Coordinated Care Plan Process Training Workshop South Simcoe and Northern York Region Let’s Make Healthy Change Happen Coordinated Care Plan Process Training Workshop Developed by: SSNYR Health Link October 19th, 2016 Version 1.4

Agenda Health Links Workshop Purpose CCT Background Health Links Target Population Health Links Value Streams High Level Health Links Process Model 1.0 Health Link Client/Patient Identification 2.0 Invite and Engage Clients/Patients 3.0 Gather Information & Initiate Coordinated Care Plan 4.0 Share Information & Conduct Case Conference 5.0 Update & Action Care Plan 6.0 Re-Assess Client/Patients 7.0 Client/Patient Transitions

Workshop Purpose To provide a review of the Health Links Processes associated with the Coordinated Care Plan implementation. To review the major roles involved in Coordinated Care Planning To gather feedback from participants

Health Care Inter-Professional Teams Well-functioning teams have the patient at the centre, communicate easily and frequently, have shared objectives and clear roles and responsibilities, and make decisions together. The Principles and Framework for Inter-Professional Care are: focus on patient needs ensure health services are relevant, based on demographics and community needs provide quality care facilitate access to the right service, at the right time, in the right place, by the right people respect learn from one another and share decision-making consult and communicate 

Coordinated Care Tool (CCT) Background In December 2012, Ministry of Health and Long-Term Care (the Ministry) announced the formation of Health Links. Health Links bring together Health Service Providers (HSPs) across the health care system (primary, community, and acute) to better coordinate care for high-needs clients / patients. Health Links are a “virtual group” who represent a diverse cross-section of champions with participation of coordinators from a variety of organizations such as family health teams to community care access centres. Health Links are tasked with organizing timely, effective, coordinated care around the patient. One of the primary objectives for each Health Link is to establish a coordinated care plan (CCP) for all patients with complex needs. The Health Links Process Model was developed by the SSNYR HL HSPs with input from the Health Link Leads from the Central LHIN and Health Quality Ontario. Health Links is evolving and improvements are happening all of the time. Health Links is a learning organization.

Health Link Target Population The Ministry of Long-Term Care has defined the advanced target population as: Patients with four or more chronic/high cost conditions, including a focus on mental health and addictions conditions, palliative patients, and the frail elderly and/or Income, government transfers as a proportion of income, unemployment and/or Social determinants (housing, living alone, language, immigration, community and socials services etc.) Health Link Total / Overall 4 + Conditions Of Overall Total: High Cost User North York Central 20,650 9,375 South Simcoe Northern York Region 13,030 5,775 South West York Region 9,170 7,720 South East York Region 12,390 5,215 North West York Region 14,245 8,190 Central LHIN Total 79,485 36,275

High Level Coordinated Care Process Model

Health Links Value Streams

1.0 Health Link Client/Patient Identification The following Health Link Identification Processes will help Health Service Providers to enroll clients in the Health Links Model: Retrospective Identification Real time/New Client Identification Self-Identification Common Intake/Referral (TBD)

1.1 Retrospective Identification

1.2 Real-Time/New Client Identification

1.3 Self-Identification

2.0 Invite and Engage Clients/Patients Inviting and Engaging Clients/Patients is the first major step for clients on their Health Links Journey. A key Health Links principle and aim is to actively involve the person in their care and to improve the patient experience. 

2.0 Invite and Engage Clients/Patients The following Health Link Client Invite & Engage Client/Patient Processes will help Health Service Providers to activate clients in the Health Links Model:

2.1 Invite and Setup Home Visit

3.0 Gather Information & Initiate Coordinated Care Plan The Coordinated Care Plan is completed from the perspective of the Health Link client but includes the inputs from the Circle of Care. The Care Team members work together to fill in sections filled out and updated regularly, however, it isn’t always possible to have all sections completed during the first case conference with the client. As such, the Coordinated Care Plan should be shared as soon as possible, even if all of the sections have not been filled out.

3.0 Gather Information & Initiate Coordinated Care Plan The following Health Link Gather Information and Initiate Coordinated Care Plan Processes will help Health Service Providers to activate clients in the Health Links Model: Gather Information from other Health Service Providers Conduct Initial Home Visit and Complete Assessments Medication Review (TBD) Obtain Consent Initiate Coordinated Care Plan

3.1 Gather Information from Other Health Service Providers

3.2 Conduct Initial Home Visit and Complete Assessments

3.3 Obtain Expressed Consent

3.4 Initiate Coordinated Care Plan

3.4 The Coordinated Care Plan- Sections Consent Directives My Identifiers My Care Team My Health Issues My known, current allergies and medications My plan to achieve my goals for care My situation and lifestyle My recent health assessments My most recent hospital visit (auto entry) My other treatments My current supports and services My appointments and referrals

4.0 Share Information & Conduct Case Conference Sharing information is the corner stone of Health Links Care. The electronic version of the Coordinated Care Plan makes this much easier. Additionally, proactive notification of issues can easily be shared with team members using the secure email services within the tool.

4.0 Share Information & Conduct Case Conference The following Health Link Share Information and Conduct Case Conference Processes will help Health Service Providers to activate clients in the Health Links Model: Engage Primary Care Provider Build Initial HL Integrated Care Team Host Initial Case Conference

4.1 Engage Primary Care Provider

4.2 Build Initial Health Links Integrated Care Team

4.3 Host Initial Client Case Conferences

5.0 Update & Action Care Plan “Patient-centered care is about an overall philosophy and approach that ensures that everything individual providers or healthcare organizations do clinically or administratively is based on patient needs and preferences. This covers a range of activities – planning, care, evaluation and research, training, and even staff recruitment.” The Patient Experience in Ontario 2020: What Is Possible? For Health Link Clients this approach is extremely important as Health Link Clients are long-term clients.

5.0 Update & Action Care Plan The following Health Links Update and Action Care Plan CCP Processes will help Health Service Providers improve CCPs.   Client Access to Health Link CCP CCP Updates Health Link Client Status Change

5.1 Client Access to Health Link Care Plan

5.2 CCP Updates

5.3 Client Status Change

6.0 Re-Assess Client/Patients Clients will be periodically assessed using a variety of methods.

6.0 Re-Assess Client/Patients The following Health Links Re-Assess Client/Patients Processes will help Health Service Providers improve CCPs: Periodic Assessments (RAI, OCAN, etc.)  

6.1 Periodic Assessments

7.0 Client/Patient Transitions Health Link clients normally have complex chronic conditions and medical needs that are not likely to improve. A HL client is often on a sliding scale somewhere between being able to totally self-manage to requiring intensive case management. Health Links care management is fluctuating. It is very possible for a HL client can be receiving self-management supports during a more stable phase of their Health Links journey, and at another time receiving intensive care in the hospital during an acute exacerbation of one or more of their chronic conditions, and then return to self-management when the exacerbation diminishes. Clients also have to get accustomed to living on the continuum.

7.0 Client/Patient Transitions The following Health Links Client Transition Processes will help Health Service Providers improve CCPs: Primary Care Provider Appointments Scheduled Prior to Hospital Discharge (TBD) Self- Management Transitions (TBD) Warm Handoffs

7.3 Warm Hand-Offs – Providers

Health Link Roles –Client/Care-Giver Client/Care Giver responsibilities include: Consenting to sharing your Coordinated Care Plan Identifying health care team members if not already identified Establishing health care goals and needs Advising Integrated Care Lead of change in Health Care Status Work towards achieving their goals as per the Coordinated Care Plan Inform new health care team members of existing Coordinated Care Plan

The Lead Health Links Lead Care Coordinator The Lead Care Coordinator (LCC) has a unique role in the Health Links client’s journey. They ensure care continuity. Obtaining Client Consent for Health Links Conducting Client Interview Conducting required Assessments, if required Initiating Care Team Referrals, if required Contacting Care Team Members, acknowledging existing members Initiating the Care Plan (if started in the Hospital may not need to do this). Support the Client in the Health Links Care Plan Acts as the Client Advocate Organizing and facilitating the Care Team Case Conference, inviting Care Team Participants, building relationships with key partners

The Lead Health Links – the Care Team Member Team members act as the eyes and ears for the Integrated Care Lead and the Primary Care Provider often learning of a worsening condition before it is too late. As a member of an inter-professional care team, the team member has responsibilities to: Identify clients who would benefit the most from an collaborative care plan Participate in Coordinated Care Conference Provide past medical history if available Add Client Services to the Care Plan Update Client Services on the Care Plan Support the Client in the Health Links Care Plan Advice Care Team members of any concerns or issues with Health Link Clients.

Questions