South West Health Links The Health Links Approach

South West Health Links The Health Links Approach to Coordinated Care Planning: Working Better Together Last Updated: November 29, 2016

Why do we need Coordinated Care Planning? • We want better care for people with many health care needs • 5% of the population account for 66% of health care costs • We want everyone involved in an individual’s care to know what is important to him/her • We want everyone involved in an individual’s care to know what the plan is for him/her

Why do we need Coordinated Care Planning? • • • Most people with many health care needs see a lot of different people for support It can be hard for patients/clients and their families to arrange appointments, travel to appointments, and keep all information straight It can be difficult for providers to understand how they each best support people with many care needs INDIVIDUAL AND PERSONAL SUPPORT WORKER INDIVIDUAL AND HOUSING MANAGER INDIVIDUAL AND ADULT DAY PROGRAM STAFF INDIVIDUAL AND RESPIROLOGIST INDIVIDUAL AND PRIMARY CARE PHYSICIAN INDIVIDUAL AND CCAC CARE COORDINATOR INDIVIDUAL AND MENTAL HEALTH ADDICTIONS NURSE

Why do we need Coordinated Care Planning? • • Coordinated Care Planning (CCP) brings all of the people a person needs for their care, together, in one meeting The coordinated care plan is based on the person’s goals

How does Coordinated Care Planning provide better care? MOHLTC Health Links Sketch Video: http: //www. videodelivery. gov. on. ca/player/download. php? file=http: //www. media. gov. on. ca/5 f 07 e 29 a 37 b 683 ba/en/pages/text. html

What is the Coordinated Care Planning Process across the South West LHIN? Identify People who would benefit from CCP Engage with individual to see if s/he would like to participate and gain consent • Anyone, anywhere can identify someone Interview individual to understand what is important to him/her Facilitate a Care Conference to collaboratively develop a care plan Implement the Care Plan and continually Follow-up and Monitor the individual's progress

What guides the Coordinated Care Planning Approach in the South West LHIN?

What do patients/clients say about Coordinated Care Planning?

Who might benefit from a Coordinated Care Plan? • People who would benefit most from coordinated support from multiple health and social service providers

Who might be at the Coordinated Care Planning meeting? The individual helps to decide; it could include the following : Family, caregivers, supports Doctor/Nurse Practitioner Nurse Specialist (e. g. Cardiologist) Allied Health Professional (e. g. social worker, dietitian, physiotherapist) Community Pharmacist Cultural/Community Supports (e. g. Traditional Healer, Translator) Someone from local Hospital (e. g. Nurse from emergency room, Navigator) Care Coordinator from Community Care Access Centre (CCAC) Someone from Mental Health and Addiction Services (e. g. Counsellor) Someone from Community Support Services (e. g. Homemaker Coordinator) • Some one from Social Services (e. g. Ontario Works) • Other Community Partners (e. g. French Mental Health & Addiction System Navigator, Spiritual Support) • • •

What does the Coordinated Care Plan (CCP) Look Like?

What are the Health Link geographies across the South West LHIN?

What has the early experience/impact been on hospital utilization in the South West LHIN?

What has the early experience/impact been on hospital utilization in the South West LHIN?

What has the early experience been for patients and providers in the South West? • Early data on a small group of patients/clients suggests: • Patients/Clients are confident/very confident in meeting their goals • Patients/Clients feel supported/very supported • Patients/Clients feel respected/very respected • Providers feel satisfied-very satisfied

What has the early experience been for patients and providers in the South West? • Patient/Client Quotes: • The conference started to "make things happen“ • “I liked that there was representation from all the pieces of my care there and they told all their information; they all said helpful things” • “I liked it. Everybody got to voice their concerns and we talked about ways to overcome problems. ” • Provider Quotes: • "I feel the client was able to hear from all parties how her goals could be achieved and could feel the support of all involved. I feel this conference was a great success“ • “Very client centred with the goals and client driven” • “Great to meet other supports" • “Better understanding of my client”

What is your role? We all share the responsibility for identifying patients/clients, actively participating in coordinating care planning, and supporting people with implementing their plans. To access all documents needed to facilitate coordinated care planning, www. swhealthlink. southwesthealthline. ca. To refer individuals for Coordinated Care Planning (CCP) anywhere across the South West LHIN, go to: http: //ow. ly/Z 2 o. Sx or Call 1 -800 -811 -5146