Abstract
Background: Southlake@home is a home-care program dedicated to enhancing accessibility, cost-effectiveness, and health outcomes through a collaborative care model that actively engages patients, carers, and healthcare professionals. Our approach empowers patients to take an active role in their self-care management, fostering shared responsibility for health and well-being. By leveraging innovative tools such as remote monitoring devices, telemedicine platforms, and electronic health records, Southlake@home enhances care delivery and improves communication between patients and healthcare providers. Embracing these innovations allows us to support patient engagement and participation, ultimately leading to better health outcomes and a more efficient home care service that meets the needs of our community.
Approach: Achieving optimal patient flow—delivering the right care in the right place at the right time—is essential to prevent suboptimal care. While many recognize this issue, comprehensive strategies to address it are often lacking. Our service delivery and funding model promotes greater integration within healthcare systems to improve patient outcomes. Public involvement and buy-in was critical to program development and success. A population-based approach at the outset facilitated understanding of the public perspective, and ensured the care planning and provision is tailed to the actual needs of the community.
Personal public involvement is a key aspect of our approach as we actively seek input from individuals directly affected by healthcare policies and services. Engaging multiple stakeholders ensures the perspectives and experiences are considered in decision making processes. We adapted a co-design approach that allowed prioritization of complex patients who were at risk of becoming ALC and bridged their knowledge about the community to support transition back. Our bundled care model encourages innovation and collaboration between all healthcare providers and the community.
Results: Since its inception, Southlake@home has served over 2800 patients in the Northern York South Simcoe area in Ontario, Canada, and saved over 5000 reduced days in care. Notably, 45% of emergency patients empowered to manage their care independently, contributing to reduced emergency department visits and hospital readmissions, with an annual system savings of $1.8 million or $18,000 per patient. Patient satisfaction has reached 96% since addressing social determinants of health and the root causes of disparities. Likewise, staff also express satisfaction with the reduced readmission rates indicating successful care delivery.
Implications: Fundamentally, Southlake@home is about transitions of care. We have shown that better outcomes, improved patient and staff experience, and reduced costs to the system are possible by redesigning the pathway home for those with complex medical and social care needs and partnering with our communities. Southlake@home serves as a valuable reference for other transitional care programs aimed at integrating home and community care for high-need populations. Like many initiatives, Southlake@home has been about developing new relationships and trialing new ways of working together.
There is much to learn for organizations who are considering integrated community care or homecare partnerships aimed at reducing hallway healthcare pressures. We welcome fellow organizations to replicate these learnings and take our experiences into consideration for future initiatives to improve alternative care pathways.