Ontario Health Teams are intended to hold fiscal and clinical accountability for an attributed population defined by primary care attachment and hospital referral and use patterns. OHTs will integrate care and use equity-based population health management approaches to deliver better health outcomes and provide better experiences for patients. Doing this requires several resources including population health data, methods to segment the population, indicators to assess improvement opportunities, engagement strategies to involve community, patients and providers in priority setting and co-design, implementation, monitoring and model adjustment. This webinar reviews the challenges faced by OHTs and identifies some key resources and opportunities for OHTs to leverage assets in Ontario to undertake these activities using diabetes management as a case example.
The learning objectives for this session are:
1) To understand the (five) principal elements of population health management
2) To understand population segmentation and the transitions of individuals between population “segments” over time
3) To understand the intersection of care pathways for acute and chronic conditions in a person-centred approach
4) To identify opportunities to improve person-centred care with an example of diabetes management.