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Healthy Change - Community Health Links

Frequently Asked Questions

What is a community Health Link?

Ontario's health care providers work hard to provide a better care experience for their patients but there's still often a lack of coordinated care. These "silos" are where gaps develop.

As Health Link members, health care providers in a geographic area (primary care, hospital, home community care and long-term care) work together to provide coordinated health care to patients – with the patient at the centre.

Health Links better and more quickly coordinate health care services for patients with complex needs, especially seniors. By linking local health care providers to share information and provide patient-centred solutions, community Health Links improve transitions between primary care providers, specialists, hospitals, home care, long-term care and community agencies.

Health Links meet the needs of complex patients – those with multiple conditions who see many different providers that can result in a lack of coordination in care delivery.

Why do we need community Health Links?

We need to close the gaps that often occur as patients move from one health care provider to another. Coordinating care is vital to improving the services for patients with complex needs.

Often these patients are seniors, have multiple chronic diseases and may have mental illness. These people often default to the emergency department and are repeatedly re-admitted to hospital when they could (and should) be receiving more appropriate care in their community.

About 75 per cent of seniors with complex needs who are discharged from hospital receive care from six or more physicians and 30 per cent get their drugs from three or more pharmacies. The result is lower quality care that costs the health care system more.

Health Links put patients at the centre of our health care system with family health providers guiding the patient's journey through the health system.

By bringing local health care providers together as a team, community Health Links give providers the ability to quickly connect patients with specialists, home care services and other community supports. For patients discharged from hospital, it allows for timely follow-up and helps reduce the likelihood of readmission to hospital.

Patients with the greatest health care needs make up five per cent of Ontario's population but use about two-thirds of Ontario's health care dollars. Better coordination of care for these patients will result in better care and significant health system savings that can be devoted to other areas of health care. This will ultimately improve both patient care and the sustainability of public health care.

Health Links are a critical component of Ontario's Action Plan for Health Care. They will help patients receive the right care, at the right place at the right time.

How will community Health Links benefit patients/clients?

People need to be supported wherever they contact the health sector and especially as they move from one provider to another.

When health care providers are working as a team, they are more involved in the full patient journey through the health system. This means:

  • Patients and their families are involved in creating a comprehensive, coordinated care plan that is available to the entire care team. This means everyone is "reading from the same playbook" and the patient's voice is always front and centre.
  • When a patient has questions, there is one person to call, eliminating unnecessary appointments.
  • The care team can think creatively about what support is needed and how it is provided because everyone is at the table with the goal of patient care in mind.

Health Links also clarify the role each provider plays in a patient's health care experience, something that can be particularly confusing for people with multiple conditions. 

Health Links aim to reduce patient and family worry and increase their confidence.  Patients will no longer fall through the cracks and will feel assured that there is a tightly-knit team of providers caring for them.

Why start with complex patients?

Complex patients are those with multiple conditions who use the system often (e.g., family doctor, nurse practitioner, walk-in clinics, ER, specialists, tests), which can result in fractured, uncoordinated care.

Complex patients might be seniors, people with multiple chronic conditions such as heart failure, cancer and a mental health illness. They are the most likely to receive unnecessary or inappropriate care.

Complex patients represent five per cent of our population, but use about 66 per cent of health care dollars. If we improving the coordination of patient care allows us to achieve even a 10 per cent reduction in costs for the highest users, we could re-invest as much as $2 billion into other health care priorities.

Providers in community Health Links work together to determine how the needs of these patients can be best met. This might mean re-designing or adjusting current programs to ensure they are better serving the most complex patients.

How will care improve for complex patients?

To help understand how a community Health Link can help a patient, let's look at a real-life example.

Bernice (not her real name) is a senior who lives at home independently. A personal support worker with the local Community Care Access Centre (CCAC) visits once a week and her children visit regularly.

One day, Bernice fell and gashed her arm. She called 9-1-1 and was taken to hospital in an ambulance. She was treated in hospital and sent back home. Her family doctor wasn't notified and Bernice received no follow up care. When the CCAC next came, they were surprised to find out that she had been injured.

A year later, Bernice fell again, and broke her hip. She was once again sent to hospital by ambulance. She waited three days in the ER, and was then transferred to another hospital where she had surgery. She spent six months recovering in the hospital, and contracted MRSA, a hospital-based infection. She then sold her house and moved to a long-term care home.

The "system" could have served Bernice better. To care for her in her long-term care home over the next five years will cost nearly half a million dollars and may not be the most appropriate place for Bernice.

With health providers coordinating care through a community Health Link, Bernice's story could look much different:

Bernice lives at home. The CCAC comes once a week and her kids are regular visitors. One day, she falls and gashes her arm. EMS comes, fixes her up on the spot and notifies her primary care provider. Her primary care provider makes a geriatric assessment referral on the spot and updates her coordinated care plan. Her children go with her to the appointment, and learn how they can improve Bernice's mobility. Bernice is then enrolled in a falls prevention program, where she makes new friends and starts going to Bingo.

One day, leaving Bingo, she slips and falls on the ice and breaks her leg. She is taken to her local community hospital. Staff members at the community hospital call the designated referral hospital and have Bernice transferred right away for surgery, her coordinated care plan is updated and her primary care provider is notified. Following her surgery, Bernice is transferred back to the community hospital where she recovers. A week later, she is discharged to a transitional care program for a month. She is then sent back home, with on-going support to help maintain her functional ability.

Caring for Bernice in her home, with access to health care in the community, will cost about $100,000 over the next five years. Throughout Bernice's journey, her care plan is updated, her primary care provider is made aware of her changes and Bernice and her family are consulted throughout the process.

What are the health system benefits?

Health Links benefit the entire health care system by delivering :

  • Appropriate care and care settings for complex patients - complex patients get the specific care they need, freeing up resources for other patients.
  • Increased patient satisfaction through better coordinated care.
  • More efficient use of resources - fewer repeated tests.  Complex patients don't receive unnecessary and/or inappropriate care, freeing up resources for other patients.
  • Shorter wait times, with more appropriate use of the ER - people in the ER who actually require emergency medical attention get it faster, because complex patients receive the care they require, at the right time and in the right place.
  • Fewer readmissions to hospital - complex patients receive appropriate follow-up care in the community, so they aren't coming back to the hospital due to gaps in their care plan.
Is Health Links based on an existing model already in place?

The ministry heard from a number of our system partners, associations and health care providers who have been looking at similar ideas.

In 2012, the Change Foundation (an independent health policy think tank) announced the Northumberland Community Partnership as winner of its $3 million investment for its Partners Advancing Transitions in Healthcare (PATH) Project. PATH targeted seniors with chronic health conditions and their caregivers, because they are frequent users of our system.

The Northumberland Partnership is a great example of how small groups of health care providers across Ontario are working together to make access to care a priority for patients, by providing those in greatest need the right kind of care, when they need it, and in a place that makes sense.  The Northumberland Community Partnership unites 12 health and social care organizations with patients and caregivers, who identify health care transition problems and work together with providers to redesign care, improve experiences and strengthen the system.

Key elements of the model include improving public education, training and tools for providers on how to shift to a person-centred care model, ensuring better seniors' support, and making better use of IT to support patients and connect providers.

Accountable Care Organizations (coordinated care models whose payments are tied to quality and results) have been growing in the United States since 2009 and are similar to the community Health Links concept.

There are also a number of other projects in the United States and Europe, where efforts are focused to design a system the needs of the most complex patients.

What kinds of health care providers could belong to a community Health Link?

Health Links are made up of providers who care for patients in a region and include practitioners from primary care, hospital and the community.  For example:

    • Primary care – family provider (e.g., doctors and nurse practitioners)
    • Hospital – ER staff, surgeons and other specialists (e.g., radiologists)
    • Community – coordinators for home care (e.g., personal support workers, nurses) community services (e.g., CCAC case coordinators, meals on wheels, YMCA)
    • Mental health providers
    • Long-term care homes
What is the current status of Health Links?

There are now 47 community Health Links across the province.  We are continually bringing on community Health Links as they are ready. The ministry is working with LHINs to identify new partnerships ready to proceed.

Where can I learn more about community Health Links?

Information about community Health Links and Ontario's health care system transformation is available at www.ontario.ca/leadinghealthychange.

For More Information

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