1. 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

2. 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

3. 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

4. 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 

5. 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.

6. 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

7. High Level Coordinated Care Process Model

8. Health Links Value Streams

9. 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)

10. 1.1 Retrospective Identification

11. 1.2 Real-Time/New Client Identification

12. 1.3 Self-Identification

13. 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. 

14. 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:

15. 2.1 Invite and Setup Home Visit

16. 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.

17. 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

18. 3.1 Gather Information from Other Health Service Providers

19. 3.2 Conduct Initial Home Visit and Complete Assessments

20. 3.3 Obtain Expressed Consent

21. 3.4 Initiate Coordinated Care Plan

22. 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

23. 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 services within the tool.

24. 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

25. 4.1 Engage Primary Care Provider

26. 4.2 Build Initial Health Links Integrated Care Team

27. 4.3 Host Initial Client Case Conferences

28. 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.

29. 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

30. 5.1 Client Access to Health Link Care Plan

31. 5.2 CCP Updates

32. 5.3 Client Status Change

33. 6.0 Re-Assess Client/Patients
Clients will be periodically assessed using a variety of methods.

34. 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.)

35. 6.1 Periodic Assessments

36. 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.

37. 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

38. 7.3 Warm Hand-Offs – Providers

39. 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

40. 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

41. 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.

42. Questions