Case Study

How Health PEI modernized home care delivery

Executive summary

In 2019, Health PEI launched a home care modernization initiative to improve service delivery, care coordination, and data-driven decision-making. The organization replaced its outdated Seniors Assessment Screening Tool (SAST) with interRAI HC and transitioned from a legacy care management system to AlayaCare’s modern platform. By implementing in 2022, AlayaCare helped standardize assessments, streamline case management, and enhance operational efficiency across home care services. Key advancements included digital scheduling, mobile access for real-time charting, and integrations with provincial systems including Oracle Health (Cerner) and the Provincial Client Registry to improve client visibility across the care continuum.

Key outcomes include:

Better care delivery: 100% of clients have multidisciplinary care plans, 15% growth in caseloads, real-time submissions to the Canadian Institute for Health Information (CIHI) for multidisciplinary care.
Enhanced workforce efficiency: Scheduling productivity rose 18%, reduced paperwork freed up clinical hour’s and assessments increased by 216% by replacing SAST with AlayaCare’s interRAI HC assessment tool.
Improved staff experience: Staff reported 50% of their paperwork was reduced, enhancing direct care and work-life balance.
Improved data visibility: Health PEI was the first province to successfully launch a province-wide hospital integration for its home care system. This milestone enabled real-time client updates, improved care coordination, and supported more proactive planning.

These results highlight the transformative impact of digital innovation in home care and serve as a model for modernizing healthcare delivery in Canada.

Introduction

The organization

Health PEI is Prince Edward Island’s single health authority, overseeing publicly funded healthcare services, including hospitals, primary care, long-term care, home-based care, and community-based care. As the province’s centralized health services organization, Health PEI ensures equitable access to high-quality care while integrating services across the healthcare continuum.

In 2018, as part of its commitment under the Pan-Canadian Health Accord, Health PEI identified home care modernization as a priority.¹ The Accord emphasizes improving access, efficiency, and integration in healthcare, particularly in home and community care.² With federal funding secured, Health PEI set out to enhance care coordination, strengthen system integration, and standardize assessments to drive better client outcomes.

Challenges

Health PEI faced several operational and technological barriers that had to be overcome to modernize home care services:

Limited system integration: Home care operated independently from provincial systems like Oracle Health (Cerner). Poor interoperability disrupted client transitions between care settings and there were limited integration capabilities with the provincial Client Registry

Manual scheduling processes and underutilized clinical resources: Scheduling relied on paper-based processes, creating inefficiencies and diverting frontline staff from direct care. Nurses and frontline staff reported spending up to half their time on administrative tasks, affecting job satisfaction and increasing costs.

Limited reporting capabilities: Without digital analytics and unified reporting tools, Health PEI could not effectively measure home care performance or strategically allocate resources based on evidence or demographic needs.

Outdated assessment tools: Health PEI previously used the Seniors Assessment Screening Tool (SAST), which produced subjective and inconsistent care plans, limiting meaningful insights into client needs. SAST lacked the evidence-based approach required for effective, standardized assessments.

Incompatible case management system: The legacy case management software (ISM) could not integrate with interRAI HC, an internationally recognized, evidence-based assessment standard selected to replace SAST. Managing separate systems would have significantly increased manual workloads, emphasizing the urgent need for a single, integrated home care platform.

Solution

Health PEI selected AlayaCare’s integrated home care platform to meet modernization objectives. The solution included:

Seamless integration with provincial health systems: Enabling real-time updates to care plans and schedules. Integration with Oracle Health (Cerner) automatically pauses and resumes services based on hospital status, while improving the integration with the Provincial Client Registry ensures accurate demographic data and reduces manual entry errors.

Mobile access for real-time charting: Staff can instantly access and update care plans, risk protocols, and document assessments on the go. This eliminated paper binders and enabled consistent, coordinated care.

Optimized scheduling for workforce efficiency: Automated scheduling improves shift allocation and resource usage, reducing administrative burden and helping coordinators manage teams more effectively.

Data-driven insights for system planning: Robust reporting tools enable Health PEI to analyze trends, submit standardized data to CIHI, and guide long-term planning and benchmarking.

Standardized assessments for better care planning: Direct integration with interRAI HC and interRAI CA ensures consistent, evidence-based assessments and care plans, while reducing manual work.

Evaluating the impact of Health PEI’s transition to AlayaCare

To evaluate the impact of Health PEI’s transition to AlayaCare, a comprehensive value assessment combined insights from stakeholder interviews, frontline staff feedback, and system data over a 24-month period. Below are the measurable improvements in care delivery, client outcomes, workforce efficiency, staff experience, and data visibility.

Better care delivery & client outcomes

The introduction of AlayaCare Cloud’s integrated case management solution and AlayaCare Assessment (interRAI HC) has led to more consistent, evidence-based care plans. Real-time tracking and sharing of assessment results reduce client risks and manual interventions. Health PEI is able to submit standardized data automatically to CIHI, strengthening benchmarking and guiding long-term planning.

Key outcomes:

Greater visibility into waitlist trends: Data tracking enables more effective service planning, reducing bottlenecks in care delivery.

Standardized care plans: 100% of clients now have multidisciplinary care plans, with 95% of items drawn from a standardized library to ensure equitable and consistent care.

Improved care plan updates: 98% of caseloads have been reviewed and modified within the last year (previously updated every two years).³ Health PEI now has a streamlined workflow that boosts visibility, makes regular reviews easier, and ensures care plans remain accurate, personalized, and responsive to evolving client needs.

Expanded access to care: Total home care caseloads grew by 15% over two years, with acute home care for short-term, episodic services seeing a significant 59% increase.

Higher service reach: 12% increase in clients over 75 years old, ensuring older adults have better access to home care services.

With AlayaCare, everything I need is on my laptop or phone. I can document during the visit and submit forms on the spot. I don’t have to return to the office or find a desktop. Having that flexibility is a game changer.”

Deina Perry, Home Care Physiotherapist, Health PEI

Enhanced workforce efficiency

Real-time scheduling, mobile access to client data, integrated dashboards, and a direct connection to the province’s clinical information system (Oracle Health (Cerner)) have transformed Health PEI’s daily operations. Previously, scheduling was paper-based and time-consuming. Now, automated processes with real-time clinical updates reduce administrative overhead and allow teams to focus on client care.

Key outcomes:

Improved scheduling efficiency: Productivity increased by 18% while caseloads grew by 13%.
Significant growth in assessments: Annual and monthly assessments grew by 216% after replacing SAST with AlayaCare’s interRAI HC assessment tool.⁴
Lower administrative burden: Live data access removes the need to rebuild schedules manually, and team leads now have better visibility for more proactive workforce planning.
Optimized staffing & care continuity: Integration with Oracle Health (Cerner) delivers real-time ADT (admission, discharge, transfer) messages, automatically canceling home-care visits when a client is hospitalized. Teams gain immediate visibility, reassign staff faster, and avoid missed or duplicate visits, reducing scheduling delays and travel.

The real-time schedule is incredibly helpful. Our whole team can quickly see if a client is in hospital or at a facility respite, thanks to the integration with Cerner. It saves us from making endless phone calls just to track clients down.”

Joanne McLaughlin, RN interRAI Assessor, Health PEI

Improved staff experience

Shifting to AlayaCare’s platform has boosted job satisfaction by reducing administrative workloads and giving care teams real-time client information. Home care staff can now spend more time providing care instead of managing schedules or navigating multiple systems.

Key Outcomes:

Reduced administrative workload: Nursing team leaders previously spent up to 50% of their time on manual administrative tasks. Automated scheduling and documentation have significantly reduced this burden.
Better work-life balance: More structured scheduling has helped decrease stress and reduce burnout.
Care continuity & confidence: Instant access to updated care plans, client risk profiles, and emergency protocols keeps teams informed and prepared.
Increased caseload for care teams: 5% increase in caseload per care worker.

Improved data visibility

Before this transformation, the province’s home care delivery team lacked a centralized system for reporting and analytics. By integrating with Oracle Health (Cerner), AlayaCare provides a real-time data ecosystem that enhances forecasting, care coordination, and province-wide planning.

Key Outcomes:

Real-time hospital and home care integration: Automated tracking of client transitions immediately alerts care teams to hospital admissions, ER visits, and discharges, helping prevent service disruptions. PEI is the first province to achieve this integration at a provincial scale.
Improved visibility: Live data access enables proactive care adjustments, allowing teams to anticipate needs, reduce unnecessary visits, and enhance care continuity.
Better system planning: Standardized data collection supports funding decisions, identifies underserved populations, and informs new programs, including the province’s French-language home care initiative.
Integrated data submissions: The first jurisdiction in Canada to submit real-time interRAI HC metadata to CIHI’s IRRS directly from its home care system.⁵

The biggest takeaway with AlayaCare is that everything we need is in one place. We can upload reports, view interRAI and geriatric assessments, and access communication from every discipline involved in a client’s care. All of it is easily available to the different home care programs we liaise with”

Kristy Andrews, LPN Team Leader Support, Health PEI

Conclusion

Health PEI’s transition to AlayaCare has modernized home care services across Prince Edward Island, improving care delivery, client outcomes, workforce efficiency, and data visibility. By replacing outdated assessment tools with an interRAI licensed tool, adopting a digital case management system, and integrating with provincial health systems, Health PEI has established a more standardized, data-driven, and coordinated approach to home care.

This transformation highlights the impact of digital solutions in streamlining home care operations, improving client care, and supporting long-term system planning. Health PEI’s approach serves as a model for other provinces looking to enhance home care through technology-driven modernization.

Methodology

Implementation strategy

Health PEI initiated a structured procurement and implementation process in collaboration with consulting firm Davis Pier, aiming to identify a case management system that could seamlessly integrate interRAI assessments, enhance care coordination, and align with provincial healthcare objectives. The process followed a phased timeline:

The procurement and selection process followed a phased approach:

2018: Health PEI, under the Pan-Canadian Health Accord, secured federal funding to modernize home care.⁶
2019: The implementation of interRAI became a priority to improve access to services in home and community care.⁷
2020: Health PEI issued a request for information (RFI) and a request for proposal (RFP) to explore case management solutions compatible with interRAI.⁸
2021: AlayaCare was selected as the vendor of choice during the global COVID-19 pandemic.⁹
2022: After a 10-month implementation, AlayaCare and interRAI assessments went live in May, streamlining over 100,000 individual assessment submissions and modernizing home care services across PEI.⁷

Methodology

To assess the impact of Health PEI’s transition to interRAI HC and AlayaCare, a structured evaluation was conducted to measure improvements in care delivery, client outcomes, workforce efficiency, and data visibility. This case study integrates qualitative insights from key stakeholders with quantitative performance data, analyzing changes over 24 months post-implementation.

Stakeholder Interviews: Conversations with executives and project leads to understand the strategic drivers and expected outcomes of the transformation.
End-User Insights: Summaries from frontline care staff and system users to identify key areas of operational value.
Defined Impact Metrics: Establishing key benchmarks to measure improvements in efficiency, care coordination, and client outcomes.
System Data Analysis: A full-day workshop extracting data from the AlayaCare platform, measuring scheduling efficiencies, assessment volumes, and workforce productivity.

Watch this video to see how Health PEI is transforming care with AlayaCare — streamlining documentation, improving collaboration, and empowering clinicians on the front line.