Health Link helps patients with complex needs

As published in The Erin Advocate

A new effort to ensure that seniors and patients with complex problems don’t “fall through the cracks” of the health care system has been announced for rural Wellington.

A Health Link partnership will be led by the Family Health Team in Mount Forest, but it will be of equal benefit to residents of Erin, Hillsburgh, Rockwood and the rural area served by the East Wellington Family Health Team (EWFHT).

“We can do better with the health care dollars we are provided,” said EWFHT Executive Director Michelle Karker. “There are areas where we know we are lacking. There will be local coordination of records and we will look at all the services that are needed for a patient to be healthy.”

That includes not only treatment from doctors and nurses, but needs such as transportation, in-home support for housekeeping and personal care, addiction treatment, mental health counselling, support groups and video consultations via the Ontario Telemedicine Network.

“Health Links break down barriers for Ontarians, making access to health care easier and less complicated,” said Deb Matthews, Minister of Health and Long-Term Care, announcing the Wellington initiative. “By encouraging local health providers to work together to co-ordinate care for individual patients, we’re ensuring our highest needs patients – seniors and those with complex conditions – get the care they need and don’t fall between the cracks.” 

Complex patients represent up to five per cent of Ontario’s population, but use two-thirds of the health care budget, so efficiency in treating that group can help the entire system. 

Joan Fisk, Chair of the Waterloo Wellington Local Health Integration Network (LHIN), said the new Health Link for rural Wellington will make a “significant difference”, by providing “one coordinated care plan that reflects their entire health situation.”

Family Health Teams are already working in partnership with organizations such as the Community Care Access Centre (CCAC), but the goal is to provide more comprehensive service and smooth transitions. 

Health Links bring together professionals in a given geographic area, including primary care providers, specialists, hospitals, home care, long-term care and community agencies. At the time a patient has contact with the system, it will be an opportunity to see what other services they might need.

The plan is to reduce avoidable emergency department visits and unnecessary hospital admissions and readmissions, provide same day or next day access to primary care, reduce referral time to specialists and home care, and reduce the number of Alternative Level of Care (ALC) patients – those taking up acute-care beds in hospitals while they wait to be discharged to other facilities. 

A recent study found that 75 per cent of seniors with complex conditions who are discharged from the hospital receive care from six or more physicians and 30 per cent get their drugs from three or more pharmacies.

A patient my still need to be seen by several doctors, but the plan is to have a common database of information on each patient, so that procedures such as X-rays and blood tests won’t be repeated unnecessarily.

“Patients need the health care system to respond quickly and seamlessly to their health care needs, especially those with complex conditions,” said Susan Eng of CARP (formerly the Canadian Association of Retired Persons). 

“Health Links is a major step towards a much needed comprehensive approach to care. CARP has called for a One Patient model – a comprehensive, well-coordinated, and integrated health care system that is easy to navigate and considers the full spectrum of health care needs as people age.”

If a patient lives in the Wellington territory but has their family doctor or specialist in another area such as Georgetown, Guelph or Orangeville, it is intended that there will be a seamless sharing of records among Health Link centres so that information is available to every health provider that needs it.

While the Health Link has been approved, the Ministry of Health will still need to approve a business plan to ensure that all the details have been worked out.

“Health Links present an exciting opportunity to collaborate and work together with our community health partners, including primary care, to put patients first,” said Liz Ruegg, President and CEO, Headwaters Health Care Centre. “This enhanced model of care will ensure higher-quality of care and improved access for our communities.”