The Continuum of Care

1. The Continuum of Care An Integrated System of Delivery

2. Continuum of Care • I could be handy, mending a fuse, when your lights have gone. • You can knit a sweater by the fireside, sunday mornings, go for a ride. • Doing the garden, digging the weeds, who could ask for more? • Will you still need me, will you still feed me, when I'm sixty four?

3. Continuum of Care • What is a Continuum of Care? • What does integrated service system of delivery mean?

4. Continuum of Care - Definition • Multifaceted and combines aspects of both health and social services. • An amalgamation of diverse categories of service integrated by an overall system of service delivery. • A system of service delivery. • Efficiency and effectiveness is based on constituent parts and the nature of the system.

5. Continuum of Care Continuing Care • A system of service delivery that includes all services provided by home and residential care. • Care continues over a long period of time. • Integrated program of care continues across service components = a continuum of care.

6. Continuum of Care • Long Term Care represents a range of services that address the health, social and personal care needs of individuals who, for one reason or another, have never developed or have lost some capacity for self care. • Services may be continuous or intermittent, but will be long term, idefinate to individuals who have demonstrated need, usually by functional incapacity.

7. Continuum of Care Home Care Maintenance and Preventative Model • Serves people with health and/or functional deficits in the home setting, both maintaining their ability to live independently; and in many cases preventing health and functional breakdowns, and eventual instituionalization.

8. Continuum of Care Home Care Long Term Care Substitution Model • Home care meets the needs of people who would otherwise require institutionalization Acute Care Substitution Model • Home care meets the needs of people who would otherwise have to remain in, or enter, acute care facilities.

9. Continuum of Care Elements of Continuing Care Single Entry • Consistent screening mechanism ensuring those with appropriate needs are provided services. • One stop shopping for care services. • Point of access to a comprehensive range of services within the system of care.

10. Continuum of Care Elements of Continuing Care Coordinated Assessment and Placement • Determines needs and development of system level care plan for the client. • Access to care in any of the components of the service delivery system. • Leads to most appropriate service provision. • Same client data on admission to system.

11. Continuum of Care Elements of Continuing Care Coordinated Case Management • Regular monitoring and review of client needs, adjustment of care plans based on changing needs, to best match needs and services provided. • Reduces likelihood of admission to acute care hospital due to lack of regular monitoring (system efficiencies).

12. Continuum of Care Elements of Continuing Care Coordination of Clinical Clients • Contact with single point of entry. • Screening process assessment takes place • Case manager assigned, visit scheduled. • Assessment determines needs, supports, identifies services required. • Care plan developed for accessing services

13. Continuum of Care Elements of Continuing Care Single System Level: Admin and Funding • Ease for reallocation of funding between home and residential settings. • Policies are developed in the context of the total continuing care system. • Clients needs are better met. • Planning and resource allocation at the system level.

14. Continuum of Care Elements of Continuing Care Consistent, system level, client classification system • Allows for the comparison of clients across service delivery components by the level of care, that is, an apples to apples comparison. • Clients treated at most cost effective location.

15. Continuum of Care “Having a well-integrated system of service delivery, based on a continuum of care characterized by single entry, coordinated assessment and placement, and coordianted care management, and supported by effective management and the capacity to plan at a systemwide level, should result in an efficient, effective, equitable and affordable method of providing care to those in need.”

17. Continuum of Care • On Lok SeniorHealth, a certified PACE program, is specifically designed to provide total long-term care for the frail elderly. Our comprehensive health plan includes full medical care, prescription drugs, home care, adult day health, transportation, and more, allowing our member to remain at home for as long as possible.

18. Continuum of Care • On Lok SeniorHealth is a comprehensive health plan serving frail seniors who live in San Francisco and Fremont. This program provides an important alternative when nursing home care and placement seem necessary. With On Lok SeniorHealth, a senior can remain within the community, enjoying the comforts of home and family, for as long as possible…inclusive of medical and personal care assistance.

19. Continuum of Care The name On Lok means "place of peace and happiness" in Cantonese, and this reflects both our roots and our philosophy of care. Through five related not-for-profit entities, On Lok provides healthcare, housing and intergenerational programs that meet the needs of seniors. The largest and oldest component of On Lok’s services is On Lok Senior Health Services, whose mission is to provide quality, affordable care services for the well-being of the frail elderly.

20. Continuum of Care On Lok SeniorHealth is a fully-integrated and licensed health plan that delivers medical and long-term care to those looking for an alternative to a nursing home. At present, On Lok SeniorHealth helps about 950 elder adults maintain their independence – by providing all necessary primary and specialty medical care, adult day health care, in-home health and personal care, social work services and hospital and nursing home care.   Our vision is to continually lead the movement to improve care for the elderly.

21. Continuum of Care • The Program of All-inclusive Care for the Elderly (PACE) model is centered around the belief that it is better for the well-being of seniors with chronic care needs and their families to be served in the community whenever possible. • PACE serves individuals who are aged 55 or older, certified by their state to need nursing home care, able to live safely in the community at the time of enrollment, and live in a PACE service area. Although all PACE participants must be certified to need nursing home care to enroll in PACE, only about seven percent of PACE participants reside in a nursing home nationally. If a PACE enrollee does need nursing home care, the PACE program pays for it and continues to coordinate his or her care.

22. Continuum of Care • With the support of a comprehensive package of services, care is coordinated and delivered by a dedicated team of: • Physicians • Nurses • Social Workers • Physical & Occupational Therapists • Dieticians • Transportation Staff • Home Care Workers • Recreational Activities Leaders

23. Continuum of Care • Each participant’s needs are monitored and addressed. Based on participant and caregiver input, the team puts together an individualized healthcare plan and then continuously assesses the participant’s status. Treatment and services are adjusted to suit the member’s situation as healthcare needs change.

24. Continuum of Care • On Lok SeniorHealth provides nursing home eligible seniors, who wish to remain living at home in the community, with a complete program of health and health-related services. • Our program includes preventative, primary and acute medical services and long-term care. • Our primary focus is on preventative measures to maintain the health and well-being of our participants. • Our goal is to help these seniors live independently, in their homes for as long as possible.

25. Continuum of Care • On Lok SeniorHealth Benefits include: • Primary medical care and specialty care as needed (such as cardiology, neurology) • Routine preventative care such as audiology, dentistry, optometry and podiatry • Rehabilitation therapy (physical, occupational, speech) and recreational therapy • Home health care and personal care • Social services

26. Continuum of Care Who should you consider On Lok SeniorHealth for their long-term healthcare needs? • On Lok SeniorHealth may be the perfect solution for a senior who:  • is 55 years of age or older • Lives in San Francisco or Fremont, California • Requires ongoing medical care and supportive services to continue living at home and • Is able to live in the community without jeopardizing the health and safety of themselves or others

27. Continuum of Care • On Lok Services, cont… • Nutrition services and home-delivered meals as necessary • Transportation and emergency medical transport • Acute hospital and nursing home care • Nursing care and monitoring • Adult day health care • Prescription drugs and necessary health care related equipment and supplies

28. Continuum of Care

29. Continuum of Care

30. Continuum of Care • Baycrest Programs & ServicesBaycrest offers programs and services designed especially for people in their 50s, 60s, 70s, 80s and beyond. • For some programs a fee may be involved and their may be eligibility criteria to take part. • Due to demand some programs maybe full but there is a waiting list.

31. Continuum of Care • Baycrest Seniors Counselling and Referral ServiceMany people find it difficult to navigate the health, long-term care and social service system. If you need information to help you make informed decisions for yourself or a loved one, Baycrest’s Seniors Counselling and Referral Service can help you get started. • These services are free of charge and include:

32. Continuum of Care • Information and Referral Services to older adults, their family members, community members and other service providers. • Counselling and support for older adults and their families, helping them cope with the stresses of aging, illness or disability. They will help clients and their families develop an effective service plan and provide on-going follow-up. • Caregiver services through groups. Social workers offer information, consultation, counselling and education supports. • Services for pre-admission to the Apotex Centre.  Social workers are assigned cases from the Community Care Access Centre (CCAC) waitlist several months prior to a bed offer and will support seniors and their families to help them make informed decisions regarding placement.

33. Continuum of Care • Healthy Living and Health Maintenance Programs These programs and services help seniors actively manage their health through education, exercise and social activities. Programs are listed on the left-hand side menu, please click on the program you are interested in to see the detailed information. Anne E. and Louis Pritzker Wellness LibraryThe Anne E. and Louis Pritzker Wellness Library is open for people who live in the community and to medical and health care professionals. Arthritis Supervised Exercise ProgramThis program is for people with a medical diagnosis of arthritis who have completed Set Your Pace: Program for Arthritis Control through Education and Exercise Hydrotherapy Maintenance ProgramThe Hydrotherapy Maintenance Program gives clients access to a warm water pool twice weekly to maintain their mobility. Joseph E. And Minnie Wagman CentreThe Joseph E. and Minnie Wagman Centre is a multilingual community centre for older adults operated by Baycrest. Its wide variety of recreational and leisure programs provide cultural enjoyment, social contacts and educational opportunities. Memory and Aging ProgramThe Memory and Aging Program is a five-week education and discussion series offered by the Psychology Department. It is aimed at community members who are interested in learning about memory changes that occur with age. Memory Intervention ProgramThe Memory Intervention Program is for older adults experiencing mild memory decline known as Mild Cognitive Impairment. MOST: Moving On After Stroke ProgramA nine-week, twice-weekly program is for individuals, and their care providers, who have completed active stroke rehabilitation, live in the community, and want to learn the skills needed to live successfully with stroke. • Osteoporosis: POWER ProgramThe Osteoporosis POWER (Promoting Osteoporosis Wellness through Education, Exercise and Resources) Program is designed for seniors who have been recently diagnosed with osteoporosis and who can benefit from more information about their condition or who can make positive lifestyle changes. • Parkinson’s Early Intervention ProgramA 10-week program for adults who have been diagnosed with Parkinson’s in the last three years and their care providers. Parkinson’s Exercise GroupsOn going weekly exercise groups specifically for people who have Parkinson’s. Parkinson’s Water Exercise ProgramThis program is a follow-up to the Parkinson's Early Management Program  and is designed for individuals in the early stages of Parkinson’s.Set Your Pace: Program for Arthritis Control through Education and ExerciseThis nine-week, twice-weekly program is designed for adults with a medical diagnosis of arthritis, such as osteoarthritis, rheumatoid arthritis, or fibromyalgia. Stroke Recovery GroupStress Management The Stroke Recovery Group integrates movement activities with discussion exploring issues related to living with stroke. Stress Management ProgramA supportive group where members identify stressors, problem-solve and learn and practice healthy coping skills.Water Exercise ClassesWater exercise classes of varying intensity levels are offered in the Joseph E. and Minnie Wagman Centre’s warm water pool.

34. Continuum of Care • Arthritis Supervised Exercise ProgramThis program is for people with a medical diagnosis of arthritis who have completed Set Your Pace: Program for Arthritis Control through Education and Exercise Hydrotherapy Maintenance ProgramThe Hydrotherapy Maintenance Program gives clients access to a warm water pool twice weekly to maintain their mobility. Joseph E. And Minnie Wagman CentreThe Joseph E. and Minnie Wagman Centre is a multilingual community centre for older adults operated by Baycrest. Its wide variety of recreational and leisure programs provide cultural enjoyment, social contacts and educational opportunities. Memory and Aging ProgramThe Memory and Aging Program is a five-week education and discussion series offered by the Psychology Department. It is aimed at community members who are interested in learning about memory changes that occur with age. Memory Intervention ProgramThe Memory Intervention Program is for older adults experiencing mild memory decline known as Mild Cognitive Impairment. MOST: Moving On After Stroke ProgramA nine-week, twice-weekly program is for individuals, and their care providers, who have completed active stroke rehabilitation, live in the community, and want to learn the skills needed to live successfully with stroke. • Parkinson’s Early Intervention ProgramA 10-week program for adults who have been diagnosed with Parkinson’s in the last three years and their care providers.

35. Continuum of Care • Osteoporosis: POWER ProgramThe Osteoporosis POWER (Promoting Osteoporosis Wellness through Education, Exercise and Resources) Program is designed for seniors who have been recently diagnosed with osteoporosis and who can benefit from more information about their condition or who can make positive lifestyle changes. • Parkinson’s Exercise GroupsOn going weekly exercise groups specifically for people who have Parkinson’s. Parkinson’s Water Exercise ProgramThis program is a follow-up to the Parkinson's Early Management Program  and is designed for individuals in the early stages of Parkinson’s.Set Your Pace: Program for Arthritis Control through Education and ExerciseThis nine-week, twice-weekly program is designed for adults with a medical diagnosis of arthritis, such as osteoarthritis, rheumatoid arthritis, or fibromyalgia. Stroke Recovery GroupStress Management The Stroke Recovery Group integrates movement activities with discussion exploring issues related to living with stroke. Stress Management ProgramA supportive group where members identify stressors, problem-solve and learn and practice healthy coping skills.Water Exercise ClassesWater exercise classes of varying intensity levels are offered in the Joseph E. and Minnie Wagman Centre’s warm water pool.

36. Continuum of Care • HousingBaycrest offers two types of housing that help seniors remain independent. Housing choices are listed on the left-hand side menu, please click on the item of interest to see the detailed information. Reuben Cipin Healthy Living CommunityThis condominium-style life lease residence of 120 suites is designed for active and independent seniors (65 years old plus). • Terraces of BaycrestThe Terraces of Baycrest provide seniors with the privacy of independent apartment living, along with supportive services.

37. Continuum of Care • Outreach (in-home assessments) and Support ServicesBaycrest offers a variety of community and in-home services that help older adults keep healthly, and continue to live independently in the community. Services are listed on the left-hand side menu, please click on any of the services for more information.Baycrest Community Day Centre for SeniorsThrough social, recreational and educational activities for older adults, the Day Centre helps provide stimulation and a renewed sense of independence for people who are living at home, but may be isolated or lonely. It also offers respite for families. • Baycrest Home Care ServicesAdults aged 55 and older living in the Greater Toronto Area and York Region can subscribe for a full range of home care services that can be tailored to meet individual needs. • Baycrest LifelinePersonal response service is available through a "help button" that can be worn as a pendant or wristband. The button activates a small in-home communicator that automatically dials the Lifeline Response Centre for emergency response.

38. Continuum of Care • Baycrest Outreach Hearing ServicesThe Baycrest Outreach Hearing Services helps homebound people aged 55 and older who require hearing services and are unable to travel to an audiology clinic or hearing aid dispensary. • Community Assessment and Treatment Team - Outreach ServiceThis program provides outreach to frail elderly people, over the age of 55 years, with complex health, functional and social problems with a goal of optimizing independence and a sense of well being. • Geriatric Psychiatry Community ServiceThis is an in-home and out-patient psychiatric assessment service for adults aged 65 years old or older experiencing mental health problems. • Seniors Counselling and Referral ServiceHelps seniors and families navigate, make informed decisions and access Baycrest and community supports. • Seniors Support ProgramThe Seniors Support Program provides weekly telephone calls to older adults and their families living in the community.

39. Continuum of Care • Out-patient CareBaycrest offers a number programs and services that provide assessment, treatment, care, support and education to clients seeking help for health concerns. For further information, please click any of the services on left-hand side menu bar. Baycrest Hearing Services - Audiology ClinicThe Audiology Clinic provides a number of services for adults who are 55 years old and older including: hearing assessment; hearing aid evaluations and prescriptions; assessment for and recommendation of assistive listening devices; hearing aid orientation and counselling for clients and caregivers; education for clients and caregivers on how to use assistive listening devices; counselling for clients and families on how to manage better in difficult listening situations.

40. Continuum of Care • Baycrest Hearing Services - Hearing Aid DispensaryThe Hearing Aid Dispensary provides hearing aid fittings (with a prescription), earmold impressions and fittings, hearing aid repairs, battery sales, assistive devices, hearing aid accessory sales, and advice on how to use aids and devices. • Brain Health Centre Clinics - Memory, Mood, and Stroke & Cognition ClinicsOut-patient care for people with disorders related to mood, memory and stroke. The Brain Health Centre Clinics is comprised of three clinics that provide client-centered care, support and education. • Memory-Link ProgramMemory- Link is a unique service established for individuals (all ages, although focus is on seniors) with severe memory impairment related to an aneurysm, stroke, infection, hydrocephalus, herpes encephalitis, Wernicke-Korsakoff’s syndrome, non-progressive tumour or focal traumatic brain injury.

41. Continuum of Care • Psychiatric Day Hospital for DepressionThis out-patient service is for seniors (65 years old plus) in the community who suffer from depressive illness. • Reuben and Helene Dennis Ambulatory Care CentreThe Reuben and Helene Dennis Ambulatory Care Centre runs medical clinics for out-patients providing a wide range of assessments and treatments. • Saul and Rae Saltsman Day Treatment Centre - Community Treatment TeamThe program assists older adults who are having difficulty managing in their own homes and have complex health problems requiring rehabilitation. • Swallowing and Nutritional Assessment - Community ServiceAn interdisciplinary team comprised of a speech-language pathologist and a registered dietician that provides services to seniors experiencing swallowing and swallowing related nutritional difficulties.

42. Continuum of Care • Reuben and Helene Dennis Ambulatory Care CentreThe Reuben and Helene Dennis Ambulatory Care Centre runs medical clinics for out-patients providing a wide range of assessments and treatments. Physician referral is required. • Clinics include: • Dermatology • Ear, Nose and Throat • Foot and Wound • General Neurology Clinic • General Surgery; Geriatric Assessment • Gynaecology; Hand and Foot Orthotics • Orthopaedics • Pessary Care (Nursing Practice Clinic) • Physiatry/Rheumatology • Skin Integrity • Urogynaecology • Urology

43. Continuum of Care • Hospital In-patient ServicesBaycrest offers in-patient services for clients with complex medical conditions and short-term health care concerns. • Complex Continuing Care Program The Complex Continuing Care Program of Baycrest Hospital, Ben and Hilda Katz Building, provides care for older patients (65 years old plus) with complex medical conditions in a non-acute hospital setting. For more information, click here. • Short-Term Stay ProgramsShort stay programs, including Behavioural Neurology, Geriatric Assessment and Treatment (GATU), Psychiatry and Rehabilitation, address short term health care concerns in an in-hospital setting with the goal of helping clients return to living in the community as independently as possible. A Palliative Care program, providing end of life care and support, is also available to appropriate clients.

44. Short Term Stay Program - Behavioural NeurologyThe Behavioural Neurology Unit focuses on assessment and management of adults suffering from brain disorders leading to abnormalities in cognition and behaviour. • Short Term Stay Program - Geriatric Assessment and Treatment (GATU)The Geriatric Assessment and Treatment Unit (GATU) provides diagnostic and functional assessments, and short-term treatment for frail elderly clients (65 years old plus) who are experiencing medical illnesses and recent functional decline. • Short Term Stay Program - Palliative CareThe in-patient Palliative Care Unit of Baycrest Hospital provides 24-hour pain and symptom control combined with emotional and spiritual support to clients (55 years old plus) who have been diagnosed with terminal illness and are in need of palliative and/or terminal illness care.

45. Continuum of Care • Short Term Stay Program - PsychiatryThe In-patient Psychiatry Program provides assessment and treatment for older people (55 years old plus) experiencing severe mental illness (including major depression, bipolar disorder, psychotic disorder, or dementia with mood problems). • Short Term Stay Program - RehabilitationThe unit is for patients requiring therapy as a result of musculoskeletal or neurological conditions (hip fracture, neurological conditions such as stroke, etc).

46. Continuum of Care • Apotex Centre, Jewish Home for the Aged and The Louis and Leah Posluns Centre for Stroke and CognitionThe Apotex Centre, Jewish Home for the Aged and The Louis and Leah Posluns Centre for Stroke and Cognition, is a 472-bed, long-term care facility which provides a range of residential and specialized programs. • The small, home-like settings provide flexible schedules for programs, meals and personal care, based on each resident's needs and preferences. Care is provided within the context of orthodox Jewish traditions. The Louis and Leah Posluns Centre for Stroke and Cognition focuses on rehabilitation programs to help seniors with dementia caused by vascular disorders such as strokes.

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48. Continuum of Care • Support Groups for Community MembersBaycrest offers a number of support groups to community members that address bereavement, dementia, experiences of holocaust survivors as well as general support. • Café EuropaThe Baycrest Café Europa opens November 24, 2006. It is a weekly drop-in place for Holocaust survivors to relax and socialize. • Caring for Your Loved One (Adult children of dementia suffers)This six-week education and support group is for children of parents with dementia who live in the community. • Child Survivor Online List Serve GroupThis is an online chat group for survivors of the Holocaust who were under 18 years old by the end of the War. • Community Members Bereavement GroupA support and discussion group for people who have recently lost a spouse. • Holocaust Child Survivors and Hidden Children's GroupThere are two support and discussion groups for child survivors. • Second Generation Support Group for Adult Children of Aging Holocaust SurvivorsA support and discussion group for children of Holocaust survivors to share experiences and identify their needs and what can be done for them and their aging parents. • Seniors Support ProgramThe Seniors Support Program provides weekly telephone calls to older adults and their families living in the community. • The Changing Relationship (Support for spouses of dementia suffers)This six-week education and support group is for individuals caring for spouses with dementia and who are still living in the community.

49. Continuum of Care • Self Management Programs for Patients and CaregiversSelf-management programs encourage people with chronic illness to improve their own health. Health professionals help clients and care partners develop the skills needed to manage their condition on a daily basis through developing problem solving skills, setting meaningful goals, and identifying resources and supports. • MOST: Moving On after Stroke ProgramA nine-week, twice-weekly program for individuals, and their care providers, who have completed active stroke rehabilitation, live in the community, and want to learn the skills needed to live successfully with stroke. • Osteoporosis: POWER ProgramThe Osteoporosis POWER (Promoting Osteoporosis Wellness through Education, Exercise and Resources) Program is designed for seniors who have been recently diagnosed with osteoporosis and who can benefit from more information about their condition or who can make positive lifestyle changes.

50. Continuum of Care • Parkinson's Early Management ProgramA 10-week, twice-weekly program for adults who have been diagnosed with Parkinson’s in the last three years, and their care providers. • Parkinson's Self-Management ProgramA 12-week, twice-weekly program for caregivers and individuals diagnosed with mid-stage Parkinson’s, including caregiver support, exercise, group discussion sessions, and multi-disciplinary therapy. • Set Your Pace: Program for Arthritis Control through Education and ExerciseThis nine-week, twice-weekly program is designed for adults with a medical diagnosis of arthritis, such as osteoarthritis, rheumatoid arthritis, or fibromyalgia.