Understanding Social Determinants of Health to Customize and Improve Healthcare Dawn Major RN, BScN, MSc(QIPS), CIC
Chief Performance, Quality and Risk OfficerGeorgian Bay General Hospital
Christine Ralhan, BCommProject ManagerNorth Simcoe Community Health Link
Canadian Healthcare System• Single-payer and mostly publicly-funded system, equitable
access to healthcare services
• 2014 health care spending as a percentage of GDP: Canada 10% vs. U.S. 16.6%*
• Team approach to managing chronic conditions and preventative care
• Provincial initiative to address the root causes of health inequities by strengthening the social determinants of health
*Schneider, E. C., et al. “Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care.” The Commonwealth Fund, 14 July 2017
Acute Care High User CharacteristicsCosting Profile
• 2016 Healthcare consumes 43.2% of the provincial budget*
• 5% of patients account for 2/3 of healthcare costs
• Top 1% of GBGH users account for 25.2% of costs
Patient Profile
• 2+ chronic conditions
• 4+ ED visits and 2+ admissions in the last 12 months
• COPD 34%, CHF 34%, diabetes 38%
“The Sustainability of Health Care Spending in Canada 2017.” Fraser Institute, 14 Mar. 2017
What is Health Link?An approach to improve the delivery and coordination of care for patients who are high users of the health care system
receiving services from several different health and social system providers.
Patient goal driven:
Emphasis on their needs, values and preferences
Clinical System Navigator role:
Improve transitions & communication between providers
Encourage greater coordination of services
Address challenges around social determinants of health
Patient Profile & Social Determinants of Health
Food Insecure - 17% (food bank, community meal delivery services)
Socially Isolated - 77% (peer support groups – i.e. living with chronic conditions, smoking cessation groups - palliative care volunteer visiting programs
Transportation - 24% (expand capacity of community volunteer driver programs, financial support and volunteer recruitment assistance)
Patient Profile & Social Determinants of HealthFinancial - 80% of patients live in poverty• Financial assistance program applications (Disabilities,
employment injuries, government pension plan coverage)• Legal Aid Clinic• Special necessity programs for dental work and eyeglasses
Mental Health - 70% require social work, CBT psychotherapists, outpatient mental health services, crisis services
Results – CTAS Events >12 months
Results – ED/IP >12 months
Patient Satisfaction Results
Has being a patient of Health Link increased your:
NSCHL* Regional Comparative*
Self confidence 69.7% 69 %Social networks 71.2% 70 %Overall well-being 72.7% 72 %
*Cumulative average Q1 16-17 – Q3 17-18
GBGH - HL Partnership1) Patient identification and measuring success:
Accurately identifying top 5% of medically complex patients who will benefit from HL approach. Ongoing measurement of impact on hospital resources.
2) Electronic Medical Record flagging:Alerts physicians and patient flow navigators to access the patient’s coordinated care plan in the ED.
3) Community Quality Improvement Plan Initiative: Focus on COPD 30 day re-admission rate. Partners include primary care, Health Link, home and community care, long-term care and palliative care.
4) Relationships with Navigators:Patient Flow Navigator direct referrals, Indigenous Patient Navigator
Where we are going… 1) Automated discharge summaries:
Notification of ED visits and inpatient stays within 48 hours facilitating timely patient follow-up or home visit as needed.
2) Connecting patients to primary care:Complex patients without a primary care provider will be rostered to team based Community Health Centre (CHC) services.
3) 2018-19 Community Quality Improvement Plan: Expand to include Mental Health indicators.
4) Improve transitions for patients from hospital to community:Patient Flow Navigator “warm hand-off” to Health Link Navigators as part of discharge process and embedded in ED
Video – Patient Story
Questions or Comments?
Dawn Major RN, BScN, MSc(QIPS), CICChief Performance, Quality and Risk [email protected]
Christine Ralhan, BCommProject [email protected]
