Integrated care refers to the coordinated continuum of care provided to patients even if they are not in the same physical location as the care provider. Integrated care delivery enables providers and health systems to improve health outcomes through real-time collaboration, access to system navigation services, and seamless transition throughout the patient-care journey.

Ontario Health Teams, therefore, are a new model of integrated care set up to innovate care delivery within a geographic region. The eventual goal of the OHTs is to provide integrated services to patients, families, and communities to improve health care in Ontario.

Integrated care across the OHTs is possible by following these tenets of health care delivery:

  • Timely access to patient health information for decision making at point-of-care;
  • Smoother patient transitions between health care providers and geographies;
  • Better coordination of care between multiple practitioners, and within health care teams;
  • More efficient workflow and reduced dependency on paper-based systems;
  • Lower cost, better-quality patient experience by eliminating duplicate tests;
  • Improved monitoring over time to support chronic disease management;
  • Fewer gaps in patient information as patients move between hospital, practitioner’s office, home care and long-term settings; and
  • Continuous improvement in the delivery of care with data to support a population health approach and research activities

Each serving up to 300,000 people, Ontario Health Teams will share funding as well accountability as they bring providers together. Funding will now incentivize care for patients who are in most need, instead of the earlier preference given to a patient’s age and sex, which made healthcare providers prefer admitting healthier patients.

Some Pre-requisites for Delivering Integrated Care

  1. Ontario maintains a series of provincial data repositories containing important patient records and digital health information. These repositories include historic as well as current data gathered from care and diagnostic settings across the province. Such repositories can help support Ontario’s transformation toward integrated care delivery and health sector efficiency.
  2. The direction set by four general digital health policies will support the implementation and/or use of all the digital health systems:
    • Digital Health Information Exchange Policy
    • Digital Health Investment and Value for Money Policy
    • Digital Health Access, Privacy and Security Policy
    • Digital Health Reporting and Performance Policy
  1. A robust in-house digital strategy or with home-grown health IT companies to deliver disruptive solutions such as real time care team collaboration, secure messaging, and secure EHR data access.

Benefits of Integrated Care in OHTs

Eventually the care delivered through OHTs would be connected and fully shared across the Ontario Health Teams network including hospitals, home care providers, acute care providers, primary care providers, doctors’ offices and mental health providers. This approach is expected to reduce duplication of efforts through effective coordination, which would ultimately benefit the patients and their caregivers. Among other things, OHTs will help:

  • Connected care teams in the OHT (including in social service agencies) address social factors which are the root cause of illness, like unemployment, housing and poverty.
  • Reduce gaps in providing home care services and mental health services.
  • Meet expectations at a lower cost than a pre-established benchmark, and thus help keep a portion of the savings to invest in improving direct patient care.
  • Enable digital solutions like patient, portals, secure messaging, virtual provider visits and virtual consultations.

Finally, Integrated Care is quintessential for the OHTs to succeed and achieve common goals related to patient experience, provider collaboration, improved health outcomes, and value based care. And while different OHTs will have different approaches to reach this common goal of providing integrated care, it will help create a coordinated continuum of care which would improve healthcare in Ontario by leaps and bounds.