4CSS the regional management agency's functional centre
for operationalizing the CSS transition from hospital to home programs

The Prince Edward County Community Care for Seniors Association, through its 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 transition from 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 CSS agencies. Services are provided to elderly or frail clients in need of practical assistance to continue living at home–either in the short or longer term. To accomplish this, 4CSS functions as a bridge from hospital to community. It provides a single point of contact for all hospitals in the SE LHIN facilitating the referral of patients for assessment for supports with the practical, logistical and social needs of daily life. To this end 4CSS accepts all referrals sent by hospital staff, makes initial contact with the client to advise and educate regarding the nature of Community Support Services (CSS) provided by Community Support Services (CSS) agencies, and then forwards the referrals on to the CSS agency in the geographical vicinity of the client's home. The hospital to home transition programs regionally managed by 4CSS are initiatives of the SE LHIN's Emergency Room / Alternate Level of Care (ER/ALC) Strategy and easier+ is part of the Ministry of Health's Emergency Department Action Plan:

• easier+ (e+) – Accomplishes ER diversion of frail elderly at KGH and QHC-B only . 4CSS receives notification from ER and contacts clients to educate and offer CSS services. There is no charge to the client for the first 30 days of CSS agency delivered service, and a referral to SMILE is made, if appropriate.
  
  
• Home At Last (HAL) – Facilitates earlier and more successful discharges of elderly and frail clients with the provision of supports for the transition to home. Clients receive instrumental and logistical assistance with discharge, transportation and settling in at home. The program provides the client with escorted transportation, assistance in the home on the day of discharge, an offer of seven days of CSS agency delivered supports at no charge, and a referral to SMILE is made, if appropriate . This service is offered in all hospital sites in the SE LHIN.
  
  
• Home First (HF) – Provides support after discharge to frail elderly patients, automatically referred to 4CSS from the hospital-based CCAC case manager as a component of the home first approach (Quinte Health Care Belleville and Trenton sites and Brockville General Hospital Kingston General Hospital, and as of January 2011,Quinte Health Care Prince Edward County site). The 4CSS involvement ensures clients receive a timely and informative offer of linkage to the CSS agency in the area of their home, an offer of 30 days of CSS agency delivered service s at no charge, and a referral to SMILE, if appropriate.