Guide to the Advanced Health Links Model

Transcript

1 Guide to the Advanced Health Links Model

2 2 TABLE OF CONTENTS ...3 INTRODUCTION ... 3 Purpose of this Guide PART ONE - Current Status ...4 Why Health Links Must Evolve: Health Links and the Action Plan ...6 ...7 Why Health Links Must Evolve: Understanding our Challenges PART 2 – THE ADVANCED HEALTH LINKS MODEL ...8 Advanced Health L inks Guiding Principles a) ...8 b) Advanced Health Links Model Overview ...9 SECTION I: STANDARDIZATION ... 10 a) - Ontario’s “5%” ... 10 Common Target Population Common Performance Measures ... 11 b) c) Common Health Links’ Structure and Accountabilities ... 12 SECTION II: PERFORMANCE MANAGEMENT AND OVERSIGHT ... 15 a) Enhanced Performance Management ... 15 b) Focused and appropriate performance management ... 15 16 ... SECTION III – HEALTH LINKS FUNDING REDESIGN AND SUSTAINABILITY PLANNING a) – A Developmental Approach ... 16 Funding Health Links up to 2014/15 Sustainability Planning ... 17 b) SECTION IV – HEALTH LINKS WITHIN THE BROADER SYSTEM ... 18 SECTION V – AND LHINS ... 18 ROLE OF THE MINISTRY a) Role of the Ministry – The Provincial Perspective ... 18 b) ... Role of the LHINs 19 SECTION VI – -FIELD SUPPORTS ... 21 IN a) Role of Health Quality Ontario (HQO) ... 21 b) Coordinated Care Tool (CCT) ... 22 SECTI ON VII – CONCLUSIONS AND MOVI NG FORWARD ... 24 Who to Contact ...24 ... 25 APPENDIX A: SUMMARY OF RCE AND HSPRN FIN DINGS ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

3 3 INTRODUCTION Ministry of Health and Long -Term Care (“the Health Links were introduced as a key commitment in the ministry”) Action Plan for Health Care to transform the system through increasing access to 2012 integrated, quality services to Ontario’s complex patient population. Since their launch in December 2012 , Health Links have made tangible gains in improving care oordination and transitions between services. c To date, Health Links have played a key role in attaching patients to pr imary care providers, improving c oordinated care for patients living with multiple complex chronic conditions ; and more meaningfully , engaging patients in their own health care. In addition, they have been crucial in strengthening relationships and communi cation between providers. Moving forward, Health Links will continue to play an integral role in the health system landscape, as atalysts that will support the advancement of the Patients First : Action Plan for Health Care . c To continue the momentum o f Health Links it is important for the program to evolve from the evelopment al stage to a more mature state of operation to support the delivery of care to all of d Ontario’s complex patients. -ordination between a patient's “Health Links will encourage greater collaboration and co different health care providers as well as the development of personalized care plans. This will help improve patient transitions within the system and help ensure patients receive more responsive care that addresses their specific needs with the support of a tightly knit team of providers” Announcement of the Health Links Initiative December 6, 2012 Purpose of this Guide On June 18, 2015, the minis try and L ocal Health Integration Network s (LHIN s) leadership co -hosted the Advanced Health Links webinar which articulated the shared vision for the future of Health Links and the enhancements that would be made over the course of the 2015/16 fiscal year t o evolve the model. Th (“the Guide”): e Guide to the Advanced Health Links Model • Outlin es the direction of the Health Links program , its objectives over the course of the 2015/16 fis cal year; and, • Details t he work the ministry, LHIN s and Health Link s wi ll undertake to transition operations and p fiscal year. 2016/17 rocesses to the Advanced Health Links M odel across all Health Links in the ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

4 4 Over the course of 2015/16 fiscal year, the ministry will engage the LHINs , Health Links and key the further the Advanced Health partners such as Health Quality Ontario (HQO) to scope out components of Model and to increase the tools and resources to help LHINs and Health Links with transition. Links PART ONE - Current Status In order to understand the future state of Health Links, it is important to explore the current context and how Health Links have evolved. Health Links have been operational for two years and while much of the development of the over p rogram has been experience d by the 26 early adopters, the program has grown considerably t o the 82 Health Links that will be in operation b y the end of 2015. Since inception, Health Links have leveraged the early “low rules” environment to maximize their patient are networks, to enhance care coordination for c omplex patients and to improve transitions between c services. 9,233 CARE PLANS DUCED PRO 20,660 Attached Patient s 1, 800 Partner s are engaged across health, community and social services sectors Operational Health Links have demonstrated success in a number of different ways:  More patients have coordinated care plans ;  More patients are attached to a primary care provider;  Patients have been engaged in their care to a much greater degree ;  Health Links are focusing on system gaps and how to better care for specific population sub -groups ;  Relationships and communication between providers have been strengthened in local areas; and,  . Providers are improving their ability t o identify complex patients in their community ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

5 5 the early adopter Health Links has emerged as best practices in a number of operational The work of . Some including care coordination , and increasing access to primary care and patient engagement areas are outlined in the chart below. examples A snapshot of Health Links ’ best practices Example Area Activity Health Link Huron Perth Health Link Care Care Planning Creation of a tool kit to support more effective, Coordination re Conference standardized approach to Ca coordination. Hamilton Centre Health Link Learning Circles: interaction with patients and providers to plan care. Patient Passport Program: care plan which addresses Guelph Health Link patient goals and perceptions of care received. Virtual MVP Clinic housing all allied professionals in Barrie Health Link one area to facilitate one -stop care for complex patients. East Toronto Health Link Advance Care Planning Resources North York Central Health Link Health Link’s Emergency Department notification for Vulnerable complex patients with mental health concerns. Populations Social worker membership within Health Link’s Circle Don Valley Greenwood Health of Care. Link Increasing Patient Using Health Care Connects to attach patients. Hamilton Niagara Haldimand Access to attachment Brant LHIN Primary Care through Health Links Patient involvement on Health Links’ Patient Connecting steering Various Engagement communities of s. committee providers to patients Patient Engagement Days Health Links have also identified trends and subgroups within their target population, adapting care planning to accommodate vulnerable populations ( e.g. individuals living with mental health conditions individuals living in precarious housing conditions, etc.) , and and/or . elderly addic tions, the frail and By providing better care to vulnerable population groups and by leveraging partners from outside the health sector to bridge services between the health, social and community sectors , Health Links have taken on an increasingly prominent role in filling system gaps. ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

6 6 Why Health Links Must Evolve: Health Links and the Action Plan Patients First: Action Plan for Health Care places The ministry’s Health Links at the forefront of the system. As illustrated below, Health Links will be instrumental in driving results across the ministry’s four priority areas: Access, Connect, Inform and Protect . Access • Continue to deliver coordinated care to all of Ontario’s complex patients ensuring patients have ti mely a ccess to quality primary care . housing the health care sector across the community, social services and • beyond Integrate c are ectors, and increas e access to the justice sector. s Connect ( Home and Community Care) • Larger number of services provided to a greater number of patients (complex and non- complex) in t he community setting. Align ministry and sectoral efforts to strengthen primary care and modernize the home and • ommunity sector. c Inform Focus on providing • through primary care. Primary care is the information to support health choices ntry point for receiving information, referrals and advice on chronic disease management, health e promotion and disease prevention. • Better integration of services to ensure pr imary care providers and patients are provided with the i nformation and community supports needed to make informed decisions about their health . Protecting Universal Health Care ystem • Maintain s expenditure growth below 2% reinforces the fiscal imperative. • Health Links are crucial to wider system integration and therefore are key support s to initiatives ed at improving quality of care while delivering on fiscal commitments . aim Health Links are a good example of how Ontario is working to bring am with ogether providers and health organizations to work as a te t patients and their families...Providers design individualized care plans, and work together with patients and their families to ensure they receive the care they need. But we have more to do. ...To further provide patients with faster access to the right care the Plan [also] includes: bringing health care providers together to better coordinate care for patients with complex medical conditions through more Health Links across the province. age 9 Patients First: The Action Plan for Health Care , p ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

7 7 Why Health Links Must Evolve: Understanding our Challenges been significant progress in the field, concentrated energies are needed to grow the While there has Health Links program is at an inflection point, which requires the ministry, Health Links Model . T he -up efforts to support a larger complex patient population. To enable LHINs and Health Links to ramp Health Links M odel must build on the experience and lessons to date . this, future iterations of the Rapid Cycle Evaluation (RCE) The ealth System Performance Research Network (HSPRN) reports , , the H onsultations with the field, and Health Links ’ quarterly reports have helped the ministry understand the c core challenges of Health Links and areas that require adjustment to support continued success: provide clarity 1. and Low Rules drove creativity, now standardization must drive consistency The at the beginning of the Health Links journey as it helped to “low rules” approach was appropriate promote novel ways of coordinating care for complex patients. It also led to variability in terms of Health Links ition of the complex patient cohort which allowed Health Links to ’ governance and defin respond to their local context. However, as the number of Health Links grows, consistency and standardization is important in these areas to ensure operations can grow to scale across the pr ovince . 2. to Performance Management support enhanced understanding of provincial, regional and local performance h Links currently report on two indicators of the 11 that were devised at the beginning of the Healt program. Reporting on a smaller indicator set allowed early Health Links to focus on establishing the performance ith two years of operations, the and support innovation. W management program framework : must be enhanced to ensure Health Links and LHINs understand the measures needed to adv ance care coordination for complex • atients ; and , p • The ministry , LHINs and Health Links can assess the long- term value of Health Links. 3. Health Links Funding Health Links funding model to As the Advanced Health Links Model evolves, there is a need to refine the s for upport provincial scale -up and empower LHINs to plan for their regional Health Links strategies and beyond. 2015/16 4. Health Links and the Wider System continue the Health Links program nts First: Action s to mature, facilitating the delivery of the Patie As lan for Health Care and other government priorities (e.g., Poverty Reduction Strategy , C ommiss ion on P the Reform of Ontario’s Public Service, Minister Hoskins ’ Mandate Letter , etc. ), consideration must be given to the following : Health Links M odel can be adjusted to allow for greater coordination of services across • How the h ealth, community, social and justice sectors; and, ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

8 8 • How an A dvanced Health Links Model supports and aligns with wider system reform and policy evelopment (e.g. strengthened primary care sector and modernization of the d home and community services sector, etc.). PART 2 – THE ADVANCED HEALTH LINKS MODEL a) Advanced Health Links Guiding Principles The program is at a critical juncture where the ministry, LHIN s and Health Links must have a Health Links s hared vision and priorities . As such, the ministry has established the Advanced Health Links M odel , to guide the collective efforts of the ministry, LHINs and Health Links by capitalizing on existing Health Links infrastruct ure and networks. The following principles have been established to guide this work: central goal of Health Links A 1. . Regular and timely access to primary care for complex patients . As most patients first ontinues to be regular and timely access to primary care providers c interaction with the health care system is thro ugh their primary car e provider, ensuring patients are attached to primary care providers is essential to the effective provision of coordinated care for all of Ontario’s complex pat ients. Effective provision 2. of coordinated care for all of Ontario’s complex patients . The focus o f Health L has not changed ; the model is scaling up to reach all of Ontario’s target population . inks aking the Consistent, quality care across the health care continuum and social services sectors . M 3. Health Links provide and their connection to health, social, and services onnection between the c community services. Focus on vulnerable populations (frail and elderly, mental health and addictions and palliati ve) 4. . ealth Links will capitalize on the work already being done to serve the complex patient population, H and focus in on the most vulnerable and marginalized within that group . Evidence 5. -based, measureable improvement of the patient experience through enhanced t . ransitions in care 6. and e coordinated care to generat e system value , sustain the Health Links Model Maximiz trengthen care coordination processes to realize greater efficiencies . s on the ground and to the inks value of Health L nd 6 , emphasis will be on understanding the For 5 a system their impact at the regional and provincial level. and LHIN s provide oversight of Health Links and are accountable performance. Ns accountability for LHI 7. to the ministry for Health Links performance. LHINs will devise the ir regional Health Links strategy within their boundaries and ensure that Health Links have the supports they need to succe ed . Refer to Secti on V1: In -field supports ols to d to for comprehensive overview of HQO and ministry enable assist LHINs and Heath Links with operations. ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

9 9 8. Shared MOHLTC, LHIN and Health Links accountability overall success . The ministry, LHINs and for H ealth Links will work together to ensure that Health Links continue to m ake positive impacts for patients and the . system b) Advanced Health Links Model Overview The Advanced Health Links Model targets specific activities across the following four policy and perational areas: o Sta to support common understanding of ndardization 1. t he target population, common measurement and common governance and accountabilities across all Health Links ; Performance Management and Oversight 2. to enhance a ccountability for performance by strengthening the framework; performance management to support LHIN Funding Model Redesign 3. up of operations around the countability , the scale- ac province and to realize true value to the system; and , to enable adaptation and 4. Wider System Integration alig overnment ther ministry and g nment with o priorities. ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

10 10 SECTION I: STANDARDIZATION Hea lth Links that paved the way for As noted, the early stages of enabled local innovations and creativity su ience and transitions in care (see examples “ A snapshot of Health Links’ best ccesses in patient exper ” on Page practices The Advanced Health Links M odel aims to standardize and embed many of these 5) . innovative practices across core areas of the Health Links model . fits all approach to the delivery of Standardization is not designed to create a homogenous, one -sized Health Links across the province. Rather, it is designed to harness the lessons that have been learned from the ministry, LHIN s and Health Links . LHINs and Health Links will continue to have the flexibility to determine “how” care will be delivered within their regional and local contexts , and standardized parameters. to effectively plan how care will be delivered, it is vital they have a In order for LHINs and Health Links c ommon understanding of the fundamental areas the efficacy of Health Links . The Advanced that impact Health Links M odel defines these areas by standardizing the following: a) Common Target Population: establishes a common approach to identifying the patient the delivery of more responsive and targeted care , establish a opulation, which will support p common baseline and track performance and progress. b) Common Performance Measures : a number of performance measures will be introduced over . Links Health impact of 15 /16 to help provide more context on the 20 c) Common Heath Links Structures and Accountabilities : st reamlines the governance and sponsibilities of Health Links lead organizations to more accurately reflect the successes and re realities in the field. d) Shared Best Practices: HQO has established a formal framework and process to identify and disseminate existing and emerging Health Links practices , tools and supports to assist LHINs best and Health Links with adoption and uptake . More information can be found in Sect ion VI- In- field supports . Common Target Population - Ontario’s “5%” a) A common target population add resses the need to establish a common starting point – who is our ta identified rget and how are they ? In the absence of a common population, measurement of progress is very difficult. Based on analyses to date, identification of the complex patient targ et population remains one of Health an effort to overcome this barrier, the ministry has proposed guidelines to inks ’ major challenges. In L facilitate the identification of the target complex patient population. This approach will enable Health Links to adopt best practices with respect to care coordination and 56 Health Links that are close to the start ther areas of activity , which is particularly important for the o line. ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

11 11 Complex Patient Identification Guidelines close to 5% of the population, who are The number of patients identified should be responsible for 65% o f health care use . The complex patient target population should: • Overlap substantially with high cost users, recognizing that not all high cost users are high needs a); atients (and vice vers p • Include patients with high needs and/or complex conditions; and, • Include patients with four or more chronic/high cost conditions, including a focus on individuals ing with mental health and addictions, palliative patients, and the frail elderly. liv wever, recognizing nuances exist across communities, LHINs and Health Links are encouraged to Ho ad apt the patient identification criteria to their local context and population needs. capturing selection criteria achieve s a balance between The 4+ chronic/high cost conditions patient -cost users. -cost users, and 60% of those who are high atients who are at risk of becoming high p Although 50% of patients with multiple chronic conditions are currently not high cost users, a preven coordinated care approach could t them from becoming high cost users. The ministry will work with the LHINs and Health Links to integrate the social determinants of health erspective into the patient identification process as a means of facilitating service integration through p Health Links for the poorest served populations. b) Common Performance Measures Through the HQO enabled Quality Improvement Reporting and Analysis Platform (QI RAP) Health Links c urrently report on two program indicators: • Number of patients with a coordinated care plan developed through the Health Link; and, • Number of patients with regular and timely access to a primary care provider. To support a better understanding o f how Health Links impact patient and system outcomes, the fo llowing three new indicators will be introduced over 2015/16: • Reduction of 30 -day readmissions to hospital; • and , Reduction in home care visits referral time; • Reduction in the number of ED visits for conditions best managed elsewhere . The three new indicators will enable a more detailed understanding of the impact of Health Links over t he long- term. However, there is an immediate need to obtain a deeper understanding of Health Links impacts across core areas. As such, b eginning in the second quarter of 2015/16, the ministry will intr oduce a number of short -term indicators that focus on patient enrollment, patient identification and be care coordination. Many of the measures will only be collected once to establish a baseline then will gradually refined or phased out in subsequent quar ters. ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

12 12 c) Co mmon Health Links’ Structure and Accountabilities ks Since 2014, the ministry has undertaken substantial work to identify and understand Health Lin p ractices, processes and structures that could optimize performance and facilitate the scale and spread of best practices. Through the RCE and HSPRN reports, Health Links ’ quarterly reports, consultations with LHINs, and the experience of the 26 early adopter Health Links, the ministry obtained: A c • atalogue of program successes and impacts; • Insights into the key steps and activities needed to establish , operate and lead a Health Link; • Insights into best practices, emergent innovations, lessons learned, barriers; and • Approaches and steps to maximize the operations of existing Health Links and inform the evelopment of future Health Links. d Through these findings, the ministry concluded the need to standardize Health Links structures and countabilities, including the roles and responsibilities of the Health Link l ead organization. ac These inputs revealed Health Links that were led by hospitals, Community Care Access Centres (CCACs) , an d primary care team s (Family Health Teams (FHTs) and Family Health Organizations (FHOs) , demonstrated high degrees of integration that strengthened care coordination proces ses. For example, hospitals had more intensive levels of integration for the complex patient population, creating specialized services and programs for this group , while primary care -led Health Links employed broad integrative processes t hat spanned across the virtual organization. : their these existing Evidence shows given organizations are best positioned to lead Health Links etworks , infrastructure and resources to mobilize efforts across multiple organizations and sectors; n -disciplinary approach to care models the principles and approach , inter . and es of the Health Links Model Evidence also points to the important role Health Links core partner organizations play in the execution o leadership model with core f Health Links. For example, some of the primary care teams had a shared , which allowed them to leverage inter- organizational strengths and capabilities to deliver partners Health Links to their complex patient cohort. As the Health Links program evolves beyond the 26 early adopters, these principles and organizational Model tructures have shaped the A dvanced Health Links and helped the ministry standardize Health s Links lead organizations and their core functions. i. Who can lead a Health Link All new Health Links will be led by hospitals , C CAC s, or primary care t eams . A primary care team can be a FHT , Nurse Practitioner- Led Clinic, Aboriginal Health Access Centre, Community Health Centre or FHO . led by other organizations. These organizations have been Currently, a handful of Health Links are i ant contributors to the Health Links program, and will remain at the helm of their Health Links. mport ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

13 13 ii. Responsibilities of a Health Link Lead Organization , Although the Health Link lead organization is accountable to the LHIN for the Health Link’s performance he Health Link is a collaborative endeavour that involves the Health Link’s lead organization and partner t organizations sharing responsibility for achieving outcomes. All Health Link lead organizations will continue to perform responsibilities in these core functional areas: governance, establishment, as outlined below . operations and performance However, although the lead organization is accountable to the LHIN for these functional areas, re ions, who may be better positioned to sponsibility can be shared with Health Link partner organizat deliver on these activities. These arrangements need to be formalized between the Health Link lead organization and partner organization through their Letter of Cooperation (formal agreement between Health Link lead organization and partner organization). 1. Establishing Health Link’s governance which includes engaging core and supporting partners and rafting Letters of Cooperation as necessary to formalize arrangements c 2. Establishing a Health Link and developing the Health Link’s virtual infrastructure Provid e project management and administration responsibilities; • • Defin e and identify the roles/responsibilities of the Health Link’s partners ; partner • Enabl e implementation of care planning processes, by working across the H ealth Link’s o rganizations to define clinical flow of complex patients across organizations, and determine how the Health Link’s infrastructure and networks will be organized to provide wrap -around, -centred care; patient • Develop a Health Link’s bu siness plan, in collaboration with their LHIN and Health Link’s Health Link ’s lead organization will identify the resource requirements needed to artners, the p the Health Link’s targets. achieve e patient engagement; and, • Ensur • Facilitat e provider engagem ent . Health Link operations 3. • Work with the LHIN to identify the target population in accordance with guidelines; • Track the patient cohort; • Oversee care plan management/implementation; • Ensur e the appropriate connection to health services and coordinated care planning; • Engage the network of providers within the Health Link to ensure providers have the necessary s ensuring upports and resources they need to reach and service the target population, and there is a common understanding of the Health Link’s objec tives and priorities; • Adopt best practices to enhance implementation; and, e ongoing patient and provider engagement. • Ensur ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

14 14 4. Health Link performance • Broker and setting targets with the LHIN and Health Link’s partners where required or appropriate; • Ensur e that the operational plan is achieved; and, • Report on performance to LHINs. Over 2015/16, the ministry will work with LHIN leadership to embed the roles and responsibilities of the ministry, LHINs and Health Link ’s lead organization ac ross all 2016/17 accountability instruments of Cooperation (s) between: the ministry -LHIN, LHIN and Health Link lead organization, and Letter between the Health Link . lead organization and Health Link partner organization(s) Standardization Key activities in 2015/16 to facilitate implementation in 2016/17: th Ministry hosted webinar on the Target Patient Population on August 12 1. . 2. HQO to develop best practices to assist LHINs/ Health Links in integrating approach into existing processes. 3. Ministry to work with LHINs to devise the target setting process for performance measures and craft language to support inclusion of indicators into 2016/17 LHIN -Health Links accountability mechanisms. 4. Ministry, in collaboration with LHINs, to review and assess the Advanced Health Links M odel accountabilities, and how they will be integrated into accountability mechanisms for 2016/17. 5. LHINs and Health Links work to integrate new requirements into the 2016/17 LHIN - Health Links accountability mechanisms. ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

15 15 SECTION II: VERSIGHT PERFORMANCE MANAGEMENT AND O Health Links mature, As an enhanced performance management framework is necessary to better u a Health Links, LHIN and ministry nderstand the value and progress of the model from perspective, so that adaptations can be made to address local, regional and system level considerations . engage in performance management discussion This will help LHINs and Health Links pinpointing s by what refinements may be needed to a as where Health Links may require LHIN level supports and are LHIN h Links strategy. ’s regional Healt An augmented performance management framework will be advanced through two avenues: a) nhanced performance measurement and b) focussed and appropriate performance management. e a) Enhanced Performance Management Enhanced Performance Measures i. /16 phased in over 2015 The new performance measures, a s o utlined in the Com mon Performance Measures section , are egral components to a robust performance management framework that will suppor t sustained int Health Links success as operations are scaled across the province. Spec ifically, t hese measures will help anchor and guide progress conversations between LHINs and wing criteria in mind: Health Links . Over 2015/16, the ministry , will engage the LHINs with the follo • Consider how the performance measures will be more formally used in performance anagement ; and , m • Ensure Health Links performance measures are aligned and advance other ministry priorities in r and modernized home and community care. cluding a strengthened primary care secto ii. Enhanced Process for Quarterly Reporting Since March 2015, LHINs and Health Links have used the ol HQO enabled QI -RAP to to su bm it key performance measures on a quarterly basis. As the Advanced Health Links M odel progresses, HQO will -RAP enabling greater levels of automation and continue to strengthen and build the capabilities of QI data analysis at the provincial, LHIN and Hea lth Links . Data reporting and review protocols will be level established to promote availability of the highest quality data to monitor progress of the Health Links and regular consultations between LHIN Health Link leads and regionally based QI specialists will support interpretation and learning from the data. b) Foc used and appropriate performance management It is imperative that Health Links have the support s needed at the regional and local level to scale perations to serve all of Ontario’s comple x patient population. As such, the Health Links program will o focus on the supports, processes and policies needed to assist Health Lin ks with meeting their as they scale operations. performance targets and priorities ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

16 16 i. Ministry -LHIN Discussions on Regiona l Performance and Provincial Objectives a policy that sets out the following: Over 2015/16, the ministry and LHINs will work together to develop The parameters and framework to anchor Health Links performance conversations within the • ntext of regional and provincial objectives; co The frequency of meetings ; and • , • The existing channels and forums that could be leveraged for these discussions . ii. LHIN - Health Links -Performance Management LHINs and Health Links will be expected to continue to work together to develop the following : • Processes assess the performance of individual Health Links with the goal of understanding the that c hallenges and barriers that may impede performance; and , Formal and/or informal strategies to improve performance as required including the deployment of • rovincial tools and use of HQO supports. p Key activities in 2015/16 to facilitate implementation in 2016/17: 1. The ministry will engage LHINs to: • Develop the performance management framework including the phasing in of three new p erformanc e measures, referenced in the Common Performance Measures section , and the d -LHIN and LHIN- Health evelopment of a target setting process for incorporation into the ministry Links accountability mechanisms for 2016/17; Devel • -LHIN and LHIN- Health op performance management policies to set out the process for Ministry Link performance monitoring for implementation in 2016/17; and, • Provide advice on any common frameworks for LHIN- HL performance management proto cols. 2. The LHINs will work with Health Links within their geography to develop their own performance anagement protocols. m SECTION III – HEALTH LINKS FUNDING REDESIGN AND SUSTAIN ABILITY PLANNING Funding Health Links up to 2014/15 – a) A Developmental Approach Over the course of two years, the n umber of has rapidly grown from the original 26 to the Health Links 8 2 that will be operational by the end of 2015. Early funding levels reflected the -up and start s. A s the Health Links program enters the next chapter, funding must evo developmental phase lve to match the maturity of the model. Starting in 2015/16, Health Links led by health service providers funded by a LHIN, shifted to a LHIN - m anaged funding approach where LHIN s were provided with a single Health Links allocation, and granted the flexibi lity and discretion to plan and fund Health Links according to their regional priorities . Health Links led by primary care teams continue to be funded directly by the ministry, and work collaboratively with their respective LHINs to ensure alignment with r egional Health Links priorities. ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

17 17 Over 2015/16, th and LHINs will work collaboratively to progressively update the Health Links e ministry : funding approach in a manner that • Builds on the learnings of the ministry and LHINs and the capacity that has resu lted from the c reation of Health Links ; and , • Considers Health Links long-term sustainability within the system. b) Sustainability Planning As the Advanced Health Links M odel progresses, greater provincial, regional and local attention will f ocus on understanding what sustainability means within the Health Links context and how Health Links care coordination processes to m aximize will harness their inter-organizational collaborations and regional investments and create opportunity for cost avoidance. Over the course of 2015/16 the ministry, with LHIN involvement, will craft a guide that will scope out LHINs and Health Link lead organizations. hat sustainability means and how it can be demonstrated by w Th e sustainability guide will be a vital resource a s LHINs and Health Links develop a sustainability plan, inistry which will be an essential requirement in the 2016/17 m -LHIN and LHIN- Health Links accountability mechanisms . Key activities in 2015/16 to facilitate implementation in 2016/17: The ministr y will consult with the LHINs to c raft a sustainability guide and d etermine the language and -Health Links accountability mechanisms. -LHIN and LHINs Ministry equirements for inclusion in the 2016/17 r ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

18 18 SECTION IV HEALTH LINKS WITHIN THE BROADER SYSTEM – Patients First Action Plan for Health Care a home and The ministry’s 2015 emphasizes the creation of c ommunity sector that provides a greater selection and volume of services to a wider population at home or close to home. have introduced new care approaches that extend to sectors beyond health Health Links , where local artners work to support the needs of complex patients, engaging over 1, 800 partners acr oss health, p community and social services. Therefore, Health Links valuable lessons learned and be st practices can be leveraged to support a number of ministry priorities : 1. Strengthened accountability and performance in primary care : w ork will be done to situate and ed primary n the A dvanced Health Links M odel with the work underway to support a strengthen alig care sector. 2. Understanding how Health Links would work within the Northern/Rural circumstance and ontext : over the past few months, the ministry has worked to understand what adaptions would c ess Rural/North be needed to adjust the Health Links model to addr realities. ern 3. Wider System Integration Across Sectors: the ministry will work to As a template to support ilitate and encourage greater coordination of health, social and community services through fac Health Links, by driving integration at the government level. These efforts will match and mirror the efforts at the provider level with respect to connectivity (e.g., creation of Connectivity Tables). The ministry will continue to advance these streams of work, ensuring alignment with bro ader ministry an d government initiatives and strategic directions. In addition to Health Links, the ministry is collaborating with a number of ministries to ensure alignment and coordination across areas of shared responsibility. For example, the ministry is working with the Ministry of Community and Social Services on the Dual Diagnosis Framework; the Ministries of Children and Youth Services, Community and Social Services, and the Poverty Reduction Strategy Office, Treasury Board Secretariat, on the Low Income Dental Integration Program; and the Ministries of Education and Municipal Affairs and Housing to advance work on community hubs. – SECTION V ROLE OF THE MINISTRY AND LHINS This section the role of the ministry and LHINs in driving the Advanced Health Links M odel outlines fo rward. a) Role of the Ministry – The Provincial Perspective The ministry sets the provincial direction for Health Links , ensuring alignment with critical provincial p riorities . The ministry also works in tandem w ith HQO to devel op provincial tools and supports through the best practices framework . ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

19 19 b) Role of the LHIN s providing The LHINs play a dual role of oversight to Health Links: they are accountable to the ministry for th e performance and execution of their regional Health Links Strategy; and ensure the strategy aligns with provincial priorities. As summarized below, both parties maintain vital responsibilities across program strategy, operations, . erformance management and communications p R esponsibilities at a Glance Ministry and LHIN Health Links Ministry LHIN Program Strategy . priorities p rovincial within Health Links Drives • • Sets the provincial priorities (e.g. • Sets priorities for coordination of care for regional p target population for Health erformance, c omplex patients Health Links. through ). Links • Facilitates and manages development of Health Health • Identifies opportunities to support within inks its geographical boundaries. L inks as they mature . L Operations ations Allocates funding as required to support oper • funding envelope to LHINs . • Overall ac . LHIN the ross lity planning with the LHINs . s sustain • Lead abi • within planning with Health Links Sustainability • Supports effective operations through . oundaries b p . rovision of provincial tools • its budgets and on Works with Health Links out of the Care Coordination Tool (CCT) • Roll- o perational plans in accordance with provincial and ac ross Health Links. regional priorities . Provincial • . practices best framework with HQO Supports implementation of provincial tools and • upport s. s Identifies supports • and implements regional tools and s upports . Performance Management within Health Links • Monitor s o verall program performance . Performance management of • oundaries: • Health Links. evaluation of b Conducts provincial through • Assesses performan ce of Health Links q , etc. uarterly reporting s on • Report performance to the ministry . • Conducts i nformal/formal performance mprovement planning with Health Links as i required. ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

20 20 Communications Provincial communications stakeholder • Regional communication and . • engagement . ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

21 21 SECTION VI – -FIELD SUPPORTS IN section explores the This in-field supports and tools that will help LHINs and Health Links transition to th e Advanced Health Links Model by 2016/17. a) Role of Health Quality Ontario (HQO) Thro ugh the Best Practices Framework (“The Framework”) HQO is a key partner in facilitating the a number of practical tools doption of the Advanced Health Links Model. Th e Framework will provide a -field supports, as described below, to assist LHINs and Health Links with deploying the Advanced and in Health Links Model on the ground. HQO may contact the LHINs and Health Links regarding performance and practices; this engagement is i ntended to inform the development of best practices and to help LHINs and Health Links transition from current operations to the Advanced Health Links M odel in a more focussed manner. These touch points are not part of the LHINs and Health Links accountability reporting requirements , rather, they are designed to support quality improve ment efforts within a LHIN or Health Link’s geography. (QI) Specialists i) Quality Improvement HQO’s QI Specialists are located across the province and are trained to help Health Link communities achieve their quality improvement goals. The QI Specialists work closely with the LHINs to review and analyze reports on provincial, LHIN and Health Link level data in order to: identify opportunities for improvement; support the sharing of lessons learned between Health Links; and to facilitate the spread of emerging and leading innovative practices. An overview of the cycle of data review can be found in the document “Health Links Data Reporting and Review Protocols”. ii) Best Practices Framework The Health Links’ early low rules environment fostered the culture that enabled healthcare teams to d evelop new and better ways to integrate healthcare delivery for Ontarians with complex chronic illness. As Health Links transition to the Advanced Health Links Model, LHINs and Health Links need a way to translate these ideas into scalable innovations, standardizing those best practices. The HQO Framework is a systematic process to harvest, evaluate, implement, measure and adapt in ework novative practices. The Framework is predicated on the Innovative Practices Evaluation Fram (Health Council of Canada, http://www.healthcouncilcanada.ca/accord_framework.php ), a tool d esigned to categorize practices as “emerging,” “promising” or “leading” based on four criteria: quality of evidence, impact, applicability and transferability ). Inno vative practices are identified through broad consultation with LHINs, Health Links, and analysis of Quality Improvement Plans, IDEAS project work, and Health Quality Transformation Scientific Abstracts. Innovative practices are to be considered for large scale implementation are reviewed by the Clinical Reference Group (CRG) comprised of subject matter experts in Health Links, academia and representatives from across the provinc e. -oriented, functional body designed to assess the The CRG, a key element in the Framework, is an action uality of evidence, impact, applicability and transferability of existing practices within Health Links for q ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

22 22 the purpose of identifying suitability and readiness for spread. By consistently and rigorously following the Innovative Practices Evaluation Framework, the CRG will inform recommendations and advise HQO in the creation of implementation packages that will simplify and accelerate the uptake in Health Links that have a similar context and need. provincial A knowledge translation strategy will be developed for all practices endorsed for pan- discussion and shared learning in the Health Links Community of mplementation. The strategy includes i ice (CoP), reference materials, tools, resources, and local support from the regionally based HQO QI Pract Specialists. The measurement plan ensures that key indicators are monitored and practices adapted to meet HL goals. Community of Practices (CoP) iii) The Health Links CoP is designed to accelerate the identification and spread of innovative practices ; and a group of LHIN and Health Link participants who share a passion for improving the care of Ontarians is with complex/high needs. The CoP interacts regularly to learn how better to care for Health Links patients and their families. The H ealth Link CoP is intended to achieve the following: • Build inter -link relationships ; • Learn and develop improved practices ; Carry out tasks/project work ; and • ledge . • Create new know The Health Links CoP meets regularly through webinars (see www.HQOntario.ca Events), is supported the QI Specialists, and provides reference materials, resources and tools on the HQO website (see by Qua www.HQOntario.ca lity Improvement – Health Links). s key best practices to be developed in 2015/16 HQO’ • Identification of HL patients • Coordinated care planning • Consent, privacy, da ta sharing • Building cross sector teams • Transitions in care • Palliative and end of life care • Persons with mental health and addictions conditions b) Coordinated Care Tool (CCT) The CCT is an electronic solution that will allow Health Link clinicians to create, maintain and share c oordinated care plans and exchange secure messages quickly and easily within a patient’s circle of care. The detailed requirements for CCT were developed in partnership with HQO through extensive consultation with LHINs and Health Links in 2013 and 2014. CCT leverages the ministr y’s existing and the Integrated Assessment investment in the Community Care Information Management (CCIM) ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

23 23 s by allowing Health Link clinicians working across the circle of care to access Record (IAR) system coordinated care plans. A proof of concept projec t is currently underway and a lead vendor (Orion Health Ltd.) has been secured to deliver CCT in partnership with Health Links, under the ministry’s oversight. The main goal of this project is to determine whether CCT addresses the core Health Link needs identified and help determine what improvements are necessary , going forward. To that end, CCT is being implemented in a flexible way with the ministry, LHIN and vendor working with each participating Health Link to help Health Links optimize their use o f CCT to support existing care coordination models. The proof of concept project is taking place from January to December 2015. 2015, 17 Health Links from 9 LHINs are participating in CCT: As of September • Wave 1: Three Health Links have been implementin g CCT since the beginning of the year . • Wave 2: Four Health Links are also at advanced stages of implementation and are forecast to begin using CCT in November . • Wave 3: Ten additional Health Links have recently begun working with the ministry and vendor. Wave 1 and 2 Health Links have also contributed over two dozen clinicians to a user working group that provided detailed feedback on early iterations of CCT. Together, the user working group participants provided over one hundred unique suggestions for imp rovement, the majority of which will be incorporated and implemented for the proof of concept this year. Two major improvements include: • Secure messaging in CCT has been enhanced in a number of ways, such as the ability for clinicians to more easily rece ive and send updates about changes made to patient care plans ; and, • An interface between CCT and an Electronic Medical Record (EMR) will be piloted by one Health FHT so Link’s main that care plans can be more easily created and updated by clinicians in the FHT for sharing with other clinicians in the Health Link. The proof of concept will be evaluated to measure the adoption, use and benefits of CCT, and uncover opportunities for improvement. The evaluation will be one of the key inputs informing the best approach to meet Health Link needs beyond the proof of concept. The ministry will also consider how CCT fits into a refreshed ehealth strategy for Ontario, called eHealth 2.0. The ministry will ensure that Health Links are engaged throughout the proces s and expects that more information on future direction for CCT will be available early in 2016. Given the progress being made on CCT, 2015 /16 Health Link funding includes a more stringent approval process for LHINs who wish to use Health Link funding to pursue interim care coordination solutions. This is being done to ensure that any investments in interim solutions are appropriate given the provincial work underway, while providing opportunities to evaluate those systems in a comparable way to CCT. ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

24 24 SECTION VII – CONCLUSIONS AND MOVING FORWARD This Guide represents the beginning of the work to move the Advance d Health Links Model forward . O ver 2015/16, the ministry will engage LHINs and Health Links in the development and execution of an provide both LHINs and Health Links with the tools needed to transition to implement ation plan that will Advanced Health Links Model in 2016/17. The plan will be collaborative and rely on the collective the efforts of the ministry, LHINs, Health Links, HQO and the sector to marshal resources to continue to to serve all of Ontario’s complex patients. scale and spread operations Who to Contact Direct any questions about the content in the Guide to your Health Links LHIN Lead or email the ministry . [email protected] Health Links Team at ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

25 25 APPENDIX A: SUMMARY OF RCE AND HSPRN FINDINGS foundational work done through the RCE and HSPRN significant overlap in terms of The has shown hallenges and successes. c : October 2013- March 2014 Health Links RCE RCE The conducted from October 2013 to March 2014 was an important first step in understanding ether Health Links were making inroads to serving the complex target population and to gauge wh Health Links progress. The RCE foc patients were being identified, how their care was being coordinated, and ussed on how ow that care contributed to their overall experience: h • Health Links were proving to be a useful interface for providers and were facilitating care c oordination ; rs and organizations within Health Links were making use of their networks to ensure that Provide • are was being well planned and this was having a good impact on transitions for patients ; c Health Links had taken the concept of heightened patient engagement to hea rt, involving patients • n ot only in their care but in the design of the Health Link ; and , • In the absence of a common definition for complex patients, Health Links faced stumbling block s w hen initially defining and identifying their target population . Whil e Health Links were resourceful in utilizing available information to help identify their target population , it was a blind spot that warranted provincial guidance. - January 2015 HSPRN : November 2014 The HSPRN research RC E that early Health Links results were promising confirmed the findings from the nd were approaches. Some of the greatest early successes were in fostered by innovative local a improvements in patient -centred care through the provision of coordinated care and communication between provide rs, as captured bel ow. Early Successes • Creation of virtual networks - an achievem ent which led to greater collaboration between providers acilitating care delivery within the Health Link and beyond. f • Improved coordination of care through the creation of common care plans and communication between p roviders. • Enhanced patient experience through participation in care planning. • Improved access to primary care. • Small scale improvements in health outcomes for high users – including reductions in ED use and hospital dmissions. a Conclusions Health Links took advantage of a low rules environmen • t to improve care for complex patients. • Successes have been small in nature but show opportunities for scale up and spread across the province. • Not all Health Links have been equally successful: o Health Links in urban settings and or high socio -economic are as are performing better. o As a result, integration of clinical and broader social services in rural and lower socio -economic p opulation will be critical for success in those areas • Further evaluation of patient groups through Health Links is required to understand conditions necessary f or scale up and the growth of Health Links . ________________________________________________________________________________________________________ Guide to the Advanced Health Links Model

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