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easier+ is an innovative, multi-component strategy to improve health care outcomes of high-risk frail elderly in the emergency room (ER/ED). It represents a collaborative partnership between acute care hospitals, specialist services for the elderly and community based Community Care Access Centre (CCAC) and Community Support Services (CSS) programs). Building on an evidence-based strategy it targets high-risk elderly and creates improved integrated care responses through linkages and liaisons between the ED (Kingston General Hospital and Quinte Health Care – Belleville), and care in the community (Community Care Access Centre and Community Support Services. Under the Provincial Emergency Department/Alternate Level of Care (ER/ALC) Strategy, EASIER+ is classified as a ‘Direct Impact’ program. EASIER+ may be rolled out across other hospital sites and communities within the South East Local Health Integration Network (SE LHIN) during the 2009/10 and/or 2010/11 period.
The primary goal of easier+ is the identification of at-risk seniors and the provision of short-term enhanced support in their homes to improve their acute need health care outcomes, allow an immediate return to community (and avoidance of hospitalization) and reduce the possibility of re-presentation at Emergency Departments.
Key components of this initiative are:
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1. A Triage Risk Screening Tool (TRST) is applied to elderly patients aged 75+ as part of the triage process in the ED.
2. Patients who have a positive TRST score and are designated ‘at-risk’ are referred to CCAC Case Managers working in the hospital.
3. All patients with a positive TRST score and who require a lower level of care, and are discharged home, receive a referral to CSS providers via a central CSS contact.
1.3.1 The Community Support Services (CSS) component of the easier+ Initiative stresses the CSS Sector’s integral role in supporting seniors and in particular, “at risk seniors” with Instrumental Activities of Daily Living necessary for the maintenance of health; prevention or delay in individual or caregiver decline or burnout; and the pro-active identification of a health crisis or decline in the individual.
1.3.2 The CSS consultant telephones the client and asks them if they wish to have CSS services, noting that financial barriers to access CSS are eliminated for 30 days with client fees waived and paid by the easier+ project.
1.3.3 With acceptance of CSS services, a referral is made to the local CSS agency for follow up; upon referral to the local CSS agency this client will be given priority so as to reduce the possibility of re-presentation at the ED.
1.3.4 If the client declines services, they are given the telephone number should they change their mind or find that their situation changes.
1.3.5 For those clients receiving services and approaching the end of the 30 day service period, the CSS agency staff will discuss their options for continuing and in some cases will make a referral to the SMILE program. An agreement with the SMILE program will see these clients receive enhanced priority for admission to service. |
** The regional management agency for the CSS part of easier+ in Southeast Ontario is The Prince Edward County Community Care for Seniors Association.
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