What is your team’s short-term action plan for improving home and community care in Year 1?

Our top priorities for H&CC in Year 1 is to integrate the functions of care coordination (including intake, assessment of patient need and integrated service delivery) into our IPCTs. Patients within our priority population groups will experience additional enhancements to their H&CC. The characteristics of these patients are as follows:

Patients requiring Care Coordination

Given our high attachment rate (97%) and 100% inclusion of primary care in this proposal, we plan to integrate care coordination into IPCTs for 100% of this population.  Patients who are not rostered with a primary care physician can have their primary care needs, including care coordination, met by the integrated primary care teams.  Every effort will be made to roster patients and for those who, for a range of reasons, are not able to be rostered, IPCT services will still be available.

Using the Guelph-Puslinch sub-region as a proxy, in 2018-19 (WWLHIN Decision Support (FY 2018-19)               

  • Approximately 4,500 primary care patients are seen daily
  • Approximately 1,000 LHIN Home and Community care patients are served daily
  • At any given time, there are approx. 3,000 patients on the H&CC caseload
  • Monthly referral rate fluctuates between 350–450 new referrals a month
  • Approximately 6,500 patients served/year
  • Patients are referred from:
    • Hospital: 55%, Outside of hospital: 45% (from Primary Care: 22%, from Community services and self-refer: 18%, Other: 5%)


100% of our palliative priority population (of approximately 550 patients) will receive varying levels of home care. Of these 550 patients, all will be diagnosed with a life limiting illness, approximately 50 patients will be socially isolated, and approximately 25 will face challenges with Social Determinants of Health. Complexity of illness will vary based on progression, comorbidities and social situation (food, money, housing and social network.) The greater majority of the palliative priority population will be aged 65+ and approximately 91% will be diagnosed with Cerebrovascular disease, Dementia, CHF, COPD, neurological disease, organ failure, Cancer or a combination of these diagnosis’. A large proportion of this population will be unable to easily leave the home. Patients in this priority population will require varying levels of symptom management, medical and emotional, spiritual, psychosocial interventions and support with activities of daily living (ADLs) and instrumental ADLs (IADLs).

Mental Health and Addictions

Tier 3 – We anticipate approximately 750 Tier 3 patients will receive care in Year 1. Tier 3 patients generally have the following characteristics:

  • Significant current suicidal or homicidal ideation without intent or plan and past history
  • Troubled relationships but controls abusive or aggressive behavior, poor physical functioning, occasional significant difficulties with activities of daily living
  • Medical conditions exist which may adversely affect course of presenting disorder; substance misuse with significant or potentially significant impact on co-occurring psychiatry disorder
  • Significant discord with important relationships. Significant disruption in life circumstance such as job loss, legal difficulties, recent loss or deterioration of interpersonal or material circumstances. Easy exposure to alcohol and drug use
  • A few supportive resources exist in current environment and may be capable of providing some help if needed
  • Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms
  • Relates to treatment with some difficulty and establishes few, if any, trusting relationships

Tier 5 – We anticipate approximately 320 Tier 5 patient will receive care in Year 1. Tier 5 patients generally have the following characteristics:

  • Current suicidal homicidal behavior or such intentions with a plan and available means to carry out this behavior
  • Extreme deterioration in social interactions, extreme disruption in physical functioning causing serious harm to health and complete inability to perform activities of daily living
  • Significant medical conditions which may be poorly controlled or potentially life threatening; severe substance dependence, all which compound difficulties managing psychiatric conditions
  • Acutely traumatic level of enduring stress; unavoidable exposure to drug use and active encouragement to participate in use. Incarceration or lack of shelter. Sustained inability to meet basic physical and material well-being. Chaotic and constantly threatening environment
  • No sources of support for assistance are available in the environment either emotionally or materially
  • Past or current treatment response to treatment has been quite minimal, even with intensive medically managed exposure in highly structured settings for extended periods of time
  • Unable to engage in treatment or recovery and has no current capacity to relate to another or develop trust

Our approach early in Year 1 will be to co-locate, second and/or transition employment as appropriate / possible H&CC care coordinators and other MH&A specific resources (MH&AN team, adult mental health team, support workers etc) with/to the IPCTs to begin to function as an integrated team.  As the providers initially continue to complete their current functions alongside their new teammates (including the H&CC care coordinator initially completing patient intake, assessment of need) and using existing tools, they will be encouraged to identify opportunities to integrate their roles, processes, tools and models of care to optimally fulfill the comprehensive set of described functions of an IPCT in a way that creates better value, better patient experience, better provider experience and better outcomes.  For example, in section A1, we described how the function of intake will be eliminated once the functions of care become embedded within the patient’s mature IPCT where care coordination and the delivery of in-home primary care services will be but a few of a full suite of services delivered by the IPCT. We believe that functioning as an integrated team of care providers will both build the trust that is required for success, optimally engage clinicians and other front line staff and inform the most ideal structure to support the required functions. This approach is also in consideration of the current constraints related to mandated RAI assessment and service provider organization (SPO) accountability, service ordering and market share restrictions. Finally, this approach is in respect and acknowledgement of the skills and expertise of H&CC Care Coordinators who we rely on to share and spread their knowledge and skills across the IPCTs.

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