About the Bigger Picture

4CSS - Managing the Hospital to Home Transition Programs

The Prince Edward County Community Care for Seniors Association, through it's 4CSS operation, manages several regional programs for the South East LHIN that are specifically designed to facilitate either discharge or diversion from hospitals. Referred to internally as the Hospital to Home referral streams the 4CSS role in these regional programs is to promote and enable the early involvement of, and provision of, services by Community Support Services (CSS) agencies to elderly or frail clients in need of practical assistance to continue living at home. To accomplish this 4CSS accepts, makes initial contact with, and then forwards all referrals made by hospital staff for hospital-based clients (patients in the Emergency Dept or in-patients) to the CSS Home Support agency in the geographical vicinity of their home. The Hospital to Home Transition Programs for which 4CSS manages the referral process, all initiatives under the SE LHIN's Emergency Department / Alternate Level of Care (ER/ALC) Strategy, are easier+, Home At Last, home first.

The ultimate value in supporting referrals from hospital sources is to secure the involvement of CSS agencies and services in the planning for, and support of, frail seniors living in their home environments, as soon as possible to promote hospital and Long Term Care Home avoidance. 

More than 1200 individual seniors and, in many cases, their spouses or other family caregivers across the SE LHIN received an offer of linkage to CSS Home Support agencies through these three referral streams in fiscal 2009-2010. Of those, almost 400 chose to be referred on to CSS Home Support agencies. Many of these individuals would not have been referred, or found their way to these agencies and the supports, without the automatic referral protocols embedded in the Hospital to Home Transition programs. 

Summary:

The Hospital to Home Transition Programs managed by Prince Edward Community Care, funded by the SE LHIN and implemented in partnership with the SE CCAC and the hospitals of the South East, have pushed the envelope on partnership and collaboration, with great results.

Together we have accomplished visible movement towards a system that region-wide recognizes that barriers to living at home can be greatly reduced, or eliminated altogether, when Community Support Service agencies are at both the planning table and the kitchen table. Through these programs we are creating a working system that ensures help with the practical daily tasks of day-to-day life at home is available and delivered at the right time to those who are vulnerable to losing their life-long option of living at home, in the comfort of "my" home.

The regional programs highlight the suitability of CSS agencies as partners in solutions to shortening or eliminating hospital stays; they also demonstrate the somber fact that healthcare without practical care is a hospital affair. .

Great strides in programming have enabled great progress in service.

Executive Director's Comments

Going home is what our clients want most. The board of directors and staff of The Prince Edward County Community Care for Seniors Association are pleased to be involved in managing regional services that help seniors throughout South East Ontario successfully make the transition from hospital to home. The easier+, Home At Last and home first initiatives are a fantastic way for hospitals, the South East Community Care Access Centre, and Community Support Services (CSS) agencies to work together in the best interest of the people we support.

The Community Support Services agencies located across South East Ontario work in partnership with family and friends of clients to provide the much-needed practical help with meals and home upkeep that enables seniors to stay living at home longer.

Debbie MacDonald Moynes, Executive Director of The Prince Edward County Community Care for Seniors Association, the regional management agency for the CSS sector involved in transition from hospital to home programs.