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Transformative Change Awards: Rural Hastings Health Link Providing Seamless Care Coordination

Some might say delivering the best possible health care these days takes a village. In the case of the Rural Hastings Health Link, it would be more accurate to say it’s taken the collaboration of service providers across several villages, towns, and cities in the eastern Ontario area to build a truly seamless and engaged model of care.

Earlier this month, the Rural Hastings Health Link (RHHL) was honoured with a 2016 Transformative Change Award, a province-wide award given by the Association of Ontario Health Centres to recognize and champion the work done by the RHHL towards improving patients’ health care experiences, decreasing usage of the local hospital’s emergency department, and leading by example for other healthcare organizations who are seeking to address the social determinants of health in their communities.

The RHHL is made up of four primary care sites – Gateway Community Health Centre (Tweed), Central Hastings Family Health Team (Madoc and Marmora), Bancroft Family Health Team (Bancroft) and North Hastings Community Family Health Team (Bancroft) – that have all helped to develop a new way of thinking and planning for care pathways, with the goal of improving patients’ experiences as they transition between organizations for different types of care and social services. That’s meant engaging working groups between various service organizations and patients themselves to break down barriers to care, as well as carefully monitoring results along the way. Emily Rashotte, RN, is the Rural Hastings Health Link Coordinator, and she says that a shift in mindset around putting the patient and her or his goals at the centre of their own care is what drove the transformation in Rural Hastings from the outset.

“As providers, we’re really shifting from saying, ‘Here’s what I’m going to tell you to do,’ to system navigators now asking patients: ‘What’s important to you? What are your goals?’ And from that, we hear about barriers and issues that patients are having that are impacting their health goals,” Rashotte said. “It’s really about taking that step back, and asking what’s important to the patient. I think that involves looking away from just the medical piece and addressing social complexity, and what’s really going on with them.”

Rashotte gives the example of a patient who’s unable to pay a hydro bill, and is facing losing the service. Knowing about a non-medical challenge, the stress it creates for a patient, and the impacts that it can have on medical conditions, such as diabetes, and other social issues such as food security, can help point towards the solutions needed in an immediate way. Sitting down to help them fill out a Low-Income Energy Assistance Program (LEAP) application, for instance, to make sure the lights stay on, would be the first necessary step to helping them improve their diet and better manage their diabetes, and could further lead to identifying other social complexity that might have been missed if the hydro issue wasn’t dealt with in a timely fashion.

“Stepping back to look at the underlying factors that can act as barriers to wellbeing and good health,” Rashotte said, “that’s really the transformative piece here: Identifying the patient’s goals, and how we can support them, and building on that.”

Part of the innovation of the Rural Hastings Health Link is how the System Navigator role has helped to redefine the relationship between doctor and patient for both sides.

“The physician goes into an appointment already knowing the patient has been to a specialist, and they’ve gotten an update from the System Navigator ahead of time,” Rashotte explained. “So now during the 15 minutes that they’re with the patient, they can really target some of the health issues that have been raised, instead of worrying about calling different agencies and trying to figure out social service referrals, transportation, or that kind of thing.”

“And for the patient,” Rashotte continued, “the System Navigator really is that strong advocate, someone who, because they’re not working with a specific agency or under a specific mandate, can support them in a broad sense, everything from transitions to community support services and mental health services, but also helping them on smaller issues, such as if someone were looking for a scooter, helping them to apply for supplemental funding from a community service group like the local Lion’s Club or others to ensure that they get one.”

Lyn Linton, Executive Director of Gateway Community Health Centre, the lead organization in the RHHL, said that the transformation that’s taken place has only been possible because the collaborating organizations of the RHHL have worked to know each other each other’s roles better. That collaborative framework is what in turn has allowed the pathways between them to built, and those pathways then enable the System Navigators to perform their roles for patients on a day-to-day basis.

“Currently, CCAC, Community Care Services, Hospice, Addictions and Mental Health Services, and Hospital Discharge Planners are working closely with the primary care System Navigators to ensure that the patient’s care is seamless between their respective organizations,” Linton said.

And the results for clients with social complexities has been staggering, both from their standpoint, and from the side of resources saved by the healthcare system in the process.

“Since January 2013, the RHHL has supported 366 patients with a Coordinated Care Plan, improved the patient’s experience by 86%, and demonstrated an 87% reduction in emergency department visits, an 86% reduction in hospital admissions and a 91% reduction in hospital length of stay.”

Transformation, as they might say now, takes even more than a village. It takes a vision to bring them together.

2016 Transformative Change Award - Rural Hastings Health Link from AOHC ACSO on Vimeo.