FLA OHT partners are working together to develop Integrated Care Pathways to help manage chronic diseases in the community, starting with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). Integrated Care Pathways start before people enter a hospital and continue throughout their care journey.
Current Challenges
- Primary care providers have limited time to spend with each person, and chronic diseases require more time to appropriately manage.
- Barriers such as transportation and access to resources exist for patients. Resources like smoking cessation, virtual care monitoring, vaccination and pulmonary rehabilitation can help people to manage their conditions and avoid hospital visits.
- Without access to preventative care, chronic diseases worsen. People who are admitted to a hospital for COPD and CHF are more likely to be readmitted.
What we are working towards
- Increasing access to key resources for those living with chronic disease before they become severely ill.
- Ensure people living with COPD and CHF receive the full inventory of care as outlined by the Health Quality Ontario (HQO) quality standards.
Integrated Care Pathways Projects
Best Care - Certified Integrated Disease Clinicians Pilot
The FLA OHT established an agreement with Best Care that has assigned two certified integrated disease clinicians working across ten FLA OHT Health Homes. Learn about Health Homes.
These clinicians will:
- provide care to people with COPD and CHF,
- screen people who would benefit from diagnostic tests, and
- help people manage these complex, chronic diseases.
Questions? Physicians can contact the Integrated Care Pathways project manager, Dendra Hillier: dendra.hillier@kingstonhsc.ca
Virtual Pulmonary Rehabilitation Program
Integrated Care Pathways aim to create more access to resources to enhance quality of life, such as pulmonary rehabilitation for those living with COPD. The FLA OHT has partnered with Lisa Dowe, a registered respiratory therapist, who offers a virtual pulmonary rehabilitation program for people across the region.
The free 8-week program offers two exercise sessions and one education session per week. The first group is now underway and registration for future groups is open until February 1, 2025.
Referrals for this program: Primary care providers (family physician or nurse practitioner) are invited to use this program referral form.
Human Resources to Support Pathways
FLA OHT funding for Integrated Care Pathways has established several key roles at Kingston Health Sciences Centre to optimize out-patient care for people living with CHF and COPD.
Roles such as COPD nurse navigator, CHF nurse practitioner and CHF physician assistant are addressing critical gaps in people's transition from the hospital to their home. They ensure each prson receives the full inventory of care aligned with Health Quality Ontario quality standards.
Questions? Primary care providers and specialists can contact the Integrated
Care Pathways project manager, Dendra Hillier: dendra.hillier@kingstonhsc.ca
Who's involved?
Community members, primary and community care providers, municipalities, hospitals and specialists from across the region are working together.
Community members include people with lived experience of mental health and addictions, family, caregivers, Indigenous and Francophone representatives, 2SLGBTQ+ and others.