Southlake@home

Southlake@home is a first initiative of its kind in Ontario, a “bundled community” approach to integrated care. This is a population bundle versus disease states or surgical procedures. The bundled community approach addresses all people with medical, social complexity and/or frailty who need significant supports to stay healthy at home after an acute stay. The program integrates primary care, hospital care and home and community care to produce one (1) point-of-care team which partners with the patients and the family to develop, implement and evaluate a unique person-centred care-plan. Each care-plan is purposefully designed to support the patient to reach their personal best functional status using the activation/re-enablement approaches to care delivery.
Key elements of the program
• A 16-week integrated, transitional care program
• Acute hospital care plan is continued into the community setting through seamless and integrated information sharing between the hospital and community providers.
• Technology and virtual care are used.
• Upon transition home, each patient and their family know who is part of their community care team and how that professional is going to assist them to reach their goals.
• Care in the home, begins within 24 hours of discharge
• Daily check-ins until patient is settled in the home
• Case conferencing at 8 and 12 weeks—confirm progress and identify if longitudinal support will be required
Southlake@home uses prototype design methodology to reduce duplication and create efficient, safe care.