Determining the Target Population for Health Links:
Q&As in follow-up to the August 12th Webinar
Q1:
With the understanding that the work to define the target population should standardize how
Health Links identify patients who are appropriate for Health Links services, how much
leverage do LHINs and Health Links have in identifying these patients?
A1:
The Target Population work is intended to provide guidance to LHINs and Health Links. While
the core definition of the complex patient includes those diagnosed with 4+ conditions listed on
slide 29 of “Health Links Target Population” presentation, this is not intended to preclude
practitioners from using their clinical judgement to identify and include patients that have fewer
than 4 of the conditions but for whom the complexity of their medical and social circumstances
deems them Health Links patients requiring the intensity of Health Links support.
Q2:
Are there expectations around the timing for application of the new definition of the Target
Population?
A2:
It is expected that LHINs and Health Links implement the new definition over the course of
2015/16, with the understanding this may take sseveral months to plan and implement.
Q3:
How was the concept of frailty defined?
A3:
We used and applied the definition of frailty that was developed by the Institute of Clinical and
Evaluative Sciences (ICES). Frail seniors as those age 65+:
a) With a complex condition:
i. One or more of the following conditions - COPD, CHF, Stroke, Mental illness; or
ii. Two or more of the following conditions - Osteoarthritis or other arthritis,
Rheumatoid arthritis, Osteoporosis, Chronic coronary syndrome, Arrhythmia,
Cancer, Dementia, Renal Failure, Asthma, Hypertension, Diabetes, AMI); AND;
b) Who had received homecare, complex continuing care, or long-term care, and had a score
of 2 or more for the ‘Changes in Health End-Stage Disease and Signs and Symptoms’
(CHESS) scale or who had experienced a functional decline in Activities of Daily Living within
the last 90 days, based on their most recent assessment in the previous fiscal year.
Q4:
How are the concepts of mental health and addictions and palliative defined?
A4:
For the purposes of the analysis, Mental Health & Addictions was defined as patients who had
an ICD-10 diagnosis in the range F00-F99 for hospital-based care or in the range 290-319 for
homecare or OHIP visits during the year. However this summary category is not included in the
count of conditions. The count of conditions includes the following specific mental health
conditions: dementia, substance abuse, schizophrenia, depression, anxiety disorders bipolar
disorders, eating disorders, personality disorders and developmental disorders. Palliative care
Determining the Target Population for Health Links:
Q&As in follow-up to the August 12th Webinar
refers to those patients with the specific palliative care diagnosis code (Z51.5) in their health
care records.
Q5:
Are people living with frailty, mental health and addictions and palliative a sub-population of
the people with 4+ conditions?
A5:
Yes, people living with mental health and addictions and palliative are a sub-group of the target
population with 4+ conditions, recognizing however that not all patients with MH&A, frailty or
palliative are in the target population. Although the target population would include many
patients with frailty, frailty was not included specifically in the criteria for identifying the target
population. Patients with ‘frailty’ were examined as an ‘overlay’ as there is no one diagnosis
associated with frailty. As shown by the analysis, there is high overlap between frail seniors and
the 4+ conditions group. The same is true for mental health & addictions, and palliative. Our
analysis shows there is substantial overlap between these patient populations and those with 4+
conditions. Specific mental health conditions (e.g. dementia or depression) and palliative care
were among the list of chronic/high cost conditions used to identify the target population.
Q6:
Are patients with fewer than four chronic conditions that access the Emergency Department
(ED) and in-patient services eligible to be targeted for a coordinated care plan?
A6:
The target population analysis is provided for guidance and information. LHINs and Health Links
may decide to customize it for their needs.
Q7:
The “List of selected conditions that are chronic and/or high cost”, as identified on slide 29 of
the “Health Links Target Population” presentation, include a number of high cost treatments,
such as hip and knee replacement, but excludes other high cost procedures such as dialysis. In
some cases the chronic condition is listed as well as the treatment. What is the rationale for
including both chronic conditions and some associated treatments, and not others?
A7:
In general we used the “condition” rather than specific treatments. A few specific high cost
treatments are included (such as hip or knee replacements, and transplants) since the expense
is attributable to the procedure rather than the underlying disease. That is, the acute care
admission, inpatient rehabilitation, and homecare expenses are due to having had a hip or knee
replacement rather due to having arthritis. CABG, valve replacement patients will likely already
be captured through the IHD/CHF/Arrhythmia diagnosis categories; dialysis patients will be
captured by ‘renal failure’ diagnosis. But the hip/knee replacement patients may have the
procedure for many different diagnostic reasons and we wanted to ensure that all patients were
captured.
Q8:
Has any Health Links team identified poly pharmacy, specifically the use of anticholinergics
with the frail elderly as a factor in high ED visits? If not, is it possible to include these two
variables as risk overlays as anticholinergics have been implicated in dementia.
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Determining the Target Population for Health Links:
Q&As in follow-up to the August 12th Webinar
A8:
Currently, the ministry has not considered poly pharmacy as we do not have detailed drug
prescription information for the entire population. However, this is something that Health Links
and LHINs can incorporate as part of their care plan development for patients.
Q9:
Do all the diagnoses identified by the ministry need to be used to identify the target
population?
A9:
No, the list of conditions identified on slide 29 of the “Health Links Target Population”
presentation were selected because they are chronic, have a high health system or population
burden (high prevalence and frequent health system use and/or expense), or may be infrequent
but expensive to treat (i.e. the have a high individual burden). The list of diagnoses is not
exhaustive, and in operationalizing the guideline, LHINs and Health Links can determine whether
other diagnoses are relevant to their demographic and local context. See Appendix A for list of
conditions with codes.
Q10:
Are all of the 11 indicators that the ministry previously released still applicable?
A10:
Yes, the 11 Health Links indicators are still applicable and will help to the ministry, LHINs and
Health Links assess:



Health Links operational effectiveness to organize care;
Health Links ability to improve coordinated care across multiple organizations; and,
Health Links overall impact to enhancing the patient journey/ experience, and realizing greater
system efficiencies and cost savings.
Under the guidance of the Performance Monitoring and Evaluation Sub-committee, the ministry has
been working on the analysis and roll-out of the 11 Health Links indicators (see table below for
summary).
Operational indicators
1. Ensure the development of coordinated care plans for all
complex patients
2. Increase the number of complex patients with regular and
timely access to a primary care provider
Outcome indicators
3. Reduce the number of 30 day readmissions to hospital
4. Reduce the number of ED visits for patients with conditions
best managed elsewhere
5. Reduce time from referral to home care visits
6. Reduce unnecessary admissions to hospitals
7. Ensure primary care follow-up within 7 days of discharge
from an acute care setting.
8. Achieve an ALC rate of 9 per cent or less
9. Reduce time from primary care referral to specialist
consultation.
10. Enhance the health system experience for complex patients.
11. Reduce the average cost of delivering health services to
patients.
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Status
Currently being reported by Health Links and
LHINs through the Health Quality Ontario
enabled Quality Improvement Reporting &
Analysis Platform (QI-RAP) tool.
Ministry has conducted analysis of these
indicators at the population level for approved
Health Links areas. Over the course of 2015/16
the Ministry will provide further information on
how these results will be shared with LHINs and
Health Links.
The focus will be on indicators 3-5 as these are
more directly relevant to Health Links.
Indicators 9-11 are under development.
Determining the Target Population for Health Links:
Q&As in follow-up to the August 12th Webinar
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Determining the Target Population for Health Links:
Q&As in follow-up to the August 12th Webinar
APPENDIX A: LIST OF CONDITIONS WITH CODES
Selection criteria for 'high cost/chronic' conditions analysis by care type.
Conditions are identified as present if the code occurs in any of the diagnostic fields in one or more care type.
Diagnoses
ICD-10-CA
Sepsis
A40-A41, R572
HIV/AIDS
B24
Neoplasm (Malignant)
C00-C97
Anemia
D50-D64
Coagulation Defects and purpura
D65-D69
Diabetes
E10-E14
Cystic Fibrosis
E84
Dementia
F00-F03; G30; G31.0-G31.1
Substance-related disorders
F10-F19
Schizophrenia & delusional disorders
F20-F29
Bipolar disorder
F31
Depression
F32-F33
Anxiety disorders
F40-F41
Eating disorders
F50
Personality disorders
F60-F62
Developmental disorders
F70-F79, F84, Q90
Any MH Condition (summary measure only - not
used for condition count)
F00-F99
Huntington's chorea
G10
ALS and Motor Neuron Disorders
G12.2
Parkinson's disease
G20-G22
Multiple Sclerosis
G35
Epilepsy & Seizure disorders
G40-G41
Muscular Dystrophy
G71
Cerebral Palsy
G80
Hemiplegia/Hemiparesis (paralysis on one side of
the body)
G81
Paralysis (Paraplegia or Quadriplegia) and spinal
cord injury
G82, G83, S14.0-S14.1, S22.0-S22.1, S24.0-S24.1, S34.0S34.1, S34.3, T02.1, T06.1, T91.3, T08, M48, M99
Hypertension
I10-I15
Ischaemic Heart Disease
I20-I25
Cardiac Arrhythmia
I47-I49, R00
(Congestive) Heart Failure
I50
Stroke
I60-I61, I63-I64, H34.1, G45, G46.4-G46.7
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Determining the Target Population for Health Links:
Q&As in follow-up to the August 12th Webinar
Diagnoses
ICD-10-CA
Peripheral Vascular Disease and Atherosclerosis
I70-I79
Chronic Obstructive Pulmonary Disease
J40-J44, J47
Asthma
J45
Influenza
J09-J11
Pneumonia
J12-J18
Ulcer
K25-K28
Hernia
K40-K46
Crohn's disease/colitis
K50-K52
Liver disease (cirrhosis, hepatitis etc.)
K70-K77
Renal Failure
N17-N19
Arthritis and related disorders
M00-M03, M05-M19, M22-M25, M32-M36, M45-M47,
M48.0-M48.2, M48.8-M48.9, M70-M71, M75-M77, M79,
M99
Osteoporosis including pathological bone fracture
M80-M82
Low Birth Weight Baby
P05-P07 or HIG=578-588
Other Perinatal Conditions
P00-P04; P08-P99
Hip Replacement
CMG/HIG= 320
Knee Replacement
CMG/HIG= 321
Congenital Malformations
Q00-Q89; Q91-Q99
Amputation (traumatic uses ICD10 codes, nontraumatic uses CCI)
Diagnosis=S48, S58, S68, S78, S88, S98, T05, Z89, T11.6,
T13.6, Z89 or Intervention=1.__93.__
Fracture
S02, S12, S22, S32, S42, S52, S62, S72, S82, S92,T02,T08,
T10, T12
Brain Injury (including diseases that cause damage
to the brain)
A81, A83-A87, C70.0, C71, C79.3, D32.0, D33.0-D33.3,
D43.0-D43.3, F07.2, G00-G06, G93.0-G93.1, G93.4, G93.8,
I62, Q28, S02.0-S02.1, S02.7, S02.89, S02.9, S06.0, S06.2,
S06.4-S06.9, S09.0, S09.7-S09.9, T90.2, T90.5, T90.8, T90.9,
T96, T97
Transplant
HIG= 110, 160, 270, 450, 610, 725
Pain Management
Z51.80
Palliative care
Z51.5
Coma
E10.0, E11.0, E13.0, E14.0, E15, R40.2, P91.5, B15.0, B19.0
Provided by:
Health Analytics Branch, HSIMI, MOHLTC
Prepared by: Linda Baigent, Capacity Planning & LHIN Support Unit
Contact: Nam Bains (nam.bains@ontario.ca)
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