If you are concerned about your health, or have worsening symptoms please advise your primary care physician and as always, go to an Urgent Care Centre or Emergency Department if needed.
COVID Care @ Home Integrated Comprehensive Care Program
Building off the successes of past innovations in integrated care and community partnerships across St. Joseph’s Health System, St. Joseph’s Home Care (SJHC) launched COVID Care @ Home in November 2020, and supported referrals until June 4, 2021.
COVID Care @ Home was a new model of care that will serve as a blueprint for future programs, linking up providers and connecting patients to care wherever they are, whenever they need it.
To support hospital partners, manage acute care capacity and primary care to deliver safe care to COVID patients at home and in the community, COVID Care @ Home was launched in Niagara, Hamilton, and Kitchener and Waterloo.
Working across multiple sectors and alongside partners in primary care and public health COVID Care @ Home engaged with over 75 partners and family and patient advisors to design a model of care to support COVID-19 positive patients with 24/7 access to one integrated team.
This program demonstrated the power of integrated care planning. Together with our partners, St. Joseph’s Home Care was able to provide outstanding care and test a new model of care that both supported high quality care and protected hospital capacity during the COVID pandemic.
COVID Care @ Home (CC@H) demonstrated patient-centred care, innovative partnerships, and value in the following ways:
For Patients
✓ Supported over 500 patients with an average duration on program of 25-30 days for Acute Care Referrals, and 14-20 days for Community Referrals (Primary Care, Public Health @ Self Referrals)
✓ Co-designed community referral program with three local Ontario Health Teams and dedicated patient and caregiver advisory group
✓ Supported centralized intake across 10 referral sources – including innovative self-referral portal
✓ Resulted in a low readmission rate; Initial evaluation results indicate that 3 per cent of patients required planned readmission back to hospital
Innovative Partnerships:
✓ Maintained a regional approach tailored to local care paths in three cities: Hamilton, Kitchener Waterloo and Niagara
✓ Integrated with existing Remote Patient Monitoring (RPM) programs in each region
✓ Worked across local and regional tables engaging over 75 partners on weekly basis
✓ Through St. Joseph’s Home Care, the CC@H program successfully introduced additional Home and Community Care Capacity in the regions of Hamilton, Niagara and Kitchener Waterloo – including forging new relationships with home and community care providers in the Kitchener Waterloo area
✓ Successfully coached St. Mary’s General Hospital through first application for lead agency status
Value:
✓ Facilitated contribution of in-kind hospital resources in the Hamilton, Niagara and Kitchener Waterloo regions to support referrals and intake from Acute Care
✓ Provided in-kind contribution of resources from the Centre for Integrated Care to develop robust Evaluation program
✓ Provided in-kind contribution of St. Joseph Health System resources to establish innovative on-line self-referral portal.
The program evolved into an innovative model of care that shows incredible promise to scale into other chronic diseases and patient populations. We believe that this collaborative spirit will play a critical role in recovery planning and inspire how we bring care to the most vulnerable patients.
Our hope is that we can continue to build on this powerful, collaborative model to support seamless, connected care in the community.
“To our valued partners, thank you for making this program an incredible success!”
– Carolyn Gosse, President, St. Joseph’s Home Care
Vice President, Centre for Integrated Care
St. Joseph’s Health System