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

2. Agenda Patient eligibility in the Advanced Health Link Model includes:
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
Patient eligibility in the Advanced Health Link Model 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

3. 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
Patient eligibility in the Advanced Health Link Model 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

4. 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.
* 5 RHH Pilot Sites have been funded throughout Ontario including: Dryden Regional Health Centre; Manitouwadge General Hospital; North Shore Health Network; Haliburton Highlands Health Services.

5. North Shore Rural Health Hub Pilot Project Goals
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.
Enhance strategies that will address the client’s navigation experience between health service providers.
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.
Develop quality improvement plans in collaboration with the Acute, Long Term Care, Home and Community Care, Mental Health and Addiction, and Primary Care sectors.

6. North Shore Rural Health Hub Pilot Project Goals Continued…
Continue to work with the tertiary sites on development of care pathways to ensure smooth transitions and repatriation.
Develop formal partnership/accountability agreements between providers to ensure the progression of quality collaborative health care.
Develop recommendations on a funding model that would provide for flexible/seamless community funding for Rural Health Hub development.
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.

7. North Shore Rural Health Hub Pilot Project Work Plan

8. 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.

9. 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 ongoing.

10. The Case to Support Complex Patients
Patient eligibility in the Advanced Health Link Model 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

11. 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

12. Health Links Guiding Principles
Regular and timely access to primary care for complex patients
Effective provision of coordinated care for all complex patients
Consistent, quality care across the health care continuum and social services sectors
Focus on vulnerable populations (frail and elderly, mental health and addictions and palliative)
Evidence-based, measureable improvement of the patient experience through enhanced transitions in care
LHINs accountability for performance
In the early days of Health Links, there was a “Low rules” environment that enabled innovation, experimentation, and continuous improvement.
Many new relationships across the health and non-health sectors were established as multi/interdisciplinary teams considered the total health needs of the individual.
Health Links across the province began developing methods and tools for core processes.
In the spirit of quality improvement, the ministry used the results of a rapid cycle evaluation of Health Links to improve the operations of health links. Using these guiding principles, a new provincial model was created to
To reduce the degree of variability in practices and outcomes across the province
To scale and spread best practices that are working well in small areas
Source: ‘Health Links Target Population’ Webinar, MOHLTC. August 12, 2015

13. 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
Source: ‘Health Links Target Population’ Webinar, The Ministry of Health and Long Term Care. August 12, 2015

14. 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
The SSM Health Link has adopted the Guided Care Model from John Hopkins. The Timmins Health Link has a similar model in primary care, utilizing nurses who create and support the CCP.
The Guided Care Model involves:
Team based chronic care management to provide comprehensive, coordinated, continuing care
A guided care nurse works in partnership with the primary care provider, the patient, the patient’s caregiver(s) and other health care professionals and community agencies
The patient and his/her care goals are the primary focus, with the right care wrapped around them, facilitated by the GCN in partnership and collaboration with the PCP
Together, the patient, GCN, PCP and broader health and social services team create a Coordinated Care Plan. The GCN serves as the primary point of contact and plays a central role in ensuring patients receive high quality, coordinated care through a “quarterback” approach.

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

16. 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

17. How to Get Involved.. North Shore Rural Health Hub Contact:
Mary Ellen Luukkonen, Project Manager
Phone: (705)
East Algoma Health Link Contact:
Dennis Guimond, Project Lead
Phone: ext. 202

18. Questions?
Jennifer McKenzie, Algoma Outreach Officer (705)