The Health Link Approach to Coordinated Care Planning Working together to improve care coordination and transitions between services

Presentation Outline What is Health Link and why is it important? 1 Why should providers get involved? 2 Coordinated Care Planning 3 Patient Story 4

Organizations Participating in Our Health Link Aamjiwnaang Health Services (First Nation) Alzheimer Society of Sarnia-Lambton Bluewater Health Central Lambton Family Health Team Chatham-Kent Health Links CMHA Grand Bend Area Community Health Centre Kettle & Stony Point Health Services (First Nation) Lambton County Community Paramedicine LHIN Home and Community Care March of Dimes North Lambton Community Health Centre Rapids Family Health Team Red Cross Twin Bridges Nurse Practitioner Led Clinic

How is Health Links Funded? Health Links are funded by a Provincial initiative through the LHINs. It is an approach to care and there is no cost to primary care providers.

Why Health Links? 5% of the population accounts for 66% of health care costs Most people with many health needs see a lot of different people for support Difficult for clients and their families to arrange appointments, keep all the information straight, and understand the role of each care provider Difficult for providers to understand how they can best support people with many needs, without duplication of services

What is Health Links? Team of providers in a geographic area (primary care, hospital, community care, long-term care, and community support agencies) working together to provide coordinated health care to people with multiple complex conditions. Providers design a care plan for each patient and work together with patients and their families to ensure they receive the care they need.

The Goal of Health Links With an emphasis on coordinated, person-centred care, the goals of Health Links are to: Improve the health care experience for people with complex needs by focusing of the person’s goals Reduce unnecessary visits to hospital and emergency departments Decrease overall health care costs

How will Health Links Help my Practice? Receive support to manage your complex patients/clients Improve coordination and continuity between care providers Provides a centralized document and contact person to help coordinate care, relay information and support patient/client goals "I feel the client was able to hear from all parties how her goals could be achieved and could feel the support of all involved. …this conference was a great success”

Who is the Target Population General target population guidance. Anyone who could benefit from a CCP should be offered one – its about prioritizing need.

Why Coordinated Care Planning? ESC LHIN Service Providers Video ESC LHIN Patient Video

Coordinated Care Planning (CCP) Collaborative approach that supports all of the people an individual needs for their care, to collectively understand the goals of the individual and develop a care plan to best support those goals The coordinated care plan is based on the individual’s goals

What is the CCP Process?

From a client/patient’s Perspective… A coordinated care plan is a document that is made up of your own health care goals and plans so you do not have to answer the same questions each time you seek medical services. The coordinated care plan also includes important information such as who to contact if you have questions about your health care.

What is the Role of a Health Links Case Manager? Work with patients/clients to understand their unique health care needs Help to coordinate resources and supports, and work closely with primary care providers and other members of the care team Ensure patient/client goals are well understood, and then develop an individualized Coordinated Care Plan to support achievement of these goals

How Does the Team Communicate? South East Integrated Information Portal (SHIIP) Technology enabler that helps to: Identify people with complex health care needs Link activity across care providers in multiple sectors in real or near time Facilitate care coordination Generate metrics for decision making Collaborate Partnership

Patient Story: About the Patient Martha is a 94-year-old widow who has multiple comorbidities, including vascular parkinsonism and visual impairment. She has a live-in caregiver and two supportive sons.

Patient Story: Health Links Support Martha was referred to the Geriatric Outreach Team (GOT) for investigation of syncope after an admission to hospital. She reported low mood due to visual impairment and isolation in the home, and decreased mobility, resulting in deconditioning and difficulty with transfers; she was taking 16 medications.  

Patient Story: Health Links Support Con’t Martha received an in-home visit from the LHIN (formerly CCAC) Care Coordinator and a care provider with a Care of the Elderly (COE) designation, who together completed a comprehensive assessment and developed a joint coordinated care plan with Martha. The COE care provider engaged Martha’s primary care provider to facilitate sharing of the coordinated care plan (CCP). All partners then facilitated comprehensive in-home care, with positive, client-focused outcomes as part of the plan.  

Patient Story: Health Links Support Con’t Recommendations included strategies to improve mood, such as having regular daily routines and trying new activities, increasing socialization by attending a community program, and improving her ability to cope with visual impairment frustrations. A physiotherapist conducted a home safety assessment and taught Martha exercises to improve strength, function, and mobility to reduce her risk of falls.  

Patient Story: Today Martha feels physically better with discontinuation of three medications and her primary care provider is engaged and aware of all changes to her coordinated care plan.   

How To Access Health Link? Health Link Lead Case Manager – North Lambton CHC Melissa Erdodi: merdodi@nlchc.com t. 519-344-3017 Ext 246 LHIN Home and Community Care: HL referrals can also be received by LHIN Home & Community Care t. 519-337-4679 Internal Referrals via Agency-identified Case Managers Join our Health Link Steering Committee: Kathy Bresett: kbresett@nlchc.com t. 519-786-4545 Ext 240

Questions and Dialogue