Enhance Community Health, Better Care Services
Your health team struggles to deliver quality, proactive health care because they do not just lack complete access to your "big picture" health data, but the "big picture" health data of everyone for which they provide care. Without access to or ability to link this health data together, your health team and health planners across Ontario are also prevented from seeing the "big picture" health data of the communities to which you and other people belong. Health Canada defines population (or community) health as a targeted approach to improving the health of an entire population or group of people. To achieve better community health, Ontario must be able to identify communities or groups of people with similar unmet health and social needs, care experiences, and health outcomes to proactively design tailored services that improve the overall health of that specific community or group of people. When individual people share their health data, the insights generated from linking this health data improves the overall health and wellness of entire communities.
End-to-End Care
Challenge: Ontario's health care system is a highly fragmented, poorly integrated, and inconsistently governed analogue and patchwork network of health providers who struggle to provide personalized care and share health data to address population health needs.
How health data was used: To address Ontario's outdated health system, the Ontario government introduced one of the largest reforms to the provincial health system through the creation of Ontario Health Teams (OHTs), which rely on data insights for integrated, one-on-one care across care settings as well as population health management, which involves providing care to defined and diverse populations through tailored services to address distinct and unmet health needs.
Result: At maturity, OHTs will provide 24/7 seamless, integrated, and coordinated person-centred care across all care settings. Currently, health providers (primary care physicians, home care agencies, long-term care homes, community health services, etc.) across Ontario are joining OHTs to work as a coordinated team - one unit - to break down silos between organizations while delivering "connected care" at all stages of a person's health journey for everyone across Ontario.
Holistic Approach
Challenge: South Georgian Bay (SGB) Ontario Health Team (OHT) sought to reduce its population's health inequities, which relate to social and environmental factors including income, social status, race, gender, education, and physical environment. Health equity can only be achieved when people have a fair opportunity to reach their fullest health and wellness potential, which means addressing social determinants of health.
How health data was used: SGB OHT developed the Community Information Exchange (CIE), a shared technology platform to allow health providers and community service organizations to make electronic referrals to 211 for people who impacted by the social determinants of health. This is known as "social prescribing" - a structured way of referring people to a broad range of local, non-clinical services (e.g., food resources, transportation services, income supports, or social activities for those who are alone).
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Result: The CIE, in connection with 211 Community Connection, improves access to 24/7 coordination and system navigation services through a holistic health equity focus. Currently, CIE partners access digital technology and sharing tools to generate referrals and share patient outcomes and create a longitudinal record to track each person's progress. SGB has already seen, for example, a 28% decline in repeat 911 calls in Simcoe Country due to the CIE.