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Foundation

Foundation

Foundation

2015 - 2016

Annual Report

Celebrating 40 Years of Service:

Building Innovation on a Solid Foundation

Contents

40th Anniversary Greetings ........................................................................................................ 1 – 5 Carefirst 40th Anniversary & Milestone Achievement ............................................................. 6 – 8 Mission & Values ............................................................................................................................... 9Strategic Plan 2016 – 2021 ..................................................................................................... 10 – 11 2015 / 2016 Report from the President & Chief Executive Officer ....................................... 12 – 13 Board of Governance ...................................................................................................................... 14 2015 / 2016 Financial Report .......................................................................................................... 152015 / 2016 Balance Scorecard ....................................................................................................... 162015 / 2016 Service Statistics .......................................................................................................... 17Carefirst One-Stop Multi-Services Centre ............................................................................. 18 – 19 Carefirst INTEGRATE Model............................................................................................................ 20 2015 / 2016 Service Highlights ................................................................................................ 21 - 30The Carefirst Family – Carefirst Family Health Team ............................................................ 31 – 36 – Carefirst Foundation .......................................................................... 37 – 40 Donors .................................................................................................................................... 41 – 42 Acknowledgement ................................................................................................................. 43 – 45 2015 / 2016 Activities Highlights in Photo ............................................................................. 46 – 49

One-Stop Multi-Services Centre300 Silver Star Blvd., Scarborough, Ontario M1V 0G2Tel: 416-502-2323 Fax: 416-502-2382Email: [email protected]

Carefirst Family Health Team & Carefirst Specialist Clinic (Scarborough Site)300 Silver Star Blvd., 2/FScarborough, Ontario M1V 0G2Tel: 416-502-2029

Carefirst Family Health Team (Richmond Hill Site)420 Highway 7 East, Suite 27, Richmond HillOntario L4B 3K2Tel: 905-695-1133 Fax: 905-695-0826Email: [email protected]

Carefirst Specialist Clinic (Richmond Hill Site)420 Highway 7 East, Suite 206Richmond Hill, Ontario Tel: 905-695-0901

York Region Community Services Centre420 Highway 7 East, Suite 104A, Richmond Hill Ontario L4B 3K2Tel: 905-771-3700

Adult Day Centre / Scarborough Health Management Centre17 – 19 Glen Watford DriveScarborough, Ontario M1S 2B7Tel: 416-649-1212 Fax: 416-649-0014Email: [email protected]

South Toronto Office / Helena Lam Community Services479 Dundas Street West, Toronto, Ontario M5T 1H1Tel: 416-585-2013 Fax: 416-585-2892Email: [email protected]

York Region Richmond Hill One-Stop Access Multi-Services Centre / Ip Fu Ling Fung Adult Day Centre9893 Leslie Street, Richmond Hill, Ontario L4B 3Y3Tel: 905-780-9646 Fax: 905-780-9045Email: [email protected]

Mississauga Community Services Centre1051 Eglinton Ave. West, MississaugaOntario L5V 2W3Tel: 905-270-9988Email: [email protected]

Carefirst Seniors & Community Services Centre

Congratulatory Message from the Governor General

1

Congratulatory Message from the Prime Minister

2

3

Congratulatory Message from the Minister of Health and Long-Term Care

Congratulatory Message from the Premier

Congratulatory Message from the Mayor of Toronto

Congratulatory Message from the Minister Responsible forSeniors Affairs

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5

Congratulatory Message from the Mayor of Richmond Hill

Congratulatory Message from the Mayor of Markham

Celebrating 40th Anniversary for Carefirst in 2016

1976 Reminiscing Carefirst’s Historic Milestone Development 2016

1976 Started Chinese meals-on-wheels service in Chinatown, Toronto with a $1,000 operating budget. In 1978 Founded the Chinese Meals- on-Wheels and Mutual Aid Association.

1980 Changed to Chinese Seniors Home Support Services Association, services grew from single meals-on-wheels service to a range of home support services.

1985 Incorporated as a non-profit charitable organization.

1986 Approved as a member of the United Way of Greater Toronto (presently known as United Way of Toronto); adopted the new agency name Toronto Chinese Seniors Home Support Services Association.

1989 Opened the Scarborough Branch Office to serve the City of Scarborough.

1992 Renamed as the Chinese Seniors Support Services Association to reflect the expanding service scope and geographic coverage.

1992 Renamed as the Chinese Seniors Support Services Association to reflect the expanding service scope and geographic coverage.

1995 Started the first Supportive Housing Services in the Alexandra Park Seniors Apartments at 91 Augusta Ave in Toronto.

1997 Opened the second Supportive Housing Service in Tam O’Shanter Seniors Apartments and started an Adult Day Service in Scarborough.

2006 Launched the Stanford Model Chronic Disease Self-Management Program.

2007 Funded by the Ministry of Health and Long - Term Care for the operation of Carefirst Family Health Team (Richmond Hill site) and opened the Carefirst York Region Specialist Consultation Service Centre in Richmond Hill.

2009 Won 2009 Health Innovation Finalist Award from the Ministry of Health and Long Term Care for the innovative project: Chronic Kidney Disease Early Identification and Outreach Program, jointly launched with the Scarborough Regional Renal Dialysis Program.

2010 Approved licence by the Ministry of Training, Colleges and Universities for the operation of the Carefirst Vocational Training Centre.

2011 Received $ 500,000 from the Ontario Trillium Foundation - Community Capital Fund towards the building of the One Stop Access Multi Services Centre in Scarborough.

2012 Study Tour to On Lok Lifeways, San Francisco, U.S. and adoption of the On Lok PACE Model of Care at Carefirst.

2013 Received approval of $12 million loan from Infrastructure Ontario for construction of “Carefirst One-Stop Multi-Services Centre”.

Held Ground Breaking Ceremony for the building of the Centre for tomorrow: “Carefirst One-Stop Multi-Services Centre”.

2014 Opened another Adult Day Program in Scarborough, a total of 3 Adult Day Program Centres (2 in Scarborough and 1 in Richmond Hill).

2015 Completed construction of capital project and operating from “Carefirst One-Stop Multi-Services Centre”

2016 Received Health and Wellness Award from 2016 European Healthcare Design Congress for the innovative architectural design of “Carefirst One-Stop Multi-Services Centre”.

1999 Opened the York Region Community Service Centre and Adult Day Care Centre in Richmond Hill; approved as a member agency of United Way of York Region.

2000 Launched an agency renaming campaign and adopted a new agency name as Carefirst Seniors & Community Services Association.

2001 Collaborated with The Scarborough Hospital’s Regional Dialysis Centre to pioneer the Peritoneal Dialysis Social Day Centre for the chronic renal patients at Carefirst.

2002 Extended services to Mississauga and was approved as a member agency of United Way of Peel Region.

2004 Achieved the first 3-year accreditation for 2004-2007 by the Canadian Council on Health Services Accreditation (presently known as Accreditation Canada).

Launched the only Chinese Elder Abuse Helpline in Toronto.

2005 Granted $1 million capital funding by the Town of Richmond Hill for “Carefirst York Region One-stop Multi-Services Centre” in Richmond Hill.

6 7

Carefirst 40th Anniversary

Chinese Meals on Wheels Services – housed by the University Settlement House

20th Anniversary Celebration

Celebrating 40 years of serving the community

30th Anniversary Celebration.

Grand Opening of Carefirst One-Stop Multi-Services Centre in 2016

Received Capital Funding from Town of Richmond Hill to set up the “Carefirst York Region One-Stop Multi-Services Centre” in 2007

Official Launching of Capital Campaign for Carefirst One-Stop Multi-Services Centre in Scarborough in 2012

Carefirst One-Stop Multi-Services Centre Ground Breaking Ceremony in 2013

Renaming Campaign in Year 2000 – new agency name: Carefirst Seniors & Community Services Association

Chinese Seniors Home Support Services with a basement office loaned by Toronto City Home Tenant Association at 36A Baldwin Street, Toronto

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Carefirst Seniors & Community Services Association

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Mission Statement

Our mission is to ensure that seniors and others in need of services, living in Toronto and surrounding areas, enjoy a high quality of life in their communities. We strive to maximize their well-being through a range of social, health care, and supportive services planned and delivered through an integrated model of care. We will ensure that a comprehensive range of services are delivered by an effective team of professionals and volunteers.

We will achieve the above mission by:

• Delivering client-centred services that reflect an integrated model of care.

• Providing top quality & culturally relevant social, health care, & support services to our clients.

• Ensuring a professional and caring attitude in all our client relationships.

• Achieving optimal wellness levels in our clients by encouraging them to participate as actively as possible in their communities.

• Promoting in the broader community an awareness of our clients’ needs for social, health care & support services.

• Advocating to government, voluntary and private sectors on issues relating to policies and programs that affect our clients.

VISION & VALUES

Carefirst will be a leader in providing comprehensive, responsive and client-focused programs to seniors and others in need of services in the Greater Toronto and surrounding areas.

• Client-and-Family-Centred Service - Respect client and family’s right to co-design and participate in discussion making about service utilization, their health and wellness.

• Quality Services - Provide and promote excellence in service through its quality standards and best practices.

• Responsiveness to Diverse Community Needs - Respect diversity within the community through the provision of culturally and linguistically sensitive services.

• Respect for Staff - Value the contribution of all employees by making every effort to meet their professional needs.

• Integrated Care Approach - Consider the needs and well-being of clients, families and caregivers by using an inclusive, holistic service approach.

• Professional Care - Provide services in a professional manner, ensuring that programs are delivered by qualified and competent staff.

Carefirst Strategic Plan 2016 - 2021

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I. Context

The new 2016 – 2021 strategic plan was developed at an important moment in Carefirst’s history. In October 2015 Carefirst moved into its long planned new quarters. The building on Silver Star Blvd. was conceptualized, designed and built by the Carefirst community. This innovative Multi-Services Centre was the culmination of a decade of planning and fund-raising. Its opening marks a new era for Carefirst. This Strategic Plan reflects the vision that underlies the development of a Multi-Services Centre that can provide an exemplary Integrated Model of Care based on the successful PACE model replicated extensively in the United States.

II. Strategic Planning process

Carefirst’s strategic plan is the result of a very thorough assessment, consultation, analysis and discussion process led by our Strategic Planning Working Group consisting of an external consultant, Board and staff members with the involvement of all relevant stakeholders. From the deliberations and consultations throughout the planning process, a number of strategic imperatives were identified and prioritized.

Strategic Imperatives

Imperative #1: Develop a New Carefirst Business Model based on the PACE Model for Promotion of Integrated Care

• Establish through performance indicators that the PACE based model implemented by Carefirst is capable of meeting the MOHLTC expectations for high-quality, cost effective integrated community-based care.

• Promote the new Carefirst Business Model as a publicly recognized integrated care model that works in Ontario, specified in terms of key ingredients and evidenced based outcomes.

Imperative #2: Promote Organizational Health as the Greatest Opportunity for Improvement and Competitive Advantage

• Demonstrate that Carefirst cares for its staff’s work-life balance and HR communications as much as it does for its clients, through adapting leading-edge human resources, policies and practices.

• Build a robust succession planning program that emphasises current talent development and increases the availability of experienced and capable employees to meet future leadership needs.

Carefirst Strategic Plan 2016 - 2021

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Imperative #3: Develop a Comprehensive and Effective Marketing & Rebranding Strategy for Carefirst and Its Services

• Reinforce Carefirst’s positioning in the home and community care sector by leveraging the new business model.

• Establish Carefirst as a leader in innovative home care practices amongst clients, funders and other service providers.

Imperative #4: Diversify and Broaden the Revenue Base to Enhance Organization’s Capacity

• Seek business partnerships to complement and augment the resource base so as to enhance Carefirst’s capacity and efficiency in service delivery.

• Develop social productive enterprises that are relevant within Carefirst’s mandate and jurisdictions to broaden the funding sources as well the service scopes for the benefit of clients and caregivers.

Imperative #5: Expand Development of Strategic Alliance and Selective Partnering to Enhance Social Impact

• Develop a matrix of strategic alliances and collaborative service partnerships to enhance the development of integrated care.

• Explore and open new forms of partnerships to gain access to new service opportunities.

2015/2016 Report from President and Chief Executive Officer

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2015/2016 earmarked significant milestone developments for Carefirst. It celebrates 40 years of service for the community, and Carefirst enters a new era with the launch of its own newly built “Carefirst One-Stop Multi-Services Centre”. The investment in constructing the new Centre demonstrates the organization’s commitment to further developing better coordinated home and community care, actively collaborating with service partners to improve the implementations of seamlessly integrated social and health care, as well as becoming adaptable to the changing needs of the community and the transforming healthcare sector.

Throughout this annual report you will find highlights of our innovative service developments and strengthened community partnerships to advance integrated care for all. Some of our key accomplishments are described below:

• Developing New Five Year Strategic Plan 2016-2021: This strategic plan was developed at an important moment in Carefirst’s history as Carefirst celebrates its 40th anniversary and begins a new era of operating from its innovative multi-services centre. This strategic plan reflects the vision underlying the development of a Multi-Services Centre providing an exemplary Integrated Model of care based on the successful PACE model replicated extensively in the United States. Led by Professor Sheila Neysmith, Board Member of Carefirst, and supported by Don Pollock, external consultant with the Management Advisory Services, the Strategic Planning Working Group had undertaken a well-thought-out engagement of stakeholders in the planning process. Carefirst’s new strategic plan is the result of a very thorough engagement, assessment, consultation, analysis and discussion process in partnership with stakeholders, clients and families, whose input was incorporated. The new strategic plan shall provide a solid foundation to guide Carefirst’s future organizational growth.

• Attaining Architectural Design Award and Relocation to State-of-the-Art Carefirst One-Stop Multi-Services Centre: Construction was completed for the Carefirst One-Stop Multi-Services Centre in the fall of 2015. Since then, Carefirst has successfully taken over and moved into the building, located at 300 Silver Star Boulevard. It has been busy but exciting to settle into a new home, a dream decades in the making. Alongside Montgomery Sisam Architects, Carefirst received the Health and Wellness Award at the 2016 European Healthcare Design Congress, held in London, U.K. The outstanding architectural design of the facility supports easy one-stop access to Carefirst’s integrative and comprehensive services all under one roof.

• Celebrating 40th Anniversary and Grand Opening of New Centre: On June 17, 2016, Carefirst celebrated its 40th anniversary and official grand opening of its own remarkable centre. Over 500 guests supported and attended, including dignitaries, government officials, service agencies, hospitals, CCACs, supporters, donors, friends, and community members. We had the honor of receiving greetings from Hon. Kathleen Wynne, Premier of Ontario; Hon. Michael Chan, Minister of

2015/2016 Report from President and Chief Executive Officer

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International Trade; MPP Soo Wong; City Councillors; Deborah Hammons, CEO of Central East LHIN; and Thomas Chanzy, Vice-President, Public Affairs of the Ontario Trillium Foundation. We also received a keynote message from Dr. Samir Sinha, Director of Geriatrics at Mount Sinai and the University Health Network Hospitals, Expert Lead for Ontario’s Seniors Strategy and Medical & Health Advisor for Carefirst Seniors and Community Services Association.

• Commencing Operation of the Transitional Care Centre: Along with the opening of the new Centre, operations at the Carefirst Transitional Care Centre also officially commenced in November 2015. The 30-bed short stay respite care centre at the Carefirst One-Stop Multi-Services Centre launched its operations by phases, with an intake of 10 clients per phase. By May 2016, Phase 1 has been completed, and the collaboration with Scarborough Hospital kicked off in the same month with hospital patients transferred to this unique and innovative facility for short recuperation. Patients are then transitioned back to their own homes or homes of destination. The transitional care arrangement not only addresses the issue of bed blockage in hospitals, patients are also all able to return home safely, as patients and families often take advantage of the tail end services provided by Carefirst, including home care, Chronic Disease Management and various social services. Client satisfaction rate has averaged at 90%.

• Preparing for 2017 Accreditation Survey: In 2013, Carefirst was accredited by Accreditation Canada with exemplary standing for four years. For this year, the organization has started the preparation process for the next accreditation, which on-site survey will take place in June 2017. To uphold the true value of client-and-family-centred care, a Client and Family Advisory Council was struck in 2016. Working in partnership and collaborating with the Client and Family Advisory Council allows Carefirst to incorporate the client and families’ perspectives and inputs into the development of the organization on all aspects, including client service delivery, policies and procedures.

Carefirst looks forward to deepening engagement with our community service users, including caregivers and families. This year’s incredible achievements and cherished opportunities could not have been made possible without the passion, hard work, and dedication of our Honorary Advisors, Board of Directors, staff, volunteers, service partners and stakeholders. We would also like to express our heartfelt gratitude toward the generous support of our funders and donors. As always, Carefirst continuously strives to provide quality and comprehensive services to meet the essential and changing needs of the community.

Sunny Ho Helen Leung President Chief Executive Officer

Carefirst Seniors & Community Services Association

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Honorary Advisory Council

Chair Irene So

Fundraising & Finance Management Advisor Stanley Kwan Charles Poon

Medical & Health Advisor Dr. Samir K. Sinha

Social Work Advisor Dr. Ka Tat Tsang

Media & Community Relations Advisor Patrick Fong

Directors

Kwan ChanDr. Joseph ChienKingson LeeJames MelocheDr. Sheila NeysmithDr. Paul NgIan PoDr. Paul TamDr. George Wu Nominees for 2016 – 2017 Board of Directors

Kwan Chan – Re-elect

Kingson Lee – Re-elect

Dr. Sandra Tam – Re-elect Dr. Sheila Neysmith – Relect Paul Fong

Board of Directors 2015 – 2016

President Sunny Ho

Immediate Past President Genevieve Wong

Executive Vice-President Michael Wong

Treasurer Olivia Mui

Secretary

Janet Lee

Committee Vice President

Building Maintenance Committee

Michael Wong

Service Quality & Safety Committee

Dr. Sandra Tam

Senior Management Team

Chief Executive Officer Helen Leung

Finance Controller & IT Director Edmund Kwan

Senior Program Director

Germaine Lee

Acting Senior Program Director Alice Mui

Director of Development & Communication

Edith Lam

Program Director Lesley Krempulec

Program Director Nancy Leung

2015/2016 Financial ReportCarefirst Seniors and Community Services Association

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2015-2016 Balanced Scorecards

Outcome Measure of Accomplished Strategies and Objectives

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• 98% clients satisfied with Community Support Services, e.g. Client Intervention and Assistance, Beareavement Services, etc. (based on random sampling of 100 clients)

• 95% client satisfied with Assisted Living Services (441 clients surveyed)

• 98% client satisfaction in Infection Control/Personal Protective Equipment of Home Care Services (477 clients surveyed)

• 45% service units increase in Exercise & Falls Prevention (Total service unit: 260,046 attendance)

• 95% staffs satisfied that their job makes good use of their skills (172 total staff responses)

• 96% staffs satisfied with the training they need to do the job well (174 total staff responses)

• 570 participations in 27 professional development courses in Demential Care, Palliative Care, Transfer Skills, and Infection Control

• 21 Carefirst delegates, including a Board Member and 2 reps from The Scarborough Hospital, particpated in the 2nd study tour to On Lok Lifeways, U.S. Model, San Francisco in July 2015

• 339 complex care needs clients participated in INTEGRATE model of care (approx. 5% of total 6,780 clients served)

• 95% staffs and 100% Board Members particpated in new Strategic Plan Development (2016-2021)

• 0% Sentinel Incident

• Set up new “Client and Family Advisory Council”

• Relocation and operation from new “Carefirst’s One-Stop Multi-Services

Centre” since October 2015

• 16% increase in total agency

revenue with total operating budget of

$18 million • 24% increase in

government and supportive grants

• 8% increase in restricted reserve funds (designated for capital project)

• 43% increase in total agency donation with total proceeds of $664,409 (majority of which went to support capital campaign)

• 90% operating budget expensed on direct client services

2015/2016 Service Statistics

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2015 - 2016 Volunteer Hours (Total: 77,682 hours)

2015-2016 Service Statistics

Carefirst One-Stop Multi-Services Centre

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Carefirst One-Stop Multi-Services Centre, located at 300 Silver Star Blvd., Scarborough, facilitates accessibility and mobility for people with various special and health care needs. It is an one-stop access to integrated medical and social care. The Centre promotes population health, enhances patient and client’s experience, provides recreational and social space to promote wellness and integration and provides integrated care services for seniors (On Lok Model of Care).

European Healthcare Design Awards 2016

Designed by Montgomery Sisam Architects, the Carefirst One-stop Multi-Services Centre won the Highly Recommended Award in the category of Design for Health & Wellness.

Full OperationJune, 2016

Moved InOct, 2015

ConstructionCompleted July, 2015

Helen Leung, CEO of Carefirst Seniors (left), Alice Liang, Principal of Montgomery Sisam Architects, Canada (middle); Liz Paslawsky, Lead Judge of Design for Health & Wellness Award (right).

Ground-breaking Ceremony

Nov 6, 2013

Establishment of Carefirst Foundation

2006

• 70,000 sq. ft.

• 4-storey building with 5 levels including lower level

• $20 million building cost, including cost of the land

• Construction duration: 20 months

Ground Level • Wellness Centre• Teaching Kitchen• Vocational Training Centre• Library, Computer and Cyber

Centre • Courtyard Garden 2nd Level • Carefirst Family Health Team-

Primary Health Care Centre• Specialist clinics• Chronic Disease Management

and Prevent Centre• Adult Day Centre• Ontario Telemedicine Network-

Virtual Care Centre• Rehabilitation Centre

3rd Level • Transitional Care Centre 4th Level • Central Administration, Finance,

HR, IT, Home Care service coordination

Lower Level • Social and Recreation Centre• Community Support Services

Centre• Volunteer Development and

Training Centre

Client Feedback:

“Easy access to medical care and other services under one roof.”“An uplifting environment, I enjoy coming to the Centre for interest and exercise classes!”

Carefirst One-Stop Multi-Services Centre

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Carefirst INTEGRATE Model

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9 Key Dimensions:

I nter-disciplinary care• Multi-disciplinary intervention, i.e. physicians, nurses, social workers, physiotherapist,

occupational therapists and frontline workers (PSWs), are involved in joint care planning and intervention

N avigation• A care coordinator works with participants/caregivers/families throughout the process

(engagement, assessment, care planning, implementation, monitoring, and evaluation) to improve access to health care and social services through case management

T eam-based practice • A group of health care professionals with complementary skills work with participants/

families toward a common purpose, with agreed upon performance goals, and approaches, e.g. coordinated care planning, for which they hold themselves mutually accountable

E lectronic health record (EHR) • A real-time, digital version of participants’ charts and records make available information

instantly and securely to authorized users• A virtual platform for inter/intra-net communication insures care coordination and monitoring

G rounded in care coordination hubs• ADP centres are “health homes” to coordinate visiting home-based and centred -based

programs/services

R esources coordination • Development of an integrated care pathway which specifies elements of care detailed in local

protocols, the foreseen sequence of events, and expected patient progress over time• Integration of home and community based services• Arrangement of an inter-organizational network through vertical & horizontal integration

A ccessibility • One portal entry to a circle, and continuum, of health care, social/community care and

housing/transitional care services• Care close to home and on-site service delivery, e.g. assisted living and ADPs

T imeliness • Care services delivered and intervention occurring at the right suitable time

E ngagement • Engagement and involvement of all relevant sectors - primary care, community care, acute

care, rehabilitation, public health, housing, and government support to make the integration model of care a success

• Client-and-family-centred care – program development in partnership with clients/families and incorporations of inputs from them

2015/2016 Service Highlights

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Adult Day Program

• Carefirst’s three ADPs in Richmond Hill and Scarborough look after 425 different individuals a year.

• With the expansion of our integrated care approach, more seniors in our ADP’s are receiving additional health services, such as mobile geriatric assessment and intervention, regular physiotherapy care and health monitoring services.

• Caregiver support groups offered family members and cares for emotion or education needs.

• In partnership with The Scarborough Hospital, the ADP has expanded our program to accommodate the medical needs for those on peritoneal dialysis.

Changes/challenges

• Coordinating transportation to and from the programs and the cost of the programs.

• Introducing portable GPS systems for improved safety and to keep a safe eye on those at risk for wandering away from the centre - staffs and families give two thumbs up!

• While managing complex frail seniors, the ADP continually strives to make our environment safer while maintaining a client’s dignity and independence.

− Increased Occupational Therapy assessments for client’s mobility equipment, falls assessments at home and physical safety at each ADP site;

− Improved access to other health professionals (i.e., geriatrician, nurse practitioner, pharmacist, nurse, social worker) to better monitor health conditions and preventable falls;

− Implemented GPS and other systems for assisting those with wandering behaviours.

“The Nostalgic Librarian”Mr. F has been a client of the ADP for 5 months.He has Dementia and presents with some inappropriate “responsive behaviours”, including pacing, exit-seeking, agitation and aggression. His children who are in school did not have the resources to care for him at home. At admission, the ADP staff really wanted to help but struggled to manage his behaviours until they used the Montessori approach to analyze the situation. They looked at his background and learned that he used to be a librarian. He thought the ADP was a library and he was responsible for overseeing it. This explained the pacing and the agitation when the room became noisy.

Staff responded by taking him to the library on the ground floor when it was too noisy in the ADP. In the library, he would organize

the books and look at Farsi magazines. When he returned to ADP, he presented as calm and contented. The staff also developed a number-code and had Mr. F help to “code” books, organize pamphlets and fill envelopes for mail-outs. He also helps to set tables at lunch and straightens up chairs at the end of the day. Staff have also learnt some Farsi to maximize communication. Since using his own language and providing Mr. F with tasks that helped him to fulfill his previous role and feel like he is contributing to the program, his undesirable responsive behaviours drastically reduced. He has even allowed his sense of humour to come out and jokes with the staff. He enjoys his time at the “library” every day, which provides his family with much-needed respite.

Our newest ADP has been growing steadily

in attendance.


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Assisted Living Services

• Assisted Living Services (ALS) addresses the needs of high-risks seniors to enable seniors to remain at home independently with personal support and homemaking services on a 24/7 basis. As a result, the percentage of hospital admissions and ER visits were significantly reduced and the program was effective in preventing premature LTCH admission among clients.

• Two main challenges encountered this year pertained to scheduling:

− Difficulties in locating and scheduling Personal Support Workers (PSWs) to provide short but frequent or unscheduled visits to clients due to distant travelling in Richmond Hill and York Region;

− Fewer PSWs willing to work full time in the York region.

Home Care Services

• Home Care (HC) Services is a Community Care Access Centre (CCAC) subcontracted service through Central East, Central and Toronto Central, which provides individuals with personal care and homemaking services to maintain/improve their quality of life. With the input of clients and families, all clients have an assessment and individualized care plan developed to meet their needs. The services are delivered by PSWs under the supervision of nurses and supported by client coordinators.

• Total of 251,897 hours of Home Care Services provided in 2015-2016, which represents a 6% increase, as compared to last year.

• Toronto Enterprise Fund (United Way initiative) is a unique funding partnership with United Way Toronto, the City of Toronto, the Ontario Ministry of Community & Social Services, and the Homelessness Partnering Strategy, a federal government program administered by the City of Toronto. The TEF was established in 2000 to support the implementation of social enterprises that provide transitional or permanent employment, or training leading to employment, for people who are marginalized. Carefirst supports and trains people living in the communities that encounter severe barrier to employment.

Positive client ExperienceMrs. Lee was a client of the Assisted Living program since August 2015. Prior to admission, she had a fall that fractured her left ankle. As a result, she was not able to walk independently with continuous pain in her ankle. Mrs. Lee was also at high risk for falls as she had multiple “minor” falls in the months prior to admission. Following a thorough care planning session with Mrs. Lee and her daughter, it was agreed that Mrs. Lee would receive two hours of services weekly, focusing on assisting with transferring, exercising, psycho-social support, as well as some light cleaning. The care coordinator

also referred Mrs. Lee to other programs, such as Diabetes Education Program and Falls Prevention Program, that deemed beneficial according to her condition. Both Mrs. Lee and her daughter reported that these programs were helpful and informative. Mrs. Lee had not fallen since admission to the Assisted Living program. In December 2015, the care coordinator received a call from them, requesting to reduce services to one hour weekly instead and allow other clients who are more in need of services to use these resources, as Mrs. Lee’s condition had improved. They also expressed gratitude and thanked the care coordinator and PSW for all the help and support.

Client Satisfaction Report

95%92%2014-2015

376

2015-2016

441

3%

# of client responded to survey


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Home Care Services (Cont’d)

Highlights of the Year

• There is minimal turnover for the Home Care Department in 2015-16, arising from our staff who are caring and supportive to clients. Carefirst’s pool of PSWs has a great combination of skills to help and support our clients’ needs.

• “Hero at Home” - Carefirst’s PSW, Lucy Lu Yao, received the prestigious, Hero at Home Award from Toronto Central CCAC. The award was given to care providers who showed compassion and family/client centred approach in the care provided.

Supportive Housing Program

• Situation and background of individual clients are assessed by Program Manager and Client Service Coordinators to make recommendations best suitable for clients. Coordinated care plans are then worked out with inputs from clients, caregivers, and staffs. On-going review of care plan is also undertaken to incorporate the changing condition(s) of client.

• In 2015-2016, 124 coordinated care plans were reviewed and updated. • In addition to on-site services provided by Supportive Housing Program, 56% of the clients are

referred to different departments, e.g. Adult Day Program and Chronic Disease Management Program, aiming to benefit clients with the total all-rounded care offered by Carefirst.

• Support to caregiver is also part of the total care:

• 149 support and counselling sessions were provided for caregivers.

• 30 caregivers were given training, information and education.

• Staff training is important for enhancement of

work knowledge and skill:• All PSWs of Supportive Housing attended the

Palliative Care training. • Other training sessions were also taken to ensure that quality care was provided to

clients.

Direct quote from the nomination:

“Lu Lucy is a PSW. Lucy is nominated by a homebound client for her work, and especially for Lucy’s going above and beyond in providing personal care, and homemaking services for the clients.”

“On behalf of my family and myself, thank-you for all the wonderful care that your staff provided for my husband over the past year. I was overwhelmed by the care my husband has received. Carefirst’s staffs were all my husband’s Florence Nightingale.” —Barbara Smith

Client Satisfaction Report

Punctuality

Infection Control/ PPE

2014-2015

477

2015-2016

477

Year

# of client responded to survey

80%

80%

96%

98%

16%

18%


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Chronic Disease Management Program (CDMP)

CDMP is a cluster of carefully designed programs to help those with chronic health conditions including:

• Cardiovascular • Diabetics • Obesity

Highlights for 2015-2016:

• Carefirst’s Geriatric Assessment and Intervention Network (GAIN) entered into its second year in providing care to complex care, to frail seniors.

• Carefirst’s Community Cardiovascular Rehabilitation (CVR) program welcomes the addition of a physiotherapist to complement the nursing and kinesiology team.

• The mobile Tele-Ophthalmology (TOP) to screen diabetic clients expanded its catchment area from Scarborough to the Durham area in an effort to reach out to more individuals.

• Carefirst’s Enhanced Recovery Program (ERP) combined this year with our new Transitional Care Centre to better reach those who require rehabilitation to go back home independently and safely.

• Carefirst’s inter-professional team provided professional and clinical support to the clients referred by other Carefirst programs/services, demonstrating the power of a unique integrated care approach.

• Frailty • COPD (Chronic Obstructive Pulmonary Disease)• Rehabilitation after hospitalization• Mobile care to sites and homes within Central East LHIN

The “Happy” COPD Client – Mr. L.

“My dad will be 90 years old in November. When he had a heart attack 14 years ago, we also found out about the emphysema because he was a heavy smoker for 30 years. Although he quitted smoking in his 50s, his lungs were damaged.

For the last 14 years, dad had been in relatively good health until the December last year, when he got the flu virus. I took him to visit the respirologist and he was still fine but suddenly became very sick and was admitted to Sunnybrook Hospital for COPD exacerbation. Soon after he was discharged, he was readmitted for aspiration pneumonia and then readmitted again for chest pain. Dad was in and out of hospital almost on a weekly basis. His weight dropped quickly from 123 lbs to 106 lbs within three months.

When the respirologist suggested that dad should come to Carefirst to join the COPD rehab program, I wasn’t sure because he was very weak. However, I decided if the doctor thinks that this is the last thing that dad should try, I would support it.

COPD staffs at Carefirst would remember that when I first brought dad in, CCAC and I were talking about palliative care for him. When you look at my dad today, he doesn’t look palliative. Medication is still the same, the only difference is dad has joined this weekly COPD Rehab Program. It is the best that we can ask for. This program has given us hope, it has provided both mental and physical stimulation for dad and he is getting stronger every week.


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“I was angry, scared, feeling isolated and lonely. I was so desperate that I have nowhere to stay and go. I have been helping and supporting my children for all my life, but now they become a stranger to me. They yelled at me and asked me to leave…..…….With the continuous support and assistance of Carefirst, now, I felt more positive and

independent as I managed to support myself with a part-time job. I learnt how to interact and communicate with my children differently. Hopefully, I could have my own space soon.” ~ Ms. Z., 68-years-old service user of Community Support Services.

over 985 intake assessments or reassessments

for high risk seniors who encountering significant life

Provided over 6,500 information and referrals

through telephone and/or face-to-face drop-ins enquiries.

Offered over 550 seniors/caregivers with information on

senior housing, seniors benefits, aging at home community

resources, and integrate care.

Community Support Services

The Community Support Services are programs/services assisting seniors and others in need of the services to access appropriate services, whether provided by Carefirst or other community agencies. Through these services, seniors and needy individuals are able to lead an independent life in a safer, better supported and more comfortable environment. The programs have adopted the use of InterRAI Preliminary Screener and InterRAI CHA common assessment tool to identify the seniors’ individual care needs and service goals. They were provided with client-and-family-centred intervention and support services, including case management, ongoing assessment and service navigation. The basket of Community Support Services includes Crisis Intervention and Assistance, Friendly Visiting and Telephone Reassurance/Security Check, Escort & Interpretation, Information and Referral, Bereavement Counseling, and Elder Abuse Prevention and Intervention.

Achieved Impactful Outcomes:

• Outreached to over 3000 seniors/caregivers residing in Toronto, York Region and Mississauga areas to equip them with elder abuse education through 48 workshops, 4 symposiums, and 7 support groups.

• Actively engaged 136 bereaved service users to join the Bereavement Network for ongoing peer mutual support to deal with the loss of loved ones. The network members have volunteered to help planning and implementing periodic social activities and trainings to promote friendship and mutual support within the Network.

Program Effectiveness: Client-centred Care: Accessibility

95% clients strengthened coping abilities and problem solving skills in daily

functioning

93% participants had better understanding of elder abuse and enhanced sense of self- protection and

safety

93% bereaved clients increased and strengthened the social support

network

100% clients reported active participation in the assessment and intervention process

96.5% clients increased usage of community

resources by overcoming language and cultural

barriers that prevent them from accessing community

support services.

93%93%95% 100% 96.5%


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Community Exercise & Falls Prevention Program

Funded by Ministry of Health & Long Term Care through the Central East, Central and Toronto Central LHINs.

Seniors’ exercise classes focus on improving and maintaining functional performance through strength and balance to prevent injury and falls. Falls prevention classes provide seniors with instruction on how to reduce the risk of falling.

“I joined the exercise class more than 1.5 years; I found the classes are very helpful. My health conditions improved a lot.” ~ Ada Leung

“I am diabetic, my sugar level is well kept. It maintains at a healthy level and is under controlled.” ~ Tony Yuen

“It’s a wonderful program and helps me a lot especially my back pain. The instructors are very professional and patient.”

The exercise classes vary in their pace and type, including tai chi practice, qigong/breathing practice, line dance, chair-yoga and the standard chair-based exercise.

• The program has demonstrated its effectiveness in promoting overall health and wellness, as well as in mobilizing seniors to encourage the same in their peers. As reflected in the client satisfaction survey conducted in September 2015:

• 81% of the seniors surveyed had noticed improvement in their overall physical function, e.g. walk longer distances than before

• 99% continue to participate in the program and will also be recommending the classes to family and friends

Locations - from downtown Toronto, Scarborough, North York, Thornhill to most of York Region and south Simcoe

County.

130 sites - including retirement homes, community centres, libraries,

community agencies, Welcome Centres, Toronto

Community Housing, York Housing, private

condominiums and places of worship.

492 classes of exercise and falls prevention classes

delivered.

For adults

65+

The program has helped approximately

5,000 seniors to stay healthy,

physically active and independent in the

community.

For Christine Chau, knitting was more than a simple hobby. It was a passion and an outlet for her to express her feelings and emotions. She originally began knitting when she was very young, but because she led a busy life she was unable to practice this passion as often as she would have liked. After her retirement, she began her search for a knitting class that would fulfill her needs.

She fell in love with the knitting program! It was affordable, allowed her to pursue her passion for knitting, and allowed her to share her life experiences

with a group of peers from similar walks of life and from similar backgrounds. Christine has also found a sense of community and acceptance, friendship and support.

Christine is now happily enjoying her life in a way she never thought possible and is continuously developing new interests. The impact that Carefirst has on a senior’s life is immeasurable, and in the case of Christine Chau, we can see firsthand the improvement that Carefirst can make in terms of seniors’ social lives, well-being and interpersonal relationships.


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96% 97% 97% 94%

The Wellness Club

The Wellness Club, which has a membership of 2,502 members, provides various social and recreational activities, fitness programs and educational workshops to promote and help the club members to stay healthy, active and well-connected with the community. It also paves the way for the retirees, baby boomers to contribute meaningfully to programs as volunteer instructors, speakers and peer leaders.

• The Club utilizes experience and skills of volunteers to plan programming/activities for their peer group. They also help in recruitment, implementation and evaluation of activities.

• Pooling together resources of four service teams (Wellness, ADP, SHS and Volunteer)

to implement a client-centred half-day program. • Rolled out a year-round falls prevention education campaign: delivered 17

education workshops for seniors (391 participants) and 6 education workshops for caregivers (201 participants).

The client satisfaction survey in Sep 2015 reflects:

are more engaged and interactive with

others

felt better both physical and

mental well being

rated excellent in overall experience participating in the

Wellness Club Program

felt happier

Christine Chau’s Story – in pursuing her interest and self-discovery

“Without Carefirst’s transportation service, I won’t be able to enjoy the time at the Adult Day Program. Thank you very much!” ~ Ms. M.H. Cheng.

“Being a caregiver is not easy, my family and I sincerely thank the whole transportation team for all the support you have given us.” ~ Mr. & Mrs. H.C. Ho, family member of transportation service user.


28

Transportation Services

• Transportation is a vital service for frail and homebound seniors to stay connected with the community as well as to maintain their quality independent community living.

• The transportation program is committed to the implementation of integrated care model within Carefirst. The team has worked closely with Carefirst’s all service departments year round in transporting frail seniors to attend adult day programs, hemodialysis treatment, rehabilitation programs, medical appointments, as well as transporting discharged patients from hospital to home. Transportation staff members also participate in the team-rounds to contribute to client’s care planning.

• Carefirst has to subsidize the transportation program annually despite it receives funding from the

government, for the purpose to meet the high demand for transportation services. The program needs to operate in a financially sustainable manner so that it does not become a financial burden to the organization. Last year, the team adopted the “LEAN” approach to review and streamline the service organization and routings, so we are able to sustain the program and continue to offer the transportation service to support clients attending essential programs.

Volunteer Development & Coordination

The program recruits individuals from all walks of life as volunteers to play an active role in the delivery of volunteer services that will both support our community and improve our society. Highlights for 2015-2016

• The program actively engaged the veteran volunteers in developing “Volunteer Training Programs” with contents where their skills and expertise are best utilized.

• The program also provides a platform for the volunteers having the same interests/hobbies to meet regularly for sharing and socialize. The hobbies clubs (Photography, Folk Dance, First Aid and Calligraphy) would not made possible without the devotion of time and skills of some volunteers who play an important role in planning and leading the clubs activities.

• Has a pool of 717 volunteers capable in communicating in Chinese (Cantonese/Mandarin/other dialects), English, French, Vietnamese and South Asian Language (Tamil, Punjabi, Hindi) to support Carefirst’s diverse clientele.

With a fleet of 12 vehicles.

With a team of 17 dedicated paid drivers, as well as 10 volunteer drivers using

their own vehicles.

Close to 40,000 transportation trips were provided to needy clients in the

Greater Toronto Areas.

Toronto

94%

90%

97%

Some of the volunteers surveyed that:

agreed their skills are utilized

agreed they had made a

difference in the community

agreed the volunteer work was rewarding

“We were told of Carefirst’s Transitional Care Centre while he was recovering from the effects of having cancer surgery at The Scarborough General Hospital. He was not ready to return home, but was not able to continue staying in the hospital surgical floor. Your facility proved to be the right place for my husband to recuperate back to normal living and possibly return to his home. The staff team was very accommodating

to his needs, the physiotherapy was intensive and extensive, the food nutritious and thus contributing to healing, and the atmosphere isl very supportive. I would like to express our appreciation of the excellent care that my husband received while staying at your facility. I would like to recommend Carefirst to any patient, especially in the process of adjusting to independence after a hospital stay.” ~ Caregiver MS

Carefirst Transitional Care Centre

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An OPTION to Transition from Hospital to Home, Caregiver Relief and Waiting for Admission to Alternate Level of Living Placement

A newly established service at the new facility, Carefirst One-Stop Multi-Services Centre, consisting of 30 beds, aiming to provide an environment promoting exceptional recovery, respite care and also simultaneously enriching the quality of life for individuals who are in need.

Specially designed and available for individuals for the following purposes:

• Recuperating from surgical procedures or medical conditions • Relieving caregivers who need a short break• Waiting for admission into long term care home facility

Achieved Impactful Outcomes

• Since its inception from November 23, 2015 untill the end of July 2016, received over 413 phone enquires and/or visits.

• Served a total of 82 individuals with 59.8% female and 40.2% male.

• Improved health condition with 84% of the program participants felt recuperated and stronger during their stay at the facility.

• Enhanced caregiver support/Reduced caregiver stress with 95.6% of the program participants/families felt better supported.

Received Overwhelming Patient Experience

Physical Environment: Overall Experience:

100% 92%expressed that the physical comfort of the transitional care centre is good/very good/excellent.

92% expressed that I received good/very good/ excellent quality of care in my stay.

Comments from OCSA PEPA surveyor: “Program staffs are dedicated and strive to provide training that will ensure graduates from the PSW Certificate Training Program will provide quality care services. The program is supported by a well-established infrastructure with resources available to students and instructors.”

Carefirst Vocational Training Centre

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• Licensed by the Ministry of Training, Colleges and Universities (MTCU).

• Registered as a Private Career College under the Private Career Colleges Act, 2005.

• Obtained another maximum of the three-year accreditation from Ontario Community Support Association Personal Support Worker Education Program Accreditation (PEPA) in June this year.

2015/2016 Program Highlights:

PSW Certificate Program

• The PSW Certificate Training Program prepares graduates to provide supportive care to individuals across the lifespan, including clients experiencing cognitive impairment, physical disability and mental health challenges, by assisting them with their activities of daily living. Last year, the team worked diligently to review and redesign the training curriculum to meet the new compliance requirements set by the MTCU.

• The redesigned training curriculum with licenced course hours, to 650 hours were approved by the Ministry that it meets the new compliance requirements for the new Ministry of Training, Colleges and Universities Personal Support Worker Training Standard, 2014. The new curriculum will be rolled out in 2016 Fall Semester.

• Accreditation by OCSA PEPA indicates Carefirst’s PSW Certificate Training Program has attained the standards in both contents and program organization.

• Thanks to the partner training organizations: Tendercare Living Centre, Mon Sheong Long Term Care Centre, St Paul’s L’Amoreaux Community Centre, TransCare Community Support Services, Scarborough Centre for Healthy Communities, and Participation House for supporting the PSW student practicum placements. Under the coaching and mentoring of experienced supervisors from the partner agencies during the practicum, the students are able to gain valuable work related experience.

Future Development

Carefirst Vocational Training Centre is actively exploring to expand the training programs to include caregiver education and food service programs to meet the needs of the community.

Lead Instructor Debbie Mancini (Front R2) and PSW students.

Carefirst Family Health Team2015-2016 Annual Report

Foundation

Carefirst Family Health Team

32

Carefirst Family Health Team (FHT) continues to be busy enrolling and serving patients on a daily basis, to develop our services in alignment with the Ministry of Health and Long Term Care (MOHLTC) Bill 210, Patients First Act, 2016 to Strengthen Patients-Centred Health Care in Ontario. For 2015/2016, Carefirst FHT has been working its goals to ensure that patients receive integrated, accessible high quality care by planning an developing programs and services. In consultation with the Local Health Integrated Networks, other community stakeholders and upholding the patient and family-centred care approach.

Quality Improvement Engagement

Carefirst Family Health Team’s Board and staff have dedicated the past year to quality improvements. In our quality improvement engagement, we have been working in partnership with:

• Health Quality Ontario (HQO) • Institute for Clinical Evaluative Services (ICES) • Association of Family Health Teams Ontario (AFHTO) • College of Family Physicians (OCFP)

Keeping track major key performance indicators:

• Cancer Screening (pap test, mammography and colorectal cancer screening)• Diabetes management (HbA1C, LDL and retinal testing) • Other health services utilization (emergency visits and hospital re-admissions)

We continue to identify patients who are due or overdue for cancer screening and have developed a reminder process to recall patients for follow-ups tests or referrals. We have implemented change ideas by developing process maps to identify gaps, encourage each physician within the team to register and sign up for their Cancer Care Ontario Screening Activity Report (SAR) to find out the patients’ screening status, and also use the Electronic Medical Records (EMR) to screen eligible patients so that the team can regularly review the baseline and set improvement targets.

Diabetes Care Comprehensive Management - Diabetes Education Program DEP

Diabetes is one of the most complex diseases and can be challenging to manage for many patients. The Carefirst Diabetes Team has been working tremendously hard and continues to identify and take concrete measures to improve and provide ongoing care for diabetic patients, who are referred to Carefirst FHT DEP from more than 300 FHT’s internal physicians and external community practitioners on a regular basis.

For 2015/2016, like in previous years, the Carefirst DEP served up to 2,000 diabetic patients and have screened patients to prevent complications from diabetes such as retinopathy and neuropathy through foot screens. The team has very satisfactory results by using the EMR and International Classification of Disease (ICD-9) codes to develop diabetes registry.

The team uses the national guidelines and diabetes flow sheet tool to ensure that we keep track of diabetic patients and to make sure that the front desk staff, RN’s, SW, physicians and those who are involved in the care of the patients provide the care that patients need.

Carefirst Family Health Team (FHT) continuestobebusyenrollingandservingpatientsona

dailybasis,todevelopourservicesinalignmentwiththeMinistryofHealthandLongTermCare(MOHLTC)Bill210,PatientsFirstAct,2016toStrengthenPatients-CenteredHealthCareinOntario.For2015/2016,CarefirstFHThasbeenworkingitsgoalstoensurethatpatientsreceiveintegrated,accessiblehighqualitycarebyplanningandevelopingprogramsandservices.InconsultationwiththeLocalHealthIntegratedNetworks,othercommunitystakeholdersandupholdingthepatientandfamily-centredcareapproach.

QualityImprovementEngagement

CarefirstFamilyHealthTeam’sBoardandstaffhavededicatedthepastyeartoqualityimprovements.Inourqualityimprovementengagement,wehavebeenworkinginpartnershipwith:

♦HealthQualityOntario(HQO)

♦InstituteforClinicalEvaluativeServices(ICES)

♦AssociationofFamilyHealthTeamsOntario(AFHTO)

♦CollegeofFamilyPhysicians(OCFP)

Keepingtrackmajorkeyperformanceindicators:

♦CancerScreening(paptest,mammographyandcolorectalcancerscreening)

♦Diabetesmanagement(HbA1C,LDLandretinaltesting)

♦Otherhealthservicesutilization(emergencyvisitsandhospitalre-admissions)

Wecontinuetoidentifypatientswhoaredueoroverdueforcancerscreeningandhavedevelopedareminderprocesstorecallpatientsforfollow-upstestsorreferrals.Wehaveimplementedchangeideasbydevelopingprocessmapstoidentifygaps,encourageeachphysicianwithintheteamtoregisterandsignupfortheirCancerCareOntarioScreeningActivityReport(SAR)tofindoutthepatients’screeningstatus,andalsousetheElectronicMedicalRecords(EMR)toscreeneligiblepatientssothattheteamcanregularlyreviewthebaselineandsetimprovementtargets.

CarefirstFHTKeyPerformanceIndicators2015/2016

78.8% patients have had their LDL cholesterol test. (Provincial

average = 67.1%)

341 or 51.3% enrolled FHT patients with diabetes had their HbA1C

test done.

78.8% patients have had their LDL cholesterol test. (Provincial

average = 67.1%)

341 or 51.3% enrolled FHT patients with diabetes had their HbA1C

test done.


33

Adoption of OntarioMD’s Hospital Report Management System (HRM)

The Carefirst Family Health team has signed up with OntarioMD’s Hospital Report Management System (HRM) that provides direct access to hospital reports for the purpose of timely information and notification on discharged patients who have been hospitalized or for those who routinely visit the hospitals.

• FHT staff will ensure that patients return to the clinic to see physicians in follow-up upon discharge within 7 days.

New Carefirst FHT—Scarborough Clinic and Integrated Coordination of Patients Care

Carefirst FHT’s patients, in particular seniors, have incredible opportunity to receive “wrap around coordinated multi-disciplinary care” through the adapted PACE model at Carefirst FHT. In October 2015, Carefirst FHT-Scarborough Clinic moved into the newly built Carefirst Seniors’ One-Stop Multi Access Centre where patients and their caregivers could receive a one-stop access to a basket of community support services: home care, meals on wheels, transportation, adult day care and also can be admitted to the transitional care unit when needed, all under one roof. This new Scarborough site provides not only family medicine care but also on site specialist access for the convenience of the FHT patients.

Seeking Accreditation

The official accreditation survey date is October 3 - 5th, 2016.

Why be Accredited?

Carefirst FHT embraces the process of accreditation, which is an ongoing organizational journey that strengthens quality improvement efforts already underway. The benefits of accreditation include the ability to:

1. Assess services and find out where to focus improvement efforts 2. Develop standardized processes to improve efficiency and reduce costs 3. Mitigate risk and support the uptake of best practices 4. Build a culture of quality, safety, and excellence 5. Identify leading and commendable practices 6. Publicly promote the commitment to offer safe, high-quality services 7. Maintain and measure a Healthy Work Place Environment 8. Embed a Continuous Quality Improvement framework

Carefirst FHT continues to strive to provide quality care for patients, clients and families in the coming year. We plan to incorporate the accreditation standards to improve communication and safety within the FHT, so as to take the FHT’s operation to an overall higher level in efficiency and efficacy.

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Carefirst Family Health Team – 2 services sites (located in Richmond Hill & Scarborough) to provide quality care for patients, clients and families

Carefirst Family Health Team Scarborough Clinic located on 2/F of Carefirst One-Stop Multi-Services Centre where patients can easily receive a one-stop access to a basket of community support services under one roof

Diabetes Education / Nutrition Counselling Physiotherapy Services

Specialized Programs & Services

Providing culturally and linguistically services



President Dr. Paul Tam

Treasurer Winter Ng

Directors

Dr. Chi Mong Chow Rahim IsmailDoreen Tai

Nominees for 2016 – 2017 Board of Directors 2016 - 2017 Dr. Paul Tam - Re-elect Rahim Ismail - Re-elect



Lead Physician Dr. Christina Lee

Acting Director of Patient Care Services

Louise Poon

Administrative Lead Myrtle Robichaud

Family Physician Team

Dr. Christina Lee (Lead Physician)Dr. Eugene KwongDr. Polly Lam (Locum)Dr. Amy Lau (until August., 2016)

Dr. Nabil Moharib (until January, 2016)

Dr. Philip SinDr. A. SrinivasanDr. S. K. Tong (until July, 2016)

Dr. Lesley WuDr. Sean WangDr. Albert Yeung (until July, 2016) Dr. Lihua Zhuang

Foundation

35

Specialist Physician Team

Dr. Gabriel Chan Gastroenterologist and Hepatologist

Dr. John Chan Psychiatrist Dr. Alice Cheng Endocrinologist

Dr. Chi Ming Chow Cardiologist

Dr. Jiang Optometrist

Dr. Ying Lu Ophthalmologist

Dr. Denise Tam Nephrologist

Dr. Melissa Tong Ophthalmologist

Dr. Gunjan Vador General Internist

Dr. Albert Yeung Allergist & Immunologist

Shirley Cheung Chiropodist

Dr. S.K. Tong Eye Doctor

16

2015/2016 Financial Report

36


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Carefirst Foundation2015-2016 Annual Report

Foundation

Carefirst Foundation

38

About Carefirst Foundation

• Registered as a charitable non-profit organization (charitable organization #83974 4943 RR0001)

• Fundraises for Carefirst Seniors and Community Services Association and other organizations with similar objectives – to provide stable and quality community services for those in need.

• Since its inauguration in October 2006, the Foundation’s Board has developed a strategic plan to realize its commitment to Carefirst Seniors and Community Services Association’s captial development of the “One-Stop Multi-Services Centre”, which combines social, medical and recreational services for the community in Scarborough.

2015/2016 Program Highlights

• Under the leadership of the Foundation Board and the Capital Campaign Committee, Carefirst achieved the Phase One fundraising target of $6 million for the development of the “One-Stop Multi-Services Centre” last year.

• The official grand opening and open house of the Carefirst One-Stop Multi-Services Centre, was held on June 17, 2016. The event showcased the new Centre as an inclusive care coordination hub, and brought together over 500 guests, including dignitaries, government officials, service partners, community stakeholders, supporters and friends. Major donor, the Fu’s family, and other donors and supporters were recognized and acknowledged at this memorable and celebrative occasion.

The fundraising activities organized last year included:

• ‘Carefirst Week’ – a week-long event comprising a Radio-Telethon • Mini-Open House • Community Health Fair • Young at Heart Charity Gala • Charity Walk for Health • Mother’s Day Celebration • Carefirst first Charity Golf Tournament

Carefirst Foundation would like to express its heartfelt gratitude to donors and supporters for designating Carefirst Foundation as their events’ beneficiaries. Special appreciation goes to:

• Buddha’s Light International Association• Toronto Elegant Lions Club• Jenny Wong Beauty Institute• Power 7 Team• Toronto Chinese Road Bike Club• MiTV• Mr. & Mrs. Fred Kwan & Mimi Chau• Mr. and Mrs. Peter Choy

To support the advancement of the Carefirst One-Stop Multi-Services Centre, donors can still participate in the Room Naming and Furniture Naming Campaign for the support of further development of the “One-Stop Multi-Services Centre”. Donors can choose their preferred areas or furniture items for honoring their loved one. Alternatively, a wish list is available with the most needed items in supporting the centre’s service delivery.

2015/2016 Financial Report

39


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40

Honorary Advisors

Irene So Stanley Kwan

Honorary Members

Benjamin Fu Samuel Tan

Dr. Ying Lu Anna Yip

John Man Alex Yuan


Chair

Ian Po

Vice Chair

Jason Chiu

Treasurer

Peter Choy

Secretary

Stephanie Ho

Directors

Maggie Deng* Sunny Ho Matthew Wan

Kevin Fu Wilson Lam Michael Wong Ambrose Fung Shirley Ng

Philip Ho Linda Tam*

*Resigned during the term

Nominees for 2016 – 2017 Board of Directors

Stephanie Ho – Re-elect Cathy Li Philip Ho – Re-elect Allan Sum Matthew Wan – Re-elect Ben Luong

Yan Liu Will Sung



Finance Controller & IT Director Edmund Kwan Director of Development & Communication Edith Lam

Foundation

Donors

41

Au Yeung, Eric KuenBassi, HarmeshBaylatry, DucChan, MirandaDr. Chang, IrisChao, Chih JunChau, Mei Lan MimiCheng, KennethCheng, PaulCheung, Yuki Sau FunDr. Chien, JosephChiu, Simon, Hon-SheungChung, KimChung, SigridDr. Choy, Ping FunChung, KimChung, SigridDiMenna, PingFan, LilingFok, Kenneth Hoi WaiFu, Benjamin W.Fu, GeorgeFung, AmbroseFung, EdmundFung, JohnnyHabra, AnthonyHo, DavidHo, DouglasHo, LingHo, StephanieHo, Sunny

Dr. Hong, CollinKam, MichelleKo, KamKwan, ThomasKwan, Wong SzeLai, WilliamLam, EdithLam, RayLaw, Edmund Yick TakLee, BarbaraLee, KingsonLeung, HelenLeung, Rosie Lok SzeLeung, StephenLoo, WhitelerMa, YingYingMin, JeffreyMui, AnitaMui, OliviaOrfi, PeriDr. Neysmith, SheilaDr. Ng, PaulNg, ShirleyNg, WinterNgai, MoiraNguyen, CatherinePo, IanSeto, WendySeng, K.H.Sie, Patsy Shuk-WahSiegal, Marissa

Dr. Sinha, SamirSo, IreneSzeto, AllenDr. Tam, PaulDr. Tam, SandraWan, MatthewWong, Arnold & DianaWong, Bernice See KaiWong, ChrisWong, ChristinaWong, FordWong, GordonWong, Justina Wai SumWong, KevinWong, Michael Chan YukWong, Susan Foon ChimWong, Teresa KWong, Yuen MingDr. Wu, GeorgeWu, PatrickYeung, Philip Kai KwongYick, Jok LeungYip, AnnaYu Iu, Shui HungDr. Yuan, AlexLate Mrs. Sun Po Chu Memorial FundLate Mr. KK Kwan Memorial FundLate Mr. Chup Yan Lee Memorial Fund

S.C.C.O. Management Inc.Torce Financial Group Inc.Toronto Chinese Road Bike Club

Mimi Chau & Frank KwanChoy, Peter & IsabellaChung, KimChung, Sigrid

Fu, Benjamin W.Fu, GeorgeOrfi, PeriPo, IanSeng, K.H. Wong, Susan Foon ChimYick, Jok Leung

AstraZeneca Canada Inc.EFES Management LtdFontana Development LtdFu's Borchun Property Management Ltd.International Buddhist Progress Society

Of TorontoPower 7 TeamSenghwa Trading Inc.

SPECIAL TRIBUTECarefirst & Carefirst Foundation would like to extend our heartfelt gratitude to the following

supports who have donated / raised $10,000 and more to Carefirst in 2015 / 2016

Our heartfelt thanks to all donors and supporters, with special recognition to contribution of$500 or more to Carefirst & Carefirst Foundation (April 2015 – June 2016)

INDIVIDUAL DONORS

donors 2015.qxp_Layout 1 9/12/16 10:40 PM Page 1

Donors

42

Our heartfelt thanks to all donors and supporters, with special recognition to contribution of$500 or more to Carefirst & Carefirst Foundation (April 2015 – June 2016)

CORPORATE DONORS

2333162 Ontario Inc3T Financial Services IncAdvanced Physiotherapy & Rehabilitation CentreAlpex Prime IncARK Group Construction & Development Inc.AstraZeneca Canada Inc.Bayview Hill PharmacyBest Deal Graphics & Printing Inc.BrokerTeam Holdings Inc.Brookfield Multiplex Construction Canada LtdCanadian Chinese Line Dance AssociationCB Ross PartnersCFMC Pharmacy LtdCHC Technology Inc.CIBCClear Tone Hearing CentreCops & Community Charity Eventcsr eco solutionsCW BroupDr Eric Hui Dentistry Prof CorpDupak IncDyamond Co. Ltd.Dynamic Security & Telephone Systems CorporationEFES Management LtdFontana Development LtdForward SignsFu's Borchun Property Management Ltd.Heart & Stroke Foundation of OntarioHighland Feather Manufacturing Inc.Homelife Gold Pacific Realty Inc.Hong Kei Fitness & Dance ClubHong Kong Economic & Trade OfficeHSBC Bank CanadaInternational Buddhist Progress Society Of TorontoJenny Wong Beauty InstituteJ.S. Cheng & Partners Inc.Kingstec Technologies Inc.

Landstars 360 Realty Inc. BrokerageMackenzie Financial CorporationMagna International Inc.Mandarin HolidaysManulife FinancialMetcalfe, Blainery & Burns LLPMiTVMontgomery Sisam Architects Inc.Mount Pleasant Group of CemeteriesNeo City CaféOn Care Pharmacy LtdPeter B. Choy & AssociatesPoon & Ho LLPRBCRBC Global Asset ManagementRESCO Mortgage Investment CorporationS.C.C.O. Management Inc.Scarborough NephrologistsSenghwa Trading Inc.Sun & Partners Professional CorporationSwismond Jewelery International Inc.Tam & Ting Medicine Professional CorporationTD Bank GroupThe Scarborough HospitalThe Toronto Cathay Lions ClubThe Toronto Paragon Lions ClubTorce Financial Group Inc.Toronto Chinese Road Bike ClubToronto Elegant Lions ClubToronto Heart CentreToronto HyundaiTown of Richmond HillTrillium Sleep CentreV Can Construction IncWah Lung Labels Canada Inc.Walton Capital Management Inc.Willow Springs Winery (2010) Limited


Acknowledgements

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Funders

Carefirst would like to extend our heartfelt thanks to the following funders, communityorganizations, business corporations and individuals for their contributions and support.

City of Toronto Community Partnership and Investment Program– Community Services Grant ProgramCommunity Care Access Centre, CentralCommunity Care Access Centre, Central EastCommunity Care Access Centre, Toronto CentralEmployment and Social Development Canada – New Horizonsfor Seniors ProgramLocal Health Integration Network, Central

Local Health Integration Network, Central EastLocal Health Integration Network, Toronto CentralOntario Ministry of Health & Long-Term CareOntario Seniors SecretariatOntario Trillium FoundationUnited Way of Peel RegionUnited Way Toronto and York Region

Community Organizations

105 Gibson CentreAccreditation CanadaAgincourt LibraryAlzheimer Society of OntarioAlzheimer Society of PeelAlzheimer Society of Toronto Alzheimer Society of York RegionBayview Hill Community CentreBridle Trail Baptist ChurchBridletowne Park Church Campaign and Community Engagement Viral Hepatitis Care

Network (VIRCAN)Canada Revenue AgencyCanadian Chinese Health Qigong OrganizationCanadian Chinese Line Dance AssociationCanadian Diabetes Association Canadian Mental Health AssociationCanadian Patient Safety InstituteCaring for Aging Relatives Group (CARG)Catholic Family Services Peel-DufferinCentre for Addiction and Mental HealthCentre for Education and TrainingCentre for Immigration and Community Services (CICS)Chinese Canadian Community Service CentreChinese Canadian Line Dance AssociationChinese Caregiver NetworkChinese Family Services of Ontario (CFSO)Chinese Inter-agency Network (CIN)Chinese Social Service Network-York (CSSN-YR)Circle of CareCity of MarkhamCity of Toronto - Parks & Recreation DepartmentCNIB (Vision Loss)Coalition of Agencies and Seniors Serving Immigrant SeniorsCommunity Care Information Management

Community Home Assistance to the Seniors (CHATS)Community Legal Clinic of York RegionCoral PlaceCreditvale MillsCummer Park Community CentreDancepooh TeamDixon Hall Neighbourhood ServicesElder Abuse OntarioFCCM Cultural CentreFife HouseGeorge Brown CollegeGoldhawk Dance GroupGreater Toronto Chinese Christian Churches CouncilHealth CanadaHeart & Stroke Foundation of OntarioHong Fook Mental Health AssociationHosanna Evangelical Free ChurchHospices Association of OntarioHousing York Inc.Joyful Christian ChurchL’Amoreaux Community & Recreation CentreLadies Leisure ClubLangstaff Community CentreLumacareMackenzie Health Richmond Hill HospitalManagement Advisory ServicesMarkham Chinese Baptist ChurchMarkham Chinese Presbyterian ChurchMarkham Federation of Filipino CanadiansMarkham Free Methodist ChurchMarkham Missionary ChurchMarkham Stouffville HospitalMarkham Wesley Community Services CentreMcConaghy Seniors CentreMcNicoll Manor


Acknowledgements

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Mill Brook PlaceMilliken Mills Community CentreMinistry of LabourMississauga Chinese Presbyterian ChurchMississauga Fire & Emergency ServicesMitchell Field Community Recreation CentreMomiji Health Care AssociationMon Sheong Long Term Care CentreMount Sinai HospitalNew Unionville Home SocietyNorth Toronto Chinese Alliance ChurchNorth York Central LibraryNorth York Elder Abuse NetworkNorth York General HospitalOak Ridges Community CentreOntario Community Health CoalitionOntario Community Support AssociationOntario Network for the Prevention of Elder Abuse (ONPEA)Ontario Service Safety Alliance (OSSA)Ontario Telemedicine Network (OTN)Peel Chinese Inter-Agency Network(PCIAN)Peel Elder Abuse Prevention Network(PEAPN)Peel Regional PolicePolycultural Immigrant & Community ServicesPrevention of Elder Abuse of York RegionPublic Health Agency of CanadaQuality Improvement and Innovation PartnershipRainbow TeamRegent Park Community Health CentreRegion of PeelRevenue CanadaRichmond Hill Chinese Baptist ChurchRouge Valley HospitalRyerson UniversityScarborough Centre for Healthy CommunitiesScarborough Diabetes NetworkScarborough Elder Abuse NetworkScarborough Housing Help Centre Scarborough NephrologistsSeniors Tai Chi Enthusiasts of MarkhamService CanadaSocial Services NetworkSouthlake Regional Health CentreSPRINT Senior CareSt. Christopher Chinese Anglican ChurchSt. Christopher House St. Elizabeth's Anglican Church

St. John AmbulanceSt. Paul’s L’Amoreaux CentreSt. Stephen’s Community HouseSteeles L’Amoreaux Strength in PartnershipStouffville LibraryTendercare Living CentreThe Canadian Hearing SocietyThe Credit Valley & Trillium Health CentreThe Scarborough HospitalThe Wellness Centre, Mount Sinai HospitalToronto Centre for Liver Disease UHN – Toronto General HospitalToronto Chinese Baptist ChurchToronto Chinese Community ChurchToronto Community Housing CorporationToronto Fire ServicesToronto Housing ConnectionsToronto Police 42 DivisionToronto Public LibrariesToronto Rehabilitation CentreTown of Richmond HillTranscare Community Support ServicesUniversity of TorontoVaughan Community Health CentreVaughan Health Care CentreVHA Home Health CareVolunteer CanadaVolunteer TorontoWelcome Center Vaughan Welcome Centre Markham NorthWelcome Centre Markham SouthWelcome Centre Newmarket Welcome Centre Richmond HillWellness Club CommitteeWest Neighbourhood HouseWinnie Wang Line Dance GroupWorkplace Safety & Insurance Board (WSIB)Xin Tian Di Senior Association Yee Hong Centre For Geriatric Care York Region Chinese Health Initiative Network (YRCHIN)York Region TransitYork Regional PoliceYWCA Toronto

Community Organizations


Acknowledgements

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Au, YvonneAu-Yeung, EricChan, EmilyChan, MichaelChawla, Dr. RadhikaChen, GuochanChen, SandyChen, Yue YueCheung, Hon TaiChiu, Dr. AlanChiu, KennethChoi, Dr. Christina Chow, EdmundChow, HenryFung, DarylFung, PatriciaFung, Phyllis Ho, Kwong Yee

Ho, Macie XiaomeiHo, PeonHoang, LindaJiao, PengKeung, AlanKo, MichelleKong, PeggyKwok, Dr. JasonLai, ThomasLam, Rev. KarlLam, Tin ChorLau, JoannaLau, LindaLaw, EdmundLee, MabelLeung, SolonLi, Mien-ChenLing, Andrew

Luk, CatherineMa, Kit YeeMak, JulieMiu, RaymondMo, CathyNg, SmilePollock, DonPoon, Dr TeresaPoon, JoanneRamasamy, SathiaRawlins, Julian Shan, Ji QingSiu, LolitaSum, SteveTang, CeciliaTang, Jun WeiTo, Dr. CharleneTong, Bobo

Tsui, JackyWan, LindaWong, AndrewWong, AnsonWong, BernardWong, Man KuenWong, MargaretWong, TeresaWong, VincentYee, Maria Yiu, Wing MuiYip, LeslieYu, WinnieYuen, JasonYung, PeterZhu, Suki

Au, SusannaChan, AliceChan, Anny Wing Kit Chan, Francis Kui Tuen Chan, Michael Kwok Siu Cheng, Hoi Fai Cheng, Jason Chung Ling Cheng, Peggy Suk Ling Ho, Hilda

Hung, James Shun Wan Ko, Jimi Kong, Doreen Fung Luen Kung, Christina Kwok, Irene Kwong, Belinda WingLam, Jack Tak Fai Lau, May Hing Lee, Kenneth Kam Wing

Leung, Shiu Hong Leung, Yee Ling Li, Ella Lo, Janny Chin YingLo, Winnie Ng, Teresa Rosario, Mario Shaw, William Shum, Peter Chung Leung

Tam, Kai Yuen Tang, AndrewTing, Gloria Tse, Karen Ching Wai Tung, Jennia U, AnissaWong, Angela KuenWong, Daisy Mo Dak

Business Corporations and Individuals

A1 Chinese RadioAltima Wellness CentreBayview Hill Pharmacy Carson Wing Tsun AcademyChartwell PlaceCirca TowersEdmund PharmacyEva Mak SolicitorFairchild RadioFairchild TelevisionFocuspoint Optical Guardian Pharmacy

HSBC Bank Canada, Willowdale BranchJenny Wong Beauty SchoolMarket VillageMing Pao Daily NewspaperMiTVMobility MattersMount Pleasant Group of CemeteriesNorth American Weekly TimesNovo Peak HealthOMNI 2Philips LifelinePierre-Yves Wong

Primo Chiropractic and PhysiotherapyRoyal Bank of CanadaSheraton Parkway Toronto North HotelSing Tao Daily NewspaperStar-3 GroupSunny C Ho – Barrister, Solicitor & NotaryToday Commercial NewsToronto Chinese Music SchoolToronto Pearson International AirportUNI shows SystemUnionville Hearing Centre

Special acknowledgement to the following volunteers who have contributed over 200 service hours in 2015 – 2016


2015 ~ 2016 Activities Highlights

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Carefirst Seniors Services, Carefirst Foundation and Carefirst Family Health Team Board Directors and the dignitaries at the 2015 Annual General Meeting.

Celebrating 40 years of serving the community

Celebrating the building completion of the Carefirst One-Stop Multi-Services Centre

Carefirst One-Stop Multi-Services Centre Open House

Carefirst One-Stop Multi-Services Grand Opening

Delegates from Agency for Integrated Care (AIC) Singapore visiting Carefirst to learn about Carefirst’s Integrated Model of Care

Carefirst Board of Governance at 2015 Christmas Party and Volunteer Recognition Dinner

Carefirst Board Directors and the dignitaries at Carefirst 2016

Young at Heart Charity Gala.


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(L to R) Carefirst Board Directors Shirley Ng, Michael Wong, Thomas Chanzy of Ontario Trillium Foundation, Carefirst Foundation Chair Ian Po, Hon. Michael Chan, Hon. Advisory Chair Irene So, former Carefirst Board Director Alan Liu, Director Stephanie Ho.

(L to R) Thomas Chanzy of Ontario Trillium Foundation, Hon. Michael Chan, MPP Soo Wong present recognition plaque to Sunny Ho

Over 500 guests supported and attended the Carefirst One-Stop Multi-Services Centre Grand Opening Ceremony

Special recognition from Carefirst and Carefirst Foundation to the Fu’s Family for their staunch support towards the development of Carefirst One-Stop Multi-Services Centre.

Glenn Chan, President of Buddha’s Light International Association Toronto (L2), Ven. Yung Ku, Abbess of Fo Guang Shan Temple(R3), Stanley Kwan, Hon. Chair, Carefirst Capital Campaign Campaign(R3) , at the Plaque Presentation Ceremony

(L to R) Dr. Ying Lu, Dr. Samir Sinha, Professor Paul Williams, Helen Leung,

Carefirst CEO, and representatives from The Scarborough Hospital

Carefirst One-Stop Multi-Services Centre Grand Opening Highlights


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Carefirst Charity Walk for Health.

Peter Choy (Foundation Treasurer), Sunny Ho (Carefirst Board President), Ian Po (Foundation Chair) and team participated in Scotia Waterfront Marathon to fundraise for Carefirst.

(L to R) Ian Po, (Foundation Chair), Irene So, (Carefirst Honorary Advisor Council Chair), and Stephanie Ho, (Foundation Secretary) at Carefirst’s first Charity Golf Tournament in celebrating Carefirst 40th Anniversary.

Peter Choy (Foundation Treasurer), and Sunny Ho (President) presenting recognition plaque to Billy Law and members of Toronto Chinese Road Bike Club for organizing “Ride for Carefirst” Event.

Carefirst Annual Radio Telethon

Dr. Joseph Chien (L3), Carefirst Board Director, and Helen Leung, CEO, receiving support from AstraZeneca Canada towards Carefirst Community Chronic Obstructive Pulmonary Disease (COPD) Rehabilitation Program

Michael Wong (Executive VP), Sunny Ho (President), Ian Po (Foundation Chair), Janet Lee (Secretary), Amanda Yeung Collucci, Markham Councillor, presenting recognition plaque to Abby Lee, renowned artist from China, for supporting Carefirst Mother’s Day Dinner.

S tephanie Ho (Foundat ion Secre tary) , and Sunny Ho (Care fi rs t Pres ident ) , and Markham Mayor Scarpi t t i , rece iv ing donat ion f rom Fred Kwan & Mimi Chau (R1 & 2)whi le ce lebrat ing the ir 30 th Wedding Anniversary .


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Community Health Fair

Carefirst Ladies Leisure Club celebrating Mother’s Day with seniorsCommunity Exercise Class

Energetic Youth Volunteer Team Dedicated volunteers receiving long service awards

Professional Staff Teams with different ethnic culture background and linguistic skills

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