Abstract
Background: The need for integrated care models that combine health and social care services within the communities where individuals reside is paramount to address people needs in an effective, person-centered, and sustainable way. A critical facilitator for such models is shared health records. Nonetheless, the realization of integrated health records continues to pose a considerable obstacle to the fruition of integrated care models. In 209, 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 was one of the initial OHTs to receive approval.
Approach: The first model executed by the Burlington OHT was the Community Wellness Hub (CWH) - an integrated care model for seniors, orchestrated by a coalition of health and social service providers collaborating as a unified team to coordinate and administer services to vulnerable seniors. The model commenced as a pilot in a single building in 209, expanded to a second in 2023, and a third in 2024. In 2022, the model was evaluated. One of the key recommendations was the establishment of a shared digital platform to enable Hub staff to effortlessly and securely access and disseminate information regarding a client care plan, status, care team, and appointments. Prior to the evaluation, providers depended on secure methods of client information exchange, such as verbal communication, fax, emails, and during their monthly rounds, as a common care record was not in use. This practice was identified by the evaluation as unsustainable and a factor contributing to diminished provider and client experience. In early 2023, a working group comprising leaders, experts, and prospective users was assembled to co-design the specifications of an integrated care record, drawing from workflows and use cases. A request for proposal was initiated, and a vendor was selected based on predetermined criteria. The working group engaged in regular meetings with the vendor to customize the digital solution to meet user needs.
Results: The CWH integrated care record was designed and is distinguished by three primary features: a) prompt communication among providers via secure messaging and notification capabilities, b) minimized redundancy through the consolidation of all health and social care assessments within one online platform accessible to the care circle, and c) a dynamic care plan document accessible to all providers, thereby obviating the necessity for clients to reiterate their needs, preferences, and care goals upon the initiation of new services or when engaging with new providers. The Integrated Care Record is currently in the implementation and testing phase. A data sharing agreement has also been crafted to support the implementation.
Implications: The design and execution of integrated health records that traverse the boundaries of various health and social sectors remains a formidable challenge that impedes the successful implementation of integrated care models. The exposition of our methodology in designing and implementing an integrated care record for an integrated care model for seniors holds significant promise in guiding policymakers, planners, funders, and implementers in strategizing and executing integrated health records within the framework of integrated care models.