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Stratavera Health

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Home and Community Care Modernization

Sukhman Kalra
May 10
6 min read

Updated: May 11


In my last article, I talked about why we need to modernize Ontario’s home and community care sector. In this article, I want to share an approach to transforming the sector. In essence, we need to rethink how care is delivered and move towards a more patient-centred health system. A patient-centred health system aims to ensure that people receive the right care in the right place at the right time.


While the province has taken its first few steps towards transformation by moving towards regionally integrated care (i.e., Ontario Health Teams - OHTs) and the Connecting Home and Community Care Act 2020, we need bolder actions to modernize home and community care in Ontario. Through my work with OHTs and home and community care providers over the last 18 months, it has become clear that the modernization of the home and community sector needs:

  • Provincial coordination and standardization:  There is a need for a provincial agency that exists independently of Ontario Health (OH) or an independent function within OH to provide structure and direction for the sector. If its an independent agency, it could be an existing one (e.g. Home Care Ontario) whose mandate evolves to meet the needs. The agency/function would potentially be responsible for:

    • Strategy development: Develop the strategy for the home and community care sector in alignment with the provincial direction for the healthcare system and be held accountable for its successful execution by Ministry of Health (MoH) and OH.

    • Contracting: Develop standardized contracts for home and community care providers, setting the direction on how the providers will be contracted, but OHTs would execute the contracts and retain the ability to tailor them to meet the goals/outcomes for their OHT. The agency/function should work with OH to explore outcome-based reimbursement models that reward providers for improving care delivery in alignment with the quadruple aim.

    • Standardization of care: Act as a centre of excellence for home and community care in Ontario by consolidating leading practices for care delivery and ensuring that these resources are available to all OHTs and home and community care providers. The agency/function becomes responsible for driving the standardization of assessments and care, establishing benchmarks to be a home and community care provider, and driving innovation and modernization of the sector. To start, the agency/function could use the lessons learned and successes from the pandemic response as a foundation to establish standards for the delivery of home and community care for OHT year-1 populations. For example, there are various transitional care models in the province that provide different guidelines for the transition of elderly patients being discharged from the hospital to their homes. While in Australia, there are national guidelines that standardize transitional care across the country. Can the same success be achieved in Ontario? Absolutely.

    • Performance management: All home and community care providers and/or OHTs would report on the metrics identified by the agency/function and OH to measure the excellence of home and community care delivery. The agency/function would track and benchmark performance, help identify performance & quality improvement opportunities, and support the required policy reforms.

  • Regionally tailored service delivery: In the short-term, it is expected that the five regional OH offices will provide direction on the implementation of OHTs and coordination of home and community care services in their region. But as the OHT model moves towards maturity, the responsibility for home and community care coordination will be handed to the OHTs. To set up the OHTs for success, the regional offices and OHTs need to ensure that they:

    • Redesign care models with a patient-centred approach to enable better integration and a smoother transition of patients into and out of the hospital. Hospitals have an incentive here to work with the home and community care sector to improve patient flow/transitions, allowing for a reduction in length of stay, emergency visits and re-admission rates, and an increase in freed-up capacity. The cost savings generated can be reinvested in the transformation of the integrated care network (i.e. the OHT), and this can be provincially supported through outcome-focused reimbursement models.

    • Increase the use of technology for the home and community care sector to provide a digital front door for patients and allow the PSWs and nurses to digitally schedule visits, access their patients’ information and coordinate with other healthcare providers. To achieve success, OHTs will need to integrate existing technologies and invest in new solutions that increase integration and collaboration across the continuum of care and provide patients with easy access to their information and health care services.

    • Conduct regional Health Human Resource (HHR) planning to ensure that the home and community care sector has the required resources (i.e. PSWs, nurses, occupational therapists, physical therapists, etc.) and equitable pay for these resources (in comparison to their counterparts in other sectors).  Additionally, this planning will need to look at deploying inter-professional care teams that enable care delivery closer to home.

  • Sustainable funding: To sustain the OHT model of care and the change towards providing care closer to home, both the government and OHTs need to ensure they invest in the home and community care sector. This investment is needed to create the required digital infrastructure, conduct HHR planning and expand the areas of care for the sector. The expanded areas of service need to include preventative and promotive health and wellness services. These services support self-reliance for people and provide them with tools and information that could prevent them from needing acute care services. There have been various innovations across the world where certain hospital services are now delivered at home or in the community, and some innovations within the province (e.g. Home @Day program in East Toronto), where the patients are discharged from the hospital to their home faster than before. In both types of innovations, the critical success factor has been sufficient and sustainable funding resources in the home/community setting to ensure that the patient has all they need for an effective recovery. These innovative practices have resulted in improved health outcomes, reduced cost of care, better access to services, and reduced emergency visits/re-admissions.

  • Digital infrastructure: A holistic provincial strategy for digital infrastructure is critically needed. This strategy would leverage policy and funding reform to enable a scalable and adaptable digital infrastructure that supports the integration of health information systems across the continuum of care (i.e. hospitals, primary care, home and community care, etc.). The goal is to have a system that enables the bi-directional flow of information in real-time for all providers across the continuum of care and puts the patient in charge of their health information. The strategy should equitably enhance the digitization of care, i.e. ensure there is sufficient investment in technology for home and community care to transform the way care is delivered. Key areas of consideration for the provincial digital infrastructure include, but are not limited to:

    • Direct access to clinical information for all providers across the continuum of care through Connecting Ontario. Home care providers currently have access to Client Health and Related Information System (CHRIS) through Health Partner Gateway (HPG), but only for administrative data. The access to CHRIS should enable bi-directional exchange of all required patient information (e.g., primary care, labs, electronic health records, etc.). Additionally, the community support service providers who don’t have access to Connecting Ontario should be granted access for bi-directional information exchange.

    • A minimum data set and data standards & definitions to enable information exchange and analytics to support decision-making, operational improvements, and population health management for providers across the continuum of care.

    • Integration with innovative technologies/platforms that support better transitions in care, better access to care and improved flow of information. For example, virtual care, scheduling platforms, remote monitoring, AI-powered chatbots, etc.


While I have shared some of my ideas, I also have some questions that I think need to be answered, and I would love to hear what you think.

  • What role can home and community care providers play in the governance of an OHT? Can they be one of the decision-making partners?

  • How can we bring digital transformation to the home and community care sector? How will this be funded?

  • What will a standardized transitional care model look like for Ontario?



If you are interested in discussing home and community care or ideating answers to the above questions, please don’t hesitate to reach out.




 Some reports and articles that inspired my thought process:

 
 
 

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