Collaborate with partners on early identification of needs and upstream care activities

• Use tools to support early risk identification and preventive management (examples included in resources below).
• Include social needs in care planning to address underlying root causes and health inequities
  • Leverage Ontario Health’s Social Determinants of Health Framework and Resource Guide and related change packages which include implementation resources:
    • Listen to what matters  
    • Shift power dynamics
    • Adopt a one system approach
• Screen for poverty or other social needs and promote social prescribing within primary care 
  • Social Interventions Research & Evaluation Network (SIREN): Social Needs Screening Tool Comparison Table

• Leverage tools and resources from the Centre for Effective Practice, including academic detailing:
  • COPD
  • Type 2 Diabetes
  • Preventative Care for Older People
  • Managing Patients with Heart Failure in Primary Care

Build capability across OHT partners on best practices for care of patients with chronic diseases

• Ensure providers have tools and resources required to promote adoption of structured self-management and action planning for patient, families and caregivers 

Connect programs and providers to training related to prevention such as motivational interviewing, chronic disease self-management, smoking cessation counselling, physical literacy, nutrition, food insecurity, diabetes management training, health promotion and best practices resources for providers around alcohol use disorder. 

Heart Failure (HF)

• Heart Failure Quality Standard
• Heart Failure Quality Standard Pathway
• Minimal requirements and key clinical services for heart failure programs within a spoke-hub-node model of care
• Heart and Stroke Foundation – heart failure resources
• Canadian Cardiovascular Society – Management of HF

COPD

• COPD Quality Standard
• COPD Quality Standard pathway
•  COPD Quality Standard implementation toolkit

Diabetes

• Diabetic Foot Ulcers Quality Standard
• Prediabetes and Type 2 Diabetes Quality Standard
• Diabetes Canada – Clinical Practice Guidelines
• Public Health Ontario – Diabetes resources
• Registered Nurses’ Association of Ontario (RNAO) Best Practice Guidelines – Diabetic foot ulcers: Prevention, assessment and management
•  International Working Group on the Diabetic Foot – Guidelines and resources
• Wounds Canada – Best Practice Recommendations for the Prevention and Management of Diabetic Foot Ulcers

Palliative care

• Palliative Care Quality Standard
• Ontario Health’s Palliative Care Program – Palliative Care Models of Care
• Ontario Health’s Palliative Care Program – Tools to Support Earlier Identification for Palliative Care
• Ontario Health’s Palliative Care Program – Palliative Care Toolkit
• RISE brief 18: Resources to support population-health management for people who could benefit from a palliative approach to care
• RISE brief 27: Ontario Palliative Care Network and how it can support OHTs as a health-system partner

Develop and implement a collaborative model for service delivery to patients with chronic diseases

• Identify and build relationships with primary care and with local supports for chronic disease prevention and management such as Diabetes Education Programs and Preventive Care Programs 
  • CorHealth Ontario – Integrating Heart Failure Care (implementation road map/toolkit)
  • CorHealth Ontario – Lower-Limb Preservation Strategy
  • Expanded Chronic Care Model

• Ensure that the pathways are co-designed with patients who have lived experience
  • Use patients, family, and caregiver engagement frameworks and tools to strengthen partnership and engagement, such as the Engagement-Capable OHTs Framework and the Engage with Impact Toolkit

• Ensure alignment with Ontario Health’s Equity, Inclusion, Diversity, and Anti-Racism Framework. Integrate principles from this framework into the pathway to address health disparities and promote equity
• Join the Integrated Care Programs Community of Practice to learn, develop skills, and access resources that can help you plan and implement Chronic Disease Prevention and Management (CDPM) and Integrated Clinical Pathways (ICPs)

Leverage digital and virtual solutions to improve processes and workflow

• Use digital health solutions and technology to support integration, documentation, communication and coordination across different sectors and care settings for the lifetime of a patient’s condition
  • Ontario Health’s Digital Health Programs
    • Includes Health811, eReferral and solutions for virtual visits
    • Provincially funded virtual care programs (remote care management for HF and COPD) 
      • Evidence2Practice Ontario provides tools for HF, COPD, diabetes, and other conditions for use in acute care and primary care to assist with screening, diagnosis, decision-making, quality interventions, monitoring, connecting patients to self-management supports, and patient conversations