Four practice guides were prepared for Ontario Health Teams (OHTs) by the Health System Performance Research Network (HSPRN). The guides are relevant for any group of providers and organizations aiming to implement a connected health care system centred around patients, families and caregivers. Each of the four guides focuses on a different aspect of a more connected and better integrated approach to care and has a slightly different emphasis and target audience. The guides can be read independently but achieving the overall implementation of OHTs will require attention to all dimensions presented.
The first guide focuses on essential aspects of implementation. It outlines key activities that are necessary at the organizational and inter-organization levels and activities required of senior management across organizations in order to enable managers and providers to reorganize around patient and family/caregiver-centred care. The implementation of OHTs will not be successful unless organizations think differently about care and set parameters so that providers and managers realign their care to think across organizational lines to encompass the patient’s journey. The primary audience for this guide is organizational leadership.
The second guide focuses on what it means for care to be centred around patients, families and caregivers and highlights 6 essential attributes of patient and family/caregiver-centred care. Two case vignettes are presented that characterize when a care system is well organized around a patient, and when the care system is fragmented. Achieving the well-coordinated system is a common thread that runs through all of the guides with specific mention in 3. This guide is central to the overall focus of Ontario Health Teams and is relevant to all leaders, providers, patients and the public.
The third guide focuses on the activities of providers and managers that are necessary to achieve patient and family/caregiver-centred care. The activities are organized around the 6 attributes and specific vignettes are provided that demonstrate what providers and managers have to do to enable the well-organized system in contrast to the fragmented case. The audience for this guide is primarily providers and managers though it is relevant to senior leadership that need to create the context that enables providers and managers to focus on these new activities and to create the space and time required for change.
The fourth guide focuses on governance. This guide outlines the internal and external changes that have to occur to create sustainable systems of connected care. The audience for this guide is organizational leadership and governors.
While there are many important aspects to implementing integrated care, this starter set provides a basis for understanding important new ways of working and fundamental shifts in collaboration across health and social care providers. Many more topics are important including population-based management, co-design, human resources and workforce transformation to name just a few. The most important guidance is to retain a focus on what is important to patients and caregivers; gather together the people you need to work with; agree to a common vision and principles that support your planning and implementation work; and build and support trusting relationships with all your team members. These essential ingredients, blended with courageous action, will accelerate your success.