Evidence of Value

HQO Report: Patient experiences of care coordination and communication

April 15- AFHTO welcomes the release of “Experiencing Integrated Care: Ontarians’ views of health care coordination and communication”, Health Quality Ontario’s (HQO) report on patients’ experiences of their transitions between health care providers and the associated care coordination and communication.

The report focuses mainly on patients’ experiences of transitions and communication between doctors, specialists and hospitals. In primary care, however, we know care coordination also involves collaboration spanning a wider array of health and social services.

Care coordination is a fundamental role of primary care. This is why the Ontario Primary Care Council (OPCC), of which AFHTO is a founding member, defined a set of principles of care coordination:

  1. Care coordination is a core function of primary care and a hallmark of a high-performing primary care system.
  2. Care coordination includes communication and planning with the patient and family.
  3. Care coordination requires a population needs based approach to planning.
  4. Care coordination will emphasize the timely and continuous delivery of high-quality, person-centred, equitable, timely and continuous services and programs that are comprehensive, evidence-informed, culturally competent and appropriate.
  5. Care coordination focuses on the provision of comprehensive services across the health and social services continuum as needed.
  6. Care coordination is predicated on collaborative inter-professional teams working to full scope of practice.

AFHTO members are working to connect patients with the care and support they need. Here are two examples from past AFHTO conferences:

McMaster Family Health Team- the System NavigatorCompromised patients are required to navigate an increasingly complex health care system as well as various government and social/community systems. Acknowledging the challenges presented by the social determinants of health to the delivery of care, the McMaster FHT applied for and received funding for the position of a Case Manager/System Navigator. This unique role was developed in recognition of the many issues, medical and non-medical, a patient faces that affect their health and well-being.

Rural Wellington Shared Governance Across Health Care PartnersNine health provider agencies – four family health teams (East Wellington FHT, Minto-Mapleton FHT, Mount Forest FHT, Upper Grand FHT) , two rural hospitals with three sites, CCAC, Community Mental Health and a mental health and addictions hospital- work together to create integrated and responsive care for patients.

Effective care coordination benefits patients and their families by creating more seamless transitions of care, facilitating access, reducing duplication and increasing quality of care. HQO’s report acknowledges this is an exploratory study and states further studies are being considered. Given the importance of primary care for effective care coordination, such studies, reflecting the broader reality of Ontario’s health system, would be welcome.