The Community Navigation and Access Program (CNAP) is a network of over 30 Community Support Service (CSS) agencies in the Toronto area that have collaborated to improve access to and coordination of CSS services for older adults. CNAP Network Agencies aim to ensure that “every door leads to service” so that older adults can reach the care they need. CNAP is supported by the Toronto Central Local Health Integration Network (TC LHIN) through the Ontario Aging at Home Strategy.
CNAP has successfully:
- Aligned member agencies intake and referral processes,
- Developed a centralized intake and referral system to simplify a complex system and facilitate coordinated access to a broad range of community supports and services,
- Completed a Demand Analysis and model development in partnership with Toronto Ride, and
- Implemented an inter-agency referral protocol (warm transfer 1) which ensures that clients and caregivers are supported across agencies and sector boundaries.
CNAP has been in operation since August 2008. However, the seed of CNAP’s original activities took place prior to the development of Ontario’s LHINs. In January 2006, CSS (Community Support Service) agencies in Toronto, through the Executive Committee of the Ontario Community Support Association (OCSA) Toronto Central LHIN District (District 7) held a conference called “The Big Think.” Amongst other issues identified during this conference, the challenge of improving access to CSS services in Toronto was identified as a critical issue for the sector. As a result, the Executive Committee of the OCSA Toronto Central LHIN District (District 7) set up a working group called the Access Working Group to examine access to services for older adults and to suggest how to further improve access to services for clients and caregivers in the region.
The Access Working Group identified navigation barriers to the service support system and developed a system navigation model. The report “Every Door Leads to Service” 2 , (attach link to report) was developed and presented by this group to the OCSA Executive Committee (which acted as the Project Steering Committee). In the spring of 2007, recommendations to adopt the report were presented to the Toronto Central LHIN.
The TCLHIN, sanctioned and endorsed the work of the group, challenging them to address issues identified in the report. The TCLHIN asked the group newly called CNAP (Community Navigation & Access Project) to develop an overall system navigation model framing the work of other TC LHIN initiatives.
During the months following the formal funding of CNAP, the project Chair (Jane Piccolotto from WoodGreen Community Services) and an Executive Committee were identified, and a process of formalizing agency membership in CNAP was initiated. The membership development process involved the signing of a Participation Agreement (link to Participation Agreement) with agencies that provided services to older adults and their caregivers. After some discussion, it was decided that CNAP would target for membership “core” 3 CSS agencies that delivered 4 (four) services or more to seniors with a CSS budget of more than $100K. Although the initial target for successful membership was established at 51% of agencies (which met these criteria by the end of March 2009), CNAP had received signed Participation Agreements (link to Participation Agreement) from 100% of the core agencies (30 agencies). These agencies, plus several others who joined in 2009/10, continue as active members of CNAP.
In June 2009, the TCLHIN renewed the CNAP project, providing the Network with additional funding and new directions which involved further consolidation of the Network and expansion of its roles.
CNAP has used the funding that had been provided by the TCLHIN to hire external resources who were contracted to manage the project and/or to generate specific project deliverables. With the assistance of these resources CNAP achieved the following in its first two years:
- Consolidated a network of 30+ CSS agencies providing services to older adults. (link to current list of agencies)
- Established network-wide consensus on 29 standard CSS service definitions (link to service definitions) + (link to service maps) and their associated service catchment maps, by agency;
- Updated the Toronto Central Community Care Access Centre’s (TC CCAC) Community Care Resource (CCR) database with the CNAP standard service definitions;
- Designed a standardized intake form and referral process with a focus on early identification of Frail At Risk and Marginalized (FARM) seniors (link to FARM Assessment Tool);
- Implemented and evaluated the standardized intake form (link to intake form) and referral process to 30+ Network agencies.
- Planned, developed and piloted a Hub Model as per TCLHIN vision. This included the identification of 3 geographic clusters, the identification of Coordinating Agencies for each cluster, the clarification of Coordinating Agencies responsibilities, and the attainment of consensus on intake and referral protocols across agencies, including protocols for overlapping services, engaged specialized services and CCAC in planning access pathways and protocols for referrals.
- Completed an Information Management /Information Technology (IM/IT) environmental scan, (link to IM/IT Executive Summary) and completed an IT survey in collaboration with E-health office of TCLHIN (Resource Matching and Referral).
- Completed a quantitative evaluation which was presented in the 2009/10 CNAP Report to the TCLHIN in March 2010.
- Provide recommendations for the future expansion of the project including opportunities for linking in physicians, hospitals, CHCs and other sector’s .
1 Warm Transfer: A warm transfer ensures clients communicating with more than one agency don’t “fall between the cracks” as they move between agencies. A Warm Transfer ensures basic intake information is shared between agencies so clients aren’t asked the same questions multiple times, and ensures each client can open any “door” and know that service will be arranged between agencies. (CNAP Orientation Toolkit: Making a Smooth Warm Transfer.)
2 Every Door Leads to Service. A proposal for implementation in community support services. Access Working Group Ontario Community Support Services, District 7, Toronto, May 2007.
3 CNAP Executive decided that some agencies were “more core” than others to the operation of CNAP. For example a community agency with a small Elderly Persons Centre program was “less core” to the goals of CNAP than a multi service CSS agency that provides 5 services to older adults. The total number of CSS agencies that delivered any level of service to older adults at that time was 39 agencies. CNAP Project Charter with Toronto Central LHIN, August 2008.