Power of collaboration - Working together
to care for those with complex needs.
WWLHIN Regional Engagement Session
www.HQOntario.ca
Power of Collaboration:
Working together to care for those
with complex needs.
Agenda
• Overview of provincial Advanced Health Link Model
• Brief update on this Health Link
• Activity: Table discussion on collaborative care
planning and call to action
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The goal:
collaboratively improving integrated
care for patients with multiple chronic
conditions and complex needs
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Advanced Health Links
Guiding Principles and Model
1. Regular and timely access to primary
care for complex patients
2. Effective provision of coordinated care
for all of Ontario’s complex patients
3. Consistent, quality care across the
health care continuum and social
services sectors
4. Focus on vulnerable populations (frail
and elderly, mental health and
addictions and palliative).
5. Evidence-based, measureable
improvement of the patient experience
through enhanced transitions in care
6. Maximize coordinated care to generate
system value, sustain the Health Links
Model and strengthen care
coordination processes to realize
greater efficiencies
7. LHINs accountability for performance.
Source: ‘Health Links Target Population’ Webinar, The Ministry of Health and Long Term Care. August 12, 2015
www.HQOntario.ca
Identifying Target Population
• Process will include:
– Patients with 4+ chronic/high cost conditions
(from provided list)
• Plus a focus on mental health and addictions,
palliative, and the frail elderly
• economic characteristics (low income,
unemployment)
– Social determinants (housing, language,
immigration, community and social services etc.)
Source: ‘Health Links Target Population’ Webinar, The Ministry of Health and Long Term Care. August 12, 2015
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THE COORDINATED CARE PLANNING PROCESS
IN PROGRESS
•
•
•
Identify Patients
Engage the Patient
Initial Interview
Care Conference
“Recognize that I may
benefit from care
coordination”
“Engage me to
participate in care
coordination”
“Let me share what is
important to me and
what my goals are”
“Together, we develop
my coordinated care
plan”
Emerged organically through the work of early adopters and
emerging Health Links.
Not mandatory- yet most Health Links have adopted or adapted
some or all of these steps into their processes.
Continues to evolve.
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Maintenance and
Transitions
“I work with my team to
meet my goals and my
team stays connected”
Waterloo Wellington’s 9 minimum elements of
a Coordinated Care Plan (CCP):
1.
2.
3.
4.
5.
6.
7.
8.
9.
Patient identification
Documentation (either paper or electronic)
Content developed in collaboration with, at minimum, with the
patient and two or more service providers external to lead agency
A minimum of one identified patient goal to meet identified need or
gap
•
What the patient hopes to achieve
A minimum of one intervention to address the gap/need
Identification of person(s) responsible for implementation of the
intervention(s)
• eg. patient, health care professional, service provider
A minimum of one expected outcome
Provision of plan to PCP (if not already involved in CCP) and/or
referral source
Date for planned review/ evaluation of the plan
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Health Link – Local Context
•
•
•
•
Brief description of the local health link process
This is how hard we have worked
You have helped us make tremendous strides
We need to do more
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Table Discussion: Question 1
Having heard this information…
At your table discuss how your own
organization is currently involved in
collaborative care planning for residents
with complex needs.
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Table Discussion Question 2
Consider the care planning process within
your organization.
Which of the 9 elements of coordinated
care planning are included in your care
plans?
Which are missing?
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Table Discussion: Question 3
Individually, write down, what is one thing
your organization can work on to improve
collaborative care planning?
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Sub-LHIN site report
What is one interesting thing that came
from your table in the workshop?
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