1. HEALTH LINKS Nepean Sportsplex May28, 2013 Peter McKenna Rideau Community Health Services

2. The context Health care spending: current trend ▫29 billion 2003; 46 billion 2012; 50 billion 2014/15 The demographic challenge ▫With increase in aging population, current spending pattern would significantly increase spending projections The opportunity ▫Opportunities for reform, system readiness for change, technological advances, increasing body of evidence

3. Future State Vision: To make Ontario the healthiest place in North America to grow up and old A system focused on wellness Faster access to family health care that serves as the hub of their health care system Better integration and accountability

4. The concentration of health care spending in Ontario 5% of the population accounting for 66% of expenditure Conditions: ▫Mostly chronic (heart failure, chronic obstructive pulmonary disease, myocardial infarction...) ▫Infection (pneumonia & urinary tract) ▫Stroke and hip fracture ▫End of life ▫Cancer

5. What is a Health Link?

6. Health Links Measurement Framework Operational (Setting the Stage for Coordinated Care) Coordinated Care plans for all complex patients Greater number of complex patients with regular and timely access to primary care provider Six Results-based Metrics (Moving the Needle) Reduce: time from PC to specialist, #30 day readmissions to hospital, # avoidable ED visits, time from referral to home care, unnecessary admissions to hospitals Ensure PC follow-up within 7 days of discharge from acute care setting Evaluation Based Metrics (How we will know we’ve arrived) Enhance patient experience Achieve ALC rate of 9% or less Reduce average cost and keep quality of care

7. Health Link- mandatory requirements Minimum population of 50,000 Includes health care providers in the care of high use/ high need patients Ability to identify and track high use/need populations Minimum of 65% of primary care providers engaged

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9. Health Links, South East LHIN ** after feedback from Webinar and Primary Health Care Council meeting 9

10. a a Perth and Smiths Falls FHO Solo Family Doctors Smiths Falls NP Led Clinic Country Roads Community Health Centre Smiths Falls Hospital CCAC VON Mental Health Services Community Support Services Addictions Public Health South East Health Collaborative Rideau Community Health Services Perth Hospital Perth Family Medicine FHO Patient (and family)

11. Experience in Province 19 Early adopters Cross section of co-ordinators (CHCs, hospitals, CCACs, FHT/FHOs) Various approaches to implementation EMR/IT focus ▫ED notification or tracking of high use patients most common objective ▫Interest in connectivity, particularly with community care Encouraged to focus on care co-ordination, complex patient attachment