Linking up for better health care

St. Joseph’s is a partner in a new model of care recently launched in London aimed at better serving high-needs patients.

The Health Link approach brings together health care providers in a community to improve coordination of and access to care for complex patients who often see several different providers, resulting in both gaps and duplication in care. Already established in about 50 other Ontario cities, Health Links encourage greater collaboration between family care providers, specialists, hospitals, long-term care, home care and other community supports. With improved coordination and information sharing, the goal is for patients to spend less time waiting for services, improve patient transitions within the health care system, and have care providers working together to develop solutions that address each patient’s specific needs. 

The London Health Link is being led by the Thames Valley Family Health Team and is currently made up of the following providers: 

With chronic disease management an important and growing role at St. Joseph’s, the Health Link approach is a good fit with our own goals of integrated, interprofessional care, says Karen Perkin, Vice President, Acute and Ambulatory, Professional Practice and Chief Nurse Executive. 

“It’s about care providers connecting differently,” explains Karen. “It’s about wrapping services around patients with the greatest needs to provide better access, better care planning, education and empowerment.” 

According to the Ministry of Health and Long Term Care, five per cent of patients account for two-thirds of health care costs and these are most often patients with multiple, complex conditions. A recent study found that 75 per cent of seniors with complex conditions who are discharged from hospital receive care from six or more physicians and 30 per cent get their drugs from three or more pharmacies. Over time, better access and care for complex patients will result in improvements such as:

  • Reduced unnecessary hospital admissions and re-admissions after discharge.
  • Reduced avoidable Emergency Department visits for patients with conditions best managed elsewhere.
  • Same day/next day access to primary care.
  • Reduced time from a primary care referral to specialist consultation for complex patients.
  • Reduced time from referral to first home care visit.
  • Reduced alternate level of care (ALC) days in hospital.
  • An enhanced experience with the health care system for patients with the greatest health care needs.

The London Health Link model will start with a focus on patients with chronic obstructive pulmonary disease (COPD).  More on the model – a Ministry of Health Initiative - is available by visiting their web site

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