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Designing an integrated model of care

To support a diverse population with complex health and social needs, Mississauga Halton’s LHIN planned multidisciplinary community health hubs. HHF helped them to better understand the needs of patients and providers as they relate to technology, presenting insights to guide the implementation of their service.

Client

Mississauga Halton Local Health Integration Network (LHIN)

Services

Contextual Interviews, Co-Design Workshops, Service Design

Challenge

Patients with complex health issues can be difficult for family physicians to support in the community. This is especially true for patients who manage several physical, mental, and social wellness challenges at once. To better serve the city of Mississauga, the Local Health Integration Network (LHIN) planned community health hubs that would be staffed by multidisciplinary teams. This would be known as CarePoint Health. The LHIN partnered with HHF to better understand the patient and provider experiences and their needs related to technology as they move through a future service flow. This would help them to increase buy-in, support interdisciplinary collaboration, ensure equitable access, and navigate patients through this new service.

Process

DISCOVERY

HHF consulted with the LHIN and conducted secondary and primary research—involving patients, providers and systems stakeholders—to uncover needs and to better understand the proposed service model. This formative research informed the activities for two large co-design workshops with over 70 local patients and providers to understand how to structure the service and integrate technologies to actionably achieve these goals. This inclusive approach ensured diverse input into the LHIN’s future service, increased community buy-in, and laid the groundwork for evidence-based implementation.

CarePoint Health would respond to the following needs:

  • A growing and diverse population with changing health and social needs across the community
  • Health issues around poverty, refugee and new immigrants, cultural and language diversity, mobility issues, lack of social supports, and limited education
  • A lack of team-based health services available in Mississauga to address the needs of more complex patients

The following research themes emerged, which informed our recommendations:

You need to be privileged enough to know how to access care. You need to be educated and well cared for, having family...

Healthcare Provider

Research Themes

Building the Culture

The need to align the team around a vision of holistic health, interdisciplinary collaboration and understanding. Facilitating an environment in which patients are respected as equal team members.

Developing the Service

The need to create clear roles, responsibilities and protocols to support the unique workflows at the integrated care centres. Providing the tools and methods needed to manage complexity and adapt to changing needs of complex patients over time.

Enabling Access

The need to focus on the integration of digital resources across providers in order to: allow two-way, on-demand access to data, enable common patient records, support collaboration, and targeted educational resources.

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We facilitated two large co-design workshops with over 70 local patients and providers.

Synthesis

Needs and opportunities that emerged from the research that were tied to technology solutions were clustered around 6 major categories: case management, appointment management, patient record (EMR), patient portal, real-time data, and general resources.

The findings from our work were consolidated into a chronological service flow, constructing the patient and provider experience throughout the CarePoint Health service. Each of the major phases of care were considered and broken down into detailed steps. Their needs at each step were synthesized from our consultations with local patients, families, providers, and system stakeholders.

What tools are there to help me? And is there anyone there to guide me?

Healthcare Provider

Outcomes

The LHIN was provided with: an overview of the core priorities of their future users groups; a timeline of the service, showing the needs of patients and providers at each moment in the journey; and a set of detailed requirements for technology to support their procurement process. These insights allowed them to move forward in developing their centres with confidence.