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Algoma OHT Annual Plan 2021-22

Strengthening Care Closer to Home

Two Wave Wide Block

The journey to releasing our first Annual Plan has been the culmination of two years’ work in engaging hundreds of stakeholders, including caregivers, clinicians, and patients, about how we might more effectively plan and deliver services in Algoma. In the midst of our application to becoming an Ontario Health Team (OHT), the COVID-19 pandemic has been an abrupt reminder of fault lines in our health system and society, whether that’s how we care for older adults, better manage conditions in the community, or deal with the growing burden of mental health and addictions. As the pandemic has taught us, we’re only as healthy as our most vulnerable members of society – and we have a lot of work to do to ensure that we don’t leave anyone behind.


This plan is our commitment to the community, not only on what we will be working on, but how we will be working together. We invite you to get involved and continue to hold us accountable for this important work.


  • Convene a Citizens' Reference Panel to engage a representative sample of individuals across Algoma


  • Develop and operationalize a patient engagement framework

  • Test and launch Caregiver ID program


  • AOHT and partners integrate and implement citizen-initiated recommendations


  • Regional alignment and uptake of the Algoma People's Health Charter (Patient Declaration of Values)

  • Improved recognition and engagement of essential caregivers across AOHT partners and regionally


Citizens are meaningfully engaged and are driving priority setting.


  • Operationalize collaborative decision making across stakeholders, organizational leads, and boards of directors

  • Develop a mechanism to measure performance and advance quality improvement

  • Develop a Harmonized Information Plan to guide digital priorities


  • Approval of central brand, communications, joint initiatives, and strategic plan (2022-2025) for the AOHT

  • Baseline measures are in place, including a performance dashboard and a Collaborative Quality Improvement Plan (cQIP 2022)

  • Mechanisms to share information are established and digital solutions are adopted, improving clinical and patient experience


  • AOHT single clinical and fiscal accountability framework

  • Integrated funding envelope based on care needs of attributed population

  • AOHT providing care according to the best available evidence and clinical standards

  • Digital health underpins service delivery, ongoing quality and performance improvements, and better patient experience



  • AOHT partner organizations

  • Health and social system stakeholders

  • Aligned funding, people, and initiatives

  • Population and planning data


  • Patients

  • Families

  • Caregivers

  • Community Members



  • Leadership Council

  • Boards of Directors

  • AOHT Transformation Office

  • AOHT Action Teams

  • Implementation Funding (Ministry of Health)

  • OHT Provincial Supports and Oversight



Healthy Aging

  • Implement post-falls pathway across community, hospital, and primary care

Conditions Better Managed in the Community

  • Design and launch an integrated complex chronic disease management program

  • Design and launch the Community Wellness Bus


  • Support community-based approaches to reduce the impact of COVID-19


Healthy Aging

  • Care has been redesigned for community-dwelling frail older adults and their caregivers, restoring independence and improving health and well-being

Conditions Better Managed in the Community

Improved health and social care coordination and transitions in the community for

  • High users of hospital-based services with complex chronic conditions

  • Underserved populations with unmet mental health and addictions issues


  • Efficient and equitable vaccination of community members against COVID-19



High quality care and experience for patients, families, and caregivers:

  • 24/7 coordination and system navigation

  • Seamless transitions

  • Patient access to information (when/where they need it)

  • Deliver full continuum of care for all but the most highly specialized conditions

AOHT is actively managing health outcomes for attributed population.


Strengthening Care Closer to Home


Engaging Patients and Communities in Co-design


Building a Foundation for Collaboration

No one left behind.

An integrated health system focused on the unique needs of Algoma residents, where people receive seamless, effective care where and when they need it.