Theme Description: Organizations in the community increasingly work in partnership to meet the needs of the patient and their community. Health Links and other initiatives have provided opportunities to improve coordination and transitions in care. Presentations in this stream will demonstrate how the patient’s journey and experience in the system has improved through successful coordination and/or integration of services across organizations.
A5 Collaborative Team focus for Developmental Delayed and Complex Young Man
Our FHT worked seamlessly with other organizations within the community, from the patient's group home, to his parents, CCAC, local hospital and Developmental services agency to provide the care that this patient required. This was a new patient to our FHT, and because of his extremely high risk, this new team did not have time to do the usual forming, storming and norming. We had to function at a high level as this patient was experiencing oropharyngeal dysphagia, aspiration and malnutrition which were potentially life threatening. Our team would like to share our successes, lessons learned and what motivated us. The patient and his mother will be joining us in discussing how effective collaboration was life saving.
B5 Hospital at Home: Innovations in Rural Primary Care
The aim of the Hospital @ Home is to divert appropriate patients requiring inpatient care to a program that wraps the necessary care around the patient in their own home – the right care at the right time in the right place. The presentation will feature discussion from multiple partner/provider perspectives on their experience of the program and learnings in addition to an incorporation of patient experience in the form of narrative or video.
C5-a Collaborative Care Model: What does it take to create integration?
The making of this health link has the elements of a process that has included the historical stages of team formation and through that process has created change in a positive format for patients and their families. We will show the approach used, the process for creating culture change, the ideas tested, evaluated and re-tested and the outcomes in relation to the patient.
C5-b A Person Centered Health and Wellness Ecosystem (presentation to follow)
With the emphasis shifting to patient- oriented care and collaborative care models with patients as partners, the electronic personal health record (PHR) has generated considerable interest and investment in recent years. The purpose of this panel will be to explore a clinics’ experience with a large eHealth system consisting of an EMR, PHR and a social CDSS, including benefits to patients and providers, implementation tips, and challenges.
DE5 Coordinated Care Planning in the Guelph and East Toronto Health Links
1. How Health Links Provide Coordinated Care Planning for Complex Patients – Keeping it Patient Centred and Provider Enhanced
Complex patients and their primary care providers often struggle with chronic disease guidelines and a health care system that has been designed for single disease entities and that does not take into account challenges with mental health, poverty, cognitive impairment, and substance usage. In our presentation we will review how Health Links can identify complex patients in their region using a combination of different approaches.
2. Integrating the community around the patient
Many community health and social service providers are serving the vulnerable population that health link addresses. Audience members will hear how Guelph has engaged both typical and atypical organizations and processes to support health link members as they would like versus, as the systems have been designed to operate.
F5 Improving The Road To Recovery
As a direct result from LHIN funding, service programs such as Addiction Services have allowed for more collaboration with health professionals to come together to meet the needs of the patient. Since our collaboration in February 2013, Addiction Services and primary care have improved communication, and success with patients with addictions. This presentation will demonstrate how simple changes and integration of two models of care can come together and effectively improve the harm reduction and sobriety of patients. A complex case that was successful with the integration of our community services around her harm reduction and sobriety will be presented.
