Health Links forging new connections

Service providers wrap around the patient to co-ordinate care

John* is happier and more engaged in planning his own care since the Health Links’ process helped him to find safe and more stable housing, which had been an issue underlying all of his complex health conditions.

This is the kind of meaningful difference that Health Links aim to generate in patients’ lives.

“There’s been quite a change in (John’s) demeanor in that he went from someone who was a little hesitant to get involved in this process and now, because (his health care) providers are coming together and listening to him and really understanding his story and where he thinks he needs help, it’s changed his perspective and attitude,” says Courtney Paxton, quality improvement facilitator at the Central East Community Care Access Centre (CECCAC), who is working with the local health care organizations and primary care providers in the Peterborough Health Link.

Uniting the patient and their care providers to develop an individualized, co-ordinated care plan is a cornerstone of the provincial Health Links initiative. This innovative, collaborative approach is taking root through Local Health Integration Networks (LHINs) to better co-ordinate care of high-needs patients, such as seniors and people who have complex conditions, so they will have better health outcomes.

Peterborough is home to the first Health Link in the Central East Local Health Integration Network (Central East LHIN), with the second one being developed in Durham North East.

Christine Quinn of the Central East CCAC, which is the Health Links’ administrative lead in the region, says learnings from Peterborough will be leveraged — a move by the Central East LHIN she commends because it will help to expedite the creation of a model of care that embeds the patient’s voice and experience in the enhancement of their own care and the overall system.

“The benefit is that it certainly leads to a more sustainable model because you’re building the capacity of the (health care) partners to use a methodology that is constantly looking for improvement,” says Quinn, who is the Central East CCAC’s director of planning performance and quality improvement. “And you’re linking that strongly with the patient’s voice and the person who is truly at the centre of all of our work.

“When you have these two pieces together, it becomes less about the task of introducing a new initiative and more about creating a consistent standard of care,” Quinn says.

Wrap-around care 

Health Links is about local health care providers, including family doctors, specialists and community supports, wrapping around the patient and everyone working collectively to identify the patient’s goals and how to collaborate to meet those goals. It’s envisioned that this tightly-knit team approach will improve patient transitions within the system and generate more responsive, effective care.

As part of the Peterborough Health Link’s process, patients and caregivers have been engaged early on to share their stories and help identify opportunities for improvement. Caregivers are also participating in a patient engagement working group and improvement team.

In this way, Quinn says, enhancements are being driven in “a truly authentic way,” which supports the shift in thinking that is central to Health Links.

“The approach to getting started in Peterborough had a very strong focus on patient engagement,” she says, noting information from patient interviews and discussions with care providers was then combined with data to identify the initial cohorts of complex patients. In Peterborough, this includes people with congestive heart failure and mental health and addiction challenges.

“This is exciting work because it’s approaching our health care problem solving from a different lens,” Quinn says. “It’s really bringing together quality improvement and patient engagement.”

*John is not the real name of this patient but a name assigned in an anecdotal story shared by the Central East Community Care Access Centre.

The Central East LHIN is currently implementing its third Integrated Health Service Plan (IHSP), setting out a shared goal for the local health care system to help Central East LHIN residents spend more time in their homes and their communities.

Health Links are part of the government’s Action Plan for Health Care, by delivering faster access and a stronger link to family health care, and providing the right care, at the right time, in the right place.

In Peterborough and across the province, Health Links are developing plans and measuring results on how they are improving access to family care, reducing avoidable ER visits and re-admission to hospitals, reducing referral time to a specialist and improving the patient’s overall experience through the health care system.

For more information on the Peterborough and Durham North East Health Links process, please click on “Resource Documents – Integration.” For an update on future Health Links in the Central East LHIN, please click HERE. 

Submitted by Lisa Bailey, Axiom News. To contact Lisa, please email