How do you plan to redesign care and change practice?

The Core Partner Team will meet regularly (monthly or bi-weekly) to provide oversight and guidance, address barriers and challenges and to review progress against implementation plans and towards Year 1 targets.

Each priority population area – Palliative, MH&A, H&CC – has established an implementation team that includes patients, caregivers, community members with lived experience, clinicians and supporting roles who have front line and management experience. These implementation teams will design and refine work plans that will support both the required change management and clinical service integration as defined by the Year 1 Key Change Activities. 

In addition to our care delivery work streams, other enabling infrastructure that has been initiated includes a Decision Support & Performance Measurement Working Group, A Digital Health Working Group and a Communications Working Group. Other enabling groups that will be developed imminently include ‘Patient Partnership and Community Engagement’, ‘Quality Improvement and Continuous Learning’ and a ‘Funding and Incentive Structure Working Group’.

One specific outcome we are aiming to achieve is a culture of “joy in work”. One additional working group that will be developed is a ‘Human Resource Working Group’ which will not only guide the required HR considerations of this transformation but will also contribute to the design of baseline evaluation of culture and development of a plan to support the development of a culture in which all staff and clinicians working in the Guelph and Area OHT feel a sense of joy in their work.

Below, we describe the current & target performance, as well as a description of how we expect our Year 1 change activities to support achievement of the target performance. The described targets were developed in the spirit of quality improvement to be both reasonably achievable and aspirational. 


Current Performance: In 2018/19, ED Visits 2.96 (Total ED visits/ Number of unique non-hospitalized patients with at least one ED visit)

Target Performance: In Year 1 our target is 2.5

Key Change Activity #1, 5 – Serious Illness Conversations (SI) which include education/expectations of illness progression, access to the SI 24/7 Call Line, and the Triage tool anticipated to reduce ED Visits.

Key Change Activity #2 – Ensuring commonly understand mechanisms for identifying patients with serious life-limiting illness, will enable patients to access the SI 24/7 Call Line and ensure other palliative supportive tools and people are in place which will assist in reducing ED visits as well as the 30-day re-admission rate.

Key Change Activity #3, 4, 5 – Access to information and navigation via supported technology virtual visits enabling care at home and the hospice social engagement volunteer will further contribute to a reduction in ED visits.

Mental Health & Addictions

Current Performance: In 2018/19 20.4% of patients who visited the ED with a MH issue, re-visited the ED within 30 days.   In 2018/19, 27.9% of patients who visited the ED with a substance use issue, re-visited the ED within 30 days

Target Performance: In Year 1, our target ED re-visit rate MH is 16.3%. Our Year 1 target for substance use issues is 22.4%

Key Change Idea Tier 5 – patients are often involved with many services (due to complex needs and challenges coordinating multiple provider care efforts and roles) or none at all (due to stigma, poor experiences, lack of trust, inability of service to meet needs of patient, etc.). By creating a Rapid Access Health Hub, outreach workers and mobile service workers will have a flexible and reliable place to connect Tier 4/5 patients to the level of care they need when they need it. In addition to providing better care and an improved experience for both provider and patient, it will also allow outreach and mobile workers more time to connect with “unattached” Tier 4/5 patients who they otherwise might not have time/ability to locate or build trust with (e.g. less time waiting in ED for services that they will be able to access immediately through Hub)

Clients that are connected with the Health Hub will have one primary point of contact and a shared care plan will reduce the amount of time and energy spent trying to navigate the system, follow up on care plans, communicating patient “story/experience” and will also reduce administrative and service duplication.

Piloting the use of e-tools will make information sharing and care planning more timely and accurate, thereby enabling better quality care and experience for both provider and patient.

Leveraging existing 24/7 crisis system navigation support to better serve this client population, by empowering crisis-line staff with an up-to-date care plan and connection to the client’s primary worker will improve care coordination and reduce duplication.

Key Change Ideas Tier 3 – Providing each IPCT with a broader range of MH&A supports, including a behavioural health consultant role, to expand the capacity of the IPCT by working alongside the primary care team as opposed to requiring a referral. Note: A behavioral health consultant is a provider who can both access system resources and is trained to provide intervention to patients with chronic persistent anxiety and depression.

Integrating MH&A services into primary care for Tier 3 patients will contribute to improved patient care by: enabling faster access to services for patients, reduce wait times and ensure that patients have access to services as soon as they are needed. We also expect that this model will contribute to inter-professional learning opportunities and skill development, thereby improving provider confidence and efficacy.

Integration of Care Coordination into Primary Integrated Care Teams

Current Performance: In Q4 17/18, the ED visit rate was 6.9 per 1000 attributed population.  For the same period 153 (16.3%) of patients were readmitted within 30 days of discharge.

Target Performance: In Year 1 our target ED visit rate is 5.75 per 1,000. This represents a 17% and would represent getting us halfway to the Ontario average of 4.6/1000.

Creating a primary care team that is resourced to respond to each patient’s needs 24/7 and that is digitally enabled to provide coordinated and seamless care to meet each individual patient’s needs will reduce visits to ED and readmission to hospital. Patients will have a ‘key contact person’ to call when they have questions or escalating symptoms and this ‘key contact person’ will ensure patient needs are addressed by the most appropriate care provider. This ‘key contact person’ will also coordinate and navigate transitions between care settings to ensure the patients care plan and goals of care are utilized, fulfilled and updated as appropriate. Finally, ensuring all team members have digital access to the patient’s care plan and have access to real-time secure means of communication will ensure the patient and caregiver needs are addressed in a timely and effective way thereby reducing preventable utilization of ED and acute care services.

Streamlining/minimizing the number of care providers in the G&A OHT, and therefore in each patient’s home and circle of care, is an important enabler of creating a cohesive IPCT that is digitally enabled, communicates effectively and builds trusting relationships amongst each other.  The change management associated with the development of IPCTs increases in complexity when there are higher number of organizations involved.  A description of how care will be redesigned and how current practice will be changed via the integration of care coordination into G&A OHT Integrated Primary Care Teams is provided in Appendix A.

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