Transforming Health Care in Ontario
HLA#2 Meeting
May 17, 2013
Purpose
1) Explain the Health Link concept and alignment to the
Champlain Integrated Health Service Plan 2013-16
2) Review characteristics of Champlain Health Link Areas
3) Clarify the process and expectations of the Readiness
Assessment
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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 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
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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
4
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
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Providers will work together at
the clinical level to achieve:
Short Term:
• Develop coordinated care plans
for complex patients
• Increase number of complex
patients with regular and timely
access to a primary care
provider
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Providers will work together at
the clinical level to achieve: (cont’d)
Longer Term:
•
Introduce same day/next day
access to primary care
• Primary care follow-up within
seven days of discharge from an
acute care setting
• Reduce time from a primary
care referral to specialist and
home care
• Reduce unnecessary hospital
admissions and re-admissions
within 30 days of discharge
• Reduce avoidable Emergency
Room visits for patients with
conditions best treated
elsewhere
• Reduce Alternate Level of Care
days in hospital
• Enhance the patient experience.
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Supports for Health Links
• Ministry of Health
and Long-Term Care
• Ministry-Led Process
• Setting direction and
performance metrics
• One-time funding
• Removing Barriers
• Communications
• Evidence based tools and
resources
• eHealth Ontario
• Health Quality
Ontario
• OTN
• LHIN
• Other Health Links
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Champlain LHIN
Integrated Health Service Plan 2013-2016
for a Person-Centred Regional Health Care System
Vision:
Healthy people
and healthy
communities
supported by a
quality, accessible
health system
Mission:
Building a
coordinated,
integrated and
accountable
health system for
people where and
when they need it
Values:
Respect, Trust,
Openness,
Integrity,
Accountability
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IHSP Strategies & Actions
Strategy 1
Strategy 2
Strategy 3
Build a strong foundation of
integrated primary, home and
community care
Improve coordination and
transitions of care
Increase coordination and
integration of services
among hospitals
•
Public Engagement
•
Public Engagement
•
Public Engagement
•
Integrated Health Networks
•
Continuity of Care
•
Regional Programs
•
Early Identification and
Management of Risk
•
Information Sharing
•
Central Intake
•
System Navigation
•
Intensive Case Management
•
Emergency Room Initiatives
•
Advanced Access to Service
•
Clinical Guidelines and
Pathways
•
Funding Reform
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How Champlain Health Link Areas were Defined
Applying the criteria:
Staff studied data for 34 smaller ‘starter’ areas and combined them
into 10 based on:
• Adjacency
• Critical mass (population, people with high needs, primary care and other
providers)
• Population characteristics (distribution & demographics)
• Which hospitals people tend to use
• Our understanding of local areas
• Alignment with census and Ottawa Neighbourhood Study boundaries.
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Some High-Needs Groups
(Champlain residents 2011-12)
1) Had two+ acute care
hospitalizations: 13,939
• Had a readmission within 30
days: 8,961
2) Had a high cost acute care
hospital stay: 8,145
People with High Needs come in
many shapes and sizes.
No single data definition can
capture the complexity.
3) Made 5+ emergency
department visits: 16,305
• Composite: met one or more
criteria: 30,514
• Met all three criteria: 1,117
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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
Sign accountability
agreement &
operationalize Health Link
Support and monitor
Health Link
implementation
Monitor and support
growth and improvements
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Readiness Assessments need to include:
• Evidence it was completed as a
collaboration of providers, with a
patient- centred focus (minimum
PC, CCAC & hospital, specialists)
• A lead organization has been
agreed upon by the collaborating
partners & clearly identified
• A description of Aboriginal
population and collaborating
partners to meet needs
• For each criterion of the Readiness
Assessment template, the rationale /
explanation section is completed and
clearly written
• An understanding of the
Francophone population and their
needs & an explanation of the a
capacity to meet the needs of
Francophones
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Helpful Tips
•
•
•
Keep the focus on patients
with the highest complexity
and health system use
Try not to get hung up on
the “lead” organization
Prepare a concise & clear
RA – answer each criterion
Ministry website
www.Ontario.ca/LeadingHealthy
Change
LHIN website:
www.champlainlhin.on.ca
LHIN email:
Ch.pclead@lhins.on.ca
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Questions
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