Wednesday, April 23, 2014
Pembroke Regional Hospital Partners With Healthcare Agencies and Community Organizations To Improve Care For High Needs Patients
PEMBROKE – Local patients with complex health needs will soon benefit from more coordinated care and better transitions between community healthcare partners with the development of the North Renfrew County Health Links.
Launched in December, 2012 and financed through one-time funding from the Ministry of Health and Long-Term Care, the Health Links initiative will bring together existing healthcare providers such as primary care, hospitals, long-term care, home care, mental health and addictions services, and community support agencies to develop new and better ways of coordinating services for patients with the highest complexity of needs while making better use of healthcare resources.
Locally, the West Champlain Family Health Team has been designated as the lead agency for Health Links while the group’s newly-formed steering committee is co-chaired by representatives from both West Champlain and the Pembroke Regional Hospital. The North Renfrew County Health Links (NRCHL) will serve a population of approximately 55,000 residents and will include the geographical areas of Pembroke and Petawawa, and westward along the Highway 17 corridor to Deep River, as well as the areas of Westmeath, Beachburg and Cobden.
According to steering committee co-chair Sabine Mersmann, who is Vice-President of Patient Services – Seniors and Community Care at PRH, approximately 1,500 high needs patients have been identified in our Health Link or approximately 24 patients per 1,000 which rates us as the Health Link with the second highest number of high needs patients in the Champlain Local Health Integration Network (LHIN).
“The Health Links concept involves a thorough assessment of those who have repeat visits to the emergency departments and repeat hospital admissions – those who often suffer from COPD or heart failure, dementia, mental health issues, or our frail seniors who often end up in hospital by default,” Mrs. Mersmann said.
“The idea is to work closely with the identified patients and their caregivers, where applicable, and create a care plan with them that addresses their core needs and links them with appropriate services within the community rather than the hospital,” she said, adding that in some cases where a need for a service is seen as a trend, Health Links would help facilitate creation of that service within the community.
Fellow steering committee co-chair Jeffrey Weatherill of the West Champlain Family Health Team said Health Links reinforces the need for community resources to work closely together in collaboration around the needs of the patient.
“What it does is it prevents community supports from working independently and instead promotes a team approach. It empowers those agencies and healthcare partners to look at gaps in the system and generate the solutions locally and as a group,” Mr. Weatherill said, adding that there is a very close working relationship with those in primary care as well which represents a real positive shift from the way it has worked in the past.
“As part of the Health Links process, there is considerable emphasis placed on the involvement of primary care among the various service providers,” Mr. Weatherill said.
He and Dr. Peter Galley, a member of the West Champlain Family Health Team, are working together to engage physicians and nurse practitioners in the process, facilitate good collaboration, and improve communication among all involved – all for the benefit of the patients they serve.
Both Mrs. Mersmann and Mr. Weatherill agree that Health Links is not becoming a new form of healthcare system but instead it is helping put hospitals back into the role they should have and it’s making full use of the community-based expertise and services based on specific patient needs.
The North Renfrew County Health Link is currently waiting for approval to go to the business plan development stage. From that point, the committee will have 90 days to develop a plan based on some of the following goals:
- Increase the number of complex patients who have regular and timely access to a primary care provider.
- Ensure the development of coordinated care plans for all complex patients.
- Reduce the time from primary care referral to specialist consultation for complex patients.
- Reduce the number of avoidable ED visits for patients with conditions best managed elsewhere.
- Reduce the number of unnecessary admissions and 30-day readmissions to hospital.
- Reduce time from referral to home care visit for patients.
- Ensure primary care follow-up within seven days of discharge from an acute care setting.
“There’s still a lot of work to be done, but we are certainly moving in the right direction,” Mrs. Mersmann said.
FOR MORE INFORMATION, PLEASE CONTACT:
Carolyn Levesque, Public Affairs and Communications Coordinator
(613) 732-3675, ext. 6165 / carolyn.levesque@pemreghos.org
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