East Toronto Health Partners’ (ETHP) Primary and Community Care (PCC) Response Teams rely on collaboration between staff from more than 15 health and social services organizations to provide care planning support to vulnerable adults in East Toronto. So when it came to the work’s evaluation — the process of assessing how successful a program or practice is to help validate processes and identify opportunities for improvement — a team-based approach made sense.
“The evaluation work group mirrors the collaborative, cross-organizational work of the PCC Response Teams,” says Lori Sutton, project facilitator for ETHP’s PCC Response Teams and a member of the program’s evaluation working group.
“An important part of this work is building transparent processes that support joint accountability,” she adds. “The evaluation results will be shared with over 80 team members who have been doing this work. This is an opportunity to celebrate their collective efforts and create a road map for ongoing improvements and evaluation.”
Since March 2020, ETHP’s PCC Response Teams have offered neighbourhood- and team-based health and social services care planning to help vulnerable adults in East Toronto, including seniors and individuals with complex needs, navigate the healthcare system and coordinate service connections.
It does this through virtual care-planning discussions, where health and social services providers from different organizations and sectors come together to create coordinated care plans for referred clients.
The health and social services providers, who make up four neighbourhood-based Response Teams, work alongside the client’s existing care and referral team to develop these coordinated care plans. The plans connect clients to primary care, mental health, caregiving, mobility and other services. The aim is to improve access to integrated primary and community-based services across East Toronto.
Now, thanks to the work of the program’s evaluation working group, PCC Response Team members have the information they need to demonstrate their impact and help continually improve integrated care.
The program’s evaluation working group includes members from multiple organizatons who have been meeting virtually each month since November 2020. Their efforts are supported by Sara Shearkhani, evaluation lead at ETHP.
“We built the evaluation plan, which included a logic model and measurement plan, based on frameworks provided by East Toronto Health Partners and Ontario Health Team evaluation webinars and workshops, ensuring they were anchored in the Quadruple Aim,” says Kathleen Foley, director of quality improvement, evaluation and accountability at South Riverdale Community Health Centre and a member of the PCC Response Teams’ evaluation working group.
“This plan aligns with the internationally recognized framework that identifies improving patient and caregiver experience, improving population health, reducing the per capita cost of health care and improving provider experience as key objectives in designing and delivering an effective healthcare system.”
For the PCC Response Teams evaluation, the working group analyzed data collected by the program’s four Response Teams. This included the number of individuals referred to the program and the number of coordinated care plans that were developed from April 2020 to March 2021.
They also looked at the results of surveys completed by referral sources, including family doctors, home and community care coordinators, supportive housing workers and others, which asked questions about their experience participating in the program.
This allowed the evaluation working group to produce a report with tangible quantitative and qualitative evidence that highlights how the PCC Response Teams program has been able to help both health and social workers and their vulnerable clients in East Toronto. Completed in April 2021, the evaluation report includes the following information for the indicated time frame:
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186 care plans were created as a result of the program;
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364 service connections were made for clients, linking them to supports related to primary care, caregiving, nutrition, medication, mental health, mobility, housekeeping, isolation and other areas;
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80 per cent of PCC Response Team members were extremely or very satisfied with their experience;
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81 per cent of PCC Response Team members reported the care-planning discussions were extremely or very successful at improving client’s access to integrated primary and community care.
In addition, the majority of respondents who completed the PCC Response Teams’ evaluation survey shared that their participation in the program helped improve their ability to work collaboratively with other providers and organizations, particularly when it comes to supporting shared clients.
The majority of these respondents also said that the PCC Response Teams helped improve their knowledge of local resources to support clients, as well as their relationships with others across programs, organizations and sectors.
“One of the most rewarding parts of this evaluation work was seeing the stories from the providers about the impact the project has had on their clients,” says Stephanie Godard, primary care physician at South East Toronto Family Health Team and evaluation working group member.
“We’ve also been able to see a deepening of relationships with people across organizations and sectors, and continued momentum and engagement that the PCC Response Teams helped build.”
“This work demonstrates the impact of cross-organizational care planning and identifies strengths and areas for opportunities allowing for continual quality improvement within the project,” adds Kathleen. “It also helps identify areas where we need increased support and resources.”
The evaluation working group says they’re encouraged by the positive feedback on the PCC Response Teams they have received so far, especially given the infancy of the program. They said one of the key learnings they’re taking away from their evaluation work is that a collaborative approach to planning, implementation and evaluation is essential moving forward.
They also agree that centralized, standardized data and a continuous quality improvement approach are required to support sustainable evaluation of the PCC Response Teams.
“We look forward to working with the broader ETHP evaluation team regarding how we can communicate and share this work across and beyond our OHT,” Lori says.