Health Link SSM

What is Health Link SSM?

Last year planning began for Health Link Sault Ste. Marie. A Health Link is a voluntary coalition of partners that treat Ontarians with complex needs. Five per cent of patients account for two-thirds of health care costs. These are most often patients with multiple, complex conditions. When the hospital, the family doctor, the long-term care home, community organizations and others work as a team, the patient receives better, more coordinated care. Health Links is an innovative model that provides coordinated local health planning for patients who often see multiple providers, access a range of health care services, and find it difficult to navigate the health system.

 

How many other Health Links exist across the Province?

There are currently five approved Health Links in the North East LHIN including Timmins (early adopter), Temiskaming (early adopter), Nipissing East Parry Sound, North Cochrane, and Sault Ste. Marie, with others underway including Sudbury. There are a total of 69 Health Links sites covering all LHINs.

 

Who are the SSM Health Link partners?

Participants in the Health Link Sault Ste. Marie initiative include, Group Health Centre, ARCH Hospice, SAH, other primary care organizations, Community Care Access Centre, community mental health and addictions, Algoma Public Health, the City of Sault Ste. Marie, the Innovation Centre, and Long Term Care. Sault Ste. Marie’s Health Link Steering Committee is led by Dr. David Fera, with the Group Health Centre (the lead agency) and project coordinator Theresa Mudge, Executive Director of ARCH Hospice.

 

Who is on the SSM Health Link Steering Committee?

No single organization can do it alone to create maximum value for patients and communities. Transformation is needed and it must be grounded in connections between multiple organizations, professionals, ministries, funders and levels of government coming together. 

 Health Link Sault Ste. Marie Steering Committee: 

  • Chair – Dr. David Fera, Algoma District Medical Group
  • Vice Chair – Dr. Alan McLean, Superior Family Health Team
  • Administrative Support – Pina Hladki, Group Health Centre

Members: 

  • Alex Lambert, Group Health Centre
  • Ali Pettenuzo, Algoma Nurse Practitioner Led Clinic
  • Annette Katajamaki, Canadian Mental Health Association
  • Bert Leith, Community Support Services
  • Christianne Monico, North East Community Care Access Centre
  • Dr. Heather O’Brien, Sault Area Hospital
  • Dr. Jodie Stewart, Primary Care Lead Algoma District
  • Elizabeth Edgar-Webkamigad, Baawaating Family Health Team
  • Jennifer Wallenius, North East Local Health Integration Network
  • Laurie Zeppa, Algoma Public Health
  • Mike Nadeau, Social Services Administration Board – City of Sault Ste. Marie
  • Paul Beach, Patient & Family Representative
  • Robert Barnett, North East Community Care Access Centre
  • Ron Gagnon, Sault Area Hospital
  • Theresa Mudge, ARCH Hospice
  • Tony Hanlon, Algoma Public Health

 

What was the process for identifying/selecting patients for the SSM Health Link?

The SSM Health Link Steering Committee has been instrumental in guiding a large team of health and social service providers to drill into the data to understand who would benefit most from Health Links and what kind of chronic conditions require care. The Sault Ste. Marie Health Link consulted with more than 120 stakeholders between November 2015 and January 2016 in developing its plan. The top health conditions found in among Sault Ste. Marie’s most medically complex patients include: hypertension; ischaemic heart disease; diabetes;  chronic obstructive pulmonary disease;  renal failure; arthritis and related disorders; cardiac arrhythmia; congestive heart failure; depression; and pneumonia.

So far, more than 400 patients have been identified. In this first roll out phase, 50 patients will be selected and asked to participate.

 

How will the SSM Health Link benefit patients?

The participating patients and their families will meet with a Guided Care Nurse, who will work with them, their primary care provider, as well as other health professionals, and agencies involved in their care. Together they come up with a coordinated care plan. This plan will help reduce unnecessary visits to the emergency department, repeat readmissions to hospital, and ensure if they do end up in hospital, staff know what their needs are and what care they require.

For patients, it means they will:

  • Have an individualized, coordinated plan
  • Have care providers who ensure the plan is being followed
  • Have support to ensure they are taking the right medications
  • Have a care provider they can call who knows them, is familiar with their situation and can help

 

What are the next steps for the SSM Health Link?

The next six months is the pilot phase of the SSM Health Link.  A total of 50 patients will be enrolled in the program to test the processes, revise the coordinated care plan if needed, develop the role of the guided care nurse, etc. 

 

Where can I find more information?

To find out more about the Sault Ste. Marie Health Link visit www.healthlinkssm.com