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Transformation On The Move

Transformation News From The Ministry of Health and Long-Term Care

Ministry of Health and Long-Term Care

Progress and Success: David Lamb Reports

Through participation in Quarterly Reporting and the Rapid Cycle Evaluation exercise, we are starting to develop a clear picture of the work that takes place to coordinate care for complex patients, as well as the challenges and success that have been experienced.


It's important to share the results and perceptions of the journey so far.


We're seeing good progress! The level of innovation and creativity, with respect to coordinating care and its relationship to strong patient engagement at all levels of the process of establishing Health Links, is clearly paying off.


We know there's more to do to provide clarity on certain issues (information and privacy, data sharing and the progression of the Ministry-led Care Coordination Tool) and we will work with our partners in these areas to provide the help that is needed.

April-September Reporting In Brief (22 Early Adopters Reported)

Every Health Link is working hard to coordinate care for complex patients. By the January-March period, each Health Link will be creating individual care plans with these complex patients.


Everyone is having success reaching out to patients. We see that patients are involved and helping to shape their care coordination. They are being consulted directly on their goals for care and treatment through interviews, surveys and case conferences, and this will lead to the creation of those individual care plans.


Where more work is required


We know that there have been delays in funding to establish Health Links and we're working to put that right. We also know that further progress on Ministry-led plans for an electronic coordinated care tool will greatly help with Care Planning.

Rapid Cycle Evaluation

Before the holidays, we engaged seven Health Links to learn more about coordinated care, patient engagement and the work undertaken to identify health links patients. We also sent surveys to another 30 health links to obtain similar information.


As a full complement of Health Links reaches maturity, the results of this evaluation will be critical for understanding what success will look like and where we need to correct our course. Further engagement is planned for the next few weeks but here's a little of what we learned:


Establishing a Health Link - Many have cited the importance of relationships developed prior to the Health Link, as well as provider networks, recognized champions, governance and tools. We'll be working with our system partners on tools and materials that will really help bring the people in Health Links closer together in order to be successful in enhancing care for your patients.


Identifying Health Links patients - While 70 per cent of Health Links reported that they'd identified their complex patient cohort, there is some work to be done to provide consistency of key definitions in shaping the cohort (e.g. 'target population' and 'complex patient'). We'll be making sure to provide guidance this year to ensure there is the best possible handle on the complex patient cohort.


Care planning - Communication and organization with traditional healthcare delivery partners is progressing well. It's clear that the circle of care is widening all the time to include the non-traditional social service providers.


Patient engagement - We're seeing that Health Links are being shaped by, and reshaping, the patient experience. Patients are directly engaged in their treatment goals, activities and care planning, and we are hearing the same thing in our quarterly surveys. It's clear this engagement is a key driver to getting care plans created.


We look forward to working over the course of the year to understand how we can leverage successes and ultimately help grow each Health Link and Health Links across the entire province.