Standardized Approach, Customized Experience: Health Links in the Central East LHIN

OACCAC Achieving Excellence Together 2015

May 29, 2015

Brian Laundry, Central East LHIN

Craig Robinson, Central East CCAC

Why Health Links?

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Provincial Program Expenses Distribution (2013-2014)

Proportion of Healthcare Expenditures in Ontario

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Current Healthcare Economics

The health system is facing pressure as patients expect and need to

move seamlessly across the continuum of care

Population is changing and the health care system designed 50 years

ago will no longer meet the needs of patients today and into the future

There are still too many barriers, for example… silos of care, funding

not aligned to health goals, need for significant investments in

community care, etc.

Sustainability for the healthcare system

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Provincial Improvement Plans

In 2012, the Ontario Government announced a new plan for health

care reform (Ontario’s Action Plan for Health Care)

Key features include:

Integration of services

Health Services Funding Reform, Quality Based Procedures

(QBP) funding

Coordination of care and services for high health care users

(Health Links)

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Provincial Health Links Outcomes

1. Ensure the development of coordinated care plans for all complex

patients

2. Ensure primary care follow-up within seven days of discharge

from an acute care setting

3. Enhance the health system experience for patients with the

greatest health care needs

4. Increase the number of complex patients and seniors with regular and

timely access to a primary care provider

5. Reduce the time from primary care referral to specialist consultation

6. Reduce the number of 30-day readmissions to hospital

7. Reduce the number of avoidable ED visits for patients with

conditions best managed elsewhere

8. Reduce time from referral to home care visit

9. Reduce unnecessary admissions to hospital

10. Achieve an ALC rate of 9% or less

11. Reduce the average cost of delivering health services to patients

without compromising the quality of care 7

Health Links Are …

About “working better together”

Patient centered and patient involved

Inter-professional, multi-sector planning and care:

- Specialists, primary care providers, home care,

community care and social services; and

- Patients and families/caregivers

Focused on the most complex, high needs patients initially

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Health Links are Not…

Programs

Clinics

CCAC-centric

Provider-centric

Working in isolation

Coordinated Care Plans (CCPs) alone

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Health Links Involve Everyone

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Aligning Health Links and the Triple Aim

Care Imperative

Care is fragmented for patients

with complex needs

Patients and their

families/caregivers are not

optimally involved in their care

and care planning

Economic Imperative

The most complex patients require

an inordinate amount of resources

Failure to control costs through

quality improvement jeopardizes

care for all residents

Health Imperative

Patients with complex needs

experience poor outcomes

and poor quality of life

System inefficiencies result in

awkward transitions and

unnecessary delays in service

and care

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Health Links: An Integrative Model of Care

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The Central East LHIN Approach

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Central East LHIN has a broad

geography and is diverse in its

populations and health care

needs.

The selection of Health Link

geography had to practical,

consistent with patient

utilization patterns and provider

practice representative

A common centralized

approach was essential to

standardization, good planning

and sustainability

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Early Adopters and Emerging Health Links

Patients/Clients and

Family Caregivers

Health

Link Partners

Central

East LHIN

Central

East Project

Management

Office (PMO)

Share their stories

Provide information for

coordinated care plan

Participate on working

groups and improvement

teams

Share ideas for system

improvement

Participate on working

groups and improvement

teams

Engage the all staff

Commit to and share

ideas for system

transformation

Test improvements with

complex patients

Participate in planning

and provide feedback on

MOHLTC submissions

Outreach with

partners and

providers

Facilitate completion

of Readiness

Assessment and

Business Plan

Participate at Health

link planning tables

Share work from other

LHINs

Facilitate

collaboration and

support integrated

care

Participate as a

Health Link partner

Coordinate

completion of

Readiness

Assessment and

Business Plan

Support Health Links

governance structure

Facilitate Quality

Improvement work

Hosted at the CCAC

Roles and Responsibilities within the Central East Health Links

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Central East Health Link Structures

Patient Engagement

Working Group

IT

Working Group

Communication

Working Group

Central East LHIN

Health Link

Steering Committee

Health Link

Design Team

Decision Support

Working Group

Primary Care/Specialist

Engagement

Working Group

Improvement

Team

16

LHIN

SUPPORT

REGIONAL

GROUPS

Health Link Leads

Planners

eHealth Lead

Communication

Leads

Decision Support

Lead

Patient Engagement

Lead

Physician

Engagement Lead

Centralized Project Management Office (PMO)

Health Links in the Central East LHIN

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Health Links Project Management Office (PMO)

Central East

Health Links

PMO

Northumberland

County

Haliburton County

and City of Kawartha Lakes

Scarborough

South

Scarborough

North

Durham

North East

Peterborough Durham

West

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PMO Organization Chart

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CE LHIN

Standardized Roll-Out

Prepare

Readiness

Assessment

Submit

Expressions

of Interest

Prepare

Business

Plan Implement

1

2

Spread,

Sustain and

Evaluate

3

5

6

Design

Small Tests

of Change

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1 MONTH 4 MONTHS 4-12 MONTHS 4 MONTHS +

Patient Engagement, Primary Care Engagement,

Quality Improvement

Common Approach

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6 MONTHS 4-12 MONTHS 6 MONTHS + 3 MONTHS

Actual Timeline

Health Links Maturity Journey

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Health Link Success Factors

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Key factors:

• Resources & Capacity

• Readiness for Change

• Leadership Approach

• Information Technology

• Physician Engagement & Leadership

• Relationship between Organizations

* Health System Performance Research Network (HSPRN)

PMO Lessons Learned Processes can be aligned at a high level

Standardized templates and reduced duplication

Sharing lessons learned and cross pollination abilities

Collaborative work groups

Ability to build a sense of community

Creates a pool of experienced Project Managers and Quality

Improvement Facilitators who are flexible enough to manage or

facilitate all Health Link aspects should the need arise

Improved predictability of project delivery

Consistent, timely communication (Communications Coordinator

support)

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Health Links in the Central East LHIN

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Current State

Recent History

• Complete Strategic Review with Peterborough Health Link

• Submitted business plans for four new Health Links

- Northumberland County

- Haliburton County and City of Kawartha Lakes

- Scarborough North

- Scarborough South

• Continue to engage with Health Links across the province to share emerging

best practices and expedite learning

• Build on previous QI training and replicate with emerging Health Links

• Communicate about Health Links to partners throughout the Central East

healthcare system including patients and health care providers

• Establish coordination and oversight structures to support Health Links across

Central East

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Patient Engagement Workshop– January 20 2015

Goal: Continue to improve patient engagement/experience methods and engage

patients/families/caregivers in planning and care

Session Objectives:

• To provide an overview of the context and evidence

• To increase partners’ knowledge of effective patient engagement principles (Through

Their Eyes: Learning from Patient and Family Experiences)

• To share current patient engagement strategies within the Central East LHIN and

lessons learned

• Health Link partner organizations will assess their level of patient engagement

participation

• Planning next steps for action to ensure patient engagement principles and strategies

are applied to current and future initiatives

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Overall Lessons Learned

• Targeted early areas of focus – moved

away from defined diseases and toward

‘complex’ patients

• Patient engagement – early

development of patient stories and

involvement facilitates progress

• Primary care involvement – different in

each Health Link; requires multi-faceted

engagement strategies

• Communication – early and often and in

various formats for all stakeholders

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The Road Ahead…

Health Links in the Central East LHIN

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Health Links Coordination of Care

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Care Coordination Tool (CCT) eSolution

The CCT Project will leverage the IAR which is a

provincially deployed solution that supports Health Service

Providers (HSPs) within the circle of care to facilitate the

viewing and sharing of assessment information as the

client moves from one HSP to another.

Central East Health Links involvement:

• Peterborough Health Link is a participant in the Wave 1 roll-out

• Durham North East Health Link has applied for Wave 3 roll-out

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Health Links as an Integrative Model of Care

SRP

(MHA)

1o Care

Complex Pt Pilot

GAIN

cGAIN

ED/Hospital

Discharge

Others

Patient

Identification

Assessment

Care Planning

Care Delivery

Follow up &

Monitoring

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Multiple programs targeting complex patients

Central East Health Links

Health Links as an Integrative Model of Care (Cont’d)

SRP

(MHA)

1o Care

Complex Pt Pilot

GAIN

cGAIN

ED/Hospital

Discharge

Others

Patient

Identification

Assessment

Care Planning

Care Delivery

Follow up &

Monitoring

Coordinated Care Plan

The Coordinated Care Plan forms the foundation of a standardized approach for caring for

complex patients across programs/initiatives and Health Links

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Multiple programs targeting complex patients

Central East Health Links

CRAIG ROBINSON

SENIOR MANAGER, CENTRAL EAST LHIN INITIATIVES

CENTRAL EAST COMMUNITY CARE ACCESS CENTRE

CRAIG.ROBINSON@CE.CCAC-ONT.CA

BRIAN LAUNDRY

SENIOR DIRECTOR, SYSTEM DESIGN AND INTEGRATION

CENTRAL EAST LHIN

BRIAN.LAUNDRY@LHINS.ON.CA

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DISCUSSION

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