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Bundled Care (Integrated Funding Models)

September 2015

Announcement of Wave 1 Teams

The Ministry of Health and Long-Term Care is acting on plans set out in Patients First: A Roadmap to Strengthen Home and Community Care by selecting the first wave of Ontario healthcare providers to roll out bundled care.

Following an Expression of Interest (EOI) process, receipt of 50 submissions, and a multi-phased assessment process, six teams have been selected to receive project management funding to support implementation of Integrated Funding Models (IFM).

In a bundled care approach, a group of health care providers determine a single payment to cover all the care needs of an individual patient's hospital care and home care. "Integrated funding models" and "bundled care" are synonymous terms to describe the ministry's initiative to implement innovative approaches to integrate funding over a patient's episode of care.

The successful teams and their corresponding project descriptions are as follows :

Connecting Care to Home: Optimizing Care for COPD and CHF Patients in London Middlesex

Project Partners : London Health Sciences Centre, South West Community Care Access Centre, St. Joseph's Health Care London, Thames Valley Family Health Team, South West Local Integration Network

In this project, patients with moderate intensity needs related to chronic obstructive pulmonary disease and congestive heart failure discharged home from London Health Sciences Centre will experience an integrated and coordinated system of care based on evidence-based practice as they transition from hospital to the community. Focused on integrating current hospital and CCAC funding, patients will be supported by an innovative eHomecare model that enables remote monitoring, 24/7 access to a clinical team, supported by a navigator, clinical care coordinator, dedicated home care provider, ambulatory clinics, and common electronic medical record. The hospital and Community Care Access Centre will work together with specialists and primary care to ensure that patients are provided seamless and patient-centred care.

Integrated Comprehensive Care 2.0: Hamilton Niagara Haldimand Brant (HNHB) LHIN-wide COPD and CHF

Project Partners : St. Joseph's Healthcare Hamilton, Brantford Community Health System, Centre de Santé Communautaire, Grand River Community Health Centre, Haldimand War Memorial Hospital, Hamilton Health Sciences, HNHB Community Care Access Centre, HNHB Local Health Integration Network, HNHB Primary Care lead, Joseph Brant Hospital, Niagara Falls Community Health Centre, Niagara Health System, Norfolk General Hospital, North Hamilton Community Health Centre, St. Joseph's Home Care, West Haldimand General Hospital

Building on the success of the St. Joseph's Health System's Integrated Comprehensive Care Program, all acute care hospitals in the LHIN and the CCAC will work closely with primary care partners and specialists to provide integrated post-acute care to patients who have been admitted to a hospital with chronic obstructive pulmonary disease and congestive heart failure and require home care after discharge. Key features of the project will include integrated care coordinators, who will provide patients with a single point of contact in hospital and at home; 24/7 access to medical expertise and care for patients; unified health records; and the use of technology to support team and patient communication.

Hospital 2 Home: The Central West Integrated Care Model

Project Partners : William Osler Health System, Central West Community Care Access Centre, Headwaters Health Care Centre, Central West Local Health Integrated Network, Ontario Telemedicine Network

Hospital to Home (H2H) will improve the patient experience by leveraging an integrated model of care that reduces handoffs as people transition from the hospital to the community. It will initially support patients requiring short-term nursing interventions, later expanding to support those with more complex needs. Care will be further enhanced through a partnership with the Ontario Telemedicine Network (OTN) which will provide eVisits and, where appropriate, leverage telewound to safely transition and care for patients in the home. Overall, this model will reduce duplication and barriers, create a more seamless experience, shorten hospital stays and reduce hospital readmissions. It will also build on the recent non-clinical integration between the region's hospitals and CCAC, as all partner organizations strive to create a more integrated health care journey for patients across Central West.

Putting Patients at the Heart: A Seamless Journey for Cardiac Surgery Patients in Mississauga Halton

Project Partners : Trillium Health Partners and Saint Elizabeth Health Care with support from the Mississauga Halton Local Health Integration Network

Trillium Health Partners will work with Saint Elizabeth Health Care to allow patients to go home on average 3 days sooner after cardiac surgery. This will be supported by continuing specialist engagement and providing care in the home for up to 30 days post-discharge. Patients will experience a seamless journey from pre-surgery through their stay in hospital and through their care once transitioned home, thereby reducing length of stay, readmissions and emergency department visits. Key features include an integrated care coordinator that works with patients beginning at pre-op, a 24/7 contact centre and telemonitoring in the home.

One Client, One Team: Central and Toronto Central LHIN Integrated Stroke Care

Project Partners : Sunnybrook Health Sciences Centre, Providence Healthcare, North York General, Toronto Central Community Care Access Centre, Central Community Care Access Centre

With a focus on stroke care and beginning with patients discharged from hospital to home for up to 60 days, this team includes acute, home and outpatient providers in two LHINs. Patients will have a seamless care experience across the continuum of care including improved quality, health outcomes and experience as a result of evidence-based pathways of care, integration across providers and settings.The model will include the use of a clinical collaboration tool; warm handoffs between health care providers when there is a transition in care - for example, when the patient moves from hospital to home; and the potential use of telecommunications technologies to deliver healthcare services to patients at home.

Integrating Specialized and Primary Care: The North York Central Collaborative for COPD and CHF Patients

Project Partners : North York Integrated Care Collaborative (North York General Hospital, Central Community Care Access Centre, Saint Elizabeth Health Care, Pro Resp Home Oxygen & Respiratory Care, Circle of Care, North York Family Health Team), West Park Healthcare Centre

This project is focused on caring for patients with chronic obstructive pulmonary disease and congestive heart failure in the mid- to late-stage of their disease as they transition from hospital to home for up to 18 weeks post-discharge. Patients will experience a collaborative and coordinated team approach across health care partners (hospital - both acute and outpatient, community, primary care) to reduce Emergency Department (ED) visits, admissions and improve the patient experience. The integrated care approach will include dedicated care coordinators, a 24/7 access line for patients, remote consults enabled through technology and specialist follow-up including ambulatory rehabilitation.

Background

On February 5th, 2015, the ministry issued an Expression of Interest (EOI) to the health system for Integrated Funding Models that will champion the delivery of quality, evidence-based care to patients. Providers (including hospitals, CCACs, direct service home care providers, physicians, and others) were encouraged to create innovative and solutions-driven approaches within a defined policy framework and are based on evidence-informed clinical pathways and focus on enhancing coordination of care. This approach will allow providers to integrate funding over a patient's episode of care, regardless of who is providing the care, or in what care setting.

This work builds on the foundation laid by the Excellent Care for All Act, Health System Funding Reform, and Vision for Home and Community Care by promoting high quality patient-centred care across the care continuum. It is one of the recommendations in Bringing Care Home, a report from the expert group on home and community care, which includes 16 recommendations to improve patient- and family-centred care, and is a key recommendation set out in Patients First: A Roadmap to Strengthen Home and Community Care.

In March, 50 EOIs were submitted in total. A multi-phased assessment process was then undertaken, including reviews by :

As a result of this combined feedback, 14 readiness assessment site visits were conducted in 10 LHINs between the end of April and mid-May. Ultimately, six of the 14 teams were selected for wave 1.

What's Next?

Teams will begin implementing their integrated funding models this fall. A real-time evaluation is taking place to support measurement of the impact of the Bundled Care initiative. After early results of the six projects are reviewed, findings of the evaluation will be reviewed to inform roll-out across the province.

Several applicants demonstrated great promise through the readiness assessment process and will be supported to ensure they are ready to join the six teams in the coming months. In addition, there is commitment to build on the momentum that was created through the call for Expressions of Interest and other options are being considered that may provide opportunities for additional LHINs and organizations, across broader populations and geographic areas to be involved in bundled care initiatives.

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