Authors:

Abstract

Introduction

In 2019, North York General Hospital (NYG) partnered with two home care providers to implement an innovative and integrated program to support safe and streamlined discharges from hospital to home called NYG@Home. Bayshore HealthCare Integrated Care Solutions, one of the home care providers, recognized early on in the COVID-19 pandemic that patients were fearful to have healthcare workers in their homes. Through the use of decision support tools and education on infection prevention and control protocols and the use of personal protective equipment, our teams successfully managed to alleviate patients' fears and reluctance to have healthcare workers in their homes.

Aims Objectives Theory or Methods

The hospital and home care providers needed to pivot quickly during the COVID-19 pandemic and discover new ways of working to provide safe and effective care to the NYG@Home patients. Teams in the home care setting had to be re-organized and the delivery of many services needed to shift from in-person visits to virtual. Capacity in the system was stretched and directives and orders that were imposed further impacted the pressures on the workforce. Collaboratively, and with the support of the hospital and home care leadership teams, we were able to continue to provide high quality care in the home.

Highlights or Results or Key Findings

In order to change how healthcare was delivered in the home a number of elements needed to be in place including: 1) providing regular and ongoing training to all home care staff on the technology to support the delivery of virtual care, 2) implementing a blended visits model where nurses work to their full scope, including providing personal care, thereby reducing the number of workers that needed to be in the home, and 3) building trust and improved communication channels to ensure that assessments conducted by other healthcare providers were completed and documented in a timely manner and accessible to everyone on the care team. Finally, with a focus on supporting our patients at home and avoiding any unnecessary emergency department (ED) visits, we developed informal partnerships with paramedicine to assist with determining which patients required transfer to ED and which ones could remain at home with enhanced monitoring.

Conclusions

We learned that delivering integrated care during a pandemic requires focused teamwork, trust, collaboration, and an openness to change. Understanding the strengths of each organization to build capacity and test new models provided an opportunity to improve our collective systems while maintaining a focus on quality and positive patient experiences.

Implications for applicability/transferability sustainability and limitations

The skills and knowledge acquired to shift models of service delivery quickly during the pandemic can be applied and transferred to future integrated care programs. A shared vision, trusting partnerships, strong infrastructure, and a relentless focus on providing safe and effective patient care have been established and are sustainable.