ISSUE 10 IN THIS ISSUE

September 28, 2021

CCHOHT Update …………………………………………….. Pg. 1

Work Stream, Committee & Workgroup Updates ….….…. Pg. 2

Primary Care Corner ..…………………………………...….. Pg. 3

Our Vision

With the communities of Halton

Hills, Milton and Oakville, we
CCHOHT UPDATE
are committed to delivering an
innovative, coordinated and
connected health system that STRATEGIC PLANNING BRAINSTORM
enables better health and
wellbeing of the population that
On September 16, 2021, Optimus SBR led the CCHOHT Collaborative
we serve. Committee in a digital white board brainstorm session.

Our Values
Respect & Dignity
Empathy & Compassion
Accountability, Transparency,
Access & Diversity
During the session, partner members discussed the latest strategic plan update
from Optimus and provided their thoughts on how it represented the CCHOHT’s
guiding principles, objectives and standard of operation.
A new draft is being prepared based on this feedback. Everything is still on track
for a late fall 2021 launch.

About Connected Care Halton

CCHOHT HIRES A PROJECT MANAGER
The CCHOHT is guided by a
Collaborative Committee with Sarah Weberman joined the CCHOHT team as a Project Manager this month.
equal leadership representation She has worked in the health care industry for over 18 years in project
from Acclaim Health, Home and management, analyst and quality specialist roles with organizations including the
Community Care Support McMaster Health Forum, Cancer Care Ontario, Humber River Hospital, Trillium
Services: Mississauga Halton, Health Partners and Hamilton Health Sciences.
Halton Healthcare, Halton
Region and Primary Care. Sarah leaves her position as the project manager for Rapid-
Improvement Support and Exchange (RISE) program at the McMaster Health
The CCHOHT has received Forum supporting the OHTs at a provincial level and was the project lead for
expressions of interest from
Accreditation 2019 at Hamilton Health Sciences. CCHOHT is excited for her to
more than 140 primary care
physicians and service provider
join the team!
organizations representing a
wide range of health care
services in the communities of
STAY INFORMED ON THE CCHOHT
Milton, Halton Hills and The CCHOHT is working to make sure all of our stakeholders remain up-to-date
Oakville. and aware of important updates. Be sure to check out our website, Twitter and
Instagram for important news.
Our approach to health care
transformation is founded on a
philosophy of patient-centered
care and a population health CCHOHT @CCHOHT @CCHOHT
approach.

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WORK STREAM, COMMITTEE &
WORKGROUP UPDATES
MENTAL HEALTH & ADDICTIONS
The Mental Health and Addictions work stream held a lessons learned meeting
with service and primary care providers for the Unified Care Plan pilot program.
The aim of this program is to reduce duplication and improve collaboration
between mental health and addiction service providers. With some comments
towards constructive improvement, overall there was a recognition and
appreciation of the value the program brings through integrated communication
and coordinated care plans.

The public awareness campaign for one-Link is all set. Figuring out what is the
right service when in need of mental health or addiction support can be
overwhelming; one-Link eliminates that stress. Since 2015, this service has
provided coordinated access to a number of addictions and mental health
services within Mississauga and Halton through one referral and intake
assessment process. Always trying to improve and further reduce barriers, one-
Link has updated its website and process, as well as improved its
communications. Click here for more information.

PALLIATIVE CARE
The Palliative Care work stream has been in discussions to expand the
Community Palliative Care Program to Halton Hills for early 2022. This program
will improve support for end-of-life patients by integrating the community into the
CCHOHT network, allowing physicians to improve communication, simplify
processes and connect community services with hospital resources. Currently,
only one physician in the area can provide these services for individuals who
don’t have a family doctor or whose family doctor doesn’t have the capacity for
these supports. The work stream met in late August with the Halton Hills
physician group to finalize the referral form and intake program.

The work stream is also completing phase two of three in training for its
Learning Essential Approaches to Palliative Care (LEAP) Paramedic Training.
When a palliative patient or their family member calls 911 or EMS, this program
empowers the paramedics with knowledge on how to problem solve the issue at
home and avoid an emergency department visit, which is against the palliative
patient’s wishes. Approximately 280 paramedics have completed the first
phases of LEAP.

HOME & COMMUNITY CARE

The Home and Community Care work stream has received feedback from its
Patient Survey, and Provider and Physician Survey regarding the High Intensity
Supports at Home Program (HISHP). Overall, all participants felt the clients
received the care they needed and were appreciative of the support provided by
this program, however, there is always room for growth and improvement.
These comments will be instrumental in making sure HISHP provides the best
support to those who need it most.

The work stream is also refocusing on the Hospital & ED Avoidance Resolution
Table (HEART) process. HEART is an escalation process created by Home and
Community Care Support Services (formerly the Mississauga Halton LHIN). The
model brings together partners to collaborate in real time to creatively address
complex needs and situations of elevated risk with a customized plan.
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 PATIENT, FAMILY & CAREGIVER
ADVISORY COMMITTEE
The Patient, Client, Family and Caregiver Advisory Committee finalized their
Engagement Framework this month and is in the process of getting final
approvals. The framework will be in place to ensure that the unique patient,
family and caregiver voice and experience is included in the CCHOHT model
from concept through to evaluation and across the continuum of care for all
CCHOHT services and responsibilities. This is achieved through authentic and
active partnership with CCHOHT leadership, service providers and partners.

DIGITAL HEALTH
The Digital Health work stream secured funding for the Remote Monitoring
program earlier this month. The goal of a remote monitoring technology system
is to ensure vulnerable populations receive appropriate clinical care and
monitoring in the community, including escalation to medical assessment or
acute care where necessary. Patients who live in Halton or have a primary care
physician in Halton will be supported.

At launch, this initiative will monitor COVID patients, as well as Chronic

Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), and
will extend its monitoring to Palliative and Mental Health and Addictions
populations in the future. Currently, the work stream is finalizing eligibility
criteria for COPD patients and is looking to determine eligibility criteria for CHF
patients next.

PRIMARY CARE CORNER

HALTON PHYSICIAN SCOPE READIES FOR
ASSOCIATION GOES DIGITAL SOFT LAUNCH

The Halton Physician Association (HPA), which was
formed during the pandemic, strives to create a
community of physicians who work with local partners
to support one another and optimize our collective
ability to provide the best care possible to our patients
within Halton Hills, Milton, and Oakville.
To better support their goals, they launched a new
website where individuals can learn more about the
HPA, see upcoming events, follow organizational and
community news, and find physician opportunities.
Click here to visit the new website. As well, to better
engage the Halton communities of Halton Hills, Milton,
and Oakville, the HPA has launched an Instagram
account. To follow them, click here.
The Seamless Care Optimizing the Patient Experience
(SCOPE) received an outpouring of interest in the
Physician Lead opportunities and is in the final stages
of selecting the five successful candidates. These
individuals will work closely with the CCHOHT SCOPE
Subcommittee to co-design the pathways in each of
the initial areas of focus.
SCOPE will host a soft launch event on November 23,
2021, with a go-live date of November 30, 2021.
The soft launch event will be focused on educating
stakeholders on the benefits of SCOPE and
encouraging physicians to sign up. Keep an eye
on the CCHOHT website and social media for
more details.

CONTACT US
info@connectedcarehalton.ca CCHOHT @CCHOHT @CCHOHT