Integration of health and social services can bring significant benefits when it comes to the health outcomes of older adults.  Extant literature suggests key factors can support integration efforts among collaborating health and social services organizations including leadership, culture, shared vision and goals, information sharing and communication, team-based care and performance measurement and accountability systems.  An exploration of successful Canadian-based integrated health and social care initiatives that support vulnerable seniors across Canada has been undertaken to determine the factors that support the success of their integration.  This exploration also examines the role that contextual factors such as healthcare governance models, funding models and public policies have on influencing the integrated initiatives.  Three integrated initiatives will be featured in this symposium. 

The Home-At-Last program is a coordinated, micro-level integrated health and social services initiative that seeks to transition seniors from the hospital setting into the home-setting in Ontario.  Healthy at Home is a multi-organizational integrated collaborative comprised of health and social services organizations that seek to address the well-being of vulnerable and high-risk seniors living in the community in Toronto through health promotion, and social support services.  The Geriatric Assessment Program Collaboratory comprises patient assessments, referrals to health and social care services, caregiver education, and health and social services provision that is comprised of health and social services partners in Camrose, Alberta.

Presenters will provide an overview of these initiatives and offer perspectives on how collaborations across a diverse set of health and social care organizations can be made possible, and the challenges and factors that support such partnerships within the context of the provincial healthcare systems.

Integrating services between health and social service organizations can be challenging, but can yield significant health and social care and services delivery outcomes.  Integration of such services can support a whole-person and client-centered approach to services delivery, which is critical when servicing older adults who are vulnerable and who present significant health and social care complexity.  A conceptual model has been developed that identifies critical enabling factors that can support the integration of health and social services among collaborating organizations from different sectors.  These factors include leadership, culture, shared vision and goals, information sharing and communication, team-based care and performance measurement and accountability systems.  This model has been tested against several Canadian-based integrated health and social care initiatives that serve seniors to determine its applicability.  The testing of this model also shows the existence of several contextual factors that are associated with Canada’s healthcare landscape.  These include the Canadian healthcare governance systems, differences between healthcare and social services funding models, patient/client characteristics and urban/rurality.  The integration of services among healthcare and social services organizations for high-risk seniors reveals the critical role that shared vision, strong communication and shared culture play in supporting the integration of services delivery among multiple organizational partners.

 

Home-At-Last” (HAL) is an integrated, community-based initiative, situated in Ontario, Canada.  HAL is a coordinated, micro-level integrated health and social services initiative that is led by CHATS-Community & Home Assistance to Seniors, a not-for-profit community and social support agency.  CHATS’ HAL program works with regional health and other social care partners to improve seamless services delivery, thereby reducing hospital readmissions in order to improve continuity of care for seniors.  It provides home and personal support services that includes providing transitional support for patients from the point of hospital discharge.  HAL has four hospital partners that provide acute care and discharge planning for patients into the community.  HAL directly provides home-support within the critical first 48 hours after discharge: social care coordination (i.e. advocacy, referrals), transportation, medication and medical equipment pickup, shopping, and other activities to support daily living.  HAL helped to reduce hospital readmissions, reduced hospital lengths of stay, and patients have experienced greater satisfaction and empowerment.  HAL’s success has depended on a strong patient-centered vision with its collaborating healthcare partners.

 

Camrose is a small rural Alberta community where approximately 25 per cent of the population is 65 and over.  The aging population has been a driver towards integrated health and social care by the Primary Care Network (PCN) and its various health and social care partners.  A geriatric assessment program (GAP) was created, in partnership with Alberta Health Services’ Mental Health Outreach Team for Seniors.  It provides in-home assessments and other supports and referrals.  GAP launched an active engagement with healthcare and social care organizational partners to seek greater services collaboration in order to provide a more holistic approach to vulnerable seniors.  As a result, an informal collaboratory has been established that comprises a mix of healthcare and social care organizational partners.  The collaboratory comprises patient assessments, referrals to health and social care services, caregiver education, and health and social services provision.  The partners include primary care, homecare, homemaking and Meals on Wheels, financial support services, and the Alzheimer’s Society.  The collaboration has resulted in positive patient/client outcomes.  There are high levels of patient satisfaction, patients are able to stay in the community / home-setting longer, there is reduced acute care utilization, greater caregiver relief and support, and enhanced services coordination among the organizational partners.  Several factors have contributed to its integration success including strong communication, shared vision and common goals and dedicated resources.

 

Healthy at Home is a collaborative project that is supported by social services and healthcare organizations with the aim of serving vulnerable and high-risk seniors living in the community and home-setting in the Toronto region.  This multi-partner project was driven by the desire to address service gaps in the community for the target client population.  This integrated network of multiple provider partners include The Bernard Betel Centre (lead partner), Toronto Community Housing; Jewish Russian Community Centre; Circle of Care; Baycrest Centre, regional health authorities and other community support agencies.  The initiative targets marginalized and vulnerable seniors living in Toronto Community Housing apartment buildings in the North York Area, immigrant newcomer sponsored seniors, and specific emphasis has been placed on outreach to both Russian-speaking seniors and Holocaust survivors.  The program seeks to provide care navigation assistance with accessing benefits, nutrition and exercise (including falls prevention), and social connection.  The program has demonstrated positive outcomes for its clients including reduced social isolation for clients, greater self-care, enhanced healthy behaviours (more exercise, healthier eating), greater community engagement, and high client satisfaction.