Failure is not an Option: The Challenges (and Solutions) of Modernizing Home Care in Ontario through a Provincial Priority Project.

The Durham Ontario Health Team (DOHT) is leading an integrated, community-based initiative to improve health outcomes and reduce inequities among residents of the City of Oshawa a region characterized by high socioeconomic vulnerability, a heavy chronic disease burden, and fragmented access to care. The initiative reimagines the role of homecare as a central connector within the health system bridging acute, primary, and community care to ensure residents receive coordinated, person-centred, and restorative support in the setting that best meets their needs.

Grounded in population health management and restorative care principles, the project represents a shift toward proactive, integrated, equitable, and holistic service delivery. Extensive engagement with patients, caregivers, and homecare providers revealed the pressing need to address upstream factors such as poverty, housing instability, food insecurity, and social isolation, all of which exacerbate frailty and limit independence. By embedding social supports and clinical interventions within integrated home care models focused on interdisciplinary teams and restorative health care, the initiative ensures care is delivered in the right place, at the right time, by the right provider.

 

The overarching goal is to enhance the intrinsic capacity of older adults and other vulnerable populations by moving supports upstream and embedding preventative, person-centred, and culturally responsive services. Shared assessments and care coordination tools are being leveraged to stratify needs, improve navigation, and reduce unnecessary hospital use, resulting in more efficient system-wide outcomes.

Since its early 2025 launch, the initiative has demonstrated promising progress while also revealing critical implementation challenges and lessons learned:

1.Fragmentation of Care Services

Challenge: Services remain siloed, leading to duplication and communication gaps.

Solution: Establish integrated care pathways and shared digital? ecosystems that enable joint visits, multidisciplinary case reviews, and clear accountability for coordinated care.

 

 

2.Data Sharing and Interoperability

Challenge: Limited data flow and non-standardized systems hinder collaboration.

Solution: Implement interoperable IT solutions, shared EMRs, and real-time dashboards while ensuring privacy compliance and advocating for policy-level change.

 

3.Funding and Resource Allocation

Challenge: Difficulty aligning financial incentives to promote collaboration.

Solution: Introduce value-based funding models that reward outcomes rather than volume, such as bundled service packages supporting cross-sector initiatives.

 

4.Governance and Accountability

Challenge: Unclear decision-making and accountability structures.

Solution: Formalize governance frameworks defining roles, responsibilities, and performance metrics to promote transparency and trust.

 

5.Patient and Family Engagement

Challenge: Limited involvement of patients and caregivers in care planning.

Solution: Adopt patient-centred models supported by care navigators and embed patient-reported experience and outcome measures within care pathways.

 

6.Human Resources and Workforce Capacity

Challenge: Staff shortages and resistance to integrated care models.

Solution: Invest in workforce development, interdisciplinary collaboration, and flexible staffing models to reduce duplication and standardize care.

 

During the oral presentation, key data and performance indicators will be shared to illustrate progress, highlight impact, and solidify the understanding of the challenges and solutions discussed. This “year-in-review” approach will offer a data-driven reflection on system transformation efforts, aligning directly with the ICIC26 themes of Population Health Needs and Local Context and Improved Outcomes through Community-Based Care