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Health Care Teams to Implement Innovative Bundled Care Approach

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Health Care Teams to Implement Innovative Bundled Care Approach

Ministry of Health and Long-Term Care

Ontario is funding six cross-sector health care teams to implement innovative bundled care projects in their communities. These teams will focus their work on patients who require short-term care at home after leaving hospital. The province plans to support additional teams across Ontario over the coming year.   

In a bundled care approach, a group of health care providers is given a single payment to cover all the care needs of an individual patient's hospital care and home care.  This approach is also known as an "integrated funding model."

The six teams that will receive the first wave of bundled care funding include:

Connecting Care to Home:

Optimizing care for chronic obstructive pulmonary disease and congestive heart failure patients in London Middlesex

Project Partners: London Health Sciences Centre, South West Community Care Access Centre, St. Joseph's Health Care London, Thames Valley Family Health Team, South West Local Health Integration Network.

In this project, patients with moderate intensity needs related to chronic obstructive pulmonary disease and congestive heart failure discharged home from London Health Sciences Centre will experience an integrated and coordinated system of care based on evidence-based practice as they transition from hospital to the community.

Focused on integrating current hospital and Community Care Access Centre funding, patients will be supported by an innovative eHomecare model that enables remote monitoring, with 24/7 access to a clinical team. The patient will be supported by a navigator, clinical care coordinator, dedicated home care provider, ambulatory clinics and common electronic medical record. The hospital and Community Care Access Centre will work together with specialists and primary care providers to ensure that patients are provided seamless and patient-centred care.

Integrated Comprehensive Care 2.0:

Hamilton Niagara Haldimand Brant Local Health Integration Network-wide chronic obstructive pulmonary disease and congestive heart failure

Project Partners: St. Joseph's Healthcare Hamilton, Brantford Community Health System, Centre de Santé communautaire, Grand River Community Health Centre, Haldimand War Memorial Hospital, Hamilton Health Sciences, Hamilton Niagara Haldimand Brant Community Care Access Centre, Hamilton Niagara Haldimand Brant Local Health Integration Network, Hamilton Niagara Haldimand Brant Primary Care lead, Joseph Brant Hospital, Niagara Falls Community Health Centre, Niagara Health System, Norfolk General Hospital, North Hamilton Community Health Centre, St. Joseph's Home Care, West Haldimand General Hospital

Building on the success of the St. Joseph's Health System's Integrated Comprehensive Care Program, all acute care hospitals in the Local Health Integration Network and the Community Care Access Centre will work closely with primary care partners and specialists to provide integrated post-acute care to patients who have been admitted to a hospital with chronic obstructive pulmonary disease and congestive heart failure and require home care after discharge.

Key features of the project will include integrated care coordinators, who will provide patients with a single point of contact in hospital and at home; 24/7 access to medical expertise and care for patients; unified health records; and the use of technology to support team and patient communication.

Hospital 2 Home:

The Central West Integrated Care Model

Project Partners: William Osler Health System, Central West Community Care Access Centre, Headwaters Health Care Centre, Central West Local Health Integrated Network, Ontario Telemedicine Network

Hospital to Home (H2H) will improve the patient experience by leveraging an integrated model of care as people transition from the hospital to the community.  It will initially support patients requiring short-term nursing interventions, later expanding to support those with more complex needs. 

Care will be further enhanced through a partnership with the Ontario Telemedicine Network which will provide eVisits and, where appropriate, leverage telewound to safely transition and care for patients in the home.  Overall, this model will reduce duplication and barriers, create a more seamless experience, shorten hospital stays and reduce hospital readmissions.  It will also build on the recent non-clinical integration between the region's hospitals and Community Care Access Centre, as all partner organizations strive to create a more integrated health care journey for patients across Central West.

Putting Patients at the Heart:

A Seamless Journey for Cardiac Surgery Patients in Mississauga Halton

Project Partners: Trillium Health Partners and Saint Elizabeth Health Care with support from the Mississauga Halton Local Health Integration Network

Trillium Health Partners will work with Saint Elizabeth Health Care to allow patients to go home on average three days sooner after cardiac surgery. This will be supported by continuing specialist engagement and providing care in the home for up to 30 days post-discharge. 

Patients will experience a seamless journey from pre-surgery through their stay in hospital and through their care once transitioned home, thereby reducing length of stay, readmissions and emergency department visits. Key features include an integrated care coordinator that works with patients beginning at pre-op, a 24/7 contact centre and telemonitoring in the home.

One Client, One Team:

Central and Toronto Central Local Health Integration Network Integrated Stroke Care

Project Partners: Sunnybrook Health Sciences Centre, Providence Healthcare, Mackenzie Health, North York General, Toronto Central Community Care Access Centre, Central Community Care Access Centre

The project will focus on stroke care, beginning with patients discharged from hospital to home for up to 60 days. The team includes acute, home and outpatient providers in two Local Health Integration Networks. Patients will have a seamless care experience across the continuum of care including improved quality, health outcomes and experience as a result of evidence-based pathways of care, integration across providers and settings.

The model will include the use of a clinical collaboration tool; warm handoffs between health care providers when there is a transition in care - for example, when the patient moves from hospital to home; and the potential use of telecommunications to deliver healthcare services to patients at home.

Integrating Specialized and Primary Care:

The North York Central Collaborative for chronic obstructive pulmonary disease and congestive heart failure patients

Project Partners: North York Integrated Care Collaborative (North York General Hospital, Central Community Care Access Centre, Saint Elizabeth Health Care, Pro Resp Home Oxygen & Respiratory Care, Circle of Care, North York Family Health Team), West Park Healthcare Centre, Central Local Health Integration Network

This project is focused on caring for patients with chronic obstructive pulmonary disease and congestive heart failure in the mid- to late-stage of their disease as they transition from hospital to home for up to 18 weeks post-discharge.

Patients will experience a collaborative and coordinated team approach across health care partners (hospital - both acute and outpatient, community, primary care) to reduce emergency department visits, admissions and improve the patient experience. The integrated care approach will include dedicated care coordinators, a 24/7 access line for patients, remote consults enabled through technology and specialist follow-up including ambulatory rehabilitation.

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