Patients in six communities across the province will now benefit from an approach called bundled care, which is helping people transition more smoothly out of hospital and into their homes.

The bundled care model provides a single payment to a team of health care providers to cover care for patients both in the hospital and at home. As a patient moves throughout the system and back to their home, the majority of their health care team remains the same. Services are coordinated around the patient’s needs, resulting in fewer emergency department visits and less risk of being readmitted to hospital.

One of the six communities includes Central and Toronto Central Local Health Integration Network Integrated Stroke Care (Sunnybrook Health Sciences Centre, Providence Healthcare, Mackenzie Health, North York General, Toronto Central Community Care Access Centre, Central Community Care Access Centre).

The project will focus on stroke care, beginning with patients discharged from hospital to home for up to 60 days. The team includes acute, home and outpatient providers in two Local Health Integration Networks. Patients will have a seamless care experience across the continuum of care including improved quality, health outcomes and experience as a result of evidence-based pathways of care, integration across providers and settings.

The model will include the use of a clinical collaboration tool; warm handoffs between health care providers when there is a transition in care – for example, when the patient moves from hospital to home; and the potential use of telecommunications to deliver healthcare services to patients at home.

“Sunnybrook Health Sciences Centre and its partners, Mackenzie Health, North York General, Providence Health Care, Toronto Central CCAC and Central CCAC are excited to be working together to develop an innovative integrated model of care for stroke patients,” said Malcolm Moffat, Executive Vice President, Programs at Sunnybrook Health Sciences Centre. “In this model, the focus will be ensuring that the patient receives the right care, in the best location, and at the right time. We will put extra focus on ensuring smooth handoffs between the partners, and ongoing communications amongst the care team, so that we can create a truly seamless model of care.”

Moving forward with bundled care is one of 10 steps outlined in Patients First: A Roadmap to Strengthen Home and Community Care, the government’s plan to strengthen home and community care in Ontario over the next three years. It is also part of the government’s plan to build a better Ontario through its Patients First: Action Plan for Health Care, which is providing patients with faster access to the right care, better home and community care, the information they need to stay healthy and a health care system that is sustainable for generations to come.

Quick Facts

  • The six communities were selected based on an Expression of Interest, which was issued on February 5th, 2015.
  • In addition to the bundled care projects, the government also funds Health Links, which coordinate care for seniors and other patients with multiple, complex conditions.
  • St. Joseph’s Health System’s Integrated Comprehensive Care Demonstration Project was the first health care initiative in Ontario to show the benefits of a bundled care approach.

Background Information

Additional Resources