Background
Seven Ontario Health Teams (OHTs), each a group of cross-sectoral health service organizations, were chosen by the Canadian province of Ontario to lead the modernization of home and community care. At the heart of this work lay the reconceptualization of care coordination, with a focus on integration. We explore how Ontario’s Ministry of Health (MOH) sought to modernize care coordination through its guidance to OHTs, OHTs’ own innovations, and the potential and limits of these efforts.
Approach
While our broader goal was to understand the key elements of each home care model and what helped and hindered its development, we focused the analysis of data collected from May to October 2024 on OHTs’ care coordination efforts. During this time, we conducted semi-structured interviews (26) and focus groups (4) with cross-sectoral participants, monthly interviews with team leads, and monthly observations of key team meetings with a subsection of three teams. Participants included senior managers from hospitals, home care and community organizations, physicians, care coordinators, patients, caregivers and OHT staff members. We also conducted a document review of relevant system-level guidance and OHT-level program proposals.
Results
The MOH sought to enact change through three key levers: First, after a competitive bidding process, a single home care service provider organization (SPO) was selected to service all home care patients within a specific jurisdiction at a capitated rate, replacing the multiple service providers and fee-for-service structure that previously existed. Secondly, the care coordinator would be accountable not only to the provincial home care organization but also to the OHT, a move that also encouraged the care coordinator to be embedded within a care team and other team members to take on limited care coordination tasks. Third, team members would have access to an information sharing platform previously accessible only to the home care sector. In addition, OHTs themselves proposed changes related to the embedding of care coordinators in primary care teams and neighbourhood settings, and new roles to bridge coordination responsibilities. While OHT stakeholders largely welcomed these changes, their concerns were threefold: First, the SPO procurement process culminated only shortly before anticipated program implementation; this was particularly challenging for some teams where an SPO unfamiliar with the area was successful. Secondly, the provincial home care coordinator agency (alongside its associated labour union) was seen as an unwilling participant that pushed back on efforts to tweak the care coordinator role to enable effective teamwork. Third, the provincial impetus to standardize care coordination approaches across projects (aimed at levelling patient experience and facilitating evaluation) was seen as discouraging local innovation.
Implications
The audience for these findings includes jurisdictions seeking to learn about the promise and limits of innovative approaches to care coordination in the home care sector. These findings indicate the importance of a locally relevant procurement process, the engagement and partnership of all sectors and open conversations in the absence of that engagement, in order to arrive at common ground.

Background
Seven Ontario Health Teams (OHTs), each a group of cross-sectoral health service organizations, were chosen by the Canadian province of Ontario to lead the modernization of home and community care. We explore how stakeholders across sectors experienced and negotiated the task of balancing standardization and local needs, required by this work.
Approach
As part of a qualitative evaluation of OHTs’ implementation plans, we conducted semi-structured interviews (26) and focus groups (4) with cross-sectoral participants, monthly interviews with team leads, and monthly observations of key team meetings with a subsection of three teams, from November 2023 to October 2024. Participants included senior managers from hospitals, home care and community organizations, physicians, care coordinators, patients, caregivers and OHT staff members. We also conducted a document review of relevant system-level guidance and OHT-level program proposals. We aimed to understand the key elements of each home care model and what helped and hindered its development. Results were shared with each OHT, allowing stakeholders the opportunity to provide input into and learn from our findings.
Results
We focus here on a key theme that emerged from our data – the tension between the need to standardize while simultaneously catering to local needs. This tension manifested at system, sectoral, managerial, provider and patient levels. OHT stakeholders found that while system stakeholders had tasked them with testing new homegrown models of homecare delivery, their transformational ideas for how the care coordinator might work within the new models, for instance, were circumscribed by homecare accountability agreements, contracts and union regulations. The home care sector’s attempts to standardize its policies to ensure uniformity of patient experience was interpreted as a lack of understanding of local context by other OHT members. OHT managers’ attempts to test innovations at different sites to enable local adaptations was sometimes met with push back from providers working on the ground. Finally, patients and family members were concerned that the initiative did not account for what truly mattered to them. We found that the tension between localization and standardization could be mediated by experienced organizational leaders able to creatively navigate between both impulses, managers able to centre the voices of patients and family members, and patients and family members able to remind people of what mattered to them.
Implications
We identified the importance of communication a) across sectors, so that all stakeholders were aware of the pressures that a specific sector may be facing and the rationale for it, to mitigate the apportioning of blame, and b) with on-the-ground providers so that they understood the rationale for change and the value of them guiding it. We are in the process of sharing these findings with system and policy stakeholders as well, to build awareness of some of the challenges to innovation that are beyond the control of OHTs themselves. The audience for these findings includes other jurisdictions navigating the task of striking a balance between localization and standardization.

Introduction: Health systems are facing unparalleled volumes of individuals in hospital awaiting discharge, often because patients’ homes are not amenable to their needs or immediate care supports are unavailable. Hospital-to-home care transition programs that integrate acute and community-based care delivery can ensure home environments are safe and conducive to recovery, and provide temporary intensive support until long term community care is available or patients regain their health. They can also expedite in-hospital care for patients who need it the most by streamlining patient flow. However, care transition programs need to flexibly offer a wide range of services depending on patient needs, so resource planning is challenging. Further, understanding patient and provider experiences with transition programs will ensure they deliver sustainable, high-quality care.

Approach: We conducted a multi-methods pilot evaluation of a hospital-to-home care transition program at a community hospital in Mississauga, Canada called THP@Home. This hospital serves a large, diverse patient population, of which 14% are aged 65 years or older, and 11% are considered to have unsuitable housing. To understand the reach, required resources, and feasibility of the program, we summarized the number and characteristics of patients served by the program and the types of services provided. To explore experiences with the program and identify strengths, challenges, comparison to usual care, and potential areas for improvement, we conducted interviews with patients, caregivers, healthcare providers, and program administrators.

Results: From March 2023 to September 2024, 398 patients received THP@Home services. Of these patients, 65% were female, 53% were over 80 years of age, the average length of hospital stay for inpatients before transitioning home was 19 days, and the average length of THP@Home services provided was 37 days. Sixteen percent of patients were provided THP@Home services following an emergency department visit with no admission. Patients averaged 32 service orders each when receiving care from the program, with occupational therapy (n=531), personal support (n=579), and physiotherapy (n=539) being the most common. Ten patients, caregivers, healthcare providers, and program administrators participated in the interviews. The overwhelming consensus was that the program positively exceeded patient and caregiver expectations, providing more support and services and facilitating a quicker return home than anticipated. Healthcare providers found the program fulfilling, but faced challenges when supporting patients who needed unanticipated services to improve home safety such as decluttering or pest-control services, purchasing basic amenities (e.g., mattress, temporary phone), or handyperson services to build or install needed furniture for medical accommodations.

Implications: Overall, this evaluation suggests that the hospital-to-home transition program at our hospital is a valuable service, as it expedites discharge and supports patients to recover in a safe and comfortable environment. Next steps for this program will focus on evaluating the program’s effectiveness in facilitating timely discharge, reducing hospital re-admissions and emergency department visits, improving readiness for providing various services, and exploring how patients in highest need of THP@Home services can be prioritized.

Background
Strategic planning and commissioning of adult social care (ASC) involves forecasting population needs across a defined area, together with availability of services or resources to meet those needs then commissioning to best meet these needs through in-house provision, shared services or procurement of independent or voluntary sector services. This paper reports qualitative research conducted on behalf of the Coalition of Care and Support Providers in Scotland (CCPS) between March and June 2024. It analyses current ASC commissioning and procurement practice across Scotland’s integrated health and social care partnerships (HSCPs) and considers the actions required to shift away from procurement largely based on price and competition.
Approach
An introductory email, information sheet and consent form were e-mailed to key contacts in seven national policy, delivery, advocacy, audit and improvement organisations working on ASC commissioning and procurement issues. Eleven people working at a national level agreed to participate. These conversations informed selection of a purposive sample of commissioning and procurement officers from local HSCPs. An introductory email, information and consent form were sent to key contacts in 13 of Scotland’s 31 HSCPs. Twenty-two professionals working in strategic planning, quality, finance, commissioning or procurement roles in 11 HSCPs agreed to participate. A further five interviews were conducted with social care provider organisations to triangulate issues raised by local HSCPs. Interviews, averaging 40 minutes, were conducted via Microsoft Teams by two researchers using three appreciative inquiry questions to frame the discussion. Data from the interview notes was analysed independently by the two researchers using Braun and Clarke’s six steps of reflexive thematic analysis.
Results
Analysis of 38 interviews resulted in six themes and related sub-themes: Resolve Ambiguity; Reduce Complexity; Refresh Practice; Rebalance Power and Relationships; Respect Place; and Realise Value. Participants spoke of multiple disconnects between adult social care policy, funding, regulation, planning, commissioning, procurement and service delivery levels. They voiced frustration with the current complex commissioning and procurement system and called for greater empowerment to commission collaboratively with local people who have lived experience and to build trusting relationships with providers. National bodies are slowly engaging with local commissioning realities but are not keeping pace with the need for local transformation or the nuances of place, particularly in remote and rural settings where interdependencies require highly integrated workforce models and commissioning practices.
Implications
There is evidence of local innovation in commissioning and procurement practice, but these innovations are not yet being shared well. Coordinated action to enable the desired change in commissioning and procurement practice requires education and support for implementation, underpinned by ASC data that includes personal and reablement outcomes and the voices of people with lived experience. This paper offers transferable learning for policy makers, national and local health and care organisations, and ASC providers. It will help them understand what can be done to enable more ethical commissioning through a stronger focus on collaborative leadership, culture and relational practice aligned with outcomes that matter to people and communities.

SMILE (Supporting Multi-morbidity Self-care through Integration, Learning, and eHealth) is a remote health monitoring program, developed by Caredoc in collaboration with the HSE and Sláintecare, that helps individuals with chronic diseases self-manage their health at home. The program utilizes a digital platform (ProACT) and nurse-led remote assessment and triage to empower participants to proactively manage their conditions and reduce the need for hospital visits.
Here's a more detailed explanation:
What it is:
SMILE is a virtual health support service that provides remote monitoring and case management for individuals with multiple chronic conditions (e.g., diabetes, COPD, chronic heart failure).
How it works:
Participants use healthcare devices (selected based on their needs) to monitor their health and wellbeing.
The data from these devices is uploaded to the ProACT platform, which also provides educational resources about the participants' conditions.
Participants are supported by a team of experienced telephone triage nurses.
Alerts are monitored daily, and participants receive support to prevent deterioration in their conditions.
Objectives:
Empower and educate participants to proactively self-manage their care.
Improve integration of services around patients with multi-morbidity.
Reduce unscheduled healthcare and hospital visits.
Enable identification of worsening symptoms.
Prevent deterioration in patient conditions and empower them to engage with their own health within the community setting.
Who it's for:
SMILE is designed for individuals with multiple chronic diseases who are at higher risk of hospital admission and who benefit from extra support to manage their health.
Implementation:
SMILE is implemented by Caredoc in partnership with the HSE, Sláintecare, NetwellCASALA, and Trinity College Dublin.
In essence, SMILE aims to provide a more convenient, accessible, and proactive approach to managing chronic diseases, allowing individuals to stay healthier and at home for longer.