Elevate Impact Hub Virtual Poster Exhibition

Elevate Impact Hub

The Elevate Impact Hub Virtual Poster Exhibition provides a platform for sector leaders, researchers, and healthcare professionals to come together and share their insights on the latest research findings, leading practices, and innovation home and community care.

Three ways to browse:

1. Scroll through and explore the collection of posters.

2. Utilize the search function to locate specific items.

3. Navigate through provided keywords to narrow your search

More info: https://www.elevateimpacthub.ca

Filter displayed posters (95 keywords)

home care 3 Collaboration 2 HHR 2 community 2 personal support workers 2 show more… Access 1 Adult Day Programs 1 Adult Day Services 1 Aging at Home 1 BPMH 1 Best Possible Medication History 1 COVID-19 1 Client-Caregiver 1 Community 1 Community Care 1 Community Programs 1 Comprehensive assessment 1 Coordinated Care 1 Dementia 1 Digital Tools 1 Discharge Planning 1 Education materials 1 Efficiency 1 Health definition 1 Holistic health 1 Home Care 1 Home care 1 Inclusion 1 Integrated Care 1 Integrated care 1 Intensive case management 1 Interdisciplinary Care Rounds 1 MedRec 1 Medication Reconciliation 1 Nursing 1 Nursing Documentation 1 Ontario Health Team 1 PCP implementation 1 PREM 1 PSW 1 Person-centered Plans (PCP) 1 Person-centred 1 Persons-Supported 1 Primary Care 1 Quadruple Aim 1 Qualitative Research 1 Recruitment 1 Resources 1 Retention 1 Simulation 1 Standard Work 1 Virtual Nursing Care 1 acute care 1 aging 1 capacity planning 1 care coordination 1 care providers 1 clinic 1 collaboration 1 community-based care 1 disability 1 eDelphi 1 health services 1 healthcare 1 homecare 1 hospital to home 1 hybrid counselling model 1 innovation 1 integrated care 1 integrated care program 1 integrated home and community care 1 interRAI 1 leadership 1 mental health 1 mixed-methods 1 models of care 1 occupational stress 1 organizational culture 1 partnership 1 patient experience 1 patient reported experience measures 1 person-centred planning 1 pharmacy 1 qualitative study. 1 schedule optimization 1 single session counselling 1 social services 1 staffing 1 teaching models 1 technology 1 vaccination 1 volunteer services 1 walk in counselling 1 work conditions 1 workforce capacity 1

Show posters with Recorded Presentation

Person-Centred Plans from the Perspective of Persons-Supported in a Community Care Setting

Brian Dunne, Gillian Young, Donnie Antony, Ruth Armstrong, Bridget Ryan, Shannon Sibbald, Leslie Meredith, and Maria Mathews

Abstract: Background context of our research: This project is a partnership between PHSS, a community care agency based in London Ontario and researchers at Western University. Person centred plans (PCPs) are created annually and have check-ins after 6 months. They are created through a formal discussion with the person-supported, the staff who support them, friends, family, and community members. PCPs are individualized and incorporated into daily activities, as well as laying a framework for larger goals. Research Question, objective, or hypothesis: Our aim was to evaluate the PHSS person-centred planning model. Main findings or results: We interviewed 19 persons-supported at PHSS. We identified three main facilitators to the PCP creation and implementation process: 1) the person-supported’s goals; 2) the person-supported’s capacity (including mental and physical health status, and likes and dislikes); and 3) the organizational capacity (including funding, staffing, organizational culture, and organizational infrastructure).
Presented by: Gillian Young <gyoung57@uwo.ca>
Institution: Western University, Department of Family Medicine and PHSS Medical and Complex Care in the Community
Keywords: Person-centered Plans (PCP), Community Care, Qualitative Research, Persons-Supported, PCP implementation

From Crisis to Innovation: VHA’s Nursing-led THRU Model

Susan Chang MSc(OT), OT Reg.(Ont.), MHSc, Mandy Wong MSc(OT), OT Reg.(Ont.), and Richard Tang MPP

Abstract: Discover how VHA's Nursing-Led THRU Model transformed vaccination efforts during the pandemic, eliminating the need for on-site physician oversight. Through collaboration with 25+ partners, various clinics were established, resulting in 60,000 vaccinations administered. Explore how THRU's success paves the way for future innovations and learnings in the healthcare sector.
Presented by: Susan Chang, Mandy Wong, Richard Tang <thru@vha.ca>
Institution: VHA Home HealthCare, Strategic Solutions & Partnerships
Keywords: Nursing, leadership, pharmacy, vaccination, innovation, home care, community, staffing, clinic, collaboration, partnership, Ontario Health Team

Increasing PSW Hiring Volume, While Delivering High Levels of Client Care and Building a Culture of Belonging

Allison Kujbida, Talent Acquisition and Retention Manager, Circle of Care

Abstract: Healthcare organizations everywhere are struggling to recruit and retain the human resources necessary to support quality services and meet client needs. The Circle of Care Human Resources team set a goal of increasing PSW hiring volumes by 20% while maintaining quality of care and positively impacting the number one factor in workplace retention, a sense of belonging. We fine-tuned operational processes that support scale for recruitment, incorporated high value in person supports to complement existing digital processes and partnered cross functionally to achieve positive people outcomes together.
Presented by: Allison Kujbida
Institution: Circle of Care
Keywords: Recruitment, HHR, PSW, Retention

How Do Health and Community Care Providers Coordinate Services for Older Adults Aging at Home: The Story of the Community Wellness Hub

Dr. Reham Abdelhalim, Lucy Sheehan, Kathy Peters, Andrew Balahura, Andrea Evershed, Adeeta Aulakh,

Abstract: The Community Wellness Hub is an alliance of health and community providers that coordinate and deliver services to seniors made vulnerable by social determinants of health. The Hub is located in government-subsidized seniors housing buildings and provides services to individuals that reside in the building and surrounding area. The aim is to enable members to lead healthy and happy lives in the community by proactively addressing health and wellness needs and reducing health crises requiring acute care. The alliance consists of fifteen health, housing and community support organizations, including one lead organization that provides day to day operation and coordination. Operations are facilitated by a Community Connector of the lead organization, who works on-site. Services provided are an intersection of three systems; healthcare, housing, and community services. The Hub started as a pilot in one building in Burlington in 2019. It has since expanded to another building in Oakville, with an implementation plan for further spread and scale. A comprehensive performance measurement and evaluation plan accompanied the implementation of the Hub. To track the performance of the Hub, a monthly dashboard was created to display the enrollment status, interactions, social events, referrals as well as client satisfaction with various activities in the Hub. To assess the impact of the Hub, the evaluation framework is guided by the quadruple aim philosophy, with a focus on client and provider experiences as well as enhancing the quality of life while achieving value in our services. Our evaluation team created multiple data collection tools that we use to gather data about experiences and quality of life. All were co-designed with clients and providers. The impact of the Hub is yielding great positive results. We will describe them in detail in the poster. Aging at home is a priority area for home and community organizations particularly in a time when our acute care and long-term care facilities are under huge pressure. However, the question is always how to create community-based care models that can be successfully implemented in our local context. Providing the delegates with a real life example that has proven to be effective and has the capability to be scaled to multiple sites is an excellent learning opportunity. The Community Wellness Hub is a real-life example of how health, housing and social service providers can come together to implement an integrated model that helps seniors age at home while leading a healthy and happy life.
Presented by: Andrea Evershed
Institution: Capability Support Services
Keywords

Integrated Care - Creating Better Healthcare Experiences

Bonnie Lum, RN, BScN, MN, Professional Practice Specialist at VHA Home Healthcare Claire Seymour, BComm, MBA, Director UHN@Home, University Health Network Tsoleen Ayanian, Project Manager –Integrated Care Surgical Lead, UHN Connected Care Courtney Bean, BSc, BScPT, DMT (cand) – VP, Strategic Solutions and Partnerships Melissa Chang, BA, ACP, Senior Director Integrated Care, Director, Operations and Sustainability, NORC Innovation Centre, UHN Connected Care

Abstract: In 2019, University Health Network (UHN), Canada’s largest research health system, launched a new evidence-based model of care called the UHN Integrated Care Program (ICP). The ICP is developed and delivered in partnership with VHA Home HealthCare (VHA) and aims to improve patient, caregiver and care provider experience, with a focus on creating a seamless experience for the patient across the health continuum. The ICP successfully wraps care around our patients and makes it easier for clinicians to communicate and coordinate care plans. Since 2019 the Program has launched rapidly with great results and has expanded with capacity to support ~2,200 patients annually. Over the coming years, the Program continues to rapidly expand. The ICP is transforming and leading the way health care is delivered in Ontario.
Presented by: Bonnie Lum <blum@vha.ca>
Institution: VHA Home Health and University Health Network
Keywords: Integrated care, integrated care program, models of care, home care, acute care, hospital to home

Using simulation to facilitate the adoption of virtual nursing care in a home care organization

Janet Chan

Abstract: Our organization has started using nursing virtual care since 2020 with the onset of the COVID-19 pandemic. However, we have noticed poor uptake amongst our nurses and with the removal of isolation mandates, virtual care utilization rates have decreased further. Therefore, to promote the use of virtual nursing care and change our nurses’ attitude and beliefs regarding virtual care, we have created a virtual care station as part of our organization’s biennial nursing competency validation. The virtual nursing station involves the nurse immersing in a video virtual encounter where low-fidelity simulation with a standardized client occurs. From this project, we aim to increase our nurses’ confidence in utilizing video virtual care, and for them to apply their learning into future practice. Nurses will be participating in the project from May- June 2023 and evaluation of whether the nurses have applied there learning into practice will be occurring from July-September 2023.

Evaluation of our project will be occurring in July-September 2023, therefore, we do not currently have outcomes to share. Outcomes will be measured using the number of virtual care visits that have been billed by our nurses who have participated in the project. Also, we will be assessing for changes in utilization and adoption rates of virtual care.

Our project will be of interest to home and community care delegates as nursing virtual care is a promising solution to increasing access to care, managing staff shortages, as well as cost saving. However, there are also numerous barriers to the adoption of virtual care amongst home care nurses. There is a lack of standardizations and guidelines regarding how virtual nursing care is to be taught and conducted in Canada, thus posing a major challenge when implementing change management. Therefore by sharing our innovative method using simulation, learnings can be adopted to other home care and community care organizations.

Trailblazing our way to nursing virtual care by considering it as a nursing competency that is to be assessed and reviewed regularly. Low-fidelity simulation is utilized to change nurses’ attitudes and beliefs regarding the use of video virtual care aiming to increase virtual care utilization and adoption
Presented by: Janet Chan
Institution: VHA Home Healthcare
Keywords: Virtual Nursing Care, Simulation

Improving Documentation of Best Possible Medication History (BPMH) in Home Care Settings

Jennifer D’Onofrio, RN, BScN, MSc, PMP, Tom Wang, RPh, PharmD, Digmanu Sharma, RN, BScN, Bonnie Lum, RN, BScN, MN, Daria Garnier, RN, BScN, MN, CCHN(C), Prosci, Norman Umali, RPh, BScPhm, Janet Chan, RN, HBSc, MN, CCHN(C), Prosci, Kartini Mistry, RN, BScN, MHI, CPHIMS-CA Prosci

Abstract: Transitions from hospital to home are a critical point when clients are at high risk of fragmented care, adverse drug events, and medication errors. To that end, accurate and timely completion of Best Possible Medication History (BPMH) and initiation of Medication Reconciliation is of paramount importance for client safety during care transitions.

This poster describes a quality improvement initiative in home care settings, where nurses support care transitions. With the ultimate goal of supporting client safety, the objectives of our quality improvement initiative were two-fold: 1. To promote leading practices in documentation related to medication reconciliation (MedRec) 2. To identify additional support needed by point of care nurses and Nursing Supervisors related to MedRec

Our outcome indicator was the percentage of non-clinic clients who had a BPMH completed. The BPMH completion rate has steadily increased since April 2023. As of September, this rate has increased 65% above the organizational target.

Moving forward, we will continue to raise the bar by increasing our target BPMH completion rate. In the spirit of client centered care, we will explore ways to engage clients & families to be active partners in their health care management. We are optimistic that BPMH completion rates will continue to improve.
Presented by: Jennifer D'Onofrio <jdonofrio@vha.ca>
Institution: VHA Home HealthCare, 30 Soudan Avenue, Suite 600, Toronto, Ontario M4S 1V6
Keywords: Medication Reconciliation, MedRec, Best Possible Medication History, BPMH, Home Care, Community, Nursing Documentation

Poster: The Dementia Resources for Eating, Activity, and Meaningful Inclusion (DREAM) Toolkit: Co-Designed Training and Resources to Promote Wellbeing of Persons with Dementia

The Dementia Resources for Eating, Activity, and Meaningful Inclusion (DREAM) Toolkit: Co-Designed Training and Resources to Promote Wellbeing of Persons with Dementia

Laura E. Middleton, Shannon Freeman, Chelsea Pelletier, Kelly Skinner, Kayla Regan, Rachael Donnelly, Claire Buchan, Alle Butler, Amanda Doggett, Huda Nasir, Isabella Romano, Emma Rossagnel, Cindy Wei, Heather Keller & the DREAM Team

Abstract: Promoting wellbeing of persons with dementia and their families is a priority. Engaging diverse partners to co-develop interventions promotes impactful solutions. The objective of the Dementia Resources for Eating, Activity, and Meaningful inclusion (DREAM) project was to co-develop, implement, and evaluate tools and resources to expand the number and quality of programs and services that support the wellbeing of people living with dementia and their families. We engaged a diverse steering team towards this objective, including people living with dementia, care partners, health care professionals, community service providers, and researchers from multiple disciplines. We describe the process, output, and lessons learned from the DREAM project. Our process included: 1) Engaging/maintaining the DREAM Steering Team; 2) Setting/navigating ways of engagement; 3) Selecting priority audience/content; 4) Drafting the toolkit; 5) Iterative co-development of tools/resources; 6) Usability testing; 7) Implementation and evaluation. The final DREAM toolkit includes a website with seven learning modules (on dementia, inclusion, physical activity, and healthy eating), a learning manual, six videos, nine handouts, and four wallet cards (www.dementiawellness.ca). Over 3-months, 33 service providers completed assessments at baseline, after a 2-week review period, and 2-3 months later. Results revealed that the DREAM toolkit promotes confidence of service providers to support people living with dementia and adoption of dementia-inclusive practices to support, improve, and maintain of wellbeing of people living with dementia and their care partners.
Presented by: Kayla Regan
Institution: University of Waterloo & University of Northern British Columbia
Keywords: Dementia, Inclusion, Resources, Education materials, Community Programs

Faced with HHR challenges - how to succeed: our journey

Kristen Corbiere, Alex Kuczak, Cat Bristow, Doug Rawson, Katrina Rehling

Abstract: Many within the home and community care sector face increasing service demands and transforming the delivery of services with a focus on quality outcomes. Helping Hands Orillia is focused on overcoming human resources challenges by aligning with the strategic plan.
Presented by: Kristen Corbiere
Institution: Helping Hands Orillia
Keywords: HHR, healthcare, community, technology,

Access to Care - Collaborating to Eliminate Fragmentation for Better Outcomes

Laura Salisbury, Heidi Yerxa, Saba Baig, Kimberly Martinez, Natalia Sokolova

Abstract: This collaborative initiative, driven by nine community service providers, addresses the efficiency paradox in delivering Adult Day Services (ADS). The providers leveraged the Central Registry to create a centralized waitlist, promoting transparency and equitable access. Implementation began in July 2022, with completion set for December 21, 2023. Outcomes so far include a 15% reduction in duplication, accurate client profiles, and standardized processes. Key performance Indicators, measured through a quadruple aim approach, highlight the success of the initiative. The poster showcases grassroots collaboration, problem-solving, and the use of technology enablers to enhance quality, efficiency, and client-centric care. The presentation will be valuable to home and community care delegates seeking innovative models to improve service delivery. Nine community service providers collaborated to create a bottom-up innovative model for Adult Day Services, fostering efficiency, transparency, and quality. The initiative, rooted in the quadruple aim, utilizes leading indicators to support clients' needs and outcomes while reducing costs to the system. The success of this initiative is significantly attributed to technology enablers such as Caredove and AlayaCare, which streamline collaboration and eliminate the need for complex data-sharing agreements. The poster will visually represent key aspects of the initiative using graphs and maps, providing a comprehensive overview of the collaborative model. Throughout the Pilot, we continue to explore options that provide opportunities to engage and support the clients and their families: Client-centered model advocacy: embracing a client-centered model over a system-centered one presents an opportunity for collaborating and engaging with funders, agencies and clients. This shift aims at the overall client experience and requires ongoing support from stakeholders to ensure its success. Optimizing ADS program enrollment: A significant number of candidates on the waitlist are already enrolled in an ADS program, yet their fill needs remain unmet due to program criteria limitations. This presents an opportunity to reevaluate and optimize structures to better align with the diverse needs of clients, ensuring maximum benefit from the services provided. Quadruple Aim collaboration: Committed to the quadruple aim model, the initiative offers opportunities for continued collaboration and engagement with providers. The Central Registry’s information empowers clients to make informed decisions about their best options considering wait times and program availability. This client-centric focus enhances the overall quality of care. Enhanced Transportation Options: The exploration of continued transportation options opens avenues for improving accessibility and ensuring that clients can access the most suitable programs based on their needs. This opportunity aligns intending to provide seamless and tailored support to clients throughout their care journey. Support for HCCSS: Continued collaboration and support from Home and Community Care Support Services (HCCSS) represents an ongoing opportunity to strengthen the initiative. Collaboration efforts with HCCSS can contribute to the sustainability and expansion of the client-centered model. Evolution of data reporting: The ongoing evolution of data and reporting, supported by technology, provides an opportunity for continuous improvement. This includes refining key performance indicators, analyzing trends and adapting strategies based on real-time insights to enhance the effectiveness of the initiative. Digital Strategy Enhancement: The current use of eReferral (Caredove) highlights the digital aspect of the initiative. There’s an opportunity for further development, including the evolution towards a shared health record for clients. This digital strategy aims to streamline information sharing among providers, fostering a more integrated and efficient care ecosystem.
Presented by: Saba Baig
Institution: Nucleus Independent Living - Central Registry
Keywords: Adult Day Programs, Access, Collaboration, Efficiency, Quadruple Aim,

The Implementation of Person-Centred Plans in the Community-Care Sector: A Qualitative Study of Organizations in Southwestern Ontario

Samina Idrees; Gillian Young; Brian Dunne; Donnie Antony; Leslie Meredith; & Maria Mathews

Abstract: Background: Person-centred planning refers to a model of care in which programs and services are developed in collaboration with persons receiving care and tailored to their unique needs and goals. This study describes how person-centred care plans (PCPs) are implemented in community-care organizations.

Methods: We conducted semi-structured interviews with administrators from community-care organizations in Southwestern Ontario, Canada. We asked participants about their organization’s approach to developing and updating PCPs, including relevant supports and barriers. We analyzed the data thematically.

Results: We interviewed administrators from 12 community-care organizations. We identified three overarching themes related to the PCP process: (1) organizational context, (2) organizational culture, and (3) the design and delivery of PCPs. Organizational context described the characteristics of the population served and services available. Organizational culture described the organization’s values in their approach to PCP development. Participants described the PCP design and delivery process as being iterative, involving initial and continued consultations, while citing implementation challenges, including in cases where communicating was difficult, or when individuals preferred not to have a formal plan in place.

Conclusions: The PCP process is largely informed by organizational context and culture. There are ongoing challenges in PCP implementation, and a need for increased adaptability and clarity in current regulations to optimize care delivery in the sector.
Presented by: Samina Idrees <sidrees2@uwo.ca>
Institution: Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
Keywords: person-centred planning, community-based care, integrated care, social services, health services, disability, organizational culture, qualitative study.

Optimizing weekend schedules in home health care: The Essential Care on Weekends for Personal Support Quality Improvement Project

Sandra McKay PhD, MBA, Margery Konan, MPA, Sandra Tedesco, RN CCHN(C), Tracey Turriff, BA(Hons), Mel Michener, MHE, & Emily C King, PhD

Abstract: The availability of personal support workers (PSWs) is a limiting factor for home care system capacity, as this workforce provides 70% to 80% paid care in this sector. Without sufficient support to live at home, many seniors and people with disabilities experience poorer outcomes and require care in more expensive and less preferred institutional long-term care or hospital settings. Insufficient PSW availability is limiting access to necessary care in the community. Capacity challenges are particularly pronounced on weekends. The Essential Care on Weekends (ECoW) program was co-developed as one solution to adapt current PSW scheduling practices to increase the number of clients with high-intensity care needs who can be served within the constraints of PSW availability. ECoW focused on increasing weekend capacity and care consistency, particularly for clients with the highest care needs, through prioritizing essential care and moving less time sensitive tasks to weekdays. ECoW was operationalized through 4 activities: communication and engagement, clinical care plan review, geographic review of PSW schedules and the creation of the ECoW schedule. Implementation of ECoW demonstrated success in increasing access to and consistency of care for clients with the highest care needs: weekend capacity increased, access to care improved for clients requiring daily or near-daily care and missed care rates decreased both on weekends and weekdays. This strategy represents a change in scheduling practices that organizations can use to provide consistent service to a growing number of clients with high-intensity care needs in the context of increasingly limited health human resource capacity.
Presented by: Sandra M McKay <Smckay@vha.ca>
Institution: VHA Home HealthCare, University of Toronto, Toronto Metropolitan University, Michael Garron Hospital
Keywords: schedule optimization, personal support workers, care coordination, homecare, workforce capacity, capacity planning

Poster: “You Have to Be Careful About Every Detail” How the COVID-19 Pandemic Shaped the Experiences of Canadian Personal Support Workers Working in Home Care

“You Have to Be Careful About Every Detail” How the COVID-19 Pandemic Shaped the Experiences of Canadian Personal Support Workers Working in Home Care

Sonia Nizzer, MSW, Arlinda Ruco, PhD, Nicole A. Moreira, MSW, D. Linn Holness, MD, FRCPC, Kathryn A. Nichol, PhD, Emily C. King, PhD, & Sandra M. McKay, PhD, MBA

Abstract: Objectives: Personal support workers (PSWs) are an essential but vulnerable workforce supporting the home care sector in Canada. Given the impact COVID-19 has had on healthcare workers globally, understanding how PSWs have been impacted is vital. Methods: We conducted a qualitative descriptive study to understand the working experiences of PSWs over the COVID-19 pandemic. Nineteen semi-structured interviews were conducted, and analysis was guided by the collaborative DEPICT framework. Results: Personal support workers are motivated by an intrinsic duty to work and their longstanding client relationships despite feeling vulnerable to transmission and infection. They experienced co-occurring occupational stressors and worsening work conditions, which impacted their overall well-being. Conclusions: Pandemic conditions have contributed to increased occupational stress among PSWs. Employers must implement proactive strategies that promote and protect the well-being of their workforce while advocating for sector improvements.
Presented by: Sonia Nizzer <snizzer@vha.ca>
Institution: VHA Home HealthCare, St. Francis Xavier University, Women’s College Hospital, University of Toronto, Centre for Research Expertise in Occupational Disease, St. Michael's Hospital Unity Health, Toronto Metropolitan University, Michael Garron Hospital
Keywords: COVID-19, personal support workers, home care, occupational stress, work conditions

Home & Community Support Innovation Centre

Jessica Lepine, Nicholas Labine, Meagan O'Gorman, Jon Newfeld, Caitlin Buck

Abstract: The Home & Community Support Innovation Centre, established through a unique collaboration between the North East Regional Home and Community Care Network and Ontario Health North, aims to revolutionize home and community care in the North East. By prioritizing enhanced client experiences, streamlined processes, and embracing digital tools, the Innovation Centre has achieved significant milestones like creating standard operating guidelines for service pathways and establishing the Northeast Community Support Services Network. Through technological advancements and collaborative approaches, the Innovation Centre addresses the diverse needs and challenges of the North East. With its innovative strategies and impactful outcomes, it serves as a model for replication across the province, demonstrating the potential to reshape the wider home and community care landscape.
Presented by: Nicholas Labine <nlabine@innovation-centre.ca>
Institution: Home & Community Support Innovation Centre
Keywords: Collaboration, Digital Tools, Standard Work

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Wrap Around Coordinated Care

Stephanie Gordon, RSW, WoodGreen Community Services; Rochelle McAlister, RSW, WoodGreen Community Services; Robin Griller, MA, St. Michaels Homes; Jeannette Kruger, BSc, Cota Inspires

Abstract: East Toronto Health Partners (ETHP)’s Comprehensive Care and Integration Specialist Team (CCIST) brings together staff from WoodGreen Community Services, Cota, and St. Michael’s Homes to support patients/clients who are 18+ with complex health conditions. Staff identify members of the client’s existing care team in the community, and then fill in gaps by connecting/reconnecting with support, providing up to 3 months of short-term intensive case management.

Case management can include: attachment to primary care, supportive counselling, system navigation, transitional support to/from hospital/home/Long Term Care, psychoeducation, harm reduction, advocacy related to housing, legal and immigration issues and connection to income tax/financial supports to increase income and access funding to cover the cost of equipment/services.

Case management support is initiated through the use of our Coordinated Care Planning process. Clients and caregivers are at the center of developing their Coordinated Care Plan (CCP), which is agreed upon by all of those offering formal/informal support to the client.
Presented by: Stephanie Gordon <sgordon@woodgreen.org>
Institution: WoodGreen Community Service, Cota & St. Michael's Homes
Keywords: Coordinated Care, Discharge Planning, Primary Care, Intensive case management

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A different model of service delivery: WoodGreen's Walk-In Counselling

Cindy Nash, Ira Gundasaputra, Ayesha Bhaidani

Abstract: The Walk-In Counselling Program (WIC) at WoodGreen Community Services offers barrier-free, single session counselling services to individuals, couples and families, with no need for a referral or appointment. We offer a hybrid model, providing in-person sessions on Tuesdays and virtual services on Wednesdays, and address a diversity of presenting concerns such as anxiety, depression, relationship and communication issues, and life stressors. The WIC at WoodGreen is an innovative model of care for several reasons, including: prioritizing ease of access to clients with different barriers; low cost operations, with a counselling team made up of solely volunteers mental health professionals and graduate-level students; addressing gaps in services, such as providing support to ease waiting lists in the community and conducting immediate crisis intervention; and, offering a teaching environment for new and/or internationally trained counsellors, as well as, graduate-level students. Regular data is collected at the WIC to identify patterns and trends, such as number of sessions provided, as well as, new or returning clients. Additionally, feedback is obtained from consenting clients to share their ideas about their experiences. All data collected assist the staff in program improvement and client-centered initiatives. Based on the data collected, there has been an increase in the representation of new clients, and volunteer counsellors from the community. There have also been high reports of satisfaction and positive experiences shared by clients, including the helpfulness and support they received from the counsellors. Moving forward, with community partnerships, the WIC hopes to increase service provision, and the number of volunteers within the agency and with outside agencies throughout the GTA to improve access to services to our community.
Presented by: Cindy Nash
Institution: WoodGreen Community Services
Keywords: walk in counselling, single session counselling, volunteer services, hybrid counselling model, teaching models

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Pushing the Boundaries at Peel Region: The Seniors Health and Wellness Village (SHWV) at Peel Manor

Whitney Harrison, Manager Community Support Services and Elisabeth Catalano-Bon, Specialist, Registered Social Worker

Abstract: The Seniors Health and Wellness Village (SHWV) at Peel Manor will include long-term care with 59 “Butterfly” dementia care beds, expanded Adult Day Services (ADS) serving up to 90 clients per day, 8 short stay overnight respite beds, a seniors-focused integrated care clinic (ICC), accessible dental operatories, community bathing, and a café operated as a social enterprise. Services will fundamentally be re-structured to enable wraparound care with intentional support for ADS clients and their caregivers. By increasing ADS capacity, the SHWV at Peel Manor will also address waitlist pressures in Brampton and surrounding community with 8 much needed overnight respite beds. Clients will also have access to primary care at the ICC while at ADS. Foundational principals include leveraging partnerships and streamlining communications to improve interdepartmental and external collaborations, along with weekly interdisciplinary team (IDT) care rounds to proactively address complex social and care related situations.

IDT Care Rounds applied a proactive lens with prioritization on the care and well-being of the client and their caregiver(s), better known as the caregiving-dyad. An iterative approach was taken to monitor, measure and inform customized decision-making to better inform interventions and program services that would enhance quality of life and improved service experiences for clients, caregivers and staff. The enhanced services and collaborative IDT efforts delivered through ADS, have begun to demonstrate reduced transfers to LTC, mitigation of client-caregiver risk situations, reduced caregiver strain and improvement for caregiver well-being. In addition, direct access to sub-specialty care through Neurobehavioural services, provided comprehensive assessments to target the underlying complexity associated with dementia and brittle neuropsychiatric symptoms of dementia allowing clients to continue to age at home.

Streamlined communications and tools have also contributed to role clarity, timely referrals by the right provider, and shared problem-solving. The measurement methods utilized to inform our services and improve practices are as follows: ADS caregiver and client experience surveys and focus groups, client CPS scores, Modified Caregiver Strain Index (MCSI) scores, service provider experience surveys and focus groups, and IDT roster client SBAR monitoring (situation-background-assessment-recommendation) to evaluate the reduction of situations presented weekly.

Increasing capacity of the ADS program to 90 clients per day with access to the community service hub elements and integrated allied health and primary care supports, will continue to meet the growing needs of the aging population, and reduce waitlist times for service initiation.

The initiative promotes collaboration amongst service providers to better serve mutual clients. Interdisciplinary team communication and wraparound supports for clients and caregivers is an upstream approach to senior’s care which reduces crisis LTC admissions, ALC bed use and enables at-risk seniors with dementia in the community to age-in-place for as long as possible.

The main floor of the SHWV at Peel Manor is intended to function as service hub aimed at meeting the needs of seniors in the community. The service hub staff will operate an integrated care model based on the evidence-informed best practices of the proven Program of All-Inclusive Care for the Elderly (PACE) out of the United States. The integrated care model is client-centred and includes strong, ongoing communication and collaboration between service providers, caregivers, and clients.

Learn about our unique redevelopment project that is enhancing services and increasing system capacity by reimagining the delivery of integrated, person-centred care through a service hub that includes adult day services, short-stay respite, clinical care supports, long term care and more.
Presented by: Elisabeth Catalano-Bon & Whitney Harrison <elisabeth.catalano-bon@peelregion.ca>
Institution: Regional Municipality of Peel
Keywords: Integrated Care, Adult Day Services, Interdisciplinary Care Rounds, Aging at Home, Client-Caregiver

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Poster: Operationalizing a holistic health definition as a framework to guide dialogue-based assessment at the point-of-care: a modified eDelphi study

Operationalizing a holistic health definition as a framework to guide dialogue-based assessment at the point-of-care: a modified eDelphi study

Leke Fowokan PhD, Justine Giosa PhD, Margaret Saari RN, PhD, Paul Holyoke PhD

Abstract: Background: Holistic assessment of client needs is an important component of person-centred care planning in home and community care. The comprehensive nature of mandated standardized assessment tools can make conducting and experiencing assessment, as a person-centred and conversational process, challenging for both the assessor and the client. Researchers in the Netherlands have proposed My Positive Health (MPH) as a broader definition of health to support more realistic and meaningful care planning for people living with chronic disease and other life-long health conditions.

Methods: We sought to map assessment items from the interRAI Home Care (HC), an internationally validated, comprehensive assessment, onto the six domains of MPH. Engaging a purposively sampled expert panel (n=39) of health care providers, researchers and older adults and caregivers, we conducted a two-stage modified eDelphi process, with each stage consisting of three survey rounds. In the first stage, the expert panel mapped 201 elements from the interRAI HC to the six MPH domains: 1) Bodily Functions; 2) Daily Functioning; 3) Mental Wellbeing; 4) Quality of Life; 5) Participation; and 6) Meaningfulness. The second stage focused on identifying opportunities to adapt or expand comprehensive assessment as it relates to the MPH domains and a broader definition of health.

Findings: The expert panel reached agreement on mapping 94% (189/201) of the interRAI HC assessment elements to the six domains of My Positive Health. This confirms the potential to use this framework to guide comprehensive and person-centred assessment conversations around a broader definition of health, building on existing international best practices in standardized assessment of home care client needs. Findings indicated that interRAI HC assessment elements are predominantly oriented toward the physical, functional, and mental health MPH domains. Complementary assessment elements and/or tools may be needed to support comprehensive assessment of ‘meaningfulness’ and ‘participation’ domains in home and community care.

Next steps: In next steps for this work, home and community care providers will be engaged in applying study findings to co-design tools and resources to guide person-centred comprehensive assessment conversations, leveraging MPH domains and additional descriptors to structure dialogue around interRAI HC assessment elements and other potential complementary assessment elements and/or tools.
Presented by: Margaret Saari <margaretsaari@sehc.com>
Institution: SE Health
Keywords: Comprehensive assessment, Health definition, Holistic health, interRAI, Person-centred, Home care, eDelphi,

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Poster: Co-designing action-oriented mental health conversations: adapting and validating the mental health continuum model for aging Canadians

Co-designing action-oriented mental health conversations: adapting and validating the mental health continuum model for aging Canadians

Justine Giosa1,2, Elizabeth Kalles1,2, Paul Holyoke2, Carrie McAiney2,3, Nelly D. Oelke4, Katie Aubrecht5, Olinda Habib Perez1

Abstract: Older Canadians face the dual stigma of systemic ageism and negative attitudes about mental health, which makes talking about mental health difficult, particularly during care interactions that emphasize physical needs. As concern for older adult mental health continues to rise following the COVID-19 pandemic, access to needed support, care and treatment is imperative. The current research study addresses two research priorities identified by aging Canadians at the onset of the pandemic: building skills for healthcare providers who are not mental health specialists (e.g., personal support workers in home care); and identifying user-friendly tools to help identify signs of positive or poor mental health in themselves or others.

Using a participatory mixed-methods design, guided by a working group of experts-by-experience (n=31), this multi-year project aims to co-design and test an evidence-based approach to starting and carrying out mental health conversations between older adults, caregivers, and community health/social care providers. To address the aim of this project, Phase 1 involved a modified ADAPTE process including online workshops and surveys with older adults, caregivers, and health/social care providers across Canada. The online workshops explored context-specific adaptations to the mental health continuum (MHC) model to guide conversations in home and community care and the online survey assessed the acceptability of the adapted MHC model. Phase 2 involves co-designing action-oriented mental health conversations with home and community health/social care providers in rural and urban communities (n=6) within three provinces (ON, BC & NS). Phase 3 involves pilot and feasibility testing of these conversations.

This poster will focus on Phase 1 findings. Four online workshops were held with older adults, caregivers, and care providers across Canada (n=59). Workshop participants endorsed the use of a visual model that depicts mental health as a complex, multi-component construct ranging in state on a spectrum to begin de-stigmatizing mental health between older adults, caregivers, and health/social care providers. Participants recommended the following adaptations to the MHC model: improving the use of natural and action-oriented language across the model; more inclusive use of colours; capturing the element of change-over-time; removing clinical jargon and diagnostic/stigmatizing labels; renaming model categories and revising/adding signs and signals to be more aging context-relevant. Respondents of the online survey (n=1068) assessed the acceptability of each adaptation of the adapted MHC model, the MHC for Aging Canadians. Each adaptation received more than 76% endorsement (> 3 on a 5-point Likert scale) from survey respondents.

Destigmatizing mental health conversations in home and community care is an important step to improve integration between physical and mental health needs as the health system works to address the negative impacts of the pandemic. The co-designed changes and survey results in Phase 1 suggest that the MHC for Aging Canadians will be useful for starting conversations about mental health with older adults and non-mental health specialist care providers. Home and community health and social care providers have a unique opportunity and window into personal, individual and unique aspects of someone’s life circumstances (e.g., home environment, relationships, family, social networks, and culture). This is particularly important when most older adults live at home and many require care and support to continue to safely do so. There are missed opportunities in home care where care providers witness signs and signals of mental health concerns/challenges, but there may be hesitation to talk about these concerns/challenges due to a lack of individual confidence/skill, and/or system-level challenges like an overemphasis on physical health concerns and over-reliance on family caregivers.
Presented by: Olinda Habib Perez <olinda.habibperez@uwaterloo.ca>
Institution: 1-School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada 2-SE Research Centre, SE Health, Markham, Ontario, Canada 3-Schlegel-UW Research Institute for Aging (RIA), Waterloo, Ontario, Canada 4-School of Nursing, University of British Columbia, Okanagan and Rural Coordination Centre of British Columbia, Kelowna, British Columbia, Canada 5-Department of Sociology, St. Francis Xavier University, Antigonish, Nova Scotia, Canada
Keywords: aging, mental health, care providers, mixed-methods

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Poster: Improving patient-reported experience measures (PREMs): Insights from cognitive testing of an integrated home and community care PREM in Ontario

Improving patient-reported experience measures (PREMs): Insights from cognitive testing of an integrated home and community care PREM in Ontario

Celina Carter, RN, PhD; Justine Giosa, PhD; Valentina Cardozo, MSc; & Paul Holyoke, PhD.

Abstract: With authentic participation of experts-by-experience we are developing a new Patient-Reported Experience Measure (PREM) for integrated home and community care that incorporates equity, life care, relational caring and continuity. Client and caregiver input led to improved relevance, representativeness, comprehension and meaningfulness of survey domains, questions, and instructions. It is anticipated that this study will result in a measure that is reliable and valid for use with home care clients in Ontario. Applying this new PREM in practice will support a more accurate evaluation of home care experience that can be used to improve quality and inform optimization of innovative home and community care models. Visit our poster to learn more about opportunities for this PREM in Ontario.
Presented by: Valentina Cardozo <valentinacardozo@sehc.com>
Institution: SE Research Centre
Keywords: PREM, patient reported experience measures, patient experience, integrated home and community care

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