Supporting people in preventing and managing chronic conditions

By optimizing care coordination, enhancing accessibility and maximizing provider collaboration in a cost effective and efficient manner, the LHIN and health service providers will be able to support people in preventing and appropriately managing chronic conditions.

Ontario recognizes the need for greater coordination of care for people with multiple complex conditions. Five per cent of patients account for two-thirds of health care costs. These are most often patients with multiple, complex conditions. When the hospital, the family doctor, the long-term care home, community organizations and others work as a team, the patient receives better, more coordinated care. Community Health Links are local partnerships where care providers work together to coordinate efficient and effective care for patients with complex needs. There are six Health Links in the LHIN. These partnerships continue to advance in alignment with provincial direction.
We continue to focus on programs that coordinate and align services to support people with chronic conditions in staying as healthy as possible. Chronic disease and self-management programs support Ontario’s direction to improve access to the right care, and to coordinate and integrate care in the community. 

Together with the LHIN, system partners will:

  • Support and expand Health Links approach to use more Experience Based Design methods and coordinated care plans for individuals with complex needs.
  • Standardize care pathways and quality-based procedures for certain chronic conditions.
  • Advance culturally-safe chronic disease care for the Aboriginal and Francophone populations, including availability of tools, resources and workshops.
  • Develop and spread electronic health tools to share coordinated care plans, the tele-homecare program, as well as the models for diabetes coordinated access, diabetes foot care, and chronic disease prevention and management.
  • Build system capacity to support people to self-manage their care.

Resources:    

  • Health Links

  • Diabetes Foot Care Report: Individuals with diabetes are at increased risk of foot ulcers and lower extremity amputations. Proper foot care from prevention of ulcers to the management and treatment of diabetes foot conditions will improve patient health, quality of life and reduce the costs associated with treatment of foot ulcers including amputations. The LHIN worked with local stakeholders and a consultant to review the current state of diabetes foot care and develop an integrated, system-level service delivery model. The model is based on a person-centred, preventative and interdisciplinary team approach that leverages existing services and organizations and utilizes harmonized risk stratification and referral algorithms.