The North East Local Health Integration Network (LHIN) estimates there are around 11,000 people in Greater Sudbury with four or more chronic health conditions.
Those individuals might have to deal with up to a dozen different health-care providers to meet their needs, and can often get lost in the complexity of the system.
“The good news is we're living longer. The bad news is our system hasn't caught up with our needs,” said Louise Paquette, CEO of the North East LHIN.
To help meet those patients' needs Greater Sudbury has become the latest city to establish its own Health Link system.
Through Health Link, 17 health-care agencies in the community, including the Canadian Mental Health Association Sudbury Manitoulin, the North East Community Care Access Centre, the Sudbury and District Health Unit and the City of Lakes Family Health Team will be able to better co-ordinate care for individuals with multiple chronic conditions.
The Canadian Mental Health Association will be the lead Health Link agency for the region.
“We found that many of those individuals (with multiple chronic conditions), regardless of the complexity of their situations, had an underlying mental illness, addiction and/or developmental disability,” said Stephanie Lefebvre, manager of service collaboration with the Canadian Mental Health Association Sudbury-Manitoulin.
Lefebvre said they have started the pilot Health Links with a few patients before expanding the system to the larger patient population.
“Every individual will have a designated lead care co-ordinator,” she said.
That care co-ordinator is chosen based on the patient's needs. For a person with mental health problems it might be the Canadian Mental Health Association, but it could also be a person's primary care provider or the Community Care Access Centre.
Once they have a care co-ordinator, Lefebvre said they go through the time-consuming process of developing a health-care plan for the individual that meets their needs, and ensures they different health-care providers are on the same page.
“You are really taking the time to understand what an individual's personal health goals are, what their challenges are, identifying their team and bringing together that team,” Lefebvre said.
Once the person's care plan is established Lefebvre that early investment leads to a long-term payoff for the patient.
With a plan in place, and all their care providers in sync, the Health Link system should help patients navigate a health-care system that can be complex and daunting, especially if a person is dealing with a number of health and social issues.
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.
