HEALTH LINKSNepean Sportsplex May28, 2013Peter McKennaRideau Community Health Services

The context

•Health care spending: current trend▫29 billion 2003; 46 billion 2012; 50 billion

2014/15•The demographic challenge

▫With increase in aging population, current spending pattern would significantly increase spending projections

•The opportunity▫Opportunities for reform, system readiness for

change, technological advances, increasing body of evidence

Future State

•Vision: To make Ontario the healthiest place in North America to grow up and old

•A system focused on wellness

•Faster access to family health care that serves as the hub of their health care system

•Better integration and accountability

The concentration of health care spending in Ontario•5% of the population accounting for 66%

of expenditure•Conditions:

▫Mostly chronic (heart failure, chronic obstructive pulmonary disease, myocardial infarction...)

▫Infection (pneumonia & urinary tract)▫Stroke and hip fracture▫End of life▫Cancer

What is a Health Link?

Health Links Measurement Framework• Operational (Setting the Stage for Coordinated Care)

• Coordinated Care plans for all complex patients• Greater number of complex patients with regular and timely access to

primary care provider

• Six Results-based Metrics (Moving the Needle)• Reduce: time from PC to specialist, #30 day readmissions to hospital,

# avoidable ED visits, time from referral to home care, unnecessary admissions to hospitals

• Ensure PC follow-up within 7 days of discharge from acute care setting

• Evaluation Based Metrics (How we will know we’ve arrived)• Enhance patient experience• Achieve ALC rate of 9% or less• Reduce average cost and keep quality of care

Health Link- mandatory requirements•Minimum population of 50,000•Includes health care providers in the care

of high use/ high need patients•Ability to identify and track high use/need

populations•Minimum of 65% of primary care

providers engaged

8

Health Links, South East LHIN

** after feedback from Webinar and Primary Health Care

Council meeting

9

aa

Perth and Smiths Falls FHO

Solo Family

Doctors

Smiths Falls NP

LedClinic

Country Roads

CommunityHealthCentre

Smiths Falls

Hospital

CCAC

VON

MentalHealth

Services

CommunitySupportServices

Addictions

PublicHealth

South EastHealth

Collaborative

RideauCommunity

HealthServices

PerthHospital

Perth Family

MedicineFHO

Patient(and family)

Experience in Province• 19 Early adopters• Cross section of co-ordinators (CHCs,

hospitals, CCACs, FHT/FHOs)• Various approaches to implementation• EMR/IT focus

▫ED notification or tracking of high use patients most common objective

▫Interest in connectivity, particularly with community care

• Encouraged to focus on care co-ordination, complex patient attachment