M a rc h 3 1 , 2 0 1 6
ISSUE 01
WHAT
INSIDE THIS ISSUE
Identifying Complex
Patients
2
Data Lead
2
Benefits of a
Coordinated Care Plan
2
TIHL Community
Partners
2
TIHL Data
3
3
Lucy’s Story
4
Thrive Program
5
SHIIP
5
IS HEALTH LINK?
Health Link is an initiative announced by the Ministry of Health and Long Term
Care in 2012. It is a model of care that aims to bring all health care providers in a
community together in an effort to improve care for people living with multiple,
complex conditions.
Health Link promotes increased communication, increased collaboration and coordinated care planning within a patients care team. Coordinated Care Plans are
patient centered and help care providers to better understand their patients’ health
care goals.
BENEFITS

TIHL Primary Care
Providers
APRIL 2016




O F H E A LT H L I N K
Improves communication within a patients care team resulting in more
coordinated care
Individualized Coordinated Care Plans are designed by patients with the
assistance of their care coordinators, who help to ensure their patients receive the care they require
Helps to reduce gaps in health care services
Helps to reduce duplication of health care services
Patients have a care coordinator they can contact, potentially eliminating
unnecessary provider visits
QUICK FACTS

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The Thousand Islands Health Link was established
in 2013
It is one of seven Health Links within the South
East Local Health Integration Network (SELHIN)
There are approximately 70, 000 patients within the
Thousand Islands Health Link
The Primary Care Providers within the Thousand
Islands Health Link are located throughout Brockville, Athens, Prescott, Gananoque, Lansdowne and
Seeley’s Bay
P age 2
TIHL
COMMUNITY
PARTNERS
I D E N T I F Y I N G PA T I E N T S W H O C O U L D
BENEFIT FROM A COORDINATED CARE PLAN

Alzheimer Society
Lanark Leeds
Grenville

Identifying complex patients who could potentially benefit from a Coordinated Care Plan is
an important first step in the coordinated care planning process. The Ministry of Health has
provided all Health Links with a definition of identifying complex patients using a list of 53
conditions that are considered chronic. If a patient has 4 or more of these conditions, they are
considered complex.
Brockville General
Hospital
(ACTT, Crisis Team,
In/Out Patient)

Children’s Mental
Health of Leeds and
Grenville

Community Care
Access Centre

Community
Pharmacies

Geriatric Mental
Health Community
Team

Health Care Connect

Lanark Leeds
Grenville Addictions
and Mental Health

Leeds, Grenville and
Lanark District Health
Unit

OTN

Rideau Valley
Diabetes Services

Specialists

Stroke Network of
Eastern Ontario

Tri-County Addiction
Services
The conditions that are included are those that:
1.
Affect a large number of patients
2.
Are risk factors for other chronic conditions
3.
Contribute to significant length of stay in one or more health care setting
The Thousand Islands Health Link Data Lead is able to determine which patients meet this
criteria by gathering data from both the primary care and the hospital sector. Patients are also
identified through recommendations from their physicians or allied health professionals involved in their care.
D A TA L E A D
Chelsea Good is the Data Lead for the Thousand Islands Health Link. Chelsea works closely with the Health Link lead to determine what
data needs to be measured, and develops the
best method for tracking this data.
Chelsea keeps track of how many Coordinated
Care Plans have been initiated across our
Health Link and identifies lists of complex
patients who may benefit from a Coordinated
Care Plan for the physicians in the Thousand
Islands Health Link.
Quarterly Chelsea also submits performance
statistics through the HQO's Quality Improvement Reporting and Analysis Platform (QI
RAP).
Chelsea participates in numerous committees
that take place in the Thousand Islands Health
Link.
Chelsea Good
BENEFITS OF A COORDINATED CARE PLAN

Patient-centered and links patient’s
physical, mental and social health
care needs

It is an important step in improving
the services available to patients

When different health care providers
work as a team, care is better coordinated

Provides patients with a care coordinator, who knows them well and is
able to provide assistance navigating
the health care system
P age 3
NUMBER OF COORDINATED CARE PLANS INITIATED IN THE
THOUSAND ISLANDS HEALTH LINK
TIHL
Primary
Care Providers
Athens District
Family Health Team
AGE BREAKDOWN OF PATIENTS WITH A
COORDINATED CARE PLAN
Comstock Family
Health Organization
CPHC - Community
Family Health Team
MOST COMMON CONDITIONS OF PATIENTS WITH A
COORDINATED CARE PLAN
Prescott Family Health
Team
Upper Canada Family
Health Team
Dr. S. Best
P age 4
L U CY ’ S STORY : A N EX AMP L E OF C OO R DINAT E D C AR E
Since the development of the Thousand Islands Health
Link in 2013 many patients have benefited from the initiation of Coordinated Care Plans. The below story is an
example of how coordinated care has assisted one of our
Thousand Islands Health Link patients to achieve her
health care goals.
Lucy is a 69 year old woman with multiple chronic conditions who lives alone with limited social and financial
resources. She was referred to an orthopedic surgeon by
her family physician due to ongoing knee pain.
Following her initial consultation with her surgeon, Lucy
was informed that she was a candidate for knee replacement surgery. Although relieved that this surgery may be
the answer to her ongoing knee problem, there were a
number of logistics that needed to be sorted out before
she could have surgery, primarily, how she would manage
her post-operative care at home, on her own?
Unaware of what resources may be available to her and
with respite not being an option due to cost, Lucy was at
a loss. Although she wished to pursue surgery, if it was
going to happen, she needed assistance making the arrangements required after she was home from the hospital.
In December 2015, Lucy was connected with her soon-to
-be Health Link Care Coordinator. At their initial meeting, Lucy was able to discuss her goals for her health care.
Obtaining post-operative home care so she could move
forward with her knee replacement surgery was at the top
of her list.
Following their initial meeting, Lucy’s care coordinator
began to look into what post-operative home care options were available to her patient. Due to Lucy’s social,
financial and medical circumstances, this proved to be
challenging. Her care coordinator was advised that knee
replacement surgery is considered an elective surgery, and
because of this, patients are required to cover the cost of
any post-operative care they may require, outside of their
hospital stay, on their own. For those with family or
friends close by able to provide assistance, or for someone who is able to cover this cost financially on their
own, this does not present a problem. Unfortunately for
Lucy, neither of these scenarios applied to her.
Lucy’s care coordinator continued to communicate with
care providers within the community regarding the services her patient would require. At the same time, she
continued to communicate with Lucy’s family physician,
the orthopedic surgeon and other doctors involved in her
care. Lucy’s knee replacement surgery was scheduled approximately two months after her initial meeting with her
care coordinator. After her surgery date had been scheduled, Lucy’s care coordinator was able to secure home
care hours through two different community agencies
who were able to accommodate her needs. It was a relief
for Lucy to find out her post-operative care was in place
as this would allow her to recover from surgery at home,
safely.
In the weeks leading up to surgery, Lucy’s care coordinator was able to help her prepare by assisting with equipment rentals, connecting her with the physiotherapy program at the hospital where she was scheduled to have her
surgery, and also helped to ensure transportation to and
from the hospital was in place. Lucy’s care coordinator
provided support to her patient and was available to answer any questions or concerns she had leading up to the
surgery date.
Lucy had her surgery on the scheduled date and was discharged home after four days in hospital without requiring an extended hospital stay. Her care coordinator met
with her while in the hospital, has followed up with her at
home and will continue to remain involved in her care. It
has now been six weeks since Lucy had her surgery. She
has been recovering very well at home with no return to
hospital and to date, she has had no complications post
discharge. Agreeing to participate with Health Link allowed Lucy’s entire care team to communicate and collaborate in order to better coordinate the care she required. In doing so, a positive patient experience was
also achieved.
Page 5
The Thousand Islands Health Link is pleased to welcome Heather MacCrimmon as our Thrive Counsellor.
Thrive is a new program within the Thousand Islands
Health Link.
To contact Heather for additional information about the
program or to make a referral, please call (613) 3400155.
The Thrive Program, funded through the South East
Local Health Integration Network, assists mothers who
are pregnant and/or parenting children, who have been,
or are currently experiencing, problems with substance
abuse.
The Thrive program offers counselling, and in-hospital
support visits. Also, parenting support and education.
The Thrive Program assists with transportation, food
and childcare so that those who are interested, are able
to participate.
Heather MacCrimmon
The South East Health Integrated Information Portal (SHIIP) is a secure information tool which allows a patient’s
primary care team to access patient hospital information quickly enabling improved quality of care. It also identifies
high needs patients who require ongoing health care support. Health Link Coordinated Care Plans are able to be
shared on SHIIP with care providers who are involved in a patient’s circle of care.
Currently, the Upper Canada Family Health Team and the Athens District Family Health Team are exploring the
functionality to further improve communication and patient care in primary care.
CONTACT INFORMATION
Sherri Fournier-Hudson
Upper Canada Family Health Team
5 Home Street, Suite 4
Brockville, ON
K6V 0A5
613-423-3333, Ext. 222
[email protected]