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

2. 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

3. 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

4. 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.

5. 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

6. 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.

7. 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

8. 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”

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

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

11. 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

12. What is the CCP Process?

13. 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.

14. 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

15. 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

16. 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.

17. 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.

18. 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.

19. 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.

20. 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. 

21. How To Access Health Link?
Health Link Lead Case Manager – North Lambton CHC
Melissa Erdodi:
t Ext 246
LHIN Home and Community Care:
HL referrals can also be received by LHIN Home & Community Care t
Internal Referrals via Agency-identified Case Managers
Join our Health Link Steering Committee:
Kathy Bresett:
t Ext 240

22. Questions and Dialogue