Don't wait for the government - create your own Health Link

Health Quality Ontario hosted a conference recently focused on Health Links, the Ontario Ministry of Health and Long-Term Care program that is intended to provided co-ordinated care to the 5% of patients who account for two-thirds of all healthcare costs. Health Links are designed to link the patient, family physician, hospital, long-term care home and community organizations in a co-ordinated effort to improve care.I followed the conference closely via social media, as I have followed the program from afar for the past few years. The underpinnings of Health Links make great intuitive sense for these vulnerable patients. Giving patients an individualized and co-ordinated plan, having care providers who ensure the plan is being followed, ensuring the patients are taking the right medications, and having a care provider they can call who is familiar with their situation. These are all incredibly attainable and important to successful care for these patients. Health Quality Ontario has developed fantastic documents available on their website, and many of their projects have been extremely thorough and well-done.But here’s my concern: The Health Links program was initially piloted in 2012 in only selected practice areas, and has been described as a success by those involved. Let’s assume the anecdotes are correct and the program does improve outcomes. Where does that leave the rest of us?Where does that leave those who haven’t been deemed worthy of access to a Health Link? Those who are restricted from joining an FHO, let alone having access to the allied health professionals in an FHT with nurse practitioners, physiotherapy, psychology, social workers, pharmacists, etc. What do the rest of us do? Do we wait for Health Links to find us?Quite frankly, physicians who aren’t in a Health Link, or an FHT or one of these privileged groups, can’t wait for the province to find us. We can try to advocate politically for our patients and practices but in the meantime, we have to make due with what we have.So let’s create our own Health Links in our offices. We don’t need a rubber stamp from the government to take similar initiatives on our own. I’ll lay out a rough guide here for you to start taking steps to improve the quality and co-ordination of care for your patients.This will be in a blog format, but I would recommend taking the aspects of these recommendations that you like, and create a standard custom form that you keep in each patient’s chart to track that they are receiving the necessary interventions.A guide to creating your own Health Links-style program1. Identify the target patients: The Health Links program identifies the 5% of top users in our system, so do the same for your practice. Identify your 5% of patients who you feel are the highest risk for admission to hospital, highest risk for deterioration, and/or have the highest need of resources (either health-related or related to social determinants of health).2. Identify all relevant family and caregiver contacts for the patient.3. Tell the patient and their caregivers who should be contacted with any health concern. Ensure they have both the physician’s phone number as well as any relevant home care emergency services. Make sure you are notified upon admission to hospital, discharge from hospital, and of any ER visits. Tell them what your availability is for being contacted after hours to prevent ER visits.4. Make medication reconciliation an ongoing priority. Typically these patients have multiple providers involved in their care, and medications are changing frequently. Medication lists are often out-of-date, leading to potential adverse outcomes. While we tell the majority of patients to bring all medications to all appointments, make it a MUST in your Health Links patients. Once you update their list, provide them a copy by doing a screen capture of your EMR medication list. Tell them that THIS is the list to show to healthcare providers (the list the pharmacy gives them is often a complete mess). Tell the patient to notify you of any medication change. If they end up in hospital, they are to notify you with any medication change. Document any medication discrepancies and how they came about. Offer compliance packaging whenever appropriate. Review Beer’s criteria. Create a culture where the accuracy of their medication list is seen a top priority, and patients understand its importance. (KnowledgeIsTheBestMedicine.org is a useful resource for capable patients to track their medications.)5. Make it clear that you can offer same-day appointments whenever needed.6. Be clear whether you offer house calls or not.7. Insist on followup with family physician within 48 hours of hospital visit. Reconcile medications and review diagnostics and management plan. Ask the following questions: How or why do you think you became too sick to stay in your home? Did you see a doctor before coming to the hospital? If yes, who did you see and when? If not, why? Has anything stopped you from taking your medications? How do you set up and take your medicines every day?8. Perform a cognitive assessment: Mini-Cog, MOCA, MMSE, whatever your heart fancies.9. Perform a falls risk assessment. Every office should have a standard falls assessment that you go through with these patients. In brief, do a complete physical exam (including "Get up and Go" test), optimize vision and hearing, avoid alcohol, remove any offending medications, encourage gait aids/handrails, take regular vitamin D and do home exercises. Remove unsafe conditions in these patients' homes. Offer an OT assessment if the home environment is a concern.10. Ensure adequate home care is in place, and communicate with case manager regularly. Regularly assess whether specific home care services are needed for patients. When care is deemed no longer necessary, reassure the patient that it can be reintroduced if deemed appropriate. Here in my office, a representative from CCAC visits regularly and we “run the list” to make sure everyone’s home care is optimized.11. Confirm your patient’s health literacy. Ask them to describe their understanding of their ailments to you. As them to describe medication administration to you. The Sixth Vital Sign Program assesses a patient’s health literacy by testing their ability to interpret an ice cream nutrition label. If you learn that their literacy is not adequate, this will certainly change your approach to delivering instructions to them.12. Set attainable goals in consultation with patient and caregivers. Remember to set SMART goals (specific, measurable, achievable, realistic and timely).13. Review advance care directives on a regular basis. The patient should inform all relevant family and friends about his or her goals of care. If they wish to be deemed a DNR, offer to complete an official Do Not Resuscitate form. These can be obtained in bulk by faxing a request to (416) 327-0329. Encourage patients and their families to visit advancecareplanning.ca.14. Ensure adequate social and financial resources.15. Plan a full family meeting at least once a year (or more often if needed). Use this meeting as an opportunity to inform all family members about the relevant info that you have reviewed through your Health Links template. This will serve to make them feel supported, and provide you valuable insight into their concerns about their family member.16. Provide the patient and their family with a copy of your Health Links template. They should be encouraged to share this with other healthcare providers.So there you have it. Try to review the above topics with your “5%” and their families and caregivers on a regular basis, and they will enjoy the majority of the benefits of a Health Link immediately, rather than on the government’s time.Dr. Mario Elia is a family physician from London, Ont. He attended the University of Western Ontario for both medical school and residency. His undergraduate degree was in Life Sciences at Queen’s University in Kingston. He is a tortured fan of the Cleveland Indians, Toronto Maple Leafs, Toronto Raptors and New York Jets. You can contact him via twitter @supermarioelia. Visit Dr. Elia online at drmarioelia.wordpress.com

Don't wait for the government - create your own Health Link

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