Community-Based Health Service Capacity

What is Community-Based Health Service Capacity?

Most people’s health and wellness is supported by access to housing, income, education, safe communities, healthy living and clean air. Community-based health and social services also contribute to health, wellness and independent living. They:

• support independent living for people of all ages; services include supportive housing, food, transportation, friendly visiting, and congregate programs;
• promote early detection and intervention; services include screening, immunization, case finding, diabetes education, and foot care;
• prevent hospitalization; services include falls prevention, palliative care, alternative medicine, and ambulatory services, and
• provide continuity of care and recovery after hospital care.

Community services linked with primary care together provide a basket of health and wellness services close to home.

Why Do We Need Community-Based Health Service Capacity?

Most people get most of their health care, most of the time, in the community. Ministry-funded (now LHIN-funded) community support services have evolved independent of each other in response to local needs. Many have multiple funders and accountabilities, employ a range of health professionals, and engage
volunteers. Existing programs and services are challenged by changing population needs (e.g. growing demands for service and clients with complex needs), and resource limitations (e.g. shortage of health professionals and volunteers, wage disparities with other sectors, funding constraints, and a competitive
fundraising environment). From the individual’s perspective, it can be hard to find services, know which services to use, and difficult to travel to services. Services are not equitably distributed across the HNHB LHIN, and there is a lack of standardized tools for assessment, care planning, and outcomes evaluation. Improving access to the right community services and linkages across the continuum of care will support a more seamless and coordinated approach to care.

Resource limitations include a shortage of health professionals and volunteers, wage disparities with other sectors, funding constraints, and a competitive fundraising environment.  At the same time, programs and services are challenged by population needs (for example growing demands for service and increasing number of clients with complex needs). Some people in hospital experience difficulty returning to the community. They often share the following characteristics:

• High to very high difficulties with their instrumental activities of daily living for example, housekeeping, meal preparation, taking medication, and doing laundry.
• More than 50% have moderate to very high impairment in the activities of daily living for example, eating, bathing, dressing, personal hygiene, getting around, and going to the bathroom.
• Take nine or more medications.
• More than a third have moderate to very high cognitive impairment.
• More than a third are incontinent frequently or all the time.
• Suffer from multiple chronic conditions for example hypertension, arthritis and congestive heart failure.
• Are predominantly senior women.

What do they need in the community?

• Coordinated care provided over extended periods of time
• Various levels of health care and human services
• Social and family supports and traditional health care services.

What Will Be Different? 

Standardized tools, protocols, and a culture of continuous quality improvement (e.g. consistent eligibility, assessment and referral criteria, and outcome-based performance benchmarks), will optimize the use of resources in the community sector. Clarity regarding the services available and how to connect to these services will improve appropriate access to services close to home. Linkages across the continuum of care will facilitate a more coordinated approach to care delivery and seamless transitions across care settings.