared for

4% more people this year

17,084 clients receiving complex, chronic

or palliative care: an

8% increase fromprevious yearExpenditures by age group:

8% under 2019% 20-6414% 65-7424% 75-8435% 85+

With a 0% budget increase, we supported 18% more people to die at home, from last year

2363 Torontonians were supported to die in their place of choice

4 5

Disruptive innovation is created at Toronto Central CCAC. We’ve been pioneering new models of care for new groups of people and partnering with other organizations for many years.

We were the first to deliver home care services for many specialized populations, and we continue to expand our services today. To serve the homeless, we brought services to shelters and hostels, and we continue to serve a large population of people who are precariously housed and experience marginalization. We were the first organization to accept clients with HIV/AIDS for care in their homes, at a time when transmission of the disease was not fully understood, and there was a lot of fear. We took maximum precautions but we educated ourselves and others. And we were the first to provide home care to people with mental health conditions. We showed that many of these individuals didn’t need to be in hospital, but they did need the support of health professionals to live in the community.

Most recently we pioneered home care for clients dependent on long-term ventilation. A remarkable specially-trained team supports clients who are dependent on mechanical ventilators to help them breathe and need 24-hour-a-day monitoring to live at home. Up until recently, these people were hospital bound, many living in intensive care units.

We launched the first population-based model of home care which allowed us to better support people with similar care needs. Recently, we were trailblazers in building more integrated team-based care to serve our most complex populations (palliative clients, older adults and children),

and as a direct result of that, developed our pioneering One Client, One TeamTM approach, which we are expanding and will be spreading to new client populations.

As the conversation about health system transformation deepens, our ground-breaking initiatives have influenced emerging health system priorities including closer working relationships with primary care, and the imperative to work together in an integrated manner.

We’re determined to continue creating new ‘firsts’, and share what we’ve learned with others to spread innovations as widely as possible, to ensure improved home care for as many people as possible, across Ontario and beyond.

Katherine McAuliffe embodies TC CCAC’s pioneering spirit of compassion. During her 33-year career with TC CCAC, she has been involved in ground-breaking initiatives including homecare for clients with HIV/AIDS and the Quick Response Program. She is currently a care coordinator helping people transition from hospital to home.

A TRADITION OF INNOVATION

“ TC CCAC is actually collaborating and partnering with support systems, like emergency medical, like the ambulance, and they are looking at everything that would wrap around a frail elderly senior – all those services we need to partner with. And we actually haven’t seen that everywhere. We’ve only seen that in a couple different locations across Canada.”

Healthcare stakeholder as quoted in Understanding the Contributions of Toronto Central CCAC

to Home and Community Care prepared by The Evaluation Centre for Complex Health Interventions

85% of all coordinated care plans in TC LHIN since Health Links were formed

6 7

Kathy Voudouris, care coordinator with our Child and Family team, and her client, two-year-old Filza.

78,000 REASONS TO CARE We had the honour to care for 78,000 people this year. It’s a responsibility and a privilege we take to heart. We are successfully placing clients and caregivers at the centre of care and listening to what is most important to them through initiatives like Changing the Conversation that have permeated the culture of our organization. In the last 5 years, we have seen a significant 5% increase in client experience scores.

Many of our clients are cared for by family or friends. These informal caregivers often have health concerns of their own and are increasingly at risk of burnout. We recognized that we needed to find ways to support our caregivers. As a result, this year we undertook a major study using the existing data from the homecare assessments of over 250,000 Ontarians. From this, we identified the factors that are most related to caregiver distress, and developed a method to identify caregivers at highest risk. Our next steps are to work with partner organizations to develop an effective caregiver support strategy.

With increasing medical complexity comes a greater need for support for difficult decisions. Bioethicists have been around for some time, but were almost exclusively working in hospitals. Ten years ago, we founded the first community-based ethics program in Ontario, and created a Community Ethics toolkit that is widely used in community practice

to support clients, caregivers and staff in making difficult decisions together. We also initiated a partnership with the Toronto Central LHIN and the University of Toronto, including the Department of Family and Community Medicine and Joint Centre for Bioethics. There are a growing number of ethical issues facing healthcare, including the need for advanced directives for dying patients as well as legal changes regarding physician-assisted death. Through our partnership, we are changing the curriculum for Family Medicine and developing new ways to educate primary care practitioners to address significant ethical issues they face with patients in their care.

As we continue our drive to become increasingly client- and caregiver-centred, this year we engaged a small group of volunteers who form the Client and Caregiver Advisory Panel for our integrated Palliative program, sharing their perspectives, influencing the development of priorities for the program, and co-designing communications materials for clients and families. This group of generous and dedicated people have helped us understand the experiences of our clients and families more deeply.

Over the past 5 years, our clients’ medical complexity has increased by

71% and cognitive impairment by

99%8 9

We know that when we challenge ourselves to deliver better value, we need to remain focussed on what’s most important for our clients. In this way, we can deliver better experiences and outcomes for our clients.

This year, we changed how we provide care to clients with chronic wounds. Fifty percent of our clients received nursing care for significant wounds, often related to chronic health conditions such as diabetes. But even with daily nursing care, these wounds were not healing. By researching evidence-based global best practices, we changed how we treat these wounds and the products we use. One of the changes we made was to more thoroughly teach clients about wound care, so they could become more informed and involved in their own care. Only three months after launching our new wound care strategy, we were healing wounds on average 21% faster, which represents a much improved quality of life for our clients, and significant health system savings.

We also looked at hospital patients identified as ALC (Alternate Level of Care), who no longer need an acute level of care, but remain in hospital waiting to transfer to another facility. Having patients who are ‘ALC’ means that patients are delayed in receiving the type of care they actually need, and other patients cannot access the acute hospital care when they need it. Finding ways to minimize the number of patients waiting in hospital for other types of care is important to improving quality of care and creating value for our healthcare system.

The TC CCAC assists hospitals in reducing the number of ALC patients by identifying those who can be brought home for

the short or longer term. Through our work with 18 different hospitals in Toronto, we recognized there was no standard approach to reducing the number of ALC patients among local hospitals, nor in other jurisdictions. We took the lead, working with hospital partners to discuss common challenges and develop best practices for preventing situations in which patients were waiting. We have now developed an ALC Avoidance Framework and Toronto Central LHIN has made the use of our tool mandatory for all hospitals for the upcoming year. In 2016/17, we will work with the LHIN and our partner hospitals to evaluate the impact of our tool on patient care.

We’re also a leader in the use of technology in homecare. We were among the first to implement the remote monitoring of clients via Telehomecare through our partnership with the Ontario Telehealth Network, and we are currently testing two electronic medical records that will support our work in integrated care. We know that there is significant demand from seniors to use technology to provide close monitoring and we’re ready to test and employ it as becomes available and is proven effective.

Anne Dumais, ALC Resource Coordinator, and a registered occupational therapist, uses her experience and creativity to support people to leave hospital and return to the community. Kathy Lashley is a Client Services Manager, Placement Services. Her team facilitates placement into long-term care. Both are also members of an employee Pride Committee, celebrating and ensuring compassionate and respectful care for LGBTQ clients. Toronto Central CCAC is proud to partner with York University in the first comprehensive study of home care access for LGBTQ people in Ontario.

PURSUING VALUE

21% faster wound healing with our new Wound Care Program, and

$5M in projected savings

10 11

Elaine Burr is ALC Lead for TC CCAC. She worked with her counterparts in acute care hospitals to identify best practices and create the ALC Avoidance Framework. Sandra Dickau is at Michael Garron Hospital, formerly Toronto East General Hospital. She led her hospital to become early adopters of the framework. By adopting best practices, in one year, the hospital saved a remarkable 800 ALC (Alternate Level of Care) days. Together, they are giving presentations in nearby LHINs, conferences and associations, and our innovation is spreading.

BUILDING PARTNERSHIPS In order to provide the best possible care for our clients, we work closely with other organizations and healthcare providers.

We have led the way in developing a strategy for working hand-in-hand with primary care – we identified how important this was from our first work in integrated care over five years ago. And, as of this year, a remarkable 72% of the 1200 primary care providers in our LHIN are linked to us. That includes all Family Health Teams, all but one Community Health Centre, and nearly half of physicians who work in solo-practices.

Our best example of building strong partnerships is our palliative care integration. Our organization has had a relationship with the home palliative physicians of Temmy Latner Centre for Palliative Care for twenty years, with significant benefits to our shared clients. We have built on

that relationship to develop One Client, One TeamTM Palliative, which creates integrated palliative care teams that include TC CCAC care coordinators, homecare physicians from Temmy Latner Centre as well as Dorothy Ley Hospice, palliative nurses and personal support workers from three service providers, St. Elizabeth Health Care, Spectrum Health Care, and SRT Med-Staff, volunteers from three hospices and additional TC CCAC homecare specialists (such as pharmacists or occupational therapists) as needed. This year, the program marked its first anniversary serving all new patients, and has demonstrated remarkable results. An extraordinary 81% of clients of the program die outside of an acute care hospital, in their place of choice. This is one of the highest rates of any jurisdiction in the world. We couldn’t do it alone, and we don’t have to ... that’s the beauty of effective, creative and expanding partnerships, focused on a shared commitment to clients.

“ Your TC CCAC care coordinator was resuming services for a child from our area receiving care at Sick Kids and worked with our care coordinator to ensure the services the parents were getting for their child were appropriate. This was so positive because parents sometimes get inaccurate information about the services we offer here, causing frustration for the parent. With communicating and working together, there were no unattainable expectations and the information provided was vital to the modification of the service plan as the child’s needs had significantly changed post-op.”

North East CCAC

72% of primary care providers are connected with a TC CCAC care coordinator

12 13

LEADERSHIP AND RECOGNITION FINANCIAL STATEMENTS Statement of OperationsYear ended March 31 2016 2015

$’000 $’000

Revenue MOHLTC/LHIN Funding 249,964 244,584 Other revenue 4,407 5,010 254,371 249,594

Expenses Client Care related expenses 236,331 232,511 Administration 18,040 17,211 254,371 249,722

Excess of revenue over expensesSurplus/(Deficit) (0) (128)

Balance SheetYear ended March 31 2016 2015 $’000 $’000

Assets Current Assets 26,394 25,125 Pandemic supplies 201 201 Capital Assets 4,122 5,259 30,717 30,585

LiabilitiesCurrent liabilities 25,861 24,592 Deferred Capital Contributions 4,122 5,259 Fund balance 734 734 30,717 30,585

We want to share our evidence-based innovations, best practices and research discoveries as widely as possible, by publishing articles and presenting at conferences. Our leadership has been recognized by our peers locally, provincially, nationally and internationally.

Awards• Accreditation Canada – Leading Practices – Changing the

Conversation• Accreditation Canada – Leading Practices – ICCT

(Integrated Community Care Team), a partnership between Toronto Central CCAC, Central CCAC, Baycrest and North York General Hospital

• World Congress on Integrated Care – Top 14 Models of Integrated Care

• Ontario Hospital Association Quality Healthcare Workplace Award – Gold level

• 20 Faces of Change – Stacey Daub• Canada’s Most Powerful Women: Top 100 – Stacey Daub

This year, TC CCAC representatives presented at major conferences, including:• Hospice Palliative Care Ontario• Ontario Gerontology Association Conference• Ontario Association of CCACs Conference• Quality Conference• Association of Ontario Health Centres Conference• Canadian Quality Congress

• BRIDGES Annual Conference• Family Medicine Forum • World Congress on Integrated Care

Major articles published:In Healthcare Quarterly...

Changing the Conversation with Home Care Clients by Anne Wojtak and Joy Klopp

Leading Integrated Health and Social Care Systems: Perspectives from Research and Practice by Jenna Evans, Stacey Daub, Jodeme Goldhar, Anne Wojtak and Dipti Purbhoo

Perspectives on Advancing Bundled Payment in Ontario’s Home Care System and Beyond by Anne Wojtak and Dipti Purbhoo

In Longwoods Essays...

Why Your Good NFP Board Needs to be Great – and 10 Steps to Get There by Anne Wojtak, Christopher Neuman and Brad Quinn

Home Care’s Tommy Douglas Moment? by Stacey Daub

VISITORS from around the world come to learn about our innovative approach to homecare, including groups from SOUTH KOREA, JAPAN, SINGAPOREand SAN FRANCISCO. We’re also thrilled to host a site visit for global participants in the World InterRAI conference in April 2016.

14 15

OUR PERFORMANCE CONNECTING WITH PRIMARY CAREWe are connecting our care coordinators with Toronto’s family doctors and nurse practitioners to improve communication and deliver better care for our shared patients

WE’RE HELPING PEOPLE FIND A FAMILY DOCTOR OR NURSE PRACTITIONER

OUR CLIENTS REPORT

ACCESS

100%90%80%70%60%50%40%30%20%10%0%

93% Felt supported, understood and had a good care plan

97% Would recommend us to family and friends

92% A positive experience

Last year, we missed

0.02% of all visits (out of a total of 3,519,718 visits)

5 85% of clients with complex health issues received their first personal support visit within five days

1 ONE day for referrals from hospital 8 EIGHT

days for referrals from the community

5 94% clients received their first nursing visit within five days

Median number of days to first CCAC visit:

0clients on waitlist

80%70%60%50%40%30%20%10%

20162015201420132012

26%CONNECTION RATE

36%CONNECTION RATE

60%CONNECTION RATE

72%CONNECTION RATE

9%CONNECTION RATE

CONNECTION RATE

ĥ 4,316 people this year

ĥ 21,705 people since the start of the program in 2009

ĥ 93.5% of people connected

ĥ 93.8% of high needs patients connected

SAFETYPatient safety is a top priority for Toronto Central CCAC. Last year, out of 3,519,718 visits, 7 incidents occurred of significant client harm. We follow up on every incident in which a client is harmed when receiving care and identify how to prevent further similar incidents

8.3% increase in clients requiring

complex, chronic or palliative care over last year

16 17

Senior Management TeamStacey Daub, Chief Executive Officer Dennis Fong, Senior Director, Human Resources and Organizational Development Jodeme Goldhar, Chief Strategy Officer, Senior Director, Strategy and Planning Dipti Purbhoo, Senior Director, Client ServicesBill Tottle, Senior Director, Corporate ServicesAnne Wojtak, Chief Performance Officer Senior Director, Performance Improvement and Outcomes

Toronto Central Community Care Access Centre 250 Dundas Street West, Suite 305 Toronto, Ontario M5T 2Z5

Telephone: 416-506-9888 Français: 416-701-4646 Fax: 416-506-1629 Toll Free: 1-866-243-0061 Français: 1-877-701-4646

Ce rapport est disponible en français. (This report is available in French.)

Healthcareathome.ca/torontocentral

The Toronto Central CCAC connects people across Toronto with quality in-home, clinic and community-based healthcare. The organization provides information, direct access to qualified care providers and community-based services to help people come home from hospital or live independently at home. Last year, 78,000 residents of Toronto were supported through the Toronto Central CCAC. Driven to provide the best possible outcomes for these clients, the organization is recognized provincially, nationally and internationally as a leader and innovator in the field of homecare.Photography: Gerald AllainDesign: Chris Caswell Design

HEROES IN THE HOME AWARDS Board of Directors 2015-16William Yetman Board Chair

Maureen Adamson Member, Governance Committee

Michael Beswick Member, Finance and Audit Committees

Gina DeVeaux Chair, Quality Committee

Nancy Dudgeon Past Chair

Laurie Hicks Member, Quality Committee

Amir Karmali Member, Quality Committee

Myra Libenson Member, Finance and Audit Committees

Shannon MacDonald Member, Governance Committee

Christopher Neuman Chair, Governance Committee

Manuel Pedrosa Chair, Audit & Finance Committees

Megan Primeau Member, Governance Committee

Karen Sadlier-Brown Member, Governance Committee

Natasha vandenHoven Vice Chair and Member, Quality Committee

Toronto Central CCAC is fully funded by the Toronto Central Local Health Integration Network.

This annual event is our way of celebrating the incredible people who take on the responsibility of helping a parent, child, brother, sister, neighbour or friend remain at home in safety and comfort. It also celebrates the

professionals – care coordinators, nurses, personal support workers and other health workers – who do their jobs with a remarkable spirit of compassion and support. Since the awards began, we have recognized over 500 heroes.

An excerpt from each recipient’s nomination letter is read as they come up to receive their certificate, and each story truly touches the heart.

One of this year’s heroes, Peter, expressed his philosophy this way: “If we don’t look out for others, who will look out for us?” Peter is looking out for others, as are all those heroes. That’s what the dedicated people of Toronto Central CCAC do every day.

Heroesin theHome

Heroes Jewell and Echo are dedicated parents helping their eldest daughter, Kaleigh, recover from numerous surgeries and providing her specialized care.

18 19

“ I want you to know how blessed and fortunate I feel to have you as my care coordinator. When you first came to me, you were very patient and empathetic. You explained every service before going on to the next one. You are a top-notch professional who is organized, extremely knowledgeable and expedient in providing me with all the resources I require. Everything that you’ve done for me and advocated for me have meant so much to me. Your contributions to the community are of utmost importance. People like you are essential assets to CCAC.”

Toronto Central CCAC client 310-CCAC (2222)