Optimizing Home and Community Care Coordination with Primary Care

We are working to forge stronger links between home and community care coordinators and primary care teams with the common goal of enhanced patient care and ensuring smooth transitions of care between home care and other health services. Early adoption has focused in the Nipissing-Temiskaming and Sudbury (City of Lakes Family Health Team and the North East Specialized Geriatric Services Centre) areas, but has now begun in other communities as well. 

Some Successes to Share from the North Bay/Nipissing Area:

  • 93% of primary care providers have been engaged.
  • 92% of the primary care providers have signed the Memo of Understanding to optimize/work more closely with NE LHIN Home and Community Care Coordination including Blue Sky Family Health Team, which shares 200 patients with the NE LHIN Home and Community Care
  • 80% of the NE LHIN care coordinators in North Bay have been optimized/embedded with primary care.

How does it work?

Evolving over time, the closer working relationship between the care coordinators and the primary care providers, the effective communication and information sharing, combined with this collaborative approach, will create a stronger partnership and improve patient-centered care. This closer connection can take many forms, from sharing space to initiating new ways of working together to plan patient care. Here are a few examples:

Creating a common workspace where the care coordinator may be physically located within a primary care team and can be used for collaborative work and discussions;

  • Setting up regular scheduled team meetings for engagement and to share patients’ plans of care with the team.  These team meetings can be weekly, bi-weekly or monthly for 1hr to 3 hrs.  
  • Sharing information, documents and/or having discussions in the same workspace.
  • Allowing time for NE LHIN Care Coordinator to establish relationships with the members of the health care team and become familiar with the each other’s practice styles.

What Team Members have to say about Optimization:

“As a physician at the Sudbury site, I have the opportunity to enjoy this service, and I was recently reminded of its value when I was on call at HSN for my group.  Having established professional relationships with our assigned care coordinators, I was easily able to determine which coordinator was involved in the patient’s care in the community, reach her through her mobile number, and discuss directly with her how to facilitate a safe and timely discharge for our mutual patient. Prior to this model being in place, this would have been an impossible task, as the relationship between myself and home and community care consisted of a fax number and a referral form.  The value of the relationship that forms between the patient, their care coordinator, and their primary care provider, as a direct result of this model of care, is invaluable to all of us and leads to improved patient care.” -- Dr. Jason Sutherland

“Patients like having Roxanne located at the Family Health Team because they see everyone working together and feel they are receiving excellent care.” --Sarah Crichton, NP

“The value to the patients has immediate results working the physicians and the team. It allows for a significant impact moving through the system in a seamless flow. Ultimately it is better care for the patients. This is without a doubt and exceptional program.” -- Roxanne McGrath, Care Coordinator

To find out more about how your primary care team can work more closely with home and community care coordination, contact NE LHIN Program Champion Melanie Tulini at Melanie.tulini@lhins.on.ca