Integrated Patient Care Team (IPCT) Home Care Program

Leading Practice

Integrated Patient Care Team (IPCT) Home Care Program

Supporting Materials

GW OHT IPCT Home Care Referral Pathway

Patient Bill of Rights

How Your Team Shares Your Information

IPCT Home Care Program Brochure

What is the Integrated Patient Care Team (IPCT) Home Care Program?

The GW OHT is one of seven OHTs from across the province that have been selected to deliver innovative, modernized home care models with Ontario Health and Ontario Health atHome. This is part of the Ontario Government’s plan to modernize home and community care in the province.

The OHTs’ projects to improve home care integration, transition, and access, with the goal of improving patient outcomes and experiences. The GW OHT and the six other Leading Practice OHTs are working closely with Ontario Health and Ontario Health atHome to put these improvements into practice as part of the broader work to modernize home care. Modernizing home care will lead to positive outcomes for patients and their families, and providers, including:

improved care for patients and families
making it easier to connect to home care services through a one-stop approach
patients and families more involved in their care plan development with easy-to-understand detailed plans before leaving hospital
family caregivers experiencing reduced distress
support for providers in recruiting and retaining workers
fewer avoidable hospital readmissions and avoidable emergency department visits

Learn more about the Ontario Government’s plan to modernize home and community care in Ontario.

What is an Integrated Patient Care Team (IPCT)?

Patients and providers told us they want one team!

An integrated team of dedicated providers (i.e. they exclusively care for the patients of the IPCT) wrap around care where care team members, within and across settings, communicate effectively to meet each patients’ goals.

GW OHT partners are committed to advancing integrated care through the Integrated Patient Care Team (IPCT) model. This ‘Home Care Modernization Leading Project’ is the vehicle by which GW OHT partners are advancing the IPCT model. The GW OHT Home Care Integration Leading Project launched early 2025 at six existing primary care sites.

Who is Eligible?

Eligible community members may receive home care services through the Leading Practice Integrate Patient Care Teams. To qualify you must be a patient of one of the eight IPCT sites:

IPCT 1: Guelph FHT Wyndham Medical Clinic and Parkview Family Medical
IPCT 2: Guelph FHT Arbour Family Medical Centre
IPCT 4: Guelph FHT Gordon Street Family Medical (806 Gordon St)
IPCT 8: Guelph FHT Norfolk 305
IPCT 14: East Wellington FHT (Erin and Rockwood)
IPCT 17: Minto Mapleton FHT
IPCT 18: Mount Forest FHT

Advancing the IPCT Model in Guelph Wellington

Functions of an IPCT

1. Patients with complex needs and/or their caregiver will have a “Go- To-Person” to call

A “Go-To-Person” is a member of the IPCT who is chosen by the patient with complex needs as their first point of contact for any questions regarding their care.

2. Patients with complex needs have a single, shared care plan so that all members of their care team know their story & plan

A shared care plan is a patient-centered health record designed to facilitate communication amongst members of the care team, including the patient and providers. Rather than relying on distinct care plans, a shared plan of care enables members of the patient’s care team to create and adapt a shared plan of care. The shared care plan will be automatically updated and will be available in both CHRIS and the TELUS PS Suite EMR.

3. Patients have access to their health information

ConnectMyHealth is a free online portal being developed by Ontario Health that will allow patients to access their own health information. It is a patient-facing clinical viewer which will display a subset of information from ClinicalConnect. It is expected to be available to patients in Guelph Wellington in the first half of 2023. Click here for more information.

4. Data is available to understand and deliver care to patients based on their complexity of their health conditions

Currently, data/information available about patients is limited to each sector of the health care system (e.g. hospital data, home care data, primary care data). Integrated Decision Support (IDS) is a platform that combines data from multiple sectors (acute care, mental health and addictions, home care, etc.) to understand each patient’s health and journey across the system. Several primary care providers/groups have also recently begun contributing their data to IDS. This is enabling a better understanding of the health needs and journey of each patient AND to plan and deliver holistic care to each patient within each IPCT (rather than developing different models of care for each diagnosis that a patient may have).

5. Care team members are able to communicate safely and securely in real-time

Hypercare is an easy-to-use, secure App (similar to WhatsApp) used for real time texting between providers. It can improve connectivity and communication between providers and facilitate transitions of care. GW OHT is currently providing licenses for GW OHT providers. To read a real case example of how Hypercare prevented an Emergency Department visit, click here

6. Care team Feedback from patients, caregivers, and health care providers is used to improve care processes are able to communicate safely and securely in real-time

Patient and provider feedback surveys take only 3 minutes and are administered annually at each IPCT site to inform the evolution of IPCTs.

What is Home Care?

Home care includes a series of support to assist people maintain independent living and manage their health care needs from home. Many people utilize home care services, like those who may need assistance to get back on track following a hospital stay, illness or injury or a complex or chronic health condition. Care professionals work with patients, their families and caregivers in determining what type and levels are appropriate to meet the needs and goals of the patient.

Types of services include:

Care coordination
Nursing
Physiotherapy
Occupational therapy
Nutritional counselling

Speech therapy
Social work
Personal support
Medical supplies and equipment

Frequently Asked Questions

Who is delivering the services in the Integrated Patient Care Team (IPCT) Home Care Program?

In September 2024, CBI Home Health and Paramed Home Health were selected as in-home service providers for the new integrated home care model in Guelph Wellington OHT. Read the media release here.

Is this program covered by OHIP? What if I don’t have OHIP?

Yes – this program is covered by OHIP. If you don’t have OHIP and are receiving care from one of the 6 IPCT sites, please speak with a member of your primary care team.

Is this change happening elsewhere in Ontario?

Yes, this change is happening in the seven leading practice Ontario Health Teams. Home Care Modernization is also happening in the Durham Region, Mississauga, Nipissing, Chatham-Kent, East Toronto, and Frontenac Lennox and Addington communities. Learn more about the Ontario Government’s plan.

Have questions or feedback about the Integrated Patient Care Team (IPCT) Home Care Program?

Please speak with your primary care and/or in-home providers OR reach out to Emmi Perkins (Emmi.Perkins@GuelphWellingtonOHT.com; 519.827.7358)

I already receive services from a home care provider, how do I transition to the Integrated Patient Care Team (IPCT) Home Care Program

Please speak with your primary care and/or in-home providers.