1. South West Health Links
Coordinated Care Planning: Person-driven care with those who need it most

2. Coordinated Care Planning is…
Putting the patient in the driver’s seat – listening to what is most important to them and their families
Building a care team, with that patient, to support them in their journey
Implementing a co-designed care plan to better support them
Follow-up and monitoring to support the patient journey

3. A R C E
As we follow this driving analogy along, the car is the care – a combination of supports and services that only take the patient forward in their journey if they all fit together properly and are matched to what’s important to the patient
As an example, you don’t need 4x4 parts if the patient is only driving on the highway; you don’t need 2 steering wheels/duplication of service – the resource would be better spent on replacing a tire with a hole in it
At the end of the day, it is critical for all of the ‘parts’ of the car (care) to work well together

4. The coordinated care planning team is the patient’s team of mechanics
The mechanics/care team source the required parts and keep the car ‘tuned’
They also pull together when the ‘wheels fall off’
With coordinated care planning, the patient/driver gets to pick his/her team of mechanics
Every decision made about the car is made with the patient and their family, based on what is important BUT, for that model to be effective, the mechanics must explain the issues and ‘the fix’ in simple terms
Clear communication is what really empowers that patient to make those decisions

5. How does Coordinated Care Planning provide better care?

6. Why do we need Coordinated Care Planning?
4+ chronic conditions
Frail senior
Palliative care needs
Mental health / addictions
Social determinants of health
We are embarking on coordinated care planning to better support those people who have it tough…
Life can be pretty tough to be one of those people in our target population – we are trying to prioritize those living with 4 or more chronic conditions and we have 3 specific sub-populations:
Frail seniors
Those with mental health / addictions challenges
Those with palliative care needs
and, then we further prioritize those who have challenges with the social determinants of health (e.g. low income, issues with housing, lack of access to food, social isolation)
That’s tough! And whether it’s someone telling us they are “sick and tired of being sick and tired” or people just telling us that they’ve lost hope, we know that it is very important for us to do coordinated care planning and do it well)
…because it’s really hard to be part of this target population… People are “sick and tired of being sick and tired” – coordinated care planning can help

7. Why do we need Coordinated Care Planning?
We’re also doing it for the people trying to care for our target population – formal and informal care givers.
It can be really tough for providers, who do what they do because they really care, to help these folks on their own…they need to feel the support of other providers and other people on the care team…
And, of course, don’t forget about the caregiver! Those informal supports can become burnt out pretty quickly – in many cases, coordinated care planning is as much of a support for them as the patient/client.
…because it’s also tough to be the caregiver – formal or informal – coordinated care planning can help

8. Why do we need coordinated care planning?
And, finally, our systems and organizations are under tremendous pressure with respect to capacity and cost….We need to develop better care plans with the most vulnerable people in our communities so that they are better supported in the community and don’t need to access resources in a reactive way as often.
…because our healthcare and social services systems are under a great deal of pressure – coordinated care planning can help

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. 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 describe “what guides the coordinated care planning approach” among a large group of providers in the fall of 2016.
This slide really reinforces the importance of letting patients and their families drive coordinated care planning.

11. Coordinated Care Planning – it’s simple
Must be comfortable space for patient/client (person-centred, culturally safe, clear language)
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
Must ask for permission
So, how do we actually implement the Health Links approach to Coordinated Care Planning?
This slide demonstrates just how simple Coordinated Care Planning can be…
Most care plans in SW documented in Home Care CHRIS system; viewable in ClinicalConnect
Anyone, anywhere can identify someone
Should include person who referred, if possible; care team built at this step

12. 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)
Someone 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

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

14. What are the Health Link geographies across the South West LHIN?
5 Health Link geographies = 5 Sub-regions across our LHIN

15. Where have we arrived so far?
How are we doing? Let’s take a look at last fiscal year…

16. More than 2200 People
This slide demonstrates how many people have received this ‘better together’ support, via Coordinated Care Planning across the South West LHIN.
As of early January/18, more than 2200 people in the South West LHIN have been supported by coordinated care planning across all of our Health Link sub-region geographies
331 people in Huron Perth
923 people in LM
612 people in Grey Bruce
200 people in Oxford
156 people in Elgin

17. Getting to know these people… the data….
19%
24%
65%
The Data…
In the South West, for our most recent quarter (Q3 – FY 17/18):
24% of all people who participated had a mental health/addictions diagnosis in hospital within 2 years leading up to their referral for a CCP
65% of all people who participated are considered chronic or complex seniors in the LHIN Home Care Client Health Record Information System (CHRIS)
19% of all people were considered palliative in the LHIN Home Care Client Health Record Information System (CHRIS) at the time they participated in their CCP

18. Making a difference… the data…
Visits
Admissions
Length of Stay
3 months post
36% ↓
35% ↓
4.4 days ↓
6 months post
26% ↓
5.8 days ↓
The data…
Across the South West, we see the following impact of coordinated care planning:
31% decrease in ED visits within 3 months and 15% within 6 months of CCP
29% decrease in hospital admissions within 3 months and 22% decrease within 6 months of CCP (includes MHA admissions)
Length of Stay in hospital: Decrease of 4.1 days within 3 months and 5.9 days within 6 months (includes MHA admissions)
(Q3 FY 17/18)

19. Making a difference… the data…
For 18 patients/clients/caregivers who completed surveys for us in Q3 of fiscal year 2017/18, the average score was 9.6/10 when asked to rate their agreement with this statement, “I felt respected during the care team meeting.” (10=
For 18 patients/clients/caregivers who completed surveys for us in Q3 of fiscal year 2017/18, the average score was 8.4/10 when asked. “How sure are you that you will be able to reach the goals on the care plan?” (10=
Patients feel respected
Patients feel they will meet their goals

20. Making a difference…the people…
Patient stories and quotes really show the impact that coordinated care planning is having for people living in the South West LHIN
“I went from being miserable to being happy; it was great”
-Brenda R, patient

21. Colleen’s Story….
Listen to Colleen talk to us about her experience with coordinated care planning.

22. Rally a team of mechanics to help someone who needs it most
Go to: OR Call
Embed Coordinated Care Planning into existing approach/programs
We want to help!
Coordinated Care Planning works and is making a difference for people in our communities with high care needs
We invite you to think about how you can best offer this opportunity to the people that you support
Not sure how to get started? Please contact us.