November 2019
This communique reflects the work of the One Client One Plan (OCOP), a system partnership project bringing together the North East region’s 70 Home and Community Care providers to deliver a consistent approach to care planning for clients. In addition, it also highlights other home and community care initiatives that support the goals and objectives of OCOP.

We’re hoping this new format is easier for you to access and view. Let us know what you think by contacting the project team at You can also visit to read past communiques.


So far 26 health service providers have received training on Caredove. This means that they can soon refer their clients to other participating North East home and community care agencies using this software solution.  In November, North East LHIN Care Coordinators will receive training and referrals throughout the sector will begin shortly after. Benefits to using Caredove; it will improve the client’s journey, intake appointments can be booked online directly into participating health service providers’ calendars, and no second phone call need to be made! To join the next training cohort contact OCOP at


Susan Hill, Care Coordinator, for Neighbourhood Model in Sault Ste. Marie.

The OCOP Team presented a poster on the work achieved so far at the 2019 Ontario Community Support Association (OCSA) Conference - Community Connect held in Toronto, Oct. 23 and 24. The focus this year was on acquiring the tools needed as leaders in home care, independent living and community support to thrive in a transformed health system.

The poster highlights the current work underway by multiple partners and workgroups to achieve Betty’s “ideal journey,” which was mapped out at our original Betty’s Journey Workshop (March, 2018).

To see the full poster click here.


A project related to OCOP’s work to improve the client’s journey, was also featured at OCSA -- the Neighbourhood Model of Care. Russel DeCou, Kerri McMaster and Susan Hill, from the North East LHIN, along with Kelly Zinger from NE Home and Community Care Regional Network, and Mara DeFazio, Elizabeth Remmer and Diane Lajambe from Canadian Red Cross presented on how the model benefits tenants and highlighted the value of collaboration. A Neighbourhood Model is a flexible and creative model of care, which maximizes and coordinates services within social housing buildings and neighbourhoods. In addition, it is designed to better support clients and tenants transitioning back to their home following an acute episode.

To date there are Neighbourhood Models in Sault Ste. Marie, Capreol, Little Current, and soon, one will open in Sudbury.


Great strides have taken place to expand virtual assisted living across the region thanks to the work of many partners. As part of this expansion, a centralized Hub has been established to accept referrals and administer the wait list for virtual assisted living requests focused on Priority One patients in hospital. This flexible model will help discharge these eligible patients, more quickly back home. Regional Hub Coordinator Nicholas Labine ( administers the Virtual Assisted Living Model. This new system was launched on November 4th in Sudbury, North Bay and Sault Ste. Marie.  Timmins will be added at year’s end.


Ever wondered what a North East LHIN Mental Health and Addictions Nurse does or what’s entailed in Family Managed Home Care? The North East LHIN’s knowledge exchange videos – focused on all the different home and community care teams within the LHIN – are now ready for viewing in three easy steps. The videos are between 3 and 11 minutes in length. Next step, is to add to the inventory of video clips with more health providers participating.
  1. Click here.
  2. Enter ‘OCOP’ with all capitals for both the username and password
  3. Choose the session you wish to watch, by clicking on it.