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
Phone 705.444.5885 ask for Health Links

healthlink@gbfht.ca

Health Link Privacy

The objective of Ontario’s Health Links is to improve the efficiency and effectiveness of care for the people with the highest needs.

Is my client or patient appropriate for the Health Link?

The Ministry of Health and Long Term Care has determined the following criteria for Health Link patients:

Patients with 4 or more chronic or high cost conditions

These conditions can include:

• Serious medical conditions (e.g CHF; COPD; Diabetes, etc. etc.)
• Mental health and addictions
• Frail elderly or palliative
• Economic issues (low income, unemployment, fixed income etc.)
• Issues related to the social determinants of health (housing, living alone, immigration, community and social isolation etc.)

What should I do if I am not sure?

Our Health Link Coordinator would be happy to review the patient with you: Email healthlink@gbfht.ca or call 705-444-5885 and ask for the Health Link Coordinator.

But as a general rule, if this is someone you are concerned about, who appears to need more help, make the referral anyway.

See below for the next steps, Invitation & Referrals

Invitation

Once you have identified someone who could benefit from the Health Link, please explain the Health Link to them, and get their agreement for you to refer them to the Health Link.

It is important that you understand the basic process, so that you can help to answer any questions: Health Link for Providers

We have found that it can be complicated to explain the Health Link concept, so here is a handout that you could provide to your patient: Health Link for Patients

Once your patient has accepted the invitation to the Health Link, you can make the referral.

Referrals

There are 3 ways to make a referral:

1. EMR message to HLS (Health Link Coordinator), providing the patient name and general reason for the referral.
2. Download and complete the SGBCHL Referral Form and fax to the Health Link Coordinator at 705-444-1393
3. Send a Portal message to Healthlink@gbfht.ca with completed referral form attached

If you have any questions at all, contact the Health Link Coordinator at healthlink@gbfht.ca or call 705-444-5885 and ask for the Health Link Coordinator.

See below for the next steps, Initial Interview & Consent

Assigning a Navigator

On receipt of a referral, the Health Link Coordinator (HLC) will upload the patient’s medical record onto the SGBC Provider Portal and will review the referral information and medical record to determine the appropriate Navigator from the “most responsible provider”.

From this point on, the Navigator will drive the Health Link process on behalf of the patient. A step-by-step guide to the Health Link process is contained in the Collaborative Care Checklist

Initial Interview and Consent

The Navigator will contact the patient to arrange the Initial Patient Interview. Ideally this will take place in the patient’s home, and will be attended by the patient, family and caregiver. Where possible, the Primary Care Provider should be invited to attend for at least part of the interview.

The Navigator will facilitate the interview. The key objectives of the meeting are:

• Ensure the patient and family understand the Health Link process and how it can benefit them.
• Ensure the patient understands the sharing of their information for the Health Link, and obtain signed consent.
• Through a conversation, obtain answers to the question in the Patient Interview form
• Begin to complete the patient’s Coordinated Care Plan

Supporting Materials:

Consent Form

Consent Script – Coming Soon!

Patient Interview Questions

Coordinated Care Plan

Once the interview has been completed, the Navigator will note the completion of the Interview on the patient’s record in the SGBC Provider Portal, and will attach the completed Interview Questions and signed Consent Form to the note.

See below for the next steps, Think Tank & Care Conference to complete the patient’s Coordinated Care Plan

If the patient interview revealed a very complex situation that could involve many varying services, the Navigator will arrange to present the patient’s story at the next Think Tank teleconference.

Think Tank

The Think Tank is a regular teleconference attended by representatives from many of the local health and community services. Up to three patients will be presented to the Think Tank attendees, who will brainstorm on ideas to improve services for the patient and help them to move toward meeting their goals.

The ideas could be additional services that attendees can offer, suggestions on other providers to follow up with, or they could be suggestions for changing the way current services are delivered. All ideas are welcomed. No idea is a bad idea!

Think Tank is held monthly on the third Thursday of each month, from 8am to 9am.

The frequency of Think Tanks is expected to increase as more Health Link patients are referred.

Currently we are joined by family physicians, navigators and representatives from:

• Georgian Bay Family Health Team
• South Georgian Bay Community Health Centre
• North Simcoe Muskoka CCAC
• Collingwood General and Marine Hospital
• Community Connection/211
• Breaking Down Barriers Independent Living Resource Centre
• Home for Life volunteer program
• Red Cross
• Victoria Order of Nurses
• Wendat Community Programs
• Alzheimer’s Society
• Saint Elizabeth Healthcare
• Georgian Triangle Housing Resource Centre
• Hospice Georgian Triangle
• Barrie Area Native Advisory Circle
• Independent Living Services Simcoe
• Health Quality Ontario
• Behaviour Management Services of York and Simcoe, Barrie Office
• Centre for Behaviour Health Sciences, Mackenzie Health
• Waypoint Centre for Mental Health Care

We welcome additional participants from providers (both health care and community) who provide services into our area.

If you would like to join us, please contact the Health Link Coordinator at healthlink@gbfht.ca or call 705-444-5885 and ask for the Health Link Coordinator.

See below for the next steps, Care Delivery, Maintenance & Transitions

CARE DELIVERY – NAVIGATORS

Navigators will work closely with the patient and family to coordinate the services that have been arranged and aligned, and will check-in with them on a regular basis to ensure that all is proceeding well.

The navigator will monitor the progress of the services and will follow-up directly if sufficient information has not been provided.

As the patient’s condition changes over time, the Navigator will again discuss with the patient and family the addition for other services that might not have been palatable in the early days. This would be a change to the care plan, so the Navigator will update the CCP , upload the new version to the Portal, and print a copy of the CCP for the patient and family.

If the care plan is not effective, or if the patient’s circumstances change, the Navigator may chose to bring the patient’s story back to Think Tank for further discussion.

As the patient’s circumstances settle, the Navigator may be able to reduce the frequency of check-ins, and possibly discharge the patient over time.

CARE DELIVERY – CARE TEAM MEMBERS

Service providers who are part of the Care Team should keep the Navigator up to date with how their services are progressing. At a minimum, each Care Team member should add a note to the patient’s record on the Portal:

• When patient has been contacted
• When service starts
• If service changes
• When service ends

In many cases, a monthly update on how things are progressing would also be helpful to the Navigator.

Care team members should use the portal’s secure messaging function to message the Navigator directly if concerns or questions arise about the patient and family.