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Championing the Future of Health: Our Unique and Integrated Model of Care

Over 80% of our patients are enabled to stay in their own home after care transition.

SE Health is redefining care at home by leveraging technology to drive innovation, ensuring that people are receiving the right care, in the right place, at the right time.

As a pioneer in integrated funding and bundled models of care, SE Health continues to lead the way in the creation and development of Acute Care Transitions Programs. These programs are designed to deliver exceptional care and service to patients and families, ensuring a focus on continuity of care as they move from hospital to home.

SE Health has been leading the development of this model of care, in partnership with hospitals and community organizations, since 2015. Today, with over 40 programs across Ontario, SE Health continues to build, scale and evolve this model, shaping the future of care at home.

“This innovative and integrated model is reinventing how we deliver authentic patient and family-centered care and inspiring our commitment to home care modernization,” said Nancy Lefebre, Chief Operating Officer and Senior Vice-President at SE Health. “Through strong partnerships and an interdisciplinary, flexible care model, we facilitate a safe and seamless transition from hospital to home for our patients and their families. We continue to enhance and expand this approach every day.”

A Proven Model for Seamless Transitions

Acute Care Transitions is an up to 16-week, integrated bundled care model that provides a direct path home for patients who have completed acute care treatment but require a complex post-acute care plan.

The program connects patients with community-based staff, social support services, primary care, and acute care teams to create personalized care plans that support their transition from hospital to home.

The program offers continuous support, a 24/7 helpline for additional patient and family support, a shared care plan, and the integration of cutting-edge technology that enhances care coordination and promotes self-management.

Innovative Technology: Remote Patient Monitoring (RPM)

As part of its commitment to modernizing home care, SE Health has evolved many of its Transitions programs to include Remote Patient Monitoring for eligible patients.

“By integrating RPM into our programs, we are improving patient outcomes, enhancing quality of care, and making it easier for patients to manage their health at home,” said Shelby Fisch, Vice President, Telehealth, Acute Care Partnerships and Rehabilitation Strategy at SE Health. “For example, patients can monitor their blood pressure and respond to health assessments from the comfort of their home, while our teams provide timely support based on real-time data and escalate to the appropriate level of care as necessary.”

To ensure accessibility, SE Health provides data-enabled tablets to patients who may not have access to technology or the internet. RPM captures patient biometrics, personalized assessments, and standardized data triggers, allowing secure, real-time communication between care teams. This is particularly valuable in community settings, where healthcare providers often work independently but need a connected and collaborative care approach.

“SE Health is truly at the forefront as they continue to evolve this model of care,” said Joshua Liu, CEO and co-founder at SeamlessMD. “We partnered with them to co-design patient pathways tailored to their care model, ensuring patient and family needs come first. This is leading-edge innovation in action, and we are proud to collaborate with SE Health as they bring these advancements to life.”

Commitment to Value-Based Health Care and the Quintuple Aim

The Acute Care Transitions Program is committed to the principles of the Quintuple Aim in SE Health’s approach to evaluation, focusing on:

• Improving the patient experience
• Enhancing the provider experience
• Driving better health outcomes
• Creating system efficiencies and cost savings
• Advancing equity and access to care

Program Impacts

• Over 80% of patients were able to remain at home once discharged from the program
• Saved over 22k hospital/alternate level of care days
• 94% of patients reported that they were able to work with their care team to adjust their care as needed

“At SE Health, we go beyond delivering care – we create value-based care solutions that benefit hospitals, patients and communities,” said Kim Utley, SE Health’s Clinical Director, Health Care Solutions. “Our approach evolves with the healthcare system, continuously pivoting to meet new challenges and opportunities. We leverage technology, foster strong hospital relationships, and remain deeply committed to community impact and giving back. Our values guide us as we innovate, ensuring that care remains accessible, seamless and responsive to people’s needs.”

SE Health will continue to build meaningful partnerships, drive innovation and bring hope and happiness to people and communities – because every person deserves care that empowers them to live their best life at home.

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Harnessing AI to Transform Care

Empowering People Through Responsible Innovation

AI is helping us to reimagine care, enhancing efficiency, strengthening connection and keeping people at the heart of every innovation.

Imagine a future where a nurse finishes a home visit and, instead of spending an extra hour typing notes, an AI assistant securely generates a draft in seconds; the nurse simply reviews, edits, and moves on to what matters most, caring for people. This is the promise of AI at SE Health, enabling our staff to spend less time on paperwork and more time bringing hope and happiness.

Over the past year, we’ve taken bold steps to responsibly advance AI across our organization. We began by building a strong foundation through governance and guardrails. With an executive sponsor table, the CAItalyst POD, clear prioritization and published organizational guardrails now in place, we have created a safe and ethical pathway for AI adoption.

We also made significant progress in improving efficiency through Microsoft Co-Pilot. Following a successful pilot with 100 users, we’ve expanded access across most departments, helping teams enhance productivity, streamline workflows and find more time for purpose-driven work.

Increasing AI literacy has been another priority. Through lunch-and-learn sessions and spotlight newsletters, we are building the skills and confidence our teams need to embrace AI with curiosity and responsibility.

To deepen our understanding of how AI can support care delivery, we established an AI Sandbox to explore clinical use cases. We’ve completed a literature review and environmental scan, identified five priority use cases and completed initial testing of four AI scribe tools leveraging our clinical staff across diverse programs. Testing of additional use cases continues to advance as we learn, adapt and co-create solutions with our teams.

Together, we’re shaping an AI-enabled future that strengthens connection, amplifies compassion and helps people live and age well in the places they call home.

Join us on this journey of responsible innovation. Together, we can reimagine what’s possible when technology empowers people and purpose leads the way.

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Workforce Innovation: Removing Barriers and Unlocking Potential

Empowering People, Strengthening Communities

At SE Health, we believe that a strong, supported workforce is the foundation of exceptional care. This year, we deepened our commitment to workforce innovation by addressing real-life barriers that affect our staff and their ability to thrive at work, at home and in their communities. Through bold partnerships and human-centred design, we introduced three transformative initiatives focused on financial stability, housing and respite.

Through our micro-lending program, in collaboration with Alterna Savings, we supported staff in overcoming one of the greatest challenges in home and community care – access to reliable transportation. We received 45 loan applications for amounts ranging from $10,000 to $15,000, helping more caregivers secure or repair a vehicle so they can remain employed and continue delivering vital care to clients.

We also expanded access to affordable housing through our partnership with Happipad, which matches our staff and students with safe, low-cost rental rooms and units in the community. This innovative approach reduces financial strain, builds stability and strengthens community connection.

Finally, through Respite for All, in partnership with Greenshield and Just Like Family, we advanced a new model of inclusive caregiver support that reaches participants in the broader Canadian community. With a target of supporting 100 working caregivers and providing 1,000 hours of respite support, this initiative prioritizes equity-deserving populations and strengthens caregiver well-being so they can remain healthy, engaged and active in the workforce.

Together, these initiatives reflect our vision to remove systemic barriers, uplift caregivers and build a future where those who care for others are supported to care for themselves – a future grounded in People Everything, Always.

We’re reimagining what workforce innovation can look like, where every solution begins with people and ends in impact. Join us in building a more inclusive, compassionate and sustainable future in care.