Transcript What is Health Links?

Patterns of Care
SE LHIN Primary Health Care Forum
October 6th, 2016
M. Kathryn Brohman, Ph.D.
Associate Professor and Distinguished Faculty Fellow
Smith School of Business, Queen’s University
Disclosure
• Name of Presenter: Kathryn Brohman
– No relationships with Commercial Interests;
– Presentation received financial support from the Southeast
LHIN;
– Presentation received in-kind support from Belleville Quinte
West CHC and Gateway CHC.
• Project was approved by Queen’s Graduate Research Ethics
Board (GREB) – all potential economic and social risks were
identified in Letter of Information (LOI) that was provided to all
participants. The following risk mitigation tactics were applied:
– All data de-identified;
– Identification of roles were removed from surveys.
2
Project Motivation
SE LHIN IHSP4: Building on the success of Health Links,
ensuring that process improvements that have been made
are extended right through the entire primary and
community care sectors.
©2015
Session Objectives
• Health Links in Ontario have reached an inflection point as they
attempt to scale and transform from an early adopter stage of
development into a sustainable service delivery model.
Session Objectives
• Part #1: Health Links Implementation: Improve Integrated Care
Delivery
– Explain how primary care providers (FHTs, CHCs, FHOs) are
enabling Health Links and develop opportunities for
improvement.
• Part #2: Patterns of Care
– Introduce Health Link Patterns of Care (HLPOC) as an
initiative to ‘grow to scale’.
4
Brief Overview: Research Methodology
• Data Collection Summary (Summer 2016)
– 65 Health Links Implementation Surveys Completed
– 28 45-minute Semi-Structured Interviews
– 300 Patient Care Plans
• Data Analysis: Health Links Implementation
– Survey data analyzed and compared to averages from 24 other
health care delivery organizations collected between 2010-2015
(e.g., hospitals, FHTs, crisis intervention, CCAC);
– Contextual Adjustment (Oct 2016): Link Survey Results to
Interview Data.
• Data Analysis: Patterns of Care
– Regression testing on 300 Patient Care Stories
– Contextual Adjustment (Oct 2016): Link Data-driven patterns to
Interview Data
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Research Limitations
• Health Links Survey response bias due to several limitations
– Health Links Awareness: 76% mean (Range 7 – 100%)
– Primary care providers: 27 / 66 respondents (41%)
• Data quality limitations
– Patient Stories: Built from care coordination tool (e.g., CCP,
data integration solution)
– Surveys represent individual perceptions
• Involvement of only two Health Links
• Scope of project did not include capturing patient experience.
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Part #1: Health Links Implementation
What is Health Links? How is it implemented? By whom?
What is Health Links?
• Five per cent of patients account for two-thirds of health care costs.
– 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.
• How is it implemented:
– 82 approved Health Links across 14 Local Health Integration Networks;
– 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.
©2015
8
How is Health Links Implemented?
The ‘Strategy’
Who is ultimately
accountable?
Health Link PLANNERS
Health Link ENABLERS
Lead Organizations,
Health System Planners
Primary Care PROVIDERS
‘Integrated Care’
©2015
The ‘Execution’
Is Health Links Working?
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Health Links Implementation is HARD
SE LHIN
HL PLANNERS
(CEO, CIO,
Directors)
HL ENABLERS
(HL Lead Org, Data
Leads, Health System
Planners)
HL Lead Organizations
FHT, FHO, CHCs, CSS,
Home Care, Hospital etc.
HL PLANNERS
Integrated Care
PLANNERS
(EDs)
HL ENABLERS
(HL PMs,
Navigators, Data
Leads)
Integrated Care
ENABLERS
(IPTs, Care
Coordinators etc.)
Care PROVIDERS
Care PROVIDERS
(Clinical Lead)
(Doctors, Nurses,
Social Workers etc.)
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Results – Existing Strengths
•
People involved in Heath Links…
– Feel they are appreciated by those who have embraced Health Links;
– Feel they are making the system aware of new ways of doing things;
– Are highly committed and working very hard.
•
LHIN and Lead Organizations have…
– Provided a supportive culture for changes that aim to deliver value to the
larger system;
– Created a low-rule environment that allowed the role of the ‘HL ENABLERS’
to evolve.
– Developed South East Health Integrated Information Portal (SHIIP).
– Created a culture where enablers feel comfortable and ‘safe’ doing what
they need to do to improve delivery of integrated patient care.
•
Primary Care Providers have …
– Recognized the connection between medical and social complexity in
patient care;
– Created an ‘appetite for change’ and openness to new ways of doing things.
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Results - Future Challenges
• ENABLERS involved in Heath Links…
– Feel overwhelmed with responsibility and are burning out;
– Feel uncertain of their future and under-resourced.
• LHIN/Lead Organization encouraged to focus on…
– Clarifying the roles and responsibilities of the HL ENABLER;
– Seeking ways to encourage care partners to work together to deliver on
patient goals;
– Technology tools and solutions that will enhance ‘operational’ data
sharing between care providers.
• Primary care providers are encouraged to…
– Support and empower ENABLERS to take appropriate risks;
– Value and work with enablers to define the most important priorities to
establish clarity and focus.
13
Part #2: Patterns of Care
How is Health Links improving integrated care and driving
down system costs?
Profiles versus Patterns
Care Profiles
Complex Patients
High Social Needs
High Medical Needs
Patterns of Care
In what context do solving the
problems provide the most
potential benefit?
What problems are being
caused by the system and/or
process of care?
What are the solutions
to these problems?
Use 2/3 of Healthcare
Resources
What costs do these problems
incur to the system?
Pattern #1: Provider Awareness
Opportunity for providers in team environments (e.g., FHTs, CHCs).
Providers don’t have a complete understanding of patient social
and medical needs.
Mary Woodman
Project Manager,
Quinte Health Link
Increased System Utilization
(e.g., hospitalizations, readmits, ED
visits, and LOS)
What are the solutions to
this problem?
Decreased System Utilization
(e.g., hospitalizations, readmits, ED
visits, and LOS)
Pattern #1: Provider Awareness
©2015
17
Pattern #2: Patient Awareness
Opportunity for socially-isolated patients.
Patients don’t have a complete understanding of the clinical
and social programs available to them.
Julia Swedak
Director of Quality and Decision Support
Gateway Community Health Centre
Increased System Utilization
(e.g., hospitalizations, readmits, ED
visits, and LOS)
What are the solutions to
this problem?
Decreased System Utilization
(e.g., hospitalizations, readmits, ED
visits, and LOS)
Pattern #2: Patient Awareness
©2015
19
Pattern #3: Social Barriers
Opportunity for older patients living at home.
Patient’s complex social needs are creating barriers to
health improvement.
Emily Rashotte
Rural Hastings Health Link Coordinator
Gateway Community Health Centre
Increased System Utilization
(e.g., hospitalizations, readmits, ED
visits, and LOS)
What are the solutions to
this problem?
Decreased System Utilization
(e.g., hospitalizations, readmits, ED
visits, and LOS)
Pattern #3: Social Barriers
©2015
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Table Discussions: Getting to Action
1. What changes could you make to improve your organization’s ability
to deliver integrated and coordinated care?
– Health Link Implementation (Slide 13)
2. What changes could you make to develop a more complete
understanding of your patient’s social and medical needs?
– Pattern of Care #1 (Slide 16)
3. What changes could you make to inform you patients of clinical and
social programs available to them?
– Pattern of Care #2 (Slide 18)
4. What changes could you make to understand the severity of your
patient’s social needs and improve access to social services?
– Pattern of Care #3 (Slide 20)
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Table Discussion Format
• Agree to discuss one of the action items on the previous slide;
• Discuss the most challenging barriers related to that action
item;
• Discuss how your primary care organizations are currently
enabling that action item;
• Write the top 2 or 3 ‘best practices’ for your action item on the
poster provided.
– Combined as the final set of recommendations to South East
LHIN and Health Links Lead Table to inform Health Links
Sustainability.
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Moving Forward
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Thank You
HLPOC Steering Committee
HLPOC Working Group
• Steve Goetz, Cheryl
Chapman, Michael Spinks,
Lyn Linton, Sheila Braidek,
and Dr. Bob Webster.
• Angela Mask, Julia Swedak,
Emily Rashotte, Mary
Woodman, Cindy Jones, and
Lisa Triemstra.
Queen’s HLPOC Research Team
• Kim Woodhouse, Jennifer Medves and Monica
LaBarge.
Interested in Getting Involved?
• Email: [email protected]