How Central West CCAC, Headwaters and Osler are taking patients from Hospital to Home

When patients return home from the hospital, they sometimes need a little bit of extra support. Osler is working with its partners at the Central West Community Care Access Centre (CCAC) and Headwaters Health Care Centre (Headwaters) – as well as the Ontario Telemedicine Network (OTN) and the Central West Local Health Integrated Network (LHIN) – to meet this need with Hospital to Home (H2H).

H2H is an innovative new model of care that is helping to improve clinical handoffs and information sharing when patients leave hospital and re-enter the community. This means that patients continue to receive short-term nursing care from the same team after they return home. H2H will initially support patients with cellulitis and urinary tract infections requiring short-term nursing interventions, later expanding to support those with more complex needs.

Last week, H2H launched at Brampton Civic Hospital. The program originally launched at Etobicoke General Hospital in December and then at Headwaters in January.

Once fully implemented, H2H will help prevent unnecessary hospital admissions, shorten the length of stay for admitted patients, provide greater continuity of care and ultimately, enhance the patient experience for those we serve.

As one of six integrated programs sponsored by the Ministry of Health and Long-Term Care’s new bundled funding model, H2H is an excellent example of how different organizations from across the continuum of care can work together to improve access to care that truly benefits patients. And it’s proving to be effective. Since November 2015, more than 135 patients have been enrolled in the program and dedicated H2H nurses have completed over 750 nursing visits in the community.

With each phase of the H2H rollout, the project team gathered feedback from staff and patients to help shape the program even further. Feedback to date has been very positive. Here’s what some H2H patients had to say:

  • I received outstanding care!”
  • My experience was fantastic. Each Nurse was extremely knowledgeable and they arrived in the timeframe as promised.”
  • “I really appreciate this program. You took the time to talk with my wife and comfort her when I did not know what to say to make her feel better.”
  • “You hired the best nurses for the job. They have all been wonderful!

This kind of patient experience is what we strive to achieve. That we are hearing such overwhelmingly positive feedback so early in the life of the program is a wonderful testament to the team’s commitment to providing patient-inspired care!


Celebrating a Year of Innovation and Partnership

Do you remember what you were doing this time last year? At Osler, we were embarking on a journey with the Central West Community Care Access Centre (CCAC) and Headwaters Health Care Centre (Headwaters) that would change the way health care is delivered in our region.

Together, we announced an innovative cross-sector partnership that joined our non-clinical (administrative or ‘back-office’) functions to improve our collective ability to meet the health care needs of our communities. So far, we’ve worked hard to build solid foundations that will impact the way health care is delivered in our region.

Here’s a snapshot of what we’ve done this year:

Planning for the Future, Together

For the first time, we joined forces to develop our Annual Business Plans (ABP) and Quality Improvement Plans (QIP). By aligning our goals and monitoring them with a set of common metrics this will enable us to collectively improve health care quality and safety while having a positive, far-reaching impact on the patient experience across the Central West region.

We also worked together to showcase our individual and collective achievements from the past year in our Annual Reports in a fresh, dynamic way.

Leading the Way Forward

The old adage “two heads are better than one” certainly applies to the partnership. But for us, five heads are better than two. By creating a Joint Non-Clinical Executive Team, we pooled the collective resources and experience of all three organizations. This innovative approach to leadership has energized our senior teams and has created an environment that fosters collaboration and cooperation.

Weathering the Seasonal Surge

There’s nothing that tests the strength of a relationship better than a challenge. We put our partnership to the test as we collectively planned for and responded to a large patient surge during an exceptionally busy holiday season that was complicated by an early spike in flu activity. In a two week period, Osler saw a more than 8,800 patients visit our emergency departments (ED), admitted more than 1,000 patients for acute care and confirmed 350 flu cases.

Needless to say, this was a challenge but by working together we were able to effectively manage the flow of patients by providing excellent care in our hospitals as well as in the community.

Over the past year we saw first hand how working together can yield incredible results and spark new ideas about how we can improve the patient experience. We will share more achievements as our relationship matures over the months and years ahead. It is an exciting time for health care in the Central West region and I’m confident that the best is yet to come!

How Osler is working with the LHIN

There are many acronyms in health care. While medical dramas on TV have made many of these terms common place – like MRI (magnetic resonance imaging) and ED (emergency department) – there are some that are a bit more unfamiliar.

One of the terms we often use around Osler is LHIN, which stands for Local Health Integration Network. It’s a long name, but what does it mean?

The LHIN system is unique to Ontario and was created so health care spending decisions could be made by local people and money could be distributed in a way that better reflects local needs of regions across the province.

Across Ontario, there are 14 LHINs that bring health care decision-making to the regional level. Everything from the planning, coordinating, integrating and funding of local health care services is managed by individual LHINs across the province. Each LHIN is overseen by a provincially-appointed Board of Directors to ensure that they remain accountable.

Osler is located in the Central West LHIN and we work closely with the LHIN to deliver programs and services that make a difference in the lives of patients. The LHIN also works closely with health care providers in the community. This means that if you’ve received care at Osler, moved a loved one into a long-term care facility, accessed community support services or visited a community health centre – you have touched part of the LHIN.

Here are just a few examples of how Osler and the LHIN are working together to meet the needs of patients:

  • Patients with COPD and Heart Failure are now able to manage their health from home through Telehomecare
  • Diversity is in our DNA and Osler is part of the LHIN’s Diversity and Equity Core Action Group to help ensure all patients receive fair and equitable access to health care
  • We’re calling for better integrated care across the community through Telephone Town Hall meetings with our regional partners
  • Through the connectingGTA Program, Osler clinicians can access the health information they need to make care decisions using a secure regional electronic health record system

This is just the tip of the iceberg. As the health care needs of the communities we serve evolve, we will continue to work with our partners at the LHIN to improve access to services and find ways for health service providers to improve the quality of care.

The Power of Three

There is a principle called the “rule of three” that authors and film-makers often use because it just makes things seem funnier, more satisfying, and more effective than other numbers do. Think of the Three Musketeers or Goldilocks and the Three Bears. I believe there is strength in numbers, which is one reason partnership has become a central focus at Osler.

Last summer, we made a ground breaking announcement that will change the way health care is delivered in the Central West region for the better. Osler joined forces with our partners at Headwaters Health Care Centre (Headwaters) and the Central West Community Care Access Centre (CW CCAC) to integrate our non-clinical functions across all three organizations.

Through this partnership we’re putting patients and families first by finding new and better ways of working together to create an integrated, patient-centric health care system that is easier for people to access, understand, and navigate.

Over the coming year, we will focus on a number of initiatives that will help to link care received in the community and acute health care services provided in a hospital setting. Here are three examples of how we will make it a reality:

Put patients at the centre of their care

By listening to patients we understand that satisfaction is largely based on their experience of how service is delivered, rather than the technical aspects of the medical care they receive. Our goal is to put patients in the Central West region first by providing better care and creating a seamless experience for them as they move throughout the health care system.

To do this, we’re collectively hiring a Chief Patient Experience Officer (CPEO) to work with all three organizations to ensure the patient is at the heart of everything we do and support our collective focus on being leaders and innovators in the area of patient experience.

Improve options for end-of-life care

Together, we’ve identified a strong need for coordinated, individualized and respectful Palliative Care in our region. Through a Joint Palliative Pledge we will commit to transforming and dramatically improving the patient experience for those living with life-limiting illnesses.

Today, the majority of patients die in hospital but most wish to die at home. By taking action together, we can change the way we collectively support patients and families – and enhance the quality of living and dying – by emphasizing respect, dignity and compassion as we support them through this journey.

Take a regional approach to planning

The Central West region is one of the most diverse and fastest-growing in the province, and our organizations share similar challenges. One of the many ways we are working together is illustrated in our regional approach to planning, which supports the delivery of quality, timely health care services.

For the first time, our organizations have begun the process of creating a joint business plan that will build upon our collective accomplishments to further drive us toward achieving our strategic goals. We will also focus on developing strategies and creating innovative solutions to so that we can best serve the patients in our communities.

Shifting from traditional thinking, breaking down barriers, and considering more unconventional methods of collaboration is taking our partnership to a whole other level. While it is still early days, the impact of the changes derive real benefits for the patients we serve.

“Coming together is a beginning. Keeping together is progress. Working together is success.” – Henry Ford

A lot can be achieved when working as a team. Osler – along with health care partners at the Central West Community Care Access Centre, Central West Local Health Integration Network, Headwaters Health Care Centre, and Region of Peel Health Services – will be hosting its fourth Telephone Town Hall to connect with people across the region about their health care services.

During the call, we will talk about how we work together to provide specialized health services to the community. This time, we will also focus on the topic of seniors’ health and the programs and resources available to them.

READ MORE: Questions and answers from the previous Telephone Town Hall

The call will happen on Monday, October 6 from 7:00 p.m. to 7:45 p.m. By joining the call, you will have the opportunity to:

  • Hear directly from health care leaders in your community about issues that matter to you
  • Learn how the health care system works in the Central West region
  • Ask questions and provide valuable opinions that can help us shape the programs and services we offer

All members of the community are invited to have their voices heard so please share this information with your friends and family, too. Get your name on the call list by leaving a message at (416) or (905) 494-2120 ext. 50200 or email your telephone number to by Friday, October 3.

Fostering bold, new partnerships in health care


A new partnership is unfolding with the potential to benefit patients in our community, across Canada, and around the world.

On Monday, October 7, Osler will be hosting an event to announce a new partnership with Canadian Blood Services. The event will recognize Osler as only one of four hospitals in Canada – and the only community hospital – that will help Canadian Blood Services build a national public cord blood bank.

What this means is that over the coming months, we will be working with Canadian Blood Services on creating a collection site for umbilical cord blood at our Brampton Civic site.

We are pleased to partner with Canadian Blood Services on this important initiative. Currently, patients from diverse populations have a greater challenge finding stem cell matches. Given the fact that Osler serves a growing and diverse community, our collection efforts will be significant – benefitting patients by providing additional opportunities for finding a match, and helping to save more lives.

As one of the largest health care providers in the province, this partnership with Canadian Blood Services can help us make a meaningful difference to patients, the communities we serve and beyond. It is an excellent example of Osler’s mandate to foster bold, new partnerships to create a unified system and speaks to Osler’s vision: Patient-inspired health care without boundaries.

As a son, brother, uncle and parent I think that this is a tremendously important initiative and one that we can be proud to have a role in.

We will continue to share more news about our partnership with Canadian Blood Services and about the significant role we have as a collection site in the months ahead.