Health Bulletins

Update: Health System Integration

February 10, 2017

We are pleased to share this update on the work supported by the Patients First Act, 2016. You will also find this update archived at this link. You may also be interested in the answers to some Frequently Asked Questions at this link.

You can count on regular emails like this as your source of ongoing information and updates, which can also be shared with staff members, local stakeholders and other stakeholders and colleagues.

Health Links: A Model of Local Collaboration

Jurisdictions around the world are examining the ways in which their respective health care systems can be better structured to meet the needs of their populations. Ontario’s Patients First: Action Plan for Health Care, enabled by the Patients First Act, 2016, mirrors efforts internationally to modernize and adapt health care systems to improve patient care and meet current and future challenges.

Ontario’s approach is informed by many of these international experiences. Although health systems differ considerably, Ontario has learned from reform efforts in other provinces in Canada, as well as from the United Kingdom, Australia, Denmark, the United States and other countries. Within our own provincial boundaries, there are several examples of excellence within Ontario’s health care landscape that will continue to drive all of us as we look to continue to innovate, both locally and provincially, to structure our system around the needs of its patients.

Health Links is an example of this. The Heath Links initiative was established in 2012 with the goal of improving care for the 1%-5% of the population who utilize the most services and for whom quality and coordination of care has been inconsistent. The Health Links model involves the identification of complex patients, engagement with them and their families to understand their holistic needs, and coordination across the care continuum to ensure their care plan is managed seamlessly based on individual needs and circumstances. This coordination of care around the patient happens within small geographies under the leadership of Ontario's Local Health Integration Networks (LHINs).

Ontario Patients vs. Provincial Health ExpendituresHealth Links

Due in large part to the commitment of front-line health care providers, the involvement of organizations across the spectrum of care, and local partnership and collaboration, Ontario has made considerable progress through Health Links. There are 82 Health Links. Together, they have developed 26,000 coordinated care plans and helped 37,000 complex patients get attached to a primary care provider. The ways in which Health Links engage with patients, their caregivers and families are diverse and meaningful. 

Ontario’s experience with Health Links teaches us many things about better organizing services around the patient.

One is the emphasis on local or sub-regional activity. Health Link regions enable a more focused look at the needs of a population and a more coordinated approach among the range of health care and social service providers required to address these needs. The new LHIN sub-regions described in last week’s update are in part based on this experience. In fact, based on care patterns in some LHINs, many of the sub-regions align with existing Health Link geographies. Work is underway to develop a plan that would eventually see full alignment across the province.

Another learning is the clinical and collaborative process that has emerged through the Health Links journey. Although the focus of Health Links has been on complex patients, we know that many of the approaches developed through Health Links for patient and family engagement and involvement, on the development of coordinated care plans, and the organization of services around the patient can be applied more broadly. This will be a key planning focus as part of the sub-region lens.

Also, the leadership of LHINs in Health Links provides an illustration of the value of locally-focused health care planning and management. LHINs have been instrumental in supporting local providers and organizations in achieving the positive results we have seen to date within the local context that they operate. LHINs have also identified and helped address provincial-level barriers that stand in the way of advancing improved coordination of care.

What could be most instructive about Health Links, though, is what can happen when local innovation is scaled up through local leadership, collaborative partnerships and patient engagement. One of many examples is the Rural Hastings Health Link.

The Rural Hastings Health Link in the South East LHIN is coordinated by the Gateway Community Health Centre (CHC) in partnership with a broad spectrum of service providers and agencies.

Through the use of a System Navigator, complex patients have been connected to a variety of health and social services to respond to their individual needs. These include referrals to specialists, Community Care Access Centres (CCAC) and Community Support Services (CSS) as well as to Alzheimer Societies, housing agencies, respite care and services through the Ontario Telemedicine Network (OTN). 87% of physicians within the Rural Hastings Health Link are utilizing the services of the System Navigator to get patients connected to the services they need.

Early results achieved from these local partnerships are impressive. All Health Link clients have received medication reconciliation. The number of avoidable emergency department visits has decreased by 87%. Avoidable hospital admissions and readmissions for this target population have decreased by 83% and length of stay in hospital has been reduced by 73%.

Partners in Rural Hastings Health Link were acknowledged last year by the Association of Ontario Health Centres (AOHC) as part of its Transformative Change Award.

What is also impressive about the Rural Hastings Health Link and others like it is the deep engagement of complex patients. Through involvement of patients and their providers in care planning and delivery, not only are Health Links able to build a strong clinical profile of Health Link clients, but they are also able to generate awareness of other factors that impact their health and well-being. In Rural Hastings, clients provide information about their housing circumstance, food security, social isolation, transportation barriers, employment status, education and income so that all of these elements can be addressed in thinking about the best approach to their health care.

Health Links show us that the combination of provincial strategy, local leadership, collaborative partnerships among primary, community, and home care services in sub-regions and deep engagement of patients and caregivers can create a system that truly puts patients first.

More Updates Coming

You can expect regular updates like this as we move forward together.

Next Webinar February 27

You’ll hear from us soon about our next Webinar, which is planned for February 27, 2017, 2:00-3:00pm. That will provide another opportunity to share updates and ask questions.

If you have questions or comments, please send an email to patientsfirst@ontario.ca.

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For More Information
Email: patientsfirst@ontario.ca