Florence’s Living Legacy

March 4, 2015

Dear Northerners,

This is a tough blog to write. But it’s harder for the family members who told me about the “hero” they lost over the holidays. They are hopeful that by telling people about Florence’s health care experiences, others will benefit.

After living with complex medical problems for decades, Florence passed away, still in her early 70s. Yes, there were wonderful individuals who looked after her and gave her great care. But the overall coordination was less than ideal leaving gaps in the transitions of care and causing Florence undue anxiety at a time when she needed to feel safe and secure.

Unfortunately, like many seniors with complex chronic conditions, Florence was in and out of hospital. Her family says her story had to be retold each time and every provider created their own care plan – their care plan, not Florence’s. 

What would have made a difference? Well her family says she needed one care plan that everyone followed - her care plan.

Florence’s experiences and her family’s desire to tell her story draw attention to the issue that while we have compassionate care providers in Northeastern Ontario, we still have a ways to go in having a strong SYSTEM of health care. The touch-points along the continuum of care may be strong, but the coordination of the full system needs improvement.

The North East LHIN is working with health and community partners on several initiatives to strengthen the Northeastern Ontario health care system. 

One example is our support for a model of care called Health Links. Health Links are a new way to care for individuals – those, like Florence, who are high users of the system and have complex medical issues. Providers in a Health Link work together to develop one care plan for an individual – a plan that follows them regardless of where they go in the system or whether they have a primary care provider.

We have a Health Link team in Timmins and Temiskaming, with others underway in the North Cochrane area, Nipissing, Sault Ste. Marie and Sudbury.  One day in the near future, we envision 11 Health Links across the region making stories like Florence’s a rare occurrence.

Florence’s family told me that providers could have done more to get to the root cause of her health problems, rather than just looking at her symptoms as something to be treated.   Florence’s family asks that we consider “the other requirements that are a part of the healing” like nutrition and social interaction. To practice patient-centred care we need to treat the whole person.

As a LHIN, we continue to concentrate on building a stronger system of coordinated care. First and foremost, it must be focused on the needs of the patient and the family. 

Many of our investments have supported this commitment -- electronic medical records,  geriatric emergency room nurses, and PATH workers who help people transition from hospital to home with the right care support -- to name a few.  We will continue to make these investments so that people like Florence who thrive with individual care, will also thrive with system care. 

In 2015, my thoughts will be with Florence as the NE LHIN further expands home care and community services, and makes targeted investments to strengthen the coordination of care, from hospital to home and all points in between. 

In fact, that’s my 2015 health care resolution: Improve Care for Frail Seniors like Florence.  I’m interested in hearing yours…


Comments / Commentaires

"This is a powerful blog. And this philosophy should be implemented in schools for education plans for students; in the mental health system, in the justice system – in any system where we want to make a person’s life better." - Anna

"J’ai lu ton blog avec beaucoup d’intérêt, car il reflète la réalité. Une réalité qui se transforme lentement mais surement grâce à vos efforts continus. Faut continuer à intégrer, à briser les silos et à encourager les organisations à travailler ensemble pour le bien-être de tous. Bravo!" - Guylaine