The Home and Community Care work stream is working towards providing equitable, accessible care to all residents within the region of Connected Care Halton by leveraging the best practices, lessons learned, and strides made in the delivery of virtual care.
Activities Completed to Date
SCOPE
- SCOPE is a platform for integrated care that promotes collaborative work between primary care physicians, hospital services, and community health partners.
Primary care providers registered with SCOPE are able to connect to an internist, outpatient services, diagnostic imaging, and other services through a single point of access.
RCM
- The goal of the Remote Care Management program is to ensure vulnerable populations receive appropriate clinical support and monitoring in the community, including escalation to medical practitioners or acute care, where necessary. Patients who live in Halton or have a primary care physician in Halton are eligible. The program will reduce unplanned visits to the ED and/or unplanned re-admissions and develop sustainable self-management techniques for the identified patient populations supported through education and resources. Health Care
Providers
Patients/Clients
Virtual Home and Community Care
- The purpose of the Virtual Home and Community Care project is to support frontline home and community care organizations in their efforts to strengthen and optimize their virtual care capacity. This project tests the use of tablet devices to allow virtual home care visits among patients who would otherwise have challenges accessing video enabled technology.
Expanding Home Care
- The Expanding Home Care program, formerly known as the High Intensity Supports at Home Program (HISHP), is a highly successful regional program supporting patients on Long Term Care wait lists to safely live at home. The program has supported patients and their families in their transition from community to Long Term Care. As wait times for Long Term Care increase, this program is essential to support patients at home and decrease hospital admissions or reduce length of stay in hospital. Collaboration and communication are at the core of the success of this program, as Home and Community Care and Support Services, Halton Healthcare, Connected Care Halton, Primary Care Physicians, and CANES Community Care work together to deliver comprehensive care to support patients in their home while they await Long Term Care placement.
Community Wellness Hub
The Community Wellness Hub (formerly known as the Program of All-inclusive Care for the Elderly) is a program that provides integrated, wraparound care and social services to support older adults living in the community to maintain their independence and age at home. This exciting initiative aims to proactively address health, wellness, social, and housing needs as one integrated team of health care professionals. This allows older adults to access the supports they require to improve their quality of life, reduce ED visits and hospital admissions, and reduce admissions to long term care.
Our collaborative partners for the Community Wellness Hub expansion at 271 Kerr Street in Oakville include:
- Acclaim Health
- ADAPT
- Alzheimer’s Society of Brant, Haldimand Norfolk, Hamilton, Halton
- HMC Connections
- Halton Paramedics
- Home and Community Care Support Services
- Links2Care
- March of Dimes
- Meals on Wheels Oakville
- Nucleus Independent Living
- OakMed Family Health Team
- OSCR Services
- Prime Care Family Health Team
- St. Elizabeth Health
- Summit Housing
- Support House
- Thrive
- Town of Oakville
- One Health
- Oak Park Neighbourhood Centre
Upcoming Initiatives
CWH New Build and Expansion
The expansion of the Community Wellness Hub initiative to a new building at 263 Kerr St brings exciting possibilities for enhancing care and support for older adults in the community. This expansion enables the program to continue providing integrated, wraparound care and social services to promote independence and aging at home. With a dedicated space, the Hub’s team of healthcare professionals can proactively address the health, wellness, social, and housing needs of older adults, building trusting relationships and intervening before crises arise. The new building serves as a central hub for this comprehensive approach, aiming to improve the quality of life for individuals, reduce emergency visits and hospital admissions, and decrease the need for long-term care placements. This expansion is a testament to the collaborative efforts of healthcare, emergency service, and social housing partners
Work Stream Co-leads
Dr. Corinne Breen
Family Medicine Physician
Dorota Azzopardi
Interim Director, Patient Services – Community (Adults) – Home and Community Care Support Services Mississauga Halton