Health Links Quarterly Report for the Period April 1 to June 30, 2016 · 2016. 9. 19. · Health...

Health Quality Ontario The provincial advisor on the quality of health care in Ontario

September 9, 2016

Health Links Quarterly Report for the Period April 1 to June 30, 2016

Health Links Quarterly Report—April 1 to June 30, 2016 Approved by LHIN Health Link Leads September 2, 2016

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Contents Introduction ...................................................................................................................................................... 3

Highlights from this Quarter ............................................................................................................................. 3

Supplemental Report: New Indicators Relevant to the Proposed LHIN Sub-Regions ..................................... 3

Updated Target Data ....................................................................................................................................... 3

Innovative Practices ......................................................................................................................................... 4

Improving and Driving Excellence Across Sectors (IDEAS) Program: Health Links Focused Cohort ............... 4

Fast Facts from 2016/17 Q1: Health Links at a Glance ..................................................................................... 4

Progression of Health Links .............................................................................................................................. 5

Coordinated Care Plans (CCPs) ......................................................................................................................... 6

Regular and Timely Access to a Primary Care Provider (PCP) .......................................................................... 7

Summary by LHIN (more details are available in the LHIN Reports) ................................................................ 8

Impact of Health Links: A Patient Story .......................................................................................................... 10

What Are We Hearing From You? .................................................................................................................. 12

Sharing Experiences from Across the Province .............................................................................................. 13

Coming Events in the Next Quarter ................................................................................................................ 15

Appendix 1: Health Links Cumulative Data .................................................................................................... 17


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Health Links Quarterly Report

Period: Fiscal Year 2016-17 Q1 (April to June 2016)

Introduction

This quarterly Health Links (HL) report provides a summary of data reported by Health Links for the period

April to June 2016 (fiscal year 2016-17 Q1). The report provides a deeper understanding of the Health Links

practices across the province during this quarter, and progress over time. To prepare each quarterly report,

observations from the previous quarter are reviewed, areas of interest are identified to guide our

conversations with each Local Health Integration Network (LHIN), and discussions are summarized. The report

is circulated broadly to all Health Link teams, LHINs, Health Quality Ontario and the Ministry of Health and

Long-Term Care (MOHLTC) to provide information about progress and to support Health Links through

implementation and ongoing improvement. Data reported by Health Links for Q1 (April to June 2016) were

reviewed by all 14 LHIN Health Link Leads and Health Quality Ontario Regional Quality Improvement (QI)

Specialists and Manager over the first two weeks of August 2016.

Highlights from this Quarter

Supplemental Report: New Indicators Relevant to the Proposed LHIN Sub-Regions

As LHINs move forward with the identification of their proposed sub-region boundaries, Health Quality

Ontario, working in collaboration with the Institute for Clinical Evaluative Sciences (ICES) and the LHINs, will

provide supplemental data to the Health Link quarterly reports. South East LHIN sub-regional data is provided

as an example.

Not all Health Links align with the proposed LHIN sub-region boundaries, but this level of analysis can highlight

regional variation and help focus LHIN attention on subsets of their population where the need is greatest. It is

important to note that the data included in the sub-regional analysis is based on fiscal year 2014-15, and

therefore does not reflect improvements that may have been made as a result of Health Links. In addition, it

reflects a broader patient base (including all patients, rather than only patients who have 4+ chronic

conditions and complex needs).

For a sample of sub-region data and its interpretation, please see the attached Supplemental Report.

Updated Target Data

The Health Analytics Branch of the MOHLTC recently released refreshed targets based on 2013-14 data for all

Health Links, including those areas currently in the planning stages. This approach allows Health Links and

LHINs to focus on identifying people within their communities who have four or more chronic and/or high cost

conditions, and could potentially benefit from coordinated care management. This provides a broad context

for the defining target populations, and is further refined on a local level through LHIN-specific targets.

Through Quality Improvement Reporting and Analysis Platform (QI RAP), LHINs are now able to enter each

Health Link’s quarterly targets for Coordinated Care Plan (CCP) completion and Primary Care Provider (PCP)

access. This allows LHINs and Health Links to refine the broad numbers provided by Health Analytics Branch to


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meaningful and achievable goals. Currently, five of 14 LHINs have entered their quarterly target data, with

more planned to begin target entry in Q2. Others are working through target setting and accountability

agreements pending receipt of their funding.

Innovative Practices

Health Quality Ontario completed a comprehensive review of the best available information about Health

Links and analyzed innovations related to the Coordinated Care Management process. Information on the

Innovative Practices Framework, the summary of innovations, and the respective toolkits can be found here.

Innovative practices are based on the highest quality evidence and information available, and have been

defined and assessed by Health Quality Ontario’s Clinical Reference Group (CRG). It is suggested that Health

Links draw upon this collection of Innovative Practices to create the foundation for supporting their

Coordinated Care Management processes and improving care for patients within their Health Link. The next

set of innovative practices will be focused on Transitions between Hospital and Home, and are scheduled be

released on September 28th, 2016, followed by Mental Health and Addictions later this fiscal year.

Improving and Driving Excellence Across Sectors (IDEAS) Program: Health Links Focused Cohort

The next cohort of the Improving and Driving Excellence Across Sectors (IDEAS) Advanced Learning Program is

dedicated specifically to Health Links, with participants using projects in Innovative Practices for either

Coordinated Care Management or Transitions between Hospital and Home as their focus for applied learning.

At this time, 59 participants from 16 Health Links have registered, with distribution across 11 LHINs. The

concentration of teams from Health Links will contribute substantially to building a community of leaders with

the knowledge and skills to embrace a quality improvement approach to change. By applying their learning to

areas typically identified by Health Links as problematic, participants will have the opportunity to lead projects

that are meaningful to patients, families/caregivers, clinicians, and staff.

Fast Facts from 2016/17 Q1: Health Links at a Glance

Number of

HLs actively recruiting patients

Number of Coordinated Care Plans

(CCPs) completed

Number of patients connected to a

Primary Care Provider (PCP)

2015-16 Q4 80 4,549* (reported by 76 of 80 Health Links)

5,711* (reported by 72 of 80 Health Links)

2016-17 Q1 79** 3,782 (reported by 78 of 80 Health Links)

3,668 (reported by 76 of 80 Health Links)

Cumulative total to date 79** 22,707 33,614

*Note: This number was adjusted in Q1 due to error corrections: CCPs previously recorded as 4,622; PCP previously recorded as 5,713.

**Note: This number was adjusted to reflect updated information from the ESC LHIN

http://www.hqontario.ca/Portals/0/documents/qi/health-links/ccm-overall-summary-of-innovative-practices-en.pdf

http://www.hqontario.ca/Quality-Improvement/Learning-Opportunities-and-Webinars/IDEAS


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Progression of Health Links

To date, 91 Health Links have been planned by the MOHLTC. It should be noted that in order to expand Health

Links to cover all geographic areas across the province, a total of 100 Health Links are noted in the most recent

Health Analytics Branch analysis (see Appendix 1).

Figure 1: Total Number of Health Links per LHIN

Interpretation (by June 2016):

In 2016-2017 Q1, 79 Health Links were actively recruiting patients and an additional 21 were identified as in planning stage (spread over 7 of 14 LHINs)

78 Health Links are reporting CCP data, and 76 Health Links are reporting access to PCP data

Anecdotally, we have heard that Q1 of each year has posed similar difficulties for existing Health Links, as uncertainties about continued funding have influenced their work and staffing models. Despite these challenges, there has been an increase in the average number of Coordinated Care Plans being completed in Q1 year over year.

Over time, there has been a convergence in the number of patients referred to a Primary Care Provider and those completing a Coordinated Care Plan. This is reflected in the narrowing gap between these two numbers.

Table 1: Health Links Q1 data by year

*In the first year of Health Links, there was no reporting requirement for the Health Link early adopters, however one Health Link entered data into QI

RAP for Q1 hence the denominator is 0.

0

2

4

6

8

10

12

14

16

ESC SW WW HNHB CW MH TC C CE SE CH NSM NE NW

Total Number of Health Links per LHIN(Total n = 100)

# HLs actively recruiting patients # HLs new in Quarter # HLs in planning stage

Year of Q1 # of CCPs # of HLs reporting

Average # CCP per HL

# of PCP # of HLs reporting

Average # PCP per HL

Comments

Q1 2013 272 1 of 0* - 272 1 of 0* - No Health Links were required to submit data

Q1 2014 922 30 of 28 30 1,805 29 of 28 62 Additional Health Links reported but not required

Q1 2015 1,814 54 of 55 33 3,554 51 of 55 70 Not all active Health Links reported data

Q1 2016 3,782 78 of 80 48 3,668 76 of 80 48 Not all active Health Links reported data


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Coordinated Care Plans (CCPs)

The indicator used in QI RAP is the “number of Health Link patients with a coordinated plan of care developed through the Health Link during the past quarter”

To be included, the CCP must: o Be developed with the patient/caregiver

and two (2) or more health care professionals; AND

o Contain a plan for one (1) or more health issues

Figure 2: Total Coordinated Care Plans by Quarter Figure 3: Cumulative Total Number of Coordinated Care Plans To Date

Interpretation: In reviewing the quarterly data, we see that there has

been a drop in the average rate of CCPs completed per Health Link in Q1 of each fiscal year

In previous years, there has been recovery by Q2 and the progression has continued with an increase in the average number of CCPs completed by HL

The actual CCP for Q1 is 3,782

The quarterly target number entered into QI RAP is 2,112. While only 5 LHINs have entered targets at this point, this will be updated in the next quarterly report as additional LHINs enter targets

When we look at the number of CCPs completed compared to the total target population in each LHIN or Health Link (Table 2), we recognize that there is potential to benefit even more patients by promoting the spread of innovative practices in coordinated care management

Interpretation: In reviewing the cumulative data to date, we see that:

Despite the decrease of CCPs in Q1, the cumulative total has increased from 18,925 to 22,707

3.5% of the overall target population (4+ conditions: 646,575) now has a completed CCP, which is 22,707 patients cumulatively

7.4% of the high cost target population (4+ conditions and high cost user: 306,380) now has a completed CCP

* Note: This number was adjusted in Q1: CCPs previously recorded as 4,622; PCP previously recorded as 5,713. Adjusted due to error corrections.

“Health Links will encourage greater collaboration and co-ordination between a patient's different health care providers as well as the development of personalized care plans. This will help improve patient transitions within the system and help ensure patients receive more responsive care that addresses their specific needs with the support of a tightly knit team of providers.”

— Announcement of the Health Links Initiative

(Dec 2012)


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Regular and Timely Access to a Primary Care Provider (PCP)

The indicator used in QI RAP is the “number of patients with regular and timely access to a Primary Care Provider (PCP)”

There are three options for data collection, with the aggregate reported in QI RAP. In most cases, a single Health Link will only choose to use one target/actual pair

Figure 4: Access to Primary Care Provider by Quarter

Figure 5: Cumulative Total Number of Patients with Access to Primary Care Providers

Interpretation: In the current quarter, 3,668 patients with complex

needs were connected to a primary care provider. Given that primary care is foundational to the provision of comprehensive care, this has far-reaching implications to patients’ care experiences and outcomes

There are considerably more PCPs reported than CCPs, though the number is converging. We are beginning to learn that while Health Links teams are connecting patients to PCPs, these patients sometimes decline CCP support and sometimes there is a planned lag between when they are connected to a PCP and when the CCP is completed

Interpretation: In reviewing the cumulative data to date, we see that:

Despite the decrease in number of patients connected to primary care from the previous quarter, the cumulative total number of patients connected to a PCP increased to 33,614 in Q1, compared to 29,946 in the previous quarter

Please note that the Q4 data for this indicator was adjusted from 5,713 in the last report to 5,711 in this report

Regular and timely access to primary care for complex patients “A central goal of Health Links continues to be the regular and timely access to primary care providers. As most patients’ first interaction with the health care system is through their primary care provider, ensuring that patients are attached to primary care providers is essential to the effective provision of coordinated care for all of Ontario’s complex patients.”

— Excerpt from Advanced Health Links Guide


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Summary by LHIN (more details are available in the LHIN Reports)

Table 2: Target Population by LHIN (Data Source: Health Analytics Branch, 2016)

Number of Health Links1

Target Population for Health Links1

# Actively Recruiting Patients

Total # HL Planned

Total Patients

# Target Population

(4+ conditions)

ESC 2 5 399,580 30,555

SW 4 6 772,248 43,795

WW 4 4 612,255 27,260

HNHB 11 11 1,192,442 80,155

CW 5 5 786,174 38,760

MH 7 7 1,018,435 47,385

TC 9 9 1,004,644 59,980

C 3 5 1,565,436 79,485

CE 6 7 1,340,417 78,395

SE 7 7 413,366 26,895

Champlain 8 10 1,074,031 56,980

NSM 5 5 385,057 23,320

NE 6 14 472,283 33,430

NW 2 5 189,746 11,540

Total 79 100 11,226,114 637,935

It should be noted that Table 2 includes the updated number of 100 Health Links (including those planned) as LHINs are working to onboard a full complement of Health Links for complete geographic coverage. Furthermore, though the targets listed in the far right column include the patients with four or more chronic conditions that may benefit from a Health Link approach to care, each LHIN is in the process of setting shorter-term goals and targets for recruitment to their Health Links.

NOTE: The information on the Health Links Target Population includes those residents within planned and approved Health Link areas who had 4 or more chronic and/or high cost conditions. Analysis is provided for the Health Links approved by the Ministry of Health and Long-Term Care.

The results are based on analysis of individuals who used acute care, day surgery, emergency, ambulatory oncology, ambulatory dialysis, inpatient mental health, inpatient rehabilitation, complex continuing care (CCC), home care, long-term care (LTC), or physician services in the 2013/14 fiscal year.

The “Total Patients” refers to all patients who used these services in the 2013/14 fiscal year. Note that “Total Patients” and the population in an area are NOT the same. The analysis identified the presence of 55 conditions/interventions within any diagnosis field in any clinical record during the fiscal year. The conditions selected were those that can be identified within administrative datasets and that: affect a large number of patients, are risk factors for other chronic conditions, or contribute to significant length of hospital stay and/or cost in one or more health care sector. The “Target Population” are patients with 4 or more of the selected conditions.

~ Prepared by Health Analytics Branch, MOHLTC


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Table 3: Quarterly and Cumulative Data from QI RAP (self-reported by each Health Link)

# Coordinated Care Plans completed # Patients with regular and timely access to

a Primary Care Provider

LHIN Fiscal Quarterly

Target # HL Reporting

Q1 Cumulative

Total # HL

Reporting

Q1 Cumulative

Total

Actual Actual Actual Actual

ESC 0 2 69 304 2 72 195

SW 169 4 168 441 4 132 3,248

WW 0 4 221 2,724 4 221 3,111

HNHB 0 11 145 1,125 10 142 2,105

CW 0 5 783 4,278 5 783 5,351

MH 0 7 161 589 7 153 589

TC 1,132 9 783 5,399 9 743 10,650

C 0 3 245 1,378 3 245 1,574

CE 0 6 416 1,671 6 410 2,260

SE 465 7 317 2,678 7 309 2,602

Champlain 180 8 105 472 8 100 426

NSM 166 5 245 1,141 5 232 1,012

NE 0 5 99 355 4 101 315

NW 0 2 25 152 2 25 176

Total 2,112 78 of 100 3,782 22,707 76 of 100 3,668 33,614

Note: Table 3 provides data on progress for the two measures at the LHIN level. Detailed information at the Health Link level by LHIN is

included in Appendix 1.


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Impact of Health Links: A Patient Story

Rob’s Story Thank you to Hamilton Niagara Haldimand Brant LHIN for sharing this story

The following is a detailed story of a patient who had frequent emergency department (ED) visits and many obstacles to self-managing his multiple health conditions and complex needs. Through the collaboration of Health Links, Rob is currently supported by a large team of health and community resources while living in his own home, has greatly reduced his emergency department visits, and his quality of life has considerably improved. About Rob

Rob is a 54 year old gentleman with a history of hypertension, diabetes, high cholesterol, multiple heart attacks, and is developmentally delayed. He lived with his mother until she passed away and then moved into his own apartment as his siblings were unable to support him. Rob receives disability support and uses the local food bank. Rob rides the local transit bus from about 11 a.m. to 1 p.m. each day. A retired transit bus employee had been s helping with Rob’s finances, but is unable to continue this support. Between July 21 and October 24, 2014 Rob made 16 visits to the Emergency Department, resulting in 6 admissions. His last admission was from October 25, 2014 to March 23, 2015 (13 acute days + 137 alternate level of care days). Part of the reason for this extended hospital stay was that Rob was not taking his cardiac and diabetes medications and was not monitoring his blood sugar. The hospital team waited for Developmental Supports Ontario to assist Rob and a referral was made to Hamilton West Health Link March 2015 where a Coordinated Care Plan was initiated.

What matters most to Rob? “I want to stay in my apartment” Discharge Planning

Prior to discharge from hospital, the following actions were taken for Rob’s discharge planning:

Meetings were held with hospital team including a Most Responsible Provider (MRP)

A Coordinated Care Plan/Action Plan was developed with Rob

Cognitive testing was completed and health literacy issues were identified

Rob was accompanied home to his apartment on three separate occasions to complete a home environmental safety assessment, and one of the team members observed Rob’s use of his glucometer and recording of blood sugars

The team organized a list of health provider contact information for Rob to use at home

A plan was developed in hospital for self-management and medication administration. The Health Link reached out to Developmental Services Ontario, Community Living Hamilton, Southern Network of Specialized Care, and a CCAC Director.

The team also consulted and worked with St. Joseph’s Home Care (which provided care in a nearby hub), Catholic Family Services, March of Dimes, City of Hamilton/Public Health, his family physician, Rob’s friend, and the superintendent of his apartment to help develop the plan to support Rob in his apartment

Post-Discharge from Hospital

The following actions were taken to support Rob after he was discharged from the hospital:

Rob was visited at home twice per week for one month, and then once per week for two months by the Health Link Care Coordinator

Currently, a Health Links Care Coordinator visits Rob every other week and Rob visits the Health Link office on alternate weeks to monitor blood sugars and medication compliance, and to continue education and support as part of the ongoing support


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A Health Link team member continues to accompany Rob to appointments including: o The lab for blood work, when required (Rob is afraid of needles and was previously thought to skip

blood work) o His family physician appointments to discuss discharge medications and follow-up plans (the

discharge summary was not available for many weeks and Rob was not a reliable source of information)

o The cardiologist, where the team member helped Rob describe the frequency of his chest pain and medication issues (his medication doses were then able to be adjusted as a result)

o The nuclear medicine lab for a test ordered by Cardiologist

The Hamilton Niagara Haldimand Brant CCAC completed his application for subsidized housing

The Health Links team connected Rob to diabetes education sessions at Wesley Urban Core for ongoing support

The Health Links team continued to advocate for Rob with Developmental Services Ontario for Passport Program funding, which was approved in February 2016

Accompanied Rob to a local charity (Good Shepherd) for financial trustee services which will remain in place until finances are sorted out for Rob

Results of a Support System for Rob

Rob is still living in his apartment and is waiting for subsidized housing. He is doing well and was able to adopt and care for a pet budgie. Rob is very proud of himself and is looking forward to using his Developmental Services Ontario Passport Funding to attend social events and activities, such as concerts and bowling. Rob had been on the waiting list for an Adult Protection Services Worker since March 2015 and was assigned a services worker in May 2016. Since being discharged in March 2015, Rob had a total of three ED visit in 2015, all occurring on weekend/holidays when support was not available. Rob had 2 admissions in 2016 one for chest pain in April 2016 for 6 days and another for a heart attack and was admitted for 2 days in May 2016. With the help of his team, he is currently doing well with his medications and the management of his chronic conditions. Having the support he needed already in place when was he discharged in March 2015 helped decreased his length of stay during both admissions in 2016.

Most importantly, Rob is still living in his own apartment and has the supports he needs.


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What Are We Hearing From You?

As part of the data analysis and narrative comments submitted from the LHIN-level reports, there were a

number of issues raised across the province explaining the dip in number of Coordinated Care Plans (CCPs) in

Q1. LHINs and Health Links have identified the following as challenges to spread and scale:

Funding delays impacting staff retention

Lack of e-solutions to share and collaborate on CCP

One-time funding for the Care Coordination Tool delayed and/or no carry-over

Difficulty with sustainable model of care

Challenges engaging primary care providers

Inactive and new Health Links

Lack of capacity and ability to transition patients to less intense support

Challenges with identification of patients

Patients going outside of a Health Link geography to find a primary care provider

In order to overcome the challenges, LHINs and Health Links have identified the following planned and current

initiatives, along with dependencies to enable sustainability and spread in their regions:

Shorter approval processes for new Health Links

Reviewing models of care, including regional project management support, standardization of tools,

resources, education, and the standardization of the CCP and PCP quarterly reporting

Timely access to funding

Accountability agreements and performance targets for Health Links and/or partner organizations

Investigating, initiating, or improving upon e-solutions for care management and CCPs

11 LHINs are sending two to three Health Link teams to the IDEAS Advanced Learning Program this fall

Initiation of action-oriented working groups focusing on care coordination, e-enablers, and primary

care engagement

Developing and testing processes to transition patients with less intense care coordination needs to a

more sustainable model of coordinated care within the primary care sector

Leveraging programs already funded that support patients with complex needs, such as intensive case

management for mental health and addictions, cardiac programs, self-management, and palliative

care

Defining and/or refining roles and responsibilities

Developing onboarding and orientation processes for providers, or providing refreshers of existing

processes

Partnering on research evaluations of Health Link model components, such as patient experience,

CCPs for intellectual disabilities, and the outcomes of patients before and after Health Links align care

coordinators to primary care


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Sharing Experiences from Across the Province

A key role of the quarterly report is to share some of the practical experiences from across Health Links to begin the spread of learning. As we work through priority topics, additional assessment of practices will follow through the work of the Clinical Reference Group (CRG) and their methodical evaluation of Innovative Practices. The following table summarizes innovations and learning shared during the development of the quarterly report.

TOPIC Sharing Ideas and Successes

Patient experience and/or engagement

In Champlain LHIN, a Health Link Patient Experience survey was developed by a working group comprised of patients (and representatives), caregivers, Health Links project managers, the LHIN, and Health Quality Ontario. The survey was piloted and is now in full implementation with eight active Health Links. Preliminary results show positive feedback from patients

Alignment to Patient’s First

In Mississauga Halton LHIN, the CCAC has geographically aligned care coordinators to primary care

In Toronto Central LHIN, transition is underway to align Health Links to sub-regions and primary care strategy

In Central West LHIN, there are increased linkages with primary care through eight Health Link Resource Coordinators and alignment of dedicated CCAC care coordinators to primary care providers

e-Solution work In Central West LHIN, Health Links are engaged in using Ontario Tele-Medicine’s Personal Computer Video Conferencing (PCVC) for care conferencing as an alternative to in person care conferences.

In South East LHIN, South East Integrated Information Portal (SHIIP) continues to be rolled out

o At the end of Q1, there were 14 sites actively using this system o Engagement with two other LHINs is underway to explore its use o New features were recently added to enable Health Links to become an author

of a CCP within the system and to enter CCP’s, make changes to CCP’s and to create a dashboard for indicators

o Migration of the tool to the Kingston General Hospital (KGH) from Brockville General Hospital is in final stages, and agreements for KGH to act as Health Information Network Provider are being reviewed

o The team is initiating the integration of post-Acute data, leveraging the Ontario Mental Health Reporting System (OMHRS), National Rehabilitation Reporting System (NRS), and Continuing Care Reporting System (CCRS) Canadian Institute for Health Information (CIHI) data sets (currently in phase 1)

In Central LHIN, a Health Link using a Care Coordination Tool has expanded to include nine unique providers, which has greatly enabled collaboration and communication for shared patients

Studies and evaluation work

In South East LHIN, one Health Link is partnering with the Centre for Studies in Primary Care in research on “An evaluation of specialized Coordinated Care Plans for adults with intellectual and developmental disabilities (IDD).” Patients will be identified and CCPs initiated beginning this Fall

As part of the provincial study led by Dr. Walter Wodchis, Dr. Michael Green (Centre for Studies in Primary Care, Department of Family Medicine, Queen's University) will be


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capturing the experience of patients with Health Links care coordination and transition in the South East LHIN. His team will be working with Rural Hastings, Quinte, and Thousand Islands Health Links and in collaboration, and with Dr. Kathryn Broham, who is doing a Patterns of Care Study with Quinte Health Link and Rural Hasting Health Link.

In Central LHIN, ongoing Health Link evaluation work is underway with Health System Performance Reporting Network (HSPRN), led by Dr. Walter Wodchis, and is a component of the overall provincial evaluation

Spread & Sustain activities

In North East LHIN, to support the Health Link philosophy in the region, the monthly Community of Practice teleconference chaired by the LHIN’s Primary Care Lead will continue to offer a space for 2-way dialogue, updates, and sharing practices among Health Links. In September, a Health Links leadership council will be established, which will work together to establish standards and structure to solidify the role of Health Links in the region

In South West LHIN, core practices have been identified for spread, including care bundles (created using Quality Based Procedures) for chronic obstructive pulmonary disorder/congestive heart failure via the learning collaborative

In North Simcoe Muskoka LHIN, spread remains a focus of all Health Links, and a collaborative approach to develop a cross-sector Quality Improvement Plan (QIP) for 30-day readmissions is planned; this is expected to impact Health Links and create further partnerships and relationships among providers

The Champlain LHIN funded and supported eight Health Links to participate in a 5-month learning and applied program with the Telfer School of Management called Leading Change Collaboratively; additionally, processes to transition patients with less intense coordination needs are being created and tested by the Health Links

In Erie St. Clair LHIN, the Health Link undertook a process to review their target population and created a model refresh that includes a more refined case management approach with defined roles and care processes, included onboarding and orientation processes for providers

In Waterloo Wellington LHIN, each of the 4 health links are testing out a new sector collaboration to initiate CCPs with the aim of spreading that collaboration to the other 3 health links in the future. For example, the Guelph health link is working with the acute care mental health hospital to streamline the approach to begin CCPs as part of the discharge process.

South East LHIN’s Health Link Community of Practice continues to work towards completion of the Care Coordination Learning Program. South East LHIN anticipates that this learning program will be completed in its draft form before the end of August 2016. Once the draft is complete, the Health Link Community of Practice will work to validate the Learning Program’s effectiveness and revise accordingly

In Central LHIN, the Health Link model is being spread and adopted by multiple providers; standardized tools are being developed and/or spread for a regional approach

In Central East LHIN, the regional Health Link sustainability strategy is facilitated by a shared Project Management Office, and work continues to integrate the Health Link model into existing programs and teams funded to manage patients with complex health needs

In Central West LHIN, a regional approach to project management is in development, along with a Health Link dashboard, and a shared model of care coordination across multiple sector organizations

In South East LHIN, the CCAC has completed their pilot for embedding CCAC care coordinators in Health Links. They will now be redesigning clinical service delivery to enhance their care coordination contribution to Health Links. The CCAC is currently in the


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process of selecting five CCAC care coordinators to have a Health Link Integration Assignment process. In addition to clinical service delivery, these care coordinators would be peer mentors to their colleagues in the area

The Toronto Central LHIN has formed a LHIN-wide patient advisory committee, developed decision support, governance structures and standardized processes and tools, such as referral forms and other supports for new Health Links

North West LHIN will be establishing a LHIN-wide Health Link steering committee table this fall to further enable information sharing. Additionally, LHIN-wide decision support is being explored to ensure consistent and standardized data entry and reporting.

Presentations In Central LHIN, a Health Link will be presenting their Care Coordination Tool work at the 45th Annual Scientific and Educational meeting of the Canadian Association of Gerontology in Montreal, Quebec on the topic “Electronic Coordinated Care Plan in South Simcoe Northern York Region (SSNYR) Health Link”

Additionally, this Health Link recently presented at the 17th Annual International Summit on Improving Patient Care in the Community in Orlando, Florida (a Learning Collaborative hosted by the Institute for Healthcare Improvement)

o The goal of the Institute for Healthcare Improvement Better Health and Lower Costs for Patient with Complex Needs Collaborative is to increase the scale and reach of the Health Link model of care and to focus on a sub-population of the high users; specifically geriatric mental health and addictions individuals with multiple co-morbid conditions

Health Links from around the province are being chosen for Health Quality Transformation (HQT) 2016 poster and panel presentations

Coming Events in the Next Quarter

1. Innovative Practices: Transitions between Hospital and Home Endorsed for Provincial Spread

As patients move through the healthcare system, transitioning from one provider to another in a

coordinated manner is integral to safety and the patient experience. Optimal patient outcomes and

positive experience of care are predicated by integrated and coordinated approaches to care. Innovative

practices related to transitions were recently tabled for consideration by the Clinical Reference Group

(CRG) for their endorsement. A comprehensive knowledge translation plan, including web-based

resources, recommended measures, and toolkits will be released following endorsement by the CRG on

September 28th, 2016.

2. Health Links Leadership Summit (September 28, 2016)

This event brings clinical and administrative leaders together to collaborate, develop and support strategic

approaches in caring for patients with multiple conditions and complex needs. Participants will share

emerging innovations and inspire ideas for change. To ensure representation from all areas of the

province, participants have been invited by their LHINs to attend.

3. Quality Rounds

Quality Rounds Ontario are monthly educational sessions hosted by Health Quality Ontario to offer

participants from across the province opportunities for knowledge exchange and idea sharing on topics


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relevant to improving the quality of health care. The sessions are held in locations across Ontario and are

facilitated by health system leaders from across the province and other jurisdictions and from all sectors.

Quality Round Ontario sessions are one-hour long and can be attended in-person or virtually through the

Ontario Telemedicine Network or via webinar. The presentations from past events are also listed on our

website and can be viewed at any time.

The next scheduled Quality Rounds will be held at 12:00-1:00 p.m. on September 20 and November 16,

2016.

4. Health Quality Transformation (October 20, 2016)

On October 20, 2016, Health Quality Ontario will host Health Quality Transformation Presents: Quality

Matters 2016, our fifth annual interactive conference for patients, caregivers, health care providers and

system leaders. Held once again at the Metro Toronto Convention Centre, the focus of our conference this

year is Quality Matters, the health system quality framework on how to realize excellent care for all. Join

delegates from across our health system, including patients, families and members of the public, as we

come together to share experiences and best practices. Registration for this event begins early September.


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Appendix 1: Health Links Cumulative Data

Health Link Names Total

patients

Target Population

Complex Patients

(4+conditions)

Fiscal Quarterly Target

# Coordinated Care Plans completed # Patients with regular and timely access to a

Primary Care Provider

HL Reporting

Q1 Cumulative

Total

HL Reporting

Q1 Cumulative

Total


01. Erie St. Clair LHIN 399,580 30,555 0 2 69 304 2 72 195

Chatham City Centre 35,451 2,460 66 301 66 189

Essex South Shore - PENDING 63,476 4,170

Lambton County Lake Huron 106,840 7,835 3 3 6 6

Windsor East - PENDING 115,441 9,240

Windsor West City Centre - PENDING 78,372 6,850

02. South West LHIN 772,248 43,795 169 4 168 441 4 132 3,248

Elgin County - PENDING 75,222 4,265

Huron-Perth County 109,169 5,905 56 36 139 1 2967

London-Middlesex County 379,098 21,200 75 88 210 88 210

North Grey Bruce 72,102 4,830 23 27 51 26 47

Oxford County - PENDING 92,547 5,005

South Grey Bruce 44,110 2,590 15 17 41 17 24

03. Waterloo Wellington LHIN 612,255 27,260 0 4 221 2,724 4 221 3,111

Cambridge 118,744 6,030 52 240 52 222

Guelph 111,106 5,260 94 1801 94 2180

Kitchener-Waterloo 310,279 12,620 43 273 43 256

Rural Wellington 72,126 3,350 32 410 32 453


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patients

Target Population

Complex Patients

(4+conditions)




HL Reporting

Q1 Cumulative

Total

HL Reporting

Q1 Cumulative

Total


04. Hamilton Niagara Haldimand Brant LHIN 1,192,442 80,155 0 11 145 1,125 10 142 2,105

Brantford, Brant & Six Nations 114,446 6,975 11 113 10 109

Burlington 159,390 9,535 11 100 11 100

Haldimand 41,226 2,590 5 68 5 62

Hamilton Central 125,694 10,065 0 107 No data 1113

Hamilton East 172,512 10,800 5 96 5 86

Hamilton West 145,829 8,225 29 175 29 175

Niagara North East 146,964 11,760 9 112 9 110

Niagara North West 53,649 2,735 14 132 14 132

Niagara South East 100,012 7,575 11 36 11 36

Niagara South West 81,099 6,325 28 84 26 82

Norfolk 51,621 3,570 22 102 22 100

05. Central West LHIN 786,174 38,760 0 5 783 4,278 5 783 5,351

Bolton 32,006 1,510 22 120 22 120

Bramalea 233,562 10,205 82 585 82 1147

Brampton 271,496 12,270 173 1028 173 1392

Dufferin 60,664 3,130 116 966 116 1045

North Etobicoke-Malton-West Woodbridge 188,446 11,645 390 1579 390 1647


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patients

Target Population

Complex Patients

(4+conditions)




HL Reporting

Q1 Cumulative

Total

HL Reporting

Q1 Cumulative

Total


06. Mississauga Halton LHIN 1,018,435 47,385 0 7 161 589 7 153 589

East Mississauga 252,766 13,790 50 332 48 328

Halton Hills 53,219 2,185 21 32 21 33

Milton 87,604 2,835 8 19 8 20

North West Mississauga 235,681 8,085 8 47 8 47

Oakville 167,114 7,525 37 67 33 70

South Etobicoke 97,428 6,465 19 32 18 31

South West Mississauga 124,623 6,500 18 60 17 60

07. Toronto Central LHIN 1,004,644 59,980 1,132 9 783 5,399 9 743 10,650

Central West Toronto 99,173 6,460 150 51 232 78 709

Don Valley/Greenwood 69,587 3,995 141 116 869 116 1222

East Toronto 153,777 9,410 141 101 928 101 1062

Mid East Toronto 107,702 6,835 110 100 466 99 1564

Mid-West Toronto 137,511 7,560 150 162 1024 162 3892

North Toronto East 104,278 5,355 95 57 853 57 1565

North West Toronto 107,896 6,275 95 66 226 0 22

South Toronto 125,874 8,235 125 77 584 77 368

West Toronto 98,846 5,855 125 53 217 53 246


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patients

Target Population

Complex Patients

(4+conditions)




HL Reporting

Q1 Cumulative

Total

HL Reporting

Q1 Cumulative

Total


08. Central LHIN 1,565,436 79,485 0 3 245 1,378 3 245 1,574

North York Central 346,206 20,650 125 627 125 660

North York West - PENDING 220,037 14,245

South East York Region - PENDING 319,008 12,390

South Simcoe and Northern York Region 248,990 13,030 76 524 76 699

South West York Region 431,195 19,170 44 227 44 215

09. Central East LHIN 1,340,417 78,395 0 6 416 1,671 6 410 2,260

Durham North East 260,589 15,945 36 208 31 185

Durham West - PENDING 291,593 13,060

Haliburton and Kawartha Lakes 77,431 5,990 11 94 11 92

Northumberland 54,776 3,690 54 146 54 142

Peterborough 117,036 9,115 34 288 34 909

Scarborough North 162,008 8,455 165 253 165 252

Scarborough South 376,984 22,140 116 682 115 680


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patients

Target Population

Complex Patients

(4+conditions)




HL Reporting

Q1 Cumulative

Total

HL Reporting

Q1 Cumulative

Total


10. South East LHIN 413,366 26,895 465 7 317 2,678 7 309 2,602

Kingston 116,803 7,835 105 42 522 41 509

Quinte 107,634 6,720 100 67 643 63 639

Rideau Tay 44,240 2,640 45 39 194 39 194

Rural Hastings 37,214 2,605 85 84 450 84 425

Rural Kingston 27,812 1,625 25 22 207 22 177

Salmon River 19,882 1,375 50 34 195 31 191

Thousand Islands 59,781 4,095 55 29 467 29 467

11. Champlain LHIN 1,074,031 56,980 180 8 105 472 8 100 426

Arnprior Region and Ottawa West 123,139 5,295 30 17 52 17 48

Central Ottawa 297,220 16,105 15 2 7 2 7

East Ottawa - PENDING 200,255 9,815

North Lanark - PENDING 25,461 1,490

North Renfrew County 43,402 2,975 20 20 51 18 47

Prescott-Russell Regional 41,383 2,930 25 14 90 14 100

South and West Ottawa North Grenville (HLA 6) 173,822 7,830 20 12 18 12 18

South Renfrew 28,122 2,460 25 12 121 10 110

Stormont, Glengarry, Cornwall and Akwesasne 78,395 5,330 20 11 84 10 47

Upper Canada 62,832 2,750 25 17 49 17 49


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patients

Target Population

Complex Patients

(4+conditions)




HL Reporting

Q1 Cumulative

Total

HL Reporting

Q1 Cumulative

Total


12. North Simcoe Muskoka LHIN 385,057 23,320 166 5 245 1,141 5 232 1,012

Barrie Community 178,516 8,325 38 152 609 140 425

Muskoka Community 49,237 3,350 30 7 69 7 68

North Simcoe Community 40,713 3,350 30 10 71 10 75

Couchiching Community 63,046 4,430 30 33 101 32 153

South Georgian Bay Community 53,545 3,865 38 43 291 43 291

13. North East LHIN 472,283 33,430 0 5 99 355 4 101 315

Algoma Central - PENDING 10,840 825

Algoma East - PENDING 10,909 1,140

Algoma North - PENDING 9,127 630

Cochrane North 17,418 1,265 1 1 No data 0

Cochrane South/Timmins 50,679 3,270 65 270 65 274

Greater Sudbury 139,323 10,050 No data No data No data No data

James Bay and Hudson Bay Coast - PENDING 5,063 225

Manitoulin - PENDING 11,425 850

Nipissing East Parry Sound 78,393 5,430 3 3 6 6

Parry Sound - PENDING 27,700 1,890

Sault Area 66,082 4,785 29 29 29 29

Sudbury East - PENDING 7,992 550

Sudbury West - PENDING 9,855 815

Temiskaming 27,477 1,705 1 52 1 6


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patients

Target Population

Complex Patients

(4+conditions)




HL Reporting

Q1 Cumulative

Total

HL Reporting

Q1 Cumulative

Total


14. North West LHIN 189,746 11,540 0 2 25 152 2 25 176

City of Thunder Bay 110,611 7,670 22 134 22 158

District of Kenora - PENDING 35,617 1,545

District of Rainy River - PENDING 17,159 860

District of Thunder Bay 15,013 880 3 18 3 18

Northern - PENDING 11,346 585

11,226,114 637,935 2,112 78 3,782 22,707 76 3,668 33,614

Additional Notes: 78 Health Links are reporting CCP data, and 76 Health Links are reporting PCP data; 79 of 100 Health Links are actively recruiting patients

Health Links Quarterly Report for the Period April 1 to June 30, 2016 · 2016. 9. 19. · Health...

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