The Oxford and Area Ontario Health Team has now been approved. Now what?

Now that we are an approved Ontario Health Team, all of our members will work together to begin implementing our plan to redesign care. This plan was identified to the Ministry of Health in our September 2020 application, which details how we will, over time, integrate our services to ensure patients receive coordinated care in the Oxford region. Our plan is to start redesigning care for three specific groups (more details below) within the first year of our partnership. Over time, we will focus care on more people across our region, so that eventually we can apply learnings and ensure coordinated care for our entire population of patients.

Each of our Action Teams will continue to meet and implement their work to ensure all aspects of integrated care are thought through. This includes digital health, primary care, patient/family/caregiver engagement, communications & community engagement, and governance.

Who will care change for?

While our plan is to eventually integrate services for all patients in the Oxford region with any health condition, we will start by focusing on three unique populations that can benefit most from coordinated care:

  • Patients at risk of frequent admission to hospital due to chronic illness
  • Patients at risk of using, or currently using, palliative care
  • Patients with mental health issues

These individuals can expect that all of their care and services will be coordinated between member organizations, making care easier to navigate. Over time, and through the lessons that we learn through redesigning care for our initial patient populations, we will grow to serve patients with more conditions until all patients in this region are served.

What will redesigned care look like?

As a patient who accesses care in the Oxford region, you will continue to work with your care providers as you previously did. What you may notice over time is how the care providers work together as a team to provide you more coordinated care. This may impact how you interact with care providers and go between health services. You will be supported 24/7 by a care navigator, have a single number to call with any questions or concerns, and have access to your health information so that you can play a more informed role in your health. Your information will be shared between the different health care providers on the team and you won’t need to continually retell your story each time you meet a new provider.

What are Ontario Health Teams?

Ontario Health Teams are groups of health care providers and organizations that are clinically and fiscally accountable for delivering a full and coordinated continuum of care to a defined geographic population.

Will patients continue to have a choice in their care provider?

Yes. When Ontario Health Teams are established, people’s choice of providers would continue.

Patients who are supported by providers who would become part of an Ontario Health Team would not need to sign up or undertake any administrative processes. What they would experience is greater access to care and support from a broader network of other physicians and inter-professional providers, working together as a team to improve their care.

How does a patient become connected with an Ontario Health Team? Will a patient be able to sign up with a team and how will this happen?

Ontarians will continue to access care from their existing care providers. As Ontario Health Teams are created, Ontarians will be provided with information about the benefits of this model. Ontarians will still be able to choose who provides their care. As the province begins this work, Ontarians can be confident that they can continue to contact their health care providers as they always have to access the health care they need.

What does an OHT look like at maturity?

As set out in the Ministry’s guidance document, at mature state, each Ontario Health Team will:

1. Provide a full and coordinated continuum of care for a defined population within a geographic region including primary care, hospital care, community and home care, long-term care, mental health and addictions services, and palliative care services.

2. Offer patients 24/7 access to coordination of care and system navigation services and work to ensure patients experience seamless transitions throughout their care journey. This does not mean that physicians are expected to be available 24/7, rather there is a patient navigator/care coordinator function required.

3. Improve performance across a range of outcomes linked to the ‘Quadruple Aim’: better patient and population health outcomes; better patient, family and caregiver experience; better provider experience; and better value.

4. Be measured and reported against a standardized performance framework aligned to the Quadruple Aim.

5. Operate within a single, clear accountability framework. Updated September 17, 2019

6. Be funded through an integrated funding envelope.

7. Reinvest into front line care.

8. Focus on digital health, in alignment with provincial digital health policies and standards, including the provision of digital choices for patients to access care and health information and the use of digital tools to communicate and share information among providers. Greater detail on the stages and expectations at maturity is outlined in the Ministry’s guidance document.