Southlake@Home Community Program in Northern York South Simcoe Ontario
Notice bibliographique
Résumé
Background: Southlake@home aims to improve accessibility, cost-effectiveness, and outcomes by leveraging new tools, such as remote monitoring devices, telemedicine platforms, and electronic health records. By embracing innovation, home care services enhances efficient care delivery, improves communication and collaboration between patients and healthcare providers, empowering patient active participation self-care management. Approach: Failing to achieve hospital-wide patient flow - the right care, in the right place, at the right time - puts patients at risk for suboptimal care. Many understand the problem, but lack the comprehensive strategies to address it. Our service delivery and funding model was designed to promote greater integration in health care delivery and improve patient outcomes. Public involvement and buy-in was essential to program development and success. A population-based approach at the outset facilitated understanding of the public perspective, and ensured the care planning and provision is tailed to the actual needs of the public.Personal public involvement is a key aspect of our approach as we actively seek input from individuals directly affected by healthcare policies and services. Engaging multiple stakeholders ensures the perspectives and experiences are considered in decision making processes. We adapted a co-design approach that allowed prioritization of complex patients who were at risk of becoming ALC and bridged their knowledge about the community to support transition back. Our bundled care model encourages innovation and collaboration between all healthcare providers and the community. Results: Since its inception, Southlake@home has served over 2800 patients in the Northern York South Simcoe area, and saved over 5000 ALC days per year. 45% of emergency patients were discharged to self-care, with reduction in ED visits and hospital readmissions, demonstrating an annual system savings of $.8M or $8,000 per patient. We have seen improved patient satisfaction (96%) by addressing social determinants of health and the root causes of disparities. Likewise, staff also express satisfaction with the reduced readmission rates indicating successful care delivery. Implications: Fundamentally, Southlake@home is about transitions of care. We have shown that better outcomes, improved patient and staff experience, and reduced costs to the system are possible by redesigning the pathway home for those with complex medical and social care needs. Southlake@home offers a model for other transitional care programs across Ontario aimed at integrating home and community care for high-need populations. Like many initiatives, Southlake@home has been about developing new relationships and trialing new ways of working together.There is much to learn for organizations who are considering integrated community care or homecare partnerships aimed at reducing hallway healthcare pressures. We welcome fellow organizations to replicate these learnings and take our experiences into consideration for future initiatives to enhance ALC across Canada.References:Southlake Regional Health Centre (SHRC). Southlake@Home Balanced Scorecard (Data File). Southlake Regional Health Centre (SHRC). 2024.
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,001 | 0,001 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,000 | 0,000 |
| Bibliométrie | 0,000 | 0,001 |
| Études des sciences et des technologies | 0,005 | 0,002 |
| Communication savante | 0,001 | 0,000 |
| Science ouverte | 0,001 | 0,002 |
| Intégrité de la recherche | 0,000 | 0,001 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,017 | 0,001 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».