Our Priority Projects

To help us get started on the work of building our Ontario Health Team, we are focusing on four priority projects that will help us start to make a difference in building more connected health care for our Frontenac, Lennox and Addington (FLA) community. Working groups for each project are made up of representatives from across our region who bring their professional expertise and lived experiences to help inform our work going forward.

Aging Well at Home Project

A couple at home

Aging in place strategies

 

Coordinated home care teams

 

Support for self management

 

Identification of “at risk” for hospitalization /LTC decreased ALC

One of the goals of our FLA OHT is to help keep our community healthy and in their homes for as long as is safely possible. Our Aging Well at Home working group is creating strategies that will help to support our older adult population based on their frailty or specific need. The supports and services will be accessible to both patients, families and providers, have the capacity to service patients, and will be embedded within the People-Centred Health Home.

Some of these strategies are planned to include:

  • Aging @ Home Advocate: This advocate will support the knowledge sharing of community resources within the Health Home and with patients, families and caregivers

  • Home Care Coordinator: A Home Care Coordinator will be embedded within the Health Home to support the planning and facilitation of home care community supports and other supports available through community services for those individuals who have moderate support needs. This coordinator will work closely with the aging at home advocate to help share knowledge and awareness on services beyond home care services

  • Aging @ Home rounds: Monthly Aging @ Home rounds will be implemented for our population that requires the maximum support, who are those with the highest risk of long term care needs and those who most experience gaps in service. These rounds will involve conversations with the patient, family and caregivers to talk through what their care is looking like and what additional supports they might need. Out of these conversations a patient, depending on their need, may be linked with the Health and Social Care organizer, a person who works with those as being identified as most at need and connects them with services and programs beyond community care.

  • Central Repository: We are working with our community partners to have one central repository of these up-to-date services and supports that will be accessible to the patient, family, caregiver and provider. We have seven community partners who each have their own repository and we are doing an inventory off all of these to house under one common interface.