Launch of Greater Sudbury Health Link

October 5, 2016 – Dora Reynolds*, in her 60s, feels like she spends most of her life in waiting rooms. She’s either waiting for the next appointment to deal with her diabetes, arthritis, breathing problems, and re-occurring depression or waiting in the Emergency Department when she gets anxious about her worsening symptoms. She’s constantly telling her “story” over and over again, trying to remember all the pills she’s on, and isn’t sure how she will continue living on her own in her Sudbury apartment without some help.
By bringing all Dora’s providers together to help her create her own care plan, the Greater Sudbury Health Link will work to change how care is coordinated for people like Dora who need a complex range of health and social services. The North East Local Health Integration Network (NE LHIN) is working to develop Health Links in communities across the region to increase care coordination for those who need it the most.

On Wednesday morning, 17 health and partner agencies – including the lead Health Link agency, the Canadian Mental Health Association (CMHA) Sudbury/Manitoulin – came together to celebrate the launch of the Greater Sudbury Health Link.

The Health Link will help people who are challenged by many chronic health conditions, mental illness, addictions, and developmental disability, as well as those who have poor access to some of the social determinants of health, like housing, education, employment.

Members of the Greater Sudbury Health Link care team may include primary care providers, specialists, allied health professionals, community health and social service providers, housing, culturally appropriate services, and other informal caregivers.

Together, with the patient, providers will develop care plans and goals to achieve them. Lead Care Coordinators will act as the first point of contact for individuals and other members of the care team, to access and navigate the range of services and supports that are needed.

*Patient identity anonymized

Quotes:
“Health Links pull together care for patients with complex needs, working with them to create their own care plan and goals. Improving the patient experience and increasing care coordination are two of the reasons why we as a LHIN are working with our providers and partners to develop Health Links across Northeastern Ontario.”
Louise Paquette, North East LHIN CEO

“The Canadian Mental Health Association-Sudbury/Manitoulin is pleased to be the lead agency for the Greater Sudbury Health Link. It is only possible, however, thanks to the experience, commitment and contributions of its collaborating and supporting partners.

We all serve individuals who require a complex range of health and social supports. We work to build access to primary health care and a broader system of care that is effective, efficient and, most importantly, results in positive outcomes for individuals, families and caregivers. The Health Link approach to care coordination will ensure that we continue to put people at the centre of their care, working as their team, towards their health and wellness goals.”
Marion Quigley, CMHA

“Monarch is pleased to participate in the Greater Sudbury Health Link as we work with some men and women who have complex medical needs and it is often difficult to access and navigate services for them. We look forward to collaborating with the Health Link partners in order to provide the coordinated care and extra support that will meet the needs of those we serve.”
Kathryn Irwin-Séguin, CEO, Monarch Recovery Services

“The North East CCAC is really excited to be a Health Links partner in Greater Sudbury. Just as it takes a village to raise a child, this approach to serving patients with complex health issues effectively wraps many different services from many different service providers and agencies around each patient and their family. It truly represents what we mean by person-centred care.”
Frankie Vitone, Senior Director, Care Coordination, North East Community Care Access Centre

“With Health Links, a person’s well-being will be improved by bringing together the right professionals at the right time to help the patient meet their health-related goals. By working as a multi-disciplinary team whose purpose is to support patients and their families, Health Links patients will avoid having to repeat their stories and health histories numerous times, as the same set of care providers and coordinators will help them navigate through the system.”
Dr. Jason Sutherland, North East LHIN Primary Care Lead

“Health Link is a new initiative aimed at helping individuals in our community, who are living with very complex conditions. One of the most important principles of Health Link is that there is a process in place to ensure timely and consistent information sharing between ALL of an individual’s healthcare providers and community service providers. This way, the focus of the team’s efforts can be guided by the individual’s self-identified values and needs to help improve their well-being.”
Dr. Liisa Levasseur, City of Lakes Family Health Team

“Health Sciences North is pleased to be collaborating with patients and their caregivers as well as other community-based providers to ensure we have timely access to the most current information about shared complex patients. The Health Link holds promise as an effective way to coordinate care within the community and between home and hospital, while respecting the patient’s treatment goals and wishes, and their rights regarding how and with whom information is shared. The Health Link will offer significant patient safety and care transition improvements.”
Maureen McLelland, Associate Vice President, Clinical Transformation & Transitions, Health Sciences North

Background:

• Health Links are accountable to the LHIN through a lead agency. The lead agency for the Greater Sudbury Health Link is the CMHA Sudbury-Manitoulin.
• The North East LHIN’s 2016 – 2019 Integrated Health Service Plan named “increased coordination of care” as one of its three priorities and new models of care delivery such as Health Links and Health Hubs as some of the ways that this priority can be achieved.
• There are currently six Health Links at different stages of development in the North East LHIN including Timmins (early adopter), Temiskaming (early adopter), Nipissing-East Parry Sound, North Cochrane, Sault Ste. Marie, and now Sudbury. Efforts are underway to establish Health Links in eight other communities.
• For more information on the Greater Sudbury Health Link click here or go tohttp://sm.cmha.ca/ and look under “services.”

Greater Sudbury Health Link Participants:

• Canadian Mental Health Association (CMHA) Sudbury/Manitoulin
• Centre de santé communautaire du Grand Sudbury
• City of Lakes Family Health Team
• Greater Sudbury Paramedic Service
• Health Sciences North
• Monarch Recovery Services
• North Bay Regional Health Centre
• North East Behavioural Supports Ontario
• North East Community Care Access Centre
• North East Specialized Geriatric Services
• North Eastern Ontario Medical Offices
• Northern Initiative for Social Action
• Réseau ACCESS Network – HIV/Hepatitis Health and Social Services
• Shkagamik-Kwe Aboriginal Health Access Centre
• Sudbury Community Service Centre
• Sudbury & District Health Unit
• Sudbury District Nurse Practitioner Clinic

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