Update on Community Health Links

November 14, 2013

Helen Angus

Associate Deputy Minister, MOHLTC

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The relatively few people with complex health problems

account for the majority of our health expenditure

5% of the

population

accounts for 66%

of health care

spending

Initial focus

♦ High cost users are a small but diverse group; typically have 2 key characteristics:

- They receive treatment from multiple health care sectors; and/or

- They have long lengths of stay in inpatient settings.

♦ The average number of episodes & cost per episode is similar for high cost and all users. However, high cost users access a greater number of health care sectors.

♦ Seniors represent the largest percentage of patients/expenses & have the highest average cost per patient.

Proportion of Ontario Patients

Proportion of Costs

♦ Acute care, physician visits, & long-term care represent the largest percentage of expenses.

♦ The top 10% patients account for 74-81% of the total expenses for Health Link residents and 74-78% of expenses for LHIN residents.

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Conditions among the top 1% of users – mostly chronic disease:

• heart failure • chronic obstructive pulmonary disease

(emphysema) • myocardial infarction • pneumonia and urinary tract infections • stroke • hip fracture • cancer • end of life care

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The top 1 per cent

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Many seniors, children and those with mental health problems have

complex, expensive health care needs

Too many people receive care in a hospital when they can be better cared for in the community

Many people do not get the benefit of a coordinated care plan

Wait times for specialty services and long-term care homes are too long

Even a reduction of

in the cost of care

for these patients

10%

$2 billion would save close to

• Health Links launched Dec. 2012

• New model of care to improve care for high needs patients

• All providers working at the local level to integrate clinical care and coordinate plans at the patient level

• Initial focus on people with complex health conditions

Coordinated and integrated care is the heart of Health Links

Hospital

Home Care

Community

Support Services

Primary Care Physicians Allied Health Professionals

Specialists

Long-Term Care Homes

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Community Health Links

Common principles for coordinated care plans so all complex patients will have the same experience

Help navigating the system

Listening to and involving the patients, families and caregivers in all stages of the care design process

Coordinated and integrated care across providers

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What will it mean for patients

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37 Health Links

Population Coverage: 5,827,660

Total Number of High Users:

523,230

Over 650 Partners

• The response to Health Links in year one has exceeded expectations • There is at least one Health Link in every LHIN and some LHINs have already

submitted proposals to ensure full coverage within their boundaries. • Future: 80+ Health Links, providing full coverage across the province

Health Links today

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Phase One

Phase Two

Phase Three

Remarkable response from health providers

• Increased collaboration among partners at the provider level to work together to identify new complex care patients, and provide support within the circle of care

• Of 37 Health Links, diversity in the leadership and participation:

– 9 led by hospitals

– 14 FHT led and 1 FHO led (primary care)

– 6 CHCs

– 3 CCACs

– 4 Community Service Organizations

• As Health Links develop, the cross-section of providers will increase, providing many potential access points for users of the health care system

Bringing partners to the table

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Ministry provides strategic direction and support

Flexible approach

Created and led by those on the ground

Advisory committees with local leaders and providers

Sharing ideas

How are we doing this?

Coordinated care: the heart of Health Links

Hospital

Long-Term Care Homes

Specialists

Home Care

Allied Health Professionals

Health Links

Primary Care Physicians

Community Support Services

Consistent Province

Wide Principles

Patient Engagement

EMR/IT Mechanisms

and Tools

Others

Coordinated Care

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Health Links care coordination tool

• Existing IT system being expanded to assist Health Links in developing coordinated care plans

• Tool will leverage existing assessment records and add new functionality: – Allow circle of care to store, modify, share

coordinated care plans for patients

– Include progress notes for patients

– Provide access to organizational and circle of care providers

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• Working with the Ministry, the tool is currently being refined by members from Health Links, LHINs, HQO, CCACs, CHCs, FHTs, and other providers

• eHealth Liaison Branch plans to demonstrate the final product in some Health Links in 2014

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Strong involvement of patients, families and caregivers in all stages

Making the patient a part of the development of his/her

individual care plan

Incorporating patients, caregivers and/or families

perspectives into the coordinated care design

process

Patient Passport Guelph HLt

Patient Family and Community Engagement Working Group SE Mississauga HLt

Care Coordination Consultation South Georgian Bay HLt

Patient engagement

• Both based on a population health framework • Share common goal: equitable outcomes • Geographic focus of Health Links lends itself to a health equity approach • Overlap between complex patients and equity seeking populations • Health Links can be leveraged to improve health equity

Status • Ministry and stakeholders share interest in further scoping/opportunities • MOHLTC completed Health Links Health Equity Impact Assessment (HEIA) in

summer 2013 • Key opportunities identified:

– Refine definition of ‘complex patients’/HL target populations (see appendix) – Strengthen Health Links’ HE capacity – Integrate health equity in performance and accountability expectations

The ministry will confirm next steps in collaboration with delivery partners

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How does health equity factor in the work of Health Links?

Early success

Patient Identification

Provider Collaboration

Patient Engagement

Care Planning

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• Developed draft templates for coordinated care plans (TC and Central LHIN)

• Rural Kingston has created care plans for 25 of their patients, East Toronto has attached four complex patient to a FHT, Hamilton creating care plans for their complex patients

• Consulting on care planning pathways and processes (CW, SE, MH LHINs)

• Holding “case conferences” to discuss identified patients (e.g., Learning Circles in Hamilton, Living Labs in Central West)

• SE LHIN holding dialogues with providers to support participation and planning (in Quinte, over 55 organizational representatives and 40 health and social service providers participating)

• Hamilton identified 322 frequent users of hospitals, 70 of which appear to be “chronic” high users

• South Simcoe & Northern York Region identified 200 high users, 80% of them were over age 55 years

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• North East Toronto created a patient advisory council

• Guelph holding “what matters to me” interviews with patients

• South Georgian Bay consulted more than 60 seniors in development of program

Supporting and enabling

Provincial Role

Alignment of Resources

Indicators & Measurement

IT Support

Barrier Removal

Leadership & Engagement

Evaluation & Sharing Best

Practices

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• The key is not about the province defining the “who” or the “how”.

• The goal is for the province to define the “what” needs to be accomplished, to provide the right supports, but allow local solutions to develop the “how” that can be expanded at scale

Where we are going

• Defining priorities

• Starting with early adopters

• Working with partners

• Fostering local solutions

Creating & Building

• What’s working and not

• Collecting stories

• Sharing best practices

• Tailoring approach

Learning & Sharing • Coverage across

province

• Seamless transitions for patients

• Strong provider relationships across all sectors

Scaling Up &

Sustaining

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Indicators of success

Setting the stage for coordinated care straight away

1. All complex patients will have a coordinated care plan

2. Complex patients and seniors will have regular and timely access to a primary care provider

Moving the needle

1. Reduce the time from primary care referral to specialist

2. Reduce the number of 30 day readmissions to hospital

3. Reduce the number of avoidable ED visits for patients with conditions best managed elsewhere

4. Reduce time from referral to home care visit

5. Reduce unnecessary admissions to hospitals

6. Faster primary care follow-up after discharge from an acute care setting

How you’ll know you’ve arrived

1.Enhance the health system experience for patients with the greatest health care needs

2.Reduced ALC rate

3.Reduce the average cost of delivering health services to patients without compromising the quality of care

Year 1

Year 2 & beyond

Leadership for Change

Spread of Innovation

Improvement Methodology

Rigorous Delivery

Transparent Measurement

System Drivers

Engagement To Mobilize

Our Shared

Purpose

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Change management model

Energizing and mobilizing the health care sector to drive local solutions to achieve goals

Come visit us!

http://ontario.ca/leadinghealthychange

Appendices

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Health Links Lead Organizations

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# LHIN Health Link Lead Organization

1 Erie St. Clair Chatham City Centre Health Link Chatham Kent Community Health Centre

2 South West Huron Perth Health Link North Perth Family Health Team

3 Waterloo Wellington Guelph Health Link Guelph Family Health Team

Rural Wellington Mount Forest Family Health Team

4 Hamilton Niagara Haldimand Brant

Hamilton Central Health Link

McMaster Department of Family Medicine/McMaster Family Health Team

Niagara North West Health Link Coordinator: West Lincoln Memorial Hospital

Haldimand Health Link Haldimand War Memorial Hospital

5 Central West North Etobicoke-Malton-West Woodbridge Health Link

Central West Community Care Access Centre

Dufferin Health Link Headwaters Health Care Centre

Downtown Brampton Health Link William Osler Health System

Bramalea Health Link William Osler Health System

Bolton-Caledon Health Link Caledon Community Services

6 Mississauga Halton South East Mississauga Health Link Summerville Family Health Team

7 Toronto Central Mid West Toronto Health Link Taddle Creek Family Health Team

Don Valley/Greenwood Health Link WoodGreen Community Services

North East Toronto Health Link Sunnybrook Health Sciences Centre

East Toronto Health Link South East Toronto Family Health Team

8 Central South Simcoe and Northern York Region Health Link

Southlake Regional Health Centre

North York Central Health Link North York General Hospital

Health Links Lead Organizations - Continued

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# LHIN Health Link Lead Organization

9 Central East Peterborough Health Link Central East Community Care Access Centre

10 South East Rural Hastings Health Link Gateway Community Health Centre

Quinte Health Link Belleville and Quinte West Community Health Centre

Rural Kingston Health Link Rural Kingston Family Health Organization

Kingston Health Link Maple Family Health Team

Thousand Islands Health Link Upper Canada Family Health Team

Rideau Tay Health Link Rideau Community Health Services

Salmon River Health Link Napanee Area Community Health Centre

11 Champlain Prescott-Russell Health Link Lower Outaouais Family Health Team

South Renfrew Health Link St. Francis Memorial Hospital

12 North Simcoe Muskoka Barrie Community Health Link Barrie and Community Family Health Team

South Georgian Bay Community Health Link

Georgian Bay Family Health Team

North Simcoe Health Link Chigamik Community Health Centre

Muskoka Health Link District Municipality of Muskoka, Muskoka Community Services

Couchiching Health Link Couchiching Family Health Team

13 North East Temiskaming Health Link Centre de santé communautaire du Témiskaming

Timmins Health Link Timmins Family Health Team

14 North West City of Thunder Bay North West Community Care Access Centre