VHA Home HealthCare (VHA) has partnered with the University Health Network (UHN) to deliver a new model of care, creating an improved, more seamless experience for patients, caregivers and healthcare providers through the Integrated Care at UHN program. VHA has been named the lead home care agency for this program, an important milestone in improving patient outcomes and population health.  

In 2019, a VHA, UHN formed a team representing acute and home & community care to co-design the integrated care experience to better support patients and caregivers throughout their care journey including the transition from hospital to home. Through Integrated Care (IC), patients benefit from: 

• One care team with one primary point of contact  
• One 24/7 phone line available to patients/caregivers  
• One shared digital health record across care sectors allowing care providers timely access to patient health information 
• One integrated fund to pay for services that allows for flexibility to provide patients with support when and where needed  

“The most exciting part of becoming the lead agency for the UHN IC Program is working towards building something more helpful for patients, families and clients,” says VHA’s Jennifer Little, IC Program Supervisor. 

“UHN and VHA are both very patient focused, so it’s a great partnership as we work towards the same goals. Clients are heard and can feel secure knowing that they are not going to be left navigating things alone.” 

Results to date have indicated that the IC program has improved the care experience, clinician satisfaction, quality outcomes and population health.  

In the first six months, Thoracic Surgery saw Length of Stay decrease by 28 per cent. Re-admission and ED visits rates also decreased by 33 per cent and 48 per cent respectively.  

VHA and UHN are now set to expand the model to other pathways, including those for Vascular surgery, Cognitive Heart Failure, Chronic Obstructive Pulmonary Disease and COVID-19.  

These pathways help the team to focus on specific patient needs. VHA and UHN co-design pathways with different patient populations and apply those learnings to ensure unique needs, as well as embedded clinical needs, are met as the program expands.  

“Given the Integrated Care Program is a new model of care that bridges that gap between acute and home & community care, a key element of success was establishing a partnership with our homecare partner – VHA Home HealthCare,” says UHN’s Katie Fong, Senior Program Manager for Integrated Care.  

As the lead home care agency, VHA manages the 24/7 phone line, on-call nursing, the shared digital health record which is accessible by all IC team members, reporting of quality outcomes and bundle utilization, as well as overall support for the entire IC team. 

“With VHA taking on these responsibilities, the IC team will gain a better understanding of patient and care team needs beyond direct clinical care and that will strengthen UHN and VHA’s partnership and position the IC Program to drive even more innovative changes,” adds Katie.