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Transforming Health Care in Ontario
A New Model of Care in Ontario
• Health care providers in a
geographic area work together
to provide coordinated care for
patients
• Patient-centred solutions
• Initially focused on people with
the highest needs / highest cost
to the health system

•

Brings family health care into
the broader health care
system
• faster access to primary care
• faster ability to connect
patients with specialists, home
care services and other
community supports
• improved transitions of care
Health Link - Key Features
•

Focus on a defined region (at
least 50,000 population)

•

Ability to identify and track
complex patients

•

Include providers that care for
complex patients (minimum
CCAC, hospital, primary care &
specialists); voluntary
participation

•

Includes primary care
providers (minimum 65% from
the geographic area)

•

Identifies a lead organization.

•

Already show a high degree of
collaboration and willing to
formalize it with a written
agreement
“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 to co-ordinate care for
individual patients, we’re ensuring our most
vulnerable patients – seniors and those with
complex conditions – get the care they need
and don’t fall between the cracks.”
Deb Matthews, Minister of Health and Long-Term Care
Implemention Process for Champlain Health Links (as of Apr 16, 2013)
Ministry of Health
and Long-Term Care
Leader & Enabler

Champlain LHIN

Interested Providers

Facilitators & Supporters

Implementers

Develop Health Link
Strategy & Framework

- Engage with potential HL
groups

(provincial definitions, tools,
data)

- Provide local tools and
resources

Organize providers /
networks

Review Readiness
Assessment

Readiness
Assessment
complete?

Submit Readiness
Assessment

No

Revise Readiness
Assessment

Swimlane Process for Health Links Implementation

Yes
Review / Approve
Readiness Assessment

Submit readiness
assessments

Review and flow initial
funding for HL to develop
business plan

Support HL’s business
plan development

- Develop & submit
Business Plan
- Partners sign MOU

Review Business Plan

Business Plan
complete?

No

Revise & resubmit
Business Plan

Yes
Approve
Business Plan & flow
funding

Assumptions
- Provider groups will organize
themselves, based on the information
provided to them by the LHIN / Ministry
- LHIN approves Readiness Assessment
and Business Plans before sending to
Ministry.
- All Health Links’ submissions are
approved by Ministry.
- Health Links will be implemented when
they are ready, not by LHIN quota (50%
by xx date)

Submit Business Plan

Implement accountability
agreements

Support and monitor
Health Link
implementation

Monitor and support
growth and improvements

Sign accountability
agreement &
operationalize Health Link
Health Links in Renfrew County
HLA 8
(Attached to Kanata
& includes Arnprior
& McNab Braeside)

HLA 9
(Hwy 60 corridor
including Renfrew,
Eganville, Barry’s
Bay)

HLA 10
(Hwy 17 corridor
or North Renfrew)

• Submitted Readiness Assessment Template to LHIN
• Waiting for approval from the Ministry to begin drafting the
Business Plan

• May 1st - Engagement event
• Early Summer - Completed Readiness Template
• Currently - Working on Business Plan (due in early Dec.)

• April - Initiated with engagement meeting
• Aug. – meeting established a working group
• Currently drafting Readiness Assessment Template
Low Income / Poverty – Families

26.2 – 4.4%*

12.6%

Aboriginal Identity

5.6%

2%

Post Secondary Ed’n Level

54%

-

Senior Population

16.8%

Unemployment Rate

7.9%

9%

Physically Inactive

47%

52%

Eat Recommended Serving - Veg & Fruit

32.3%

44.1%

Smoker

26.8%

18.6%

Overweight and Obese

61.1%

51.4%

High Blood Pressure

18%

10.6%

Ischemic Heart Disease

139

118

Cerebrovascular Disease

63

44

12.7%
Framework for Building Healthy Community Action
Interventions
Downstream

Upstream

Disease
Treatment &
Prevention

Communication
Strategies

Health
Education &
Empowerment

Community &
Health
Development

Infrastructure
& Systems
Change

Primary

Health
Information

Knowledge

Engagement

Policy

Secondary

Behaviour
Change
Campaigns

Understanding

Community
Action

Legislation

Skill
Development

Advocacy

Organizational
Change

Tertiary
Primary Care
Approaches

Lifestyle/BehaviouristSocioecological
Approaches
Approaches
Questions?

For more information on Champlain LHIN Health Links:
http://www.champlainlhin.on.ca/Page.aspx?id=7440

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Health Links - Health Committee - M.Nolan

  • 2. A New Model of Care in Ontario • Health care providers in a geographic area work together to provide coordinated care for patients • Patient-centred solutions • Initially focused on people with the highest needs / highest cost to the health system • Brings family health care into the broader health care system • faster access to primary care • faster ability to connect patients with specialists, home care services and other community supports • improved transitions of care
  • 3. Health Link - Key Features • Focus on a defined region (at least 50,000 population) • Ability to identify and track complex patients • Include providers that care for complex patients (minimum CCAC, hospital, primary care & specialists); voluntary participation • Includes primary care providers (minimum 65% from the geographic area) • Identifies a lead organization. • Already show a high degree of collaboration and willing to formalize it with a written agreement
  • 4. “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 to co-ordinate care for individual patients, we’re ensuring our most vulnerable patients – seniors and those with complex conditions – get the care they need and don’t fall between the cracks.” Deb Matthews, Minister of Health and Long-Term Care
  • 5.
  • 6. Implemention Process for Champlain Health Links (as of Apr 16, 2013) Ministry of Health and Long-Term Care Leader & Enabler Champlain LHIN Interested Providers Facilitators & Supporters Implementers Develop Health Link Strategy & Framework - Engage with potential HL groups (provincial definitions, tools, data) - Provide local tools and resources Organize providers / networks Review Readiness Assessment Readiness Assessment complete? Submit Readiness Assessment No Revise Readiness Assessment Swimlane Process for Health Links Implementation Yes Review / Approve Readiness Assessment Submit readiness assessments Review and flow initial funding for HL to develop business plan Support HL’s business plan development - Develop & submit Business Plan - Partners sign MOU Review Business Plan Business Plan complete? No Revise & resubmit Business Plan Yes Approve Business Plan & flow funding Assumptions - Provider groups will organize themselves, based on the information provided to them by the LHIN / Ministry - LHIN approves Readiness Assessment and Business Plans before sending to Ministry. - All Health Links’ submissions are approved by Ministry. - Health Links will be implemented when they are ready, not by LHIN quota (50% by xx date) Submit Business Plan Implement accountability agreements Support and monitor Health Link implementation Monitor and support growth and improvements Sign accountability agreement & operationalize Health Link
  • 7. Health Links in Renfrew County HLA 8 (Attached to Kanata & includes Arnprior & McNab Braeside) HLA 9 (Hwy 60 corridor including Renfrew, Eganville, Barry’s Bay) HLA 10 (Hwy 17 corridor or North Renfrew) • Submitted Readiness Assessment Template to LHIN • Waiting for approval from the Ministry to begin drafting the Business Plan • May 1st - Engagement event • Early Summer - Completed Readiness Template • Currently - Working on Business Plan (due in early Dec.) • April - Initiated with engagement meeting • Aug. – meeting established a working group • Currently drafting Readiness Assessment Template
  • 8. Low Income / Poverty – Families 26.2 – 4.4%* 12.6% Aboriginal Identity 5.6% 2% Post Secondary Ed’n Level 54% - Senior Population 16.8% Unemployment Rate 7.9% 9% Physically Inactive 47% 52% Eat Recommended Serving - Veg & Fruit 32.3% 44.1% Smoker 26.8% 18.6% Overweight and Obese 61.1% 51.4% High Blood Pressure 18% 10.6% Ischemic Heart Disease 139 118 Cerebrovascular Disease 63 44 12.7%
  • 9. Framework for Building Healthy Community Action Interventions Downstream Upstream Disease Treatment & Prevention Communication Strategies Health Education & Empowerment Community & Health Development Infrastructure & Systems Change Primary Health Information Knowledge Engagement Policy Secondary Behaviour Change Campaigns Understanding Community Action Legislation Skill Development Advocacy Organizational Change Tertiary Primary Care Approaches Lifestyle/BehaviouristSocioecological Approaches Approaches
  • 10. Questions? For more information on Champlain LHIN Health Links: http://www.champlainlhin.on.ca/Page.aspx?id=7440

Editor's Notes

  1. Provide background of Local Health Integration Network role in our health care systemHealth Links represent a shift and possible system wide change to address health care sustainabilityCurrent data – staying the course with rising diabetes, acute, complex health needs, cardiovascular disease etc. means our health care system ‘as is’ is not sustainable
  2. Established in Nov., 2012 province wide. Prior to this, there were 19 early adopters across the Province (none in Champlain region)LHIN identified geographic areas are designated Health Links.Each Health Link is designed to serve populations of approximately 55,000They represent a collaborative and integrated approach to find locally relevant ‘patient-centred’ solutions
  3. Co-ordinated & Collaborative Approach – to positively affect and change the system  
  4. 3 Health Links in Renfrew CountyHLA 8 - Arnprior has been assigned to Ottawa region – defined by established patterns, health care system useHLA9 - From Renfrew to west of Barry’s Bay and reaching the southern parts of Renfrew CountyHLA10 – Hwy. 17, east of McNabBraeside to the north western reaches of Renfrew County.
  5. Steps for Health Link DevelopmentIdentification of Health Links (done by LHIN)Engagement by ‘lead’ (voluntary and is completed)Completion of Readiness TemplateBusiness Plan/Case drafted and approved (75K is provided to each Health Link to complete the Business Plan)Up to 1 million to implement Business Plan / Case
  6. Updates for each Health Link in Renfrew County & where they are in the processLeadership is intended to be shared and collaborative. There is a ‘banker’ for each HLA (Health Link Area). This was not designated, but relied on a Health Service Provider to step forward or be chosen/identified by the engaged group of stakeholders.HLA 8 = West Ottawa & Arnprior) Readiness Assessment is submitted.HLA 9 = Hwy 60 corridor or South Renfrew Madawaska Circle of Care (St. Francis Memorial Hospital, Barry’s Bay & Area Home Support, Rainbow Valley CHC & more – leadership and much in kind contribution is being provided by Renfrew Victoria Hospital). This is very much a shared leadership model and is moving forward strongly.HLA 10 = Hwy 17 corridor or North Renfrew (West Champlain Healthy Communities Corporation is the ‘lead organization’)Challenges for Renfrew CountyWe are divided by the designated Health LinksMany of our services are provided County wide – therefore this process is stretching some providers very ‘thin’ – challenging to attend meetings for 3 Health LinksSolutionsCommitment by some County-wide providers to act as ‘links’ between the 3Healthy Communities Partnership has committed to sharing all three HLA updates and contribute to the Business Plan development so that we are being proactive in our planning and ensuring that we are planning for both the acute users of our health care system (5%) and the remaining 95% to put supports in place so we are not continuing to replace the ‘5%’ – some prevention and community based health promotion with shared services and existing resources (eg: Community Paramedic Program)
  7.  Health Links are currently being developed to identify and co-ordinate care for the top 5% of Health Care users (using 65% of health care funds). However, in order to stem the flow of users into this top 5%, there is strong consensus among stakeholders in Renfrew County that we need to take this opportunity to also address the 95% and integrate prevention & rehab into the business plans.Ischemic HD / Cerebrovascular - Causes of death per 100,000
  8. Upstream Health Approach – definition – sociological approach and look at system change, community based work.Sustainable Health Care System (and economy)– requires a stronger, healthier population base.Health Links represent one opportunity to co-ordinate planning for the top 5% and also be innovative and co-ordinated in our more upstream approach to health.
  9. "If you are passionate about something, you are probably going to be a leader"The idea and how action and a mindset makes it happen – shifting from talk to walk the talk and value action – regardless of where it comes from.