Work starts on high-needs patients

Partners of the North East Toronto Health Link are now able to locate their most complex patients on a Top 100 list, allowing clinicians to target those who may require more enhanced or coordinated care. This marks a significant milestone in the Health Link, which has been working to not only identify complex patients but to provide that information to partners through data sharing and confidentiality agreements.

Patients on our Top 100 list are defined as those with the highest number of admissions and emergency department visits to Sunnybrook's Emergency Department. In all, 63 Sunnybrook patients are actively shared with the Toronto Central Community Care Access Centre.

The top five diagnoses of these patients are congestive heart failure; chronic obstructive pulmonary disease; pneumonia, myocardial infarction and fracture.

We are working on our fourth iteration of the data, due in part to the high death rate (about 24 per cent) and as some patients had acute episodes with long hospital stays then left. Only two patients on our first Top 100 list (Nov. 2011-April 2012) remained on it by this past spring. One patient had 103 visits to Sunnybrook's emergency over nine months.

A further analysis on the patient data shared by the TC CCAC and Sunnybrook's Top 100 list, revealed 24 patients in our Link. As we did not want geography to be a barrier to more coordinated care, partners are working off the entire list of 63. In fact, one partner found that six of their patients were on the list. Three of the 24 patients were unattached, prompting us to start the work of attaching them to a primary care physician.

The agreements we have in place allow partners to share Sunnybrook's Top 100 information with the TC CCAC but our Health Link is looking at what agreements will be necessary for the partners to share their most complex patient lists with the TC CCAC some time in the future.