PEMBROKE– A relatively new health care initiative is gaining momentum in Renfrew County as service providers work together to co-ordinate care for patients with complex needs.
Funded by the Champlain LHIN (Local Health Integration Network) and the Ministry of Health and Long-Term Care, Health Links are an innovative service delivery model focused on the five per cent of patients with the highest needs, often with multiple, complex conditions, and who account for two-thirds of Ontario’s health care dollars.
Through better collaboration with providers of care, patients gain seamless access to the services they need through individual care plans and co-ordinated support from a tightly knit team that could include doctors, nurses, specialists, hospitals, home care, long-term care and community agencies. The goals of Health Links are to improve the health care experience for those with complex needs, reduce unnecessary visits to hospital emergency departments, reduce hospital admissions and decrease overall health care costs.
There are now three Health Links in Renfrew County administered by lead agencies – North Renfrew County (Pembroke Regional Hospital), South Renfrew (St. Francis Memorial Hospital in Barry’s Bay) and Arnprior Region and Ottawa West (Arnprior Regional Health and Western Ottawa Community Resource Centre).
“People with many complex chronic medical problems often have to deal with other issues that affect their wellbeing including financial strains, social isolation, and housing insecurity,” said Dr. Declan Rowan of the Petawawa Centennial Family Health Centre.
“The benefit of Health Links is that it is there to support people with all these issues as well as the medical problems,” he said. “This person-centred approach is a shift in the usual way of providing care but it is really needed. It means different groups are having to learn different ways to work together with the singular aim being to improve the lives and wellbeing of Health Links patients.”
On January 25th Dr. Rowan was one of 60 people representing nearly 30 organizations from across the county who met for the first joint Board-to-Board governance engagement session.
Held at the Makwa Centre at Pikwakanagan, and facilitated by Kelly Hollihan, Board Chair for Pembroke Regional Hospital, the purpose of the session was to introduce the diverse group of local leaders, which included those from community boards and senior leadership of health and social service providers, to Health Links.
The gathering was a Renfrew County event because many providers serve the entire county and interact with all three Health Links.
Participants from the full-day session heard from Julia Huckle, Project Manager of the South Renfrew Health Link who gave a joint update on the Renfrew County initiatives.
In an overview, she explained that there are currently 132 patients enrolled in the three Health Links. Of those, 75 percent have more than four medical conditions plus other concerns (socio-economic factors, caregiver strain, social isolation and safety).
Ms. Huckle detailed several patient stories to illustrate the variety of patients’ health and social concerns including one who lives in a rural setting, has multiple health issues and a child who is both primary caregiver and also has significant health issues. Another patient she spoke of has a chronic illness, has had multiple visits to the local emergency department and has multiple challenges managing at home due to physical health needs. In that instance the patient’s spouse and adult children are coping poorly and are extremely scared regarding the future, compounded by financial concerns.
She noted that in each situation Health Link Care Co-ordinators have worked creatively and collaboratively with existing service providers to help patients meet their goals.
They also heard from Eric Hanna, President and CEO of Arnprior Regional Health, who spoke about the need for boards to make Health Links a matter of strategic importance, recognizing that change has become a constant in the health care sector and it is in the best interests of all boards to look at their role as part of the whole system.
“The day provided a great opportunity for boards of multiple organizations to hear about the progress of Health Links in our region,” said Chris Ferguson, Vice-President of Patient Care Services at Renfrew Victoria Hospital, adding that a highlight of the event was hearing many patient success stories – a clear sign that Health Links are headed in the right direction.
Participants were then guided through two work sessions where they were asked to consider potential roles that boards could play in promoting the work of Health Links. There was excitement to bring back ideas of systems integration and systems redesign to individual organizations.
“If we are to address the needs of this specific population we need to look at different models of care coordination, identify the gaps in the system and find news ways to support patients” said Sabine Mersmann, Vice-President of Patient Services – Seniors and Community Care at Pembroke Regional Hospital.
Ms. Mersmann said that if each service organization can make Health Link a priority and there is broad-based support from all levels of governance, it will allow for work to be done which will ultimately benefit not only the patients but the system as well.
Participants planned to share information gained at the session with their own organizations. Going forward, the individual Health Links plan to meet in the spring with a second Renfrew County session planned for the fall.
