North York CARES: Providing customized health and social care at home

The drastic changes brought by the pandemic have also given rise to extraordinary collaboration and innovation in health care.

North York General Hospital (NYGH), along with other members of the North York Toronto Health Partners (NYTHP), an Ontario Health Team, has launched an initiative to offer seamless, tailored care to enable patients with complex needs to transition from hospital to home. The new program, North York Community Access to Resources Enabling Support (North York CARES), helps individuals who would otherwise stay in the hospital for a prolonged period, to safely return home. Many of these patients will ultimately move to long-term care or another setting for ongoing care. Besides the benefits to individual patients and their families and caregivers, North York CARES also opens hospital beds for those who need them most.

“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 Home HealthCare’s Manager of Strategic Projects & Initiatives, who is the NYTHP Backbone Lead for the program. “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 clients and caregivers to determine which services are needed, whether they be home and community care resources, virtual care devices, telemonitoring, community support services, community paramedicine supports, addiction services, behavioural supports, caregiver supports or respite care. When a client’s needs change, so does their care plan.

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

Kim is one of about 60 people across North York who contributed her experience and knowledge to help design North York CARES. She understands the challenges caregivers face and brings a unique perspective to this program. Kim was her husband’s caregiver for the two years he received in-home supports before being admitted 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, in the Greater Toronto Area. Over the next 20 years the percentage of those aged 65 and over in North York is expected to rise from 15% to nearly 25%.

“The 13 different organizations, primary care providers and caregivers that are part of North York CARES are all equally passionate and committed to this model of care,” says Susan Chang. “It is unlike anything else that currently exists in our health care system.”.

In addition to each person’s customized basket of care and support services, 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 by working together to deliver the right care in the right place at the right time.”