How have the members of your team worked together previously?

We have a successful history along the integration continuum and we will continue to include broad health and non-health sector (including municipalities, police, housing, fire etc.) partners to ensure the OHT addresses the comprehensive needs of ALL of our residents. A key example of how we have previously worked in a formal capacity to advance integrated care, shared accountability, value-based healthcare and population health is the spread of existing resources to 11 independent family practices serving 23,000 patients to ensure all local residents have access to interdisciplinary team-based primary care.

Guelph was the first community to begin work on the Health Links (HL) program. We laid a strong foundation by working together on various projects to support complex clients, including joint steering committees, sharing of staff resources across sites and collaborative funding models.  Contributing organizations include Guelph FHT, Homewood, CMHAWW, Primary Care Psychiatry, and Guelph CHC.  This provides evidence of Guelph organizations not only working together to support best care practices, but their commitment to the identification of patients with complex health needs to ensure optimal and proactive patient care.  Since 2013, Guelph HL has identified and created a coordinated care plan (CCP) for over 2,300 our most vulnerable citizens. With primary care as the central point of access, HL Members have coordinated care plans involving primary care, H&CC, MH&A and are supported to address challenges related to housing, food security, community safety and isolation etc. This model of integrated service serves as a strong foundation for the G&A OHT. 

Data has been consistently collected to measure patient outcomes and identify areas for improvement to support the development and growth of the HL approach. We are partnering with the eHealth Centre of Excellence (eCE) and WWLHIN to complete an evaluation of the impact of the HL program.  As of March 2018, it was reported that mental health issues are the most common chronic condition in the Guelph HL population (70%). An algorithm was also used to identify those who have potentially undiagnosed mental health issues, which was successful in identifying an additional 11% of the population.

Another example of how our team has worked together to integrate care along the continuum is evidenced through community improvements for heart failure (HF) and COPD.  Due to high HF and COPD readmission rates to hospital in Guelph, the decision was made that keeping complex individuals with HF and COPD out of the hospital was a community effort, so we needed to plan and work together. Active partners including Guelph General Hospital (GGH), Guelph FHT, St. Joseph’s Health Center Guelph (SJHCG), Guelph YM-YWCA, Guelph CHC, WWLHIN, Guelph Wellington Paramedic Services (GWPS) with additional collaboration from eCE, CorHealth, and St Mary’s General Hospital (SMGH). Using data to map the current and future state, key gaps and opportunities to achieve both the desired end state and the respective HQO quality standards were identified, prioritized and actioned.   As a result, the following achievements related to HF were realized:

  • A Primary Care documentation tool was tested, refined and spread to other physicians
  • Leveraged NP, RN and RT leadership to educate primary care teams and test care delivery models
  • Acute care implementation of new documentation care pathways for HF and COPD at GGH
  • Acute care cohorting of HF and COPD patients for consistent care
  • Testing increased use of Guelph Wellington PareMedicine Remote Patient Monitoring Program for both COPD and HF
  • Development of recommendations for Hub level cardiac rehab care in Guelph.
  • Integrated a Respiratory Therapist from St. Mary’s within Guelph FHT and CHC primary care with accountability/funding centred with Woolwich CHC
  • Joint education for care providers on assessment and management of HF
  • Participated in the IHFI project with CorHealth to influence provincial recommendations for collaborative Heart Failure Work.
  • Design and implementation of pulmonary program focused on exercise support at Diabetes Care Guelph to help transition people after discharge from pulmonary rehab.
  • Interdisciplinary (RT, RN, PT) discharge education and teaching at GGH for all COPD patients.
  • This collaborative redevelopment of care led to a 37 percent reduction in COPD readmission rates and a 39.6% reduction in Same/Related Readmissions for HF in our first year of cQIP.

Other examples of how we have worked together in a formal capacity to advance integrated care, value-based healthcare, or population health include:

  • GGH & Guelph FHT share data related to patient outcomes through the Daisy platform – a decision support platform at GGH. Daisy Links is a shared platform created by GGH to permit certain admission/discharge data to be collected and presented for the purpose of QI projects and QI reporting at the Guelph FHT.
  • To support consistent communication, a formal process was developed that brings together the Guelph FHT Executive Director meeting with the GGH Senior Leadership Team once a month to ensure alignment with strategic plans and to discuss and resolve issues that impact the transition from hospital to primary care.
  • Board retreats where board members from other organizations have been invited to discuss how to impact the health of the community. e.g December 2018, GGH held a joint session with Guelph FHT, Guelph CHC & SJHCG

Bundled Care – GGH is in the planning phase for Bundled Care for Hips and Knees and is working closely with SJHCG, Groves Memorial Hospital and North Wellington Healthcare for outpatient rehab for these patients.  GGH is also working closely with patients, surgeons and outpatient rehab to integrate the care for these patients and to improve the patient experience.

‘Act as One’ – Since 2017, the ‘Act as One’ initiative, psychiatry and mental health patients from the Guelph FHT, associate practices, Guelph CHC, CMHAWW and University of Guelph Student Wellness have enhanced access to psychiatric assessment and treatment as well as structured Cognitive Behavioural Therapy treatment groups.

Specialized Outreach Services – The SOS program is an integrated team of peers and professionals that offer flexible outreach services to homeless or street-involved individuals with addiction, mental health, or concurrent issues by providing supportive nursing and counselling, supported connections to primary care and referrals to other community services. This service is delivered by an integrated team of nurses, counsellors, and peer workers who are employed by Guelph CHC and Stonehenge Therapeutic Community.  From April 2017-March 2018 there were 361 individuals served and from April 2018-November 2018 there were 263 individuals served. These individuals are some of the most complex and vulnerable in our community and often struggled to successfully engage and maintain relationships with healthcare services.  58% reported better access to primary care support for physical health, 52% reported better access to mental health supports and 48% reported better access to addictions support. 90% of clients surveyed reported improved connections to services and supports.

Primary Care at Home (PC@H ) (See Figure IV) – Access to PC@H supports has been extended to all patients in the Guelph community, including Guelph CHC patients. Through PC@H, patients who are vulnerable, with complex needs and an inability to leave their homes are supported with outreach nursing and social work with virtual connection to their family physicians or nurse practitioners.  The PC@H program can help by being an extension of the family doctor’s office and visit patients in their own home. This service plays a key role in integrating primary care, home care, paramedicine and other community services to better support patients needing care at home.  The goal is to reach individuals who are at risk for isolation, living in unsafe conditions, or have limited access to resources so that help can be provided and a care plan created with collaboration between community agencies/services before these issues become a crisis.  In 2018-2019, PC@H supported 610 Guelph and Area residents to manage their health safely at home. 96% of patients reported being better able to cope with their chronic conditions because of primary care at home support.

Wellness Matter – Demonstrating our commitment to population health, health promotion, disease prevention and self-management, Guelph FHT offers Wellness Matters, a variety of workshops and programs geared to health promotion, disease prevention and self-management.  These programs are accessible to the general public, regardless of their affiliation with any primary care group. Each year nearly 1,000 local residents participate in these programs.

Diabetes Care Guelph – Approximately 8% of our local population has diabetes.  While primary care provides the core support for these patients, a small subset of the population needs enhanced education and support to help manage their day-to-day lives while living with diabetes. Diabetes Care Guelph, available to all Guelph and Area patients (regardless of roster affiliation) is delivered in in-kind space offered by Guelph CHC. The program has integrated specialized diabetes support with primary care at Guelph FHT, Guelph FHT associate practices and Guelph CHC.  The DCG team integrates care with local endocrinologists and has partnered with Guelph Wellington Seniors Association, WDG Public Health, Guelph Food Bank and local private industry to offer diabetes supports more broadly in the community. Diabetes Care Guelph has always supported all patients of the community regardless of physician. In 2018-2019 the DCG team received over 300 new unique patients each quarter. Despite increasing patient volumes, DCG meets urgency requests for first appointment 70% of the time and by 9 months in the program the average hbA1C of patients is <7.5% compared to 9.0% on average at intake.

Emergency Mental Health and Addictions Services – Guelph General Hospital (GGH) is the only acute care and Emergency Department in Guelph and Wellington serving a population of greater than 240,000. GGH also provides the only emergency mental health services in Guelph and Wellington. The service is located within GGH and a 4-bed Emergency Mental Health Unit is adjacent to the GGH ED, delivered through partnership with Homewood Health Centre. GGH is not a scheduled mental health hospital and therefore does not have an inpatient mental health program or beds.  A formal partnership between HHC and GGH has existed since 2009 and CMHAWW has also partnered to support transitions back to the community at the time of discharge.

In 2015-16, it was recognized that the model of care originally developed in 2009, was insufficient to manage the increased complexity and volume of patients being seen within the ED setting. A steering committee was struck, comprised of members from across the continuum of care, including senior executives from the proposed OHT partner organizations with the goal to improve access to high quality care for patients. The following key changes were made in support of improved patient care and transitions over the following year:

  • More timely access to assessments by psychiatric nurses in the ED
  • Addition of addictions counsellors to the care team
  • Revision to the model of care within the Emergency Mental Health Unit (EMHU), moving it from a 4-bed holding area for patients awaiting a Schedule 1 bed (original 2009 model) to a Short Stay Assessment Unit.
  • Development of care pathways with CMHAWW to support seamless patient transitions to and from the community
  • Standardization of assessment tools across the care continuum to reduce duplication of assessments
  • Development of a MH&A Emergency Follow-up Service to support patients while awaiting community services, in an effort to reduce repeat ED visits
  • Implementation of a ‘Consult Liaison’ service for admitted patients with concurrent MH or addictions

A formal evaluation of the revised services models was completed in the fall of 2017 which showed:

  • A 28% reduction in ED length of stay (LOS) for patients with MH&A related visits
  • A 64.4% reduction in consultant turnaround time for psychiatry
  • A 71% reduction in alternative level of care (ALC) days to a mental health facility
  • Patients who accessed the Mental Health and Addictions Emergency Follow-up Services, had only an 8% repeat visit rate
  • Improved transition of information at time of discharge as measured through patient satisfaction surveys, demonstrating that patients knew what the next step was in the plan of care and who they would be seeing for follow-up
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