Huron-Perth health providers celebrate beginning of new coordinated planning system

Leaders in local health care were out to learn more about the new system of Coordinated Care PLanning last Friday at Stratford General Hospital. From left, are Southwest LHIN CEO Mike Barrett, founder of the Toronto-based health policy organization Instincts at Work Penny Paucha, North Perth Family Health Team Executive Director and HPHA board of directors chair Mary Atkinson and Southwest LHIN vice chair Ron Bolton. Also in attendance Friday were Southwest LHIN chair Jeff Low and HPHA President and CEO Andrew Williams.

By Dan Rankin

It was a different kind of celebration last Friday morning at Stratford General Hospital. Representatives from the Southwest Local Health Integration Network (LHIN) and Huron Perth Healthcare Alliance (HPHA), as well as health providers from around the area were celebrating not the completion of a journey, but the beginning of one.

Health Link Coordinated Care Planning is a new way of thinking for health care providers in Ontario that involves hospitals, family doctors, long-term care facilities, community organizations and others working together as a team to support the healthcare needs of patients with complex or multiple health conditions. One of the drivers behind this new coordinated care planning system is the fact that five percent of patients facing such health issues as congestive heart failure and chronic obstructive pulmonary disease account for two-thirds of health care costs.

By working as a team, the different health providers in this area can ensure patients at risk of falling into that “five percent” group receive better, more coordinated care, with fewer gaps that have previously existed between health providers and systems, said HPHA board of directors chair Mary Atkinson. Goals of the new system include reducing avoidable emergency room visits and unnecessary re-admissions to hospitals, reducing referral time between primary care and specialists, and improving patients’ experience during their journey through the health care system.


Penny Paucha, founder of the Toronto-based health policy organization Instincts at Work, leads a brainstorming session for Huron-Perth health providers involved with the new system of Coordinated Care Planning last Friday at Stratford General Hospital.

Locally, this planning is overseen by the Huron Perth Health Link, of which Atkinson is also chair. The North Perth Family Health Team, for which Atkinson is Executive Director, is the lead agency for the Huron Perth Health Link. North Perth first applied for funding for coordinated care planning in January 2013, and it has been slowly growing in the area since Fall 2013. A total of 81 patients have received coordinated care plans to date in Huron-Perth. In the Southwest LHIN area, Health Links have also been set up are or are taking shape in London-Middlesex, Elgin, Oxford, South Grey-Bruce and North Grey-Bruce.

Through the Coordinated Care Plan system, health providers design an individualized plan by working together with the patient and their families to ensure they receive the care they need in order to achieve their desired lifestyle.

“What we are doing is creating a system-wide philosophy of caring for patients where the patient is now our partner,” Atkinson said. “We’re not doing ‘to’ the patients anymore. We’re now working to do ‘with’ the patients, as peers. We’re asking providers to be consultants, interviewing the patient who is the expert on their health.”

By holding conferences that involve bringing the patient and their different health providers all under the same roof at the same time, it creates a patient-centric environment where they are able to express what they want, she said.

Simply stated, it’s about helping patients achieve goals, said Atkinson. “That’s really our mantra as a health link: it is about the patient.”

Collaborators throughout Huron-Perth include, but are not limited to, hospitals, long term care, home and community support services such as Meals on Wheels, the South West Community Care Access Centre, Canadian Mental Health and Addictions, the Alzheimer’s Society, Community Living, Perth District Health Unit and Huron County Emergency Medical Services.

In Stratford last Friday, it was evident just how new the Coordinated Care Planning system was to some of the area’s health care providers, as discussion leaders including Huron Perth Health Link project coordinator Catherine Shackleton and Penny Paucha, founder of the Toronto-based health policy organization Instincts at Work, held brain storming sessions with the attending health providers on how to improve conferences with patients and encouraged them to make time to commit to the new process.

“Providers across Huron-Perth have really come together with the plan,” Shackleton said. “Developing our own processes and, with their clinical knowledge, thinking of programs for the patients. It’s about really seeing the patient as an equal partner, and basing the plan of action on their goals; what they’d like to have done.”

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