Improved Access to Care Coordination in Primary Care Settings

 Improved Access to Care Coordinators in Primary Care Setting Document Cover 

Improved Access to Care Coordination in Primary Care Settings - PDF

 

In aiming to preserve a focus which puts patients first, the LHIN embarked on a journey towards the end of 2017, in order to engage patients, families, caregivers, primary care, home and community care as well as other community-based organizations. This was done using an experienced based co-design approach with the ultimate goal of enhancing patient experiences, through improved coordination models and communications.

This feedback was used in order to develop a plan that seeks to:

  • Be responsive to patient needs, values and preferences;
  • Provide consistency to ensure that patients and caregivers know what to expect; and
  • Improve access to care coordination and system navigation function in primary care settings to enable smooth transitions of care as required.

This initiative builds on work initiated for Health Links with better linkages between the care coordinators (CC) at both the home care and primary care levels. It also builds on pilot projects underway to test partial and virtual integration models in primary care settings, with a goal of improving access to care coordination by primary care practices across the region.

The report – Improved Access to Care Coordination in Primary Care Settings – was finalized in September 2018 and approved by the South East LHIN Board of Directors. As a result, the South East LHIN is ready to move forward with improving the connection between home and community care and primary care.

What does this look like?

There are three recommended models that will provide this flexibility for a Care Coordinator working with Primary Care, which includes:

  • Over the next several months, the South East LHIN will reach out to Primary Care providers to determine what the connection for their practice could look like, because we know from our consultation process that there are differing needs.
  • There are three recommended models that will provide this flexibility for a Care Coordinator working with Primary Care, which includes: Total Integration; Partial Integration; and Virtual Integration.
  • Full implementation of the integration will be a phased approach over the next few years that will build on examples already in place, testing these models and using the Health Links philosophy as we strengthen the partnerships between Care Coordinators and Primary Care.

Next Steps

  • Forming an Implementation Committee to oversee the Home and Community Care/Primary Care integration initiative which will include representation from primary care and health links.
  • Further understanding and mapping current home and community care with primary care linkages, including both virtual and partial integration models.
  • Initiating the fully-integrated model with the four Care Coordinators dedicated to spreading the Health Links approach to care.
  • Developing tools and mechanisms to support the integration implementation of Care Coordinators within primary care, while adopting the Health Links approach to care.
  • Using a phased approach for rollout across primary care, linking with sub-regions for planning input.
  • Providing ongoing progress updates and opportunities for expanded integration with primary care.

Feedback or questions?

If you require any further information about this project, or wish to share some of your ideas, please feel free to contact:

Kris Walker at 613-966-4601 ext. 2769 or kris.walker@lhins.on.ca.


Primary Health Care Council of Southeastern Ontario

Primary Health Care Forum