Abstract
Background: One of the key early clinical deliverables of these Ontario Health Teams is the creation of Integrated Clinical Pathways (ICP), specifically targeting Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF). The primary objective of the ICP project is to enhance the quality of life for individuals living with chronic diseases and their caregivers by simplifying management pathways and improving overall care experiences. The Couchiching Ontario Health Team (COHT) leveraged partnerships for the ICP project to establish a regional Chronic Disease Program.
Approach: Planning and implementation of the COHT Chronic Disease program required an integrated care approach. To engage people as partners, co-create a shared vision, and address unique local needs, a planning day was conducted in collaboration with the COHT Patient Family Caregiver Network (PFCN) to identify care gaps and design a future state pathway for chronic disease management. The involvement of community partners and PFCN members was crucial in program co-design to ensure care and services were people-centered and that they meet the needs of users. As planning progressed, the team identified the need to engage additional partners to ensure pathway work adequately captured and supported the needs of more complex patients within the program. Taking an innovative approach to the province’s ICP project, COHT partnered with Waypoint Centre for Mental Health Care and the region’s North Simcoe Muskoka Specialized Geriatric Services program to better incorporate mental health needs and the needs of older adults and their caregivers into the pathways.
Results: Through the planning day and collaboration with the PFCN, a ""Chronic Disease Hub"" is now in place that empowers patients to be active participants in their care. An interdisciplinary team-based approach is employed that prioritizes the needs of both patients and their care partners, with regular check-ins to assess well-being. The pathways emphasize culturally safe care and address social determinants of health, including poverty, language barriers, and facilitating referrals to essential community services. With engagement of a specialized mental health partner and a specialized geriatric service program leader, screening tools are incorporated into pathways, new referral processes have been embedded and programming is being developed to build the self-management capacity of patients and their caregivers and to build the clinical capacity of the team. To ensure our ongoing commitment to co-design and continued quality improvement, the PFCN remains an active and engaged partner.
Implications: The integrated approach demonstrated by the COHT, in collaboration with our PFCN and community partners, underscores the significance of comprehensive care pathways in enhancing health outcomes and enriching patient experiences. This project serves as a model for fostering holistic chronic disease management through community engagement and support. In this presentation, we will share our approach and results to date. We will highlight lessons learned in our co-design journey and will provide insight into potential opportunities to expand, collaborate and consider further scale and spread.