Sep. 03, 2015
Ontario is funding six cross-sector health care teams to implement innovative bundled care projects in their communities. These teams will focus their work on patients who require short-term care at home after leaving hospital. The province plans to support additional teams across Ontario over the coming year.
In a bundled care approach, a group of health care providers is given a single payment to cover all the care needs of an individual patient's hospital care and home care. This approach is also known as an "integrated funding model."
The six teams that will receive the first wave of bundled care funding include:
Connecting Care to Home:
Optimizing care for chronic obstructive pulmonary disease and congestive heart failure 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 Health 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 Community Care Access Centre funding, patients will be supported by an innovative eHomecare model that enables remote monitoring, with 24/7 access to a clinical team. The patient will be 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 providers to ensure that patients are provided seamless and patient-centred care.