Health Links – a New Health Care Initiative Underway

What are Health Links?

Five per cent of patients account for two-thirds of health care costs. These are most often patients with multiple, complex conditions. When the hospital, the family doctor, the long-term care home, community organizations and others work as a team, the patient receives better, more coordinated care.  Working together, providers design individualized Care Plans with patients and their families to ensure they are supported to reach their goals and receive the support and care they need. For the patient it means:

  • Care being focused on the patient’s goals
  • Providers having a consistent understanding of their patients’ conditions
  • Easier navigation of health care services
  • Feeling more supported in their health care journey, having fewer visits to hospitals, and focusing on improved quality of life.

Ontario’s experience with implementing the Health Links approach has demonstrated many aspects about how to better organize services and providers around the needs of the patient.

What is the Health Links Approach to Care?

The Health Links approach to coordinated care planning is about bringing health care, social service providers and other supports together to better understand the patient’s goals and support the patient in a more coordinated way.

The Coordinated Care Plan will help the patient and the providers supporting the patient to better manage the patient’s health and wellbeing.

The Health Links approach to coordinated care planning promotes a shared understanding of what is most important to the patient through the establishment of a Coordinated Care Plan, inclusive of clear roles and responsibilities for each member of the patient’s Care Team.

Coordinated care planning is meant to support a patient’s overall wellness.  It considers the “whole person” needs – mentally, physically, emotionally and spiritually. Think about cultural or community support people that patients would want included on their Care Team to support this “whole person” approach (e.g. spiritual support, traditional healer, naturopath, neighbour, friends, etc).

Who Could Benefit from a Coordinated Care Plan?

The following guidelines can be utilized when considering who might benefit most from a Coordinated Care Plan:

Target Population

People living with 4 or more complex or chronic conditions

Identified Sub-Groups

Those with Mental Health and Addictions Challenges

Palliative Population

People who are frail

Other Considerations

  • Economic characteristics (e.g. low income, unemployment)
  • Social determinants (e.g. challenges with housing, social isolation, language)
  • High users of hospital based services i.e. Emergency Departments or primary care visits
  • Clinical judgment

 

14 NE LHIN Health Links in Various Stages (as of Spring 2017)

Sub-Region

Health Link

Lead Organization(s)

Algoma

Sault Ste. Marie

Group Health Centre

East Algoma (North Shore and Elliot Lake)

Huron Shores Family Health Team

Algoma North

Lady Dunn Health Centre

Wawa Family Health Team

Cochrane

Timmins

Timmins Family Health Team

North Cochrane

Centre de santé communautaire de Kapuskasing et région

Nord-Aski Family Health Team

MICs Area

Iroquois Falls Family Health Team

Cochrane Family Health Team

James and Hudson Bay Coasts

James and Hudson Bay Coasts

Under development

Nipissing-Temiskaming

Nipissing-East Parry Sound

West Nipissing General Hospital

Powassan & Area Family Health Team

Temiskaming

Blanche River Health Centre (Kirkland & District Hospital)

Great Northern Family Health Team

Temiskaming Hospital

Sudbury-Manitoulin-Parry Sound

Greater Sudbury (includes Sudbury East)

Canadian Mental Health Association Sudbury-Manitoulin

Parry Sound

West Parry Sound Health Centre

Espanola/Sudbury West

Espanola General Hospital

Espanola Family Health Team

Manitoulin Island

Manitoulin Health Centre

Health Links & Health Quality Ontario

Health Quality Ontario (HQO) allows Health Link programs to succeed by offering expert leadership and the tools to help Health Link communities identify, address, and deliver key services to individuals with complex chronic illnesses.

HQO lends support to Health Links by providing evidence-informed change ideas, assisting in patient engagement and helps to build sustainable capacities for change and improvement.

Health Links Innovative Practices

Health Quality Ontario is a key partner in Health Links.  HQO has developed an Innovative Practices Framework to assess the implementation of clinical processes. HQO has created for Health Links a way to systematically learn from one another and translate these innovations into scalable practices. The following innovative practices are available to Health Links, with more under development:

 

Background on Health Links

Resources for Establishing a Health Link in NE LHIN

Communications Resources for Health Links