SE Health and AMS Healthcare are collaborating on a 4-year project to implement an innovative holistic model of community care.
About
The Hope Initiative
The Hope Initiative will create a Living Lab where the H.O.P.E. Model® (Home, Opportunity, People, Empowerment) and emerging technologies will be piloted with clients, their families, neighbourhoods, and teams of self-directed nurses.
Goals
Provide a sandbox and methodology to experiment in two key policy areas that are of high priority for the Ontario health system – new home & community care models and digital enablement
Validate and build systemic capacity for adoption of the H.O.P.E. Model®
At scale, explore how emerging technologies can be integrated into compassionate care within the home setting
Key Focus Areas
Living Lab (H.O.P.E Model®)
Create a sandbox to validate, test, refine the model in Ontario, learning and positioning it for spread and scale; Layering in emerging technologies across three 1 year client cohorts.
Capacity Building and Ecosystem Engagement
Raise awareness, educate and support system wide readiness to embrace new models of care that incorporate emerging technologies through public events, webinars, publications & sharing results.
Developmental Evaluation
A multi-pronged independent evaluation of the H.O.P.E Model® implementation with rapid, real-time feedback focused on supporting learning & an ability to adapt to dynamic project environments.
The H.O.P.E. Model®
The H.O.P.E. Model® stands for Home Opportunity People Empowerment. The model was created by SE Health based on more than a century of community nursing expertise, with inspiration from the Dutch Buurtzorg model of neighbourhood care.
The H.O.P.E. Model® aims to address many of the gaps identified in the current transactional fee for service model of home care. Through combining both the health and social aspects of clients' lives; H.O.P.E aims to reduce utilization of high cost acute services while delivering a community-based care model whereby nurses provide a more integrated and holistic approach to care. Clients are supported to meet their goals by self-managing teams of nurses that take care of a person's full set of needs, including the majority of care services (nursing, PSW, therapies etc.), care coordination, and connections to both formal and informal care. The empowered teams of nurses work to their full scope to manage complex patients in the community with a lean infrastructure and management backbone.
The interventions are grounded in the following concepts:
People & Family Needs and Aspirations
Care planning based on client and caregiver life priorities with careprovider continuity.
24/7, Comprehensive Client & Family Care
Life care, not just health care. Addressing social determinants of health while empowering clients and caregivers in their selfmanagement capabilities.
Nurse-led, Self-Directed Accountable Teams
Self-managed, autonomous teams with clear accountability. Empowered to solve problems; the team decides how they organize their work, and make shared decisions.
Informal and Formal Networks
Leveraging community and neighbourhood supports. Integrating community services and social networks into care delivery.
Living Lab
The H.O.P.E Model® is being tested in neighbourhoods across Ontario; starting with at least two neighbourhoods in 2019. The H.O.P.E. Model® will be tested for 12 months with a cohort of nurses and clients in each neighbourhood.
London-Middlesex
• 4 Nurse (RN) team will provide care to ~100 clients across London Middlesex
• Setting: Rural geography
• Key Partner - Southwest LHIN
• Launch: August 2019
Englemount Lawrence (North Toronto)
• 3 Nurse (RN) team will provide care to ~75 clients
• Setting: Urban geography
• Partner - Toronto Central LHIN
• Launch: October 2019
Next cohorts
We are in the process of codesigning 3 additional cohorts (stay tuned). If your neighbourhood is interested in starting a cohort, please contact us.
Technology and the H.O.P.E. Model®
Each 12 month cohort will incorporate technologies to augment the home care model in 3 waves.
Wave 1
First 4 months - involves basic technology to get the model started, such as an EMR, asynchronous and synchronous communication with patients and families, Samsung tablets for the nurses, and digitizing processes such as assessments and ordering supplies
Wave 2
After month 4 - will incorporate common digital tools by giving patients a tablet and allowing them to participate in remote monitoring, have full access to their own health records, and seamless communication with the full circle of care
Wave 3
Final 4 months of the 12 month pilot - will test emerging technologies such as AI-enabled digital companions in wave 3
The layering on of emerging technologies will allow the team to research, test and integrate innovative digital tools while ensuring compassionate care remains front and centre.
Who is involved with the Hope Initiative?
Core Team
• H.O.P.E. Nurses
• Zayna Khayat, Future Strategist, SE Health (Co-Lead)
• Tazim Virani, Managing Director, SE Global (Co-Lead)
• Tori Edgar, SE Health (Program Manager)
• Jocelyn Bennett, AMS Healthcare
• Sandra Nalli, SE Health (Clinical Operations)
• Andrea Carter, SE Health (H.O.P.E. Coach)
• Brianna Croft, SE Health (Technology Testing)
• Joe Au-Yeung, SE Health (Technology Testing)
• Paul Holyoke, SE Health (Research Lead)
Advisory Council
• Shirlee Sharkey, CEO SE Health (Chair)
• Gail Paech, CEO AMS Healthcare (Co-Chair)
• Judy Berger (Patient)
• Samira Chandini (Caregiver)
• Kaiyan Fu, VP (SE Health)
• Gail Donner, Board Member (AMS Healthcare)
• Daryl Nancekivell, VP Home Care (Southwest LHIN)
• Tess Romain, CEO (Toronto Central LHIN)
• Barb Steed, VP (Markham Stouffville Hospital)
• Anya Kravets, VP (Gene Inc.)
• Ru Taggar, SVP (Sunnybrook Health Sciences Centre)
• Scott Ovenden, VP (Baycrest Health Sciences)
• Paul Woods, CEO (London Health Sciences Centre)
• Cheryl Reid Haughian (Nurse leader)
Additional Partners
•
Health Commons Solutions Lab
- community partner engagement
•
CanHealth Network
- funding to test technologies
•
Canadian Foundation for Healthcare Improvement
- summit partner (2019)
Technology Partners
•
AlayaCare
- EMR software
•
Samsung
- tablets for nurses and patients
• Others - in process
Resources
Reports and Publications
SE Health White Paper: Bringing Nursing Back to the Future with People Powered Care
SE Health's CEO Shirlee Sharkey and Senior Vice President of Clinical Services Nancy Lefebre wrote this white paper in 2017 to set the stage for the design and roll out of the H.O.P.E. Model®. In this white paper, Shirlee and Nancy explore how nurses can lead the way towards a more person- and family- centered health care system by empowering staff, patients and their families.
Read Article >Empowered Home Care Summit
In May 2019, SE Health and AMS Healthcare partnered with Canadian Foundation for Healthcare Improvement (CFHI) to host the inaugural Empowered Home Care Summit. The theme explored how emerging models of home care can empower people to live their best lives in their homes and communities. Real world experiences were explored from organizations and health systems across Canada, the US, Sweden, UK and Netherlands who are experimenting with new ways to transform home care.
Download Summary Report > Watch Summit Highlight Video >Videos and Webinars
In May 2019, SE Health and AMS Healthcare partnered with Canadian Foundation for Healthcare Improvement (CFHI) to host the inaugural Empowered Home Care Summit. The theme explored how emerging models of home care can empower people to live their best lives in their homes and communities.
Other readings and transformative models
Buurtzorg is a Dutch-originated healthcare organization that has been delivering holistic community care with a nurse-led model for over 10 years. The model scaled very quickly across the Netherlands; and now has spread to 25 countries and has been an inspiration for the H.O.P.E Model.
Join the Global Community
Please sign up below to join a community of interest focused on home/community health delivery innovation; a place to to exchange ideas and learnings from each other about model design, implementation, and ways to influence change to enable sustainable spreading and scaling of evidence-based home care models.
Contact Us
Address
90 Allstate Pkwy
Markham, ON L3R 6H3
Canada
Telephone
416-779-7201
E-mail the H.O.P.E. team at
SEFutures@sehc.com
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