CCACs are making progress towards achieving the quality improvement goals set out in the 2012-2013 Quality Report (PDF). Some of their results are featured below:
Opportunity #1: Working with primary care in Ontario's Health Links
CCACs across Ontario are working together with physicians, nurse practitioners, pharmacists, hospital staff, service providers and others in each Health Link to support patients with high needs with care in their homes and communities.
2012/2013 Quality Report goal: As the number of Health Links expands, CCACs' have committed to having CCAC Care Coordinators working directly with the participating primary care teams in each Health Link to support patients with high needs and provide care coordination.
Progress: CCACs are continuing their efforts to ensure that Care Coordinators are working directly with the participating primary care teams in each Health Link.
2012/2013 Quality Report goal: By June 2014, the CCAC electronic health record will have the capacity to register all patients of active Health Links, enabling more timely communication between the CCACs and primary care and early identification of patients who need a physician or primary care.
Progress: CCACs have invested in changes to their common electronic health record to enable the capacity to register all patients of active Health Links, effective June 2014. This ensures more timely communication between the CCACs and primary care and has the potential to facilitate capacity for electronic transmission of this data across the health system.
Opportunity #2: Building capacity to care for those in the greatest need
Funded through the Ministry of Health and Long-Term Care, Rapid Response Nurses, Mental Health and Addiction Nurses, and Hospice Palliative Care Nurse Practitioners are being hired by CCACs across the province to support patients to safely transition home from hospital, to support children and youth with mental health issues, and to expand support to high-needs end-of-life patients.
These nurses enhance the ability of care teams to support vulnerable patients at home, and students with more intensive mental health care in schools. This support is key for patients who might otherwise return to the emergency department, be readmitted to the hospital, or who may be unable to continue attending school. In the next year, CCACs will begin reporting on the value these nursing programs bring to people across Ontario.
2012/2013 Quality Report goal: To have all three of these nursing programs fully operational, and have the ability to describe the people being served by these programs and demonstrate the impact these programs are having by publicly reporting on:
- How many fewer patients visit an emergency department because of more specialized CCAC nursing care
- How many fewer patients are readmitted to hospital (after being discharged) because of more specialized CCAC nursing care
Progress: All CCACs have been collecting information since April 2014 to demonstrate the effectiveness of the direct care nursing programs in reducing avoidable hospital readmissions and visits to the emergency department. CCACs are also assessing the impact of Rapid Response Nurses by measuring connections to primary care within seven days of hospital discharge, and changes in the percentage of patients who take their prescribed medications as directed.
Opportunity #3: Meeting and exceeding the wait time target for patients receiving nursing care and patients with complex care needs receiving personal support
Many patients who have complex health issues are fearful that they will not be able to manage new treatments or medications after being discharged from hospital. Having home support available as soon as possible helps provide peace of mind. The 2013 Ontario Budget included a commitment to reduce home care wait times (to within five days) for nursing services and improve personal support services for clients with complex care needs following a CCAC assessment.
2012/2013 Quality Report goal: The CCACs are committed to meeting wait time targets for nursing services and personal support for complex patients and will publicly report on wait times for these patients beginning in April 2014.
Progress: Beginning April 2014, CCACs began publicly reporting their performance on their Quality Improvement Plans targets, including the five-day wait time target for nursing services and personal support for complex patients.
Quality Improvement Update (PDF)
