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Community Health Links provide coordinated, efficient and effective care to patients with complex needs. Five per cent of patients account for two-thirds of health care costs. These are most often patients with multiple, complex conditions. When the hospital, the family doctor, the long-term care home, community organizations and others work as a team, the patient receives better, more coordinated care. Providers will design a care plan for each patient and work together with patients and their families to ensure they receive the care they need. For the patient it means they will:

  • Have an individualized, coordinated plan
  • Have care providers who ensure the plan is being followed
  • Have support to ensure they are taking the right medications
  • Have a care provider they can call who knows them, is familiar with their situation and can help.

 

 

Here is an example of how Health Link has worked with a local patient:

 

“Edna’s” Story

 

Edna is a senior in her late 70s, who lives at home with her spouse. She loves to bake, entertain and look after her grandchildren as often as possible.

 

Edna was admitted for surgery. During surgery she suffered a stroke, resulting in severe mobility, speech impairment with slight cognitive impairment as well.

 

After receiving rehabilitation at Georgian Bay General Hospital in Penetanguishene, she has made good progress and has learned to stand again. She was discharged to home with Community Care Access Centre (CCAC) services. During this time Edna suffered frequent seizures, resulting in several visits to the Emergency Department.

 

Following one particularly severe seizure she was admitted to Collingwood hospital. Prior to discharge Edna, her spouse and one daughter felt that Edna’s rehabilitation had regressed significantly since leaving Penetanguishene.

 

Edna’s spouse is exhausted with caring for his wife. Even with support from the personal support workers he is finding it difficut to manage.

 

On Edna’s return from hospital CCAC services have resumed. Services include personal support service, speech therapy, physiotherapy and occupational therapy.

 

Edna’s daughter says she doesn’t quite know everyone’s role or when they are coming.

 

SGBC Health Link coordinated care team conducts an in-home care conference and all of the care providers, Edna’s physician, Edna, and her caregivers attend. The care team is introduced and Edna’s goals are shared with the team. The family describes their difficulties and concerns.

 

What Changes Were Made For Edna?

 

The SGBC Health Link care team suggests small, yet effective changes:

 

  1. Establishing one coordinated care plan.
  2. Determining medication changes to avoid frequent seizures.
  3. Creating a ‘seizure plan’ to equip caregivers with information on what to do when a seizure happens and when to call 911.
  4. Regular weekly scheduled calls from the care coordinator.
  5. Adjusting personal support worker (PSW) visits into blocks of time that allow the spouse to run errands and get out of the house for awhile, or just take a well-needed nap.
  6. Creating goals that make Edna successful – tailored by the physiotherapist.
  7. Encouraging Edna to do her rehab exercises – with help from PSWs.
  8. Finding a Home for Life (HFL) volunteer with similar interests to Edna, who helps her bake.

 

Did The Health Link Changes Help Edna?

 

Edna’s seizures have significantly reduced in number and severity with medication changes. The HFL volunteer and Edna bake togther, allowing Edna to entertain her grandchildren again. The volunteer is trusted by Edna’s spouse allowing him some down-time for himself.

 

The scheduled weekly call from the care coordinator is significantly reducing anxiety and the stress of coping alone for Edna and her family. They are now able to list things they want to discuss easily and without worry.

 

Thanks to SGBC Health Link small changes make a huge difference.

 

Result

 

No additional cost is incurred to improve Edna’s health care experience.
No multiple visits to ED or in-patient stays. Edna enjoys her time at home.

 

Contact Health Link

705.444.5885. ext 277

healthlink@gbfht.ca

 

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Health Link Collaborative Care Toolkit