N’Mninoeyaa Aboriginal Health Access Centre

 

Long Term Care and Aging at Home Program(s)

 

On August 28, 2007 the Ministry of Health and Long Term Care announced the Aging at Home Strategy with an aim to reinforce the ability of community support services to allow seniors to live healthy, independent lives in their own home.

This Strategy involves a significant shift in emphasis away from long-term care (LTC) home beds to providing a comprehensive mix of community-based services for seniors to live at home, created by “doing things differently”, that is, linking existing services and providers with new and different approaches to service and non-traditional providers.

On April 1, 2008 the North Shore Tribal Council, in partnership with the Indian Friendship Centre and the Métis Nation of Ontario in the city of Sault Ste. Marie launched the newly funded Aging at Home Program. The goal is to provide discharge planning, service coordination, and to facilitate client-centered care to the senior population who are being discharged from hospital.

This ambitious initiative was highlighted at the Aging at Home Innovation Showcase Conference in Toronto.

Edith Mercieca, Long Term Care / Aging at Home Program Administrator works with our Long Term Care Sub-committee, made up of one representative from each community, active participation in the program development and implementation of the plan.



Successes
In this first year of implementation the staff is to be commended on the significant achievements and accomplishments.

• 304 AAH clients have been assisted in less than a year.

• 962 served by the Physiotherapy Service; 207 served by the Occupational Therapy Service.

• Integrating within the discharge planning process of the area hospitals; Sault Area Hospital, Blind River Health Centre, St. Joseph’s Hospital in Elliot Lake, Espanola General Hospital and the four sites of the Sudbury Regional Hospital.

• A Voluntary Aboriginal Self-Identification Strategy was developed and launched.

• Collaboration and protocol development has been initiated with the Community Care Access Centre CCAC.

• Collaboration with community home care services.

• Participating in the GiiC Initiative: Geriatric, Interprofessional, Interorganizational Collaboration and the North East Specialized Geriatric Services for geriatric assessments.
• Continues to provide both physiotherapy and occupational therapy services to the five participating First Nation communities.

• The Occupational Therapy (OT) services program review was conducted over the summer months of 2008. As a result a revised job description and 3 year workplan has been developed. The workplan was formed with an annual theme to assist in the development, productivity and value of this role in NSTC communities.

o Year 1 theme: Creating an in-road to the NSTC community
o Year 2 theme: Expanding our circle through partnership
o Year 3 theme: Strengthening our circle through advocacy
• Successfully filled the vacancy in the OT position, Grace King commenced employment on November 17, 2008.


Challenges
• FNIHB, Non Insured Health Benefits limitations with lengthy and complex approval process.

• Limited resources for specialized assistive devices.

• Lengthy process with the provincial ADP process.

• Lack of housing options and financial resources for seniors in convalescent care, palliative care and housing renovations.

• Lack of qualified human resources to provide 24/7 care in the community.

• Hospitals challenged with deficit budgets, increased ALC beds leading to discharge of patients with high needs in the home.

 

Contact: Edith Mercieca -
Long Term Care/Aging at Home Program Administrator

 

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