Care Coordination Working Group Report

Transcription

1 Care Coordination Working Group Report June 4,

2 Table of Contents Executive Summary 4 Overaching Recommendations: 6 Context 8 Ministry of Health and Long Term Care 8 LHIN Mandate Letter 9 Background 9 Brief Literature Review 9 Current State Overview 12 Care Coordination Working Group 15 Considerations 15 The Workshop 17 Key Messages TC LHIN is Unique Care Coordination is a Functions not a Role Care Coordination is a Continuum of Functions Models Must be Flexible Partnership with all Primary Care Providers is Required Relationships are Essential Use the Matrix to Organize Care in the Sub-region System Navigation is a Key Function Secure Communications is Essential 22 2

3 The Care Navigation Survey 23 Results 23 Analysis and Discussion 24 Recommendations Develop a Definition that Reflects the Uniqueness of the TC LHIN Revise the Framework Matrix and Use it for Planning Build Models Around Care Coordination as Functions Use Existing Mechanisms to Facilitate Sub-region Organization of Access Provide Flexibility to meet Population Needs, Geographic Realities and Provider Care Models Develop Criteria to Assist in Determining the Best Delivery Model for the Circumstance Develop One (or a Limited Number of) Consistent Client Assessment Tool(s) Develop and Implement Standards for Communication and Collaboration with Primary Care Develop Tools and Streamlined Processes for Access and Referral to Community Resources Facilitate Electronic Sharing of Client/Patient Information Across Community and Primary Care Providers Leverage Existing Resources to Improve Care Navigation 31 Appendix 32 Care Coordination Definition and Key Activities 32 Key Care Coordination Activities 33 A Framework for Matching Care Coordination to Population Need 34 Care Coordination Models in Primary Care 37 Care Navigation Survey Results 39 3

4 Executive Summary A time limited Working Group was assembled at the request of the LHIN CEO to consult with, and receive input from, front line primary care providers and care coordinators working with the CCAC. The Working Group was asked to review current models of collaboration, assess strengths and weaknesses and make recommendations on opportunities for improvement. Through review of literature, a survey of FHTs and CHCs, and a day long workshop, the Working Group learned that there is no universally agreed to definition of care coordination and that in fact, it is not a role but more a series of functions/activities that span a spectrum depending on the needs of the client. Care coordination must be centred on the needs of the client and the family/care givers and be flexible and adapted to meet not only clinical needs but also social determinants of health factors. These functions do not always require a regulated health professional to perform and in many cases system navigation and administrative tasks can be better undertaken by others. A sense making framework prepared by Dr. Phil Ellison was reviewed, adapted and recommended as a tool to be used in planning and organizing care coordination functions in the LHIN. The Working Group prepared this report and recommendations based on the unique geography, population diversity, demographics and mobility, and provider practice models within the TC LHIN. It cautions that this report reflects these unique circumstances and should not be translated as a model or approach that would be appropriate for the Province as a whole. Aspects of the recommendation may be appropriate to other LHINs but would require modification to take into consideration their own unique population and provider profiles. The Working Group has made overarching recommendations below, provided detailed recommendations with proposed action items in the final section of the report and included a summary of the survey, workshop proceedings, literature scan and information on the current approaches to care coordination within the TC LHIN. This report is focused on the care coordination functions within home care and the relationship with primary care. It is recognized that care coordination functions occur across other health service providers in relationship to a variety of care transitions and care processes centred on meeting population needs. Key themes emerged from the review: The greatest risk to successful models of care coordination is the assumption that one size or one model will fit all. Populations, neighbourhoods and individual patients are 4

5 unique and success in meeting these diverse needs rests with being able to be flexible and adaptive while providing a consistent and equitable access to care across the LHIN sub-regions; Relationships are key to the success of any model of delivery of care coordination between the coordinator and the client/family as well as with the primary care provider and others in the circle of care. For this reason, care is best organized at the sub-region level where trust can be built through a network of relationships; Flexibility is required in the model of delivery to reflect the patient population of primary care providers and criteria need to be developed in consultation with those delivering care to determine which approach best meets the diversity of needs; Information exchange and sharing is essential and new tools are required to support system navigation and communication amongst and between providers; Existing resources should be leveraged to ensure maximum matching of skills with the needs of the clients; Approaches to delivery of care coordination should be based on population need and characteristics of the community served rather than specific provider models of care; Care coordination needs in primary care requires organized linkages with home care, community and mental health services, hospitals, specialists, and a variety of support services related to determinants of health (e.g. housing, transportation, financial support, family and care giver relationships). These go beyond the resources and skill sets of the traditional care coordinator employed by the CCAC. The Working Group is pleased to be given the opportunity to provide advice and input into these fundamental and much needed roles and functions. The detailed recommendation at the end of this report provide some suggestions on a path forward. Key within this is that the LHIN take time to complete the reviews, develop an in-depth understanding of the unique population and providers within each sub-region, to create the foundation needed prior to settling on approaches to care coordination. Tests of change and pilots of innovative organization and delivery models are recommended as early opportunities to assess, review and adapt approaches. The role/function is to essential to the lives and wellbeing of too many residents to be quickly changed through a cookie cutter approach to care organization. Patients First and the creation of the sub-regions with their building of networks and collaboratives provides a truly innovative and exciting opportunity to provide more patientcentred, flexible and adaptive care based on needs. Page 5 of 43

6 Overaching Recommendations: The following recommendations have been developed with input and advice from front line care coordinators and primary care providers from across the LHIN. These recommendations reflect the unique context of the TC LHIN, including its diverse population, significant patient mobility, and variation in provider delivery models. While there is an urgent need to address many of the recommendations in this report, the Working Group cautions the LHIN about rushing to rapid implementation due to the complexity of the issues and to put some foundational elements in place first. Moving quickly to change, with only some provider groups, brings with it risk of significant disruption in service and the high probability of unintended consequences including expanding current inequities in access to service across the LHIN. An underlying premise of all of the recommendations is that care coordination is a set of functions, not a role, and that the sense making framework (Refer to Appendix) can be utilized to facilitate care being organized locally around population need and not provider model of practice. Key Recommendations of the Working Group: The TC LHIN should: 1. Implement flexible models of care coordination that reflect the uniqueness of the population, geography and providers within its geography. Each model should provide for different functions along a continuum of alignment/integration with primary care providers. These functions may be provided by different individuals depending on the skills required. 2. Ensure that all clients and providers residing within the TC LHIN have equal access to a full spectrum of services organized within each of the five sub-regions. An equity lens should be applied based upon the needs of the local populations and reflecting the unique assets within each geography. 3. Develop an inventory of home, community and mental health and addiction services (including admission criteria and wait lists) within each sub-region. Make this information available through coordinated centralized access points (including on line tools) to primary care providers and residents. Page 6 of 43

7 4. Review and catalogue the various care coordination roles within the home and community care sectors and develop and implement a process to remove duplication and clarify roles and responsibilities. 5. Agree to and implement a limited number of standardized client assessment tools that reflect social and functional status and needs. Make assessments accessible to all primary care and community care providers through a secure electronic communication method. 6. Develop in consultation with front line providers, criteria that can be consistently applied to determine a) which model/approach to care coordination will be available to primary care providers and b) appropriate care coordinator caseload based on patient needs. 7. Develop and implement standards and processes, through a time-limited working group, for closed loop communication between primary care providers and communitybased providers, beginning with the CCAC. 8. Work with hospitals to ensure a standard, inclusive approach to transitional care coordination in each sub-region that involves primary care and home and community care providers. 9. Develop and implement care navigation and team assistant functions that support care coordinators and primary care providers. These functions should be available at the sub-region level and provide an expert knowledge of providers and services available. 10. Establish a common set of definitions and terminology for care coordination functions and roles across the LHIN, including care navigation, case management, care coordination and care plan management. Adopt the following definition of care coordination and utilize the sense making framework for regional and sub-region organization of services: Care Coordination is the patient centered and needs-based organization of interdependent people, services, related activities and equipment committed to the common purpose of meeting patient, family and caregiver goals. It is a collaborative activity in which patients, families and caregivers are participants. Recognizing the complexity of the health care and community environments the process needs to be flexible and adaptable. It requires a team approach that reflects the importance to the patient, family and caregivers of building and enriching relationships, continuity, compassion and the willingness to hold each other in the circle of care Page 7 of 43

8 accountable. 11. Work through the developing sub-region primary, home and community structures and processes to develop and organize approaches and apply criteria to determine models/approaches. This would include implementing standard assessment tools and communication protocols, and clarifying roles and responsibilities of all providers to remove duplication and streamline access. For more detail on the recommendations, including timeline and implementation suggestions, refer to the final chapter of this report. Context Ministry of Health and Long Term Care The integration of the CCAC within the LHIN and the LHIN assuming new responsibilities for primary care organization and planning presents a unique opportunity to assess current models of care coordination and the current state of the care coordinator role aligned with primary care and other settings. The objective is to recommend a model (or models) for the future that builds on the strength of the existing models, the work TC CCAC has done in aligning care coordination to primary care, learning from Health Links experience and taking full advantage of the new sub-region structures and processes that address the breadth and diversity of patient and provider needs across the LHIN. The Ministry has established an executive level committee to review the future role and placement of over 4,100 care coordinators currently employed by the CCACs. The Ministry has indicated its expectations are: (1) To align care coordinators with sub-regions; (2) Increase the presence of care coordinators within a community; (3) Improve alignment and integration of care coordinators and primary care. The Ministry has undertaken consultations with a variety of stakeholders on the future role of care coordinators and has summarized these as follows: Page 8 of 43

9 o Home Care Service Providers: are seeking to take on some of the responsibilities of care coordination, and are critical of the need for care coordinators to approve changes to care plans. o Primary care associations have been advocating for care coordination to be tightly integrated ( embedded ) into primary care settings, with an emphasis on creating a seamless and coordinated experience for all patients (not just CCAC) and to provide more clinical coordination of primary and consultant specialty care services. o Some Hospitals have requested a greater role in care coordination, particularly to support a more seamless care experience for post-acute patients. o Long term care homes have suggested that the location of care coordinators in long term care homes could support client transitions. LHIN Mandate Letter In May 2017 the LHIN s received their first mandate letter from the Ministry of Health and Long Term Care in this letter LHINs are instructed to: As a priority, develop and implement a plan with input from primary care providers, patients, caregivers and partners that embeds care coordinators and system navigators in primary care to ensure smooth transitions of care between home and community care and other health and social services as required. Background Brief Literature Review A decade of research and demonstrations has developed evidence of varying levels of strength regarding care coordination interventions that target both improved patient outcomes and reduced expenditures. This experience has demonstrated that the devil is in the details, in that many apparently promising approaches have not proven to be effective. A common theme has been that careful attention to matching skill sets and roles to population need is essential if care coordination is to fulfill its perceived potential. Care coordination is not yet consistently defined by the various organizations and researchers that have addressed the topic. In general, care coordination definitions encompass coordinating health services delivery and social support interventions directed at patient, family Page 9 of 43

10 and/or caregiver needs, along with supporting patient/family self-management, system navigation and care plan management across the range of settings from the home to ambulatory care to the hospital and post-acute care. A 2009 US Study by Randall Brown found three types of interventions to be effective in reducing hospitalizations for Medicare beneficiaries with multiple chronic conditions who in general are not cognitively impaired. The following paragraphs are excerpts from that study. 1) Transitional care interventions in which patients are first engaged while in the hospital and then followed intensively over the 4-6 weeks after discharge to ensure they understand how to adhere to post-discharge instructions for medication and self-care, recognize symptoms that signify potential complications requiring immediate attention, and make and keep follow-up appointments with their primary care physicians. Naylor and colleagues (2004), using advanced practice nurses (APNs), and Coleman et al. (2006), using a Care Transitions Intervention (CTI) guided by an APN transition coach, have demonstrated the effectiveness of this intervention for this specifically identified population using randomized control trials in a number of different hospitals. 2) Self-management education interventions that engage patients for 4-7 weeks in community-based programs designed to activate them in the management of their chronic conditions. Randomized controlled trials by Lorig and colleagues (1999, 2001) and by Wheeler (2003) have demonstrated that such interventions significantly reduced hospitalizations and costs over a period of 6 21 months. The interventions enable patients to self-manage symptoms/problems, engage in activities that maintain function and reduce health declines, participate in diagnostic and treatment choices, and collaborate with their providers. The necessary education is provided by a mix of medical and non-medical professionals. 3) Coordinated care interventions that identify patients with chronic conditions at high risk of hospitalization in the coming year, conduct initial assessments and care planning, and provide ongoing monitoring of patients symptoms and self-care working with the patient, primary care physician, and caregivers to improve the exchange of information. The Medicare Coordinated Care Demonstration (MCCD) initiated in 2002 and, for selected programs, continuing today, is the major source of insights into the details of effective interventions and what distinguishes them from other interventions (Peikes et al. 2009). At the time of this 2009 study, no single program had yet combined all three types of interventions. The model notes as gaining the greatest momentum was the Patient- Centered Medical Home (PCMH), a concept developed under the joint auspices of the American College of Physicians, the American Academy of Family Practice, the American Academic of Pediatrics, and the American Osteopathic Association. Large clinics, group Page 10 of 43

11 practices, and academic medical centers may have the array of staff, services, and systems to meet the requirements to qualify as medical homes and advanced 5 medical homes. Small practices of one or two physicians, who represent 83 percent of all practices in the U.S and 45 percent of all physicians, will not (Pham 2007). The Medicare Demonstration set out qualifications to be a patient-centred medical home: including several characteristics associated with effective care coordination: co-location of care coordinators with primary care physicians, having the same care coordinator for all of a physician s patients, access to timely information on hospitalizations, and opportunity for substantial in-person contact between the care coordinator and the patient. The authors recommend other criteria: inclusion of a patient self-management component, inclusion of a transitional care intervention, and access to staff who can address isolation and community care needs. Small practices should be encouraged to meet the criteria for a medical home by linking with a community health organization, an integrated delivery system, a local clinic, or a medical center that has assembled the staff and resources to provide effective care coordination. A Canadian version of the patient centered medical home has been proposed by the College of Family Physicians of Canada ( ) with examples developing across Canada ( A Patient s Medical Home provides continuity of care, relationships, and information for its patients. Continuity of care is defined as consistency of care over time, throughout the course of a patient s life. Having most medical services provided or coordinated in the same place by one s personal family physician and team has been shown to result in better health outcomes. How can planning evolve at the level of primary and community care to best support populations through a needs based approach to care coordination services and resources? To facilitate the discussion, Dr. Philip Ellison has provided a matrix, including using the IHI Triple Aim as outcome targets (copy of presentation has been provided in first meeting reading materials). This sense making framework stratifies different patient needs based on complexity criteria involving function (particularly cognition and mobility) and their capacity to address determinants of health status issues (particularly social isolation). Analyzing these relationships results in the recommendation for four representations for care alignment: 1) Support for Self Management; 2) Navigation to Improve Access to Community and Social Services; 3) Clinical Coordination of Clinical Services; 4) Intensive Care Plan Management for Complex Patients. Page 11 of 43

12 Elliott and Stolee, University of Waterloo 2016 studied Care Coordination in Primary Care for Older Adults, and concluded that primary care could provide an enhanced role if provided with sufficient tools and supports including, 1. Consistent processes to assess and stratify older adults and develop care plans based on risk profiles (such as Resident Assessment Inventory); 2. Improved care coordination and system navigation; 3. Improved access to appropriate services; and 4. Improved patient and caregiver engagement. Current State Overview There are approximately 1400 comprehensive primary care physicians and 87 primary care nurse practitioners within the TC LHIN. The most common payment model for physician in the TC LHIN has the majority of physicians being in independent fee-for-service practice. The TC CCAC has focused on connecting Care Coordinators with primary care and reports a 75% connection rate with primary care in the TC LHIN. These connections have primarily been with organized primary care (Family Health Teams, Community Health Centres and some Family Health Organizations). The TC CCAC has 200 community-based care coordinators. These CCAC care coordinators are geographic/neighbourhood based. Primary care physicians while in the community, provide services to patients who live outside of their local community (in fact 55% of primary care encounters with TC LHIN primary care physicians are with residents from outside the TC LHIN) and thus the patients of these physicians are not neighbourhood based. There are currently two models being used at the TC CCAC for connections to primary care: 1. Embedded Function In this approach the Care Coordinator works out of the primary care practice and supports the primary care physicians in a shared cared approach to care for their most complex clients. The TC CCAC invested additional care coordination resource capacity for this and currently has embedded care coordinators with the 7 of the 13 TC LHIN FHTs and 1 (of 17) CHCs in Toronto that have home based primary care teams. These care coordinators work with the family health teams to support homebound complex clients and carry an exclusive caseload of these clients. The goal has been to intensively support the primary care physicians of these family health teams to provide primary care at home for these home bound clients, and by necessity the case loads are far less than the average community based coordinators. This has helped fill the primary care gap for clients who are home bound and can t access office based care. These embedded Care Coordinators are also be a point of contact for questions or information related to the CCAC or community resources. They help facilitate connection to other CCAC community based coordinators for other non-home bound clients of the FHT or CHC. At least some of these Care Coordinators are based with academic family health teams and thus have an ancillary benefit of indirectly supporting engagement of trainees in learning about community based service coordination. There are embedded coordinators with the regional geriatric program at Baycrest. Page 12 of 43

13 2. Liaison Function In this model the Care Coordinator in the community acts as a liaison for the primary care physicians within their geographic boundary. In this case the Care Coordinator has a full caseload of clients and allocates a portion of their time to regularly connect through weekly/bi-weekly or monthly rounds with the physicians in the neighbourhood. Their role is to act as the key contact for these physicians about information about the CCAC and community based resources. They may provide information or referral, provide coordination support for the clients they carry on their caseload and follow-up with the appropriate care coordinators for clients they do not carry. Their role is to make it easier for the primary care physicians they are connected to in terms of accessing CCAC support. The reason for this approach is that the current primary care model is that primary care physicians carry clients from any geography whereas care coordinators are neighbourhood based and carry clients within a neighbourhood. 3. Information and Referral Function - In this model assistance is accessed through the CCAC dedicated primary care phone line and physicians are able to obtain information about CCAC and other community based services. Care Coordinators provides updates regarding existing shared clients and the physician can be case conferenced into the care coordinator for consultations. This approach is used for patients with infrequent needs and is available on a regional basis. It has worked well for people who access multiple primary care providers or for primary care practices with irregular or infrequent office hours. 4. Transitional Function This approach is used for clients with significant health and social complexity. Clients are assigned to a Transitional Care Coordinator that works to stabilize the client with primary care and other needed community services. The goal is to transition the client to the most appropriate community agency or CCAC for ongoing care. This approach is most appropriate for sub-region implementation. Health Links Experience The Toronto Central CCAC had assigned a Health Links Liaison Care Coordinator to lead the development of coordinated care plans for the populations they served. Subsequent to an 18 month period, key lessons learned included: The need in having a transitional care coordination role (for immediate post acute care) The requirement to support, triage and process urgent care coordination gaps in the system The ability to mobilize the existing care coordination capacity in the broader system to take on long-term care coordination for identified complex clients, particularly home bound and those having no resources. Page 13 of 43

14 Supporting Primary Care in care coordination particularly those practicing in non- FHT/CHC settings The need to align and converge identification strategies, processes and workflows across the various Health Links to ensure adoption of best/leading practices and consistency in experience for both providers and clients/caregivers In 2015/16 the TC CCAC consulted with the TC LHIN and Health Link Lead Executive Sponsors on their proposed plan to revise the Health Links Liaison Care Coordinator role to function as a community based transitional care coordinator. The transitional care coordinator role has entailed leading the development of coordinated care plans for clients that have identified through Health Link acute care identification approaches. The transitional care coordinators also function as a point of contact for coordinated care plan initiation and development to Health Link partners. There have been challenges, in some instances, with organizations accepting priority patients from Health Links before others on their wait list. A virtual team of dedicated Transition Care Coordinators (TCCs) from three community organizations (CSS, MH and CCAC) was developed and is shared between the Mid East Toronto and Don Valley Greenwood Health Links. Each TCC team member brings a particular area of expertise medical complexity, mental health and addictions, or seniors care. The TCCs: Begin a CCP on an urgent basis when the patient does not have an existing provider to lead the CCP or the provider does not have the needed skills. When PCP exists, connect with them to support their involvement in the CCP process. When the patient does not have a PCP, TCCs connect them to appropriate PCP practice. Attend various hospital rounds to encourage and facilitate hospital identification of patients for referral and to build the relationship between hospital and community. Work with and coach referred patients existing lead care coordinators and provide short-term urgent care coordination (less than 3 months) until such time as another organization can assume ongoing care coordination. Provide intensive short-term case management when needed. Ensure the transition of care across care coordinators in different agencies is seamless for the patient. Page 14 of 43

15 Care Coordination Working Group In February 2017, the TC LHIN created a small, time-limited working group to gather information from front-line care providers (including primary care providers and CCAC care coordinators) and provide advice to the CEO. The mandate of the working group was to: Review current literature on successful models of care coordination. Review and report on the current models of care coordination, care navigation, self management and intensive case management being used within the CCAC within the TC LHIN. Review and assess current capacity within the system and identify any gaps or unmet needs. Develop a list of functions (including supporting rationale) needed in the current system for care coordination and care navigation and other related functions, as required. Develop and recommend a model or models of care to respond to population needs and the current primary care and CCAC care coordination context that will maximize the use of LHIN resources, leverage sub-region structures and align with the Primary Care and Integrated Community Care Strategies. Make other recommendations relevant to transition to the preferred model, including timing and implementation considerations. Considerations When reviewing the role and function of CCAC care coordinators in the health system there are several areas of consideration that the working group was mindful of in making recommendations to the TC LHIN, including: Role and Need Definition: There is currently no universally accepted definition of a care coordinator. Care coordinators have been employed in a number of different settings, with different labels, roles, responsibilities and qualifications. The roles include, but are not limited to: patient assessment and service need determination; development of co-ordinated care plans; Page 15 of 43

16 coordination of various health care providers to provide services to patients in a variety of settings (outpatient, at home, in rehabilitation settings); navigation services for patients to specialist or specialty based services; discharge planning services for placement in alternative care settings; arrangements for a variety of community and social support services for patients. There is often an unclear definition in roles and responsibilities between a clinical care coordinator that includes patient assessment and that of a care navigator that facilitates and assists with the implementation of a care plan. Further, care coordination functions exist in all sectors, including Community Support Service and Community Mental Health and Addictions models of care. These will be important models to consider as part of this longer-term work to ensure all populations are being equitably served. Settings and Target Populations: Care coordination can be situated within a specific care setting and be unique to the role and needs of that organization (e.g. hospital discharge planning) or can be a patient centred and/or team based approach to care coordination for a specified patient population (often those defined as complex or vulnerable such as in Health Links). Care coordination services can vary in the degree of complexity based on patient need and/or the setting from which they are delivered. Consistency and Standards: The Ministry has specifically asked LHINs to look at ways to improve care quality and consistency across the province. Sub-regions and Flexibility: The recommended model(s) should consider and build upon the TC LHIN s model of primary care sub-region planning and organization while providing the necessary flexibility to respect patient and provider choice. A specific challenge will be related to LHIN geographic boundaries and when organizing care around primary care the challenge that patients within practices may cross sub-region planning areas or even LHIN geographic boundaries. Primary Care: Organizing primary care into a system within sub-regions is taking time. Flexibility will be needed in considering models that can work for a variety of different practice models (solo, Family Health Groups, FHOs, FHTs, CHCs). When looking at the breadth of needs within primary care it may be helpful to consider how care coordination can also be used to facilitate improved linkages between hospital and primary care; primary care and specialty care; hospital and long term care; hospital, primary care and home care; primary care and community care. Employer and Labour Relations: Considerations related to who is best to employ care coordinators and the labour relations implications of these relationships are also important. Page 16 of 43

17 Current State Assessment It will be important to complete a capacity assessment based on current resources to use and apply to any proposed model or models. The Workshop The Toronto Central LHIN hosted a workshop on April 20 th to consult with and obtain advice from a variety of front line CCAC care coordinators and primary health care providers. The event was attended by 58 individuals and was very well received by the participants who praised the openness, passion and opportunity to be part of the change agenda. A full summary of the evaluation is available on request. The discussion at each table was recorded by a facilitator and the feedback is being used by the Care Coordination Working Group to prepare this draft report. Key Messages 1. TC LHIN is Unique It is essential that the TC LHIN unique context be fully understood and appreciated when designing a model of sub-region based care delivery. The LHIN is unique in a number of features, including: significant patient mobility across sub-regions and across neighbouring LHIN borders; primary care provider typically have 50% or more of their patients travelling from outside their geography to receive care; primary care providers are predominately practicing in smaller, less organized FFS based practices, however unique large multispecialty clinics e.g Albany Clinic also exist; there are uniquely distinct populations and neighbourhoods within sub-regions that have very different population needs, often due to particular challenges in determinants of health and functional status; e.g. inadequate housing, social isolation, language and cultural diversity etc. These must be taken into account in any system or model design. 17 academic hospitals. Lack of consistent local referral patterns and alignment between primary care, hospitals, and hospital based consultants. The definition of care coordination (see Appendix) presented at the workshop must be reviewed and revised so that it reflects the discussion at the workshop and becomes a definition for use by the TC LHIN. Generally, it was met with mixed reviews with concerns that the language was not accessible to all, too Page 17 of 43

18 administrative, too provider centric and does not speak to the breadth of care coordination function(s) and the importance of relationship building. 2. Care Coordination is a Functions not a Role Care coordination is a function not a role. There are a variety of functions required that can be carried out by more than one individual depending on the needs of the patient and the skill set of the provider. Not all care coordination functions need to be performed by a regulated health professional. The functions (see Appendix) considered to be part of care coordination needs to be broadened to include: education, provision of care; and advocacy. 3. Care Coordination is a Continuum of Functions Care coordination needs to be seen as a continuum with respect to the degree of integration/alignment with primary care. Reinforce that care coordination is a set of functions that have a continuum and aspects in each of the quadrant of the matrix presented by Dr. Ellison. There needs to be flexibility on how this is applied in each of the sub-regions as the geography, assets and clients vary considerably. Advocated that the LHIN adopt a working principle that the full spectrum of care coordination functions needs to be available across the system in each subregion to every patient and every provider. 4. Models Must be Flexible Strong feedback that one size will not fit all for proposed roles and models, and that there needs to be flexibility to develop models and approaches that meet the patient and community of providers needs. There was a strong dislike of the word embedded as not being representative of the role and it is a concept that is not well understood and often used inappropriately. It was instead recommended that different levels of alignment/connectivity/integration be considered and that this be based upon the needs of the patients of different providers not the payment model or organizational model of the provider. Page 18 of 43

19 This is not about one provider or one model it needs to be clear that a whole system view is what is required and there needs to be clarity of roles, responsibilities and often shared accountabilities between entities to ensure collaboration, integration and reduce duplication. Criteria need to be developed and used to determine which care coordination delivery model would best meet client and provider needs and could include specific characteristics of the population, geography and the provider practice size and model. It was noted that with an average case load of care coordinators of 100 clients most PC practice will not be able to support a FT fully integrated care coordinator. It was noted however that some practices who have a focus on the home bound frail elderly or vulnerable populations could support a care coordinator with a smaller case load (e.g. 30) due to the intensity of client needs. The Integrated Community Care Strategy and CCAC work will need to be leveraged and focused on how to organize care for the most complex patients while taking into account the role and function of the Health Link process - but not necessarily the model and processes as they currently exist. 5. Partnership with all Primary Care Providers is Required There is a growing acknowledgement of the importance of primary care as the long term care relationship with the patient and this needs to be leveraged instead of PC being seen as an obstacle or problem to be managed. Within the principles there needs to be something on partnerships with primary care and development of standards for communication between the care coordinator and primary care providers and (if present) their team members. Primary care physicians must be meaningfully engaged in the care coordination process and it must not be a time consuming administrative exercise. 6. Relationships are Essential Development of personal relationships amongst providers is a key enabler or building block that much of the success hinges on this and it isn t enough to put a care coordinator with an existing practice or team; there needs to be work done to ensure roles and responsibilities are well understood. It was universally noted that personal relationships between care coordinators and primary care providers are Page 19 of 43

20 key to success. It is necessary to build trust and an understanding of each other s role and how best to work together with the patient to meet their needs. Concepts of building interprofessional teams need to be applied in designing and implementing the model as the care coordinator or care coordinator functions are integral to this and must bridge the health and social needs of the most complex patients. The care team can be seen as a primary or small core team (which should be as constant as possible) that includes the care coordinator, patient, care giver and the patient s primary care provider as quarterback. The secondary team would be the circle of care of providers that can come in and out depending on the patient s needs. There must be continuity of care (and providers) within this circle of care. 7. Use the Matrix to Organize Care in the Sub-region The sense making framework that was presented at the workshop (see Appendix) was very well received and it was recommended that it be used to guide considerations of stratifying population needs and the appropriate alignment of resources to support a broad spectrum of care coordination and categories that could include supports for patient self-management, system navigation particularly with respect to local community support and mental health services, clinical coordination for those with higher clinical needs and intensive care plan management functions for the most complex populations. May need to have discussions on potential adjustment of coordinators case loads depending on the functions they perform and the where their clients reside most commonly within the quadrants of the matrix. Care coordination should be organized by sub-region and linked across the LHIN as well as addressing an important liaison function with adjacent LHINs services in recognition of the mobility of patients. More consideration should be given to geographic organization of care --- residential buildings or areas with high concentration of clients should be organized with a dedicated care coordinator and ideally a dedicated list of providers. The philosophy of neighbourhood based care is important and will assist in developing relationships with primary care providers in the same neighbourhoods. Page 20 of 43

21 The system designed needs to provide a model that allows connection with care coordinators in nearby LHINs to provide for easier connections to PC providers in this LHIN and enable better continuity perhaps the team assistants or the CCAC call centre could provide some assistance with this. It was noted that primary care providers often want to speak with the service delivery provider to their patient and that some consideration of aligning these service provider resources geographically would help to develop these relationships. Need to consider a community based care/community provider philosophy. The system and processes must consider services to the noninsured or newcomers on Interim Federal Health benefits noted that the LHIN has a current working group on this that can be leveraged. It was suggested that CHCs should be continue to be the fund holder for these services. One area of care coordination and CCAC services that could be developed initially would be related to palliative care, particularly for the uninsured. A unique model should be considered for high intensity post hospital short term care for transitions --- perhaps sub-region SWAT teams, virtual ward models or dedicated clinics. Sub-region organization and leadership will be essential, to assess current needs, inventory current assets, and determine how to best organize local resources to meet local population and provider needs. There needs to be an assigned lead for this type of organizational work in each sub-region with defined processes, tools, roles and expectations. There needs to be consideration of, and development of, structures and processes to organize the delivery of care within each sub-region. There was support for the CCAC moving to align nursing and PSW resources with sub-regions. 8. System Navigation is a Key Function There are currently inadequate or non-existent online tools and resources for patients and providers to use to help navigate available services locally it was felt that improvement in these could significantly reduce administrative burden of care coordinators, patients and caregivers. Page 21 of 43

22 There are a lot of logistical tasks that no one owns and as a result a lot of regulated health providers spend a lot of time doing these. There was strong support for the role of team assistant much of the time of the care coordinators are taken up in scheduling and administrative follow-up that could be performed by an assistant thereby freeing up the time of the care coordinators to assist additional clients. It was suggested that the LHIN consider a possible expanded use of the CCAC call centre. It was also noted that the call centre could potentially take on the role of team assistant that was identified as a need by some groups. In all cases, it was agreed that some type of on line tools on available community services and assets that can be used by navigators and caregivers. 9. Secure Communications is Essential The ability for care providers to communicate securely is critical. It was suggested that the development of communication standards and protocols would be beneficial and well received. Some suggestions regarding LHIN potentially having a role in some encryption for the use of personal smart phones of care coordinators or some other means to share client information securely. Closed loop communications were seen as essential to building trust, developing a collaborative relationship and reducing duplication of effort. A principle enabler is the need to address the information platform for sharing of client information and addressing privacy and enable/ensure secure communications. It was noted that this must also take into consideration of sharing information in CHRIS and within the Integrated Assessment Record (IAR) platform across CCAC boundaries (at least at a high level in terms of care being provided). A shareable electronic record and care plan was seen as a priority. It was recommended that the LHIN and/or the Ministry would also need to devote resources to addressing the issue of privacy in sharing information across the broader team of community care providers to enable improved care continuity and reduce the need for the patient to repeat their story and advice providers of the work of each other. This could be in the form of community based standards for confidentiality. Page 22 of 43

23 There needs to be agreement on one, or a limited number, of standard assessment tool(s) to use across primary care, home care, CSS, and community mental health and addictions preferably those that consider functional and social assessment and includes primary care elements. The Care Navigation Survey The Care Coordination Working Group asked that a short survey be designed and conducted to gather information on a care navigator function within primary care inter-professional teams. The survey was sent out in late March and most responses were received by late April. The survey provided a brief introduction to the work of the LHIN on care coordination and asked each FHT and CHC the following 4 question: 1. Do you employ one or more care navigators? Or have you employed a care navigator in the past? 2. Describe the main role, function and responsibilities of the care navigator. 3. Describe the population/clients served by the care navigator. 4. Is the care navigator a regulated health professional? If yes please specify. If no please describe the qualifications. The survey was sent to 13 Family Health Teams (FHTs) and 17 Community Health Centres (CHCs) within the TC LHIN. Forteen CHCs (82%) responded. No response was received from Planned Parenthood, LAMP or Central Toronto. Eleven FHTs (85%) responded. No response was received from Women s College Hospital or Toronto Western FHTs. Results Results are summarized in the attached Appendix. Page 23 of 43

24 Analysis and Discussion There was a high response rate to the survey and significant interest expressed in the work of the LHIN and the working group. General observations from the survey result include: Almost universal recognition of the need for the care navigation function; 4 FHTs and 5 CHCs responded n/a on anyone doing the role or function but perhaps it could be included in the role of others as this was not an expressly asked question; Confusion between terms of navigator and coordinator; Broad based set of functions that cover navigation, case management and care coordination; No common provider either regulated health professional or other staff; Clients with complex health, cognitive and/or social issues. Recommendations 1. Develop a Definition that Reflects the Uniqueness of the TC LHIN The draft definition of Care Coordination discussed at the workshop (Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies Volume 7 Care Coordination AHRQ Publication No. 04(07) June 2007) was received with mixed reviews. It was recommended that the LHIN develop a unique definition that is in plain language, speaks to the partnership and collaboration with clients and caregivers, that the role must be flexible to adapt to the needs of the client as well as the availability of resources within the geography, and reflects the compassionate/caring nature of the relationship. Proposed TCLHIN Definition: Care Coordination is the patient centered and needs-based organization of interdependent people, services, related activities and equipment committed to the common purpose of meeting patient, family and caregiver goals. It is a collaborative activity in which patients, families and caregivers are participants. Recognizing the complexity of the health care and community environments the process needs to be flexible and adaptable. It requires a team approach that reflects the importance to the Page 24 of 43

25 Functional patient, family and caregivers of building and enriching relationships, continuity, compassion and the willingness to hold each other in the circle of care accountable. 2. Revise the Framework Matrix and Use it for Planning The sense making framework presented at the April 20 th workshop was very well received with minor modifications proposed. It is recommended that this modified population based framework be adopted and used by the LHIN as a reference point for organizing care in sub-regions ensuring that every resident and every provider has equitable and timely access to the supports depicted in each quadrant depending on need. This framework recognizes the strong impact that functional status and social supports have on the needs of home care clients. Underpinning the framework is the triple AIM objectives of improving: 1) Population health outcomes through more effective care; 2) the patient experience; 3) the cost of health care. Effective application of the framework would facilitate the organization of services based on client need and risk status. Refer to the appendix for a full description of the Framework and its application. High Low Absent Below is a revised graphical depiction of the framework that reflects input from the workshop. Care Plan Matrix* 4 3 Provided by Dedicated Clinicians Need Professional Development and Continuity of Circle of Care IM/IT Project Decision Assist Tools 2 Intensive Care Plan Management Social Community & Services Navigation Provided with CSS, CMHA, Need Build Relationships IM/IT Project Database Development Experience Determinants of Health Clinical Services Coordination Provided by Primary Care Teams and Community Health Service Agencies Need Customer management IM/IT Project Document Management Facilitated by Care Providers Need Toolkits, apps IM/IT Project Registry and Portal Social Supports Self- Management Support 1 Present Normal Human Labour Intensive Managing Highest Risk IM/IT Intensive Support Lowest Risk Losing IADLs Cognition & Mobility * Used with permission Page 25 of 43

26 3. Build Models Around Care Coordination as Functions That the LHIN continue work with front line providers to refine and clearly articulate the functions involved in care coordination using feedback from the workshop. These functions should additionally be aligned to the quadrants of the sense making framework and complemented by a description of skills required to carry out the function. The functions should be implemented through the redefinition of roles and responsibilities in the approaches to care coordination and the development of the care navigation/team assistant role. Working Group participants asked that each of the functions be defined and that additions be made to include the care giver role, add recognition of the importance of relationship building and softer skills like listening, network building and advocating on the clients behalf. It was also noted that the importance of some logistical supports like assistance with transportation to and from appointments and language interpretation. The review should consider the following core functions as being common to the provision of care coordination. The descriptions were compiled from a variety of sources and do not represent any one organization or sector s perspective but rather provide an overview of what is intended by each function. Engage: An ongoing focus on developing and maintaining relationships with patients, families, and communities based on mutual respect and trust and seeking to understand patients as individuals with unique needs, circumstances, values and preferences. Assess: A dynamic and ongoing collaborative process that actively involves the patient and others to secure information in a timely manner and to identify the client s values, goals, functional and cognitive capacity, strengths, abilities, preferences, resources, supports, and needs. It may also include information to determine a person s service or program eligibility. Inform & Refer: An interactive process of exchanging information between patients/families and providers about available services and supports and how to access them within the community. Page 26 of 43

27 Plan: A collaborative process of establishing goals and priorities and documenting agreed-upon actions to achieve the person s goals and desired health outcomes, including the use of formal and informal resources and services. Implement: All parties involved in the plan of care work collaboratively to initiate and carry out the mutually agreed-upon activities, interventions and interactions. Coordinate & Navigate: Organizing care plan activities and resources to facilitate effective information exchange and appropriate and harmonious delivery of care / services across providers, settings, and participants; providing education and guidance about health system resources and supporting the patient/family access services from other organizations/ providers Evaluate: Periodic reassessments involving the patient/family and care team to identify current needs, status, and experience and to monitor progress towards goal attainment, including the effectiveness/efficiency of the care plan in achieving the goals. The results will inform care plan adjustments. Transition: A collaborative process that supports the seamless movement of the patient to a different setting, role or care plan to achieve their goals. In 2012, the National Case Management Network of Canada identified specific case management provider roles and corresponding competencies. These roles and descriptions have been modified to reflect Care Coordinator competencies developed by the Toronto Central CCAC and comments from Workshop participants. Page 27 of 43

28 Communicate/Educate: Use effective education and communication strategies to develop and enrich patients health and social networks, and to build partnerships and relationships at the patient and system level Collaborate: Use expertise and influence to advocate for and speak on behalf of patients, community or population to advance health and well-being; work within the broader system skillfully engaging individuals and groups to share information, create meaningful care connections, and assist with consensus building within the care team and along the continuum of care. Navigate: Educate patients and their families about health and social systems and help them navigate these systems by using organizational resources and leveraging population networks to facilitate equitable access to needed services / care Leader/ Advocate: demonstrate leadership behaviour in advocating for and serving the interests of patients and their families within the mandate and values of the organization. Resource: Integral participants in advocating for improved care / services and in making decisions about time, resource management, and priorities that affect care coordination Coordinate: Experts in health and social needs planning and in integrating key coordination activities to provide education and promote and support the health, wellbeing and independence of patients / families and populations 3. Use Existing Mechanisms to Facilitate Sub-region Organization of Access The TC LHIN should adopt the principle that all TC LHIN residents will have equal access to core primary care and community-based services within the LHIN geography regardless of where they live or the model of care their physician practices in.. An equity lens should also be applied to respond to the needs of local populations, specifically those that are most vulnerable and marginalized. The LHIN should review and scale promising models of delivery based on population need and build on emerging sub-region planning including Local Collaboratives and the Primary and Community Care Committees to ensure and enable access locally. The LHIN should develop a comprehensive inventory of local services and develop an electronic tool to facilitate access to information by clients and providers. 4. Provide Flexibility to meet Population Needs, Geographic Realities and Provider Care Models The TC LHIN should make available, in each sub-region, a series of approaches to care Page 28 of 43

29 coordination that will be offered to clients and providers based upon defined criteria. Consideration should be given to, where possible, organizing PSW and nursing providers by geography/neighbourhood. The current four roles and approaches to care coordination (refer to appendix for details) will be reviewed using the sense making framework (see appendix) and adapted based on recommendations in this report to be made available in each subregion. The LHIN will work with the local PCCCs, local collaboratives and others, to implement the continuum of care coordination approaches based on local provider and patient needs. The LHIN will convene a workshop with neighbouring LHINs and their providers to develop strategies, processes and protocols to ensure seamless care for clients who cross LHIN boundaries. 5. Develop Criteria to Assist in Determining the Best Delivery Model for the Circumstance The LHIN should develop and refine the approaches to care coordination and develop criteria that would be used within each sub-region to determine the most appropriate approach to ensuring care coordination functions are equitably available to the population and all primary care providers. Access to the different approaches must be based on client attributes and population needs and not the physician model of care. The skills of the care coordinator need to match the matrix quadrant,the needs of the clients in that quadrant and resource availability within that sub-region. The higher the needs of the patient population the tighter the alignment should be between the primary care practice and the care coordinator. A consistent approach to transitional care coordination should be implemented across all sub-regions that includes in-person participation of home and community care providers in hospital discharge planning. This approach should include and enable post-discharge follow-up contact with general internal medicine specialists. The future state model should align care coordinators to primary care based on client needs using a standard and replicable set of criteria. These criteria should include: o geographical proximity to clients e.g within 5 kms; level of care coordination required; o type of patient populations e.g medically complex, mental health and addictions, socio economic status, social determinants of health; Page 29 of 43

30 o alignment with existing primary care practice model care navigators; o differentiation from community based coordination and clinical coordination; o state of readiness of the practice. The development and implementation of criteria and processes, to determine care coordinator caseloads that vary depending on the needs of the clients should be integral to, and a component element of, the determination of models of integration with primary care. 6. Develop One (or a Limited Number of) Consistent Client Assessment Tool(s) The LHIN should assemble a time limited task group that will review existing client assessment tools in use in Ontario and internationally and recommend a standard tool for use across all community-based providers in the LHIN. The tool should be modular in nature and must include clinical, functional and social(determinants of health) aspects. The task group should be asked to report by January 2018 and include recommendations on implementation processes and requirements. The completed assessment should be made available on a common electronic LHIN wide platform to all providers involved in the clients circle of care. The LHIN should consult with privacy experts on how to enable appropriate sharing of information. This work should build upon the work being done by the Levels of Care Working Group. 7. Develop and Implement Standards for Communication and Collaboration with Primary Care The PCRC should create a time-limited task group with primary care providers and care coordinators and home care providers to make recommendations on standard communication protocols and processes that align with the LHINs four approaches to care coordination. The work group should report in December Develop Tools and Streamlined Processes for Access and Referral to Community Resources The LHIN should develop a comprehensive inventory of services within each sub region, including a standardized access and referral process and information on admission Page 30 of 43

31 criteria and wait times. The information should be made accessible through an electronic tool that can be accessed by clients, care navigators and providers. Ideally this inventory and tool should be available in 2018/ Facilitate Electronic Sharing of Client/Patient Information Across Community and Primary Care Providers The LHIN should investigate and enable opportunities to share home care client information with primary care providers through a secure electronic portal. 10. Leverage Existing Resources to Improve Care Navigation The LHIN should work with providers to develop and articulate care navigation and team assistant functions that would complement the care coordination functions and provide additional support to clients, caregivers and providers. The LHIN should review and catalogue all care coordination/care navigation/case management functions across organizations in each sub-region and develop a plan to remove duplication, and clarify roles and responsibilities based on recommendations in this paper. The organization and delivery of these functions should consider expanded use of the CCAC call Centre as a source of information, navigation and possibly referral assistance. Page 31 of 43

32 Appendix Care Coordination Definition and Key Activities There is no common definition of care coordination and the activities that care coordinators undertake in Ontario s health care system vary widely. In fact, an extensive analysis completed by the USA Agency for Healthcare Research and Quality found more than 40 definitions of care coordination that were extremely heterogeneous but noted elements that were common to care coordination 1 Numerous participants are typically involved in care coordination Coordination is necessary when participants are dependent upon each other to carry out disparate activities in patient s care In order to carry out these activities in a coordinated way, each participant needs adequate knowledge about their own and others roles, and available resources To manage all the required patient care activities, participants rely on an exchange of information Integration of care activities has the goal of facilitating appropriate delivery of health care services In the absence of a commonly accepted definition of care coordination, we chose one that is evidenceinformed, broad and inclusive to guide our discussions for care coordination in the TC-LHIN. We have also identified key care coordination activities. Working Definition of Care Coordination Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care. 1 1 (Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies Volume 7 Care Coordination AHRQ Publication No. 04(07) June 2007) Page 32 of 43

33 Key Care Coordination Activities Transition Engage Assess Monitor & Adjust Coordinate Care Initiate Care Patients Families & Families Navigate System Inform & Refer Set Goals Plan Care Page 33 of 43

34 Functional Complexity A Framework for Matching Care Coordination to Population Need This sense-making framework was modified for the workshop. It was initially developed within a project guiding the development of a chronic disease management model for diabetes mellitus with participants from the University Health Network, the Toronto Central Community Care Access Centre (and facilitated by the Courtyard Group). Dr. Phil Ellison will present the framework to all participants - outlining the care coordination services common to all four quadrants and those that are unique to each one. The small group discussions will give participants an opportunity to comment on and apply the framework within the TC-LHIN. High Intensive Care Plan Management Social and Community Services Navigation Clinical Services Coordination Self-Management Support Losing IADLs Low Absent Determinants of Health Social Supports Present Notes of Interpretation Interior borders are porous and may shift exterior boundaries are more solid and requires a liaison for linkages to service providers in other regions. Level of client risk dictates increased resource investment. Graduation of risk for adverse outcomes and high cost utilization from those with highest capacity and lowest complexity to those with least social supports (determinant of health) and highest functional impairment. The following services would be provided in ALL quadrants by all care providers to all clients, as needed: Client needs assessment; Optimize client self-management; Co-ordinate care through primary care teams Facilitate access to providers, devices and resources Facilitate efficient health care system navigation Advocate for clients Link to community services Quadrant 1: Self Management Support For clients with good social supports and low functional impairment. Page 34 of 43

35 Hosted within the primary care team and facilitated by all care providers on the team Identify and prioritize health care goals IM/IT: requires self management through patient portals, disease management registries, tools and tool kits for patients and providers (including wearable devises, use of social media, apps) Secure patient/provider communication Quadrant 2: Navigation to Improve Access to Community Health and Social Services For clients with low level of social supports and low functional impairment Hosted by primary care team and/or partnered with community health and social service agencies to all clients Primary care links clients to community services; subsequent navigation of service delivery provided within primary care and/or community agency Navigators need extensive local community knowledge Requires database development and maintenance of accessible inventory of services and secure PHI information exchange platform (e.g. Patient s Health Care Home) Quadrant 3: Coordination of Clinical Services For clients with high level of social supports and high functional impairment Referral by primary care teams with engagement of community and hospital diagnostic, consultative and home care services Services include: facilitating timely access; co-ordinate access to resources, specialists, other health care professionals, care in the home Services could be accessed via portals or a 24/7 call centre Needs health care system knowledge Requires document management, scheduling, and repository of clinical record information Quadrant 4: Intensive Care Plan Management for Complex Patients For clients with low level of social supports and high functional impairment Highest need clients/patients need investment for high touch and direct engagement of providers --- high risk of (re-)hospitalization if system fails Probable significant component of caregiver involvement Requires decision guidance and coordination in support of providers, both in direct care and system navigation Provided in circle of care by clinical community health and social service agencies to all clients, with primary care provider as partner and quarterback Providers of Self Management Support and Navigation Quadrants 1 and 2 Need not be a regulated health professional as clinical skill set not a required role. Likely applies to larger population base so could be strongly aligned if not embedded in organized primary care models. Page 35 of 43

36 Individuals need good understanding of local community and resources available and should be seen as a relationship builder within the community. Providers of Clinical Care Coordination and Intensive Care Management Quadrants 3 and 4 Need to be regulated health care professionals as largely application and monitoring of clinically driven care plan. Intensive care plan management may need to be provided by skilled clinician in the home e.g. advance practice nursing, primary care physician. Smaller eligible population so likely best aligned on sub-regional basis --- perhaps through a hub of service aligned to multiple primary care practitioners and teams. Requires face to face monitoring and continuity of the circle of care team. Majority of clients likely to be high risk populations such as frail elderly home bound and/or transitional care post hospitalization of targeted conditions such as congestive heart failure, COPD and multiple morbidities Page 36 of 43

37 Care Coordination Models in Primary Care There is no one model of care coordination that has proven to meet the needs of all patient populations. Gayle Seddon, {insert title}, will provide an overview of the care coordination models that are currently being used in the region for the purposes of the Workshop the models have been given working titles these titles and models may change over time.. Staffing Role / Activities Clients Embedded Liaison Info & Referral Transitional Care Coordinator Works in a Primary Care Practice Exclusive caseload of Primary Care Clients On-site member of inter-professional team Complex Need Clients Homebound Clients Care Coordinators Assigned to Primary Care Practices Standard hours when available at primary care site Key Conduit for all Community services Shared clients community and primary care Care Coordinators and Team Assistants Integrated Call Centre Health Line Website Client updates Clients with infrequent need for information or access to services Integrated interagency team Help to stabilize client needs & plan coordinated care Transition to most appropriate agency for care Most complex need clients with services across multiple agencies Geography Small 5 km radius Defined region size to be determined To be Determined Existing Health Links regions Page 37 of 43

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