WHAT IS SOHT
Aligned with the mandate of Ontario Health and the Ministry of Health, the Scarborough Ontario Health Team (SOHT) is responsible for delivering a full and coordinated continuum of care to patients attributed to their OHT. SOHT is leveraging historic relationships among health and community care providers to continue collaborating to drive system integration across the 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.