Five per cent of patients account for two-thirds of healthcare costs. These patients most often have multiple, complex conditions along with having several healthcare providers looking after them. When a hospital, a family doctor, a longterm care home, along with several community organizations connect, these high needs patients receive better, more coordinated care.
Connecting patients to their care providers lies at the heart of today’s journey towards population health management. More and more providers and patients are embracing new technologies and looking for ways to be actively involved in care planning. This approach is being embraced by healthcare professionals due to a greater access to medical information between multiple care providers when creating Coordinated Care Plans (CCPs).
Without a care plan, the gap in communication among healthcare providers, along with the lack of updated medical information, can potentially result in unnecessary duplication of testing, increased patient episodes and leaves patients at a higher risk for Emergency Room visits.
When collaborating between hospitals, healthcare providers and community care organizations, Coordinated Care Plans provide reliable information about these complex patients along with critical clinical information for the entire care team. Clinicians are then able to design a care plan for each of their patients along with working together with their patients and their families to ensure they receive the care required.
In order to meet the challenges of coordinating care for the greatest users of the healthcare system, Ontario formed Health Links to help provide coordinated, efficient and effective care to patients with complex needs.
Several Health Links have already started creating standardized care plans in a nonelectronic “paper” format to be used by healthcare providers from primary care, hospital, home, community care, long-term care providers, community support agencies and other community partners to provide coordinated healthcare to patients with multiple complex conditions.
Creating a digital view of the patient journey
A patient’s plan must be flexible and allow for modifications and changes. Circumstances can change quickly especially for complex patients who have multiple conditions that require frequent use of various parts of the healthcare system.
A Care Coordination Tool (CCT) can bridge the gap between the patient and their healthcare providers. The tool allows care teams to better uncover and mitigate risks by identifying the factors affecting a patient’s medical condition. The tool also provides immediate access to a patient’s information to create a fluid plan, in a single, easy-to-read digital format. The CCT then tracks a patient’s progress through their entire healthcare journey.
CCT enables effective care coordination through its capacity to:
- Design a highly detailed care plan that includes both clinical and patient descriptions of ongoing issues, next steps to be taken, perceived patient risks and contact information for all care plan team members;
- auto-populate up-to-date patient history, past/active prescriptions and demographic information for each patient;
- allow authorized healthcare providers to create and update care plans and give secure visibility to other providers for proper coordination, all with the ability to ‘follow’ or ‘unfollow’ care plans for notifications when updated; and
- enable users to send secure messages to any other user of CCT in order to further bridge communication gaps.
CCT ensures that no matter when or where a patient consults with their healthcare provider, the care plan is updated continuously within a secure and private system.
Putting the Patient First
With Coordinated Care Plans, patients and their families have more visibility, understanding and control over their own healthcare. They are able to review their own plan and ask for adjustments or clarity based on discussions with their care team.
There is no doubt that CCPs can improve the healthcare experience for healthcare providers, patients and their families. By being able to view care plans in real time, healthcare providers can ensure that a patient is on track for their specific goals.
By using a Coordinated Care Plan, patients are being put first therefore creating a sustainable healthcare plan for now and for the future.