Projects
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 Almaguin Ontario Health Team.
Electronic Referral
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.
Telehomecare Program
Telehomecare is a free program that helps people with COPD or Congestive Heart Failure manage their health from home. Using a simple tablet and monitoring tools, patients enter daily readings that are reviewed by a Telehomecare nurse in real time. Nurses provide follow-up, coordinate with primary care providers, and offer weekly coaching on symptoms, medications, diet, and when to seek care.
Telehomecare helps reduce emergency visits, improves confidence in managing chronic conditions, and offers reassurance for both patients and caregivers.
Learn more about Telehomecare or make a referral by clicking here—available for patients, caregivers, and health care providers.
Hospital to Home
Muskoka Algonquin Healthcare, Closing the Gap Healthcare, and Muskoka Almaguin 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
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.
Note: MyChart is available to individuals who are or have been patients at Muskoka Algonquin Healthcare (MAHC).
Surgical Transitions
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.
Heart Function Program
The MAOHT has launched a Heart Function Program, in partnership with Best Care, to provide patients with comprehensive, local care for heart failure. The program is available through primary care practices as well as at the South Muskoka Memorial Hospital Heart Function Clinic in Bracebridge. It offers routine management of heart failure, with care coordinated between your primary care provider and cardiologist, if needed, so you can receive care close to home.
This team-based approach follows Ontario’s Quality Standards for Heart Failure Care in the Community for Adults. If your primary care provider is not part of the program, they can refer you by sending an Ocean e-referral (preferred) or by completing and scanning a referral form.
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 across Ontario, and can use relationships with peers to enable coordinated access to acute specialist or program care outside of Muskoka Almaguin OHT.
The MAOHT offers a unique mental health pathway that provides access to a Social Worker for mental health services navigation and short-term psychotherapy services. The Social Worker collaborates with regional and provincial mental health service providers to facilitate access to appropriate and available resources.
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.
Digital Literacy
Improving digital literacy is a priority for the Muskoka and Almaguin OHT as we work to ensure every resident can confidently access and benefit from digital health tools. Many residents in our rural, remote, and underserved communities face barriers such as limited connectivity, varying levels of comfort with technology, or difficulty navigating online health platforms. We are focusing our efforts on supporting seniors, caregivers, and populations who experience inequitable access by providing user-friendly resources found here. By strengthening digital skills across our region, we aim to improve access to care, enhance patient navigation, and ensure that digital transformation benefits everyone.
Visit the Digital Literacy page.