Population-health management year in review

Since January 2021, RISE has offered webinars, peer sharing and learning sessions and coaching supports to help OHTs implement a population-health management (PHM) approach to care. OHTs have taken significant strides this year to continue improving care for patients through a PHM approach. Activities included:

  1. understanding their populations and identifying an initial population with which to start/to focus on next
  2. segmenting their initial populations to understand the spectrum of needs, risks and barriers to care
  3. co-designing and testing care models which address the identified needs, risks, and barriers to care
  4. starting to implement these new care models and beginning to spread care models to other populations
  5. monitoring and evaluating using an equity-centred quadruple aim approach.

There are many examples of OHTs conducting this foundational work to improve care delivery for their patients.

  • The Algoma OHT progressed their work in social equity by coming together to collaborate on a research project exploring community experiences at participating organizations. The goal of the research is to develop a deeper understanding of their attributed population and health and social inequities. In the future, this information will be used to implement evidence-informed, co-designed interventions to prioritize and address the needs of their community. A survey tool has been developed, with data collection occurring in early 2025. 
  • The Archipel OHT used a collaborative, thoughtful, and pragmatic process to select a limited family of indicators that will provide a longitudinal framework for learning about and understanding the effects of changes over time on important outcomes. The approach strategically combines required OHT indicators with important frameworks like the equity-centred quadruple aim. The committee uses time-series data displays (run charts) to learn about the effects of changes over time and is observing impressive evidence of improvement in their cancer-screening indicators.
  • The Chatham-Kent OHT is piloting an initiative called Pathway2Care (P2C) which strives to help individuals experiencing houselessness to access essential medical and social supports. The P2C program brings together a diverse team of health and social service professionals to provide person-centered care, bridging gaps between hospital and community resources.
  • The Mississauga OHT aims to reduce escalation in mental health and addictions that could result in emergency visits. Through addressing lived experience identified gaps in care and by focusing on an upstream approach, the team has tested and is beginning to spread an evidence-informed self-management support (brief action planning) which has helped clients make action plans to address the aspects of their health or situation that are most important to them and improved their self-efficacy and confidence.
  • The Noojmawing Sookatagaing OHT came together with their local communities to understand gaps in care for those with chronic obstructive pulmonary disease (COPD). To address the needs which surfaced, the group is now piloting an approach to connect people with COPD who do not have a primary-care provider to a comprehensive primary-care team. This includes referral pathways from the emergency, inpatient departments, and self-referral.
  • The Northwestern OHTs have taken a regional approach to integrated clinical pathway (ICP) development that supports both local OHT contextualized ICP implementation, alongside regional approaches. This work is enabled by a working group inclusive of all four OHTs with a space to collaborate and strategize regional change initiatives to develop ICPs across the northwest. The first phase of change initiatives included: 1) spirometry equipment/software standardization and training/capacity building; 2) palliative care spread and scale; 3) self-management program spread and scale. The OHTs will continue progressing this model in 2025.

OHTs have collectively accomplished a lot in their PHM efforts, which is central to realizing the vision of OHTs and is a multi-year journey in Ontario. Thank you to the OHTs and expert groups for working with us, for your continued feedback to shape these supports, and most importantly for your dedication to improving care. We look forward to continuing to support you in the new year as you continue transforming care for your attributed population.