I’d like to start with showing where Health Links fit within our IHSP. Our IHSP 2013-16 is a plan for a Person-centred regional health care system. This is what Health Links are all about – as Nicole described, they are a new model of bringing providers together to coordinate care for people with the highest health care needs.We envision that our region will have “healthy people and healthy communities supported by a quality, accessible health system”. Health Links will make a significant contribution to realizing this vision. We have six key result areas and three strategies. Health Links align with our strategy to ‘Build a strong foundation of integrated primary, home and community care and to improve coordination and transitions of care” and will drive improvements in all of our key result areas.
Those in the health system who:require care that is much more costly than the average; andhave needs that can be better addressed through improved coordination of services across providers.All data based on fiscal year 2011-12 only. *High cost defined to include those with acute inpatient stays in the top 10% by resource intensity weight (RIW), excluding, however, certain very high cost groups (e.g. transplants, premature babies, burns). People with missing postal codes are excluded from all counts.
23 HLs (5 Hospitals, 2 CCACs, 11 FHT/FHO, 4 CHCs, 1 community services organization) + 4 more approved
Transforming Health Care in OntarioHLA#9 MeetingMay 1, 2013
Purpose1) Explain the Health Link concept and alignment tothe Champlain Integrated Health Service Plan 2013-162) Review characteristics of Champlain Health LinkAreas3) Clarify the process and expectations of theReadiness Assessment2
Health Links“Health Links will break down barriers for Ontarians,making access to health care easier and less complicated.By encouraging local health providers to work together toco-ordinate care for individual patients, we’re ensuring ourmost vulnerable patients – seniors and those with complexconditions – get the care they need and don’t fall between thecracks.”Deb Matthews, Minister of Health and Long-Term Care3
A New Model of Care in Ontario• Health care providers in ageographic area worktogether to providecoordinated care forpatients• Patient-centred solutions• Initially focused on peoplewith the highest needs /highest cost to the healthsystem• Brings family health careinto the broader health caresystem• faster access to primarycare• faster ability to connectpatients with specialists,home care services andother community supports• improved transitions of care4
Health Link - Key Features• Focus on a defined region(at least 50,000 population)• Include providers that carefor complex patients(minimum CCAC, hospital,primary care & specialists);voluntary participation• Already show a high degreeof collaboration and willingto formalize it with a writtenagreement• Ability to identify and trackcomplex patients• Includes primary careproviders (minimum 65%from the geographic area)• Identifies a leadorganization.5
6Short Term:• Develop coordinated careplans for complex patients• Increase number of complexpatients with regular andtimely access to a primarycare providerProviders will work together atthe clinical level to achieve:
Providers will work together atthe clinical level to achieve: (cont’d)Longer Term:• Introduce same day/nextday access to primary care• Primary care follow-up withinseven days of discharge froman acute care setting• Reduce time from a primarycare referral to specialist andhome care• Reduce unnecessary hospitaladmissions and re-admissions within 30 days ofdischarge• Reduce avoidableEmergency Room visits forpatients with conditions besttreated elsewhere• Reduce Alternate Level ofCare days in hospital• Enhance the patientexperience.7
Supports for Health Links• Ministry of Healthand Long-TermCare• Ministry-Led Process• Setting direction andperformance metrics• One-time funding• Removing Barriers• Communications• Evidence based toolsand resources• eHealth Ontario• Health QualityOntario• OTN• LHIN• Other Health Links8
Vision:Healthy peopleand healthycommunitiessupported by aquality, accessiblehealth systemMission:Building acoordinated,integrated andaccountablehealth system forpeople where andwhen they need itValues:Respect, Trust,Openness,Integrity,Accountability9Champlain LHINIntegrated Health Service Plan 2013-2016for a Person-Centred Regional Health Care System
10IHSP Strategies & ActionsStrategy 1Build a strong foundation ofintegrated primary, home andcommunity careStrategy 2Improve coordination andtransitions of careStrategy 3Increase coordination andintegration of servicesamong hospitals• Public Engagement • Public Engagement • Public Engagement• Integrated Health Networks • Continuity of Care • Regional Programs• Early Identification andManagement of Risk• Information Sharing • Central Intake• System Navigation • Intensive Case Management • Emergency Room Initiatives• Advanced Access to Service• Clinical Guidelines andPathways• Funding Reform
How Champlain Health Link Areas were DefinedApplying the criteria:Staff studied data for 34 smaller „starter‟ areas and combined theminto 10 based on:• Adjacency• Critical mass (population, people with high needs, primary care and otherproviders)• Population characteristics (distribution & demographics)• Which hospitals people tend to use• Our understanding of local areas• Alignment with census and Ottawa Neighbourhood Study boundaries.11
Some High-Needs Groups(Champlain residents 2011-12)1) Had two+ acute carehospitalizations: 13,939• Had a readmission within 30days: 8,9612) Had a high cost acute carehospital stay: 8,1453) Made 5+ emergencydepartment visits: 16,305• Composite: met one or morecriteria: 30,514• Met all three criteria: 1,11712People with High Needs come inmany shapes and sizes.No single data definition cancapture the complexity.
14Implemention Process for Champlain Health Links (as of Apr 16, 2013)Ministry of Healthand Long-Term CareLeader & EnablerChamplain LHINFacilitators & SupportersInterested ProvidersImplementersSwimlaneProcessforHealthLinksImplementation Develop Health LinkStrategy & Framework(provincial definitions, tools,data)- Engage with potential HLgroups- Provide local tools andresourcesOrganize providers /networksReview ReadinessAssessmentSubmit ReadinessAssessmentSubmit readinessassessments- Develop & submitBusiness Plan- Partners sign MOUReview and flow initialfunding for HL to developbusiness planReview Business PlanSupport HL’s businessplan developmentImplement accountabilityagreementsMonitor and supportgrowth and improvementsApproveBusiness Plan & flowfundingReadinessAssessmentcomplete?YesRevise ReadinessAssessmentNoSign accountabilityagreement &operationalize Health LinkSupport and monitorHealth LinkimplementationAssumptions- Provider groups will organizethemselves, based on the informationprovided to them by the LHIN / Ministry- LHIN approves Readiness Assessmentand Business Plans before sending toMinistry.- All Health Links’ submissions areapproved by Ministry.- Health Links will be implemented whenthey are ready, not by LHIN quota (50%by xx date)Business Plancomplete?YesRevise & resubmitBusiness PlanNoSubmit Business PlanReview / ApproveReadiness Assessment
Readiness Assessments need to include:• Evidence it was completed as acollaboration of providers, with apatient- centred focus (minimumPC, CCAC & hospital,specialists)• A lead organization has beenagreed upon by the collaboratingpartners & clearly identified• An understanding of theFrancophone population andtheir needs & an explanation ofthe a capacity to meet the needsof Francophones• A description of Aboriginalpopulation and collaboratingpartners to meet needs• For each criterion of theReadiness Assessment template,the rationale / explanationsection is completed and clearlywritten15
Helpful Tips• Keep the focus onpatients with the highestcomplexity and healthsystem use• Try not to get hung up onthe “lead” organization• Prepare a concise &clear RA – answer eachcriterion17Preliminary Comments on theDraft:- Simplify & ensure explanationsare aligned to the criterion- Reduce duplication- Add statement supportingrationale for <50,000 population(higher needs, chronic conditions,Aboriginal health, seniors, mentalhealth, determinants of health)- Take out acronyms- Add Francophone population –Le Reseau can help- Identify a “lead organization(criteria #13 to 16)- Add PC to #3- Delete #17 and put this contextpiece in Criteria#2