Sookatagaing (Working Together) for Care: Innovative Development of Integrated Care in Northwestern Ontario through Collaboration

BACKGROUND: The Noojmawing Sookatagaing (Healing Working Together) Ontario Health Team (OHT) is developing new methodologies for developing integrated care, and pathways, in an area marked by its vast and diverse geography. Spanning approximately 03,000 square kilometers, the OHT area includes the District and City of Thunder Bay, encompassing rural, fly-in, First Nation, and urban communities. These unique conditions necessitate adaptable, community-specific integrated care pathways (ICPs). Two of the four OHTs in Northwestern Ontario received funding to develop pathways specifically for COPD and heart failure. Recognizing the number of people who must travel for services in the northwest, it was important for Noojmawing Sookatagaing and All Nations Health Partners (ANHP) to involve the two non-accelerated OHTs in the region to foster a regional approach to equitable access. The projects involve clinicians, service providers, and individuals with lived experience including patients, families, and caregivers who provided information on the current healthcare landscape. Through design sprints, these stakeholders co-created and validated prototypes for integrated care pathways, ensuring they are tailored to local needs.

APPROACH: Our first ministry-funded Integrated Care Pathways (ICPs) provided the information and experiences needed to develop future processes for integrated care in our OHT. We subsequently developed a framework for integrated care that ensures that Indigenous culturally-safe care is the foundation of our work, and that our principles of equity, person-centred care, collaboration, and continuous improvement drive everything we do. It also ensures our seven priorities: meaningful partnership with Indigenous communities, consensus decision-making, mental and substance use health, people-centred leadership, primary care, digital health, and Francophone needs are represented in the work we do. Additionally, the values of Noojmawing Sookatagaing, as determined by our Collaboration Council, serve as the foundation for all future work.

RESULTS: An Integrated Care Framework was subsequently developed at the Noojmawing Sookatagaing OHT level, emphasizing co-design with service providers, First Nation communities, and individuals with lived experience at every stage from inception to ongoing monitoring and evaluation. This framework promotes a holistic vision of care, recognizing the importance of spiritual and emotional health alongside physical and mental well-being. At the core of this framework are the OHT priorities and values developed through co-design by the Collaboration Council partners that make up the consensus-based decision-making group for Noojmawing Sookatagaing OHT.

IMPLICATIONS:This presentation will share key lessons learned, highlight the significance of building strong relationships, and discuss the Integrated Care Framework developed through this collaborative effort. Our findings demonstrate the critical role of inclusive, region-specific planning in creating effective, integrated healthcare systems that meet the diverse needs of Northwestern Ontario communities. KEYWORDS: integrated care pathways, integrated care, Ontario Health Team, co-design, Northwestern Ontario, equitable healthcare, holistic health, frameworks, integrated care framework.