Rural Health Hubs and Health Links PatientCentered Models

Rural Health Hubs and Health Links Patient-Centered Models of Care Jennifer Mc. Kenzie, Algoma Outreach Officer, North East LHIN Mary Ellen Luukkonen, Project Manager, North Shore Rural Health Hub Dennis Guimond, Project Lead, East Algoma Health Links

Agenda • Current Health Initiatives In Central and East Algoma • Overview of North Shore Rural Health Hub Pilot Project • Overview of East Algoma Health Links Project • How Does It All Fit? • How To Get Involved 2

Current Health Initiatives In Central and East Algoma • North Shore Rural Health Hub Project • Project Lead: North Shore Health Network • Project Manager: Mary Ellen Luukkonen • Project Catchment Area: Echo Bay to Spanish • East Algoma Health Links Project • Project Lead: Huron Shores Family Health Team • Project Manager: Dennis Guimond • Project Catchment Area: Laird to Elliot Lake 3

North Shore Rural Health Hub Pilot Project Overview • Purpose: A Rural Health Hub is designed to improve care coordination for all people within a given catchment area through enhanced partnerships among local stakeholders. • Catchment Area: Echo Bay to Spanish. • Project Approach: The Rural Health Hub will be developed through the collaborative efforts of both LHIN-funded and non. LHIN funded providers from acute care, primary, care long term care, mental health and addictions, palliative care, home and community care, public health, social services, municipalities, patients and families. • Project Timeline: August 2016 to March 31, 2018. 4

North Shore Rural Health Hub Pilot Project Goals 1. Develop a Rural Health Hub model that provides care based on the unique needs of our population and supports the provision of equitable care closer to home. 2. Enhance strategies that will address the client’s navigation experience between health service providers. 3. Explore innovative strategies with the Home and Community sector to develop a new model of service delivery that would improve the flow of services to patients/clients and align with primary care. 4. Develop quality improvement plans in collaboration with the Acute, Long Term Care, Home and Community Care, Mental Health and Addiction, and Primary Care sectors. 5

North Shore Rural Health Hub Pilot Project Goals Continued… 5. Continue to work with the tertiary sites on development of care pathways to ensure smooth transitions and repatriation. 6. Develop formal partnership/accountability agreements between providers to ensure the progression of quality collaborative health care. 7. Develop recommendations on a funding model that would provide for flexible/seamless community funding for Rural Health Hub development. 8. Involve every level of stakeholder from governance, leadership, staff, and community in the development of a Rural Health Hub to ensure the end point is a system redesign that is based on evidence, best practice, and is person- centered. 6

North Shore Rural Health Hub Pilot Project Work Plan 7

North Shore Rural Health Hub Current State Assessment • Purpose: To identify gaps, challenges, bright spots, and opportunities for improvement within the North Shore health system. • Service Provider Interviews: 46 face-to-face meetings have been conducted with health service providers. • Patient/Family Focus Groups/Surveys: Ongoing • Next Steps: • Current State report will be reviewed by Project Governance and Management Teams. • Model and Action Plan will be developed based on results. 8

East Algoma Health Links Project • Purpose: The purpose of a Health Link is to create an individualized, coordinated care plan on a standardized provincial template for medically complex patients. The patient and family, and all health and social service providers who support the patient, are involved in the creation of the plan. This plan will be shared between all service providers so that everyone knows what the plan is to support the patient, wherever the patient seeks care. • Catchment Area: Laird to Elliot Lake (Echo Bay patients are covered by the Sault Ste. Marie Health Link). • Project Approach: The East Algoma Health Link will be developed through the collaborative efforts of local stakeholders. • Project Timeline: December 2016 - ongoing. 9

The Case to Support Complex Patients 10

How Health Links will Help For providers it means they will: • • • Work together with patients and their families to ensure the patient receives the care they need Design an individualized, coordinated care plan for each patient in partnership with other health services providers Have real-time access to the care plan so everyone is aware of the patient’s treatment plan and wishes, wherever the patient seeks care 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 & their care plan 11

Health Links Guiding Principles 1. Regular and timely access to primary care for complex patients 2. Effective provision of coordinated care for all complex patients 3. Consistent, quality care across the health care continuum and social services sectors 4. Focus on vulnerable populations (frail and elderly, mental health and addictions and palliative) 5. Evidence-based, measureable improvement of the patient experience through enhanced transitions in care 6. LHINs accountability for performance Source: ‘Health Links Target Population’ Webinar, MOHLTC. August 12, 2015 12

Identifying Target Population Patient eligibility includes: • Patients with 4+ chronic/high cost conditions Plus a focus on mental health and addictions, palliative patients, and the frail elderly Economic characteristics (low income, unemployment) • Social determinants (housing, language, immigration, community and social services etc. ) • Or at the clinician’s discretion that the patient could benefit from a coordinated care plan 13 Source: ‘Health Links Target Population’ Webinar, The Ministry of Health and Long Term Care. August 12, 2015

The Coordinated Care Planning Process • Example of Care Coordination Process (Sault Ste. Marie Health Link) • Guided Care Nurses, based on John Hopkins Model, support patients and families to connect to services wanted and required by the patient 14

Process to Create a Health Link 1. As a community, submit a Readiness Assessment to the MOHLTC with a designated Lead Agency 2. Once approved, create a Business Plan 3. Once Business Plan is approved, begin Pilot Stage and evaluate 4. Scale-up and build sustainability of Health Link 15

Rural Health Hub and Health Link: How Does It All Fit? • A Rural Health Hub is focused on strengthening the healthcare system for all residents within a specific catchment area, whereas a Health Link is focused on developing coordinated care plans for medically complex patients with all services a patient utilizes. • Through the Rural Health Hub project, working groups will be created to help address gaps/challenges that are identified through the current state assessment. The Health Link Steering Committee, is an existing working group that is focused on addressing the needs of complex patients. • Both the Rural Health Hub and Health Link projects are working together to improve patient care in Central and East Algoma. Rural Health Hub Governance and Project Teams Health Link Steering Committee Working Group 16

How to Get Involved. . • North Shore Rural Health Hub Contact: • Mary Ellen Luukkonen, Project Manager • Phone: (705) 862 -1446 • Email: mluukkonen@nshn. care • East Algoma Health Link Contact: • Dennis Guimond, Project Lead • Phone: 705 -356 -1666 ext. 202 • Email: dguimond@nshn. care 17

Questions? Jennifer Mc. Kenzie, Algoma Outreach Officer Jennifer. Mckenzie@lhins. on. ca (705) 256 -2554 18