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The HNHB CCAC provides services across a 7,000 km area, encompassing Brant, Burlington, Haldimand, Hamilton, Niagara and most of Norfolk. With approximately 1.4 million people, it is the second-largest LHIN in Ontario in terms of population size. Approximately 32,000 clients are receiving services at any given time through the HNHB CCAC. The CCAC services people of all ages: approximately 10-20% of our clients are under 18 years of age and 50-60% are seniors.
Community Care Access Centre's (CCACs) were created to offer a simplified point of access to Ontario ’s long-term health care system.
Specifically, CCACs have the following major roles:
- Authorize and arrange for health and personal support services in people’s homes;
- Authorize and arrange in-school services for children with special needs;
- Contract with local service providers through an Request for Proposal process to provide these health services.
- Support clients in the application and admission process to
- Provide health-related information and referral services to the public, community agencies and service providers;
The CCAC provides information and referral to the community, manages placement into long-term care homes and adult day programs, and facilitates referrals to CCAC-funded services and other community supports.
The Family Health Team Case Management Model
The primary objective of the model is to establish and maintain a CCAC primary case management partnership with Family Health Teams (FHTs) which would support and enhance the continuity and comprehensiveness of service to a common group of (patients) clients.
The model includes the following components:
- Attachment of a Primary Case Manager (CM) that is a; regulated health care professional (RN, OT, PT, SW) to each FHT physician
- Increased communication and rapid response to changing client needs
- System navigation in community health and social services
- Following physician’s clients in the community while on CCAC service
- Identified FHT clients on admission to CCAC services
- Remote computerized access to client database and forms
- Individual meetings with the Family Health Teams
- Client awareness of the partnership between the FHT and the Case Manager
At present about 3,000 clients across the HNHB are attached to FHT’s. Currently the CCAC has developed attachments with FHTs in the Brant, and Niagara regions and are in the planning phase for Burlington. With over 35 Community Case Managers attached to FHTs the HNHB CCAC is able to provide client centered care, supporting primary care with an emphasis on collaboration and team practice.
Outcomes
The CCAC and FHTs have both seen significant positive outcomes as a result of the partnership. These include:
- Successful and sustained collaborative partnerships between CCAC case managers and FHT physicians and other professionals
- Improved and positive patient health outcomes (e.g., health and wellness, self-care management)
- Increased patient satisfaction
- More efficient use of physician time (e.g., working with one primary case manager)
- More efficient use of CCAC Case Manager time (e.g., working with fewer physicians)
- More appropriate, effective and efficient use of health care resources
- Enhanced case management of patients / CCAC clients
- Better management of CCAC-funded services
- Enhanced information management through better verbal, written and electronic communication
Qualitative data from the FHT physicians and Case Managers support the fundamental principles of the model and the expanding future prospects for linkages between the HNHB CCAC and primary care.
The CCAC is in the process of establishing partnerships with all of the Family Health Teams in the Hamilton Niagara Haldimand Brant LHIN area. We are also establishing partnerships with other primary care settings such as Community Health Centres.
The role of the Primary Case Manager in primary care is changing as the partnerships evolve. There is less emphasis on service monitoring and greater focus on the Case Manager as a system navigator. This has resulted in:
- Increased collaboration in Chronic Disease Management programs
- Development of programs to support the frail elderly
- Development of strategies to reduce acute care utilization
Conclusion
The HNHB CCAC Family Health Team Case Management model has delivered consistency in client care, and high quality service with seamless transitions to the clients we serve. Case Managers (as pillars of the model) have demonstrated the value of providing assessment, planning, intervention and evaluation of community health services in the primary care setting.
As leaders in community health, the HNHB CCAC continues to embrace opportunities and partnerships as it works towards our vision to be recognized across the country as a Centre of Excellence for integrated community services and health information by 2017.
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