Central East Health Links Toolkit

Coordinated Care Planning

January 2016 – Version 2

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Central East Health Links Toolkit Coordinated Care Planning

Contents Page

Background 3

1.0 Target Population 4

1.1 Health Links Indicators 5 1.2 What Health Links Will Achieve 5 1.3 Central East Health Links 6

Coordinated Care Planning Process and Practice

2.0 Introduction 7

2.1 Coordinated Care Plan 7 Components of the Coordinated Care Plan 7

2.2 Defining the Stages of the Coordinated Care Plan 8 2.3 Care Coordination Tool 8 2.4 Coordinated Care Planning Framework 9

2.5 Business Process Map and Operation Guidelines 10 2.6 Roles and Responsibilities 11

Identify and Invite 12

3.0 Identifying the Patient 12

3.1 Ministry of Health and Long-Term Care List of High Cost Conditions 13 3.2 Educating the Patient/Caregiver 13 3.3 Determining Care Team Participants 14

3.4 Obtaining Consent 14

Interview 14

Coordinated Care Conference 15

5.0 Coordinated Care Conference Objectives 15

5.1 Organizing a Coordinated Care Conference 15 5.2 Facilitating a Coordinated Care Conference 15

5.3 Coordinated Care Conference Patient Experience Survey 16 5.4 Sharing the Coordinated Care Plan 16

Inter-Disciplinary Team Management 16

Additional Resources 16

Central East Health Links Toolkit Coordinated Care Planning

Who should use this Toolkit?

The Central East Health Links Toolkit is for any individual/organization who will be participating in coordinated care planning.

What is the purpose of the Toolkit? The Central East Health Links Toolkit will describe the Coordinated Care Planning Framework

and provide front line staff with the tools and resources available to support the creation and maintenance of Coordinated Care Plans with an inter-disciplinary care team which includes the patient/caregiver as equal partners in the patient’s care.

Background

A Health Link is a local health network consisting of patients, caregivers, Health Care Providers, and Community Support Service agencies that are committed to working together to improve

the health outcomes for patients with complex health care needs. The collaboration in care will result in Care Plans that are patient-centred, ensuring that the patient’s goals are effectively met and that they have smooth transitions between care providers.

The templates and resources provided are to be used in accordance to the

Personal Health Information Protection Act (PHIPA), 2004 and organizational policies.

All Health Information Custodians are individually responsible for the Personal Health Information (PHI) of patients collected, used and disclosed as a result of the use of these templates.

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Canada’s aging population generates growing demands on the health care system. Complex

health issues, financial strain, and systems of care silos are creating challenges for those receiving the care, their caregivers, and health and social service providers. Health Links seek to improve the quality of care and the patient experience through the health care system, while

reducing waste at the system level to create a collaborative network of care.

1.0 Target Population

The Health Links target population focuses on the top 5% of Ontario’s Complex patients. The common process for identifying Health Links populations is patients with four or more chronic/high cost conditions including:

Vulnerable populations (a focus on mental health and addictions

conditions, palliative patients, and the frail elderly)

Economic characteristics (low income, median household income,

government transfers as a proportion of income, unemployment)

Social determinants (housing, living alone, language, immigration, community and socials services etc.)

Complex, high needs patients

In addition, patients can be identified as complex and appropriate for Health Links based on clinical judgement.

This specific population of patients accounts for 65% of Ontario health care expenditures:

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Tools and Resources:

Ministry of Health and Long-Term Care Target Population Questions &

Answers 1.1 Ontario Health Links Indicators

Health Links are driven by 11 indicators put forth by the Ministry of Health and Long-Term Care.

Operational Indicators

Status

1. Ensure the development of Coordinated Care Plans for all

complex patients

2. Increase the number of complex patients with regular and

timely access to a primary care provider

Currently being reported by Health Links

and LHINs through the Health Quality

Ontario enabled Quality Improvement

Reporting & Analysis Platform (QI-RAP)

tool.

Outcome Indicators

3. Reduce the number of 30 day readmissions to

hospital

4. Reduce the number of ED visits for patients with

conditions best managed elsewhere

5. Reduce time from referral to home care visits

6. Reduce unnecessary admissions to hospitals

7. Ensure primary care follow-up within 7 days of discharge

from an acute care setting.

8. Achieve an ALC rate of 9 per cent or less

Ministry has conducted analysis of these

indicators at the population level for

approved Health Links areas.

Over the course of 2015/16 the Ministry

will provide further information on how

these results will be shared with LHINs

and Health Links.

The focus will be on indicators 3-5 as

these are more directly relevant to

Health Links.

9. Reduce time from primary care referral to specialist

consultation.

10. Enhance the health system experience for complex

patients.

11. Reduce the average cost of delivering health services to

patients.

Indicators 9-11 are under development.

1.2 What Health Links Will Achieve

For Patients/Caregivers

An individualized Care Plan that fosters and encourages a comfortable environment for

two-way communication between a patient and their providers Smoother transitions between care providers Patient-provider relationships built on trust and respect

Improvement to the patient’s journey through the health care system Reduced wait times, visits to the emergency department, and unnecessary hospital

admissions

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Haliburton County and City of Kawartha Lakes Health Link

Northumberland County Health Link

Durham North East Health Link Durham West Health Link

Peterborough Health Link

Scarborough North Health Link Scarborough South Health Link

For Health Care Providers

Collaborative care that effectively meets patient goals Improving patient safety by reducing risks (i.e. relating to medication errors, incomplete

referrals, and multiple treatment regimens), and dissatisfaction associated with fragmented care

Increased access to up-to-date information about your patient Improved ability to communicate and problem solve with an inter-disciplinary, multi-

organizational team

The opportunity to work together to create one, comprehensive Coordinated Care Plan by providing the infrastructure needed for successful coordination of care (e.g. tools,

processes, established accountabilities, electronic information system).

1.3 Central East Health Links

The Central East Health Links Project Management Office is housed at the Central East

Community Care Access Centre. The Project Management Office allows for a for a standardized approach across the seven Health Link Communities within the Central East LHIN, while

creating a unique and customized experience to coordinated care planning that is appropriate for the population of complex patients wthin each Health Link.

The Central East Local Health Integration Network (CE LHIN) has organized the Central East region into seven individual Health Link Communities:

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Coordinated Care Planning Process and Practice

2.0 Introduction

It is anticipated that the Central East Health Links will achieve improved health outcomes for patients with complex heath care needs by facilitating the coordinated care planning process.

Coordinated care planning refers to the process of engaging all participants in a patient’s Care Team, including the patient and caregivers, to ensure a holistic, patient-driven approach to care.

Coordinated care planning includes:

conducting Care Conference(s)

creating an individualized Care Plan based on the patient’s expressed goals and needs continuous updating and follow-up as required and as pre-determined by the patient and

their Care Team

The result of this process will be the Coordinated Care Plan that accompanies the patient

throughout their health care journey.

2.1 Coordinated Care Plan

The Coordinated Care Plan is a standardized form that was created by a cross-sector,

inter-disciplinary focus group with province-wide representation in conjunction with the Ministry of Health and Long-Term Care (MOHLTC). The Coordinated Care Plan is a written or electronic plan created and maintained by the patient/caregivers and their Care Team, which may include

LHIN funded and non-LHIN funded Health Service Providers (HSPs) and Community Support Service (CSS) agencies.

Components of the Coordinated Care Plan

My identifiers My Care Team My health issues

My known, current allergies and medications My plan to achieve my goals for care

My situation and lifestyle My recent health assessments My most recent hospital visit

My other treatments My current supports and services

My appointments and referrals

The Coordinated Care Plan outlines the patient’s short and long-term needs, recovery goals and care coordination requirements and identifies who is responsible for each part of the Care Plan.

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2.2 Defining the Stages of the Coordinated Care Plan

There are four stages of development for a Coordinated Care Plan as defined by the Central East Health Links Project Management Office.

1. Initiated Coordinated Care Plan: Patient has been identified and invited to participate

in a coordinated care planning process, including the use of the Coordinated Care Plan; consent has been obtained.

2. Basic Coordinated Care Plan: Coordinated Care Plan has been developed with the patient/caregiver and two (2) or more Health Care Providers and contains a plan for one

(1) or more health issues.

3. Active Coordinated Care Plan: Some or all sections of the Coordinated Care Plan have been completed to meet the needs of the patient and their Care Team; a Lead Care Coordinator has been identified; plan to support the continued use of the Coordinated

Care Plan has been established; and the most recent copy of the Coordinated Care Plan has been shared with all Care Team participants.

4. Closed Coordinated Care Plan: Patient has deceased or consent for the Coordinated

Care Plan has been revoked.

Tools and Resources:

Health Care Provider Brochure Central East Health Links Planning Your Care Patient Workbook

Coordinated Care Plan (v1.0.0) Coordinated Care Plan User Guide (v.1.0.0)

(This document describes how the Coordinated Care Plan template is intended to be used and the purpose of each individual field.)

2.3 Care Coordination Tool In the spring of 2015, the Ministry of Health and Long-Term Care (MOHLTC) received approval

to conduct a Care Coordination Tool (CCT) Proof of Concept (POC). Orion Health was selected by the MOHLTC as the vendor to support Health Links around the province by providing

software and services needed to deliver the CCT. The goal of the CCT is to enable efficient and effective care coordination across Health Links

partner organizations within a patient’s Care Team through the provision of a technology-enabled Coordinated Care Plan and secure messaging. The CCT allows participating

organizations to create and view Coordinated Care Plans for their patients by leveraging the Integrated Assessment Record (IAR) provincial assessment repository.

The CCT will allow participating Care Team members to:

Gather reliable information about patients, including patient goals so that this information can be known to the entire Care Team;

Create, maintain, and share standardized, high-quality Coordinated Care Plans so patient care can be delivered in the most effective and appropriate way; and

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Communicate quickly and securely with providers across different sectors of the health

system to manage issues as they arise.

The Central East Health Links Project Management Office (PMO) is providing support to the

Peterborough Health Link, which was selected by the MOHLTC for Wave 1 of the provincial POC and the Durham North East Health Link, selected for Wave 3. The Peterborough Health Link

went live on September 25, 2015 and the Durham North East Health Link went live on November 17, 2015. The PMO is continuing to support the implementation and spread of the CCT in the Peterborough and Durham North East Health Links.

Lessons learned from both waves have been submitted to Orion Health and the MOHLTC for

review. In addition, the MOHLTC has contacted Power Analysis, a third party evaluator, to conduct an evaluation of the CCT. The purpose of the evaluation is to understand the project’s

successes and challenges, and to help inform how to proceed with the CCT beyond the POC. The evaluation component is expected to be complete by March 2016.

2.4 Coordinated Care Planning Framework The Central East Health Links strive to create a standardized approach to coordinated care

planning across the seven Health Link Communities. The Coordinated Care Planning Framework aims to provide this standardized approach which can then be adapted by each Health Link and

its’ stakeholders. The Central East Health Links have created a number of tools and resources to support each step of the framework. Please note that these are optional tools and resources that may be used when appropriate.

Coordinated Care Planning Framework

Legend

CCC = Coordinated Care Conference

CCP = Coordinated Care Plan

Complete CCP demographics

Conduct patient interview/

explore patient’s goals and

needs

INTERVIEW

Organize CCC

Invite care team

Conduct CCC

Determine action plan based

on patient’s expressed goals

and needs

Determine Lead Care

Coordinator

Determine communication and

follow up strategy

COORDINATED CARE

CONFERENCE

Lead Care Coordinator shares

completed CCP and consent

with care team/securely

stores original copies

Proceed with actions and care

as determined during CCC

Track/assess progress and

update CCP as per the

communication and follow up

strategy

INTERDISCIPLINARY TEAM

MANAGEMENT

Identify patient/ Patient self-

identifies

Engage patient through

discussions about coordinated

care planning (including

Coordinated Care Plan and

Coordinated Care Conference)

Decide care team participants

Obtain consent

Patient/PoA/SDM

Initiating Provider

Lead Care

Coordinator

Care Team Participants

IDENTIFY AND INVITE

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Important note: Although partners within each Health Link will be unique in their processes,

the Coordinated Care Plan and the appropriate Health Links Consent Form must be used.

2.5 Central East Health Links Business Process Map and Operational

Guidelines The Central East Health Links Business Process Map and Operational Guidelines were developed to support the standardization of the coordinated care planning processes being developed

across the Central East LHIN. All Central East Health Links participated in developing these documents and many organizations are adapting the process maps to integrate the use of the Coordinated Care Plan and Coordinated Care Conferences into their current practices. The

Operational Guidelines serve as a mechanism for creating consistent coordinated care planning practices across organizations by incorporating lessons learned from early adopters within

Central East and the common practices currently in place.

Central East Health Links Business Process Map

Tools and Resources:

Central East Health Link Coordinated Care Planning Framework

Central East Health Links Coordinated Care Planning Business Process Map Central East Health Links Operational Guidelines

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2.6 Roles and Responsibilities

Please note that these lists are not prescriptive or all-inclusive.

Patient/Caregiver Responsibilities

Consent to a Coordinated Care Plan if in agreement

Identify who is currently involved in their care Share their health care and lived experience

Engage in exploring their goals and needs Participate in Coordinated Care Conference(s) Work towards achieving their goals and needs as per the Coordinated Care Plan

Adhere to the communication and follow-up strategy as determined during the Coordinated Care Conference

Inform providers that they have a Coordinated Care Plan

Initiating Provider: An organization or individual that identifies and engages the patient in

coordinated care planning. The initiating provider, in some cases, may not be determined as the Lead Care Coordinator.

Responsibilities

Obtain consent from the patient to proceed with a Coordinated Care Plan Work with the patient to identify their Care Team

Conduct patient interview Begin to complete the Coordinated Care Plan Support the patient in defining their goals and articulating their needs

Organize and facilitate the Coordinated Care Conference, which will include inviting Care Team participants to be involved in the patient’s Coordinated Care Plan

Lead Care Coordinator: The Lead Care Coordinator must be a Health Information Custodian (HIC) and should be chosen with the patient’s preference considered as first choice. Ideally, the

role of the Lead Care Coordinator will be assumed by the organization/individual who is “most responsible” for the care of the patient and/or who is anticipated to be involved in the patient’s

care for the longest span of time. The Lead Care Coordinator may be selected at the beginning of the care planning process when the patient has been identified or may be determined during a Coordinated Care Conference. The Lead Care Coordinator may change throughout a patient’s

healthcare journey.

Responsibilities

Store the most current copy of the consent and Coordinated Care Plan and share copies

with the Care Team Collect pertinent updates from the Care Team

Share updates with the Care Team Adhere to the communication and follow-up strategy as determined during the

Coordinated Care Conference Work collaboratively with the patient and the Care Team to assist the patient in

achieving their goals identified in the Coordinated Care Plan

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Care Team Participants: The Care Team includes organizations/individuals that the patient

has consented to contribute to and be involved in their Coordinated Care Plan. Participants do not have to be Health Information Custodians (HIC) and will include both formal and informal care providers.

Responsibilities

Participate in a Coordinated Care Conference Complete sections of the Coordinated Care Plan

Adhere to the communication and follow-up strategy as determined during the Coordinated Care Conference

Work collaboratively with the patient and the Care Team to assist the patient in achieving the goals identified in the Coordinated Care Plan

Identify and Invite 3.0 Identifying the Patient

Patients will primarily be identified by providers, but it is suggested that processes be

developed to support patients who self-identify for a Coordinated Care Plan. The organization that identifies the patient is considered the Initiating Provider.

On August 12, 2015, the Ministry of Health and Long-Term Care shared a standardized Health Links target population. The target population will continue to focus on the top 5% of Ontario’s

Complex patients and the common process for identifying Health Links population includes:

Vulnerable populations (a focus on mental health and addictions conditions, palliative patients, and the frail elderly)

Economic characteristics (low income, median household income, government transfers as a proportion of income, unemployment)

Social determinants (housing, living alone, language, immigration, community and

socials services etc.)

Complex, high needs patients

Patients can be identified as complex and appropriate for Health Links based on clinical judgement.

Tools and Resources:

Central East Health Links Identifying the Patient Check List

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3.1 Ministry of Health and Long-Term Care List of High Cost Conditions

3.2 Educating the Patient/Caregiver

Coordinated care planning may be a new concept for patients/caregivers. Resources for

patients and their caregivers have been created to explain Health Links, coordinated care planning and how patients may benefit from having a Coordinated Care Plan.

Tools and Resources:

Coordinated Care Planning Information Sheet Script for Introducing Coordinated Care Planning

Script for Introducing the Coordinated Care Conference Coordinated Care Planning Care Team Cover Sheet

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3.3 Determining Care Team Participants Once the patient/caregiver has agreed to participate, the initiating provider will support the

patient in deciding who will be a part of their Care Team. Ideally, the Care Team will involve the patient and their caregiver as well as all Health Care Providers (including primary care) and

Community Support Service agencies involved in the patient’s care. At this point of the care coordination journey, the Care Team participants should be documented in the Coordinated Care Plan.

3.4 Obtaining Consent The Central East Health Links Coordinated Care Plan Multi-Agency Consent for the collection,

use, and disclosure of Personal Health Information forms are unique to each Central East Health Link. The consent form must be signed by the patient or their Substitute Decision Maker

(SDM) before proceeding with the coordinated care planning process. Successful coordinated care planning requires communication and information sharing between all members of a Care

Team including the patient and caregivers. The Central East Health Links Consent Form permits members of the Care Team to request and

release Personal Health Information with all individuals/organizations listed and consented to on the form. Additionally, the consent form states that Personal Health Information will only be

shared for purposes of planning the patient’s care and improving the health care system. Consent can be refused or withdrawn at any time by contacting the Lead Care Coordinator.

Furthermore, patients can add/remove individuals/organizations at any time. The Lead Care Coordinator will be responsible for sharing the most current version of the consent with all

participants of the Care Team. Tools and Resources:

(Please note that the mandatory consent form must be signed by patients)

Durham North East Health Link Multi-Agency Consent Form Haliburton County and City of Kawartha Lakes Health Link Multi-Agency Consent Form

Northumberland County Health Link Multi-Agency Consent Form Peterborough Health Link Multi-Agency Consent Form

Scarborough South Health Link Multi-Agency Consent Form Scarborough North Health Link Multi-Agency Consent Form

Interview

The patient interview is intended to capture a holistic understanding of the patient and support

them in identifying goals and articulating their needs. The provider guides the patient through discussions about their experiences in order to inform the patient’s Coordinated Care Plan.

Health Care Providers may use their existing methods and tools to conduct the patient interview or conduct the interview as part of their existing assessment.

The Central East LHIN Self-Management Programs offer self-management training to patients

and caregivers, as well as offering Health Care Provider training. If you would like further information please visit healthylifeworkshop.ca or call 1-866-971-5545 ext. 5000.

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Coordinated Care Conference

The purpose of the Coordinated Care Conference is to bring together the Care Team to share information and to collaboratively create an action plan for meeting the patient’s expressed

goals and needs. The Coordinated Care Plan will be finalized at the Coordinated Care Conference and will be shared with the Care Team along with the signed consent.

When possible, the patient should be present at the Coordinated Care Conference. If they are not able to attend or choose not to attend, efforts should be made to ensure that a caregiver is

present and that the patient’s goals are understood and clearly recorded in the Coordinated Care Plan as a result of the patient interview.

5.0 Coordinated Care Conference Objectives

To further develop and finalize a patient-centred Coordinated Care Plan To establish and clarify roles and responsibilities of the Care Team in supporting the

success of the Coordinated Care Plan, including identifying the Lead Care Coordinator To align the health care goals of the providers with the patients’ goals To determine a communication and follow-up strategy

5.1 Organizing a Coordinated Care Conference

When scheduling a Coordinated Care Conference, it may be helpful to offer different options to

accommodate Care Team participants (e.g. in-person or by teleconference/videoconference). There is no prescribed number of Care Team participants that must attend for a conference to take place. Care Team participants who are unable to attend the conference should still receive

a copy of the Coordinated Care Plan.

Tools and Resources:

Working Together to Coordinate Care with Patients

Central East Health Link Partner Letter Coordinated Care Conference Fax Sheet

5.2 Facilitating a Coordinated Care Conference

Steps include:

Introductions

Ensure that proper consents are in place (update if required) Remind participants about confidentiality

Present patient goals in a meaningful way Present background information (summarize recent medical history) Highlight strengths (e.g. patient efforts/ progress, family supports, recent success, etc.)

Identify challenges/explore solutions/create possibilities

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Create a communication and follow-up strategy based on the patient’s needs. These

strategies will evolve as the electronic solution (Care Coordination Tool) develops. Examples of strategies:

Updates made by Care Team participants are shared with the Lead Care

Coordinator who then records the updates on the Coordinated Care Plan and share the updated version of the Coordinated Care Plan on a predetermined basis

Teleconferences are planned bi-weekly with the Care Team

Review and summarize individual responsibilities and next steps

Tools and Resources:

Coordinated Care Conference Preparation Worksheet Coordinated Care Conference Facilitation Worksheet

5.3 Coordinated Care Conference Patient Experience Survey

In an effort to continuously improve health care processes and ensure that the patient remains in the centre of the coordinated care planning process, the Central East Health Links Project

Management Office has developed a patient experience survey to be completed by the patient/caregiver after the Coordinated Care Conference.

Tools and Resources:

Coordinated Care Conference Patient Experience Survey

5.4 Sharing the Coordinated Care Plan

Upon completion of the Coordinated Care Conference, the Lead Care Coordinator is responsible

for storing the most current copy of the consent form, completed Coordinated Care Plan, and for sharing copies of the Coordinated Care Plan and consent with all Care Team participants.

Inter-disciplinary Team Management

For a Coordinated Care Plan to be considered active, the Care Team, including the patient,

must have an established follow-up and communication strategy. The Coordinated Care Plan will be successful only when it is continuously used by the inter-disciplinary team (the Care Team) to provide care for the patient and to work collaboratively with the patient in meeting

the patient’s goals.

Updating the Coordinated Care Plan and communication with Care Team participants will be unique for each patient, as their needs and goals will differ and their Care Team will have various organizations involved. Care Team participants who are not in attendance at the

Coordinated Care Conference should be made aware of the strategies for follow-up and communication when they receive their copy of the Coordinated Care Plan and consent form.

Additional Resources

Glossary /Commonly Used Terms

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