Coordinated Care Planning

Coordinated Care Planning What is a Coordinated Care Plan? A plan for your care that is created with you and your family (as per your direction) and involves all the members of your health care team. What s involved? Your care team will meet with you and your family to design a care plan that meets your specific needs and goals. Allied Health Professionals Primary Care Specialists Community Service Providers After the meeting you will have: Hospitals An individualized, coordinated plan focused on your goals Care providers who ensure the plan is being followed Support to make sure you are taking the right medication A care provider that you can call someone who knows you, is familiar with your situation and can help CCACs Long-Term Care

Why is your consent needed? To create a plan to improve your care, some information may need to be shared by your care team in order to: Determine eligibility for certain services Provide services Evaluate the services provided Plan Programs How will we protect your privacy? We will only collect, use, and disclose the minimum amount of your personal health information necessary to fulfill one of the purposes described above. Our goal is to provide the right care, at the right time, in the right place. Questions? Sandra Beausoleil, Project Manager (705) 645-2412 ext. 219 www.muskokahealthlink.ca Email: healthlink@muskoka.on.ca Secure Fax: 705-645-9358

Muskoka Community Muskoka Health Link Frequently Asked Questions Q1. What is Muskoka Health Link? A1. Muskoka Health Link is a team of providers in Muskoka (primary care, hospital, home care, community care, long-term care providers, community support agencies, and other community partners) working together to provide coordinated health care to Clients with multiple complex conditions often seniors with the Client at the center. Providers design a care plan for each Client and work together with Clients and their families to ensure they receive the care they need. Q2. What are the Guiding Principles of Muskoka Health Link? A2. The Ministry of Health and Long Term Care (MOHLTC) provided the following for Health Link Guiding Principles: 1. Regular and timely access to primary care for complex Clients; 2. Effective provision of coordinated care for all of Ontario s complex Clients; 3. Consistent, quality care across the health care continuum and social services sectors; 4. Focus on vulnerable populations (frail and elderly, mental health and addictions, and palliative); 5. Evidence-based, measureable improvement of the Client experience through enhanced transitions in care; 6. Maximize coordinated care to generate system value, sustain the Health Link Model, and strengthen care coordination processes to realize greater efficiencies; 7. North Simcoe Muskoka Local Health Integration Network (NSM LHIN) has accountability for performance. NSM LHIN provides oversight of Muskoka Health Link and is accountable to the MOHLTC for Muskoka Health Link s performance; and 8. Shared MOHLTC, NSM LHIN, and Muskoka Health Link s accountability for overall success. 1

Muskoka Community Q3. What is Muskoka Health Link doing for Muskoka? A3. Our key goal is to strengthen linkages between primary care and the broader system of health and social services. Rural communities have easier access to primary care in Muskoka through the Muskoka Community Health Hubs in Dorset, Port Carling, Wahta, and the Mobile Unit which provides services to Vankoughnet, Port Sydney, and Severn Bridge. Developing coordinated care plans for clients with complex or chronic health and social needs. Q4. Who can receive coordinated care planning through Muskoka Health Link? A4. Any individual who is: 1. Living with complex conditions and is a high user of the health system, or is at risk of becoming a high user of the health system in one or more of the following ways: o Individual hospitalized in the last 3 months o 1 or more visits to the emergency department in the last month o Greater than 3 contacts with primary care provider in the last month o Greater than 3 organizations providing care to this individual AND 2. Currently dealing with 4 or more of the following criteria: o Lives Alone o Multiple Medications (5+) o Caregiver Burnout o Identified Disability (e.g. physical, visual, hearing, other) o Addiction Issue(s) (e.g. alcohol, smoking, drugs, gambling, other) o Chronic Disease(s) (e.g. diabetes, CHF, COPD, cancer, other) o Failure to Cope at Home o End of Life / Palliative o Poor Nutrition o Low Income / Ontario Works / ODSP o Cognitive Impairment / Dementia o o Frail o Risk of Falling o Other Mental Health Issues (e.g. depression, bipolar, PTSD, schizophrenia, other) 2

Muskoka Community Q5. How can you become a Muskoka Health Link Client? A5. Ask how you can be connected to Muskoka Health Link by speaking to your primary care provider or social services provider. More information can be found on our website at muskokahealthlink.ca. Q6. Who can refer clients to Muskoka Health Link? A6. Any health care provider or social services provider, including: Primary care providers (i.e. physicians, nurse practitioners, etc.) Family health teams Social service agencies North Simcoe Muskoka Community Care Access Centre Canadian Mental Health Association Muskoka Parry Sound Muskoka Algonquin Healthcare (Hospitals in Bracebridge and Huntsville) Muskoka Paramedic Services Ontario Provincial Police Fire Fighters Hospice Schools Other 3

Muskoka Community Q7. What is the Muskoka Health Link Referral Process? A7. Muskoka Health Link has attempted to make the referral process as efficient as possible. 1. Identify and refer clients who meet the criteria as outlined on the Muskoka Health Link Eligibility Form (as indicated in Question 4 above). a. Obtain Client consent and have the Client sign the Muskoka Health Link Participant Consent Form; b. Complete the Muskoka Health Link Eligibility Form; and c. Securely fax the completed Eligibility Form and signed Participant Consent Form to 705-645-9358. 2. A Health Link Care Navigator will be assigned to work with the Care Team to assist and support the Client s needs: a. Muskoka Health Link Needs Assessment Tool may be used to identify Client goals; b. A Coordinated Care Plan will be completed for the Client; and c. Scheduling a Coordinated Care Conference, if required. Q8. What is a Coordinated Care Plan? A8. A Coordinated Care Plan is: A document that summarizes the Muskoka Health Link Client s needs, goals, barriers, identifies Care Team members, and shows a plan to meet the Client s goals, including advanced care plans; Shared with all Care Team members; and Anticipated to be updated based on the progress of the Client. 4

Muskoka Community Q9. Who are the Muskoka Health Link System Navigators and the Muskoka Health Link Care Navigators? A9. System Navigators are health care or social services providers who are the most appropriate primary contact to support the Muskoka Health Link Client. System Navigators may be primary care providers, social workers, case managers, patient experience flow navigators, or care coordinators. Care Navigators may act as System Navigators, or may act in a supportive capacity to the System Navigators. Care Navigators also work together to improve efficiencies to the Muskoka Health Link process so that Clients receive the best care possible. Q10. What do System Navigators and Care Navigators do? A10. System Navigators and/or Care Navigators: Are responsible for collaborating with Muskoka Health Link partners to identify and link Health Link Clients with health, social, and community services and programs; Aid in the facilitation and development of the coordinated care plans with care partners and providers, organizes and facilitates coordinated care conferences, monitors Clients needs, conducts surveys, and evaluates outcomes; Arranges, coordinates, and ensures the effectiveness of the services being provided to Clients with multiple medical and/or socially complex needs; Communicates with Clients to explain the Muskoka Health Link approach to care, schedule meetings and coordinated care conferences, completes assessments / reviews, and maintains regular contact with Clients and care partners; and Facilitates communication and collaboration with members of the Care Team, the Client, and their caregivers in order to optimize outcomes and to ensure the Client s goals are met. 5

Muskoka Community Q11. What is a Coordinated Care Conference? A11. The purpose of the Coordinated Care Conference is to bring together the Care Team to share information and to collaboratively create an action plan for meeting the Client s expressed goals and needs. The Coordinated Care Plan will be finalized at the Coordinated Care Conference and will be shared with the Care Team along with the signed consent. When possible, the Client should be present at the Coordinated Care Conference. If they are not able to attend or choose not to attend, efforts should be made to ensure that a caregiver is present and that the Client s goals are understood and clearly recorded in the Coordinated Care Plan as a result of the Client interview. Q12. What is the role of the Coordinated Care Conference? A12. The role of a Coordinated Care Conference is to: 1. Review, confirm, or revise a Client s Coordinated Care Plan (CCP), including goals; 2. Identify any gaps in programs, supports, and services required to implement the CCP; 3. Problem solve for better coordination of services to address any gaps in programs, supports, or services; 4. Clarify roles of each team member, including the client and family / caregiver; 5. Identify any other service providers who should be added to the Care Team going forward; and 6. Assign or re-assess the most appropriate provider to serve as System Navigator, or Care Navigator. 6

Muskoka Health Link facilitates bringing care providers together to coordinate and improve care delivery for individuals living with complex and chronic health needs. Patient/Client Eligibility Step 1: Checklist and Referral Information Page 1 of 2 INSTRUCTIONS: Please securely fax completed form and consent to 705-645-9358. A. PATIENT/CLIENT INFORMATION Eligibility Assessment Date: Patient / Client Name: Date of Birth: (Health Link is NOT age specific) Client Phone: ( ) Gender: Female Male Heath Card Number: Town/Community: (Please include HC version code, e.g. xxxx xxx xxx AA, where AA = version code) B. HEALTH LINK (HL) PATIENT/CLIENT IDENTIFICATION Using the criteria below, is the individual living with complex conditions a high user of the health system and/or at risk of becoming a high user? (Please check all that apply.) Individual Hospitalized in the last 3 months 1 or more visits to the emergency department in the last month Greater than 3 organizations providing care to this individual Greater than 3 contacts with Primary Care Provider in the last month Please list, if known. Note: if more than 5, please document in the Client s Coordinated Care Plan. Organization Contact Name Contact Email Contact Phone C. HEALTH LINK (HL) CRITERIA Does the patient also meet 4 or more of the identified criteria below? (Please check all that apply.) Lives Alone Caregiver Burnout Cognitive Impairment / Dementia Poor Nutrition Failure to Cope at Home Low Income/ Ontario Works / ODSP Frail Multiple Medications (5+) Risk of Falling End of Life / Palliative Chronic Disease(s) (e.g. diabetes, CHF, COPD, cancer, other): Please list. Addiction Issue(s) (e.g. alcohol, smoking, drugs, gambling, other): Please list. Mental Health Issues (e.g. depression, bipolar, PTSD, schizophrenia, other): Please list. Identified Disability (e.g. physical, visual, hearing, other): Please list. Other: Please list. When your health becomes more complicated, you often have more appointments, confusion with knowing the providers and what they do and maybe duplication or missed appointments. Health Link puts you in the centre with all of your providers working together to better coordinate care for you by developing a care plan to meet your needs. Health Link Eligibility Form Version Date: February 2017

Muskoka Health Link facilitates bringing care providers together to coordinate and improve care delivery for individuals living with complex and chronic health needs. Patient/Client Eligibility Step 1: Checklist and Referral Information Page 2 of 2 D. ACCESS TO PRIMARY CARE Does Patient/Client have a Primary Care Provider (PCP)? Yes No If Yes, provide name of PCP: PCP Phone: ( ) E. HEALTH LINK (HL) CARE TEAM Name of person who completed this form: Title: Email: Organization: Phone: ( ) Has a Coordinated Care Plan (CCP) been developed? Yes No (CCP includes Name of System/Care Navigator, Names of Care Team Members, Summary of Patient/Client Needs and Goals, Linkage to Advanced Care Planning if appropriate, and has been developed with Patient/Client and/or Caregiver, System/Care Navigator, and Care Team.) If Yes, provide the date when the CCP was developed (mm/dd/yy): If Yes, please provide the name of the organization/agency where the CCP is stored: If No, the CCP has not yet been started, please identify reason: Provide Name of Primary Health Contact / System Navigator (e.g. Care Coordinators, Social Workers, Nurse Practitioners, Case Managers, others): Provide Email and Phone of Primary Health Contact / System Navigator: Email: Phone: ( ) F. HEALTH LINK (HL) PATIENT/CLIENT CONSENT Patient and/or Health SDM/POA Accepts HL Service and has Completed HL Consent Form: Yes No If No, please identify reason: Please fax completed Health Link CLIENT ELIGIBILITY FORM and signed Health Link CONSENT FORM to: 705-645-9358 When your health becomes more complicated, you often have more appointments, confusion with knowing the providers and what they do and maybe duplication or missed appointments. Health Link puts you in the centre with all of your providers working together to better coordinate care for you by developing a care plan to meet your needs. Health Link Eligibility Form Version Date: February 2017

Muskoka Health Link Participant Consent Form Name Date of Birth / / (mm/dd/yyyy) I understand that in order to receive the best possible health outcomes, some information relevant to my care may need to be shared in order to: Determine eligibility for certain services; Provide services; Evaluate the services provided and plan programs. I understand and agree to the collection, use and disclosure of my personal health information with those care providers participating in the Health Link that have put information management practices and systems in place to make sure my information is shared only as necessary to fulfill the purposes described above. I understand that the Muskoka Community Health Link may ask for permission to disclose some of my information to additional service providers, on my behalf, with my specific agreement. I understand and agree that the Muskoka Community Health Link will only collect, use and disclose the minimum amount of my personal health information as necessary to fulfill the purposes described above. I also understand that I may: Withdraw consent for the sharing of personal health information by notifying my care provider; Have access to my information being held by my care provider by making a request to the care provider; Find out more about the Health Link and the way it manages my personal health information at www.muskokahealthlink.ca Forward any questions I may have about my information or make a complaint if I believe that my personal health information has not been managed properly by contacting: Sandra Beausoleil, Project Manager Phone: 705-645-2412 x219 Yes, I have received the Health Link Post Card and have discussed this information with my care team. Printed Name of Health Link Client or Substitute Decision Maker Signature of Health Link Client or Substitute Decision Maker Date (mm/dd/yyyy) Printed Name of Witness Signature of Witness Date (mm/dd/yyyy) www.muskokahealthlink.ca Version Date-February 2017

Coordinated Care Plan (CCP) Template Step 2: Health Link Coordinated Care Planning INSTRUCTIONS: Complete this form in collaboration with the Client and/or Health SDM, the Care Team, and HL Navigator. A. Coordinated Care Plan (CCP) Details Date Developed: Developed By: Next Review Date: Reviewed By: B. Health Link (HL) Client Information Given name: Preferred name: Surname: Date of birth: Telephone number: Marital status: Health card number: Official language: Ethnicity / Culture: People who live with Client: Where Client currently lives: People Client relies on most at home: People who depend on Client: Main Client contact: Relationship to Client: Telephone number: Emergency contact: Relationship to Client: Telephone number: Name(s) of Power of Attorney (POA), or Substitute Decision Maker (SDM) for Health: Telephone number of Power of Attorney (POA) or Substitute Decision (SDM) for Health: C. Health Link Client Care Team Name Role or Relationship Telephone # Primary Health Contact / System Nav. Participated in CCP?Y/N Health Link Care Navigator Has the Client and/or Health SDM been involved in the development of coordinated care plan? Revised: February 2017 Page 1

Coordinated Care Plan (CCP) Template Step 2: Health Link Coordinated Care Planning D. Client Medical Information Medical Diagnosis: Medications: See Attached (copies of medications from Pharmacies) Medication Review / Reconciliation Needed Past Medical History (May include allergies, significant surgeries and/or implanted devices such as pacemakers, transplants, stents.): Pharmacies Used in the Past 12 Months Name Tel E. Client Goals For Health and Well-Being Date Developed: What is most important to the Client right now: What does wellness mean to the Client: What are the Clients strengths and weaknesses: Expected Outcome (What Client Hopes to Achieve) Steps to Achieve Goal (What Client Can Do to Achieve it) Who Will be Responsible Barriers and Challenges Results So Far Review Date Revised: February 2017 Page 2

Coordinated Care Plan (CCP) Template Step 2: Health Link Coordinated Care Planning Expected Outcome (What Client Hopes to Achieve) Steps to Achieve Goal (What Client Can Do to Achieve it) Who Will be Responsible Barriers and Challenges Results So Far Review Date Expected Outcome (What Client Hopes to Achieve) Steps to Achieve Goal (What Client Can Do to Achieve it) Who Will be Responsible Barriers and Challenges Results So Far Review Date Revised: February 2017 Page 3

Coordinated Care Plan (CCP) Template Step 2: Health Link Coordinated Care Planning Expected Outcome (What Client Hopes to Achieve) Steps to Achieve Goal (What Client Can Do to Achieve it) Who Will be Responsible Barriers and Challenges Results So Far Review Date F. Client s Plan for Future Situations / Advanced Care Planning Do you have a plan for your future care? YES NO Would you like more information to help make plans for your future care? YES NO FOR HL NAVIGATORS ONLY: Copy of CCP provided to Primary Care Practitioner? YES NO Comments: Revised: February 2017 Page 4