AFHTO’s Health Link Community of Practice met on May 26^th. This communique provides an overview and highlights key items discussed:

• What we Heard from the Ministry
• The Status of the Electronic Care Coordination Tool
• Integrating Care Planning into a FHT
• Advanced Care Planning
• Building Support for the Health Link CoP

Update from the Ministry

Ben King (Program Manager – Primary Health Care Branch) provided a brief overview on the status of health links. Key topics included:

Funding

Current focus for health links includes preparing 2016/17 funding packages and finalizing funding allocations; working with LHINs to improve clarity and consistency re. terms of funding; and building sustainability by enabling local leadership to grow successes achieved to date.

Patients First

The Government has now taken a key step to move forward with its proposal for health care – the Patients First Act was tabled in the legislature on June 2^nd. The Ministry indicated that once funding allocations are completed they will turn attention to how health links will need to evolve and the critical role health links will play in the context of Patients First and the establishment of sub-LHIN regions.

Performance

The ministry is mindful of the need for a long term shift to more outcome based metrics – to give a better sense of how health links are performing and the value they are providing. Performance data will be a critical component of the future, while streamlining and minimizing unreasonable reporting burdens.

Care Planning

Coordinated care plans (CCP) that define how providers, patients and their families work together to coordinate and deliver care for complex patients, has been a prominent facet of Health Links. However, the approach and intent of designing CCPs has varied across the province. The ministry recognizes that care plans do ensure some measure of accountability and volume of patients; however, the focus should not be solely on the “# of care plans” achieved but the value they are providing. The ministry encourages conversations with your LHINs to improve long term metrics and the approach to target stetting to maximize the intended benefits of care plans.

Mental Health & Addiction

Developing collaborative and integrated service delivery of primary care and mental health and addiction services remains a top priority for the Ministry; they continue to seek advice on how to decrease the gaps in service and coordination of care, and to build the interface with primary care.

Care Coordination Tool (CCT)

The care coordination tool was deployed in 17 sites as an initial release and proof of concept phase is now complete. Orion will be the authorizing platform for the CCT. A very intensive evaluation has been provided to the Ministry regarding usability and functionality with a number of recommendations to consider before widespread implementation across the province occurs. AFHTO staff will follow up with AFHTO members who participated in this proof of concept, to collect feedback and develop recommendations for the Ministry and LHINs.

A reminder that ETHEeL has completed a legal review and comments from the lawyer are available for use by any Health Link that will be using the CCT tool. If you would like more information, please contact Kavita Mehta (Kavita.mehta@setfht.on.ca).

If teams are using PSS as their EMR and are interested in a customized data entry tool please contact Jennifer.Mackie@guelphfht.com.

Integrating Care Planning into a FHT

Through discussion led by Dr. Dale Guenter (McMaster Academic FHT + Hamilton Central Health Link), members of the CoP shared their experiences and approach to the development of care plans. Highlights include:

• Relationships are critical. Relations between Primary Care, the LHIN, CCAC, hospital and other health service providers are the most important aspect of developing a successful Health Link. If any teams are experiencing challenges in their relationship with the LHIN as related to Health Links, please contact AFHTO to discuss help or advice that can be offered: Hamilton@afhto.ca
• Access to data, through hospital reports or LHINs, remains the number one enabler (or in some cases the biggest barrier) to the successful identification of complex patients. Once identified, the next step is to determine the need and value of developing a care plan. This approach still varies significantly across the province.
• Understanding the typology of the heavy users and reoccurring ER patients (i.e. palliative vs. acute crises ongoing medical crises, etc.) may help to standardize the approach to care plan development. There is interest amongst the CoP members to further understand this subset of users – if any members would like to be more involved in initiating research please contact: guentd@mcmaster.ca
• Physicians must be engaged for health links to succeed. Showing FHT physicians their list of ‘high user’ patients, and bringing the allied team together to discuss the levers of improving care coordination via health links can be an invaluable approach to getting physicians on board. (Reaching out to non-FHT physicians still remains a challenge in many areas).

Advanced Care Planning

East Toronto Health Link is offering a free Advance Care Planning E-Learning Module. Click here to register. Anyone can sign-up!

Help us Build a Repository of Support for Health Links

AFHTO has created a section on our website to share tools, resources and updates for Health Link leaders to support knowledge translation and promote a culture of continuous learning. We ask that you submit any health link related materials you are willing to share to support the members of the Community of Practice; please send these to Bryn.Hamilton@afhto.ca.

Looking for a new Health Link CoP Chair

The Health Link CoP is looking for a new leader! If you are interested in chairing the CoP, please contact AFHTO (Bryn.Hamilton@afhto.ca). We ask that you are from a lead/host organization health link.