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Introduction: In 2017, building on over 25 years of partnership, a group of more than 50 health and social care delivery organizations formed East Toronto Health Partners (ETHP) in order to co-create a system without discharge; it translates into a seamless journey for patients/clients and their caregivers and families transitioning from one care setting to another. The Anchor Partnership Model brought together different facets of health and social care, an evolving network of health, community care, and social service providers that supports 300,000 residents in 21 diverse neighborhoods including five priority neighborhoods. Aim and methods: The aim is to create a learning health system (LHS) within ETHP by embedding rapid cycles of evaluation to support learning for scale and the spread of a new integrated model of care. A partnership was formed between ETHP and several University of Toronto members to lead the evaluation endeavor. Early-implemented ETHP projects were evaluated using a developmental evaluation approach. Series of consultation sessions with internal and external experts, and community members are being held to create a framework for a community-led LHS, and a plan to operationalize the concept. The ideas generated are being tested by evaluating additional integrate care projects.Highlights or Results or Key Findings: A framework was developed based on the “6 phases of the rapid-learning health care system”. Three consultations sessions were held in the fall of 2021 and more are being scheduled for the winter of 2022. A purpose statement was drafted and short-term, intermediate and long-term outcomes were identified. Series of interviews are being held with partners to identify the following assets and resources within ETHP including research, quality improvement, evaluation, knowledge translation, data sources, and digital and analytical supports. Learning from evaluating ETHP projects includes but not limited to: a) a need for significant investments in building internal evaluation capacity such as choosing appropriate metrics at the project-level; b) a need for a collaborative approach to address the system-level issues identified through the evaluation (e.g. primary care attachment); c) an immediate need for redefining the evaluation processes to meet the project-level needs. Conclusion: By embedding rapid cycles of evaluation and holding consultation sessions in order to create a community-led LHS, ETHP aims to support strategic expansion of integrated models of care across its entire population.

Introduction: East Toronto Health Partners (ETHP) is comprised of 50+ health and social organizations in East Toronto, with a leadership council consisting of patient/caregivers and six anchor organizations representing the continuum of care. ETHP is implementing a new model of integrated care (IC) and the stakeholders of ETHP collaborated to respond to the pandemic since March of 2020. We evaluated ETHP’s collective response to the COVID19 pandemic.Aim and methods: The main objective of this evaluation was to understand and document ETHP integrated response to the COVID-19 pandemic from a partners and staff perspective. We interviewed 30 key informants, who have been identified as playing critical roles in the East Toronto COVID-19 response across acute care, home care, community care, and long-term care. The semi-structured interviews were designed to learn about the ETHP COVID-19 strategy and impact of the response, and lessons learned moving forward for advancing a new model of IC in East Toronto.Key Findings: The main building blocks of our response included, but not limited to, caring and critical roles of champions, innovation and risk taking, distributed leadership, distributed knowledge and capacity building, community and clinicians’ leadership, leveraging existing relationships and building new partnerships, agility and nimbleness, active use of data for planning, taking an equity lens in shaping our response, and advocacy on behalf of our community. Participants identified missed opportunities including advocacy for broader health care reforms; better (re)allocation of resources for mental health needs and food security; and fully catalyzing our relationship with government agencies. The main implications for advancing the new integrated model of care within ETHP are to continue using the structures built during COVID19 to not only support infectious disease but also chronic disease management, as well as a greater focus on population health and integrated of health and social care services.Conclusion: Lessons learned from this evaluation will be used to inform the ongoing COVID-19 strategy as well as next steps in the development of integrated health and social care (Ontario Health Team) in East Toronto.

IntroductionEast Toronto Health Partners (ETHP) is implementing a new model of integrated care (IC). ETHP is comprised of 50+ health and social organizations in East Toronto, with a leadership council consisting of patient/caregivers and six anchor organizations representing the continuum of care.Short descriptionETHP is co-creating an IC model in which hospital, primary care, community providers and patients and families work together as one coordinated team in order to improve population health, patient and provider experience, and value for money (Quadruple Aim). Aim and theory of changeThe aim is to create a learning health system within ETHP by embedding rapid cycles of evaluation to support learning, knowledge transfer, and decision making for scale and spread of this new model of care. To achieve this goal, a Developmental Evaluation (DE) is being implemented led by an embedded researcher. The evolution to having an embedded researcher is, itself, part of ETHP’s evaluation learning journey started in 2017. Targeted populationThe priority populations include seniors with chronic care needs and their caregivers, and individuals of all ages with mental health challenges and substance use issues. ETHP’s mandate is to expand the model’s scope and coverage to cover the entire population of East Toronto, over its first 3-5 year mandate. TimelineBuilding on findings of The DE started in the fall of 2020 and is set up for 2 years.HighlightsIn year 1 of DE and within 4 months, ETHP established an evaluation steering committee including two patient advisors to provide advice on the evaluation framework for the partnership, and ongoing evaluations of individual initiatives. To build capacity, ETHP held a series of evaluation workshops focusing on evaluation types, developing logic models, and measurement. Project level evaluations are being undertaken in to programs, Primary and Community Care Hubs and Winter Surge initiatives (each with multiple specific projects). A common evaluation template used across projects enabled the embedded researcher to guide teams toward a similar logical model structure, measures definition and reporting. Teams have started data collection and analyses, with reporting expected in March 2021. Transfer-ability and sustainabilityBy embedding rapid cycles of evaluation, ETHP aims to support strategic expansion of the IC model across its entire population. The focus on building internal evaluation capacity and an evaluation community of practice ensures sustainability.Conclusions; DiscussionsLessons learned: ETHP is using DE to create a more integrated system of care for residents and providers across East Toronto. In its early stages, DE focused on identifying the processes of change in collaboration with executives, providers, staff, and patients/caregivers, as well as building internal evaluation capacity for internal teams to engage in ongoing evaluation activities, creating a community of practice. Main finding regarding evaluation of ETHP IC model is that it is critical to a) measure the integrated way of working from different perspectives, b) closely monitor implementation and redefine evaluation plans to address the reality of working within an ever-changing and complex care setting, and c) to assess teams’ capacity and evaluation needs.