Abstract
Introduction
The Western Ontario Health Team (WOHT) is a newly formed entity aiming to support the primary and secondary healthcare needs of a population of over 514,000 in London-Middlesex, Canada. Adopting a population health management approach, the WOHT “strives to address health needs at all points along the continuum of health and well-being through participation of, engagement with, and targeted interventions for the population” by building (and implementing) integrated, patient-centred care pathways for Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF).
Aims Objectives Theory or Methods
The key purpose of developing care pathways is to build the foundations of a population health management strategy. Specific objectives will be guided by a co-design process [refer to Abstract: A Co-Design Approach for System Transformation], and will include building care pathways with a sustained care relationship, informing the development of a shared care record, and laying the infrastructure for patient individualized care plans. The process of developing the care pathways will have a secondary objective of building relationships and partnerships which can support implementation efforts across stakeholders.
Highlights or Results or Key Findings
Care pathways leverage Business Process Model and Notation, which is an emerging standard being used in healthcare. The result will be an end-to-end care pathway including identification, prevention, assessment/diagnosis, management, and rehabilitation. Care pathways are being focused on COPD and CHF patients, but will be inclusive of holistic elements of care including screening and managing social determinants of health. Care pathways will also be iteratively co-designed with patients, from their perspectives, so they can both be a part of the design process and use the pathway as a self-management tool. Additional results from this exercise will include:
• A patient-centred pathway including a minimum standard set of activities to inform individualized care plans and patient education/self-management;
• A capacity planning resource which can be used to make system decisions on resource allocation and acquisition;
• A quality improvement tool which can be regularly evaluated to promote standardization, integration, and/or transformation where appropriate.
Conclusions
Developing care pathways is a foundational step in designing a broader population health management approach, which will include system evaluation and digital health solutions. Both the process and end-product of care pathway development have tangible outcomes which can support system transformation and population health management.
Implications for applicability/transferability sustainability and limitations
Care pathways are focusing initially on the minimum standard set of activities which should be considered for all patients, which makes them scalable to other jurisdictions regardless of regional variation.