Timmins, Temiskaming pilot Health Links

The Timmins Family Health Team and Le Centre de santé communautaire de Temiskaming in the North East LHIN have been selected as pilot sites for the Ministry of Health and Long-Term Care’s new Health Links program.

Health Links is touted as a new model of care for patients with multiple chronic diseases and mental health and addic­tion issues who are frequent users of the health-care system.

The program aims to improve collabo­ration between primary care providers, specialists, hospitals and home care agen­cies to reduce emergency room visits and hospital readmissions.

It’s hoped that by working together as a team, local health care providers and agen­cies can speed up referrals to specialists, home care services and other community supports.

Seniors participating in the Health Links program will receive enhanced medica­tion monitoring and an “individualized comprehensive plan.” They will be able to call a health care provider, eliminating unnecessary provider visits, and have access to same day or next day office visits as required.

According to the Ministry of Health and Long-Term Care, patients with complex conditions represent five per cent of Ontario’s population, but use approximately two-thirds of the health-care budget. Many of them have six or more physicians and just under a third of seniors with complex conditions receive their drugs from three or more pharmacies.

The 19 pilot sites across the province submitted business plans to the Ministry in February.

According to executive director Jennifer McLeod, the Timmins Family Health Team was selected as a pilot site, because of the strong partnership it has with health-care agencies in the community.

“It was a really good fit for us because we’re already working together. We had plans to meet to try to address gaps within the system. Health Links gave us the opportunity to access some funding and to be able to (address gaps) in a more meaningful way.”

The Ministry is offering start-up funding of up to $1 million per project, but “the initiatives we develop must be with current resources,” noted McLeod. “Whatever it is we do in the course of this project must be patient-centred and it must be sustainable without additional funding.”

Reviewing data on seniors who are heavy users of the health-care system in Timmins resulted in some surprises, said McLeod.

“We thought that frequent users of hospital services were seniors without a primary care provider, but that’s not nec­essarily the case, so the data is giving us some trends that will probably lead us in a new direction.”

Enhanced sharing of information through electronic health records is one of the objectives of the program.

Primary care providers at the Timmins Family Health Team receive electronic reports from the Timmins and District Hospital, but sharing of information with specialists, home care agencies and the Canadian Mental Health Association is not as efficient.

“There’s no doubt that facilitating the sharing of client information with a primary care provider’s office helps to facilitate care because then that individual has a much better idea of what’s happen­ing,” said McLeod.

The Timmins Family Health Team also served as a pilot site for the Ontario Telemedicine Network’s Telehomecare program, which has since been rolled out province-wide. The North East CCAC’s telehomecare nurse in Timmins works out of one of the Timmins Family Health Team’s offices, ensuring convenient access to a primary care provider if there are concerns about a patient’s condition.

Under the Telehomecare program, patients with chronic conditions are equipped with a tablet and a toolkit of diagnostic equipment, including a weigh scale, blood pressure cuff and pulse ox­imeter. The devices attach to the patient’s telephone or computer and transmit read­ings and other health status information keyed in by the patient and transmitted to a central database. The telehomecare nurse monitors the data and takes action if the numbers or the patient’s responses to a list of questions indicate a need for intervention.

The Timmins Family Health Team has been tasked to co-ordinate the Health Links program for the community, but is only one of several participating health-care organizations and agencies. The East End Family Health Team is also at the table as a partner and the city’s solo practitioners will be plugged in too, said McLeod.

Promoting collaboration without incur­ring extra costs or detracting from the productivity of primary care providers are some of the challenges with which the Health Links program will have to contend because “sitting in meeting after meeting” will negatively impact client care, said McLeod.

The Timmins Family Health Team cur­rently consists of 28 primary care provid­ers, including 23 family docs and five nurse practitioners. The team is not accepting new patients at this time, but is expecting to open up the practice as new primary care providers are recruited.

Health Care Connect has 753 orphan patients registered in Timmins, “but we suspect there are many more people who haven’t registered,” said McLeod.

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