Abstract
Background: Primary care is the cornerstone of integrated care models for managing chronic conditions, offering continuous, comprehensive, and coordinated care. Primary care providers (PCPs) focus on preventive care, early intervention, and ongoing monitoring, which are key to managing chronic conditions and preventing complications. For that, PCPs needs to adhere to quality standards and be experts in navigating their patients not only through the healthcare system but through social and community services given the important role that social determinants of health play in the outcomes of chronic conditions management. However, PCPs face challenges in adopting quality standards for chronic conditions management. Integrating these standards into busy workflows can increase administrative burdens and lead to burnout. The diverse needs of patients and the personalized nature of chronic conditions care make applying standardized guidelines challenging. Continuous education and staying updated with best practices require time and resources, which are often limited. Sufficient awareness of and ease of referrals to social and community services is another challenge.
Approach: In 2019, the Ministry of Health and Long-term Care in Ontario, Canada, unveiled Ontario Health Teams (OHTs) as a groundbreaking integrated care model designed to provide integrated, person-centered care to Ontarians throughout their life span. Presently, there are 58 OHTs in operation. The Burlington OHT, Greater Hamilton Health Network and Middlesex London OHT were among the initial OHTs to receive approval.
In late 2023, the three OHTs were identified as high performers who would be supported with additional resources to accelerate their journey to become designated OHTs. A designated OHT will be fiscally and clinically responsible for their attributed population. A new set of deliverables and tasks were assigned to the accelerated OHTs. The first of these tasks was building care pathways for chronic conditions.
The three OHTs put together a very comprehensive engagement process that included PCPs, specialists, patients, caregivers, community organizations, academics and leaders to understand the current state, identify the gaps and determine the change ideas.
Results: The main outcomes of the engagement process were:
•Primary care providers are the corner stone for any integrated care model for chronic conditions management
•Integrated care networks like OHTs can support PCPs and other providers in this role by creating a digital enabler- a one-stop shop platform that includes all the resources that providers need to access in order to diagnose, manage and navigate patients living with chronic conditions.
•This platform needs to be free, accessible to all providers and regularly updated.
Over the last year the three OHTs went through an extensive process of finding a solution that can fit the purpose, an international model was identified and adopted to the local context through an RFP process. Currently, we are in the design phase and the platform will be ready to share with the audience in May.
Implications: At the conference, we will unveil the detailed co-design and implementation blueprints of the platform, setting the stage for other integrated care systems to follow suit in deploying comparable health interventions