Transforming Health Care in Ontario

HLA#9 MeetingMay 1, 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

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Health Link - Key Features

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

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

• Already show a high degree of collaboration and willing to formalize it with a written agreement

• Ability to identify and track complex patients

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

• Identifies a lead organization.

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Short Term: • Develop coordinated care plans

for complex patients

• Increase number of complex patients with regular and timely access to a primary care provider

Providers will work together atthe clinical level to achieve:

Providers will work together atthe 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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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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Champlain LHINIntegrated Health Service Plan 2013-2016for a Person-Centred Regional Health Care System

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IHSP Strategies & Actions

Strategy 1

Build a strong foundation of integrated primary, home and

community care

Strategy 2

Improve coordination and transitions of care

Strategy 3

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

How Champlain Health Link Areas were DefinedApplying 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

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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People with High Needs come in many shapes and sizes.

No single data definition can capture the complexity.

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Implemention Process for Champlain Health Links (as of Apr 16, 2013)

Ministry of Healthand Long-Term Care

Leader & Enabler

Champlain LHINFacilitators & Supporters

Interested ProvidersImplementers

Swiml

ane Pr

ocess

for He

alth Lin

ks Imp

lement

ation

Develop Health Link Strategy & Framework

(provincial definitions, tools, data)

- Engage with potential HL groups

- Provide local tools and resources

Organize providers / networks

Review Readiness Assessment

Submit Readiness Assessment

Submit readiness assessments

- Develop & submit Business Plan

- Partners sign MOU

Review and flow initial funding for HL to develop

business plan

Review Business Plan

Support HL’s business plan development

Implement accountability agreements

Monitor and support growth and improvements

ApproveBusiness Plan & flow

funding

Readiness Assessment complete?

Yes

Revise Readiness Assessment

No

Sign accountability agreement &

operationalize Health Link

Support and monitor Health Link

implementation

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)

Business Plan complete?

Yes

Revise & resubmit Business Plan

No

Submit Business Plan

Review / Approve Readiness Assessment

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

• An understanding of the Francophone population and their needs & an explanation of the a capacity to meet the needs of Francophones

• 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

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Questions

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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

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Preliminary Comments on the Draft:- Simplify & ensure explanations are

aligned to the criterion- Reduce duplication- Add statement supporting rationale

for <50,000 population (higher needs, chronic conditions, Aboriginal health, seniors, mental health, determinants of health)

- Take out acronyms- Add Francophone population – Le

Reseau can help- Identify a “lead organization (criteria

#13 to 16)- Add PC to #3- Delete #17 and put this context piece

in Criteria#2