Kingston Community Health  Centres (KCHCs) plays a coordinating role for the Salmon River Health Link (SRHL), one of Ontario’s Health Links, which were established as a key commitment in the Ontario Ministry of Health and Long Term Care’s Patients First: Action Plan for Health Care. Key goals of Health Links are to: improve the delivery and coordination of care; enhance the experience of care; and improve the quality of care at lower cost for patients with complex health and social needs (SELHIN Health Link Sustainability Plan 2016). One area of potential impact is reduced hospital utilization, which may reduce health care system costs.

The Health Link model is a targeted, holistic approach to care coordination for complex patients. Health Links are intended to foster greater collaboration and coordination between clients’ different health care providers while developing a coordinated care plan for individuals.

Coordinated care plans identify client goals and priorities which are to be integrated with their medical and service plan of care. This supports a team approach to care, promoting collaboration and service integration. Coordinated care planning helps improve client transitions within the system and helps ensure clients receive more responsive care that addresses their specific needs with the support of a tightly knit team of providers.

Throughout Ontario, Health Links are targeting the 1–5% of patients who utilize 66% of the total health care dollars spent in Ontario. Through data analysis, we have found that these patients predominantly have four or more chronic/high cost conditions, frequent hospital admissions, re-admissions and multiple emergency department visits and often experience barriers to health such as food security, transportation, housing or income insecurity. Clinical judgment is also important in identifying patients who would benefit from the Health Link approach.

The SRHL, led by Kingston Community Health Centres, is one of seven Health Links in the South East Local Health Integration Network (SELHIN). It is one of the smaller Health Links in the region and the province, serving a population of approximately 23,700 people from the town of Greater Napanee, the hamlet of Deseronto, Tyendinaga Township and the Tyendinaga Mohawk Territory. There are 19 primary care organizations within this geography.

Sixty percent of the population covered by the SRHL lives in rural municipalities, with Napanee as the only larger population centre. Statistics Canada states that 4.5% of the population identifies as Aboriginal (2006), although we know that this number is under-reported since 5% of our Community Health Centre’s clients in Napanee alone identify as Indigenous. Like many small towns, KCHCs support an aging population, with 31% between the ages of 45 and 64, projecting for the 65+ age group to continue to grow steadily.

The SHRL initiated care coordination and intensive case management for individuals with complex needs beginning in September 2014. A care coordinator was hired through KCHCs and acts as the front-line lead for this regional approach, working with all primary care providers in Napanee and the surrounding area to support clients with complex needs.

KCHCs’ leadership of the SRHL helps to ensure that there is a multi-disciplinary team that understands the impact of social and economic deprivation on health outcomes. Recent research suggests that low socioeconomic status, high disease burden, low accessibility, greater healthcare coordination problems and low comprehensiveness of care contribute to high emergency department utilization (Hudon et al, 2016). Additionally, a recent review found that a disproportionate number of individuals with mental health concerns are presenting in emergency departments. Researchers for the valuation found a relationship between the continuity of care and frequent emergency department use for mental health concerns (Digel Vandyck et al, 2013).

Coordinated care offers a systematic approach to supporting people with chronic conditions that is responsive to their needs.

In addition to all primary care partners, the SRHL works closely with the Lennox and Addington County General Hospital and other key community partners to ensure a central referral process for patients with complex needs. A process has also been established to receive regular data pulls of patients who have 3+ emergency department visits within a three-month period as well as a readmission under 30 days. The SRHL care coordinator follows up with an individual’s primary care provider to prompt a referral and to obtain patient consent to engage the patient in developing a coordinated care plan.

EVALUATING IMPACT
As part of the on-going development and evaluation of the Health Link initiative, KCHCs and SRHL partners conducted a small-scale evaluation looking at hospital utilization among the first 100 SRHL clients at six months pre- and post-Health Link involvement.

Results showed a 31% decrease in emergency department visits and a 51% decrease in length of stay in hospital for clients who received Health Link assistance.

The SRHL evaluation measured client emergency department use and hospital admissions at the Lennox and Addington County General Hospital from September 2014 to July 2016. 

This was done through assessment of Health Link patient records (N=100). The records were used to quantitatively determine the number of emergency department visits and the number of days admitted in hospital for each client as well as the number of re-admissions under 30 days.

IMPACT: 31% decrease in emergency department visits 
Clients involved in the SRHL visited the emergency department a total of 189 times in the six months before their involvement and a total of 131 times post-involvement. Results indicate an average reduction of 0.6 emergency department visits per person in the six months following Health Links enrollment. Overall, there were 58 fewer visits to the emergency department in the six months following Health Links participation, which resulted in a 31% decrease of emergency department visits.

One individual, an outlier of sorts due to their unusual case, was removed from the data calculation because they visited the emergency department 21 days in a row to receive an antibiotic injection.

High frequency emergency department presenters: A subset of individuals who visited the emergency department most frequently (4 to 11 visits) in the six months prior to Health Link involvement showed a decrease of 51% in emergency department visits in the six months following the intervention. This subset of 26 individuals visited the emergency department 138 times prior and 67 times post-Health Link involvement. The average number of visits changed from 5.3 visits per person pre-Health Link to 2.6 visits per person following Health Link involvement.

IMPACT: 51% decrease in length of hospital stay
With one outlier (mentioned above) removed, length of stay was reduced by approximately one day per person post-Health Link enrollment. This is a reduction of 51% with a total of 228 days in hospital pre-Health Link involvement and 116 days in hospital post-health link involvement. The one outlier patient stayed in hospital for 88 days, which is nearly three times as long as any other patient-stay within the sample population. As a result, this data point was removed.

Highest admission subgroup: Individuals with the most admissions before the Health Links intervention (four or more), showed the greatest changes in length of stay post intervention. Amongst this subgroup of 19 individuals, days spent in hospital decreased from 217 days to 67 days, a decrease of 69%.

Three SRHL clients passed away during or shortly after their involvement. Two individuals were noted as deceased during the six-month period following initial involvement. In both cases, the length of stay increased in the post-involvement period (from zero days pre- to 10 days post-Health Link and from two days to three days). Both clients were close to the end of their involvement at their time of passing. A third client was noted as deceased one month after the post-enrollment period ended. All three clients were included in the data analysis.

Readmissions under 30 days: In the six months before Health Link involvement, five individuals were readmitted under 30 days while only one individual was readmitted under 30 days post-Health Link involvement.

Conclusions and Reflections
Results from the evaluation suggest a significant reduction in emergency department visits and admissions once patients were involved in the SRHL, and the reduction was most notable among those with the highest frequency of emergency department visits and longest admissions.

The evaluation provides early evidence demonstrating the importance of coordinated care for more effective and efficient care of patients with complex needs and suggests that the Health Link approach may positively impact emergency department use and length of hospital stays among patients with complex needs. It also starts to help illuminate improvements around the patient experience and health outcomes while decreasing cost to the health care system.

A limitation of the evaluation was that KCHCs and SRHL were not able to access hospital utilization data for hospitals outside of the Health Link’s region. However, it is exciting to note that the seven Health Links within the South East LHIN are in the process of integrating acute hospital utilization information to help identify the target population throughout the LHIN.

Identifying patients with complex needs, who have high utilization of hospital services, or are at risk of hospitalization, will enable Health Links partners to target efforts on this high-needs and vulnerable segment of the population.

References

• Hudon, C., Sanche, S., and Haggerty, J.L. (2016). “Personal Characteristics and Experience of Primary Care Predicting Frequent Use of Emergency Department: A Prospective Cohort Study“. PLoS ONE 11(6): e0157489. doi:10.1371/journal.pone.0157489
• Digel Vandyck, A., Harrison, M.B., VanDenKerkhof, E.G., Graham, I.D., and Ross-White, Amanda. (2013). “Frequent Emergency Room Use by Individuals Seeking Mental Healthcare: A systematic Search and Review” Archives of Psychiatric Nursing. 20 (4). Pp 171-178.