How do you propose to provide care coordination and system navigation services?

How do you propose to coordinate care?

In the Guelph and Area OHT envisioned mature state, care coordination is not a service but rather a set of functions that are integrated within and across partners of Integrated Primary Care Teams (IPCTs).  In Year 1, care coordination will be delivered by experienced LHIN H&CC Care Coordinators who will become functionally part of and physically co-located alongside existing primary care teams.  LHIN H&CC Coordinators and primary care team members will be provided with information about the required functions of them as an emerging IPCT and they will be empowered to co-design their team in the most ideal way to deliver the full suite of functions to their rostered population. LHIN H&CC Care Coordinators will share their expertise, skills and knowledge about care coordination with other members of the IPCT.

Given the primary care attachment rate in Guelph and Area is 97% and 100% of primary care providers have access to inter-disciplinary teams (FHT and CHC models) the full population of our OHT will begin to experience the benefits of integrated care coordination in Year 1.

The core functions of a G&A OHT ‘Interdisciplinary Primary Care Team’ (IPCT) were developed by combining the functions of care coordination as described by the ‘Ontario Health Teams: Guidance for Healthcare Providers and Organizations’ (MOH May 2019) and this OHT Full Submission document:

  • 24/7 support
    • Caregiver support
    • Seamless transitions between settings
    • Needs based assertive/proactive support to ensure seamless coordination & navigation of care
    • System navigation
    • Primary medical, psychological, wellness, prevention care
    • Coordination of an invitation and on-boarding of additional members to the primary care team when a patient’s needs exceed the capacity or capability of the IPCT
    • Issues management including complex problem solving, collaborative solution finding, cross ministerial advocacy etc.
    • Support access to specialized services e.g. housing, addictions beds, ABI programs etc.
    • Assess client need for in-home services
    • Coordination of primary and secondary in-home care
    • Delivery of all primary care (in-office & in-home)
    • Determine eligibility for secondary/specialized in home services
    • Determine the type(s) and amount of secondary/specialized in home service(s) 
    • Order secondary/specialized in home services i.e. invite secondary/specialized service to join IPCT
    • Reassess clients and adjust in-home services

When a patient’s care needs require hospitalization, and the acute care team becomes part of the patient’s IPCT, care planning and proactive planning for discharge home will be led by the patient’s IPCT ‘Key Contact Person’ throughout the hospitalization to ensure that the timely transition from hospital to home is seamless, coordinated and supported with the appropriate resources and supports.

Given the overlap between the functions of current ‘Rapid Response Nursing’ resources, integrating these roles into IPCTs will also be supportive of optimized integrated service delivery.

We are in the process of completing a survey of G&A OHT partners asking them to identify resources within their current organization that perform care coordination.  Next steps include identification of naturally occurring IPCTs in the G&A OHT and to use the results of this survey to allocate available resources across the IPCTs. This includes LHIN care coordination resources.

To determine our success, we will monitor our key performance metrics: 30-day inpatient readmission rate and Avoidable emergency department visits (ED visit rate for conditions best managed elsewhere).

How will you help patients navigate the healthcare system?

Implicit in our “Integrated Primary Care Team” (IPCT) model is the integration of system navigation as a core required function of that team, rather than creating a stand-alone role. Every patient in the G&A OHT will have a “Primary Contact/MRP” (most responsible physician) on their IPCT.  Each IPCT in collaboration with the patient, will assign this function to a member of the IPCT as most appropriate given the nature of the team and the needs / relationships of the rostered patients – some may choose to have a designated person on the team who is the primary contact for all rostered patients while others may choose to disperse the function across members of the IPCT.  While the full role description of the “Primary Contact” will be developed as a next step, from a navigation perspective, the “Primary Contact” will possess a comprehensive understanding of how the health system works, and will:  

  • Know where to find information about services, including availability and eligibility
  • Connect patients and caregivers to services and service providers to other providers
  • Gather and share information about local health services
  • Advocate on behalf of patients for access to services
  • Monitor and manage the patient’s shared care plan

In Waterloo Wellington, we have long contributed to and invested in two digital platforms to support system navigation. Both platforms are accessible to patients online 24/7:

  1. Caredove (a local platform that lists access to home care and community services)
  2. HealthLine is a non-profit established with a mandate to support patients, caregivers, healthcare providers and system planners with information about services available across the province.  HealthLine is partly funded by the Ministry of Health, and manages the provincial service directory database, provides information management to support it, collects information about services and presents it in many different ways (including through 14 regional websites, special purpose sites). HealthLine also supplies the data that powers the Ontario government’s Healthcare Options tool.  HealthLine has the benefit of providing information about services that are available across the province. The ability to customize HealthLine to meet local needs is limited as a function of its provincial mandate.

As a next step to further enhance the functionality and clinical utility of HealthLine, the G&A OHT will explore the development of Application Programming Interfaces (APIs) to embed health services information into EMRs, EHRs (electronic health records), secure patient and provider portals as well as existing websites.

For our Year 1 priority populations, after-hours system navigation will be supported by:

Palliative – The 24/7 Serious Illness Support Line supported by SYKEs Homecare Assistance. This number will be offered to our palliative priority population in Guelph and Area and positioned as the number for patients and caregivers to call if they:

  1. Have not been able to get in contact with their intended healthcare team member or
  2. Are not sure who they should be calling.

SYKEs employs approximately 40 palliative nurses that will be managing these calls. The SYKEs nurse will attempt to resolve the call independently however will also have the ability to connect with members of the patient’s care team. The SYKEs nurse will have access to the patient’s care plan and team members via HPG.

Mental Health  Addictions – “Here 24/7” service through CMHAWW will maintain shared care plans for Tier 5 MH&A patients for the Tier 5- focused IPCT prototype site. This will give both the patient and service providers the ability to speak to someone 24/7 who is knowledgeable about the patient’s care plan and who can provide contact information for the patient’s primary worker as well as other providers involved in the patient’s care. “Here 24/7” is also available on a 24/7 basis for all MH&A patients (inclusive of Tiers 3, 4 and 5) to call in for support and system care navigation as needed.

In Year 1 we will learn from and build off of the palliative and MH&A 24/7 supports to develop an after-hours solution for the full attributed population. Currently, sufficient resources do not exist to support this – efficiencies from integrated service delivery implementation and back office integrations will be targeted to support this service.

We are confident that our integrated approach to system navigation (i.e. integrated as a function assigned to each patient’s “Key Contact” within their IPCT) and our existing digital platforms will drive integration and smooth the patient journey.

To determine our success, we will monitor our key performance metrics: 30-day inpatient readmission rate and avoidable emergency department visits (ED visit rate for conditions best managed elsewhere)

How will you improve care transitions?

At maturity, the Guelph and Area OHT will minimize the need for care transitions by transforming our current system into one that is made up of IPCTs designed to provide a wide range of functions necessary to meet the needs of our full attributed population. In instances where care transitions are unavoidable (e.g. hospital admission / discharge, outreach, RAAC, mobile services etc.), the Guelph and Area OHT will ensure they are as seamless as possible by establishing clear and consistent service pathways that connect back to the IPCT, inviting specialized services into the patient’s IPCT as needed and utilizing a digital shared care plan to inform, track, coordinate patient care and transitions. Transitions between settings will be optimized by the role of the ‘Key Contact Person’ on the IPCT and the use of the CCP to provide IPCT members across providers and settings with a mechanism to view and contribute to information about the patient’s care plan and goals of care.


Through the early identification of patients who would benefit from palliative care services we will better support patients to understand their disease and care options.  Early identification is a vital precursor to reduction in hallway medicine and improvement in patient experience near end of life. We know that patients who are identified as appropriate for a palliative approach to care early in their illness trajectory are less likely to visit the emergency department near the end of life.

We also know that when patients and caregivers are given more time to communicate values and plan for end of life, they report a better care experience. Using the Coordinated Care Plan (CCP), the patient’s goals and wishes will be communicated allowing for ongoing alignment of care decisions throughout the patient’s journey. 

We plan to leverage a range of commonly understood mechanisms to identify and flag seriously ill patients. Serious illness conversations will be initiated after identification. The conversations will occur across sectors and be shared in the CCP. These conversations will evolve with trusted care partners as per patient and family readiness.

The CCP will also provide healthcare team members with an opportunity to view and contribute to documented information about the patient’s journey across providers and settings. Care coordinators will be the owner of the CCP, ensuring the document is kept up to date with pertinent clinical updates. Virtual visits will be offered to increase access to primary care clinicians, support seamless transitions between settings, strengthen accountability and ensure transparent transfer of patient information.

Virtual care will also be leveraged for palliative specialist consultation and assessment in community, acute care and LTC settings. 

Other initiatives currently underway include the certification of palliative clinicians from Guelph and Area to provide point of care ultrasound (POCUS) in the community thereby reducing acute care transitions for diagnostics.  Initiatives to provide in home blood work and chest X-rays will also be explored to reduce hospital visits and unnecessary travel for home-bound patients.

Mental Health & Addictions

Care coordination will be integrated as a function into primary care to support all patients including the priority populations, who may benefit from support to access required care and services as they transition between settings. Tier 5 MH&A patients will have a primary worker of their choice (e.g. nurse, outreach worker, social worker) who will work closely with the patient throughout their journey, monitor and manage the care plan and be the primary contact should the patient arrive at hospital and/or prior to discharge.

The G&A OHT will also form one integrated outreach team who will work closely with the IPCT’s, hospital, mobile services and housing services to support Tier 5 patients by bringing services to patients virtually or by connecting them to IPCT’s and other community resources as needed.

Also in Year 1, outreach workers from various community agencies will be brought together into one integrated team of outreach workers to enable improved communication, capacity and capability building, as well as opportunities for shared learning and skill development. These workers will be invited to join IPCTs when patients have Tier 5 needs that are most ideally addressed by an IPCT that includes the skills of an outreach worker. 

To determine our success, we will monitor our key performance metrics: 30-day inpatient readmission rate and avoidable emergency department visits (ED visit rate for conditions best managed elsewhere).

Scroll to Top