Community care-providers require smoother communication

Emergency departments are overflowing. Hospital beds are full. Wait lists continue to grow. Across Canada, health systems are responding by investing in hospital@Home programs, community paramedicine, integrated palliative care, and other models that shift care out of hospitals and into the community.

But these new models expose a fundamental problem: while organizations are expected to work together, the technology they rely on was never designed for shared care. Hospitals, primary care, community agencies, social services, patients, and families often operate from different systems with no shared view of the plan. That’s where new technology like Careteam comes in.

When Renfrew County in Eastern Ontario was approved for a Homelessness and Addiction Recovery Treatment (HART) Hub in April 2025, it brought together the healthcare, housing, mental health, addiction and other community partners that would participate in caring for the program’s clients.

Frontline staff were quick to identify collaboration and communication as a priority that had to be addressed, said Renfrew County HART Hub lead Molly Fulton.

The partner organizations, including hospitals in Renfrew and Pembroke, community paramedics, and various addiction, housing and support agencies all used different documentation systems and none of them talked to each other.

The solution they came up with was a collaboration platform called Careteam, a PHIPA compliant, AI-enabled application that replaces phone, fax and email communications frontline staff in the community traditionally relied on.

Vancouver-based Careteam Technologies was launched in October 2017 by Dr. Alexandra T. Greenhill, Jeremy Smith and Rob Attwell and is now used by healthcare teams supporting a wide variety of patients receiving community care through Ontario Health Teams, HART Hubs and hospital-based atHome programs.

Careteam is also used by many different integrated care and complex chronic condition programs, spanning heart failure, COPD, palliative care, pediatric diabetes and eating disorders.

Teams connect community service providers caring for individual clients and can also include patients, family members and caregivers so everyone is on the same page. Team members can message each other, check the schedule for patient encounters, review to-do lists and access educational material. Patients and families can invite a family doctor, a pharmacist, a neighbour or anyone else to join either on a view-only basis or as a participant.

“Every patient has a loved one somewhere who is worried and involved in their care,” said Dr. Greenhill, Careteam’s CEO and chief medical officer, a family physician who was in the past an occupational therapist and an ER doc. “In the absence of Careteam, there’s no visibility of what’s going on and how to help, whereas we enable both families and friends to be fully informed and aware, while being role-based access to protect privacy, so they can help to the maximum of their ability.”

If a family member knows there’s an upcoming appointment for their loved one at a primary care clinic or hospital, they can offer or reserve a ride, and if an outreach nurse needs to update a patient’s four adult children, one group message in Careteam is much more efficient than making four phone calls.

“Some clinicians don’t want families involved, fearing they’ll message them all the time, but we have years of experience with more than 25,000 patients and that’s not the case,” said Dr. Greenhill. When patients and families understand what the plan is, she added, they don’t bother the clinical team and the number of phone calls from family members drops because the care plan and all the instructions are on the Careteam platform for them to see.”

One Careteam user taking advantage of the ability to include patients and family members is the Bruyère@Home program in Ottawa. Offering rehabilitation, complex care, palliative care and transitional care, Bruyère Health launched its @Home program in November 2022. Patients discharged from Bruyère are offered an 8-week or 16-week bundle of home care services.

“Following an initial phase of operation, we did an evaluation and some of the feedback we got from both family caregivers and community providers was that we needed to find a way to collaborate from a digital perspective so there would be clear communication flow and more clarity about who was on a client’s team,” said Natasha Poushinsky, Bruyère Health’s director of strategy and planning.

Prior to using Careteam, community outreach providers communicated with each other using phone, fax and email, despite the Ontario Privacy Commissioner’s counsel that fax is not a secure method for healthcare communication. Searching through multiple emails to pick up the thread of what happened over a period of time was inefficient and neither was communication via phone ideal if the recipient wasn’t available or was otherwise occupied.

“We’re at a time in healthcare where we have to find efficiencies for our frontline staff,” said Poushinsky. “Playing phone tag for days with someone is not an efficient use of staff time.”

Bruyère Health trialed Careteam in January 2025 through a commercialization project with the CAN Health Network that also introduced the technology to two additional Health atHome programs in Ontario. Impressed with its performance, the hospital procured the Careteam platform in March 2026 which means that it’s now available without the need to go through procurement from any of the CAN Health Networks members.

Before discharging patients from hospital, the Bruyère@Home program co-ordinator assembles a care team from community outreach services that may include occupational therapists, physiotherapists, rehabilitation assistants, personal support workers and homemakers. Equipment rentals and Meals on Wheels service are also ordered as required.

The program co-ordinator sets up Careteam, invites the community providers to join, introduces the application to the patient and family members, and populates it with the care plan and educational materials so it’s ready to use as soon as the patient is home.

Having all this information available to patients and caregivers in Careteam is important, explained Poushinsky, because “we overwhelm them with pamphlets, brochures and schedules prior to discharge. It’s a very stressful time.” If all the information they’re given on paper and verbally in the hospital is embedded in Careteam, they have it at their fingertips.

“One of the things we learned after our six-month evaluation was that almost no one was aware of the 1-800 number they could call to reach their community provider after hours – not because they weren’t given the information at the time of discharge, but because it wasn’t assimilated,” said Poushinsky.

The Renfrew County HART Hub’s Careteam app isn’t client-facing just yet by design, explained program lead Fulton. “Because we’re working with so many partners, we wanted to get it right before we added clients. It’s also hit and miss as to whether they have cell phones. We might see them for five days straight, then they’re gone.”

The program is one of 29 HART Hubs in Ontario and covers the entire county from Arnprior to Deep River. There’s an intake centre in Pembroke with 20 recliners, a transitional housing location and a supportive motel program. Some facilities have computers that clients can use to check email or access Careteam in the future.

Team members, including health, housing, mental health and addiction personnel, can use Careteam to locate a client, access their care plan, and review recent encounters. In addition to facilitating communication, Careteam streamlines reporting of individuals served and other metrics for Ontario Health. Prior to the use of Careteam, the required information had to be pulled from multiple systems, often resulting in duplication.

Additionally, and just as important, “Clients are no longer required to repeatedly share their stories or re-explain their needs each time they connect with a different service provider,” said Fulton.

Careteam doesn’t duplicate charting in EMRs, hospital information systems and other documentation tools used by community providers, according to Dean Henderson, Careteam’s director, integrated care. Instead, it provides the shared care infrastructure that connects people, workflows, and information across organizations so everyone can work from the same care plan.

“We don’t do any of the things an EMR does,” he insists. “I support implementations, so I get this question a lot from clinicians. What Careteam is replacing is all of the stuff that happens outside the EMR: the faxing, the telephoning. No one’s putting a SOAP note in Careteam. Instead you’re sharing status updates that would be helpful for the other organizations, team members and families to know.”

Some health data is exchanged when needed, acknowledged Henderson, citing the example of an integrated palliative care program that will share an updated palliative performance scale assessment. “That number will go in Careteam so everyone on the team can see it. That will allow everyone to make more informed decisions.” Also available for review by team members are key elements of a patient’s discharge summary.

The information accessible on Bruyère@Home’s Careteam application includes “contact information, scheduled appointments, patient goals and quick notes so other members of the team across organizations know if there’s anything that needs to be followed up,” said Poushinsky.

Careteam can also be used to distribute surveys to groups of patients, not just individually, added Dr. Greenhill. “The resulting data allows organizations to see patterns across the population of patients and caregivers and how they’re doing. For example, if caregivers of palliative care patients are burning out, they can send them a survey to confirm it and follow up with mass messaging to invite them to a get-together. They get it as an addition to their to-do list, so it’s not lost in an email.” During COVID, organizations used it to send notifications telling patients their appointments were now virtual or new rules were to attend masked. Such group action messaging can also be used to inform patients if there’s a guideline change or a new treatment available.

One use case for Body Brave, the largest eating disorder program in Ontario, illustrates how Careteam can positively impact long wait lists. During COVID, the number of people on the wait list tripled, said Dr. Greenhill. “There were 3,000 patients on the list, so they used the Careteam platform to create a self-management pathway. That allowed the program to see the patients who really needed assistance and directed everyone else to the self-management path, so there was no wait list!”

As organizations compare pathways and outcomes across programs, they become continuously improving learning health systems rather than collections of isolated services. Body Brave programs using different pathways can be compared and those with better outcomes can be emulated to mirror that success. And, if there’s a new video about eating disorders that has been well received in one location, everyone else can be invited to watch it and it goes on their to-do list. “That’s population health at scale,” said Dr. Greenhill.

Careteam supports integrations through its API and SMART on FHIR capability with EMRs, hospital information systems and other software, including Caredove, a referral management platform for home care, mental health and community support services. It can also integrate with Ocean MD for referrals to specialists and ISAAC, Cancer Care Ontario’s Integrated Symptom Assessment and Collection platform used by patients to securely submit details about their pain, symptoms and quality of life.

This enables single sign-on capability for Careteam users accessing Caredove and other integrated software platforms.

FHIR compliant interoperability allows Careteam AI to integrate data from both internal and external-connected sources, including “EHRs and EMRs, labs, devices, patient reported information and other systems, subject to appropriate permissions and governance,” said Dr. Greenhill. Careteam’s AI “turns insights into action,” she added.

“That longitudinal dataset becomes incredibly powerful because it allows organizations to move beyond isolated clinical events and begin understanding what actually drives positive and negative outcomes across the full continuum of care.”

Dr. Greenhill expects AI to play a role in improving the delivery of home and community care. “Healthcare is moving toward community-wide models where hospitals, primary care, home and community care, long-term care, mental health, social services and other organizations work together around shared patient populations,” she predicts.

“One of the things we’re most proud of is that a lot of our growth comes from referrals. Clients like Bruyère Health, for example, was one of our first users and is now a huge champion. We literally used to send people home with a binder after being discharged from hospital. We’ve replaced the binder and we’ve grown since then.”

According to Dr. Greenhill, Careteam’s largest customer base is currently in Ontario, reflecting the province’s investment in integrated care initiatives. She believes the company’s experience points to a broader lesson about healthcare innovation: “Transformation happens when intention, action, and funding all come together. Without all three, even the best ideas can struggle to move from concept into practice.”