What is your team’s integrated care delivery capacity in Year 1?


The Year 1 population includes approximately 550 patients:

  • 250 are patients currently on H&CC palliative caseload
  • approximately 200 are patients with a diagnosis of a life limiting illness and are on a general H&CC caseload
  • up to 100 other patients are currently on the G&A HL caseload and have been diagnosed with a life limiting illness.

By the end of Year 1 Guelph & Area patients who are diagnosed with a serious illness will be identified early and have their chart flagged by a common mechanism. Identification tools to be utilized are the HOMR tool in acute care, CHESS score in RAI HC in H&CC and the Palliative EMR Toolbar in primary care. All care team members will be granted access to the coordinated care plan (CCP).

All palliative patients will receive integrated care coordination from their primary care team.  Currently there are 5 FTEs in G&A supporting patients receiving specialized palliative care including functions such as direct NP and Care Coordination. Early in Year 1 we will consider how to optimally integrate these, and other Hospice Palliative Care (HPC) system resources (including contracted service provider functions, Hospice services and existing primary care resources), into the IPCT model to support primary care capacity and capability to deliver palliative care whilst preserving the demonstrated success of having a dedicated secondary HPC team that serves the secondary / more complex palliative and end of life care needs of our patients.

Mental Health & Addictions

  1. Tier 5 – A ‘Rapid Access Health Hub’ will be developed to deliver needed services to this complex population including primary care, psychiatry, MH&A services (including Acquired Brain Injury services). Every client will be assigned a primary outreach worker who will coordinate the client’s care.  Outreach workers will access the resources in the hub to ensure timely and easy delivery of care. Virtual care visits will be utilized to reduce barriers to clients accessing the healthcare services they need. The total Tier 5 population in the G&A OHT is approximately 320 and we will deliver this care to 100% of these patients in Year 1. This service will be offered in collaboration between CMHAWW, Guelph CHC, Stonehenge Therapeutic Community, and Sanguen Health Centre
  2. Tier 3 – This service is customized to the needs of Tier 3 clients and will see the integration of MH&A counselling, integrated behavioural health consultants and care coordination into primary care team.  The total Tier 3 population in the G&A OHT is approximately 9,760 and we will deliver this care to approximately 750 of these patients.  This service will be collaboratively delivered by the Guelph FHT, in collaboration with CMHAWW, Stonehenge Therapeutic Community, Family Counselling and Support Services and H&CC.

For our third priority population, care coordination will be fully integrated within the integrated primary care team. Given the primary care attachment rate in Guelph and Area is 97% and 100% of primary care providers have access to inter-disciplinary teams the full population of our OHT will begin to experience the benefits of integrated care coordination in Year 1.

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