Benefits to the Patient and the Health System

In just over a decade, Ontario is expected to see its number of seniors, 85 years and older, quadruple. As Ontarians age, they also develop more comorbidities, with 70 per cent of seniors expected to live with two or more chronic conditions by 2030. For these frail patients requiring services from multiple providers, accessing the right level of care at the right time is bound to be tricky.

That’s where care coordination comes in. It’s a fundamental health service that assesses and coordinates the most appropriate services for a person’s health needs. Through this process, care coordination facilitates smooth transitions between varying levels of care. Care coordinators are regulated health professionals with backgrounds in nursing, social work, occupational therapy, physiotherapy or speech therapy. They work directly with patients receiving care either in hospitals, doctors’ offices, community clinics, schools, or in their own homes.

Care coordinators take a holistic view of the person’s clinical and social status to identify the most appropriate services for the patient, such as nursing care, personal supports for daily living, occupational or physiotherapy, adult day programs, or help finding a primary care provider.

Reducing health risks

At the patient level, care coordination reduces health risks by ensuring that every patient receives health services to match their needs. Seniors with multiple chronic conditions rarely require the same level of care over a consistent period of time. Their health fluctuates. Sometimes they require intensive care, while at other times they may be able to live more independently, needing less care.

Care coordinators are crucial in helping patients and families weave through these different types and levels of care by assessing patients’ clinical statuses, monitoring their outcomes and adjusting the plan of care with all health care providers. They also focus on patient’s social determinants of health, such as income, housing status and social supports, which might affect their wellbeing.

As I mentioned in a recent post, “3 Steps to Addressing Socioeconomic Barriers to Achieve Better Outcomes,” patients with socioeconomic barriers can’t afford to follow health care directions if they don’t have the necessary social supports. Care coordinators have the means to link with other organizations and share information with partners in the patient’s circle of care to address socioeconomic issues through non-clinical supports. These supports could be help related to lifestyle changes or assistance in accessing social support services and volunteer programs.

Providing effective care coordination that addresses clinical and social determinants of health enables patients to live safely in their home. This health service spares patients the social impact of leaving the comfort of their home. It also saves the financial costs of hospitalization or a premature move to long-term care.

Optimizing Resources

An unnecessarily early move to long-term care isn’t just costly for the patient – it’s taxing on the entire health system, with long-term care costing $126 per day, compared to $42 per day for home care. Beds are also limited – the Mississauga Halton LHIN for example, has 25 per cent fewer beds per senior than the provincial average.

Yet we still see some patients moving prematurely to long-term care homes without first receiving Supports for Daily Living, Adult Day Programs, assisted living or home care – services that could help patients retain their independence for as long as possible, while easing the demand for beds in hospital or long-term care homes.

Without having a care coordinator involved in their care, patients might skip these crucial levels of care when they experience health crises and go to the hospital emergency department or seek a physician’s care. During crises, patients and their families may also rush to obtain care in a long-term home believing it’s the only solution. Many have difficulty understanding that with the proper supports, they may improve at home or in their community.

To optimize our province’s resources, we have to ensure that long-term care beds are reserved for patients with the highest needs. Care coordinators can help patients who don’t require services in long-term care by empowering them to remain at home and independent. They can also arrange for home and informal care services to help discharge seniors admitted to long-term care following an acute episode.

Evolving Care Coordination to Meet Patient Needs

To best serve our patients, care coordination must be consistent in its service delivery – something we learned after surveying the Mississauga Halton Community Care Access Centre’s (CCAC’s) patients and caregivers. Feedback from this survey showed that patients value consistency above all. Regardless of where they live, patients want to receive the same approach to care coordination and the same quality of care, as any other individual in the region.

Based on this survey’s findings and results from the Community Capacity Plan, the Mississauga Halton CCAC saw an opportunity to redefine and enhance the role of care coordinators.

We found care coordinators to be most effective when they’re connected to every part of the health system, serving as the single point of contact for patients to obtain services and information in their neighbourhoods. To facilitate this, our CCAC implemented the Care Coordination Program of Work, through three key phases:

1. Care Coordination Enhancement

To ensure patients receive consistent care, we trained care coordinators on the following eight core competencies, which serve as the foundation for delivering a patient-centred, holistic approach to care:

• Assessment
• Communication
• Navigation
• Quality and patient safety
• Collaboration
• Sustainability
• Care transitions
• Care planning

These core competencies modernized the way we deliver care by establishing consistent care practices for coordinated care planning.  They also leveraged technology and proactively engaged all those in a patient’s circle of care.

2. Neighbourhood Realignment

Because Socioeconomic and Cultural (SEC) statuses vary significantly across neighbourhoods, it’s important to have a strong understanding of the social, cultural and economic factors that impact the ability of people in those neighbourhoods to access care.

Our CCAC also realigned care coordination teams and caseloads to specific neighbourhoods within the Mississauga Halton region. This helped care coordinators hone expertise in the specific resources available in the dedicated neighbourhood where they work. With this knowledge, they can remove barriers to care, tailor services to patients and arrange for support from local resources.

3. Connecting to Primary Care

Finally, to deliver quality care, we must establish strong connected teams that wrap care around patients and in collaboration with their family physician or other primary care provider. To help achieve this, Mississauga Halton CCAC created the Primary Care Advisor (PCA) role. PCAs serve as the point of contact for primary care physicians in Health Links boundaries.

Through this relationship, they’re able to increase awareness of LHIN programs and services among primary care physicians and also gather feedback to improve patient outcomes and experiences.

Expanding the Role of Care Coordination

I’ve seen efforts to reimagine the role of care coordinators to become coordinators for the entire health system move forward, largely due to the eight core competencies that now guide and standardize care coordination in our region. Looking ahead, we need to understand that care coordination offers value among the broader circle of care, and that sometimes, there might be minimal involvement from partnered service providers.

Care coordination could be expanded to include other partners funded through community and social services, such as Development Services Ontario and Correctional Services for specific patient populations, rather than just through the health system. It could also involve coordinating care to include pharmacy, laboratory, imaging and physician services, which are beyond the LHINs’ current mandate.

What do you think? In what other ways do you see care coordination evolving?