1. www.HQOntario.ca Power of collaboration - Working together to care for those with complex needs. WWLHIN Regional Engagement Session

2. 1 Power of Collaboration: Working together to care for those with complex needs. Agenda Overview of provincial Advanced Health Link Model Brief update on this Health Link Activity: Table discussion on collaborative care planning and call to action www.HQOntario.ca

3. 2 The goal: collaboratively improving integrated care for patients with multiple chronic conditions and complex needs www.HQOntario.ca

4. Advanced Health Links Guiding Principles and Model 1.Regular and timely access to primary care for complex patients 2.Effective provision of coordinated care for all of Ontario’s complex patients 3.Consistent, quality care across the health care continuum and social services sectors 4.Focus on vulnerable populations (frail and elderly, mental health and addictions and palliative). 5.Evidence-based, measureable improvement of the patient experience through enhanced transitions in care 6.Maximize coordinated care to generate system value, sustain the Health Links Model and strengthen care coordination processes to realize greater efficiencies 7.LHINs accountability for performance. www.HQOntario.ca Source: ‘Health Links Target Population’ Webinar, The Ministry of Health and Long Term Care. August 12, 2015

5. 4 Identifying Target Population Process will include: –Patients with 4+ chronic/high cost conditions (from provided list) Plus a focus on mental health and addictions, palliative, and the frail elderly economic characteristics (low income, unemployment) –Social determinants (housing, language, immigration, community and social services etc.) Source: ‘Health Links Target Population’ Webinar, The Ministry of Health and Long Term Care. August 12, 2015

6. 5 www.HQOntario.ca THE COORDINATED CARE PLANNING PROCESS IN PROGRESS Identify Patients “Recognize that I may benefit from care coordination” Engage the Patient “Engage me to participate in care coordination” Initial Interview “Let me share what is important to me and what my goals are” Care Conference “Together, we develop my coordinated care plan” Maintenance and Transitions “I work with my team to meet my goals and my team stays connected” Emerged organically through the work of early adopters and emerging Health Links. Not mandatory- yet most Health Links have adopted or adapted some or all of these steps into their processes. Continues to evolve.

7. 6 Waterloo Wellington’s 9 minimum elements of a Coordinated Care Plan (CCP): 1.Patient identification 2.Documentation (either paper or electronic) 3.Content developed in collaboration with, at minimum, with the patient and two or more service providers external to lead agency 4.A minimum of one identified patient goal to meet identified need or gap What the patient hopes to achieve 5.A minimum of one intervention to address the gap/need 6.Identification of person(s) responsible for implementation of the intervention(s) eg. patient, health care professional, service provider 7.A minimum of one expected outcome 8.Provision of plan to PCP (if not already involved in CCP) and/or referral source 9.Date for planned review/ evaluation of the plan www.HQOntario.ca

8. 7 Health Link – Local Context Brief description of the local health link process This is how hard we have worked You have helped us make tremendous strides We need to do more www.HQOntario.ca

9. 8 Table Discussion: Question 1 Having heard this information… At your table discuss how your own organization is currently involved in collaborative care planning for residents with complex needs. www.HQOntario.ca

10. 9 Table Discussion Question 2 Consider the care planning process within your organization. Which of the 9 elements of coordinated care planning are included in your care plans? Which are missing? www.HQOntario.ca

11. 10 Table Discussion: Question 3 Individually, write down, what is one thing your organization can work on to improve collaborative care planning? www.HQOntario.ca

12. 11 Sub-LHIN site report What is one interesting thing that came from your table in the workshop? www.HQOntario.ca