Multiple studies have shown that use of health care resources is highly concentrated among a small number of patients. Data from Canada suggest that high-cost users (the top 5% of the population) account for two-thirds of annual health care spending, including 29% of payments for physician services and 61% of hospital and home care costs. Similar findings have been reported in the United States. With limited health care resources available, transforming the delivery of health care services to better meet the needs of patients with the most complex needs is required for sustainability of the health care system.
In response, Ontario’s Ministry of Health and Long-Term Care launched Health Links, an ambitious strategy aimed to better provide coordinated, community-based health care for patients with complex health and social needs. The program started with 26 early-adopter Health Links in December 2012, and 82 sites were in operation throughout the province by the end of 2015. Each Health Link is voluntary and operates under a low-rules approach, having the flexibility to determine how coordinated care will be delivered within the regional context. Patients are typically referred into Health Links during a presentation to the health care system, based on (any of) being at high risk for inpatient admission or readmission, having multiple inpatient and/or emergency visits in the previous year, or having multiple coexisting chronic conditions or socioeconomic challenges (such as low income or lack of social support). Once enrolled, patients are provided with intensive care coordination, including multidisciplinary care, and a patient-centred coordinated care plan is completed that outlines the patient’s needs, goals, providers, treatments and appointments. These processes aim to engage patients and their care providers to ensure that the plan is being followed, that patients are taking the right medications and that patients have a care provider who knows them whom they can call, all with the aims of improving access to care, reducing wait times and preventing unnecessary hospital and emergency visits.
We have undertaken an extensive program of research relating to Health Links inclusive of examining precedents in Accountable Care Organizations to determine key performance measures and an entire case study methodology to evaluate the Context and Capabilities for implementing Integrated Care. We approach our evaluation of Health Links as complex adaptive systems and implemented a comprehensive qualitative and quantitative evaluation of the implementation and health system effects of the Health Links approach to care.