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Areas of Focus

Models of Care Delivery

The SE Research Centre is focused on innovative solutions to health care delivery across the care continuum to support the health and social care system in more effectively and efficiently responding to the needs of challenging and high priority disease groups and patient populations. The following are some of the specific topic areas we are actively exploring in this field:

  • Adapting clinical best practice guidelines
  • Integrated patient assessment methods
  • Models of dementia care
  • ALC diversion/Restorative Care/ Community Reactivation
  • Care transition models
  • Virtual care/ support programs
  • Health coaching/ behaviour change
  • Remote Patient Monitoring
  • Home care/primary care/ community support services integration
  • Hospitality models of seniors care

Why Models of Care Delivery?

Most qualitative health services research on new models of care is either highly theoretical in nature, and/or presents a small snapshot of outcomes and impacts based on pilot projects and program evaluation. Truly innovative models of care delivery, require future-focused thinking and research involvement from the design stage, through delivery and evaluation. By partnering with system users including patients, families, health care providers and our colleagues in innovation, business and operations at SE Health and beyond, we see an opportunity to co-create more innovative solutions to deliver effective, efficient and high quality person- and family-centred care.

How did we get here?

Our journey of research in interdisciplinary home care has been foundational to the priority research field of Models of Care Delivery.

While models of interdisciplinary care continue to emerge in health care research and delivery, the focus is usually on institution-based care and regulated health professionals who work within the same physical space. Interdisciplinary care in home care requires thinking about virtual teams and supporting everyone involved in the circle of care including regulated and unregulated health care providers, family/friend caregivers and individuals receiving care.

Since 2010, we have been exploring the use of secure private online networks called Tyze Personal Networks to bring all members of home health care teams together as a virtual team. Client and family-member Tyze users have reported positive experiences with enhanced communication and working towards common care goals; however, more work is need to integrate these networks with existing health care charting and communication practices from a provider perspective.

In 2011, we partnered with Red Cross and Care Partners in a research study funded by the Ministry of Health and Long Term Care and the Ontario Stroke Network to investigate the role of personal support workers in evidence-based stroke rehabilitation and community care teams. The project team was comprised of both researchers and interdisciplinary health care providers, including personal support workers. What emerged was a framework for integrating PSWs into interdisciplinary health care teams. The Observe, Coach, Assist, and Report (OCAR) framework can guide improvements to team communication and information sharing in home care and beyond.

What are we currently working on?

Better Care Closer to Home by Making the invisible VISIBLE: Co-Design and Evaluation of a Brain Health screening and risk management program

We are working as part of a health innovation team to develop and test a program for using groundbreaking brain health assessment and risk management technology called BrainFX. We are co-designing the implementation of this technology with hospital, primary care and home care stakeholders. We will evaluate the impact this program has on improving access to services, independence to age in place and quality of life for patients and their family/friend caregivers. A more detailed summary of this project can be found here. Preliminary results are expected to be available here in September 2018.

Developmental Evaluation of the Hillcrest Reactivation Centre Program

We are working to evaluate an innovative reactivation and reintegration program targeted at frail older adults, persons with dementia and individuals with mental health issues. This program is being delivered by Saint Elizabeth who partnered with University Health Network to open the Hillcrest Reactivation Centre in downtown Toronto. The goal of the program is to help individuals, their families and their care team work together on the goal of going home from hospital with the appropriate supports in place. A more detailed summary of this project can be found here. Preliminary results are expected to be available here in September 2018.

Evaluation of the Elizz 5 LifeStages of Caregiving Employee Program

Building on the promising practices and indicators for caregiver education and support, The Elizz 5 Lifestages of Caregiving program is a virtual program aimed to create caregiver-friendly workplaces with confident, healthy and engaged employee family caregivers. We are working in partnership with the Elizz 5 LifeStages of Caregiving Program team to evaluate its impact in multiple different workplace settings across America. A more detailed summary of this project can be found here. Preliminary results are expected to be available here in September 2018.