Before the health link, I was very depressed and very stressful. It was very, very hard for me, because I had to do it all by myself.
Maire Hollo lives in Toronto and has more than a dozen children, grandchildren and great grandchildren who keep her days full. She also suffers from colitis, dehydration and bladder infections, which mean regular trips to the doctor, prescription medications, and, until recently, a fair amount of time spent in the emergency department.
She’s not alone. There are thousands of patients like her with unmet needs who end up in emergency for treatment of their chronic conditions. Conditions that could be best managed elsewhere. Some have several chronic conditions, making it daunting to navigate the health care system.
That’s why Ontario launched Health Links, including the North East Toronto Health Link, coordinated by Sunnybrook Health Sciences Centre. Once enrolled, patients become part of a virtual program that provides coordinated care in the hospital and in the community.
Walter Leahy
Health Links Liaison Care Coordinator (Toronto Central Community Care Access Centre):
It ensures that the client knows that when they talk to anyone on the team, that information is then transmitted to the entire care team.
Here’s how it works: an information management system called Better Care tracks when a patient goes to the Emergency Department or is admitted to hospital. If a patient reaches a certain number of visits, an email is sent to authorized providers.
Inside the hospital the information can be viewed on a mobile device, outside the hospital, providers log into a secure portal. There they can see the list of patients they enrolled and the date of the most recent hospital visit. With one more click a more detailed report appears, including the reason for the visit and the diagnosis.
Amy Chen
Geriatric Emergency Management nurse:
When someone arrives in the emergency room, there are registered through the triage process, we will receive an alert on our pager, or our email. At which point in time we will approach the patient, enroll them into the Health Link program.
In the community patients are identified if they have a certain number of chronic conditions and other vulnerable factors that includes social determinants of health.
Each patient enrolled in the North East Toronto Health Link Better Care Program works with their care team to design a plan that focuses on what matter most to them.
Amy: Some people they want to breathe a bit better and we talk about how we can make that happen, they talk about home oxygen, different medications and or they talk about gaining more mobility back.
Authorized members of the care team have secure access to the Health Links Better Care portal and can stay up to date on their patients’ health. For example, the main reason why the patient went to hospital, how long that patient stayed and for what.
Walter: Before I go see client in the community, I can check the portal, which will give me give me current information so that will help to inform my visit.
Every patient has a point person for their care – helping pull together the entire team in the hospital and in the community.
Marie: Now if I have a problem, there is one person I can call and she knows all about my health and it makes so much easier
Amy: And this will hopefully cut down on avoidable emergency visits and even if these patients enrolled in the Health Link do present to the emergency room, their visit is much smoother and much more efficient, because we have their entire medical history in front of us.
Marie: And I can spend my time more, on what I want to do, going to exercise, going yoga, going shopping, going walks and visit my family
