Abstract
The Durham Ontario Health Team (OHT) has reorganized multi-agency resources serving the Downtown Oshawa neighbourhood to better meet the medical and social care needs of the residents, supporting better health outcomes, and elevating the patient experience journey by way of the Home and Community Care Modernization Leading Project (HCCMLP). Approximately ,000 people live in the Downtown Oshawa Neighbourhood as defined by the Regional Municipality of Durham. The health status of the residents within this area is significantly below that of the rest of the Durham region and results in higher utilization of emergency and community and social services and higher rates of chronic conditions when compared to the regional average. The Durham OHT partners have identified a significant opportunity and need to reduce health inequities that have been observed in the neighbourhood by redesigning how care is provided, coordinated, and integrated using a holistic approach to population health management. The HCCMLP has been developed, informed, and endorsed by all members of the Durham OHT Steering Committee and the Durham Advisory and Working Group Committees which includes representatives from Patient, Family and Care Partner Advisors. The goal of the HCCMLP is to integrate service delivery across health and social care providers, thereby lowering Emergency Department (ED) visits, improving patient experience, and ensuring that care is provided in the right place, at the right time by the right provider. The HCCMLP model leverages the expertise of diverse health system leaders to collaborate in addressing the needs of the community by co-designing and building connected systems of care with clients, family, caregivers, care partners, primary care, home care, community services etc. The model of care has great potential to reduce the reliance on reactive/avoidable emergency services with a deliberate focus on upstream care including proactive and preventative culturally appropriate services aimed at improving experiences across the health and social care system. The intended results include: Improving Population Health by enhancing access to comprehensive community health services delivered by an interdisciplinary team operating as;one team. Reducing Cost of Care Better Value for Money. Enhanced Patient Experience - by ensuring active resident and caregiver involvement in the care plan. A fundamental learning of the HCCMLP is to understand how leveraging assessment outputs to stratify resident needs to determine appropriate care amongst multi-system partners can create system wide efficiencies. Our model repositions and utilizes existing resources, to foster intrinsic capacity of older adults. The HCCMLP aims to move supports upstream, providing proactive and preventative culturally appropriate services that will reduce the need for crisis supports in reaction to an acute care episode. Next steps include scaling the program to expand within the Durham Region. The Durham OHT has established a Patient Family and Care Partner Advisory Council (PFCPAC). The 0 actively engaged PFCPAC members participate in decision making and are members of: Leadership Tables, Forums, Councils, Working Groups and Committees. Members are consulted on all ongoing initiatives to ensure their experiences, reactions and reflections are considered consistently. In an effort to improve quality, patient safety, patient health outcomes and establish greater relationships between hospital and the community at-large. Patients, families and care givers continue to remain at the forefront of all activities within the DOHT and the HCCMLP. The Durham OHT partners focus on equity; to ensure residents of the Durham Region impacted by social determinants of health have timely access to care. The project aims to provides access to individuals who identify as marginalized/vulnerable to ensure they receive culturally affirming care. An intentional focus on healthy equity through strategic partnerships will continue into 2025-26 and beyond.