Abstract
Background: Ontario, like other provinces, continues to face challenges caring for patients within the current system; hospitals in the region seeing increasing occupancy rates that are regularly above 100%. With significant bed pressures due to increasing acuity and complexity of patients these system pressures compels us to accelerate integrated models of care. However, implementing rapid system wide changes to deliver care is complicated and challenging in a siloed system.
University Health Network (UHN), Canada's largest research and education health system, launched an Integrated Care Program in 2019. This model of care streamlines and breaks down barriers to provide better care experiences for patients, essential care partners and providers with improved outcomes while also creating much needed in-patient bed capacity resulting from lowering hospital lengths of stay at hospital as well as preventing avoidable Emergency Department revisits and readmissions.
Methods/Results: Critical to the success of this system-wide change was the shared vision, collective commitment and partnership with patients, essential care partners and practitioners from acute care, home care and community paramedicine.
Investing time in creating a true one team is the foundation for sustainable change towards integrated care but continues to remain elusive to many teams. This presentation speaks to the key elements that fostered the environment for trust, collaboration and accountability for a program that over five years has delivered 17 pathways across surgery, medicine and transplant benefiting ~4,000 patients annually.
Strategies for success include the following:
- Guiding Principles to support ongoing decision-making
- Co-creation of pathways with a view to advance care at home
- Collective commitment to standards
- Clear accountabilities with aligned incentives
- Use of real time data to learn from success and failure and enable continuous quality
This approach has led to the following benefits:
1)Delivering the right care at the right time - Improved connectedness and communication amongst care providers fosters and supports a one care team approach with a focus on where care is best delivered. This has resulted in a significant impact to reduce ED (Emergency Department) visits and hospital admissions.
2)Faster Access to Care – ability to create acute care capacity and accelerate recovery by decreasing total lengths of stay and hospital readmissions.
3)Partnering with homecare to hire/retain more health care workers - Build teams to work to their full scope of practice, create new models of education and training and move away from historical pay per visit care.
By removing siloes care providers have gained a better understanding of care experiences across the continuum and a better appreciate for challenges across environments. By enabling collaboration teams have been able to ongoing identify opportunities to advance care at home and increasingly support complex patients.
Conclusion and Next Steps: Rapid and enterprise wide change is possible, and with a shared vision and commitment, can deliver both meaningful and sustainable change to for patients, essential care partners, and care providers.