The main purpose behind establishing an OHT (Ontario Health Team) is to encourage collaboration with the formation of specific groups of healthcare providers and organizations which are clinically and fiscally accountable for delivering a full and coordinated continuum of care to a defined geographic population within Ontario. The OHT assessment makes sure that the teams are fully equipped to function collaboratively and those in development are to be supported by the Ministry of Health until full provincial coverage of OHTs is achieved.

The OHTs will be prioritized for future investments and receive incentives based on performance. They are set to redesign relationships, accountabilities, and incentives which put patients at the centre of how seamless care and services are delivered and funded. There are 8 building blocks of OHTs which act as guiding principles for establishing a truly connected healthcare system. Let’s look at what they are and why they matter:

  1. Defined Patient Population: OHTs should be responsible for the health outcomes of patients, through access to sustained care and meeting service delivery targets, within the
  2. In-scope Services: OHTs should leverage existing capacity to deliver coordinated services across at least three sectors of care (especially hospital, home care, community care, and primary care) while putting a plan in place to include or expand primary care services to a significant portion of the population. When mature, an OHT shall provide a full and coordinated continuum of care for all but the most, highly specialized, conditions.
  3. Patient Partnership & Community Engagement: Be committed to an integrated patient engagement framework and demonstrate a history of meaningful patient, family and caregiver engagement. Commit to a plan which encourages patient leadership and include patients, families and caregivers in the governance structure.
  4. Patient Care & Experience: Implement programs to ensure improved digital access to health information, transitions and coordination, key measures of integration, patient self-management and health literacy. Offer 24/7 coordination and navigation services with zero cold handoffs as well as virtual care to improve patient experience. Be committed to measure care and redesign care by offering digital access to health information, as and when needed and from anywhere.
  5. Digital Health: Develop the ability to digitally record and share information across partners by addressing any existing gaps in digital health activities. Increase the adoption of digital health tools to harness data. Adopt or provide digital options to streamline and integrate point-of-service systems and use data to support patient care for decision support, operational insights, population health management, and for tracking/reporting key indicators. Mature OHTs should be able to adopt digital health solutions to support effective healthcare delivery, ongoing quality and performance improvement, and better patient experience.
  6. Leadership, Accountability, & Governance: OHTs need to develop a central brand, demonstrate a history of working together to provide integrated care through physician and clinical engagement and inclusion in leadership and/or governance structure(s) through formal agreements, where necessary. The aim is to have every OHT operate through a single clinical and fiscal accountability framework, with appropriate financial management and controls.
  7. Performance Measurement, Quality Improvement & Continuous Learning: OHTs need to demonstrate a track record of responsible financial management and understanding of population costs, cost data and cost drivers. They should work towards an integrated funding envelope, based on the care needs of their attributed patient. Teams shall identify a single fundholder and reinvest savings to improve patient care.
  8. Funding and Incentive Structure: OHTs should be able to collect data and pursue joint quality-improvement activities, engage in continuous learning and champion integrated care. They shall also demonstrate an understanding of baseline performance on key integration measures and a history of quality and performance improvement. They need to reduce inappropriate variations and implement clinical standards and best evidence and provide complete and accurate performance reporting on the required indicators. The aim is to ensure that integrated care is offered based on the best available evidence and clinical standards, with an ongoing focus on quality improvement.

When they reach a mature state, each Ontario Health Team will be ready to demonstrate the ability to:

  1. Provide a full and coordinated continuum of care for a defined population within a geographic region,
  2. Offer 24/7 access to coordination of care and system navigation services to patients while working to ensure that their patients’ care journey is a seamless transition through the various stages of care,
  3. Improve performance to ensure the quadruple aims of better patient and population health outcomes; better patient, family and caregiver experience; better provider experience; and better value,
  4. Follow a standardized performance framework and be measured and reported against it,
  5. Operate within a single, clear accountability framework,
  6. Receive funding through an integrated funding envelope,
  7. Reinvest the funds into front line care; and
  8. Adopt a digital first approach and be aligned 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.

As the needs and preferences of patients are known ahead of time and communicated at the right time to the right people, providing safe, appropriate, and effective care to the patients in Ontario will become seamless and efficient.