an overview of the health links maturity model
TRANSCRIPT
An Overview of the Health Links Maturity Model
April 18th 2018
HEALTH LINKS COMMUNITY OF PRACTICE
1
Webinar Learning Objectives
• To build an understanding of the Health Link Maturity Model
• Review the Maturity Model domains with examples
• Hear how the Maturity Model has been used to advance the
Health Links approach to care regionally.
• Familiarize and review the supports and tools made available
for the completion of the Health Link Maturity Assessment
survey.
2
PARTICIPATING IN THE WEBINAR
www.HQOntario.ca
• This webinar is being recorded.
• ALL participants will be muted (to
reduce background noise). You can
access your webinar options via the
orange arrow button.
• If you would like to submit a question
or comment at any time, please use
Question box feature.
• Answers to questions not addressed
today will be posted on QUORUM
(found at quorum.hqontario.ca)
3
Background
Health Links Funding Letters detail requirements for regular reporting
on the maturity of Health Links. Health Links self-assessed their
maturity in 2016.
The data collected around the current state of Health Links maturity
will provide guidance to help the LHINs move to a higher state of
alignment and maturity.
HQOs role includes assisting in the administration of the data
gathering process for these reporting requirements, and to
incorporate the findings into their regular quarterly reporting process
for Health Links
Feedback from the LHINs around the need for additional knowledge
translation tools and supports to ensure provincial consistency.
www.HQOntario.ca
4
Health Link Maturity Model Survey
Process and Timelines
Health Link LHIN Leads complete the survey in collaboration
with the Health Links in their region
Due date for submission of assessment results is May 4th
HQO will share survey results in Q4 Health Link provincial
quarterly report (mid-June)
Next maturity assessment survey will be distributed in 6 month
timeframe (October).
5
Maturity Model Task Group
Acknowledgements
www.HQOntario.ca
Local Health Integration
Networks
Kim Sontag (NSM)
Linda Hunter (HNHB)
Marley Budreau (CE)
Ana MacPherson (C)
Tory Merritt (C)
Amber Alpaugh-Bishop (SW)
Susan McCutcheon (SW)
Ministry of Health and
Long-Term Care
Nirojini Suthaharan
Salima Allibhai-Hussein
Health Quality Ontario
Kim Kinder
Monique LeBrun
Jennifer Wraight
Sue Jones
Caroline Buonocore
Karen Poon
6
WEBINAR SPEAKERS
www.HQOntario.ca
South West Experience from the Field…
Sue McCutcheon, Director, Planning and Integration, London Middlesex
Sub-Region for the South West LHIN
Amber Alpaugh-Bishop, Program Lead, South West Health Links
Maturity Model: Overview
Jennifer Wraight, Regional Quality Improvement Specialist, Central East, Health
Quality Ontario
7
Health Links Maturity Model Overview
The Health Links Maturity Model provides a roadmap for Health Links
across the province to achieve population impact at scale
The model outlines five levels of maturity across four domains related to
coordinated care planning
Four Maturity Domains:
1) Identification of Complex Patients
2) Coordination of Care
3) Patient-centred Care
4) Measurement and Continuous Performance Improvement
Five Levels for each domain:
Level 1 – Start Up Level 4 – Integrated Excellence
Level 2 – Evolving Level 5 – Population Impact
Level 3 – Functional Excellence
www.HQOntario.ca
Overview of Levels Within Each Domain
LEVEL 1 • Reflects the current system; siloed providers,
single condition, health focused
• Eligibility criteria known
• Some communication between service
providers
• Care for patient is episodic
• Health Link lead adopting the approach to
care
• Beginning to understand the partnership
required to support the approach
Start -up
www.HQOntario.ca
LEVEL 2• Some organizations adopting the approach
to care (representatives of acute, non-acute,
community and primary care)
• Some collaborative work underway between
partners
• Working with partners in health e.g. within
acute; acute and community; acute,
community and primary care
• Contribute to coordinated care planning
(minimum of two service providers)
• Teams are using the Coordinated Care Plan
template (v.2)
• Establish a shared understanding of the
approach and roles of each provider in
supporting the patient at each point of care
• Some sharing of information
Evolving
www.HQOntario.ca
LEVEL 3
• Broader adoption of the approach among the
organizations across sectors
• Focus on sub-populations e.g. people
requiring mental health and addiction
services, palliative care and end of life
• Roles and responsibilities of partners
understood
• Contribute to common care planning
establishing a multi-disciplinary team
(multiple sectors)
• Relationship and partnerships are
established between health and social
domains
• Mechanism in place to communicate with
patients/caregivers
Functional
Excellence
LEVEL 4 • Partners working together
• Service pathways are integrated along a
continuum of care between organization and
within organizations
• Eligibility criteria to align between services
• Primary care engaged and participating in
the planning, implementation and
maintenance of a patient’s care plan
Integrated
Excellence
www.HQOntario.ca
LEVEL 5• Health service and social agency providers
have adopted the approach to care
• Approach has been embedded into the
program and service design; a part of the
provider QI initiatives, vision,
education/orientation programs
• Seamless transitions
• One integrated EMR
• Providing services using an health equity
lens
Population
Impact at
Scale
www.HQOntario.ca
14
Reference Guide/Document
15
www.HQOntario.ca
17
18
19
Driving the Health Links approach to Coordinated Care Planning forward
South West Health LinksApril 18, 2018
South West Health Links
Amber Alpaugh-Bishop & Sue McCutcheon
Health Links Maturity Journey Domains
#1: Identification of Complex Patients
#2: Coordination of Care
#3: Patient-centredCare
#4: Measurementand Continuous
Performance Improvement
The Health Links approach is… person-driven, coordinated care to better support those with
high care needs
Start-up Evolving FunctionalExcellence
Integrated Excellence
Population Impact at Scale
Levels
Tools and supports leveraged to advance the Health Links approach
#1: Identification of Complex Patients
Using the
Assessment and
Urgency Algorithm
(AUA) pathway to
offer coordinated
care planning to
those at high risk
Coordinated Care
Planning included in
work of Care
Coordinators
Coordinated Care
Planning built into
Palliative Care
pathways
Coordinated Care
Planning built into
Connecting Care 2
Home pathway
“Anyone,
anywhere” can
identify people
with high care
needs
Building identification into
organizational
processes/programs (e.g.
Primary Care processes, Falls
prevention programs)
Tools and supports leveraged to advance the Health Links approach
#2: Coordination of Care
Home Care CHRIS and
ClinicalConnect to
enable Coordinated Care
Planning to
follow patients
through the system
thehealthline.ca to build
and host our Local
Health Link microsites
and our SW Specialist
directory
Implementation of Heath
Partner Gateway to diversify
leadership of Coordinated
Care Planning & interim
solution
Health Link
Learning
Collaborative
series and other
educational sessions
(e.g. Motivational
Interviewing) to teach
all providers how to
lead high quality
Coordinated Care
Planning
Leveraged existing
South West Health
Link eEnabler group
for planning/
prioritizing digital
health strategy
Tools and supports leveraged to advance the Health Links approach
#3: Patient-centred Care
Health Links Leadership
Collaborative to
build/evolve standardized
approach
Health Link Learning
Collaborative (practice
Coordinated Care
Planning with simulated
patients)
Outcome measures
(ED visits,
hospitalizations, and
length of stay)
reported in quarterly
dashboards
Local Health Link
Steering
Committees to
escalate barriers,
strengths
Local Health Links
Working Groups
to identify
barriers,
strengths,
implement
continuous QI
On-line patient and
provider surveys to
track outcome and
balancing measures
(Survey Monkey)
Tools and supports leveraged to advance the Health Links approach
#4: Measurement and Continuous Performance Improvement
Data Analyst
resourcesHome Care Client Health
Record Information
System (CHRIS)
leveraged for centralized
data collection
South West
Health Link
Dashboard
On-line patient and
provider surveys
(Survey Monkey)
Local Health Link
Sub-Region
Dashboards
Experience-based
design
HEIA/Sustainability
Tracking Matrix
Measuring, sharing, and spreading progress: Health Equity and Sustainability Matrices
Measuring, sharing, and spreading progress: Dashboards
Measuring, sharing, and spreading progress: Dashboards continued
Measuring, sharing, and spreading progress: Dashboards continued
Measuring, sharing, and spreading progress: South West and Local Health Link groups
• South West HL Leadership Collaborative, Local HL Steering Committees, Local HL Working Groups, South West Cross-Health Links Evaluation Group, South West HL Project Managers Group, South West HL eEnablerGroup
• Review HEIA/Sustainability Matrices
• Review Dashboards
• Discuss Barriers/Challenges
• Discuss Successes
• Review work plan progress
• Share Patient and Provider Stories/Experiences
• Strategize/Standardize
Measuring, sharing, and spreading progress: South West Health Link Learning Collaborative
What are we planning for this fiscal year?
IMPLEMENTING THE
PRACTICES IN YOUR HEALTH
LINK
Discussion;
Please submit questions to us via the
“Question” box.
www.HQOntario.ca
34
Health Link Maturity Model Survey Resources
LHIN HQO QI Specialist Email address
01. ESC Carol Moore [email protected]
02. SW Carol Moore [email protected]
03. WW Julie Nicholls [email protected]
04. HNHB Julie Nicholls [email protected]
05. CW Kamal Babrah [email protected]
06. MH Julie Skelding [email protected]
07. TC Courtney Paxton [email protected]
08. C Karen Poon [email protected]
09. CE Jennifer Wraight [email protected]
10. SE Dana Summers [email protected]
11. CH Monique LeBrun [email protected]
12. NSM Sue Jones [email protected]
13. NE Joanna deGraaf-Dunlop [email protected]
14. NW Caroline Buonocore [email protected]
Please remember the survey is due on May 4. For resources to support the
completion of the survey, please visit Quorum to access the Resource Guide,
or contact your regional HQO Quality Improvement Specialist.
HEALTH LINK LEADERSHIP
COMMUNITY OF PRACTICE; Resources and Events
www.HQOntario.ca
Health Links CoP Webinar – Save the Date
May 23rd – more information to follow by email
Quality Rounds Ontario – Improving Wound Care in Ontario on April
26th 12:00-1:00 pm EST
Health Links Summit Save the Date – September 27th by invitation
only!
Quorum - Continue to share and collaborate online using your HL CoP
online page. Register today!
WE WANT TO HEAR FROM YOU!
36
Polling
www.HQOntario.ca
