Coordinated plan for high users of health care
By Linda Fox
Gayle Seddon, Director of Community Programs for the Toronto Central Community Care Access Centre (TC CCAC), is charged with one of the biggest tasks in Health Links: overseeing coordinated care plans for patients who require them — some 45 patients who are frequent users of the health care system. Gayle considers the patient as the most important factor. I asked her a few questions about getting this program launched.
Q. How do you create 45 individual care plans?
A. What is great is that we have been able to work in a really defined way to understand the needs of the patient. The patient gets to be part of the conversation and to tell us what is important to them. It is all about expectations. How many times do we really have an honest conversation with a patient? Health care has to say, "we can't necessarily fix the disease, but we can control medications, the treatments, the comfort level." We have to be very careful not to remove hope.
Q. Who are considered high users of the health care system?
A. The largest group are those over the age of 65 with complex medical issues. Conditions range from diabetes, heart or lung disease, epilepsy, asthma and renal diseases. These are patients who need how to understand their diseases in the context of everyday life to minimize organ damage.
Q. Are there other types of frequent users of the health care system?
A. We have patients who have a combination of diabetes, cardiac and respiratory disease. Dementia is another area where careful co-ordinated planning is needed.
Q. Do any incidents stand out where patients have done the unexpected?
A. One dementia patient didn't usually know what day it was if asked. But he began getting the newspaper every day. He knew from the paper what the day and date was and felt better being able to talk to others about the weather, or events of that day. Sometimes it is the small things that help. Overall, we found that about one in five patients had intermittent relationships with their family doctor - they were loosely connected to primary care.
Q. How often does a care plan change?
A. They are updated as often as every month for high-user clients. The plan needs to be extremely elastic. Some patients may need a whole team of care givers while another may suddenly need a specialist. Things change.
Q. What impact will the co-ordinated care plans ultimately have on the users?
A. A huge benefit is that patients are given an opportunity to identify what their goals are and to work with their providers. Going forward we would like to see a web base tool in place to help people with self-management of their professional care.
Q. How has working on the plans affected you personally?
A. It is intense work, but rewarding and truly heartfelt work. Prioritizing patient needs is the key to the program's success
