Shifting to an Integrated Team Care Network

The Thames Valley Family Health Team (TVFHT) is shifting from a site-based model to an Integrated Team Care Network. This three to five year project is based on two of our strategic directions:

  1. Advance collaborative and integrated care, where TVFHT is asked to optimize service capacity and partner with various stakeholders, including patients and their families, to improve the coordination of services for patients, and,
  2. Prioritize Health Equity and Cultural Safety, where TVFHT is asked to improve health equity and expand access to team-based primary care.

This project will also align TVFHT with the vision of Ontario Health Teams for more seamless and coordinated care for patients and allow TVFHT to be nimbler in its ability to scale up its services if additional funding becomes available to support team-based primary care.

To support the two strategic directions listed above, we have created a conceptual model for providing team-based primary care to existing patients and others within the community.

This conceptual model shows how we will provide centralized virtual and in-person care by our employees from one or more anchor locations.

Such a model can improve efficiencies and access to services for patients by offering each patient all services available from the hub as opposed to just the services that are limited to one practice site.

Questions about our Conceptual Model? Please email us at [email protected].

How we will move to an Integrated Team Care Network

Defining our core services: we will clearly define who we are and what we do – where we can have the biggest impact on people we serve in primary care. This is a requirement for the successful implementation of the Integrated Team Care Network.

The shift to providing core services will be rolled out in a phased approach, although TVFHT respiratory therapists are already working on core service delivery (COPD and Asthma) through our partnership with ARGI/Best Care.

Creating a model where TVFHT Nurse Practitioners will lead team-based care by working to their full scope as independent providers: Starting as a pilot project, a group of four Nurse Practitioners (NP) will collaborate with physicians to become independent providers with a panel of patients attached to them. Our conceptual model will be implemented as part of this pilot — interdisciplinary professionals will provide team-based care to NP patients, and administrative support will be provided to this team.

The results of this pilot will inform planning for gradually moving to independent provider status for the full NP team.

Core services implementation for the rest of the team: our pharmacists, dietitians, mental health counsellors. and occupational therapists will also shift their care focus and provide core services to patients.

Patients with complex needs: as we are also tasked to improve health equity through our Strategic Plan, we will work with other health system partners (e.g., hospitals and other community agencies) to improve access to team-based care to patient groups that have higher and more complex needs.

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