- Participants
- Program Design
- Providers & Care Settings
- Maturity, Measurement & Evaluation
- Policy Environment
Target Populations
Currently Enrolled
unknown
Total Serviced
10,000+
Expected Total
unknown
Entry Process
Self-entry (e.g., patients or families can self-refer)
Referral/Intake/Enrollment Process
A clear process exists but this is implemented variably by different initiative navigators or health care administrators
Standardized Intake Assessment
Yes
Post-Intake Re-Assessment
Yes, at regular intervals (e.g., once every 3 months, at discharge)
Care Coordination
Deliberate organization of patient care activities between two or more service providers involved in a patient’s care to facilitate the appropriate delivery of health care services. This is an activity amongst care providers.
Inclusion Level
Not included
Care Navigator
A health professional that helps patients access health and social care services available in the system. This is an activity directly involving patients.
Inclusion Level
Not included
Staffing Model & Resources
Staffing Model
Staff employed by their parent organizations
Staffing Changes
N/A
Care Transitions
Transfer of a patient between different care settings and health care providers during the course of an acute episode or throughout ongoing management of a chronic illness.
Management Process
Protocols exist for some transitions but not others or protocols exist but are not routinely used
Patient Involvement
The process of building the capacity of patients, alongside families, carers, and health care providers, to facilitate and support the active involvement of patients in their own care, in order to enhance safety, quality and people-centredness of health care service delivery.
Commitment
Strong organizational support for, training in, and culture that promotes patient involvement and shared decision-making
Activities Goal-setting with patients
Patient advisors on boards, or committees
Patient Self-Management
Support Approach
Promoting self-management occurs to some degree, but no formal support for or training in processes to promote patient self-management and empowerment.
Activities Supporting Self Management
Educational materials and information sharing
Caregiver Support
Commitment
Strong organizational support for, training in, and culture that promotes caregiver support and coaching
Activities
Caregiver advisors on boards, or committees
Other Essential Elements
N/A
Providers Involved
N/A
Care Settings / Sectors Involved
Cross Sector Activities
Program operational or management meetings
Provider Co-Location
No
Primary Care Involvement
Limited involvement of primary care providers, including nurse practitioners.
Health–Social Integration
The initiative is primarily focused on integrated delivery of health care OR of social care services BUT NOT both (e.g. clinical pathway OR community program)
Data Sharing Infrastructure
Processes and procedures exist to share patient information across providers and organizations involved in patient care, but there is not shared access on a single data infrastructure platform.
Digital Health Tools
Electronic referral (eReferral) and/or Electronic consultation (eConsult)
Initiative Maturity Stage
Initiative Goals
Better patient or population health outcomes
Equity & Community Commitments
enhance capacity and resources of community members to more effectively engage in self-defined healthy living
Data Collection
Data on activities is routinely collected and used to monitor the initiative
Use of Collected Data
Data on activities is used to demonstrate accountability to stakeholders
Evaluation Status
There is a completed formal evaluation by the program funder
Funding Structure
There is a well-defined budget or annual funding for the initiative
Funding Sources
Government/ministry/agency
Innovativeness Assessment
| Very different | Somewhat different | Not at all different | Don't know | |
|---|---|---|---|---|
| Who pays for care | ||||
| Who is involved in planning care for patients | ||||
| How care is organized and provided to patients | ||||
| How data is shared |
Governance Structure
Shared governance structure – all partners involved
Differentiators From Usual Care
This initiative provides a low-barrier access to people in one location to access mental health and addiction care for all age groups and will soon expand to include grief and bereavement supports. Regionally, there are no other coordinated mechanisms for regional residents to self-refer and book into service. This initiative allows patients to choose the service that best fits their needs and interests.
Key Learnings & Advice for Others
The key takeaway is having a core of highly invested partner organizations that truly believe in the project. This initiative was a partnership from the outset and remains a partnership to date with the core initial partner organizations staying involved and truly invested in the work. The support and investment of these partners has led to a “grape-vine” situation where other organizations hear about the initiative and are expressing interest to participate as they see the benefit to others.