After receiving confirmation of our invitation to complete a full proposal to become an OHT in July 2019, the G&A OHT Core Partners confirmed leads for the two priority population work streams. The G&A OHT Core Planning Table (including representation from all 12 Core Partner Organizations) has, and continues to meet each week to provide executive leadership and guidance on all areas of the OHT planning, including the submission development. Additionally, throughout September, the partners of the Core Planning Table each blocked 1.5-3 hours per week in their schedules to contribute to this submission document. A “LIVE” version of our submission was housed on Google Docs for joint contribution.
On August 7th, a ‘Transformation Lead’ role was initiated (a secondment from the WWLHIN) to support and lead the full submission process. The decision to not use a third party/consultant for this work was intentional as it was agreed that a local, neutral/ objective lead would best understand and advance the strong trusting partnerships that are the foundation of our success.
We have met with City of Guelph Mayor, Cam Guthrie, MP Lloyd Longfield and MPP Mike Schreiner to keep them informed of our progress towards development of the Guelph and Area OHT. Each endorse and support our work. June Hofland, City of Guelph Councillor has participated in several community engagement sessions.
The Palliative leads held engagement sessions on July 4th and August 21st that involved family caregivers, and staff from primary care, home and palliative care, acute care and others in palliative planning roles.
The MH&A Group held an engagement session on June 24th and August 7th with Individuals with lived experience, peer workers, outreach workers, front line staff from various MH&A organizations, physicians, management and directors from various MH&A organizations, first responders, front line providers to gather an in-depth understanding of what is and isn’t working within current MH&A system and identify population(s) with the greatest need for transformed care during Year 1. These themes and change ideas were then finalized at two separate engagement sessions with front line providers and patients on August 20th and September 8th. Final change ideas were then brought to an implementation planning group of service providers on September 19th to map out what a future state could look like and how it might be achieved.
With the mature state models of care designed for the priority populations, we held a H&CC engagement session with front line LHIN staff, representatives from service provider organizations and other stakeholders to create guiding principles for the transformation of H&CC (See Table V) and to create a vision for care coordination, system navigation and supported transitions within the G&A OHT. This event intentionally brought the MH&A and Palliative Work Streams together to ensure that a broader population-level model of integrated H&CC emerged, thus mitigating the risk that specialized care coordination models be developed for unique client populations (which would lead to extensive patient & provider confusion). That said, the groups acknowledge the need for flexible, client-centred approaches to care for differing population groups, which has been captured and incorporated into the design.
With the models of care for our priority populations developed and a vision and plan for care coordination, system navigation and supported transitions overlaid on these models, we then held a digital health engagement session on September 5, 2019. The purpose of this session was to begin to understand the clinical problems being addressed in Year 1 and to identify digital health enablers to both achieve Year 1 key change activities for the priority populations and to vision an ideal future state for digital health in the G&A OHT. The group, now named the G&A OHT Digital Health Working Group (DHWG), met 4 additional times between September 11th– October 2nd to collectively respond to the questions in Appendix B of this submission.
On September 10th, we presented information about OHT in general and some high level plans for the G&A OHT to the WWLHIN Guelph H&CC staff and feedback was collected re: opportunities and barriers, how OHTs can best improve the patient experience and transitions in care.
September 12th was an inaugural meeting of the Data/Decision Support Group. An A3 facilitated session was held to help confirm the functions of a decision support service for the OHT to then enable them to envision a structure. This session was held on September 24th where the group excitedly envisioned an integrated decision support function and structure for the G&A OHT stating, “we are better together” and “we’ve been waiting a long time for this!”.
On September 18, 2019 Core Team Partners had a full day planning session where “Integrated Primary Care Teams” were envisioned (See Figure VI) and a “Guelph and Area OHT Leadership Structure” (See Figure VII) were developed. On this same day, another patient, caregiver and persons with lived experience engagement session (with 22 attendees) was held to report back what we had done with the feedback they had given us in earlier co-design engagement sessions and to seek their suggestions as to how they should be engaged, informed and involved moving forward as the G&A OHT develops. Their feedback is being used to inform the design of a patient engagement strategy for our OHT. A representative from the French Language Health Planning Entity participated in this session.
On September 26th, we held a governance engagement session with the following objectives:
- Provide and update on the mandate for OHTs, and the status of the G&A OHT submission to date
- Provide input to establish the joint Purpose and Guiding Principles for governing the G&A OHT
- Discuss Interim Governance Structure options for the G&A OHT
We shared a short video (www.kingsfund.org.uk/joinedupcare) with our governors to help them envision the impact that truly integrated care has on patient outcomes and experiences. They were inspired and motivated towards this reality within the G&A OHT.
This was a VERY successful event at which energy and trust was built, Year 1 governance functions and structures were identified and a plan to develop long term governance was established.
In September 2019, each Core Partner board passed the following joint motions:
- To approve, in principle, the G&A OHT Submission
- To direct leadership of each G&A OHT core partner to jointly develop a proposal for a joint strategic planning process to be completed in Year 1 (2020)