Table 1
Elements of the ICCM Program.
| ICCM PROGRAM ACTIVITIES | IMPLEMENTATION ACTIONS | PURPOSE | ORGANIZATION/PROGRAM RESPONSIBLE FOR IMPLEMENTATION |
|---|---|---|---|
| Create an On-Line Referral Network | Procured and implemented a software platform to manage referrals | Improve linkages between local health and social sectors via a referral network, where clients could be referred from one provider agency to another. | Lambton Elderly Outreach and Lambton Public Health |
| Conduct Situational Assessment | Review and collation of community and health support services | To provide accurate and complete information for the Healthline.ca website. | Lambton Public Health |
| Develop a User-Friendly Interface for the HealthLine.ca Website | Create a user-friendly interface and test the interface with community members | Enhance the design of the Healthline.ca website to increase the connections among community service agencies and the residents of Sarnia-Lambton. | Lambton Public Health/Erie St. Clair Local Health Integration Network and the City of Sarnia partner organizations |
| Increase Capacity of Tel-Check Program | The Tel-Check program added a new staff member to assist with program promotion and volunteer recruitment and training. | Support socially isolated older adults via a service that provided a daily telephone call to older adults and persons with disabilities for the purpose of social interaction and medication reminders. | Family Counselling Centre/Tel Check Program |
| Expand Community Paramedicine Program | The Community Paramedicine Project: 1) held Wellness Clinics that were open to the general public throughout Lambton County, and 2) increased their capacity to deliver home visits to clients referred by community providers. | Provide outreach services to high-risk older adults (high users of emergency medical services and the health system) through home visits and Wellness Clinics to promote aging in place/independent living. | County of Lambton Emergency Medical Services/Community Paramedicine Program |
| Expand Lambton County Adult Day Program | Increased the Registered Practical Nurse (RPN) staffing hours from part time to full time in the Adult Day Program, thereby enhancing capacity to complete health monitoring assessments. | Increase health care monitoring services for clients of the Adult Day Program & client referrals to other services. The Adult Day Program provides individualized support to older adults living in the community and their caregivers. | County of Lambton Long Term Care/Adult Day Program |
| Implement a Community that Cares Campaign | With the assistance of the Community Support and Health Services Sub-committee, host events (e.g. workshops and fairs) and create products (e.g. videos) and promotional resources (e.g. pens). | Promote available supports and volunteer capacity needs. Inspire individuals, groups, and organizations to volunteer and to support causes they cared about. | Lambton Public Health |
Figure 1
ICCM Program Implementation and Evaluation Timeline.
Figure 2
Logic Model Overview – Building an Integrated Community Care Model for Sarnia Lambton.
Table 2
Activities, Indicators and Data Collection Methods.
| ACTIVITY | INDICATORS | DATA COLLECTION | |
|---|---|---|---|
| QUANTITATIVE | QUALITATIVE | ||
| 1. Build a referral network for Sarnia-Lambton health and social sectors |
| Monthly status reports; satisfaction surveys | Interviews |
| 2. Complete situational assessment to inform Healthline content |
| Analyze existing programs | Reflective Discussion |
| 3. Create a user-friendly interface for Healthline & conduct community outreach and engagement |
| Monthly status reports; satisfaction surveys | Interviews; program/meeting notes |
| 4. Build capacity of Tel-Check Program to support isolated older adults |
| Monthly status reports; satisfaction surveys | Interviews; reflective discussion |
| 5. Expand capacity of Adult Day Program for health care monitoring |
| Monthly status reports; satisfaction surveys | Interviews; reflective discussion |
| 6. Expand capacity of Community Paramedicine Outreach Program |
| Monthly status reports; satisfaction surveys | Interviews; reflective discussion |
| 7. Implement a “Community Cares” campaign |
| Monthly status reports; satisfaction surveys | Interviews; reflective discussion; program/meeting notes |