What is your implementation plan?

As confirmed by the Guelph and Area OHT Core Partners, the work to continue to move our OHT towards maturity will continue immediately following the completion of this submission. The implementation plan below describes our Year 1 plan to continue to both support the priority population key change activities and service integrations and to build the infrastructure that is required to continue to advance the Guelph and Area OHT to full maturity in 5 years. Plans for Years 2-5, including the sequencing of adding additional priority populations, core partners and partners etc. will be informed by the strategic plan that will be developed in Year 1. Partners have already begun exploring opportunities to find efficiencies related to corporate functions and are committed to considering ways to share functions that arise through staff attrition.  In our first year we will be conducting a detailed inventory of services with a view to addressing integration opportunities.


As described in section 4.2, an interim Year 1 ‘Strategic Steering Council’ will be created in Fall 2019.  This Council will oversee the joint strategic planning process and will develop formal conflict resolution and shared decision making frameworks/processes. Later in Year 1, and based on the strategic plan, this group will develop and recommend a long term governance structure to be implemented in Year 2.


The Core Partner Planning Table will evolve and formalize to become a “Guelph and Area OHT Core Partner Committee”.  An implementation lead will be retained to work across OHT partners to help drive implementation.  In Fall 2019 terms of reference will be developed including a description of decision making and conflict resolution processes.  The Committee will continue to focus on supporting the development of a local medical association which will offer guidance and leadership in the OHT’s work.  As part of the development of the terms of references, core partners will explore whether there will be any formal accountability structures in place between individual team partners and the team as a whole for ensuring that individual performance or compliance issues are addressed. Another key Year 1 function to be completed within 90 days will be to identify service integrations that are part of the three priority population activities.   Finally, in Year 1 this group will complete a strategic review of back office/administrative integration opportunities/needs and corresponding system capacities. Partners have already begun exploring opportunities to find efficiencies related to corporate functions and are committed to considering ways to share functions that arise through staff attrition.   In the first 6 months we will be conducting a detailed inventory of services with a view to addressing integration opportunities.  

Enabling Infrastructure/Working Groups

As previously mentioned, Executive Leads have been identified for each working group and work stream.  Operational Leads and terms of reference will be developed for each group in Fall 2019. Each group will then create a work plan to guide their work in Year 1. 


A communications working group is already in place and has been supporting communications throughout the submission development phase including monthly ‘Key Messages’ to keep broad stakeholders informed of the status and progress of the submission, two media releases, upgrades to the Guelph and Area OHT website etc. A key priority in Fall 2019 is to finalize the draft Year 1 communications and engagement plan that is based on an established stakeholder analysis. This plan includes targeted communications for the following stakeholders: media, physicians, staff at partner organizations, non-core partner healthcare and non-healthcare organizations, community at large, municipalities, politicians, patients and caregivers.

Patient Partnership & Community Engagement Working Group

Following up on our September 18th Patient & Caregiver Engagement session, we will develop a plan that will both ensure our patient & caregiver partners are included in working groups and will plan for quarterly meetings of PFAC members from each Core Partner organization. We are currently planning a next engagement session in early November.

Quality Improvement & Continuous Learning Working Group

This group will be formalized and Terms of Reference developed.  A key focus of this group will be continued support and oversight of the 2019-20 cQIP and development of the 2020-21 cQIP.  This group will also develop a plan to support quality improvement capability amongst G&A OHT providers including ‘rapid learning and improvement’ and utilization of a population health approach.

Funding and Incentive Structure Working Group

Members of this working group from core partner organizations have been identified and contributed to this submission via e-mail. The group will have its first meeting in late October 2019 to discuss:

  • Labour issues that will impact cost, different rates, union vs. non-union, different unions etc
  • Benefit costs, every organization may have different arrangements, especially bringing smaller organizations level of services to the larger organizations
  • Pension plans
  • Procurement practices
  • Contract renegotiation and merging of contracts /aligning them
  • Merging policies and procedures
  • One health record/system

Human Resources

Similarly, members of this working group from core partner organizations have been identified.  They will meet jointly with the Funding and Incentive Structure Working Group for their respective initial meeting in October 2019 and then break off to create its own terms of reference and develop a work plan to address HR specific issues.

Digital Health Working Group

Since its initial visioning session on September 5th, the Digital Health Working Group, comprised of representatives from most core partner organizations, has met four additional times to develop and apply a ‘Digital Health Tool Comparison Template” to a list of potential solutions to each of the 4 areas within Appendix B of this document. Collaboratively, the group developed and collectively endorsed the detailed responses to Appendix B. Next, the group will formalize through the development of terms of reference and build a ‘Guelph and Area OHT Digital Health Strategy’ from the plans described in Appendix B.  Physicians, front line providers and patients/caregivers will be engaged in the design of the ‘Guelph and Area OHT Digital Health Strategy’ to optimize its clinical utility and impact.

Caregiver Support Working Group

This group will be developed in the first 60 days and will include strong caregiver representation. Its first task will be to complete an inventory of available caregiver support resources across the G&A OHT compare this with what is considered to be required in an ideal state. We will then build a ‘Caregiver Support Strategy’ that addresses the gap between current state and ideal state that leverages leading and best practices from organizations like the Change Foundation. The G&A OHT Caregiver Support Strategy will build on the Patient Declaration of Values for Ontario and will describe plans to both prepare, support and empower caregivers as well as to build the capacity of health providers to support caregivers in their roles.

Data & Performance Measurement

This group, with representation from most OHT core partners, has met twice. During their second meeting they completed an A3 process to define their common purpose and identity the functions required of a strong decision support service for the G&A OHT.  This group was very excited and inspired by the opportunity to work together to be more effective and efficient as an integrated team. As a next step, this group will formalize through the development of terms of reference.  In the first 90 days this group will envision and make a recommendation to the Executive Group, an ideal structure to support the required functions of a Guelph and Area OHT Decision Support Service. 

Priority Population Work Streams

Palliative and Mental Health and Addictions Implementation Working Groups are forming and in October 2019 will develop detailed Year 1 work plans for each key change activity including opportunities for service integrations. 

The palliative leads have identified the following key deliverables for Fall 2019 – 15+ clinicians from acute, primary and home and community care will be LEAP trained.  24/7 ‘Serious Illness Care Line’ will be launched.  Commence interRAI CHESS score early identification process. Initiate sharing of coordinated care plans.  Commence CAPACITI program and serious illness workshops for IPCT members and other caregivers. A Guelph FHT clinic with several clinicians (including an MD, NP, Chronic disease RN) are starting the CAPACITI program in January 2020. This study project is solely based on increasing palliative care capacity in primary care. Along with this, half a dozen Guelph FHT clinicians have registered for LEAP training in November. Serious illness workshop programs will be expanded to non-registered clinicians, volunteer roles and family caregivers in addition to the existing program for registered clinicians.

Mental Health & Addictions Care resources including behavioural health consultants, support workers and others will be integrated into the three Tier 3-focused IPCT pilot sites. Other specialized services (e.g. psychiatry) and community services (e.g. outreach, mental health, addictions, ABI, nursing etc.) will be integrated into the three IPCT sites either physically or via virtual technology.  The MH&A Working Group will develop an operational implementation plan, including service integrations, in the first 90 days with implementation in 6 months.

The implementation plan for the ‘Integration of Care Coordination into ‘Integrated Primary Care Teams” is described in Appendix A

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