Health Links Coordinated Care Planning & Management
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1 Health Links Coordinated Care Planning & Management Mary Eastwood Primary Care Manager Sub-Region Mid-East Toronto Sub-Region
2 Health Links Health Links were designed to bring together existing health and support service providers to better integrate care and facilitate transitions between providers across the health care continuum for the patients with the most complex needs. The top 5% of patients account for about two-thirds of health care spending and, yet, this group often receive the most poorly integrated care. Top 1% of users = 35% of cost Top 5 % of users = 65% of cost Top 10% of users = 77% of cost The goal, through care coordination, is to improve health outcomes for complex patients and improve the patient experience.
3 Coordinated Care Planning & Management Care coordination ensures that providers in the circle of care work together to support clients with complex health needs in reaching their health related goals. Providers may include primary care, CCAC, MHA, CSS, hospitals, social services, housing, justice, as well as family and other supports. Ideally the client experiences one team working together to provide seamless care. Coordinated Care Planning & Management requires that all health care providers involved in a client s care: Understand the client s health related goals Work together with the client to develop a Coordinated Care Plan (CCP) Communicate on an ongoing basis to manage and update the client s care plan providing Coordinated Care Management
4 Target Population for Health Links Target Population Considerations Patients or clients with 4 or more chronic and/or high cost conditions Consider patients or clients with Economic characteristics (low income, median household income, government transfers as a proportion of income, unemployment) Social determinants (housing, living alone, language, immigration, community and social services etc) Identified Sub-Groups Mental Health & Addiction Palliative Frail Elderly
5 Chronic and/or High Cost Conditions Checklist Chronic and/or High Cost Conditions 4 or More ALS (Lou Gehrig s Disease) Amputation Anxiety Disorders Arthritis and Related Disorders Asthma Bipolar Blood Disorders (anemia, coagulation defects) Brain Injury Cerebral Palsy Chronic Obstructive Pulmonary Disease Coma Cardiac Arrhythmia Congenital Malformations (Congestive) Heart Failure Crohn's Disease/Colitis Cystic Fibrosis Dementia Depression Developmental Disorders Diabetes Eating Disorders Epilepsy & Seizure Disorders Fracture Hernia Hip Replacement HIV/ AIDS Huntington's Disease Hypertension Influenza Ischaemic Heart Disease Knee Replacement Liver disease (cirrhosis, hepatitis etc.) Low Birth Weight Malignant Neoplasms (cancer) Muscular Dystrophy Mental Health Conditions (unspecified/unknown) Osteoporosis Including Pathological Bone Fracture Multiple Sclerosis Other Perinatal Conditions Pain Management Palliative Care Paralysis And Spinal Cord Injury Parkinson's Disease Peripheral Vascular Disease and Atherosclerosis Personality Disorders Pneumonia Renal Failure Schizophrenia & Delusional Disorders Sepsis Stroke Substance Related Disorders Transplant Ulcer
6 HQO Coordinated Care Management Process
7 Coordinated Care Planning & Management The client and care team work together to develop a Coordinated Care Plan based on the client s goal for care care team should always include the primary care provider CCP is documented and shared with the care team and client The client and care team watch out for transitions or crises requiring coordination Team communicates on an ongoing basis to manage and update the client s care plan the client s needs change
8 Guiding Principles Client Choice Lead Care Coordinator Partners in the Care Team Manage Transitions Evolving Care Plan Ensure all components of the process are guided by the patient s choice to the greatest degree possible CCPs coordinated by an assigned Lead CCPs supported by the right team members Team facilitates smooth and timely care transitions Team creates accessible, effective and evolving CCP & provides Coordinated Care Management
9 Identify and Engage the Client Identify appropriate clients based on the Health Link target population definition and on who would benefit from coordination of care where There are a minimum of two providers involved Providers need to work as a team ongoing Engage clients to Explain the coordinated care planning and management process and get their agreement to participate Begin to identify the client s health related goals Identify who should be the lead and who should be included in the care team Get the client s consent to talk to the other providers involved and to track the CCP process
10 Engage the Care Team & Develop the CCP Engage the care team by explaining the CCP process and inviting them to participate include the primary care provider Bring the care team together to complete the CCP Hold a care conference that includes everyone able and willing to attend either in person or by phone Come together in other ways if a care conference is not possible Complete the CCP with the care team and the client Work through the CCP Template beginning with the client s goals complete relevant sections Determine who will support the client to work on each identified goal Determine how the CCP will be managed ongoing Communication plan Future team meetings
11 Understand Care Team Roles and Responsibilities The Lead Care Coordinator will Be available to client for care coordination issues and concerns Be responsible for distributing and updating the care plan Communicate updates or new information to the care team Call the care team together when agreed to or when needed Care team members will Be responsible for providing updates of relevant information or changes in the care plan to the Lead Care Coordinator Carry out responsibilities agreed in care plan Agree not to withdraw from service without consulting with care team The care team is collectively responsible for Coordinated Care Management
12 Questions
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