Author: Kerry Waddell, Kaelan A. Moat, John N. Lavis,

Publication Date: April 2023

Description: Why is the issue important?

• The Connecting Care Act, 2019 lays out the requirements of health service providers (HSP) – including the 14 home- and community-support service organizations – and Ontario Health Teams (OHTs) to provide home and community-care services.

• The regulation identifies care coordination as being the entry and exit point to home- and community-care services and the mechanism through which services are planned and adjusted over the course a patient’s care.

• The regulation sets out a number of requirements related to care coordination, including that: o prior to providing a service, an HSP (or eventually an OHT) shall ensure that the patient’s needs are assessed, their eligibility for service determined, and their services set out in a care plan, which should be reassessed when appropriate given changes to the patient’s condition or circumstances

- patients and caregivers are given opportunities to participate in needs assessment and care planning o needs assessment and care planning decisions consider certain information (e.g., availability of other publicly funded services that could meet the patient’s needs) and should be regularly evaluated and revised when patient’s requirements change

- care plans must include certain information (e.g., care goals)

- patients have a right to clear and accessible information about their services, and to a clear and accessible explanation of their assessment information and care plans.

• As early steps in building the capacity to meet the requests of OHTs, Ontario Health is supporting seven ‘Leading Projects’ whereby select OHTs have been approved to test new models of home-care delivery – leveraging as needed the new legislative and regulatory framework and collaborating with home- and community-support service organizations and their care coordinators to support implementation.

• This rapid synthesis provides a detailed look at the evidence on care coordination in the home- and community-care sector (i.e., optimal target populations) and frameworks available to inform the development of new models of care.

Access: Free

Keywords: Care coordination