Central East Health Links Supporting the Spread of Health Links and Coordinated Care Planning in the Central East LHIN
Presenters Mandy Lee Quality Improvement Facilitator Central East Health Links Andrea Smith Project Manager Central East Health Links
What is a Health Link? A Health Link is a local health care network consisting of patients, caregivers, Health Care Providers and Community Support Service agencies who are committed to working better together to improve the health outcomes for patients with complex health care needs. Through enhanced collaboration among Health Link networks, patients with complex health care needs, along with their Health Care Providers, will develop individual Coordinated Care Plans that more effectively meet their goals and ensure smoother transitions between care providers.
Target Population The Health Links target population focuses on the top 5% of Ontario s complex patients. Health Links patients typically experience four or more chronic/high cost conditions including: Vulnerable populations (focus on mental health and addictions conditions, palliative patients, and the frail elderly) Economic characteristics (low income, median household income, government transfers as a proportion of income, unemployment) Social determinants (housing, living alone, language, immigration, community and socials services etc.) Complex, high needs patients
What do Health Links Plan to Achieve? Over time, the Health Link approach aims to achieve the best possible health outcomes and enrich the patient s experience of the health care system by reducing wait times, visits to the emergency department, and unnecessary hospital readmissions.
Benefits of Health Links Improved communication between patients/caregivers, primary care providers, hospitals, homecare, and community agencies Improved patient and family satisfaction Better health outcomes and quality of life Easier transitions to/from hospitals and other services Increased efficiencies in the health care system Activities are directed by community and population needs
Improving the Patient Experience The patients journey through the health care system will be improved through more effective communication with their Health Care Providers and more involvement in decision making. By having a Coordinated Care Plan, patients with complex health care needs will benefit by not having to continuously repeat their health story or answer the same questions every time they require care.
Improving the Provider Experience Collaborative care that effectively meets patient goals Improving patient safety by reducing risks and dissatisfaction associated with fragmented care Increased access to up-to-date patient information Improved ability to communicate and problem solve with an inter-disciplinary, multi-organizational team The opportunity to work together to create one, comprehensive Coordinated Care Plan by providing the infrastructure needed for successful coordination of care
Central East Health Link Communities
Central East Communities Snapshot As a geography, a Health Link defines the community of patients to whom efforts and resources will be directed. The specific Cluster size and Health population Link Km2 for each % Health Pop. Link is % as follows: Density/k2 DURHAM NORTHEAST SCARBOROUGH Durham West 449.1 2.7 320,400 21.1 713 Durham North East 2,172.1 13.0 287,800 19.0 132 Haliburton County & City of Kawartha Lakes 7,893.8 47.3 89,310 5.9 11 Northumberland 1,766.9 10.6 72,475 4.8 41 Peterborough 4,215.2 25.3 135,085 8.9 32 Scarborough North 42.4 0.3 178,395 11.7 4,207 Scarborough South 138.3 0.8 434,815 28.6 3,144 Totals 16,667.8 100.0 1,518,280 100.0 (Avg.) 91
Central East LHIN Model for Health Links Integrate coordinated care planning and the Coordinated Care Plan into existing programs Build sustainable processes that do not require new resources Utilize a centralized Project Management Office to support Health Links standardization within the Central East LHIN
Quality Improvement Project
Engaging the Health Link Network Partner Organizations Health Link Network Steering Committee Design Team Improvement Teams
Steering Committees Responsibilities include: Provide oversight of the Health Link community Advance integrated systems of care by mitigating barriers or risks that may impede progress Ensure environmental supports are in place to sustain system improvements Facilitate communication between partners
Responsibilities include: Design Teams Identify change opportunities and areas of focus for the Improvement Teams Develop work plans and design future state Provide oversight of the change ideas at the Quality Improvement Teams Continue to engage Health Link network organizations
Improvement Teams Responsibilities include: Operationalize coordinated care planning Test processes for integrating the Coordinated Care Plan into existing practice Build relationships and enhancing collaborations Identify challenges and risks to bring forward to the Steering Committee and Design Team
Additional Supports for Health Link Network Organizations Offering IHI Open School access to all partner organizations Inviting Health Quality Ontario to provide workshops and training Central East LHIN s Integrated Health Service Plan and Accountability Agreements / Letter of Commitment Working groups developed as needed Quality Improvement Initiatives Funding Proposals
Gaps Analysis To progress the Health Link initiative, the Project Management Office conducts gaps analysis reviews on a regular basis to guide next steps, priority activities and to address any challenges revealed. The Gaps Analysis measures: - Organizations currently testing the Coordinated Care Plan - Challenges Identified - Existing Solutions to the Identified Challenges - Current Work - Future Recommendations
Example: Gap Analysis
Central East Health Links Coordinated Care Planning Framework
Central East Health Links Business Process Map
Operational Guidelines
Central East Health Links Toolkit The Central East Health Links Toolkit is for any individual/ organization that will be participating in coordinated care planning. The Central East Health Links Toolkit describes the Coordinated Care Planning Framework and provides front line staff with the tools and resources available to support the creation and maintenance of Coordinated Care Plans with an inter-disciplinary Care Team which includes the patient/caregiver as equal partners in the patients care.
Where can I find the Toolkit? Available for Download at: http://healthcareathome.ca/cent raleast/en/who/documents/healt h_links/toolkit/cehealthlinks- Toolkit-V2.pdf
Community Sharing Events & Education Days Community sharing days to spread program information in respective communities Education days share available tools and resources Great location, agenda and day! Durham North East Event Participant 400 management and front-line staff in attendance across all Health Links I enjoyed meeting the group and networking. Haliburton County and City of Kawartha Lakes Event Participant [Health Links uses] a great collaborative case conference model. Peterborough County Event Participant It was a very good use of my time hearing about what other organizations do.
Process Improvement Events To work with multiple partners to develop and formalize sustainable processes including front-line staff and management Conducted as small Kaizen events with the intent of making decisions and having agreed upon processes in place at the conclusion of each event
Example: Process Improvement Day Output
Example: Process Improvement Day Output
Spread and Scale Strategies Asking partners to identify others with whom they consistently have shared patients Arranging meetings with leadership Providing education/training Lunch and learns All-staff meetings Program specific meetings Community fairs/open houses
Engaging with Partners Example Northumberland County Health Link Initial State Fourcast NCHL partners currently involved in initiating Coordinated Care Plans CMHA Community Care VON PATH Project CECCAC Port Hope CHC GAIN Trent Hills GAIN CMH Multi-Care Lodge LTC Homes Trent Hills FHT Patient/ Caregiver CMH Port Hope Retirement Homes NHH NFHT Solo Primary Care Physicians Transportation Housing Food Security DVA EMS Police Community and Social Services NCHL partners participating at NCHL Steering Committee/Potential Care Team Members 27/10/2015
Engaging with Partners Example Northumberland County Health Link Current State Fourcast NCHL partners currently involved in initiating Coordinated Care Plans NCHL partners participating at NCHL Steering Committee/Potential Care Team Members CMHA Community Care VON PATH Project CECCAC Port Hope CHC GAIN CMH CMH Multi-Care Lodge LTC Homes Trent Hills FHT Patient/ Caregiver Trent Hills GAIN Port Hope Retirement Homes NHH NFHT Solo Primary Care Physicians Transportation Housing Food Security DVA EMS Police Community and Social Services Specialists 27/10/2015
CMH Community MH Services Community Living Fourcast NHH Community MH Services NCHL partners currently involved in initiating Coordinated Care Plans NCHL partners participating at NCHL Steering Committee/Potential Care Team Members Northumberland County Health Link Future State CMHA Community Care VON PATH Project CECCAC Port Hope CHC GAIN CMH CMH Multi-Care Lodge LTC Homes Trent Hills FHT Patient/ Caregiver Trent Hills GAIN Port Hope Retirement Homes NHH NFHT Solo Primary Care Physicians Transportation Housing Food Security DVA EMS Police Community and Social Services Specialists Alzheimer s Society 27/10/2015
Coordinated Care Plans in the Central East Health Links
Continuing Progress in 2016/17 Development of a common performance measures framework E-learning modules and training videos Continue to engage, educate and train new partners Continue to develop and refine coordinated care planning processes Offer additional Education and Training Sessions Conduct process improvement events
Beyond 2017 Development of train-the trainer models Change management training for Health Link network organizations Full integration of coordinated care planning as standard work
Project Management Office
For More Information Central East Local Health Integration Network www.centraleastlhin.on.ca Ministry of Health and Long-Term Care www.health.gov.on.ca
Questions?
Andrea Smith Project Manager, Central East Health Links AndreaM.smith@ce.ccac-ont.ca Mandy Lee Quality Improvement Facilitator, Central East Health Links Mandy.lee@ce.ccac-ont.ca