Build Integrated Networks of Care

Health Links and Primary Care

Health Links are a core component of Ontario’s health care strategy that involve a targeted approach to improving care for the most complex and resource intensive patients. Health Links coordinate the services being offered by primary care providers, home and community care providers, hospitals, specialists and, in some instances, Long-Term Care homes. They focus on enhancing transitions and coordinating care for high needs patients to improve access to care, reduce avoidable hospital visits and readmissions, and improve the patient’s experience. Moving into 2015/16, there will be an increased focus on the standardization and scale of Health Links. Over the next three years, the Central West LHIN is committed to building on the success of Health Links to date through:

  • coordinated care for all identified complex patients
  • improving individuals’ use of the right services
  • a focus on “upstream” care to identify those at risk of becoming complex
  • evolving governance structures for Health Links.

The five Central West LHIN Health Link geographies including Bolton-Caledon, Bramalea Brampton and Area, Dufferin and Area, and North Etobicoke-Malton-West Woodbridge, will be used to develop geographically-based integrated networks of care, and will support province-wide renewal strategies (i.e. primary care, and home and community care).

Teamwork

At 76 years of age, Agnes lives with a variety of conditions including diabetes, obesity, Chronic Obstructive Pulmonary Disease, and is awaiting a knee replacement for arthritis.

Agnes was a high risk for repeated admission to hospital due to her poor health history and, with little want to self-manage her health conditions, knee replacement was unlikely so long as Agnes was unable to lose weight. Referred to the Dufferin Area Health Link by her Primary Care Physician, Agnes was able to access a tightly knit team of health care professionals able to provide her with a personalized care plan suited to her specific health care needs.

Following her referral Agnes became self-motivated to self-manage her own care, following a home exercise program that included in-home physiotherapy. With help from a dietician, Agnes was able to adhere to a diet which improved her overall physical health, losing over 250lbs., and chronic diabetes, which inevitably allowed her to obtain the knee replacement she was once only hoping to receive.

With the support of her family, friends and Primary Care Physician, whose goal it is to see Agnes maintain her improved physical, mental and dietary health, Agnes has regained her independence, continuing to enjoy a healthier, more active lifestyle.

"I was fortunate to receive the care I needed close to home and from a group of very dedicated and persistent professionals. They helped me when I could not seem to help myself. I was given a second chance... one which I will do not take for granted."

–Agnes
Teamwork

The Role of Primary Care

Ontario's Patients First: Action Plan for Health Care commits to bringing forward a plan “to ensure that primary care providers (including both physicians and other primary care providers) are organized around the needs of our population such as those in northern, rural and fast-growing communities, focusing on greater accountability and access for individuals and families.” Fulfilling this commitment will be a key priority for the MOHLTC and the Central West LHINs moving forward, along with other strategies such as home and community care renewal, and Integrated Funding Models.

This priority will be addressed through a multi-year collaborative strategy to be implemented by the MOHLTC and LHINs with the goal of improving access, accountability and performance. Most importantly, this strategy will work to achieve the government’s goal of ensuring a primary care provider for every Ontarian that wants one. The strategy has many features, but its core is to provide the mandate and tools to improve how Ontario’s primary care sector performs for patients and how it functions as part of the broader health care system.

Especially for medically complex and frail individuals, but also for the rest of the population, family physicians and primary care providers are often the first point of access to the health care system, and thus they play key roles in Health Links in the Central West LHIN. Primary care physicians and their teams are often the first to see sick people, responsible for referring them to specialists, connecting them to home and community care, and maintaining and monitoring their health, particularly for those with ongoing health issues. Accordingly, renewal of primary care in the Central West LHIN will be aligned to the ongoing development of Health Links.

The Central West LHIN strategy to advance primary care renewal proposes a plan built on and informed by consecutive waves of evolutionary change in this sector, while being flexible to strategically align with other transformative change initiatives also taking place. Within and across Health Link geographies, this strategy for renewal will be informed by readiness assessments and ongoing collaboration within existing primary care structures, and will also include additional service providers to facilitate collaborative partnerships within other models of primary care delivery.

Medically Complex and Frail Individuals

Medically complex and frail individuals require consistent, collaborative and high quality care. These individuals are generally high users of the health care system, and are often seniors. Medically complex and frail individuals are characterized by having multiple diagnoses and complex medication regimens that require frequent intervention. Their circumstances significantly impair their ability to perform one or more activities in their daily living, which often makes them reliant on caregivers and/or the community for support. Family and caregivers can often suffer from burnout, requiring respite care for their loved one as a result.

Health Links aim to improve care and the coordination of care for these populations regardless of where they live–urban, rural or remote settings – as well as to prevent medically complex conditions from developing.

Build Integrated Networks of Care | Health Links and Primary Care
Strategic Direction Strategic Initiative Strategic Action
Build Integrated Networks of Care Health Links and Primary Care Identify and connect all Health Link patients in the LHIN, starting with the medically complex and frail.
Implement Health Link Care Coordination Tool in the 5 Health Links
Work with and engage primary care to position Health Links within the wider primary care framework to increase the scale of Health Links.
Develop a new population-based case management model.
Confirm a governance sustainability model for Health Links.
Implement provincial primary care strategy locally.
Use Health Links geographies as the basis for developing integrated networks of care, including primary care services focused on the community.
Continue to oversee the Hospital to Home Program as one of the provincial Integrated Funding Model pilots
Identify medically complex and frail individuals within the LHIN through Health Links
Expand home and community care services to meet the needs of Medically Complex and Frail Individuals identified in the seniors capacity plan
Maximize the use of virtual care technologies including Telehomecare and other newly developing technologies)