Early Outcomes and Mechanisms of Integrated Home Care Improvement: Aligning Provider Perspectives with Performance Indicators

Background: Seven Ontario Health Teams (OHTs), each a partnership of health and community organizations, were selected by the Ontario Ministry of Health to lead the Leading Projects in Home Care initiative. These projects test new models of integrated home and community care designed to improve coordination, continuity, and patient-centred outcomes. All introduced key structural changes, including contracting a dedicated service provider organization and shifting from fee-for-service to a per-capita funding model.

 

Models varied in focus, with some organized around primary care or neighbourhood teams and others targeting specific populations such as palliative or high-needs clients. Additional innovations included enhanced digital communication systems and revised care coordination roles to support more collaborative, team-based care. This study examined early impacts, focusing on provider perceptions of outcomes and drivers of change.

 

Approach: The evaluation used a mixed-methods, longitudinal design examining both implementation and outcomes. Outcome measures, guided by the Quadruple Aim framework and developed in consultation with project teams, included home wait times, acute-care utilization, health care costs, and caregiver distress. Baseline data were derived from populations meeting program eligibility criteria in 2022–23. Semi-structured interviews (n = 31) and six focus groups were conducted with care coordinators, nurses, primary care providers, service provider organization managers, and project leads.

 

 Interviews explored implementation experiences, structural and process changes, facilitators, challenges, and perceived impacts. Qualitative findings on outcomes and mechanisms of impact were compared with administrative indicators to better understand both whether programs were achieving results and how improvements were occurring.

 

Results: Baseline data showed considerable room for improvement in caregiver experience, with 37-95% of clients reporting that their primary informal caregiver experienced ongoing distress, anger, or depression over a six-month period. Qualitative findings illustrated how caregiver trust and effective provider communication helped identify and address issues that had previously fallen through the cracks. Participants linked strong interdisciplinary teamwork to reduced emergency department use and lower system costs. In palliative-focused models, where costs were highest, providers perceived that flexible, self-directed care supported more appropriate service use and cost efficiencies.

 

Wait times from referral to first service ranged from 5 to 24 days at baseline, and providers reported that streamlined processes led to timelier access and smoother transitions. While the evaluation did not include quantitative indicators of collaboration or patient-centred care, providers frequently described working together as teams to improve the quality and responsiveness of care.

 

Implications: Findings suggest that streamlined processes, interdisciplinary communication, and flexible service delivery contributed to greater timeliness, continuity, and responsiveness for patients and families. The lessons emphasize that integrated home-care models can strengthen both outcomes and workforce capacity when collaboration and shared accountability are built into design and implementation. For international audiences, this work offers early evidence of how provider collaboration and patient-centred flexibility can jointly improve access, outcomes, and efficiency in home care.