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

2. 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

3. 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 RESPIROLOGIST
This graphic shows how the individual with high care needs interacts with lots of different people at lots of different times and demonstrates how that individual is the only common thread across all of those interactions
INDIVIDUALAND PRIMARY CARE PHYSICIAN
INDIVIDUAL AND MENTAL HEALTH ADDICTIONS NURSE
INDIVIDUAL AND HOUSING MANAGER
INDIVIDUAL AND CCAC CARE COORDINATOR
INDIVIDUAL AND ADULT DAY PROGRAM STAFF

4. 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
Everyone may be face to face
Some people may join via video conference
Some people may join via telephone

5. How does Coordinated Care Planning provide better care?
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MOHLTC Health Links Sketch Video:

6. 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
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
There is some flexibility in the process
Anyone, anywhere can identify someone
Provider Conference may precede the full Conference, especially when many providers who haven’t previously experienced the coordinated care planning process are involved
To refer individuals for Coordinated Care Planning (CCP) anywhere across the South West LHIN: Go to: OR healthcareathome.ca or Call
Anyone, anywhere can identify someone

7. What guides the Coordinated Care Planning Approach in the South West LHIN?
As we have planned and implemented the Coordinated Care Planning approach across the South West LHIN, this is what providers have told us guides this new approach to care – the larger the word, the more often it was used to describes “what guides the coordinated care planning approach” among a large group of providers in the fall of 2016.

8. What do patients/clients say about Coordinated Care Planning?
And these are the key words that patients have used to describe their experience with the Coordinated Care Planning process – these words were collected across interviews with 8 different individuals/patients/clients.

9. Who might benefit from a Coordinated Care Plan?
People who would benefit most from coordinated support from multiple health and social service providers
As you are thinking about how to embed coordinated care planning into your practice, you may want to reference this slide to help you think about who you might consider/identify/refer for coordinated care planning.

10. 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)
This long list is not trying to encourage a long list of people for the Care Team and conference, but rather, many different options to think about …
Specifically, think about people to invite who would provide a ‘comfortable’ environment for the patient, perhaps, specific cultural supports

11. What does the Coordinated Care Plan (CCP) Look Like?
The real interest to note here is that the plan itself is very person-centred (e.g. My Care Team, My plan to achieve my goals for care)

12. What are the Health Link geographies across the South West LHIN?
Want to ensure that this stays current…So no real content re: status, number of CCPs…Could just say the order of implementation?

13. What has the early experience/impact been on hospital utilization in the South West LHIN?
This graph illustrates the impact that the Coordinated Care Planning process is having on patient admissions to hospital and is based on this data is based on the before and after journey of approximately 100 patients/clients
The dotted orange line represents the date that the person/patient/client’s Coordinated Care Plan is documented as complete, following a Coordinated Care Planning conference
The bar graphs before and after the dotted line show the rate of hospital admissions before and after the Coordinated Care Plan
For example, if you compare the 30 days before Coordinated Care Planning with the 30 days after Coordinated Care Planning, you can see that the rate of admission drops from approximately 36 admissions per 100 people before Coordinated Care Planning to approximately 18 admissions per 100 people after Coordinated Care Planning

14. What has the early experience/impact been on hospital utilization in the South West LHIN?
Similarly to the previous graph, this one shows the impact that the Coordinated Care Planning process is having on ED visits
When we look at the bars before and after Coordinated Care Planning, we can see a reduction in ED visits after Coordinated Care Planning

15. 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

16. 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”

17. 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,
To refer individuals for Coordinated Care Planning (CCP) anywhere across the South West LHIN, go to: or
Call