Process Evaluation of the North York CARES (Community Access to Resources Enabling Support) Integrated Care Program for Complex Older Adults

Adora Chui; Kimia Sedig; Katie N. Dainty

doi:10.5334/ijic.9824

Figures & Tables

Timeline of NYCARES iterations and key features.
ALC: alternative level of care; FY: fiscal year; TBD: to be determined
*Nine patients from NYCARES 1.0 continued receiving services during fiscal year 2021/2022; 31 new patients were enrolled into NYCARES 2.0; total caseload for fiscal year 2022/2023 was unreached at the time of this study which took place in fiscal year 2021/2022.

NYCARES 2.0 process-oriented logic model.
ALC: alternative level of care; HCCSS: home and community care support services; IPT: interprofessional team; NYTHP: North York Toronto Health Partners; PCHC: patient and caregiver health council; PCP: primary care provider; PSW: personal support worker; RPM: remote patient monitoring.

Table 1

Logic model of NYCARES 1.0.

RESOURCES/INPUTS	ACTIVITIES/STRATEGIES	OUTPUTS	OUTCOMES	IMPACT
Patient and caregiver engagement via the PCHC Project support from NYTHP staff Holistic menu of services via NYTHP organizations Primary care at centre Navigator model of care (single point of contact) Menu of services including professional, personal support, homemaking Virtual care for physician visits Remote patient monitoring	Identify appropriate patients for referral Develop needs-based care plan with patient, family, IPT Provide IPT care at home, home care, overnight supports, equipment and supplies, community support Provide specialist care: medical, mental health, behavioural supports Meet transportation needs Provide timely access to community programs	# staff trained on eligibility criteria # individuals screened for program eligibility # patients enrolled # needs-based care plans developed Types and # services provided	# ALC days saved # unnecessary ED visits avoided # unnecessary hospital admissions avoided # LTC placements avoided or delayed Reduced per-patient cost Reduced family/caregiver burnout # patients transitioned home post-program	Goal: To support patients requiring high intensity supports of home and community care, including community supports, to live safely and well at home Target 1, hospital model: Hospital ALC patients with discharge destination of LTC or home care Target 2, community model: Community-dwelling patients waitlisted for LTC and/or patients in the ED who are at risk of hospitalization or ALC designation

[i] ALC: alternative level of care; ED: emergency department; IPT: interprofessional team; LTC: long-term care; NYTHP: North York Toronto Health Partners; PCHC: patient and caregiver health council.

Table 2

Logic model of NYCARES 2.0.

RESOURCES/INPUTS	ACTIVITIES/STRATEGIES	OUTPUTS	OUTCOMES	IMPACT
Funding Strategic direction and guidance from leadership Time and human resources from NYTHP partners across all sectors of healthcare PCP participation and commitment	Co-design with patients and caregivers Use eligibility criteria for community model with 3 streams: Acute caregiver episode Acute medical episode Stable, but indirect care needs Provide NYCARES education and marketing via online and newspaper methods to referral sources Integrate virtual care and digital health	# unnecessary ED visits avoided Decreased # hospitalizations resulting in ALC designation Increased # of virtual care visits, digital devices uptake, remote patient monitoring uptake	Client-driven collaboration within a trusted team Integrated care to create continuity across agencies Flexible boundaries and scope of practice Compassionate and empathetic support Efficient and clear information flow Safe and consistent community care based on patient needs	Goal: Improved North York seniors’ health and in-home care to allow seniors to safely live at home for as long as possible Target 1, hospital model: see description in Table 1 Target 2, community model: see description in Table 1 Target 3, rehabilitation model: rehabilitation patients needing more care before being discharged

[i] ALC: alternative level of care; ED: emergency department; NYTHP: North York Toronto Health Partners; PCP: primary care provider (physician, nurse practitioner).

NYCARES 2.0 implementation summary map.
ALC: alternative level of care; HCCSS: home and community care support services; IPT: interprofessional team; PSW: personal support worker; QoL: quality of life; RPM: remote patient monitoring. Thicker outlines and arrows indicate mechanisms of impact (care navigator, basket of services); circular component indicates the novel care navigator mechanism; transverse lines (≠) indicate actions that did not occur; greyed out boxes and text indicate under-implemented components; boxes with broken lines indicate outcomes that should be added.

Process Evaluation of the North York CARES (Community Access to Resources Enabling Support) Integrated Care Program for Complex Older Adults

Figures & Tables

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Table 1

Table 2

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