How Health Links Keeps Improving for Complex Patients

Those who work in healthcare know how much support highly-complex patients require. If you’re not a health professional, here’s a statistic that’s sure to surprise you. An estimated 5% of Ontario’s population accounts for two-thirds of healthcare spending.

Of course, it’s not all about money. Consider the day-to-day difficulties faced by many patients who make up that 5 per cent. How can the province improve health outcomes and quality of life for its most complex patients?

Care coordination and patient-centredness represent major pieces of the puzzle. More coordinated delivery leads to quicker, higher-quality care. And services that align with patient goals and preferences provide care recipients with a sense of independence.

This is why Health Links is so important. By making care delivery more coordinated and patient-centred at the local level, Ontario’s regional Health Links are making life better for patients. Crucially, they focus on top users of the healthcare system.

The Health Links initiative has made a lot of progress since it was introduced. In this post, we’ll look at some of its most significant developments.

Improving complex care

Health Links helps patients who use Ontario’s healthcare system most. But what does “help” mean in practice?

It means that the providers who deliver care to a patient—from the family doctor to community services—work together. It means that the patient is at the centre of her care, and that providers are communicating with her—and one another.

In late 2012, 19 geographical regions in Ontario were selected as early Health Links adopters. Each of these areas had its own Health Link—an interdisciplinary bundle of service providers.

A complex patient referred to the Mid-Toronto West Health Link would have had an interdisciplinary team made up of providers from that region. She would have played an active role in creating her own personal coordinated care plan—a document that would have acted as a roadmap to her care, reflecting her own preferences.

This process was developed to meet specific goals. According to a 2012 announcement, Health Links was designed to “help improve patient transitions within the system and help ensure patients receive more responsive care that addresses their specific needs.”

Scaling up was always the plan. Early on, The Ministry of Health and Long Term Care (MHLTC) announced that its 19 early adopters would become 77 Health Links. This number has continued to grow—and the results have been impressive.

Growing the initiative

Making any healthcare initiative work is a significant challenge. In the case of each Health Link, continuous improvement is dependent upon cooperation between the MHLTC, Local Health Integration Networks (LHINs), and Health Quality Ontario (HQO).

HQO supports the collection and analysis of data from Health Links. The organization helps policymakers measure, make sense of, and act on results.

According to HQO, by the end of the 2015/2016 year, 4,622 coordinated care plans had been created. Upwards of 5,713 patients had been connected to a primary care provider. These numbers are low, as not all participating Health Links reported their results.

Measuring the effectiveness of healthcare initiatives is notoriously difficult. And with so many moving parts, progress can seem slow to those on the outside. But ambitious plans require a solid foundation. And Health Links is certainly ambitious.

Consider the recent plan put forth by the Champlain LHIN, which plans to have 10,000 Health Links patients by the end of 2019.

Scaling at this magnitude will bring on many challenges. But there’s no doubt that improved coordination and increasingly patient-centred care leads to better outcomes.

In the years ahead, it will be a matter of continuing to find out what works. Monitoring outcomes will enable policymakers to further develop best practices within the Health Links framework.

Ongoing improvement

In the few short years since the initiative was introduced, Health Links has expanded rapidly. By the end of the 2016-2017 year, 84 Health Links were actively recruiting patients.

That same year, a total of 36,772 coordinated care plans were created. And 47,098 patients were connected to primary care providers. These numbers are impressive, and recent quarterly reports reveal that they’re only continuing to grow.

It’s clear that policymakers see Health Links as one of the keys to improving healthcare in Ontario. As the population ages and rates of chronic disease rise, investing in this large-scale solution is essential.

To a large extent, the province’s level of dedication will determine how successful Health Links is as it moves forward. But apart from committing to making the initiative work, what can be done to ensure it helps complex patients?

Innovation is important. From the beginning, Health Links has been, at least in part, about innovation. Individual Health Links have embraced new technologies and approaches to care delivery.

As just one example, the Rural Hastings Health Link won a Transformative Change Award for developing “a truly seamless and engaged model of care.”

Why does this matter? Because innovative thinking at the local level can be scaled up, leading to province-wide breakthroughs.

Consistency remains critical

While innovation can result in the development of new best practices, consistency is truly crucial.

Across Health Links, standardization should remain a priority—as should the ongoing measurement of results. With cooperation between the organizations involved, there’s no reason why these processes shouldn’t lead to continuous improvement.

Feature image courtesy of Michael Havens

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COPD Education – Onboarding


To complete a thorough needs assessment / initial evaluation for a COPD patient of an outpatient clinic

Patient, Educator (Nurse, RT, the Physician could also be the educator)

One 60-90 min session with the Educator

  • This protocol should be established for all COPD patients from a given clinic, independently of whether they are new patients or they are known to the clinic. This protocol is the basis to engage the patient into other protocols such as education, exacerbation follow-up, etc.
  • We need to identify patient goals/concerns to guide the interventions
  • A thorough evaluation is carried on, with the objective of understanding where the patient is on their disease journey and follow-up treatable traits: dyspnea, exacerbation or dyspnea and exacerbation.
  • It includes the use of objective questionnaires such as the mMRC, CAT, HADS, Frailty Scale, etc.
  • Identify if the patient needs to be referred to other resources (e.g. Physiotherapist, social worker, occupational therapist)
  • Once Onboarding is completed, the patient continues to the COPD Education workflow
COPD Education – Continuous Maintenance


To cover in depth all the necessary elements of self-management education as per the LWWCOPD, with priorities based on patient goals and identified treatable traits

Patient, Educator (Nurse, RT or Physician)

A number of “Core” educational modules have been identified which cover the basic COPD education from the LWWCOPD program. Additionally, optional modules can be used to respond to patient needs. The timeline (frequency, number of modules to be covered at a given education session) is fully customizable, although we recommend to have education sessions every 2-weeks during the “active” phase of education. Once this is completed, the patient continues to the Maintenance Mode (see below).

  • Launched at the onboarding protocol
  • Provide basic overview of COPD self-management based on LWWCOPD (medication adherence, inhaler techniques, PLB technique & energy conservation) up to the development of an Action plan for early exacerbation recognition and management.
  • Prioritize self-learning by the patient (e.g. watching videos, reading educational materials, completing homework) in addition to live sessions with the Educator. Educational materials are sent to the patient directly via the platform, and become the patient’s own library. The Educator can customize which “homework” the patient receives.
  • Educators have access to “User guides” to standardise their educational intervention. These user guides include: objectives, interventions, suggested questions, evaluation of self-efficacy, and learning contracts for each module.
  • Once the core education is completed, the patient can continue to the Respiratory Status Follow-up Workflow (run in parallel)

The Maintenance Mode
  • As soon as the maintenance mode is engaged, the frequency of visits Educator/Patient is reduced to once every 6 months.
  • During the Maintenance Mode sessions, the educator has access to all the education modules and can choose any piece of content that needs to covered with the patient. 
  • A streamlined evaluation (similar to the initial eval.) is done during each “maintenance” visit to identify any substantial changes on the patient’s needs that will require some adjustment. The patient could come back to an “active” education mode (more frequent education sessions, e.g. every 2 weeks).
COPD Respiratory Status Follow-up


Monitoring of stable patients from a clinic in order to identify early any aggravation of symptoms (exacerbation) and implement an action plan

Patient, Educator (Nurse, RT or Physician)

Scheduled regular automated follow-up to the patient symptoms. Intensity/Frequency can be adjusted by the Educator depending on patient needs (e.g. daily, every week, etc.). Ongoing through the year.

  • Launch: Patients who have completed the Core Educational including setting-up an action plan.
  • Regular automated questions allow to identify any change in patient’s symptoms and severity.
  • If an exacerbation is detected the patient gets a reminder to engage their self-management strategies while waiting for the Educator to call back.
  • An alarm is generated for the Educator, so they immediately call back the patient. At this call they will evaluate any further intervention required and schedule additional follow-up.
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