Percentage of patients/clients identified as meeting Health Link criteria (Retired)

Percentage of patients identified as meeting Health Link criteria who are offered access to Health Links Approach

Percentage

The percentage is calculated as: numerator divided denominator times 100.

Total number of patients who were offered access to the Health Link approach

Total number of patients identified through clinical level assessments and/or data-driven case-finding methods sourced as meeting HLs criteria

Exclusions: 

• Patients who meet the criteria but who are not offered access to the Health Link because they have moved beyond Health Link catchment area, or have died.

Local data collection

Local data collection

This is an additional indicator for QIP 2018/19. Current performance reporting period: most recent 3 month period. This indicator is common across the following sectors: acute care/hospital, home care and primary care. In late 2015, Health Quality Ontario completed a review of the best available information about Health Links and analysis of innovations related to Coordinated Care Management (http://www.hqontario.ca/Portals/0/documents/qi/health-links/ccm-overall-summary-of-innovative-practices-en.pdf). The innovations framework includes detailed information to help organizations identify patients with multiple conditions and complex needs through clinical level assessments and data driven case finding methods at any point in the patient’s healthcare journey. Patients identification approaches: Use clinical level patient identification mechanisms to support identification of patients during a service encounter. For example, as each patient presents to a health or wellness organization or program to receive care, the provider may identify that the patient may benefit from a Health Links/Coordinated Care Management approach. To further support clinical decision making, the provider may then administer a standardized risk assessment tool, if indicated. Use data driven case finding mechanisms to support prospective identification of patients with multiple conditions and complex needs using utilization data to identify complex patients. For example, triggers such as the number of visits to the emergency department, number/length of admissions to hospital within a specified time frame, or patients with specific diagnoses or conditions can be built into the electronic medical record or can be managed by targeted data extraction and analysis methods, to support the identification of potential Patients with multiple conditions and complex needs. Note: A single, cross-sectorial clinical level risk assessment tool/method with adequate sensitivity and specificity to capture every patient who would benefit from a Health Links/Coordinated Care Management approach was not identified. However, the following risk assessment tools were highlighted by Health Links during the environmental scan, and are presented here for consideration based on the practice setting. The decision to implement/administer one of these tools must be considered alongside other contextually relevant information. • LACE (Length of Stay, Acuity of Admission, Comorbidities, Emergency Room Visits) • PRA (Predictive Repetitive Admission) • DIVERT Scale (Detection of Indicators and Vulnerabilities for Emergency Room Trips Scale ) For more technical details, please refer to Identify Patients: Use a combination of Clinical and Data Driven Strategies (http://www.hqontario.ca/Portals/0/documents/qi/health-links/ccm-identify-patients-use-clinical-and-data-driven-approaches-en.pdf) Note: Once a patient who has multiple conditions or complex needs has been identified, the organization should connect to the processes established by the local Health Link. This indicator was retired in the 2019/20 QIP.

04/03/2019 10:14:00