The landscape of health care in Ontario has drastically changed over the last year. The COVID-19 pandemic has placed added pressures on the health system and forced hospitals and health care organizations to pivot and deliver innovative care in different ways.

VHA Home HealthCare (VHA) and North York General Hospital (NYGH), in partnership with North York Toronto Health Partners (NYTHP), an Ontario Health Team, has launched a collaborative initiative to offer seamless, tailored care to help patients transition from hospital to home. The new program, North York Community Access to Resources Enabling Support (NY CARES), provides care and support for patients, who would otherwise be in hospital, so they can safely stay at home while waiting for a bed in long-term care or another setting. The program also benefits the hospital by creating more available beds for those who need them most.

Susan Chang

“All of our North York CARES clients have complex health care needs and the best care for them isn’t always in a hospital,” says Susan Chang, VHA’s Manager of Strategic Projects & Initiatives, working as a Backbone Lead for NY CARES with the NYTHP. “Through this program we are breaking down silos in our health care system and developing customized care plans based on each person’s needs.”

The North York CARES team works with patients and caregivers to determine which services are needed, whether it be home and community care resources, virtual care devices, telemonitoring, community support services, community paramedicine supports, addiction services, behavioural supports, caregiver supports and/or respite care. When a client’s needs change, so will their care plan.

“This integrated care model enables us to break down barriers and really focus on a patient’s individual needs,” says Kim Leung, a current caregiver and NYTHP Patient & Caregiver Health Council member who helped co-design the program.

Kim is one of about 60 people across the North York health care network who helped contribute her experience and knowledge to help build North York CARES. She understands the challenges and pressures caregivers face and brings a unique perspective to the development of the program. Kim was her husband’s caregiver when he received in-home supports for two years before he transitioned to a long-term care home.

“Each time we connected with a health care provider I had to repeat my husband’s medical history and list of medications. It was very fragmented,” says Kim. “What makes this program unique is each family is connected with a key worker who remains your single point of contact, ensuring there is no duplication of assessments and providing seamless care throughout.”

North York has one of the largest populations of older adults, including those who live alone, compared to other neighbourhoods in the Greater Toronto Area. Over the next 20 years the percentage of those aged 65 and over in North York is expected to increase from 15% to nearly 25%. Seniors’ Health is also one of NYTHP’s key areas of focus.

“In addition to primary care providers and caregiver partners, we are working with 13 different organizations from the health care sector who strongly believe in it and are equally passionate about it. We wanted to ensure North York CARES is unlike anything else that currently exists in our health care system,” says Susan.

In addition to each person’s customized basket of care and support tools, which allows them to stay at home for as long as possible, there is always someone to connect with when clients and/or families have questions.

“Picking up the phone and speaking with someone who knows your loved one’s medical history and health care needs is what really connects all pieces of the program,” adds Kim. “We’re addressing gaps in health care services by working together to deliver the right care in the right place at the right time.”