Advancing Health Links: Using Year 1 Results to Move Forward

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1 Advancing Health Links: Using Year 1 Results to Move Forward

2 Progress to Date Province: 3,264 WW: 1,014 CARE PLANS PRODUCED Health Links are improving their care plan processes and laying the groundwork for more coordinated care Integrated Care led by agencies from all sectors WW: FHT - 3 CHC - 1 Province: 14 LHINs WW: 4 HLs Are working collaboratively with their partners by: Creating Terms of Reference Standardizing processes and tools Improving and strengthening transitions in care Province: 8,197 patients have been attached WW: 100% of complex individuals from HHC have been attached Health Links have been using Health Care Connect and other resources to find unattached patients Health and social service providers have joined their local health links to service and plan for their communities better Province: 1,000+ Providers engaged WW: 45+ organizations sit on the Steering Committees WW: over 60+ organizations are involved in the Health Links work at some level 2

3 Health Links like work Health Links Principles - One Coordinated Care Plan with Primary Care integral part of the Care Team - Asking the Patient - What Matters to Me? Health Links Connectivity Tables Implementation of Community Paramedicine Programming Improved Case Management between Mental Health & Addictions, CCAC, and Primary Care Development in-homes teams Mental Health & Addictions Top 40 Mental Health Users Project Extraordinary Needs Program Improvement of Assertive Community Treatment (ACT) Teams Here 24 / 7 Palliative Care End of Life Advanced Care Planning End of Life Needs for Aboriginal Population Integration of Palliative Care Teams with In-Home Teams Community Sector Coordinated Access for community support services Specialized Geriatric Services Integrated Geriatric Service Worker GEMS Nurses S t r a t e g i c I n v e s t m e n t s

4 Success to date Health Links are proving to be the way through which many primary care providers are getting better integrated CCAC Case Managers being embedded with Primary Care Intensive Mental Health & Addictions Case Manager, funded by CMHA-WWD, embedded in the Rural Wellington Family Health Teams Coordinated Care Plans used by the In-Home Teams are completed in CHRIS (CCAC) Communication, communication, communication

5 Making a difference to Henry 54 year old man Addicted to alcohol & cigarettes Has COPD Hep C+ Medication for depression & anxiety >45 visits to ED Lives alone in a third floor walk-up High risk for falls Unemployed due to addictions Socially isolated

6 Working Together towards the Same Objective worked with providers across the system to deliver quality care in appropriate settings, to our most complex patients, and you will continue to build upon these successes Letter to the Honourable Dr. Eric Hoskins Minister of Health and Long-Term Care Develop a policy on community hubs, reflecting the perspective of health and wellness Letter to the Honourable Dipika Damerla Associate Minister of Health & Long-Term Care Engaging in a coordinated approach and working with community partners, stakeholders and other ministries, consider mental health and substance abuse issues when delivering front line services Letter to The Honourable Yasir Naqvi Minister of Community Safety and Correctional Services Working closely with the Minister of Health and Long-Term Care to ensure that the health care services provided in home and communities reflect the needs of seniors Letter to the Honourable Mario Sergio Minister Responsible for Seniors

7 Moving Forward Towards Maturity Demonstrate value to the patient and health care system Enhanced Governance Structure Integrated Performance Management Framework Develop a model for shared accountability that supports value, quality and sustainability Quality / Best Practices Framework Increase capacity of Health Links to deliver coordinated care at scale while continuing to enhance patient experience and increase quality of care Use Health Links as the catalyst enhancing performance for vulnerable populations (e.g., mental health, palliative care, frail elderly)