Our first 18 months of success!

Message from Executive Lead, Dr. Kim Morrison

It’s been an exhilarating ride as the FLA OHT has evolved over our first 18 months. Our rocket ship has a solid structure and is hurdling towards our North Star of the People-Centered Health Home. Let’s take a collective breath and enjoy the successes we have all achieved as our partnerships expand, and we build stronger relationships and collaborations. The overarching goals that we aspire to achieve are grounded in the Quintuple Aim. This anchors our focus on health equity; provider well-being; and the pursuit of better health, improved outcomes and experiences, and better use of resources as we work together to transform the health-care system.

At the end of November, the Ministry of Health released The Path Forward for Ontario Health Teams., which identified five key directions OHTs need to take to ensure there is a standardized approach across the province. I’m proud to say we have achieved tremendous progress in all five of those directions and are in a strong position to succeed with the next steps of OHT development. Stay tuned to future newsletters, where we will provide more information on how we are implementing the Ministry guidance.

It is impossible to highlight a single success that is contributing to improving the experience of the people we serve. There are so many pieces of this work bringing us together and transforming care from the ground up.  A few key highlights that support our success include: 

• Primary Care engagement and leadership are critically important as a foundation for building a model of high-quality care. All primary care physician groups in the FLA OHT area have signed on as partners, and come together with a strong voice through the Primary Care Alliance. Primary care providers support all working groups as co-leads, together with representatives from our Community Council.

• Community engagement is essential to understanding the experience of the people in our OHT. Community members co-lead and co-design all priority working groups and come together at our Community Council.  Hundreds of community members have also been engaged in building our first strategic plan.

• Partnerships and strong leadership have fostered our successes. The Partnership Council has more than 300 members who have come together to form the Transitional Leadership Collaborative which oversees our work. We are fortunate to have the skills, interest, and energies of so many people who are leaders in providing care, accessing care, and enabling research and evaluation of this learning health system that is the FLA OHT.

There are five priority population working groups at the FLA OHT which have all achieved significant milestones.

1. The Palliative Care working group has identified and worked with unattached community members who need palliative care and connected them to primary care physicians who now provide home-based palliative care.

2. Through the work of the Aging Well at Home working group, two new roles have been created; an Aging-Well-at-Home Advocate, and a Health and Social Integrator, who all help people access the right care to help keep them well in their homes where they wish to age.

3. The Mental Health & Addictions working group has launched a new initiative called Shared Care, which involves discussions with primary care providers and representatives of mental health and addictions services who collaboratively work together to review individuals’ situations and identify the most appropriate support to meet their needs and help them with their care journey. Shared Care discussions are active at 63 percent of FLA OHT Health Homes.

4. A new Health Home Care Navigator position has been created through the work of the Coordinated Discharge working group.  This role works with people to provide seamless transitions into and out of the hospital, helping them access the appropriate supports at home and in the community.

5. The newest priority population working group has been named Access to Primary Care. This group is building new models of care for people who don't currently have a primary care provider – a family doctor or nurse practitioner – with the support of other health and wellness providers. The group’s goal is to ensure everyone, including children, youth, seniors, francophones, Indigenous people, newcomers to Canada, and people experiencing or at risk of homelessness have timely access to the care they need.

Through the Digital Support Structure, we are using digital technologies to advance research into understanding how to capture changes that are meaningful to people and their quality of care. Technology is being used to improve workflows for providers and to offer multiple ways for people to book appointments. The FLA OHT is also working towards achieving the vision of one single health record for each individual who accesses care in our region, which is shared across all providers involved in their care.  With funding from Ontario Health, we are exploring how primary care providers, hospitals, long-term care residents, and community programs can all use the same medical record to understand a person’s full history and provide care across a lifespan.  

These are just a few of the many incredible FLA OHT achievements that are improving the quality of care for people, families and caregivers.