1. Mid East Toronto Health Link
Let’s Make Healthy Change Happen
Ministry of Health and Long-Term Care New Health Link Indicators Mid-East Toronto Health Link Staff Training

2. Objectives
To explain the context for the modified/new indicators for Health Link
To clarify the definitions of the modified/new indicators for Health Link
To orient you to the tools and process for data collection

3. The Context

4. In April 2018, the Ministry of Health and Long Term Care released a series of new indicators for Health Link.
There are six indicators in total:
Two are a modification of the original two indicators
Three are new indicators for Health Service Providers (HSPs) to report on
One is required for the sub-region to report on
The goal of the new indicators is to standardize the approach to tracking quality and value of the Health Link approach.
Data collection on the new indicators is to begin January A manual data tracking spreadsheet/Word document was developed provincially. Agencies will need to begin with manual data collection.
It is very likely that all 5 indicators will be possible to track centrally at TC LHIN via the eCCP (CHRIS + HPG). Nonetheless, all staff should collect data manually for Q4 FY 2018/19 (Jan March ) even if they are being on-boarded to eCCP (CHRIS + HPG).
Our hope is that as of April , staff will be actively using eCCP (CHRIS + HPG) and manual data collection will no longer be necessary.

5. The Definitions

6. Indicator 1: New CCPs Developed
Number of individuals living with multiple chronic conditions and/or complex needs with a new CCP developed through the Health Links approach to care.
Definition:
New CCP developed in the given quarter
Created with client and/or caregiver and 2+ healthcare professionals
Follows provincial CCP template (paper or electronic)
Contains an action plan for 1+ health issues (physical, functional, mental, social, etc.)
Available to individual and/or caregiver and team members
This indicator (and all subsequent indicators) are reported on based on the client’s sub-region of residence.

7. Determining Client Sub-Region of Residence
Mid-East Toronto sub-region is highlighted in green, and East Toronto in purple.
You can use the following links to determine sub-region of residence as well:
For homeless clients/those without a fixed address, please use the sub-region in which the agency or site leading the client’s CCP is located.

8. Indicator 2: Primary Care Attachment through Health Link
Percentage of individuals with a CCP who are newly attached to a primary care provider through the Health Links approach.
This indicator refers to the number of clients who are newly rostered with a primary care provider as a result of the Health Link work.
This indicator does not refer to whether the client regularly see their primary care provider nor does it refer to the quality of their relationship with their PCP, but rather, simply if they are registered with a Primary Care Provider.
Clients who were unattached to a PCP at the time of being identified/referred to Health Link is indicated first, then the date of attachment is recorded for these clients.
This indicator relates to all clients with a CCP developed, not just those with a CCP developed in the given quarter. It is a “rolling” indicator, updated on an ongoing basis.

9. Indicator 3: Timely Access to PCP, Self-Report
Percentage of individuals with a coordinated care plan (CCP) and attached to a primary care provider (PCP) who self-report timely access to PCP.
This indicator measures all individuals with a CCP who are attached to a PCP who self-report timely access to their PCP.
Set Question: “Would you say the length of time between making the PCP appointment and the actual visit was about right, somewhat too long, or much too long?”
Note: If the client requires clarification, you can re-phrase the question
You need to record the answer and the date you asked the question.
There is a drop-down in the spreadsheet with specific answer options listed: about right, somewhat too long, or much too long, other, don’t know, or no answer.
Clients should be asked this question at the care conference where the CCP is developed.
Ideally, the client is asked this question each time their goals change.
There is a drop-down in the spreadsheet to indicate the last date the question was asked.

10. Indicator 4: Wait Time from Identification to Initiation
Percentage of individuals living with multiple chronic conditions and/or complex needs who waited 7 days or less from Health Links identification to initiation of the coordinated care plan (CCP).
Date of initiation is recorded as the point of a face-to-face visit with the CCP lead where the provincial CCP template is used.
It is necessary to report both the date of identification/referral and the date of the newly initiated CCP/first face-to face visit.
The spreadsheet will automatically calculate the number of days between these two dates.
If your spreadsheet does not automatically calculate the number of days between identification/referral and the newly initiated CCP, please calculate the number of days on your own.

11. Indicator 9 – Patient Confidence Score
Percentage of individuals with a coordinated care plan (CCP) who have a recorded patient confidence score.
Question : “How confident do you feel that your care goals will be reached?” The client is asked to give “a score” between 0 (not very confident) and 10 (very confident).
The question should not be adapted. If the client needs clarification, you can re- phrase the question.
If you are concerned that the client may perceive a conflict of interest, you can say: “This will not put you at risk for any reductions or changes in service as a result of your answer, it is intended to help us serve you better”.
Only the date of the first confidence score should be recorded (not the answer to the question).
This question should be asked in the Care Conference where the CCP is developed. Ideally, the question is asked whenever the clients goals or approach to their goals changes.
When the client states that their confidence score is less than 7, the provider should ask the client: “What would it take to increase your score?” The response to this question is intended to influence the work you will do for the client.

12. The Tools & Process

13. Manual Data Collection Sheet
See the CCP Reporting Tool Word Document or use the Excel spreadsheet

14. Excel Manual Data Collection Sheet

15. Health Quality Ontario Coordinated Care Management Process Manual Data Collection Points – Corresponding Columns on Spreadsheet
Row
A, B, C, F
Row J
Row
G, H
Row P, K
Row
I, L, M, N
Row D, E

16. FAQ Which clients do I report this data on?
All new clients identified January 1st 2019 onward, plus all those identified previously, who have not yet had a CCP developed.
What would the sub-region of a client with no fixed address/homelessness be?
The address of the agency or site that is leading the CCP.
How often do I fill out the CCP Reporting Tool Word Document?
Each time you have a new client identified for a CCP, or when any of the indicator data changes: i.e. when their care coordination status changes, when they were attached to a PCP if they were unattached, or when their goals change and you have asked the patient experience questions again.