Ministry of Health
November 2022

Introduction

In 2019, Ontario Health Teams (OHTs) were introduced as a way of better connecting a fragmented system. Since then, 54 teams have been approved and are seeing successes, including more efficient hospital-to-home transitions, strengthened primary care foundations, improved digital health and virtual care access, better data and analytics, and more meaningful partnership and engagement with patients, families and caregivers.

These gains have been made in the face of current health system challenges, where teams have had to balance their efforts to implement integrated care while dealing with the extraordinary demands posed by the pandemic.

Seeing OHTs rise to these challenges has made it clear that they are on the right path. The vision of a connected health system remains, where patients experience improved health care, delivered by providers who share responsibility for the outcomes of their care. OHTs will continue to integrate care and use equity-based, population health approaches to deliver better health outcomes, and provide better experiences for patients. They will keep Ontarians healthy and move more care into the community.

To maintain momentum toward this vision, new direction is being introduced to make sure OHTs are built to last and positioned to deliver better patient care, across Ontario. This will ensure there is a standardized approach across the province, based on lessons learned to date and expert advice.

The eventual designation of OHTs in accordance with the Connecting Care Act, 2019 is still being planned.

OHTs have achieved tremendous progress to date and will be set up to succeed so that Ontarians can continue to receive the care they need when they need it.

Delivering better care

Common clinical pathways to improve patient care

Through OHTs, Ontarians can expect to receive comprehensiveand coordinated care wherever they interact with the health system that is suited to their needs. Patients will experience easier transitions from one provider to another, with one patient record and one care plan, right in their own communities.

OHTs are continuing to build the capacity to deliver on this promise. They have selected target populations based on local needs and are focusing their efforts on where they know they can make a difference by working better together. While maintaining this focus remains key to OHTs’ local success, there is untapped potential to accelerate the impact teams can have on patient outcomes and experiences at a provincial level.

This will be accomplished through the phased introduction of integrated clinical pathways for OHTs, which will help teams deliver proactive, evidence-based care for patients with specific conditions.

Over time, OHTs will implement integrated clinical pathways for people living with the following chronic conditions:

  • congestive heart failure (CHF)
  • diabetes (focused on avoiding amputation)
  • chronic obstructive pulmonary disease (COPD)
  • stroke

Implementation of this initial set of pathways for chronic conditions will be grounded in primary and community care with a strong focus on prevention and disease management. When patients need to be seen in hospital, pathways will identify what is required for their successful transition back to the community and into a supportive primary care environment. As patients move through the system, virtual and clinical tools will support care in the most appropriate setting. Patient-reported outcomes and experience measures will be incorporated to improve care and for continuous quality improvement.

Initial implementation of the above pathways has begun and will continue on a rolling basis until all OHTs are participating.

Additional integrated clinical pathways will be developed, with input from OHTs, in the areas of mental health and addictions and palliative and end-of-life care. These pathways will complement other initiatives to expand access to evidence-based care.

What OHTs need to know right now

Our team is focused on a different target population. Do we need to change? The Ministry of Health (ministry) and Ontario Health recognize that OHTs’ local priorities are important for advancing integrated care in their communities and that working together to select and design care for their populations has been a key ingredient to success. Many OHTs have chosen initial target populations that align with the first set of clinical pathways. The ministry and Ontario Health want to build on work already underway to move towards greater standardization over time.

My OHT is focused on mental health and addictions. Why isn’t it an initial priority for pathway implementation? We know that many OHTs have selected people living with mental health and addictions issues as their initial focus. Ontario Health has recommended the initial set of integrated clinical pathways based on readiness to implement and the availability of the information, data and processes required to deliver on a population health management approach. The development of consistent, evidence-based and measurable mental health and addiction pathways for OHTs remains a goal. It is critical for OHTs to continue their local and provincial efforts to improve mental health and addictions care while common clinical pathways and supporting information are developed.

Given that the system is supporting many different priorities (e.g., vaccine rollout and seasonal flu clinics, reducing surgical wait lists, etc.), have the ministry and Ontario Health reflected on challenges OHTs are facing to meet all emerging priorities? The ministry and Ontario Health will work with OHTs to ensure implementation reflects capacity and readiness. Routine OHT requirements like the collaborative Quality Improvement Plan (cQIP) will be adapted to reflect local priorities and minimize reporting burden (more information will be shared shortly on the 2023/24 cQIP process).

Building OHTs to last

A common structure to progress to full implementation

Preliminary collaborative decision-making structures have enabled OHTs to achieve consensus-based goals in connection with their target populations and COVID-19 response and recovery efforts. However, for OHTs to continue to evolve and provide solutions to issues facing their own communities, the decision-making structure needs to reflect this evolution. Based on learnings from OHT implementation to date and expert advice, the ministry has identified a standard model that will support the future-state vision of integrated clinical and fiscal accountability: a new not-forprofit corporation created for the purpose of managing and coordinating OHT activities.

The corporation would be responsible for OHT initiatives to design and deliver integrated care. OHT member organizations would maintain their existing accountabilities.

Further details to support the incorporation process and expectations related to governance and decision-making practices (including equity considerations) will be provided.

What OHTs need to know right now

By when will OHTs be expected to create not-for-profit corporations? Will support be provided? The ministry acknowledges that creating a new not-for-profit corporation represents a significant undertaking that will take time. OHTs should await ministry and Ontario Health guidance and supports.

Our existing collaborative decision-making arrangement works for us. Why are we being asked to change? The creation of not-for-profit corporations will support integrated accountability and funding. The ministry and Ontario Health will work with OHTs to assess their readiness and determine appropriate timelines for implementation.

Is this about restructuring services? Is the corporation a merger? No. This newly created corporation would be separate from, and would work alongside, the members of the OHT.

Consistent collaboration in decision-making

While over a thousand providers are participating in OHTs, there is variation in who is participating and how. To advance integrated care for patients across the full care continuum, the ministry is standardizing the inclusion of the following groups in OHT decision-making:

  • Primary Care Providers (see below)
  • Home and Community Care Providers: Guidance will be provided once future accountability for home and community care services is articulated. OHTs should continue to work with their current home care members, i.e., Home and Community Care Support Services, contracted service provider organizations.
  • Community Care Providers: this includes Community Support Services, Assisted Living Services, and services for people with Acquired Brain Injury.
  • Public Hospitals
  • Mental Health and Addictions Providers: this includes not-for-profit organizations funded by the ministry or Ontario Health to deliver mental health and addictions services in the community (e.g., community addictions services, including bed-based services, and mental health/addictions supportive housing).
  • Patients, Families and Caregivers (see below)
  • Physicians and other Clinicians (see below)

Beyond the above list, OHTs have discretion to include other groups as part of their decision-making, with the following encouraged: long-term care homes, municipalities, emergency health services and community paramedicine providers, and public health units.

It is important to emphasize that equity-based and culturally appropriate approaches to integrated care are key ways for OHTs to improve patient outcomes and reduce health disparities. Partnering with Indigenous-led service providers.

French-language service providers, and High Priority Community Lead agencies has helped some OHTs design their activities to be culturally responsive and equity-focused. These OHTs are continuing to build relationships and trust, which will take time and meaningful engagement to foster.

We are also continuing to work with First Nations, Inuit, and Métis and urban Indigenous partners to ensure we are taking the most appropriate approach to addressing specific challenges and unique needs throughout the province.

What OHTs need to know right now

Our OHT does not presently include some of these groups in our decision-making. What do we need to do? Partnership expansion has been an ongoing expectation for OHTs. As teams await further guidance, they should continue to identify ways to expand their reach.

Our membership includes a broader list of organizations than those noted above. Are we meant to narrow our partners to only this mandatory list? No. There is no expectation that OHTs narrow their membership.

Are OHTs allowed to require financial contributions from members? As previously communicated in the ministry and Ontario Health’s ‘Year End Memo’ (April 2022), financial contributions from OHT members must not be a requirement or a barrier to their participation in OHTs.

Enhancing primary care connections within OHTs

The Ministry recognizes the valuable role that primary care can play in OHTs. Many OHTs have made strides in creating structures and processes to ensure primary care has a strong voice within OHT decision-making and leadership structures. However, we know more can be achieved to ensure this foundation is strengthened.

The ministry and Ontario Health will work to support greater primary care involvement in OHTs, including more consistency in how they are involved in OHT decision-making.

What OHTs need to know right now

We have included primary care partners in a way that works for us. Do we have to change? The ministry and Ontario Health will look at successful approaches to primary care inclusion and organization in OHTs to inform common expectations for all teams. We anticipate that some adjustments will be required to meet expectations.

Is participation still voluntary in OHTs? Yes. While participation is voluntary, the ministry and Ontario Health are hopeful that the value proposition for involvement in OHTs continues to draw meaningful participation from primary care providers and organizations.

Reaffirming physician and other clinicians as leaders in OHTs

Family and specialist physicians and other clinicians have been critical to the successes of OHTs to date. They have taken on leadership and advisory positions, joined working groups and communities of practice, and are implementing digital and virtual tools to strengthen local care delivery and coordination in their OHTs.

The ministry is analysing emerging models of physician and other clinician representation in OHT decision-making to determine what further guidance or requirements may assist these groups to participate more consistently.

What OHTs need to know right now

Is involvement in OHTs still voluntary for physicians and other clinicians? Yes. OHTs have demonstrated success in involving local physicians and other clinicians in OHTs. OHTs should continue to work locally to communicate and demonstrate the value of being involved in an OHT.

Embedding patient, family and caregiver voices in OHT decision-making

Across OHTs, patients, families and caregivers have taken on leadership roles to support OHT implementation. The inclusion of patients, families and caregivers will enable OHTs to benefit from diverse expertise and lived/living experiences now and as they continue to advance.

Driving sustainable operational capacity

Many OHTs have strengthened their capacity with the support of in-kind contributions from their member organizations. These OHTs are finding ways to work more effectively and efficiently across their organizations, reducing duplication and leveraging each member’s individual organizational strengths. They are working together with a view to sustainability.

OHTs have some foundational skills and capacity in place; however, to achieve the next level of full implementation and impact, OHTs will need to build more sophisticated, sustainable capabilities.

To that end, the ministry will require OHTs to identify an Operational Support Provider (OSP) that will provide certain back-office functions in support of OHT activities on an ongoing basis.

The ministry and Ontario Health will develop guidance for the selection of OSPs, including operational requirements. OSPs will be required to meet specified criteria. A guiding principle for OSP selection and operation will be that they may not exercise any greater influence than other OHT members over decision-making.

What OHTs need to know right now

How will the relationship between the OSP and the OHT be governed? What services will the OSP provide? It is anticipated that the relationship between the OSP and the OHT would be formalized through an agreement. The OSP role will be scoped to include largely back-office functions such as communications, project management, procurement and contract management, financial management, decision support, and analytics. Guidance will be provided relating to these elements.

What is the benefit of identifying an OSP? Making sure every OHT can sustain its back-office functions enables teams to focus their efforts on core OHT activities, including integration, coordination, and navigation.

In our OHT, we have many members presently serving these functions; these contributions have been a proof point of our shared commitment and a demonstration of our trusting relationships. Won’t driving these functions to one provider disrupt these core values? The ministry and Ontario Health will engage OHTs as OSP guidance is developed; consideration will be given to ensure trusting relationships and core values are upheld.

Cultivating consistency in OHT-led public communications

A consistent and recognizable approach to communicating about OHTs across the health system will help raise awareness about the important role OHTs play in delivering better coordinated and connected care – the right care in the right place.

To build on the positive momentum of OHT successes and local recognition OHTs have gained, the ministry will set a more consistent approach to OHT-led communications. This will support greater comfort and trust for patients, caregivers and families, encourage excellence for OHT members and distinguish OHTs as an easily recognizable, publicly funded entry point to the health care system.

The ministry will require OHTs to:

  • Make best efforts to include patient and provider benefits in all communications
  • Include standard hashtags in all social media posts: #OntarioHealthTeam, #OHTs
  • Ask each member organization to include “proud member of [name of Ontario Health Team] Ontario Health Team” in their communications
  • Link to the government websites, where possible
  • At the end of all communications, include: “[Name of Ontario Health Team] is supported by funding from the Government of Ontario”

What OHTs need to know right now

Do we need to revisit how we have been communicating? Most OHTs have established a strong public presence in their communities through social media, websites and other communication channels. These new requirements are meant to complement existing communications and outreach efforts and we anticipate that they can be easily integrated in OHT practices.

Will OHTs receive support to implement these requirements? We have heard directly from some teams the need for tools or resources to help them establish and maintain a public presence. To support OHTs, the ministry and Ontario Health will be engaging teams to develop a communications protocol and a branding/visual identity approach.

Conclusion

This document only touches on a few of the core ‘building blocks’ of the OHT model. We know that OHTs are advancing across all building blocks and are eager to hear further direction. We anticipate upcoming direction or guidance in the following areas:

  • The government remains committed to integrating home and community care within the OHT model and will share additional information in the coming months related to the modernization of home and community care delivery models.
  • The ministry and Ontario Health appreciate the efforts of OHTs to capitalize on the investments available to advance the adoption and implementation of digital health and virtual care solutions. These investments have enhanced patient care and experience and supported the maturity of the OHT model. We will continue to support OHTs with digital guidance and standards related to integrated care, population health management and other OHT digital priorities.
  • OHTs are advancing their initial plans to better coordinate and integrate navigation services with the goal of creating a more seamless patient experience. To ensure navigation remains a priority for OHTs, they will be provided with additional guidance and examples of leading practices for broad adoption.

As set out throughout this document, the ministry and Ontario Health are committed to designing the way forward collaboratively with OHTs. Engagement with OHTs to inform further guidance and supports will begin shortly.

The elements set out in this document are intended to advance OHT maturity. The ministry and Ontario Health are committed to supporting OHTs on this journey towards the vision of integrated care for Ontarians.