1. Transforming Health Care in Ontario
HLA#9 Meeting
May 1, 2013

2. Purpose
1) Explain the Health Link concept and alignment to
the Champlain Integrated Health Service Plan 2013-
16
2) Review characteristics of Champlain Health Link
Areas
3) Clarify the process and expectations of the
Readiness Assessment
2

3. Health Links
“Health Links will break down barriers for Ontarians,
making access to health care easier and less complicated.
By encouraging local health providers to work together to
co-ordinate care for individual patients, we’re ensuring our
most vulnerable patients – seniors and those with complex
conditions – get the care they need and don’t fall between the
cracks.”
Deb Matthews, Minister of Health and Long-Term Care
3

4. A New Model of Care in Ontario
• Health care providers in a
geographic area work
together to provide
coordinated care for
patients
• Patient-centred solutions
• Initially focused on people
with the highest needs /
highest cost to the health
system
• Brings family health care
into the broader health care
system
• faster access to primary
care
• faster ability to connect
patients with specialists,
home care services and
other community supports
• improved transitions of care
4

5. Health Link - Key Features
• Focus on a defined region
(at least 50,000 population)
• Include providers that care
for complex patients
(minimum CCAC, hospital,
primary care & specialists);
voluntary participation
• Already show a high degree
of collaboration and willing
to formalize it with a written
agreement
• Ability to identify and track
complex patients
• Includes primary care
providers (minimum 65%
from the geographic area)
• Identifies a lead
organization.
5

6. 6
Short Term:
• Develop coordinated care
plans for complex patients
• Increase number of complex
patients with regular and
timely access to a primary
care provider
Providers will work together at
the clinical level to achieve:

7. Providers will work together at
the clinical level to achieve: (cont’d)
Longer Term:
• Introduce same day/next
day access to primary care
• Primary care follow-up within
seven days of discharge from
an acute care setting
• Reduce time from a primary
care referral to specialist and
home care
• Reduce unnecessary hospital
admissions and re-
admissions within 30 days of
discharge
• Reduce avoidable
Emergency Room visits for
patients with conditions best
treated elsewhere
• Reduce Alternate Level of
Care days in hospital
• Enhance the patient
experience.
7

8. Supports for Health Links
• Ministry of Health
and Long-Term
Care
• Ministry-Led Process
• Setting direction and
performance metrics
• One-time funding
• Removing Barriers
• Communications
• Evidence based tools
and resources
• eHealth Ontario
• Health Quality
Ontario
• OTN
• LHIN
• Other Health Links
8

9. Vision:
Healthy people
and healthy
communities
supported by a
quality, accessible
health system
Mission:
Building a
coordinated,
integrated and
accountable
health system for
people where and
when they need it
Values:
Respect, Trust,
Openness,
Integrity,
Accountability
9
Champlain LHIN
Integrated Health Service Plan 2013-2016
for a Person-Centred Regional Health Care System

10. 10
IHSP Strategies & Actions
Strategy 1
Build a strong foundation of
integrated primary, home and
community care
Strategy 2
Improve coordination and
transitions of care
Strategy 3
Increase coordination and
integration of services
among hospitals
• Public Engagement • Public Engagement • Public Engagement
• Integrated Health Networks • Continuity of Care • Regional Programs
• Early Identification and
Management of Risk
• Information Sharing • Central Intake
• System Navigation • Intensive Case Management • Emergency Room Initiatives
• Advanced Access to Service
• Clinical Guidelines and
Pathways
• Funding Reform

11. How Champlain Health Link Areas were Defined
Applying the criteria:
Staff studied data for 34 smaller „starter‟ areas and combined them
into 10 based on:
• Adjacency
• Critical mass (population, people with high needs, primary care and other
providers)
• Population characteristics (distribution & demographics)
• Which hospitals people tend to use
• Our understanding of local areas
• Alignment with census and Ottawa Neighbourhood Study boundaries.
11

12. Some High-Needs Groups
(Champlain residents 2011-12)
1) Had two+ acute care
hospitalizations: 13,939
• Had a readmission within 30
days: 8,961
2) Had a high cost acute care
hospital stay: 8,145
3) Made 5+ emergency
department visits: 16,305
• Composite: met one or more
criteria: 30,514
• Met all three criteria: 1,117
12
People with High Needs come in
many shapes and sizes.
No single data definition can
capture the complexity.

13. 13

14. 14
Implemention Process for Champlain Health Links (as of Apr 16, 2013)
Ministry of Health
and Long-Term Care
Leader & Enabler
Champlain LHIN
Facilitators & Supporters
Interested Providers
Implementers
SwimlaneProcessforHealthLinksImplementation Develop Health Link
Strategy & Framework
(provincial definitions, tools,
data)
- Engage with potential HL
groups
- Provide local tools and
resources
Organize providers /
networks
Review Readiness
Assessment
Submit Readiness
Assessment
Submit readiness
assessments
- Develop & submit
Business Plan
- Partners sign MOU
Review and flow initial
funding for HL to develop
business plan
Review Business Plan
Support HL’s business
plan development
Implement accountability
agreements
Monitor and support
growth and improvements
Approve
Business Plan & flow
funding
Readiness
Assessment
complete?
Yes
Revise Readiness
Assessment
No
Sign accountability
agreement &
operationalize Health Link
Support and monitor
Health Link
implementation
Assumptions
- Provider groups will organize
themselves, based on the information
provided to them by the LHIN / Ministry
- LHIN approves Readiness Assessment
and Business Plans before sending to
Ministry.
- All Health Links’ submissions are
approved by Ministry.
- Health Links will be implemented when
they are ready, not by LHIN quota (50%
by xx date)
Business Plan
complete?
Yes
Revise & resubmit
Business Plan
No
Submit Business Plan
Review / Approve
Readiness Assessment

15. Readiness Assessments need to include:
• Evidence it was completed as a
collaboration of providers, with a
patient- centred focus (minimum
PC, CCAC & hospital,
specialists)
• A lead organization has been
agreed upon by the collaborating
partners & clearly identified
• An understanding of the
Francophone population and
their needs & an explanation of
the a capacity to meet the needs
of Francophones
• A description of Aboriginal
population and collaborating
partners to meet needs
• For each criterion of the
Readiness Assessment template,
the rationale / explanation
section is completed and clearly
written
15

16. Questions
16

17. Helpful Tips
• Keep the focus on
patients with the highest
complexity and health
system use
• Try not to get hung up on
the “lead” organization
• Prepare a concise &
clear RA – answer each
criterion
17
Preliminary Comments on the
Draft:
- Simplify & ensure explanations
are aligned to the criterion
- Reduce duplication
- Add statement supporting
rationale for <50,000 population
(higher needs, chronic conditions,
Aboriginal health, seniors, mental
health, determinants of health)
- Take out acronyms
- Add Francophone population –
Le Reseau can help
- Identify a “lead organization
(criteria #13 to 16)
- Add PC to #3
- Delete #17 and put this context
piece in Criteria#2