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Our Plan

Transformation Plan (Click to enlarge)

Transformation Plan

Transformation of the health system in our region will be powered by the core methodology of our novel ‘Learning Circle’, involving person-centred problem solving, engaging all relevant agencies and sectors, improving current services that target high utilization, developing a high impact individual care planning process, conducting small quality improvement experiments for innovation, and promoting broader system and policy changes at all levels.

Invent the Learning Circle (Circle A): Our core methodology is a novel learning and problem-solving process that will drive changes in how direct care for specific individuals is delivered, as well as changes in systems and policy. Our project will need to draw upon the experience of people who work within health care and community agencies and the experience of people who need and/or receive service and care.

Create Comprehensive Person-Centred Care Plans (Circle B): Our region has within it many types of service coordinating roles: case managers, system navigators, care navigators and others. These are housed in a variety of organizations: hospitals, family health teams, community health centres, social service agencies, assisted living locations, and many more. One person may receive service from several of these, and it is often not clear if one coordinator plays the primary role. There are many different philosophies, models and approaches being used, and a variety of different goals being achieved.

Quality Improvement for Current Targeted Services (Circle C): There are many programs and services already being implemented in this community that explicitly or implicitly include the aim of reducing hospital utilization. We have developed an initial inventory of these, and will maintain this inventory to be able to constantly review their function, quality, impact and value to the community overall.

Intersectoral change in Systems and Policy (Circle D): We predict that our Learning Circle activities will help to illuminate where system and policy factors are helping and where they are hindering our attainment of the aim. Where these become clear, the Partners will determine how to advocate for change in these systems and policies at relevant levels of administration and governance.