COVID Care @ Home
COVID Care @ Home
COVID Care at Home (CC@H) is an integrated new model of care that was rapidly developed and deployed by St. Joseph’s Home care to serve COVID-19 patients at home and in the community. COVID Care @ Home delivered customized care plans to COVID patients of all complexities (low-moderate-high) with an integrated team of home and community care service workers. CC@H supported patients by helping them navigate the system/supports, coordinating in-home or virtual visits, and offering 24/7 phone access.
CC@H was launched in November 2020, and supported referrals until June 4, 2021. The program was offered in Niagara, Hamilton, Kitchener, and Waterloo.
Program goals:
Deliver safe care to COVID-19 patients at home and in the community
Support hospital partners
Manage acute care capacity and primary care
CC@H was active across multiple sectors and alongside partners in primary care and public health. St. Joseph’s Home Care (SJHC) co-designed a model of care to support COVID-19 positive patients with the help of over 75 partners and family and patient advisors. The collaborative partnerships enabled St. Joseph’s Home Care to provide outstanding care and test a new model of care that both supported high quality care and protected hospital capacity during the COVID pandemic.
Project Impact:
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Supported over 500 patients
Co-designed community referral program with three local Ontario Health Teams and dedicated patient and caregiver advisory group
Resulted in a low readmission rate; initial evaluation results indicate 3% of patients required planned readmission back to hospital
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Maintained a regional approach tailored to local care paths in three cities: Hamilton, Kitchener Waterloo and Niagara
Integrated with existing Remote Patient Monitoring (RPM) programs in each region
Worked across local and regional tables engaging over 75 partners on weekly basis
Successfully introduced additional Home and Community Care Capacity in the regions of Hamilton, Niagara and Kitchener Waterloo – including forging new relationships with home and community care providers in the Kitchener Waterloo area
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Facilitated contribution of in-kind hospital resources in the Hamilton, Niagara and Kitchener Waterloo regions to support referrals and intake from Acute Care
Provided in-kind contribution of resources from the Centre for Integrated Care to develop robust Evaluation program
Provided in-kind contribution of St. Joseph Health System resources to establish an innovative on-line self-referral portal
Project Lead:
CC@H Impact:
“I truly feel if [CC@H Provider] had not convinced me to go to the hospital, I would have been one of those statistics. She saved my life.”
— CC@H Patient
“[CC@H provider]'s expertise, advice, encouragement and support have been invaluable in this journey, especially on those days when we were both ‘down’ and discouraged since this virus affects both physical and mental health. [CC@H Provider] was our “ray of sunshine” on several “gloomy” days!”
— CC@H Caregiver
“Early intervention usually leads to better outcomes. COVID patients can deteriorate quickly.”
— CC@H Provider
FAQ
How was CC@H accessed?
CC@H supported patients referred to program from Acute Care Referrals and Community Referrals (Primary Care, Public Health, Self-Referrals) via an innovative self referral portal. The community referral program was co-designed with three local Ontario Health Teams and dedicated patient and caregiver advisory group
Where was the program offered?
The program was offered in Niagara, Hamilton, Kitchener, and Waterloo.
What is the legacy of the CC@H program?
The CC@H model will serve as a blueprint for future programs, linking up providers and connecting patients to care wherever they are, whenever they need it.