There was a kind of sliding sound and then a rattle as a woman fell to the floor during Tuesday afternoon’s session of the Ontario Hospital Association’s HealthAchieve. When someone asked if there was a doctor or nurse in the house, a variety of arms shot up. We could have probably added a few allied health professionals too should the distressed conference attendee also need a lab test or an x-ray.
If you are going to pass out, this was the place to be.
Each year the OHA features a number of well-attended “candy” sessions that do more to inspire than really inform, often involving high-profile individuals. This was not one of them.
In fact the five panelists joked about whom the big crowd had come out to see.
There is great curiosity about the province’s new Health Links. As one person told me, the session attendance is in inverse proportion to how much knowledge there is about the subject. Given the crowded standing-room only audience that was driving up the room temperature, many wanted to know more.
Ontario is by no means the first jurisdiction to come to the realization that a very small number of system users are responsible for a significant portion of the cost. In Ontario’s case, one per cent of users account for 34 per cent of that cost. If you expanded that number to 5 per cent of heavy users, that cost expands to 66 per cent – or two-thirds of health care costs. The theory goes that if you can wrap services around these individuals, you can both improve the quality of care and dramatically reduce costs, including unnecessary hospital admissions.
The Health Links are a grouping of local health providers – such as hospitals, home care, long term care, primary care providers and other community agencies – that share information and work towards a common care plan for these individuals. They operate within sub-regions of the Local Health Integration Networks (LHINs). Communications between providers is the key, as is a significant focus on the social determinants of health.
At present there are 37 health links in the province covering about 5.8 million people – or nearly half the population. There are 650 partners attached to these links. Every LHIN has at least one. Hamilton Niagara Haldimand Brant appears to be the most advanced with nearly a third of these provincial links.
Helen Angus, the provinces assistance deputy minister who leads the transformation secretariat, said her job is to become “the silo buster.”
Murray Martin, the departing CEO of Hamilton Health Sciences, said it was important to involve the municipalities in these links given their local experience.
That becomes particularly relevant when one of the key health determinants may be homelessness.
Lisa Priest, the Project Director and Patient Engagement Lead at the North East Toronto Health Link, spoke of one patient who was showing up with such regularity that staff anticipated the person was dealing with his or her homelessness by attending various Toronto-area emergency rooms.
Martin says that with the patient’s consent, a flag appears in the shared database indicating there is already a care plan for this person.
Within these sub-regions the one per cent can be a manageable number. Martin indicated one Hamilton sub-region that had 206 high users. Michael Feraday, representing a Barrie-area family health team, said it translated to 300 to 500 patients in their sub-region.
Feraday’s Health Link is beginning its work by addressing unattached patients with complex care needs. Their longer-term goals include a focus on chronic disease prevention, complications of aging and quality of life issues.
It was clear from the presentation that there is no standard approach to these Health Links. Ontario is still at an experimental stage, although Angus says they are working towards a set of common principles and doing “rapid cycle evaluations.”
While HNHB is gathering permission to share care plans among health providers, clearly the links are using the Privacy Commissioner’s edict to do privacy by design. Feraday said that while they have the Chief Privacy Commissioner on side, they are still looking for more definitive clarification around how they can share information.
Unlike HNHB, at present the Barrie Link has no IT solution available to provide a common view of the patient in real time.
Camille Orridge, CEO of the Toronto Central LHIN, said they have identified key population needs specific to micro-geographic areas within the LHIN. In the East its more about chronic disease and high-risk seniors. In the Western part of the LHIN there is high need to address issues around mental health and addictions. In the Northern part of Toronto its about children and youth. Orridge says their understanding of population need is so great now that they know exactly which building should house a specific clinic.
She says it appears the Toronto LHIN has a lot of primary care available to its citizens, but cautions that 60 per cent of users don’t live in the LHIN.
Getting the system up and running is one thing, keeping it current is an ongoing challenge especially given the high mortality rate within the one per cent.
Murray Martin indicated one sub-region had a mortality rate of 30 per cent annually among the high user population. Another speaker indicated the constant turnover within her region given a 24 per cent death rate among this identified group.
Having a common care plan and a strategy for high users of the system also helps to ease anxiety, especially when patients consider who they should call.
Feraday spoke of the difficulties of supporting this population.
“People don’t understand the system,” he said. “And the system doesn’t understand them.”
Orridge spoke about contracting a telephone language service in her LHIN given the difficulties of providing good care without being able to fully communicate.
Providers in her region are also being supported with training around “cultural competence” given a straight literal translation doesn’t always lead to understanding.
The province is pinning much of its hope on this, especially in an environment where money is so tight.
Providers have been telling them that given the fiscal restraints that they are under, there is room needed to allow them to experiment with new approaches.
Angus says that it is still early days. While there is no data yet to show the approach is working, she says they are beginning to hear anecdotal evidence that the Health Links are producing results.
As for the woman who passed out, she did regain her feet and was helped to a waiting ambulance.