Adopting a “Bundled Community” Approach to Integrated Care

​​By: Arden Krystal, President and CEO, Southlake Regional Health Centre

As the cliché goes, necessity is the mother of invention. Southlake is one of Ontario's most over-crowded hospitals. As we reviewed our alternate-level-of-care (ALC)  data in the lead up the 18/19 winter surge, we concluded a different approach was required.

Before Southlake@home, complicated patients waited an average of 14.2 ALC days while homecare and community support services were arranged. During these two weeks in a costly acute bed, patients decondition and face an increased risk of hospital-acquired conditions. Staff are frustrated, as they see ALC patients often getting worse and patient care being provided in unconventional spaces because our hospital is bursting at the seams.

We launched Southlake@home in March 2019. We knew a fundamental redesign was required, not merely incremental change. We partnered directly with homecare providers, a community support service agency, and primary care with the goal of eliminating ALC for our most complicated homecare patients. By minimizing non-value added process steps and integrating acute, homecare, primary care and community support teams into transition planning, we believed that we could produce better clinical outcomes, improve patient and staff experience, and significantly reduce costs. We felt that direct clinician-to-clinician communication would produce better results and improve the confidence of patients and families that care would be ready when the patient arrived home.

Key design elements of Southlake@home include:

  • 16-week post-acute integrated transitional community care bundle that any complex patient can be enrolled in (not a CMG/HIG-based approach)
  • Hospital, homecare and community care team begin care plan co-design (based on goals of care) at the first available opportunity with patient/family as partners, so patients are transitioned home on the day they are ready
  • Patient/family learn about their homecare team prior to transition home and understand care plan
  • Services can be delivered virtually
  • Community Support Services are included (Southlake has a CSS license)
  • The care plan can be modified as the patient's care needs change in real time at the point of care
  • Geographically-based service model (patients have one team, and teams get to know the community)
  • Engagement with primary care prior to the patient transitioning home
  • All patients receive first homecare visit within 24 hours post-transition home
  • 24/7 number to call for support and navigation 


As of October 31, ​2019, 144 patients have transitioned home (average age is 80 with the oldest being 99). Each element of the Quadruple Aim is being improved:

Better Outcomes

  • 100% had their first homecare visit within 24 hours of transitioning home
  • 72% had primary care contact within 7-days of transitioning home
  • 6 patients enrolled from ED (acute admission avoided)
  • 100% of patients have their discharge prescriptions filled
  • Low repeat ED visits and readmission rates given the complexity of the population

​Improved Patient Experience

  • Overall satisfaction: 90% satisfied, 2% dissatisfied
  • High proportions of Southlake@home patients strongly agreed or agreed that:
  • They can work with their care team to adjust their care as needed (83%)
  • They are receiving the right support at home (87%)

Enhanced Provider Satisfaction

Baseline data is not available, but providers (at Southlake and our homecare partners) are providing very positive feedback in surveys regarding job satisfaction and the differences compared to the traditional homecare approach.

​Efficiency and Value

  • 47% of patients were enrolled during their acute stay and had zero ALC days (baseline 14.2 days)
  • Factoring in patients enrolled while already ALC, the average ALC for all Southlake@home patients is 1.8 days (baseline 14.2 days)
  • Total ALC days avoided = 1,825
  • Cost avoidance = $0.9M (based on average cost of ALC days at Southlake)

Critical Success Factors

A number of elements have contributed to the success of Southlake@home:

  • Direct partnership between all organizations
  • Strong involvement of primary care throughout (program design, daily operations, etc.)
  • Daily virtual rounds for all patients while they're on the program (supports real-time issues management, service recovery and flexible changes to the care plan)
  • Flexible enrolment (target a broad population – i.e. frail seniors with complex medical and social needs, not a specific CMG/HIG)
  • Trust and communication (multiple daily interactions between the team)
  • Rapid cycle evaluation (representatives from each organization plus family physicians and hospitalists meet biweekly to iterate program design and remove barriers based on data and patient/provider feedback)  
  • Minimize burden of assessments/paperwork that do not add value
  • Relentless focus on common sense solutions
  • Patients at the table every step of the way (planning, design, evaluation, etc.)

One of Southlake's new Strategic Goals is to "own our role to improve the system". There has been significant interest from other hospitals in Southlake@home and we have coached various organizations through the details of the model.

I strongly believe that most of the critical success factors described above have wide applicability to the care redesign that Ontario Health Teams will focus on. Through collaboration, a commitment to building trust, and a focus on both outcomes over process and common-sense problem-solving, connected care initiatives like Southlake@home can be scaled across the province. Perhaps more importantly, the types of innovative thinking that are behind integrated care initiatives such as this can be applied to other challenges that OHTs will face in the coming months and years.