How will you transform care?

Consistent with our approach to be very focused on a small number of key priority improvement initiatives, our Year 1 performance improvement opportunities to address the listed measures are directly aligned with our priority population key change activities.  This approach has proven successful both within our individual organizations and amongst our partner organizations with respect …

What opportunities exist for your team to improve care for your population and health system performance in Year 1 and at maturity? Read More »

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 …

How do you plan to redesign care and change practice? Read More »

How do you propose to coordinate care? In the Guelph and Area OHT envisioned mature state, care coordination is not a service but rather a set of functions that are integrated within and across partners of Integrated Primary Care Teams (IPCTs).  In Year 1, care coordination will be delivered by experienced LHIN H&CC Care Coordinators …

How do you propose to provide care coordination and system navigation services? Read More »

How will you improve patient self-management and health literacy? The Coordinated Care Plan (CCP) is based on patient identified health goals. The CCP will be broadly initiated across Guelph and Area to encourage patient involvement in their care and improve provider communication regarding patient goals. The teach-back method will continue to be utilized to empower …

How will you support patients (and caregivers) to be active participants in managing their own health and health care? Read More »

How will you work with Indigenous populations? The actual number of Indigenous residents is estimated at 5 times higher than reported (WWLHIN IHSP 2016-19).  There are various reasons for not self-identifying as Indigenous but most common is due to the generational trauma related to the abuses/genocide of the past and the biases/racism that still exist …

How will you address diverse population health needs? Read More »

So far on our journey towards becoming an Ontario Health Team, three streams of engagement have been undertaken, focused on the needs of those with mental health and addictions needs, those with palliative care needs and on how home care services can be integrated with primary care for improved service delivery. The three streams have …

How will you partner, engage, consult or otherwise involve patients, families, and caregivers in care redesign? Read More »