Abstract
Background: Southlake@home aims to improve accessibility, cost-effectiveness, and outcomes by leveraging new tools, such as remote monitoring devices, telemedicine platforms, and electronic health records. By embracing innovation, home care services enhances efficient care delivery, improves communication and collaboration between patients and healthcare providers, empowering patient active participation self-care management.
Approach: Failing to achieve hospital-wide patient flow - the right care, in the right place, at the right time - puts patients at risk for suboptimal care. Many understand the problem, but lack the comprehensive strategies to address it. Our service delivery and funding model was designed to promote greater integration in health care delivery and improve patient outcomes. Public involvement and buy-in was essential 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 public.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, and saved over 5000 ALC days per year. 45% of emergency patients were discharged to self-care, with reduction in ED visits and hospital readmissions, demonstrating an annual system savings of $.8M or $8,000 per patient. We have seen improved patient satisfaction (96%) by 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. Southlake@home offers a model for other transitional care programs across Ontario 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 enhance ALC across Canada.References:Southlake Regional Health Centre (SHRC). Southlake@Home Balanced Scorecard (Data File). Southlake Regional Health Centre (SHRC). 2024.