How will you support patients (and caregivers) to be active participants in managing their own health and health care?

How will you improve patient self-management and health literacy?

The Coordinated Care Plan (CCP) is based on patient identified health goals. The CCP will be broadly initiated across Guelph and Area to encourage patient involvement in their care and improve provider communication regarding patient goals. The teach-back method will continue to be utilized to empower patients and caregivers in supporting their own care in the community where possible.


Serious illness conversations will happen earlier, empowering patients to participate in planning regarding healthcare goals. Patients and caregivers will also have increased modes of communication with their healthcare team such as the 24/7 serious illness line, and virtual visits and access to their healthcare chart via “MyChart.” A Year 2 initiative includes investigating leveraging an existing virtual care application called Relief whereby patients/caregivers can track their symptoms daily. Concerning trends are flagged to a member of the IPCT.

Palliative patients currently receive a plethora of literature from H&CC, acute care, service provider agencies. We will streamline existing literature to offer consistency and also to provide literature earlier to enable patients to better plan for end of life (EOL). Literature will be specific to the patient’s diagnosis however we plan to consistently provide serious illness conversation literature to all with a life limiting illness who are flagged by one of the 3 mechanisms (HOMR, CHESS, Palliative EMR toolbar.) Literature to explain how to access the 24/7 palliative support line will also be provided to all palliative priority population patients to ensure they can get in touch with someone when they cannot reach who they are trying to access OR do not know who to call.

The Coordinated Care Plan includes a section related to self-management of symptoms. The OPCN clinical co-leads from the Waterloo Wellington Integrated Hospice Palliative Care Regional Program in partnership with Hospice Wellington, will create and offer Serious Illness Conversation workshops to families and caregivers in year one. The palliative nursing team will continue to offer the teach-back method to assist families, patients and caregivers in managing therapies/interventions independently where appropriate (eg. oxygen therapy and medication management.).  Self-Management tools for COPD and CHF currently exist we will investigate how to further leverage these tools.

Mental Health & Addictions

In the G&A OHT, patients will be able to choose who has access to their shared care plan (e.g. neighbor or peer as well as medical providers assisting/supporting their care).  Self-management may be supported by enabling the patient to choose their “primary key contact” from their IPCT.  As members of the IPCT, peers and/or outreach workers may coordinate and/or attend appointments with patients to help facilitate a patient-centered approach to care and optimize follow-up self-management. This approach will allow patients to access the care they need from where they are most comfortable accessing it (e.g. virtual care via mobile services or outreach, virtual care from their home).  We will continue to promote self-management tools including but not limited to “Big White Wall” (MH&A online information support service) and Woebot.

How will you support caregivers?

The G&A OHT considers caregivers to be an extension of the patient is committed to ensuring the needs of caregivers are considered and incorporated into the coordinated care plan.  According to The Change Foundation, WWLHIN residents are more likely to say the organization of healthcare providers is difficult, rather than easy, and are more likely to feel their loved ones would miss appointments if it was not for their care. They would value a central location for information and financial support from the government. HQO’s ‘Measuring Up’ (2018) reveals that WWLHIN had the second highest percentage (33.6%) of long-stay home care clients whose primary family or friend caregiver experienced continued distress, anger or depression in relation to their caregiving role.

To further help us understand the areas that we should focus our caregiver support efforts, we will leverage the ‘Geospatial Hotspot Analysis of Caregiver Burden among Older Adults Receiving Home Care Services in the WW LHIN’ – a recently completed study by the WWLHIN and the University of Waterloo that identified ‘hot spots’, or clusters of caregiver burden of caregiver burden, in the WWLHIN. We will also leverage the Ministry-funded caregiver education and training program lead by St. Joseph’s Health Centre Guelph.

Once we understand the need and our available resources, we will leverage leading and best practices, including but not limited to those developed by The Change Foundation, to design a G&A OHT Caregiver Support Program that will minimize caregiver burden and distress.  This will be in strong partnership with the Community Support Sector who plays a key role supporting caregivers.


In Year 1 we will launch a ‘social engagement volunteer’ program. The volunteer will support system navigation and link with the care team when care coordination is required.

  • The 24/7 serious illness support line was also seen as a positive option for family caregivers.
  • The e-Shift program will promote caregiver self-care by offering respite shifts to patients near end of life.
  • Hospice Wellington offers a day program which allows caregivers to receive respite and will continue to offer a series of caregiver respite programs and services

Mental Health & Addictions

Many of those experiencing complex MH&A challenges at a Tier 5 level are often isolated from family and caregivers, stemming from the strain that their illness has placed on family units over time. We will also continue to support family members for people of all ages struggling with Tiers 4 and 5 complex MH&A through an “open” family education group that all family members can drop in to on a weekly basis for support and education related to the often significant challenges of caring for their loved one.

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