Evaluating the Implementation of Health Homes in the Frontenac Lennox and Addington Ontario Health Team

Background: The Frontenac, Lennox, and Addington Ontario Health Team (FLA-OHT) is advancing a foundational model of Health Homes as part of a regional effort to achieve a person-centred Health Home for all. In collaboration with primary care organizations across the region, the FLA-OHT is developing a roadmap for scaling the Health Home framework, conducting a gap analysis of the existing primary care landscape, and identifying opportunities for co-design in program delivery. This initiative directly supports the quintuple aim by aligning resources, team composition, and care processes to population health needs.

 

Approach: The evaluation and planning work collectively aim to (1) assess Health Home outcomes across quintuple-aim domains; (2) identify organizational characteristics and processes influencing these outcomes; (3) develop a maturity model for Health Home implementation; and (4) design resource allocation models for allied health professionals based on physician panel management and population health data. Together, these deliverables will guide regional planning, enhance primary care capacity, and support the attachment of currently unattached patients to comprehensive primary care.

 

The project employs a mixed-methods approach integrating data on primary care team characteristics and administrative databases. Quantitative measures include patient-reported outcomes and experiences and utilization metrics, while qualitative data are gathered through organizational interviews and surveys. The Current State Assessment Tool, co-designed with primary care partners, describes organizational structures, team composition, access practices, and readiness for Health Home implementation.

All patients rostered to participating organizations, including equity-deserving populations, and all providers within interdisciplinary teams are included. The evaluation also analyzes variation across diverse practice models to understand maturity levels and readiness for regional program alignment.

 

Key instruments include: (1) a bi-annual Patient Health and Experiences Survey using EQ-5D and HQO measures; (2) an annual Provider Well-Being Survey; and (3) a Health Home Current State Assessment evaluating maturity across domains such as interprofessional collaboration, patient engagement, access, and continuous quality improvement. Results from these tools inform the resource allocation model, which matches allied health resources to population health needs and panel sizes to expand capacity for attachment.

 

Results: Primary outcomes include patient health status, experiences of care, provider well-being, health equity, and efficiency. The maturity matrix within the Current State Assessment provides a longitudinal measure of Health Home development, while resource ratios identify optimal configurations for expanding capacity without overburdening primary care physicians.

 

Implications: Preliminary findings indicate variability in Health Home maturity across practice models. The Current State Assessment provides a valuable planning and monitoring tool, supporting longitudinal tracking of organizational growth and regional resource mapping. The resource allocation model offers evidence-based guidance on the additional interdisciplinary resources required to attach patients and meet population needs. Collectively, these initiatives position the FLA-OHT to build a learning health system, continuously measuring and improving how Health Homes advance the quintuple aim and strengthen the sustainability and equity of primary care in Ontario.