2. Summary
Strengths Gaps
• regular meetings that include
multiple members
• well-established connections
within the health link and the LHIN
and reaching out to other LHINs,
health links
• highlighted areas need
clarification, verification or statistics
• electronic linkages between
partners
• how we work with organizations
outside out SRHL and LHIN
3. A Broad Coalition and
Diverse Leadership Models
19 early-adopter Health Links providing care to almost one million
people, through the co-operation of 18 hospitals, 42 primary care groups and
over 60 community service providers
S Cross section of partners
S Mental Health Agencies
S Public Health Units
S Food Banks
S Emergency Medical Services
S Educational Providers
S Community Social Service
Providers
S Long Term Care Facilities
S Police Services
S Cross section of coordinators
S 4 Hospitals
S 2 CCACs
S 8 primary care (FHT/FHO)
S 4CHCs
S 1 Community Services
Organization
4. Metrics for Health Links
– as per Business Plan template
S Operational Metrics (Setting the Stage for Coordinated Care Straightaway)
S 1. Ensure the development of coordinated care plans for all complex patients
S 2. Increase the number of complex patients and seniors with regular and timely access to a primary
care provider
S Results based Metrics(Moving the Needle)
S 1. Reduce the time from primary care referral to specialist consultation
S 2. Reduce the number of 30 day readmissions to hospital
S 3. Reduce the number of avoidable ED visits for patients with conditions best managed elsewhere
S 4. Reduce time from referral to home care visit
S 5. Reduce unnecessary admissions to hospitals
S 6. Ensure primary care follow-up within 7 days of discharge from an acute care setting
S Evaluation Based Metrics (How you’ll know you’ve arrived)
S 1. Enhance the health system experience for patients with the greatest health care needs.
S 2. Achieve an ALC rate of 9 per cent or less
S 3. Reduce the average cost of delivering health services to patients without compromising the
quality of care
5. Work still to be done
S Accuracy of current data
S Missing data
S Missing partners
S Francophone
S Aboriginal
S Results oriented