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St. Clair West Services for SeniorsCREMS 2010 ROUNDTABLE
December 3, 2010
Embracing Diversity, Encouraging Independence, Ensuring Dignity
Embracing Diversity, Encouraging Independence, Ensuring Dignity
We are a non-profit charitable organization serving seniors and/or adults with disabilities. Our agency welcomes multilingual and multicultural caregivers, participants and clients.
ABOUT US
OUR FUNDERS
Supported by:
St. Clair West Services for Seniors
Embracing Diversity, Encouraging Independence, Ensuring Dignity
Celebrating more than 35 years
1973 :St. Clair West Meals on Wheels was established by local churches, with a federal grant, to deliver meals three days weekly. Our name originates from our initial location.
2010:• We employ 86 staff the majority Personal Support Workers
• We benefit annually from the contribution of 50 placement students and over 200 volunteers.
• Our client and participant base is 1700
• We are leaders in innovation in Meals on Wheels and Intake and Assessment
• We are community focused and partnership driven
St. Clair West Services for Seniors
Embracing Diversity, Encouraging Independence, Ensuring Dignity
Adult Day Centre, Respite Care, & Case Management, Information and Referral
Adult Day Centre, Respite Care, & Case Management, Information and Referral
Our Service Boundaries
Embracing Diversity, Encouraging Independence, Ensuring Dignity
Our Service Boundaries
Home Help, Meals on Wheels, & Transportation
Home Help, Meals on Wheels, & Transportation
Embracing Diversity, Encouraging Independence, Ensuring Dignity
Demographics
• Toronto inner suburb area.
• In the immediate environs, 26% - 39.9% of families live below Statistics Canada low-income cut-off line.
• However, the catchment area is diverse and our clients and participants range from very poor to affluent.
• Immediate community and its seniors are concerned about safety.
• Greater than average incidence of diabetes, hypertension and heart disease.
• Low levels of literacy, a high immigrant population and many individuals whose first language is not English.
• Service area is one of the most multicultural communities in Canada populated by significant numbers of Italians, Portuguese, Latin Americans, Somalis, West Indians, South Asians and Eastern Europeans.
Embracing Diversity, Encouraging Independence, Ensuring Dignity
• Adult Day Centre• Case Management, Information and Referral• Community Programs• Home Help and Respite Care• Meals on Wheels• Supportive Housing• Transportation
• Donating • Volunteering
OUR SERVICES
OPPORTUNITIES TO GIVE
St. Clair West Services for Seniors
Embracing Diversity, Encouraging Independence, Ensuring Dignity
Community Development
The Agency has a Community Development focus.
Training in Community Development, funded by United Way has assisted us on our path.
At St. Clair West Services for Seniors Community Development is a participatory process that includes clients, participants, volunteers, employees and supporters. This process creates mutual and equitable opportunities that build sustainable communities and empower individuals and groups to influence decisions which affect their lives.
Embracing Diversity, Encouraging Independence, Ensuring Dignity
Adult Day CentreSupervised social, recreational and therapeutic programming.
• Service 7 days a week, with extended hours
• Meals, transportation to the program, and assistance with personal care
• Modest fee (Subsidy available).
Three program streams:1.Adult Day Program for Frail Seniors2.Alzheimer Day Program3.Interlude Program (Overnight Respite Care)
St. Clair West Services for Seniors
Embracing Diversity, Encouraging Independence, Ensuring Dignity
Adult Day Centre
Baking
Celebrations
Snoezelen Therapy
Outings
Therapeutic fun - Dr. Clown:http://www.youtube.com/watch?v=8F-E_t2EUMw
Embracing Diversity, Encouraging Independence, Ensuring Dignity
“The program gives the caregiver time for themselves to do or enjoy some “me” time without having to worry about their loved ones because they are in good hands”, Caregiver, St. Clair West Services for Seniors (SCWSS)
“The Interlude program allows caregivers time to attend functions that otherwise they may not be able to such as attend a wedding, visit family in another city or even attend a baseball game”, Staff Member, SCWSS
“I feel that the program is a blessing. It will allow me to keep him home longer. I wish to avoid him from going to a long term care facility.” Caregiver, Downsview Services to Seniors
Interlude Program
Embracing Diversity, Encouraging Independence, Ensuring Dignity
Case Management, Information and
Referral
Case Management: Friendly and professional team available to provide assistance and supportive counseling in response to identified needs or crises. Information and Referral: provides information about the eligibility criteria to access programs, and referral and connection to appropriate agencies providing services within specified geographic areas. • Services offered in Portuguese, Italian, Somali, Spanish, Urdu and others
• No fee applies.
St. Clair West Services for Seniors
Embracing Diversity, Encouraging Independence, Ensuring Dignity
Home Help and Respite Care
Home Help: Assistance for seniors with routine household activities, and other services that enable their independent living.
• Light housekeeping, laundry, and light meal preparation• Assistance with banking, shopping and errands• Companionship• Personal care
Respite Care: Home Help workers offer in-home short-term relief for family and caregivers, allowing them free time for other activities.
• Modest fee (Subsidy available).
St. Clair West Services for Seniors
Embracing Diversity, Encouraging Independence, Ensuring Dignity
Meals on Wheels
Home delivery of nutritious meals. Our staff and/or volunteers deliver hot meals, frozen meals, milk, juice, and fruit and vegetable baskets. They also check regularly on the clients’ safety and wellbeing.
• Innovative delivery system which offers clients variety and choice.
• Modest fee (subsidy available).
St. Clair West Services for Seniors
Embracing Diversity, Encouraging Independence, Ensuring Dignity
Supportive Housing
24-hour on-site personal care and support services for seniors and/or adults with disabilities in designated Toronto Community Housing (TCH) buildings.
• Tenants who require frequent assistance with their Activities of Daily Living or need short-term help because of injury or illness are eligible for this service.
• No fee applies.
St. Clair West Services for Seniors
Embracing Diversity, Encouraging Independence, Ensuring Dignity
Transportation
Personalized door-to-door assisted rides to clients who are unable to use public transportation.
Escort assistance is available for frail seniors who need more help.
• We offer rides to and from medical appointments, grocery shopping, banking and hairdressing, Day Programs, and social outings
• Modest fee, plus parking charges if applicable (Subsidy available).
St. Clair West Services for Seniors
Embracing Diversity, Encouraging Independence, Ensuring Dignity
Community Programs
Community programming offered at 8 locations within our service boundaries.
• Activities include culturally sensitive social dining, exercise, educational workshops, bingo, gardening, outings, special events, line dancing, and much more!
• A Community Development focus drives our work. We are moving from ‘doing for’ to ‘doing with’.
• United Way funded training has assisted us in our transition.
• Modest fee. Some programs are free of charge.
St. Clair West Services for Seniors
Community Programs
Community Kitchens Social Action Theatre by Seniors (SATS)
Gardening
Summer trips andyear-round outings
Drumming
Embracing Diversity, Encouraging Independence, Ensuring Dignity
• Working with others to deliver programming.
• Currently offering dance, computers classes, Community Kitchen, English conversation classes, health workshops.
• Our Agency focuses on building community and neighbourhood inclusion
• Recent Elderly Persons Centre and Ontario Trillium Foundation funding will expand our program offerings and the scope of the centre.
•Nurse Practioner-Led Clinic Opening in April 2011
Eglinton Hill Centre
Embracing Diversity, Encouraging Independence, Ensuring Dignity
• ASHTOR (Asociacion de Seniors de Habla Hispana del Gran Toronto)• Art Starts• City of Toronto• Hazel Burns Hospice• Social Planning Toronto• Syme 55+ Centre• Toronto Public Health• Unison Health and Community Services (formally New Heights Community Health Centre and York Community Services)• West Park Healthcare Centre• York Hispanic Centre• York West Active Living Centre• Funders including United Way Toronto and New Horizons for Seniors
Partnership Power
Embracing Diversity, Encouraging Independence, Ensuring Dignity
Volunteering
We have various volunteer positions including:
• Board Member• Meals on Wheels Driver and Runner• Office or Program Assistant• Where possible, we can develop volunteer opportunities to accommodate your objectives and skill set
St. Clair West Services for Seniors
Days of Caring Volunteers
Embracing Diversity, Encouraging Independence, Ensuring Dignity
Community Support Services Initiatives
INTEGRATED INTAKE
HOME AT LAST
CNAP
interRAI CHA
Embracing Diversity, Encouraging Independence, Ensuring Dignity
Collaborative approach by CSS agencies to provide easy and timely access to community
support services through common processes
INTEGRATED INTAKEWorking Together
Embracing Diversity, Encouraging Independence, Ensuring Dignity
Since March 2007
Partner agenciesSt. Christopher HouseSt. Clair West Services for SeniorsWest Toronto Support Services
GoalsProvide easy single point accessibility to partner agenciesProvide live information, referral and intake coverage Share common resources, processes and tools
INTEGRATED INTAKE
Embracing Diversity, Encouraging Independence, Ensuring Dignity
Home At Last
Partnership between community support service agencies, Community Care Access Centre (CCAC) and hospitals
Provide planned, escorted discharge from hospital to home following their hospital stay
Preferably for seniors living alone, with an older or frail caregiver or with family away all day
Support with transportation and the services of a Personal Support Worker
Escorted from the hospital and settled in at home safely and
comfortably
Embracing Diversity, Encouraging Independence, Ensuring Dignity
Program Goals & Priorities
•Enhance existing hospital/CCAC/ community care processes to minimize delays in discharge
•Ensure that seniors do not remain in hospital any longer than needed
•Facilitate safe and timely discharge
•Coordinates patients, caregivers, hospital and community service staff to smooth the transition from hospital to community
•Ensure that needed community care supports are coordinated and initiated on time to minimize preventable readmissions
Home At Last
Embracing Diversity, Encouraging Independence, Ensuring Dignity
•Program Benefits•Allows senior to leave hospital at the earliest possible discharge date
•Prevents a possible trip back to emergency or return to hospital – thus reducing costly hospital expenses.
•Contributes to a sense of security and well-being and ensures a speedy recovery.
•Seniors without existing service supports are provided with information and care options to suit their immediate and future needs
•Families see their loved ones well taken care of; settled at home, food and medication arranged, connected to community resources as appropriate.
Home At Last
Embracing Diversity, Encouraging Independence, Ensuring Dignity
The Community Navigation and Access Program (CNAP) is a network of over 30 not-for-profit organizations, working together to serve seniors in communities across Toronto
http://www.cnap.ca/content/home/home.aspx
Community Navigation and Access Project (CNAP)
Embracing Diversity, Encouraging Independence, Ensuring Dignity
1-877-540-6565 begin_of_the_skype_highlighting 1-877-540-6565 end_of_the_skype_highlighting
Adult Day Program for Frail SeniorsAdult Day Program for Seniors with Alzheimer's Disease and/or DementiaAdult Day Program with Overnight Stay for Seniors with Alzheimer's Disease and/or DementiaCase ManagementCrisis Support and AssistanceFoot CareFriendly VisitingGroup Dining
Health Promotion and EducationHome Help or HomemakingHome Maintenance and RepairHospice CareMeals on WheelsNursingPalliative CarePersonal Care or Personal SupportRehabilitationRespiteSecurity CheckShopping Assistance
Shopping List PickupShopping TripsSocial and Recreational ActivitiesSocial WorkSpecialized Geriatric ServicesSupport for Individuals or Families Caring for a SeniorSupport Groups for Individuals or Families Caring for a SeniorSupportive Housing for SeniorsTransportation
Connect to services for seniors in your community with one phone call:
Embracing Diversity, Encouraging Independence, Ensuring Dignity
•interRAI CHA training • August 2008, University of Waterloo
•October 2008 : implementation of the interRAI CHA as standard assessment tool for Supportive Housing Clients
•Paper - hard copy •Research grade software, University of Waterloo
•March 2009: implemented in Adult Day Services•July 2010: Draft Screener/interRAI CHA for community clients
The interRAI CHA:Creating and Acting on Evidence in the
Community Support Sector
Embracing Diversity, Encouraging Independence, Ensuring Dignity
The interRAI CHA:Creating and Acting on Evidence in the
Community Support Sector
Embracing Diversity, Encouraging Independence, Ensuring Dignity
Top Five Triggers
Louise Towers
Doug Saunders
Outlook Manor
Eagle Manor
1 Informal support – triggered
Prevention – Triggered because preventive strategy not pursed despite a recent physician visit
Prevention – Triggered because preventive strategy not pursed despite a recent physician visit
Prevention – Triggered because preventive strategy not pursed despite a recent physician visit
2 Cognitive loss – Triggered to monitor for risk of cognitive decline
Cognitive loss – Triggered to monitor for risk of cognitive decline
Cognitive loss – Triggered to monitor for risk of cognitive decline
Informal support – triggered
3 Social relationship – triggered
Informal support – triggered
Informal support – triggered
Cognitive loss – Triggered to monitor for risk of cognitive decline
4 Cardio-respiratory conditions – triggered
Physical activities promotion - triggered with potential for improvement
Cardio-respiratory conditions – triggered
Physical activities promotion - triggered with potential for improvement
5 Physical activities promotion - triggered with potential for improvement
Social relationship – triggered
Social relationship – triggered
Cardio-respiratory conditions – triggered
Embracing Diversity, Encouraging Independence, Ensuring Dignity
MAPLe Score
Bldg A Bldg B Bldg C Bldg D Alzheimer Day Program
Frail Day Program
5 1 2 0 7 12 4
4 10 12 3 20 10 6
3 21 22 4 30 3 6
2 2 3 1 4
1 24 6 2 2 1 4
Total 58 45 10 63 26 20
The interRAI CHA:Creating and Acting on Evidence in the
Community Support Sector
Embracing Diversity, Encouraging Independence, Ensuring Dignity
Partnership with EMS Community Service Organization
Notification Program
. Applied for FundingGo ahead with the projectTry in one Supportive Housing Building Consent of clients/tenants
Embracing Diversity, Encouraging Independence, Ensuring Dignity
•This proposed demonstration project aims to address service gaps by creating better linkages and establishing protocols with Toronto EMS/hospital emergency departments around SH residents calling 911• •These protocols would initiate timely community services which prevent admission or reduce length of hospital stay
•Services may include monitoring, assessment, provision of home, personal and instrumental supports
•Plans would include expanding these protocols to non-supportive housing settings and to other jurisdictions
Partnership with EMS Community Service Organization
Notification Program
Embracing Diversity, Encouraging Independence, Ensuring Dignity
• opportunities for client outreach and education, prospects for preventing unnecessary unscheduled hospitalization and for assisting clients to transition from hospital to home as quickly and safely as possible
Partnership with EMS Community Service Organization
Notification Program