OUR WORK
Aligned with the mandates of Ontario Health and the Ministry of Health, the Scarborough Ontario Health Team (SOHT) is committed to delivering a comprehensive and coordinated continuum of care to the population it serves. Building on long-standing relationships among health and community care providers, SOHT continues to foster collaboration and advance system integration across the entire care continuum.
WHO WE SERVE
The Year 1 population of SOHT is frail seniors living with mental health and/or addictions issues and multiple chronic conditions. These conditions commonly present in tandem, with one’s degree of frailty often inexplicitly linked to chronic conditions and mental health and/or addiction issues.
WHAT HAVE WE DONE
IN RESPONSE TO THE COVID-19 PANDEMIC:
- Scarborough community service agencies collaborated and by created a centralized intake line for referrals for Scarborough providers and residents.
- Provided testing, safety assessments, and education to all LTC homes, retirement homes, assisted living settings, and public spaces in high-risk neighbourhoods. Transportation support was provided for hospital teams.
- Launched a new program called “Safe and Warm in Scarborough” – a collaborative response to flu season, by analyzing data to identify high-risk neighborhoods where partners could offer additional flu clinics.
- Multiple COVID-19 Assessment Centres were set-up as outreach testing services in high-risk areas, including testing for residents and staff of all LTC homes, several retirement homes, assisted living and congregate care settings and community-based testing clinics in target neighbourhoods.
- PROTECH (Pandemic Rapid-response Optimization to Enhance Community-Resilience and Health): a rapid response community-based action project that is an online resource and training hub, supported by the Government of Canada).
FOR OUR YEAR-1 POPULATION:
- GAIN: 2 hospital teams and 2 community-based teams collaborating within a standardized model of care, providing navigation, referrals, and intervention to persons experiencing age-related frailty.
- PCCT: a cross-sectoral partnership including long-term care, hope, and home and community care providers, that builds on existing community hospice services to include palliative system navigation with expert nurses, 24/7 on-call, pain and symptom management consultation, psychosocial spiritual counseling, and recruiting community palliative physicians to become the hub of hospice palliative care.
- Assess and Restore program: for physical and occupational therapy for seniors after they leave the hospital.
- Hospital and community senior care partnering with McMaster University, on research studying community-based interventions in diabetes for older adults.
- Provided addictions programs for older adults and seniors involving supportive housing, case management and counselling, consultation with a geriatric psychiatrist, and knowledge exchange with a group of local.
- Improved service delivery and outcomes for people with an acquired brain injury (ABI) in Scarborough.
- SCOPE Transformation: Enhancement of SCOPE in Scarborough to enhance inter-professional support of primary care providers through a single point of access.
- Lawrence East Partnership Program: Hub-style services within TCHC buildings, providing case management, nursing, housing connections, PSW support and peer support to residents.
- Established the COVID-19 Response Central Line for Community Support Services.
- Medicine clinics transitioned to virtual and phone appointments primarily for those discharged from ED or inpatient units, referrals from the community (GPs) and LTC Homes.
