The COVID-19 pandemic has required the Ontario health system to come together and connect care for people and communities in unprecedented ways.

As we begin to turn our minds to pandemic recovery and planning strategies, many of the achievements and lessons learned throughout our pandemic response could be scaled to become the building blocks to a more integrated, less-siloed health system. The team at St. Joseph's Health System's Centre for Integrated Care believes connected care innovations are the fastest and most innovative model of care to not only build on lessons learned but also create a roadmap for a truly transformed continuum of care at the front-line.

In October, the Centre for Integrated Care launched a new web presence that includes case studies it has led in designing new connected care paths. The Centre's mandate is to address systemic silos and barriers in our health system as a way to maximize innovation in health system planning.

For example, COVID Care @ Home is an integrated model of care that was rapidly developed and deployed by St. Joseph's Home care to serve COVID-19 patients at home and in the community. In collaboration with 75 partners and working directly with primary care and community partners, including public health, the program was transformed from an idea and reached full scale, bridging the gaps acute care providers and clinicians were grappling with to manage care for hundreds of patients across three cities.

The program delivered customized care plans to COVID patients of all complexities (low-moderate-high) with an integrated team of home and community care service workers. The model of care supported patients by helping them navigate the system and available supports, coordinating in-home or virtual visits, and offering 24/7 phone access to the care team.

This model could be scaled as a blueprint for future integrated care paths.

Creativity and innovation thrive in chaos. Core to the Centre for Integrated Care's ethos is to create a collision space between research and clinical practice and redesign care delivery working with the front-line to develop a menu of flexible care offerings based on people's needs that maximizes all available resources.

The team is now taking lessons learned and turning their minds to how to scale to new patient populations with a focus on chronic disease management – specifically longitudinal virtual care and remote monitoring models that are embedded in primary care.

​With expertise across disciplines, including research and care partner engagement, the team is designing a core framework to support local Ontario Heath Teams and health care organizations seeking to design new connected care pathways, including exploring how a modernized home and community care sector could deliver immediate results towards a transformed, people-centered system. The core pillars to the framework are:

1) Knowledge Exchange — Learning, celebrating and sharing across diverse perspectives and lived experiences to improve people-centered care;

2) Research & Evaluation — Generating and communicating evidence about new models of integrated care;

3) Quality Improvement & Performance Management— Working directly with organizations to help reach their goals;

4) Thought Leadership — Building organization capacity to become leaders in integrated care

The COVID-19 pandemic has catalyzed health system partners and providers to provide more integrated care offerings, to identify and deliver essential services, and to identify and overcome long-standing barriers created by separate organizational structures, silos, practices and policies. The Centre for Integrated Care hopes to be a convener for a stronger, more resilient health system as we recover and provide a transformed, smarter way of delivering care to meet the local needs of the communities we serve.

To learn more about the Centre for Integrated Care, please contact Carrie Beltzner, Director CIC & Advisory Services 905-870-2749, cbrunet@stjosham.on.ca