Home Care Tasks Checklist

• Description: The checklist provides a semi-structured approach to identify the types of tasks individuals need assistance with and how often the assistance is required.
• Work originates from: USA
• Resource can be applied to: home and community care sector
• Applicable to: Programming and service delivery

How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations

• Description: The guide describes three key areas that need to be addressed when transitioning individuals from hospital to home care. It identifies several steps that can be taken to address each of these areas in order to reduce rehospitalizations, and presents a number of approaches that can be used to determine the extent to which patient/client care is improved.
• Work originates from: USA
• Resource can be applied to: home and community care sector
• Applicable to: Programming and service delivery

Frameworks of Integrated Care for the Elderly: A Systematic Review

• Description: This resource contains the background, rationale and methods for the literature review. It also presents results on trials of integrated models of care, and reviews of programs of integrated health and social care for the elderly. It reports on the OECD Survey of Care Coordination and the European Union Survey of Integrated Care Approaches. Finally, it presents key frameworks of integrated care including the CARMEN Framework and the Hollander and Prince Framework.
• Work originates from: Canada
• Resource can be applied to: home and community care sector
• Applicable to: Policy

Integration: A New Direction for Canadian Health Care. A Report on the Health Provider Summit Process

• Description: This resource contains three parts, that is, taking action, outcomes and stakeholder engagement. It presents the three phases of the provider summit: the continuum of care, the continuity of care; and integrated care. Finally, it presents five foundations for integrated care: patient access, patient-centred care, informational continuity, management continuity and relational continuity.
• Work originates from: Canada
• Resource can be applied to: home and community care sector
• Applicable to: Policy

CMA Policy: Funding the Continuum of Care

• Description: This resource contains a discussion of the history of continuing care and how health care has moved over time from institutions to the community. It presents the CMA’s guiding principles for funding the continuum of care and also discusses the elements of the system such as prevention and health promotion, pharmaceuticals and home care. Finally, it provides recommendations in each on how to move forward, for example in the home care section the recommendation is that patients actively participate in care and treatment plan.
• Work originates from: Canada
• Resource can be applied to: home and community care sector
• Applicable to: Policy

Organizing Healthcare Delivery Systems for Persons with Ongoing Care Needs and Their Families: A Best Practices Framework

• Description: This resource contains key challenges to care coordination and integration including differences in philosophy and regionalization. It presents a detailed list of types of community based services provided to type of population group (i.e., seniors, persons with disabilities, mental health and children with special needs). Best practices framework for organizing systems of continuing/community care services including: the philosophical and policy prerequisites; administrative and clinical best practices; and linkages with hospitals, primary healthcare and other social and human services.
• Work originates from: Canada
• Resource can be applied to: home and community care sector
• Applicable to: Policy and Program

Impact of PRISMA, A Coordination-Type Integrated Service Delivery System for Frail Older People in Quebec (Canada): A Quasi-Experimental Study

• Description: This resource contains a study on the PRISMA model for frail older adults. Data was collected using bi-monthly telephone questionnaires and the level of disability in the participants was measured using the Functional Autonomy Measurement System. The findings were that the PRISMA model improves the efficacy of the health care system for frail older adults.
• Work originates from: Canada
• Resource can be applied to: home and community care sector
• Applicable to: Programming and service delivery

Post Discharge Tool

• Description: The tool contains forms (which can serve as communication tools for family members and home care workers) for monitoring follow-up appointments, follow-up care, and post-discharge medications. It also contains a number of tips to help individuals understand their condition, reduce the possibility of being readmitted, and communicate with their health care provider(s).
• Work originates from: USA
• Resource can be applied to: health care sector
• Applicable to: Programming and service delivery

TOC (Transitions of Care) Checklist

• Description: The checklist can be used to communicate information regarding: physiological functioning; psychosocial functioning; cultural factors; health literacy and linguistic factors; financial factors; spiritual and religious functioning; physical and environmental safety; family and community support; medical issues; and continuity/coordination.
• Work originates from: USA
• Resource can be applied to: health care sector
• Applicable to: Programming and service delivery

The Care Transitions Program^®

• Description: This resource includes a four week program during which patients are supported by a Transitions Coach^®. It also includes a short survey to assess the quality of care transitions, a medication discrepancy tool, a discharge preparation checklist and a tool to assess the contributions of family caregivers.
• Work originates from: USA
• Resource can be applied to: health care sector
• Applicable to: Programming and service delivery

Integrated models of care delivery for the frail elderly: international perspectives

• Description: This resource contains a literature review of integrated systems of care for the elderly. The full search found 2,505 documents which were narrowed down by independent reviewers using specific criteria for a total of 9 documents (e.g., there had to be a good description and it had to have been evaluated). It was found that there were two different kinds of models of integrated care for the frail elderly: 1) smaller, community based cooperative models focused on home and community care; and 2) large scale national/provincial/state model with a single administrative authority and budget and included both home and community care and residential services.
• Work originates from: International
• Resource can be applied to: home and community care sector
• Applicable to: Programming and service delivery

Interventions and Measurement Tools Related to Improving the Patient Experience through Transitions in Care: A Summary of Key Literature

• Description: This resource contains a literature review, evaluation strategies and tools, definitions, a conceptual framework, key findings and models of the patient experience through transitions in care.
• Work originates from: Canada
• Resource can be applied to: health care sector
• Applicable to: Policy

Mapping the State of the Art: Integrating Care for Vulnerable Older Populations

• Description: This resource contains the purpose of the review and why integration is important. It presents the methodology and findings from the review of models of integrated care, which include different care settings. It presents six common and key design features including: targeting services to appropriate needs groups; flexible case management; flexible services; diversity of care settings; integrating funding; and integrating structures and institutions. Finally, it presents a table with key information on all 47 models.
• Work originates from: Canada
• Resource can be applied to: health care sector
• Applicable to: Policy and program

Safety in Canadian Health Care Organizations: A Focus on Transitions in Care and Required Organizational Practices

• Description: This resource contains information on the partnership between health care organizations and Accreditation Canada and describes the number of organizations in Canada that are accredited with them. It also contains information on care transition standards and required organizational practices, i.e., evidence based practices that mitigate risks, strengths and trends in safety as well as presents improvements and enhancements to safety. Finally, it present information on the 2012 compliance rates on a variety required organizational practices, from highest to lowest compliance.
• Work originates from: Canada
• Resource can be applied to: health care sector
• Applicable to: Programming and service delivery

Collaborative Care: A Medical Liability Perspective

• Description: This resource defines collaborative care and discusses its benefits. It presents the current status of collaborative teams in Canada. It also discusses accountability and liability issues for policy makers and health professionals. It presents two models which address the above issues.
• Work originates from: Canada
• Resource can be applied to: health care sector
• Applicable to: Policy

Making Way for Change: Transforming Home and Community Care for Ontarians. A White Paper

• Description: This resource contains facts about the current system and makes a case for change. It provides barriers to transformation including the complex structure of the system and lack of funding stability. Furthermore, it argues that the legislative, regulatory and policy framework is outdated. Finally, it presents recommendations for change including adopting a flexible, adaptable home care service model and providing funding stability.
• Work originates from: Canada
• Resource can be applied to: home and community care sector
• Applicable to: Policy

Integrating Care for Seniors Living at Home

• Description: This resource contains a discussion on the challenges of home care delivery and the importance of accessing, coordinating and managing multiple services for seniors. It posits that more attention should be paid to integrated care as it’s a cost-effective method of delivering coordinated, accessible, and high quality care to seniors. It discusses the Ontario SMILE program, which seems to be a good example of an integrated care program.
• Work originates from: Canada
• Resource can be applied to: health care sector
• Applicable to: Policy

A Survey of Leading Chronic Disease Management Programs: Are They Consistent with the Literature?

• Description: This resource contains data on the characteristics of programs and health systems in relation to chronic disease. 72 programs were identified by experts and then compared to a Model for Effective Chronic Illness Care. The model was found to be useful in describing the characteristics shared by success programs and could be used as a checklist for new programs or may provide a road map for organizations wanting to change their systems.
• Work originates from: Canada
• Resource can be applied to: health care sector
• Applicable to: Programming and service delivery

Integrated Models of Primary Care and Mental Health & Substance Use Care in the Community: Literature Review and Guiding Document

• Description: This resource contains a literature review of themes that support integrating primary and mental health/substance use community care. In total, nine different types of collaborative models were found, from models that address mild to moderate needs (communication models) to models that address severe and complex needs (integrated team models). It also addresses subpopulations such as the elderly and children and how to make it work (e.g., using an interdisciplinary team approach and fostering relationships).
• Work originates from: Canada
• Resource can be applied to: health care sector
• Applicable to: Programming and service delivery

Evidence Boost: A Review of Research Highlighting How Patient Engagement Contributes to Improved Care

• Description: This resource contains strategies to improve patient care, barriers that prevent improvement, strategic responses, organizational factors that support successful patient engagement, key dynamics and key findings from case studies and interviews with key experts.
• Work originates from: Canada
• Resource can be applied to: home and community care sector
• Applicable to: Policy

Patient and Family Engagement. Involving People: The Path to Improvement

• Description: This resource contains information on the Canadian Foundation for Healthcare Improvement’s patient engagement projects and collaborations, a resource hub, webinar series, and ingredients to successful engagement
• Work originates from: Canada
• Resource can be applied to: home and community care sector
• Applicable to: Programming and service delivery

Putting Patients First: Patient-Centred Collaborative Care. A Discussion Paper

• Description: This resource contains the Canadian Medical Association view of collaborative care as well as the principles of collaborative care including clear communication.
• Work originates from: Canada
• Resource can be applied to: health care sector
• Applicable to: Programming and service delivery

Home Care Toolkit

• Description: The toolkit contains information and forms related to: determining a client’s needs; finding, interviewing and selecting home care workers; creating a written contract; creating and following both a care plan and a care log; tracking medications; tracking expenditures related to the client’s care; creating an inventory of the client’s belongings; supervising, communicating and problem solving with the home care worker; and meeting employment requirements.
• Work originates from: USA
• Resource can be applied to: home and community care sector
• Applicable to: Programming and service delivery