Treating patients with complex care needs at home isn’t easy. Often, it takes a whole team of caregivers and medical practitioners.
The word “team” is critical here. If you’re involved in providing this type of care, you’re aware of what can happen when communication becomes fractured.
Poor health outcomes for patients is one consequence. Increased hospital readmissions and unnecessary strains on the health care system are others. These kinds of repercussions can occur when inadequate complex care planning and execution play out in patients’ homes.
In Ontario, the government is taking major steps in the right direction.
The creation of provincial Health Links and increased funding for home care is vastly improving at-home complex care. The province is putting patients front and centre to provide better, more coordinated services.
Will at-home care continue to get better for complex patients? The future looks very promising.
Complex care challenges multiplied at home
The challenges associated with complex care have always been significant. As the population ages, health care systems will be tested by an influx of seniors with complex needs.
That said, it’s a relatively small number of patients who require the highest level of care. It’s estimated that just 1% of Ontario citizens account for one-third of the province’s health care spending.
Finding cost-effective ways of treating these patients – many of whom have complex needs – is in everyone’s best interest. But it’s also a very tall order.
When a patient receives care from many providers, coordination is a challenge. Doctors, nurses, specialists, personal support workers (PSWs) – the more professionals in the mix, the greater the opportunities for confusion.
This is true even when patients are set up in hospitals or care facilities.
In facilities, paper charts move around, which means they’re frequently unavailable when practitioners needs them.
Fortunately, Ontario has an impressive rate of electronic health record adoption. But even in facilities that use this technology, some coordination challenges persist.
Consider what happens when a patient is admitted to the hospital. Often, her electronic health record isn’t accessible to hospital staff. This is a problem. Information from primary health care providers – such as notes on allergies and immunization updates – may impact treatment during emergency situations.
For complex-needs patients, communication gaps can be especially wide. Because these patients often have extensive medical histories, their records contain a lot of critical information.
Ensuring the right information gets into the right hands can be difficult, even in facilities. So it’s no surprise that those who contribute to care in patients’ homes face significant challenges.
Ontario’s home care sector is undergoing rapid development. What steps are being taken to ensure the timely transfer of patient information? How is complex care being delivered in settings without the on-site infrastructure of hospitals?
Provincial progress leading to success
In 2013, Ontario’s Ministry of Health and Long Term Care began instituting Health Links. For patients with complex care needs, this initiative has been a very positive development.
Health Links bring community health care providers together to ensure coordinated care for high-needs patients. Currently, there are 82 Health Links networks across Ontario.
One of the biggest advances associated with the initiative is coordinated care planning.
A coordinated care plan is an actionable tool for those involved in a patient’s health journey. These plans facilitate collaboration within circles of care. They create accountability by clarifying the roles of providers.
Such outcomes are crucial to providing better home and community care. Outside of a facility, circles of care are more likely to become disconnected.
How successful has Ontario’s care planning been so far?
According to a recent fourth quarter report, 18,926 complex patients have received coordinated care plans since Health Links began.
That’s almost 19,000 complex patients who have enjoyed better continuity of care than they otherwise would have. It’s likely that many of these patients avoided being admitted to a hospital as a result.
Patient involvement is another component of care planning that can’t be overlooked.
Part of the appeal of home care is that it empowers patients, helping them remain independent. The same can be said of coordinated care plans, which are designed with patient goals and preferences in mind.
The Ontario Medical Association notes that patients involved in planning their care are more likely to be compliant. And as we all know, compliance is a major factor in improving health outcomes and avoiding readmissions.
In recent years, the Ministry of Health and Long Term Care has received criticism for its home care services delivery. But few can deny that the province’s Health Links represent a major step forward – especially for complex-needs patients.
Ongoing investment, developing solutions
Along with the creation of Health Links, Ontario recently announced a $100 million investment in home and community care.
Funding will strengthen the sector, including areas that impact complex patients and their circles of care. For example, a number of projects will look at innovative ways of improving patient transitions between care environments.
When it comes to improving the lives of patients with complex care needs, innovation is key. Evolving infrastructure – such as we’re seeing with Health Links – coupled with technology is making a difference.
Generally, technology and new care models serve home care providers in two ways. They strengthen communication within circles of care, and they empower patients.
Innovation that improves home care communication can take many forms. We mentioned electronic health records above. It’s worth noting that the only Ontario-wide e-health platform belongs to Community Care Access Centres (CCACs).
In fact, there’s no shortage of digital tools that enable the real-time communication that promises better health outcomes. The process of transferring information related to patient health and wellbeing continues to improve.
Coordinators, nurses, PSWs, specialists, pharmacists, family members – these circle of care members must be on the same page. High quality care depends on it.
Of course, we can’t forget about patient involvement. Too often, patients with complex care needs are shuttled from one medical environment to the next. They’re forced to repeat their medical histories without fully understanding the care they’re receiving.
Those who understand home care believe in encouraging patient’s to play an active role in managing their care.
There are tools to help in various areas – from diet and medication adherence, to patient participation in circles of care.
There’s good reason for home care providers and relevant government organizations to team up with providers of digital solutions. Digital technology has vast reach, and the costs to maintain it are generally very low.
We look forward to seeing how Ontario’s health ministry harnesses the power of these solutions in the years ahead.
The creation of Health Links and the funding of new home care initiatives are important developments for Ontario health care.
Through these actions, the government is rejuvenating its approach to treating patients with complex care needs. In general, industry attitudes are following suit.
Coordinated care planning encourages providers to think of patients as more than the recipients of three, six, or fifteen different services. More and more, the patient’s journey is the biggest priority.
Feature image courtesy: sima dimitric