Oxford Ontario Health Team Together in Coordinated Care

Update, Summer 2019

Focus for Today

1. What is Ontario Health (the “Superagency”)?

2. What is an Ontario Health Teams (OHT)?

3. Which patients will be in which OHT?

4. Why an Oxford OHT?

5. What is next?

Ontario Health

Ontario Health Responsibilities

System management and performance planning and delivering health care – provincial & local; ensuring financial and clinical targets are met; improving quality

Population-based programs and clinical quality standards overseeing highly specialized care like organ donation and critical care; managing provincial population health programs like cancer screening; developing evidence-based guidelines for health service delivery and patient

care.

Back office support managing supply chains

System oversight Accountable for Ontario Health Teams Mental Health and Addictions Centre of Excellence

What is an Ontario Health Team?

.

Ontario Health Teams….

What Are Ontario Health Teams?

A new model of care that will enable patients, families, communities, providers and system leaders to work together, innovate, and build on what is best in Ontario’s health care system.

As a team, health care providers will work as one coordinated team no matter where they provide care.

The members of the OHT will work to achieve common goals related to improved health outcomes, patient and provider experience, and value for money (quadruple aim).

At Maturity, OHT’s will:

Provide a full and coordinated continuum of care for an attributed population within a geographic region

Offer patients 24/7 access to coordination of care and system navigation services

Be measured, report on and improve performance across a standardized framework linked to the “Quadruple Aim”

Operate within a single accountability framework

Be funded through an integrated funding envelope

Reinvest into front line care

Improve access to secure digital tools,

Hospitals

NPLC

CHC

GP LTC

Home Care

FHT

FHO

Meals on

Wheels

FHO

Current State: X Separate organizations X Separate Funding X Separate Health Records X Separate Intake, History X Separate Admits and

Discharges Patients need to navigate through this

Ontario Health Teams

Patients receive all their services, including primary care, hospital

services, mental health and addictions, long-term-care and

home and community care from ONE TEAM

Future State: One organization Single Funding Envelope enabling funds to follow the patient, focus on reducing hallway medicine Integrated Health Records, single patient record- so patients don’t have to tell their story over and over Enhanced 24/7 Care Coordination and system navigation to support patients regardless of where they are

Which Patients will be in which OHT?

Attributed Populations: Which patients belong to which OHT?

• Ontario residents are not attributed based on where they live, but rather on how they access care

Attribution determines the population that the Ontario Health Team is responsible for

There are no restrictions on where residents can receive care

Oxford OHT Submission

Strengths: Identifying existing mechanisms available to propose a clear vision and

plan for patient/community engagement within the region Demonstrating a strong history of trusting relationships among

partners, and commitment towards integration and shared financial management

Opportunities Exploring the existing digital health landscape / committing to enhance

digital health Working to more clearly identify immediate implementation priorities /

plans for Year 1 priority

The Oxford OHT self assessment has been designated as “In Development” meaning the Self Assessment submission demonstrated a commitment to the OHT model, and showed a

degree of readiness to implement.

Going from current to future state in Oxford

Hospitals

NPLC

CHC

GP

LTC

Home Care

FHT

FHO

Meals on

Wheels

FHO

Oxford Ontario

Health Team - Year 1

population

Proposed Year 1 Population for Oxford OHT

The early work of the Oxford OHT will be to focus on caring for people in the community rather than hospital

Rate of hospitalization and morbidity due to CARDIOVASCULAR DISEASE higher in Oxford than Ontario

Mortality rate due to ISCHEMIC HEART DISEASE higher than provincial average

Higher rate of hospitalization due to COPD in Oxford

5.4% of residents have 4 or more chronic diseases

YEAR 1 Target Population: People who have a readmission to hospital within 30

days of discharge due to a chronic disease

Oxford OHT Submission- NEXT STEPS

Over the next several months we will:

1. Work together to achieve readiness with the support of provincial resources

2. Establish action teams (Digital Health, Patient/ Family engagement, etc.)

3. Enhance governance structure

4. Further engage our partners (Home Care, Primary Care, Long Term Care, Community Supports) through “Sector Engagement” meetings over the fall to enhance model development

5. Meaningfully engage patients, families and community members as we build our model together with them.

6. Utilize the tailored supports (including customized ”attribution data”, Ministry of Health single point of contact, on-line resources and an OHT community of practice) to assist in refining our application

Proposed Oxford Ontario

Health Team Partners

~ Coordinating

Table

Oxford OHT

Partners

Community Support Services

Palliative Care

Outreach Residential

Hospice

Woodstock Hospital

TDMH

AHI

Home & Community

Care

NPLC

CHC TVFHT

Child/Youth MH

Adult MH

Addictions

LTC

Human Services

Paramedic Services

eHealth

Public Health

Moving forward together

Oxford OHT Steering

Committee

Patient Engagement Action Team

Communications Action

Team

Year 1 Population

Action Team

Digital Health

Action Team

Oxford OHT

Partners

Community Support Services

Palliative Care

Outreach

Residential

Hospice

Woodstock Hospital

TDMH

AHI

Home & Community

Care

NPLC

CHC TVFHT

Child/Youth MH

Adult MH

Addictions

LTC

Human Services

Paramedic Services

eHealth

Public Health

Governance Action Team

Oxford OHT at Maturity

At Maturity, the Oxford Ontario Health Team will provide a full and coordinated continuum of care to people residing in the geography of Oxford County.

are not the medium for informing their physician

that they have been hospitalized or undergone

diagnostic or treatment procedures; been

prescribed drugs by another physician; not

filled a previous prescription; or been

referred to a health agency for follow-up care

have 24-hour access

to a primary

care provider

do not have to repeat their

health history for each provider

encounter

with chronic disease, are routinely contacted to have tests that identify problems before they occur; provided with

education about their disease process; and

provided with in-home assistance and training in

self-care to maximize their autonomy

do not have to undergo the

same test multiple times

for different providers

do not have to wait at one level of care because of

incapacity at another level

of care

can make an appointment for

a visit to a clinician, a

diagnostic test or a treatment

with one phone call

have a wide choice of

primary care providers who

are able to give them the time

they need

have easy-to-understand

information about quality of care and

clinical outcomes in order to make

informed choices about providers and treatment options

How will patients know when an integrated healthcare

system exists?

When they:

Thank you

Questions?