The ongoing partnerships between CE LHIN hospitals, the Central East Community Care Access Centre and Community Care is making a difference in the lives of seniors in Central East communities.  This story, which appeared in Durham and Northumberland papers at the end of 2010, highlights the impact of new programs funded by the Central East LHIN.   For more information on Home First and GAIN, please visit the Get Connected with Care page on the CE LHIN website. 

New programs get local seniors out of hospital, back home

by Jillian Follert 

In July, Shirley Holliday took a spill in her Oshawa apartment and ended up with a fractured pelvis.

The 72 year old was already struggling with loss of vision as she waited for a cornea transplant and said the two ailments combined left her in "pretty bad shape."

She was admitted to Lakeridge Health Oshawa and stayed for six weeks.

"It was very frustrating being in hospital ... after some time I didn't really need to be there for medical reasons but I couldn't go home," Ms. Holliday said.

Until a new program paved the way for an unexpected homecoming.

Home First -- part of the province's Aging at Home strategy -- aims to see every senior admitted to hospital sent home by making available help such as nursing, personal support workers, physiotherapy, friendly visiting and transportation services.

Lakeridge Health Oshawa was the first local hospital to try out the program. New data released this month said more than 500 seniors have been successfully sent home since it launched in September.

In Ms. Holliday's case, she received 56 hours of personal support care for the first couple of weeks, a number that gradually tapered off as her condition improved.

After a successful cornea operation, she now has her sight back and only needs seven hours of help each week.

"I'm very glad to be home. I've seen all the hospital I want to see," she said.

The Central East Local Health Integration Network is moving briskly to make Home First available in all nine hospitals in its coverage area -- which includes Durham, Northumberland, Peterborough and Kawartha -- by April.

"Most people want to live independently in their home as long as possible," said James Meloche, senior director of system design and implementation for the Central East LHIN. "Rather than waiting for them to go home and determine what they need, as soon as they arrive in the hospital, we ask 'what does it take to get this person home?' It could be meals, transportation, or nursing services. In one case, it was a ramp to the front door because they were using a wheelchair."

Even if long-term care is in the cards, Mr. Meloche said it still makes sense to get the patient back home in-between the hospital and the nursing home, so important decisions can be made in a less stressful environment.

Rouge Valley is introducing Home First at its Ajax and Scarborough locations this week and Northumberland Hills Hospital is slated to start offering it in February.

While the program is aimed at helping seniors, Rouge Valley spokesman David Brazeau said it actually improves the entire health-care system.

"It's all one continuum of care. When there is a clog somewhere, it affects the whole thing," he said. "Hospitals provide great care, but it's not the right place for everyone. The better we are at addressing that, the more we will decrease wait times in the emergency department."

Lakeridge Health Oshawa is also the site of the area's first Geriatric Assessment and Intervention Network clinic, another Aging at Home initiative.

The specialized clinic offers a range of services targeted at seniors including nurse practitioners, community care case managers, physiotherapists, occupational therapists, pharmacists and social workers. They work closely with other health-care professionals including the geriatric emergency management nurses stationed in emergency departments.

The Oshawa GAIN clinic has seen 61 patients since opening in October and the majority were treated and sent home, as opposed to being admitted to hospital.

Kenneth Hugh Robertson, 81, was one of them.

The Whitby man was sent to the GAIN clinic after his family doctor was unable to come up with a solution for problems with his feet.

"The nurse practitioner at the clinic spent an hour and 15 minutes talking to me. She listened to me and talked about the things going on in my life," Mr. Robertson said. "She took a look at the broad picture."

He was referred to a physiotherapist and is now seeing improvement in his feet.

"It's the best thing medically that happened to me in years," Mr. Robertson said of the clinic, calling it a "marvelous" solution for an overburdened health care system.

reposted with permission from the Metroland Durham Region Media Group

LHINs bring together health care partners from the following sectors – hospitals, community care, community support services, community mental health and addictions, community health centres and long-term care – to develop innovative, collaborative solutions leading to more timely access to high quality services for the residents of Ontario and the Central East LHIN.  By supporting these important partnerships, LHINs are ensuring that Ontarians have access to an effective and efficient health care system that delivers improved health care results and a better patient experience.