Concurrent Sessions

EF5 Creative solutions for complex patients: different strokes for different folks

Theme 5. Coordinating care to create better transitions

Presentation Details

  • Date: 10/18/2016
  • Concurrent Session E & F
  • Time: 10:45am – 12:30pm
  • Room: Harbour C
  • Style: Presentation (information provided to audience, with opportunity for audience to ask question)
  • Focus: Balance between both (e.g. Presentation of a best-practice guideline that combines research evidence, policy issues and practical steps for implementation)
  • Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

  • Describe three clinical innovations for transitions and coordination of care for complex patients
  • Determine feasibility of adopting and/or adapting one or more of the innovations presented
  • Identify success factors in developing and spreading clinical innovations
  • Consider potential roles for their own HealthLinks initiative in supporting innovation


This presentation highlights clinical innovations in transitions and coordination of care for complex patients.  It illustrates key elements of three different approaches and outlines the success factors and learnings so others with similar needs can consider implementing in their settings. The three presentations will be followed by a panel discussion to explore the role of HealthLinks structures in these innovations and themes around enablers and barriers to developing and spreading these innovations.  Briefly, the three programs to be presented are as follows:

  • Thamesview : 3 Family Health Teams located in the same LHIN who have worked closely with the community hospital and community partners will present on the Health Link High User Process.  Who the cohorts are, how the patients are identified, validated, the stratification (ie: frequent vs. long user over period of time), connection (how to connect with the patient, phone, home and office visits), monitoring (establishing Action Plan and its effectiveness) and how inactivation of the patients occurs.
  • Prescott : Health Link is an innovative initiative that provides care to the most complex patients. Personal health goals are identified and the elaboration of a coordinated care plan is shared among the circle of care. The particularity of our Health Link is the home visit by a nurse practitioner, who provide direct care to the patient, on top of coordinating care. All pertinent interventions are shared with the primary care provider.
  • NorthumberlandThe presentation will highlight the innovative and successful model of care that was created through a collaboration between the Northumberland Family Health Team  and Northumberland Hills Hospital  that provides interventions that reduce gaps in care for patients, with COPD/and or CHF  as they transition from the hospital to home. A team based approach to care, lead by an NP,  provides more intensive care in the patient’s homes in order to prevent hospital readmission, ER visits and to ensure positive patient experiences and positive health outcomes for the patient. 


  • Andrea Atkinson, Health Links Case Manager, Thamesview FHT
  • Diana Hegedus, Health Links Case Manager, Tilbury District FHT
  • Barb Lather, Business and Program Manager, Thamesview Family Health Team
  • Francois P. de Courval, NP, M.SC, Nurse Practitioner, Prescott-Russell Health Link
  • Sylvie Lemaire, Programm Manager, Prescott-Russell Health Link
  • Laurie Angione, MN-NP Adult – Lead “Home Based Transition Care Team”, Northumberland Family Health Team
  • Karen Peters, RPh, Northumberland Family Health Team
  • Joanne Jury, Access & Patient Flow Improvement Specialist, Northumberland Hills Hospital

Authors & Contributors

  • Laura Johnson, Executive Director, Chatham Kent Family Health Team
  • Kelly Griffiths, Executive Director, Tilbury District Family Health Team
  • Denise Waddick, Executive Director, Thamesview Family Health Team
  • Nancy Snobelen, Director Partnerships & System Integration, Chatham-Kent Health Alliance
  • Audrey Larocque –A.A. – Prescott-Russell Health Link