Abstract
Background: Head Injury Rehabilitation Ontario (HIRO), a community agency, sought to improve care for individuals with cognitive and behavioural disabilities by creating a sustainable and equitable model of community-based care. The goal was to keep clients in the community rather than transitioning them to acute settings, by building stronger partnerships and optimizing client care.
Approach: This workshop is designed for organizations working on community collaboration, co-design, and equity in care, particularly those focused on individuals with acquired brain injuries, mental illnesses, dementia, or developmental disabilities. It offers lessons for policymakers and organizations seeking integrated care solutions in community settings.
HIRO began by conducting a literature review and environmental scan, followed by extensive stakeholder consultations, to identify opportunities to improve access to primary care for cognitively impaired clients. Using a co-design approach, HIRO engaged a diverse group of stakeholders—including unregulated staff, allied health clinicians, specialists, primary care providers, ethics advisors, clients, and families with lived experiences. This collaborative process allowed for diverse thinking, ethical analysis, and critical discussion, ultimately contributing to the design of a new care model.
The final model focused on enhancing collaboration between primary care, home care, and other community service providers. Key elements included:
Engaging dedicated primary care providers.
Providing leadership training and role clarity.
Enhancing client recordkeeping software.
Establishing interprofessional communication standards.
Assigning a dedicated clinician to oversee the model’s implementation and evolution.
Results: Nearly five years after implementing the model, HIRO has seen substantial improvements in client care. Clients and families report better access to and quality of care. Notably, the model has reduced the frequency of inappropriate urgent care use:
911 calls without transport to the ED have decreased by 75%.
Urgent care/walk-in clinic visits have dropped by over 90%.
911 calls with transport to the ED decreased by 50%, and the proportion of these calls resulting in appropriate hospital admissions increased from 12% to 24%.
Hospital re-admissions within 72 hours decreased significantly, from 11 to 2.
These outcomes suggest improved health management and reduced strain on emergency and hospital services.
Implications: The success of this model underscores the importance of creating conditions for diverse, collaborative discussions that can drive systemic change. It highlights that fostering innovation requires shared values, openness to power-sharing, and humility. Engaging diverse stakeholders—including providers, clients, and families—is critical to sustaining long-term, integrated community-based care models. HIRO’s experience demonstrates that with ongoing engagement and a commitment to co-creation, health equity can be achieved, even in the face of complex challenges.
HIRO is committed to sharing these lessons to inspire and guide other organizations and policymakers in their efforts to promote health equity and improve care for individuals with cognitive and behavioural disabilities.