South West LHIN Exchange Newsletter – October 2017

Connecting Care to Home garners national award and international recognition
Patients First Update: Sub-region integration tables set to tackle local change

South West LHIN welcomes Dr. Cathy Faulds as Chief Clinical Lead
Video: Connecting the Dots
Restorative care program wins provincial award
South West LHIN Nurse Practitioner recognized for contributions

Help improve digital health in the South West LHIN


Connecting Care to Home garners national award and international recognition 

Connecting Care 2 Home

 Connecting Care to Home (CC2H), a new local collaborative program aimed at integrating patient care between  hospital and home is gaining the attention of European researchers and health care providers. Results of the  program, launched in October 2015, are significant. Hospital length of stay is roughly 54 per cent shorter, hospital  readmissions are down by almost 60 percent, and the total cost per patient to the health care system has declined   by almost 50 percent.

 Based on CC2H’s success Donna Ladouceur, South West LHIN Vice President of Home and Community Care, was  invited to present the innovative care model to researchers at the first Annual European eShift research conference  in Paris, France in September. All expenses were supported by the National Health System.

 The model is the result of a collaboration between the South West Local Health Integration Network, London Health Sciences Centre, St. Joseph’s Health Care London and the Thames Valley Family Health Team.Donna Ladouceur

CC2H works by engaging patients, and ensuring that hospital, community and family physicians are working together to support the best care possible for those with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF), a patient population with high rates of emergency department visits and hospital readmissions.  

“This model truly exemplifies collaboration and provides patients with the tools and support they need to live well in their homes,” said Donna Ladouceur, Vice President of Home and Community Care, South West LHIN.

CC2H successfully integrates patient care between hospital and home by offering patients education and involvement, leading practice care pathways, physician participation through teleconference with both family and hospital physicians, clinical patient data, a 24/7 live support phone line and supported self-care initiatives. Patients are given the knowledge and tools to manage their symptoms at home.

CC2H has also been recognized nationally as the recipient of the 3M Health Care Quality Team Award. Recognition is based on three elements: innovation, quality and teamwork. This model was built on the success of the eShift program supporting medically fragile children and palliative patients at home. Partners are now looking at ways to expand the program to possibly support those with other chronic conditions and to treat mental health. 



Patients First Update: Sub-region integration tables set to tackle local change

QuotesAs part of our plans to implement Patients First and drive local system change, the South West LHIN Sub-region Integration Tables held their inaugural meetings on October 5, 2017. The five tables, aligned to the South West LHIN sub-region geographies will drive local health care priorities, affecting change through innovation and collaboration.

The patient, family caregiver and care provider groups will leverage system thinkers, local leadership and the patient voice within the healthcare system to help the LHIN identify, plan and make recommendations for both local and system priorities.

"With the right mix of health service providers and patients, the integration tables will have the insights needed to effectively identify local care gaps and influence change in a powerful way that can improve patient outcomes and provider experiences in a meaningful and sustainable manner," says Dr. Paul Gill, Clinical Lead, Huron Perth Sub-region.

Members will influence the important changes needed to improve population health and wellness; patient experience and outcomes; as well as value for money.

Visit for a full listing of Sub-Integration Table members and background information.   





South West LHIN welcomes Dr. Cathy Faulds as Chief Clinical Lead

Cathy Faulds


The South West LHIN is pleased to announce Dr. Cathy Faulds has been named Chief Clinical Lead. Dr. Faulds brings over 30 years of experience in comprehensive family medicine working in various models of care including hospital and long-term care. In her new role she is working collaboratively with other system partners to develop a more integrated, patient-focused health care system.

As Chief Clinical Lead, Dr. Faulds is providing clinical leadership and strategic direction to advance engagement among partners, clinical standards implementation, patient safety and quality improvement. She is leading and coordinating a team of LHIN primary care and specialty clinical leaders to improve clinical coordination and achieve quality improvement within LHIN sub-regions.

"I am excited to be leading the inception of a strong clinical leadership team in the South West LHIN,” says Dr. Faulds. “The participation of all sectors, with a voice from the primary care alliance at the Sub-region Integration Tables, will reduce poor transitions in care and truly allow a patient-centred health care experience.”  

During the course of her career, Dr. Faulds served as President Elect, President and Past President of the Ontario College of Family Physicians. Dr. Faulds currently serves as Adjunct Scientist and Professor at the Lawson Health Research Institute and University of Western Ontario and has served on the Board of Directors for the College of Family Physicians of Canada and the London Family Health Team.

Find out more about the LHIN’s clinical and sub-region leadership team



Mike Bachner suddenly became caregiver to his wife Cathy when she contracted a life-threatening illness requiring intense medical treatment that lasted for three months. During this stressful time he was asked to make fast, critical decisions on her behalf with what felt like limited, simplistic information.

“They saved her life and I can’t give them enough praise,” says Mike. “However I was not part of the communication flow.”

Following Cathy’s recovery, Mike has become an advocate for improved communication between caregivers and care providers, and is involved in the ‘Connecting the Dots for Family Caregivers’ initiative. Aimed at co-designing systems of care provision and communication, the ultimate goal is to improve quality and experience for caregivers, patients and health care providers.

Focused in Huron Perth, Connecting the Dots is a partnership with The Change Foundation, health system partners, family caregivers and patients and the South West LHIN. Watch Mike’s story and learn more



Outreach team supports enhanced palliative services in Huron Perth

Huron Perth Team

Palliative patients living in Huron Perth and their families will benefit from enhanced clinical resources available to primary care providers through a new outreach team.

A Huron Perth Palliative Care Outreach Team has been established in the region offering 24/7 consultation and mentorship for those caring for patients in the community with complex physical, psychosocial or spiritual needs in their palliative illness trajectory.


The team is part of a broader South West LHIN strategy to strengthen palliative care services. Oxford, Grey Bruce and Elgin counties also have outreach teams. Evidence shows that patients in the community are more likely to receive well-coordinated, high quality care within this type of model.

“In Huron Perth we don’t have any palliative care specialists, so we are trying to increase capacity for the people who provide care to patients in the region,” says Sandra Gaunt, Manager, Huron Perth Outreach Team.


The multidisciplinary team includes on-call physicians, primary care providers, a pain and symptom management consultant, visiting hospice coordinators, nurse practitioners, a psychosocial/spiritual clinician, care coordinators, manager and support staff.

Primary care providers seeking advice or assistance in caring for palliative care patients can call the Huron Perth Palliative Care Outreach Team toll free at 1-844-361-3877. Mentorship and consult is provided either by phone or in-person. A physician is on-call 24 hours a day, seven days a week.

Knollcrest Lodge has received AdvantAge Ontario’s 2017 Innovation and Excellence Supporting Seniors Award for its Restorative Care Program. The program helps residents to improve their physical, psychosocial, and mental health, and has had a significant impact on residents' physical functioning and, ultimately, their independence.

”We are extremely proud of the work we have done to find innovative ways to improve the quality of life for our residents,” says Susan Rae, CEO, Knollcrest Lodge.

The staff team works in partnership with residents and their families to identify rehabilitative goals and design care plans. Support from a multidisciplinary team may include restorative care, physiotherapy, or nutrition. Each activity is customized, and incentives are tailored to each resident.

Results of the Restorative Care Program show participants have a lower rate of a physical decline in functioning than residents in other long-term care homes. Over a two-year period, the number of residents experiencing a deterioration in their ability to perform daily living tasks dropped from 18 percent to 9 percent.

If you wish to inquire about long-term care in your community, please contact our Access Team at 1-800-811-5146.  



South West LHIN Nurse Practitioner recognized for contributions

Ann Becks

Ann Becks, a nurse practitioner with the South West LHIN, has been named as one of 150 nurses across the country being recognized as part of the Canadian Nurses Association’s Canada 150th celebrations.

150 for Canada Nurses celebrates those in the profession who make a difference in our county’s health care system as strong advocates and leaders in advancing a patient-centred approach to quality health care through traditional, innovative or interprofessional practices.

In her role as a palliative care nurse practitioner with the South West LHIN, Ann is dedicated to supporting patients and families to optimize health in the presence of chronic disease and provide comfort during end-of-life care.

“The incredible courage of patients and families is what motivates and inspires me,” says Ann. “It is an honour and a privilege to be part of people’s lives, to support them as they navigate a difficult journey.”

With a life-long passion for caring for others, Ann has worked as a nurse for 30 years. Appreciative of the opportunities she has experienced, she gives back to the profession through mentorship, teaching and promoting excellence in patient-centred care. 



Seeking feedback from system partners on digital health

Connecting South West OntarioConnecting South West Ontario (cSWO) is conducting a public education campaign to raise awareness of the current and future benefits of digital health in the region and to share the many success stories about digital health and its impact on patient care. Feedback will help understand what people think about digital health in our region. A digital survey is now available for health system partners to distribute to their patients. Participation is voluntary and all responses are confidential. No identifying information is collected and participation in the survey will not result in any further communications.

cSWO is designed to implement a regional ehealth program that will make an individual’s health information from across the continuum of care available in a timely and secure fashion at any point of care. This includes an integrated electronic health record (EHR) and a regional clinical viewer integrated with local and provincial information sources, to enable health care professionals to continue to provide south west Ontario residents with excellent care. 




Connecting Care to Home garners national award and international recognition