The planned changes in the way health care is delivered in Ontario are moving forward. Part of the plan is to integrate services provided by the various types of health organizations. There are presently three integration strategies being pursued by the Central East Local Health Integration Network (CE LHIN) to which Scarborough belongs: (1) Hospitals and Community Health Services Integration, (2) Small Rural Northern Hospital Transformation, and (3) Creation of Health Links. So, what exactly is a Health Link?
Health Links are a new model of care planning and care delivery at the clinical level where all health service providers in a community, including primary care, hospitals, Long Term Care and community care are working together to best treat the patient. Participation in Health Links is voluntary on the part of providers. The onus is for the providers to collaborate and develop co-ordinated care plans for the patient at lower cost by preventing unnecessary visits to Emergency Departments or extended hospital stays. Primary care involvement is mandatory, and one of the providers will act as the co-ordinator of the Link. The Link will have Information sharing systems among its providers. The Health Links will report to their LHIN. The initial focus will be on patients with high needs, for instance a person with severe heart failure and chronic obstructive pulmonary disease who has early dementia. Health Links support the LHIN’s goal of Community First.
Factors determining Health Links include: (1) Patterns of referral between primary health care to specialist care (based on data developed by the Institute for Clinical Evaluation Sciences). (2) Simplicity of administration, i.e. creation of the fewest possible Health Links to enable effective collaboration and integration. (3) Manageable size to ensure physician engagement and relevance. (4) Standardization and efficiency without the creation of unmanageable geographic and complex networks.
The CE LHIN has divided Scarborough into two areas for the purpose of establishing Health Links: (1) Scarborough South and (2) Scarborough North. Here is some interesting information provided by the LHIN.
Scarborough South Health Link
Total Population 451,045
Emergency Dept. visits per 1,000 population 419.6
Admissions per 1,000 population 50.1
# of Primary Care Physicians per 1,000 pop. 0.4
High Users 4750
Total Inpatient (acute) High Users 1197
Total Ambulatory (ED) High Users 3894
Admissions 57.0%
Emergency Department 62.3%
LHIN funded Health Service Providers (Not Exclusive)
The Scarborough Hospital – General
Centenary (RVHS)
Central East CCAC
Pinewood & Destiny Manor Addictions (Lakeridge Health)
Yee Hong Centre for Geriatric Care
Carefirst Seniors & Com. Serv. Assoc.
Momiji Health Care Society
TAIBU Community Health Centre
TransCare Community Support Services
Scarborough Centre for Healthy Communities
St. Paul’s L’Amoreaux Centre
Potential Primary Health Care Partners
(FHG = Family Health Group, FHO = Family Health Organization)
Scarborough Medical FHO
Neilson (FHO)
Rouge Valley FHO
Surrey FHG
East GTA (FHG)
East GTA Sixth FHO
One-Stop Medical Centre FHG
22 other FHG/FHO’s
Scarborough North Health Link
Total Population 176,772
Emergency Dept. visits per 1,000 population 327.5
Admissions per 1,000 population 45.0
# of Primary Care Physicians per 1,000 pop. 0.7
High Users 1852
Total Inpatient (acute) High Users 468
Total Ambulatory (ED) High Users 1209
Admissions 36.6%
Emergency Department 31.0%
LHIN funded Health Service Providers (Not Exclusive)
The Scarborough Hospital Birchmount
Central East CCAC
Pinewood & Destiny Manor Addictions
Scarb. Centre for Healthy Communities
Yee Hong Centre for Geriatric Care
Hong Fook
Carefirst Seniors & Comm. Serv. Assoc.
St. Paul’s L’Amoreaux Centre
TransCare Comm. Support Serv.
Momiji Health Care Society
Potential Primary Health Care Partners
North East Scarborough FHO
Bridlewood Medical Clinic FHG
Comprehensive Care Group
East GTA First FHO
East GTA FHG
Scarborough FHO
Agincourt FHG
14 other FHG/FHO/s
In summary, a Health Link is an integrated model of care that focuses on the chronic needs of the complex patient population. Working in partnership with patients, care givers, primary care providers and specialists, a Health Link tries to shift the care of these chronic conditions into the community rather than to hospitals. Patients in a Health Link should encounter higher co-ordination and self-direction in their care.
Your local CARP chapter will keep their eyes on future developments in the integration process. If you have any particular concerns, please forward them to [email protected].
