B16 Challenges and Opportunities of Being a Health Link

Don Valley/Greenwood Health Link

Challenges and Opportunities of Being a Health Link Working Better Together AOHC Conference June, 2013

Nine Health Links within Toronto Central LHIN Early Adopters

TC LHIN Implementation Strategy

Being one of nine Links in a big city has its challenges • Patients use multiple hospitals, multiple agencies across Link boundaries and LHIN boundaries • Many patients live outside of the city but access their care in the city • Not every Link has an acute care hospital partner, some have multiple acute care hospitals • Catchment areas for CHC, CSS, CMHA agencies do not align with Link boundaries • Are we focusing on the population that lives in the Link or the population served by the providers in the Link?

Residents of our Health Link visit multiple hospitals

Don Valley/Greenwood Health Link • • • •

Population 77,515 Smallest Health Link in the TC LHIN The only Health Link in the province led by a CSS agency Initial Partner Organizations: • WoodGreen Community Services • South Riverdale CHC • Bridgepoint FHT • Bridgepoint Health • Albany Clinic • TC CCAC • EMS

Who is our 1%?

Chronic Health Conditions •

91% have been diagnosed with a chronic health condition

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30% have three or more chronic health conditions

•Mental Health and Substance Use •

65% have a diagnosis of mental illness

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32% have a dual diagnosis (mental health and substance use)

Who is our 1%?

Age

90% of complex clients are under the age of 65 Housing

10% are homeless Poverty

All live below the LICO

Client Journey: Right Care by Right Provider In the last year: •

60% of individuals saw a clinician (NP, MD, N) and a social worker

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37% had seen a chiropodist

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27% had seen a respirologist

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14% had seen a dietician

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13% has seen a member of the Diabetes education team

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59% had attended a group program

Being a small fish in a big pond has its advantages In a smaller Health Link, we can add value by: • • • • •

Testing new processes and ideas on a smaller scale Building on established relationships Implementing quickly and getting results Working in a system that is community led and oriented Working in a system that includes expertise in complex care – develop and test Bridgepoint’s unique role in TC LHIN • Working in a system that is strongly oriented to community support services – one stop CSS point through WoodGreen • Working in a system with different Primary Care models: -one stop shop and working within SDOH framework (CHC) -urgent care and large FHO -FHT affiliated with Rehab hospital

Early Initiatives – Cross Link • • • •

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Connect unattached patients to a primary care practitioner Develop coordinated care plans for top 5% New model for Bridgepoint Health to allow direct access (rather than through acute care) Providing support to solo practice physicians with complex patients (e.g. embed a social worker at Albany Clinic; Diabetes program) Physician engagement Community engagement

Lessons Learned • • • • • • • • •

Some partners knew very little about each other and the services we each offer Checking assumptions Challenges being first group – not all figured out Opportunities being first group – not all figured out Some things can accomplished without additional $ Importance of early physician engagement If you tell the PCP’s you can do something, deliver!

Challenges describing and identifying the top 5% Mental Health is a consistent theme and seems to be the most challenging to address

Recommendations •

Have right people involved

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We come with assumptions - identify

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Mixed perspectives enrich conversations

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Build trust

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Value good process

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Find the right questions

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End users need to be present from the beginning

Consider……

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How can we create a system that is truly accountable to system users especially the 1-5-10% ?

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How can we hold our organizations accountable to users especially the hardest to serve?

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What are our assumptions?

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What questions do we need to ask?

Miigwetch