How do you propose to transition home and community care responsibilities?

Our plan to transition H&CC resources, assets, programs and local knowledge and expertise will be developed once further clarity and commitment is received from the WWLHIN as to which resources are available to be integrated in the Guelph & Area IPCTs.  As described in section A2, in Year 1 we plan to co-locate, second and/or transition employment as appropriate / possible to fulfill our Year 1 objectives towards our fully mature vision.

As is highlighted in other sections of this application, we are requesting that the proportionate WWLHIN Care Coordination staffing and financial resources be allocated to the Guelph and Area OHT to enable full service integration within primary care teams and hospital.  We are also requesting a reallocation of WWLHIN planning and administration resources to support the success of our OHT development.

 As we have highlighted in our application, remarkable leadership investments will be required to support the successful service integration, digital health transformation, patient and family engagement, ongoing planning and governance development that we are proposing.  As Core Partners to this application, we have the utmost confidence in our capacity to work with our existing leadership teams’, alongside our clients, clinicians and governors to reach the outcomes that we have proposed. However, we also aware that our success in the short to medium term will rely on additional system resources to plan, coordinate, implement and sustain the transformation that we have proposed.

 The Guelph and Area OHT has been grateful to have seconded a WWLHIN Director role to support our Application development. Our WWLHIN has a wealth of talented and experienced leaders that our OHT has experienced first-hand.  We respectfully request for consideration to support our OHT through transitioning some of the LHIN roles to our OHT.

In alignment with its commitment to the Quadruple Aim, we will seek to leverage the expertise and knowledge of those working in the current home and community care system.  In building the broader system of home and community care, the OHT leadership will work with all community based partners to establish a functional band of care coordination across the system which will connect the patient and their IPCT to other specialized services in the system e.g. ABI services.  A truly integrated approach to care coordination will be established through strengthening linkages between similar roles in the continuum of care, eliminating redundant activities and functions, and streamlining processes.  It is in the context of this broader system transformation that the evolved vision for home and community care will be successfully and sustainably implemented.

The WWLHIN has found ways to free up approximately 20% of care coordinators’ time on some teams, to create more time to provide care.  This has occurred through the judicious application of assessment protocols, reducing redundancy in activity, transferring transactional functions to team assistants and employing enabling technology to reduce documentation demands.  This kind of innovation will continue to be pursued and enhanced in the G&A OHT in order to maximize the utilization and benefit of limited resources.

The Guelph and Area OHT will work closely with the Ministry and the Waterloo Wellington LHIN to advocate for the policy changes required to support a smooth transition of functions, and is committed to the application of sound change management practices.  The G&A OHT will work closely with other OHTs as necessary to ensure that patients travelling between OHTs for care are well supported. The Guelph and Area OHT will leverage some of the provincially recognized leading practices that have been implemented in home and community care in Waterloo Wellington and across the province. These initiatives have demonstrated potential for significant improvement in the sector, change that can drive efficiency, build capacity and improve patient outcomes. Examples that may be explored include but are not limited to:  neighbourhood models of care, care coordination activities embedded in clinical roles providing interventions in the home, interval care in retirement homes, partnerships with community paramedicine, the use of pharmacists in home care and so on.

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