Appendix A – Home & Community Care

What is your team’s long-term vision for the design and delivery of home and community care?

Guiding principles to support the transformation of H&CC in the G&A OHT are included in Figure V. These principles, informed by patient/caregiver, provider and governor feedback, inspired our vision for the design and delivery of transformed H&CC.  Our vision, which builds on the ‘Primary Care at Home’ program (see Figure IV) is two-fold and includes: …

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What is your team’s short-term action plan for improving home and community care in Year 1?

Our top priorities for H&CC in Year 1 is to integrate the functions of care coordination (including intake, assessment of patient need and integrated service delivery) into our IPCTs. Patients within our priority population groups will experience additional enhancements to their H&CC. The characteristics of these patients are as follows: Patients requiring Care Coordination Given …

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How do you propose to transition home and community care responsibilities?

Our plan to transition H&CC resources, assets, programs and local knowledge and expertise will be developed once further clarity and commitment is received from the WWLHIN as to which resources are available to be integrated in the Guelph & Area IPCTs.  As described in section A2, in Year 1 we plan to co-locate, second and/or …

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Have you identified any barriers to home and community care modernization?

Current evergreen contracts and market share restrictions do not allow for integrated care delivery and perpetuate fragmented care.  Our patients describe a desire to have all services provided by a single team of providers so as to limit confusion and re-assessments. And our providers tell us that they need a common mechanism for communication and …

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