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Building better patient and family outcomes
Building better patient and family outcomes through integrated care models and pathways

Central Ontario Health Team for Specialized PopulationsWith a goal to fix a fragmented and siloed health care system, three years ago the province of Ontario embarked on a health system transformation to redesign care delivery so it is more connected. The creation of Ontario Health Teams (OHT) brings together clients, families and providers to create a more connected network of services with the goal of improving access and transitions between organizations. 

Waypoint is a member of the Central Ontario Health Team for Specialized Populations, a network of agencies, clients, families and care partners with expert knowledge and experience in specialized services focusing on mental health and addictions, seniors, and Indigenous populations. The goal is to collaborate with other local OHTs to ensure access to highly specialized regional services and build capacity to provide care for specialized populations.

One of the projects underway is the partnership to build regional integrated care models and pathways. Continuing to transform how the system is organized so that care is more integrated and connected.

Quote from Susan Lalonde Rankin This is an important project because while everyone in the mental health system is working incredibly hard to support clients and their families, the experience of care is uneven - some people feel supported and have good outcomes, while others have a more challenging journey. They cannot find a service that meets their needs; they wait too long or have to retell their story multiple times. Even health professionals find navigating the mental health system challenging. 

Integrated care pathways translate evidence-based guidance into care processes within and across organizations. They map out the care journey from start to finish to show what care is delivered, by which providers, to achieve what outcomes. Care pathways have been implemented in other sectors of health such as cancer care, and have greatly improved outcomes for clients and families. 

"This work involves aligning all aspects of care at different levels, from systems integration right on down to clinical and service integration," said Susan Lalonde Rankin, Director, Health System Integration. "Improving how care fits together across organizations will help achieve better client experiences and outcomes." For example, in treatment for people living with mood disorders, we want to be sure that each part of the system from primary care, to community agencies, to hospital programs are using consistent standard assessment tools - otherwise clients have to complete multiple different assessments when they interface with different part of the system. Using consistent tools across organizations also helps clients to monitor their progress and know if their treatment plan is working: are they getting better? If not, the integrated care pathway will tell them what options to consider.    

Regional Integrated Care Pathways are a mechanism that can address both the quality gap and the fragmentation of the health care system. To develop a care pathway, clients, family members and health service providers come together to co-design who is going to deliver what intervention and how outcomes will be measured, informed by available evidence. The process of co-creation leads to better connections between agencies, busting silos while at the same time improving quality. Really, a win, win. 
For more information on the Central Ontario Health Team for Specialized Populations, visit