Ontario’s Health Links initiative is a “big manoeuvre” in a complex provincial system, acknowledges Helen Angus, associate deputy minister with the transformation secretariat of the Ministry of Health and Long Term Care (MOHLTC).

The initiative aims to facilitate coordination of care at a local level for high needs patients. It comes in the wake of the province’s primary care reforms and the introduction of accountability agreements with hospitals.

After a selection process in late 2012, the ministry received business plans earlier this month from the first 19 of an anticipated total 77 Health Links.

Hoping to provide better care for the top 1 to 5% of users

One of the goals of the initiative is to provide better care for the 1% to 5% of citizens who, research has indicated, are high users of health care. The focus is to be on the subset who are high users with multiple chronic conditions and on senior citizens. The definition and identification of high users will vary at the local level but might include, for example, a person with severe heart failure and chronic obstructive pulmonary disease who has early dementia.

It also aims to reduce costs, particularly expensive hospital visits, based on the assumption that many of these patients’ hospital emergency ward visits, admissions and re-admissions, can be prevented with better coordinated care.

Approximately 50,000 citizens are expected to be covered by each Health Link—though the population totals vary—and each Health Link reports to its Local Health Integration Network (LHIN).

The size and number of the Health Links is based on research by the Institute for Clinical Evaluative Sciences (ICES) that identified natural referral patterns between doctors and hospitals in local areas. The Health Link is supposed to provide a governance model, and a political push, for the ICES-identified groups to work together.

All Health Links are required to have physician involvement. The OMA has indicated support for the model and recently provided its members with a summary that is reproduced in the attached box.

A focus on coordination

Need for more coordination is evident, as the fragmentation and disconnects in the province’s health care system are obvious to many users. “Many patients are left to navigate the system alone, seeing a myriad of unconnected providers, who are unaware of patients’ past experiences, leading to duplication of diagnostics and care,” the ministry notes in a background document on the Health Links initiative.

The push towards better local coordination of care for high needs “complex” patients is being launched concurrently with health system funding reform and austerity measures.

Still, most observers applaud the intent of the networks, though they emphasize that “the devil is in the details”, and some warn that the limited development funding for the local groups—capped at $75,000 each—may prove inadequate to the challenge. (Once a plan is in place, each Health Link may receive up to the $1-million in one-time funding.)

The Health Links initiative, which is based on voluntary participation, is modelled in part on accountable care organizations in the United States, and similar groupings in the United Kingdom and Australia and New Zealand.

While each Health Link has to provide baseline data and develop measures that will allow for evaluation of the initiatives, the emphasis is on better information sharing and on innovations that allow providers to respond to local needs.

Privacy concerns about health professionals sharing patient information should not present a barrier as these issues have been clarified by the information and privacy commissioner of Ontario, Angus notes.

Further, a team within the health ministry is committed to responding in a timely fashion when individual Health Links identify real or perceived barriers to better coordination of care, she says. Barriers might include, for example, policies that appear to unreasonably limit home care for post-acute care or palliative patients. The ministry’s response will indicate how the barrier might be removed and while eliminating some barriers could be relatively straightforward, removing others could involve regulatory or legislative change,  Angus noted.

Guelph and Temiskaming among the early adopters

One of the 19 “early adopters” is a Health Link led by the Guelph Family Health Team (FHT) which, with 75 doctors as well as nurses and other health professionals, provides health care to about 100,000 of the city’s 120,000 citizens. The group’s steering committee includes the police chief, and representatives from the local hospital, the children’s aid society and the local community health centre.

Patients who incur high costs and could benefit from more coordinated care are being identified by reviewing their primary care medical charts, says Ross KirkConnell, executive director of the FHT.

He cites the example of a patient with several mental health issues and a limited income who can’t afford to get to the family doctor when symptoms become overwhelming, and so opts to take an ambulance to the hospital emergency ward.

A different way of providing care for such a patient could better suit the person and also reduce ambulance and hospital costs, he notes. “The challenge—and this is a system challenge— is not to be health care centred but to also look at poverty, transportation and disability issues,” he adds.

In the beginning, Angus does not anticipate that funding will be re-assigned among  providers and agencies, but rather that they will be more aligned, and work together.  “If a big improvement is demonstrated,” she said, there may in the future be an opportunity to redistribute money upstream to, for example, better housing for a high needs patient.

The Guelph Health Link aims to assign one person in primary care, likely a doctor or a nurse, to be the “go-to person” who can keep in touch and intervene as necessary on behalf of each patient who is deemed high needs and would benefit from more coordinated care. “’If there was just someone I could call’ is a statement that we hear from patients a lot,” says KirkConnell.

The approximately 33,000 people in the Temiskaming Health Link, another one of the 19 who submitted a business plan, are spread out geographically and represent diverse populations (about 24% of the population is French speaking and 8% are First Nations.)

The Health Link is led by Le Centre de santé communautaire du Témiskaming and membership includes three hospitals, four other community health centres as well as the Northeast regional Community Care Access Centre, the public health unit and representatives from the Canadian Mental Health Association and seven local nursing homes, says Jocelyne Maxwell, executive director of the CHC.

Maxwell explains that a group called the Temiskaming Collaborative Health Providers predated the call for the formation of health links. The group’s aim was to better coordinate care and, although all were health providers, “we spent a good year just trying to understand what each other did,” she said.

The group had launched plans for joint human resource plans, and welcomed the Health Link initiative, because it provided an initial target patient population to focus on. “The exciting thing about Health Links is that it forces us to step back and really think about how to provide health care differently, as partners in a system with joint responsibility.”

Importantly, patients are included in this process, she says. “After all, they are the ones who can best identify the challenges they face.”

Scaling up across the province will be a challenge

Rick Glazier, who co-authored the ICES research (not yet published) that laid the groundwork for the configuration of the Health Links, said the main challenge facing the voluntary organizations will be to prevent unnecessary, costly hospital admissions. “Let’s face it, preventing one visit to a primary care practitioner is not going to save much money.”

Getting providers together to improve the quality of care is a great ideas, says Adalsteinn Brown, Director of the University of Toronto’s Institute for Health Policy, Management and Evaluation. The challenge will be “what to do next, how to get from one side of the province to the other—how to scale up— and how to get the evidence base” to support an authoritative evaluation.