What is your team’s long-term vision for the design and delivery of home and community care?

Guiding principles to support the transformation of H&CC in the G&A OHT are included in Figure V. These principles, informed by patient/caregiver, provider and governor feedback, inspired our vision for the design and delivery of transformed H&CC.  Our vision, which builds on the ‘Primary Care at Home’ program (see Figure IV) is two-fold and includes:  

  1. Integration of the functions of care coordination into primary care through the creation of ‘Integrated Primary Care Teams’ (IPCTs)
  2. The core functions of IPCTs were developed by combining the functions of care coordination (as described by the ‘Ontario Health Teams: Guidance for Healthcare Providers and Organizations’ (MOH, 2019)) with the requirements described in this OHT Full Submission document, and include:
    1. 24/7 support
    2. Caregiver support
    3. Seamless transitions between settings
    4. Needs based assertive/proactive support to ensure seamless coordination and navigation of care
    5. System navigation
    6. Primary medical, psychological, wellness, prevention care
    7. 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
    8. Issues management including complex problem solving, collaborative solution finding, cross ministerial advocacy etc.
    9. Support access to specialized services e.g. housing, addictions beds, ABI programs etc.
    10. Assess client need for in-home services
    11. Coordination of primary and secondary in-home care
    12. Delivery of all primary care (in-office & in-home)
    13. Determine eligibility for secondary/specialized in home services
    14. Determine the type(s) and amount of secondary/specialized in home service(s) 
    15. Order secondary/specialized in home services i.e. invite secondary/specialized service to join IPCT
    16. Reassess clients and adjust in-home services
  3. IPCTs are envisioned as a sideways triangle divided into three sections (See Figure VI).
    1. The first section (at the broad end of the triangle) is the primary care physician/NP by whom many of our residents can have their full primary care needs met. 
    2. For those who have greater needs, the middle section of the triangle includes a full resourced interdisciplinary team of primary care providers who complement the medical care and fulfill ALL of the patient’s primary care needs.
    3. The third section of the triangle describes the services that are beyond the capacity and/or capabilities of the primary care team including all in-patient care & specialty/secondary in-home & clinic care (e.g. HPC, wound care, ABI, specialist addiction care & residential treatment, ACCT/ FACCT, CSS, housing & social services & other secondary and tertiary clinicians, programs & services)
  4. Some other key features of this model include:
  5. Every patient will have a “Primary Contact Person” (PCP) who is responsible for proactively managing/coordinating the patient’s care needs and system navigation
  6. “Referral” and “discharge” will be eliminated – when a patient’s care needs exceed the capacity or capability of the integrated primary care team, additional providers and services will be invited to join the patient’s care team (rather than patients being referred to a separate and distinct provider).
  7. 24/7 support (for priority populations in Year 1)

Integration of care coordination functions within the IPCT will occur through/result in the elimination of redundancies in functions, streamlining of processes and digitally-enabled care coordination.  Additionally, this integration will eliminate several of the current care coordination functions. For example, care coordination will be embedded within the patient’s care team and not require referral to or assessment by a separate team thereby eliminating the current function related to the management of “the intake of clients for H&CC services”. Rather, care coordination and the delivery of in-home primary care services will be but a few of a full suite of services that the IPCT will offer to maximize patient health and wellbeing. See Figure X for a full analysis.

  • Reduction in the number of service provider agencies

Our vision for the design and delivery of H&CC requires re-alignment of service provider agencies to streamline the number of provider agencies delivering care to our clients. Patients and caregivers described being very confused and overwhelmed at the number of different agencies that were coming into their homes to complete assessments and deliver care:

After being diagnosed with ALS, one patient described having three different agencies visit his home on the same day to all ask him the same questions and provide three different numbers and packages of information and appointment times in order for him to initiate PSW, nursing and OT services.  After initiating services, the patient described an obvious lack of communication between the providers that were coming into his home about his disease status, progression, care plan and goals of care. His primary care physician was also unaware of the care he was receiving at home.

Reducing the number of agencies that are delivering secondary in-home services will both reduce confusion for patients and allow better integration of secondary in-home providers into the patient’s IPCT. In the G&A OHT, patients will have one provider for all of their in-home services, one number to call and significantly reduced assessments. In-home providers will ALL document electronically and will have access to, and be able to contribute to, the patient’s digital care plan.

Our strategy to strengthen innovative service delivery is grounded in both our “Digital First” philosophy and our collective commitment to work with our partners to leverage innovative programs that are proven to enhance the integration of care.  Our OHT has a significant foundational advantage in that almost all primary care providers use the Telus Practice Solutions EMR software.  We will build on that foundation as we develop more integrated care models and digital tools.

The G&A OHT ‘Digital First” philosophy is both a design principle, a clinical approach to care and an element of our emerging culture whereby IPCTs will be supported to offer patients increasing elements of care, including care delivery, care & appointment coordination and access to health information, virtually / through digital means. Some examples include:

  • Utilization of PCVC to support virtual visits with care team and patients/families
  • Paramedic services including paramedicine and remote patient monitoring
  • Direct eReferral from the IPCT to secondary in-home service providers
  • Pilot eAppointments for IPCT and secondary in-home service visits, phone calls and virtual visits to support a warm transition for patients returning home from hospital

The G&A OHT will support the escalated scale and spread of innovations in home and community care which have shown evidence of improved outcomes and patient experience in local tests of change including:

  • Efficiencies in the completion of assessments
  • Interval care in retirement homes 
  • The neighbourhood model of care
  • Integrated Campus Care Delivery model
  • PSW Neighbourhood Model of Care – Personal support services provided in a flexible arrangement and staffed by PSWs in a ‘eShift’ model
  • Telehomecare
  • Direct referral by primary care to service provider organizations
  • Accountability for Performance

In an ideal state, the G&A OHT would enter a competitive procurement process and select a single provider and one overflow provider, or 2 providers that would provide support/overflow to each other, to deliver the full scope of specialized and secondary in home services in Guelph and Area. Reimbursement would be outcome-based rather than strictly fee-for-volume.  The contract with the selected provider(s) would be based on, or at least include incentive payments, for patient and population outcomes. For example, providers would be rewarded for achieving target performance related to patient reported experience, ED admissions, readmissions to hospital, falls etc. for the patients who they serve. Remuneration would be tied to health outcomes on specific care pathways (e.g. wound care, rehabilitation). Within the realities of current contracts, accountability for performance will be strengthened by working with the WWLHIN to exercise the full scope of levers including market share reallocation and financial penalties for below target performance. Additionally, the G&A OHT will work with the WWLHIN to streamline the number of providers in Guelph to achieve our vision that “every patient in the G&A OHT will have one provider for all of their in-home services, one number to call and significantly reduced assessments. In-home providers will ALL document electronically and will have access to, and be able to contribute to, the patient’s digital care plan.”

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