Central East Health Links
Glossary of Commonly Used Terms
Acronyms:
ACP: Advanced Care Plan
ADL: Activities of Daily Living (examples: Walking, Toileting, Bathing, Transferring)
ADP: Adult Day Program
AL: Assisted Living
ALC: Alternate Level of Care
BSO: Behavioural Supports Ontario
CCAC: Community Care Access Centre
CCC: Coordinated Care Conference
CCP: Coordinated Care Plan
CCT: Care Coordination Tool
Central East LHIN: Central East Local Health Integration Network
CHC: Community Health Centre
CHF: Congestive Heart Failure
COPD: Chronic Obstructive Pulmonary Disease
CSS: Community Support Service
CWG: Communications Working Group
DNEHL: Durham North East Health Link
DSWG: Decision Support Working Group
DT: Design Team
DWHL: Durham West Health Link
ED: Emergency Department
EMR: Electronic Medical Record
ER: Emergency Department
FAQ: Frequently Asked Questions
FHO: Family Health Organization
FHT: Family Health Team
GAIN: Geriatric Assessment and Intervention Network
GEM Nurse: Geriatric Emergency Management Nurse
GTA: Greater Toronto Area
HCCKLHL: Haliburton County and City of Kawartha Lakes Health Link
HIC: Health Information Custodian
HL: Health Link
HSP: Health Service Provider
IADL: Instrumental Activities of Daily Living (examples: meal preparation, ordinary
housework, managing finances, managing medications)
ISWG: Information System Working Group
MH&A: Mental Health and Addictions
MH: Mental Health
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MOHLTC: Ministry of Health and Long-Term Care
MRP: Most Responsible Provider
NCHL: Northumberland County Health Link
NP: Nurse Practitioner
NPSTAT: Nurse Practitioners Supporting Teams Averting Transfers
PCP: Primary Care Provider
PDSA: the Plan, Do, Study, Act cycle
PHL: Peterborough Health Link
PMO: Project Management Office
POA: Power of Attorney
PPT: PowerPoint Presentation
QI: Quality Improvement
RAI: Resident Assessment Instrument
RN: Registered Nurse
RRN: Rapid Response Nurse
SDM: Substitute Decision Maker
SH: Supportive Housing
SNHL: Scarborough North Health Link
SSHL: Scarborough South Health Link
T/C: Teleconference
USB: Universal Serial Bus
WG: Working Group
Commonly Used Terms
Alternate Level of Care
Alternate Level of Care (ALC) is a clinical designation that identifies patients who no longer require
the intensity of resources or services provided in their current settings (e.g. hospital) and who are
waiting for ALC. These patients often wait weeks, months, and sometimes years in acute and postacute hospitals for transfer to ALC settings, such as Long-Term Care home, supportive housing,
home (with or without services), rehabilitation facility, group home, and palliative care beds.
Care Coordinator/Case Manager
Care Coordinators/Case Managers are regulated health professionals with expertise in nursing,
social work, occupational therapy, physiotherapy or speech therapy, who work directly with
patients in hospitals, doctor’s offices, communities, schools and in patients’ homes.
Care Coordination Tool
The Ministry of Heatlh and Long-Term Care (MOHLTC) received approval to conduct a Care
Coordination Tool (CCT) Proof of Concept (POC) Project that leverages the Integrated Assessment
Record (IAR) for viewing care plans. The CCT will support Health Service Providers (HSPs) within
the circle of care by facilitating the viewing and sharing of Coordinated Care Plans as the patient
moves from one HSP to another.
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Circle of Care
It is a term commonly used to describe the ability of certain health information custodians to
assume an individual’s implied consent to collect, use, or disclose personal health information for
the purpose of providing health care.
Community Health Centre (CHC)
Community Health Centres are non-profit organizations governed by community-elected board
members, providing primary healthcare and health promotion to communities across Ontario.
Coordinated Care Conference
Is a planned and structured meeting attended by the patient, their family/caregivers, and the
health care providers involved in their care to discuss, plan, and evaluate the patient’s care,
including their goals. A Coordinated Care Conference aims to improve the coordination of care,
integrate services across providers, and reduce duplication, while ultimately ensuring the patient is
supported in achieving their expressed goals.
Coordinated Care Plan (CCP)
The Coordinated Care Plan (CCP) is a written or electronic plan created and maintained by the
patient/caregivers and their Care Team, which may include health service providers (HSPs) and
community support service (CSS) agencies. It outlines the patient’s short and long-term needs,
recovery goals, and coordination requirements and it identifies who is responsible for each part of
the plan (e.g. the primary care provider, care team, patient, etc.).
Coordinated Care Planning
Coordinated care planning refers to the process of engaging all participants in a patient’s care
team, including the patient and caregivers to ensure a holistic, patient driven approach to care.
Coordinated care planning includes:
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creating individualized Coordinated Care Plans based on the patient’s expressed goals and
needs
conducting Coordinated Care Conference(s)
continued communication and collaboration and as pre-determined by the Care Team
Experience-Based Co-Design
Experience Based Design (EBD) is a field of study and a method of obtaining the Voice of the
Customer (VOC) by capturing the ‘emotions’ the customer experiences while moving through the
health care system. Experience Based Design is considered a form of customer co-design. Most of
the research and theory on EBD comes from the National Health Service (NHS) in the United
Kingdom.
Experience Based Design uses the patient’s perception of their experience to gain insight which
assists in the identification of opportunities for improvement. Experience Based Design
methodology utilizes a tool known as ‘emotional mapping’ to capture the patient’s experience and
their corresponding emotions as they travel through the ‘touch points’ in the health care system.
The ‘touch points’ technique focuses on the patient’s actual emotional experiences not attitudes or
opinions about the care they received. It moves the quality improvement journey beyond simple
patient satisfaction measurement to a process of honest patient engagement. The focus is on the
relational aspects of care which impact thoughts, feelings and experiences.
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Family Health Team (FHT)
Family Health Teams bring together physicians and interdisciplinary health professionals to provide
patients with better access to care, closer to home. Working in a collaborative environment, along
with other community-based healthcare organizations, Family Health Teams focus on providing
primary healthcare, chronic disease management, disease prevention, and health promotion.
Focus Group
A focus group is a form of qualitative research in which a group of people are asked about their
perceptions, opinions, beliefs, and attitudes towards a product, service, concept, advertisement,
idea, or packaging. Questions are asked in an interactive group setting where participants are free
to talk with other group members.
Health Care Provider/Health Service Provider/Health Service Partner
The terms Health Care Provider and Health Service Provider can be used interchangably to
describe a professional providing health care supports and services to patients. These providers
may include: Physicians, Nurse Practitioners, Physician Assistants, Registered Nurses, Registered
Dietitians, Social Workers, Chiropodists, Occupational Therapist, Respiratory Therapist,
Physiotherapist, Pharmacist, or Registered Practical Nurse.
Lean Methodology
A methodology eliminating non-value added steps in a process to improve quality and timely
delivery of service.
Model for Improvement
A strategy for testing, implementing, and spreading practice innovations. The model includes the
use of Plan-Do-Study-Act (PDSA) cycles or rapid cycle tests of change to drive improvement.
Nurse Practitioner-Led Clinic
Announced in 2007 by the Ontario Ministry of Health and Long-Term Care, Nurse Practitioner-Led
Clinics provide a model of care in collaboration with other interdisciplinary healthcare
professionals. With a focus on providing primary care, disease prevention, health promotion and
self-management, Nurse Practitioner-Led Clinics work alongside community based programs and
services.
Plan, Do, Study, Act (PDSA)
PDSA cycles are part of Quality Improvement methodologies that test an idea by temporarily
trialing a change and assessing its impact.
The four stages of the PDSA cycle include:
Plan: the change to be tested or implemented
Do: carry out the test or change
Study: data before and after the change and reflect on what was learned
Act: plan the next change cycle or full implementation
Primary Care Provider
A primary care provider (PCP) is a health care practitioner who sees people that have common
medical problems. This person is usually a physician, but may be a physician assistant or a nurse
practitioner.
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Process Mapping
A visual representation of the roles and steps involved in a given process.
Quality Improvement
Quality Improvement is an approach to making changes that lead to better patient outcomes
(health), improved performance (care), and enhanced professional development. It draws on the
combined and continuous efforts of all stakeholders — health care professionals, patients and their
families, researchers, planners, and educators — to make better and sustained improvements.
Spread
Spreading information, innovation, and change amongst healthcare professionals and applying
these processes to different chronic illness models of improvement.
Sustainability
Maintaining the changes created as a result of quality improvements within the healthcare system.
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