The following are projects that are currently underway with planning for implementation in the future or have been implemented by the collaborative efforts of Partners within the Muskoka & Area Ontario Health Team.
Electronic Referral (eReferral) provides primary care providers like doctors and nurse practitioners with access to services for their patients using a secure, easy, online digital process. They can make referral requests with participating clinics and specialists close to home or, by using a geographical search (map-based), anywhere in the province. This is a growing program in Ontario that allows the clinician and the patient to track their referrals, confirm appointments, receive instructions to prepare for appointments and access two-way communication.
Locally, clinicians can refer for Diagnostic Imaging requests, Diabetes Education appointments and Cardio-respiratory consultations. More clinics are coming on board in the near future, including Seniors Assessment Support and Outreach Team and the Heart Function Clinic.
Online Appointment Booking
Online appointment booking empowers patients and helps to free-up clinic staff by allowing patients and caregivers to request or directly schedule their own appointments, virtual or in-person. This option is convenient for patients, with less time spent on the phone waiting on hold while having ability to choose a time that fits into their schedule. For clinics it means fewer incoming calls for clinic staff to respond to, and less follow-up is needed because patients are sent email notifications and reminders.
Remote Care Monitoring
This program empowers individuals to take an active role in managing conditions that lead to hospital admission, Chronic Obstructive Pulmonary Disease and Congestive Heart Failure. The program has easy to use equipment to measure key biometrics (e.g. weight, blood pressure, blood glucose and blood oxygen) so that patients can monitor their conditions at home and answer questions concerning their symptoms each day. The Remote Care Monitoring Team monitors patient’s biometric data and responds back to them with a helpful management plan and ongoing coaching and education as needed.
The local collaborative model has these 3 community partners: Community Paramedic Program, Primary Care, and Home and Community Care Services. The partners work together, maximizing the capabilities of their team members and providing long term sustainability that will ultimately benefit the patient as they manage their condition together.
Hospital to Home
Muskoka Algonquin Healthcare, Closing the Gap Healthcare, and Muskoka & Area OHT have developed the Hospital to Home program which focuses on coordinated care and seamless transitions as patients and their families move from hospital care into the home environment. Patients and their families interact with a multidisciplinary team that provides high-quality care in a well-coordinated, patient-driven manner.
The Hospital to Home program provides patients with support and resources as they move out of hospital and back into their home. The program supports recuperation while preparing patients and family/caregivers to manage care needs as independently as possible.
Transitional Care Beds
Muskoka Algonquin Healthcare, along with existing facilities in our communities, is working to transition patients out of the hospital when hospital level care is no longer required. They are partnered with Hospice Muskoka (Andy’s house) which provides 5 beds for palliative patients with a prognosis of 3 months or less so that they can receive specialized palliative care outside of the hospital setting. Hospice is also supporting patients in a symptom crisis who have a goal of returning home when the crisis has resolved. MAHC has also partnered with Muskoka Hills Retirement Villas which provides a supportive transitional environment for patients who are awaiting a more permanent placement.
Transitional beds allow patients to receive the care they need in the setting that is right for them. It allows them to move out of the hospital while still receiving the care they need, whether time to get stronger, time to recuperate, or time to move through a waitlist at their desired end location.
MyChart is an application that allows patients to view their medical records from their personal devices, 24/7, through a patient portal. By registering using their own private information, health records from participating organizations and health care providers becomes easily and securely accessible.
This will allow the user to monitor and share personal health information with other health team members, loved ones and care providers. Best of all, use of MyChart is free.
Surgical Transitions is a program that uses an application called Seamless MD to prepare patients for surgery, provide a library of educational materials about their procedure, do personal health checks after surgery and connect with a nurse if they have questions or concerns about their recovery.
Patients are enrolled by email or mobile phone number and can access this app 24/7. They stay enrolled for 30 days after leaving the hospital and can use the app as much or as little as they choose. Often this provides access to the help needed, without a trip to the doctor or the emergency department. So far, over 85% of the patients who have used Seamless MD were happy with the program and would recommend it to others or use it again.
The Heart Function Clinic is currently located at the South Muskoka Memorial Hospital in Bracebridge, with plans to expand to Huntsville District Memorial Hospital, and provides care to patients with Congestive Heart Failure by a Nurse Practitioner. The program is overseen by an Internal Medicine physician, and the goal is to provide optimal care and treatment of heart failure in Muskoka.
This outpatient clinic opened February 6, 2023 and continues to grow and evolve. Referrals are accepted from physicians, nurse practitioners or other credentialled members of your health care team.
Seamless Care (SCOPE)
The Seamless Care Optimizing the Patient Experience (SCOPE) program’s main objective is to support primary care providers by improving access to high-quality care for their patients. SCOPE acts as a connector between providers and the health care system.
A Nurse Navigator is a cornerstone of the SCOPE model, building relationships with Primary Care Practitioners and facilitating access to programs and services. The Nurse Navigator is part of a network of nurse navigators within the greater Toronto area, and can use relationships with peers to enable coordinated access to acute specialist or program care outside of Muskoka & Area OHT.
SCOPE is a program that makes it easier for primary care providers to connect their patients to the services they need, allowing them more time to spend with their patients. By facilitating these types of calls, SCOPE also helps get patients the care they need faster.
Home Care Modernization
The HCC Modernization Working Group aims to understand local needs for home and community care, and make recommendations to the province for a phased transition plan that will deliver the kind of care our patients need.
As an OHT, delivering home and community care means working collaboratively with patients, families, and caregivers, and all health care partners to design and deliver home care in a way that makes sense based on the unique needs and geography of Muskoka and Area. Patients will be able to expect timely and effective care when and where they need it. Receiving care at home is often preferable and more beneficial than at hospital. Keeping patients out of hospital who don’t need to be there also preserves capacity in our hospitals for those who truly need acute levels of care.
Health Human Resources
Through the Health Human Resources Task Force, the Muskoka & Area OHT is designing and building an integrated waitlist for people who do not currently have a primary care provider. This list will provide a single, centralized list that will consolidate the many lists currently kept by individual primary care groups.
Using a single list will reduce duplication and inefficiency, and ensure people are connected to a primary care provider in a timely way, ensuring that everyone who wants a primary care provider can have access to one.