caring together…better together oxford ontario health team
TRANSCRIPT
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?