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Health Links: the Impact of Care Coordination for Patients with Complex Needs on Hospital Utilization


I Introduction
II Overview
III Methods
IV Results
V Discussion and Conclusion
VI Resources

--Submitted by Meghan O’Leary, MSc, Manager of Primary Health Care and Lead for Salmon River Health Link, Kingston Community Health Centres, and Laurissa Watson, MPH, Research Assistant, Kingston Community Health Centres

I Introduction

Ontario is improving coordination of care for patients with complex needs through the creation of health links across the province. The Salmon River Health Link (SRHL), one of the seven health links in the South East Local Health Integration Network, initiated care coordination and intensive case management for patients with complex needs starting in September 2014. A care coordinator, hired through the Kingston Community Health Centres, is the lead front-line staff for this regional approach, working with all primary care providers in the Napanee and surrounding area (Salmon River Health Link area) to support patients with complex needs. Ultimately, the goal is to improve the patient experience and health outcomes while decreasing cost to the health care system.

Salmon River Health Link is one of the smaller health links in the region and the province, with a population of approximately 23,700 people covering a geographic area that includes the town of Greater Napanee, the hamlet of Deseronto, Tyendinaga Township and the Tyendinaga Mohawk Territory. There are 19 primary care providers within this geography. Sixty percent of the population lives in rural municipalities, with Napanee as the only population center. Statistics Canada states that 4.5% of the population identifies as Aboriginal (2006), although we know that this number is underreported, with 5% of our community health centre clients at our Napanee site, identifying as Indigenous.  Like many small towns, we support an aging population, with 31% between the ages of 45–64; projecting for the 65+ age group to continue to grow steadily.

As part of the on-going development and evaluation of the health link initiative, we are looking to see if the work of the health link team, through intensive case management, leveraging community and health services supports in the community, and creation of coordinated care plans, is making an impact. One area of potential impact is reduced hospital utilization, which may reduce health care system costs. In a small scale evaluation, we looked at the hospital utilization six months pre and post health link involvement for the first 100 health link clients. The results suggest a 31% decrease in emergency department visits and a 51% decrease in length of stay in hospital for patients who received health link assistance.

II Overview

Health links were established as a key commitment in the Ontario Ministry of Health and Long Term Care’s (MOHLTC) Patients First: Action Plan for Health Care to improve the delivery and coordination of care, enhance the experience, and improve the quality of care at lower cost for patients with complex health and social needs (SELHIN Health Link Sustainability Plan 2016). Health links is a targeted, holistic approach to care coordination for complex patients. It fosters greater collaboration and coordination between clients’ different health care providers while developing a coordinated care plan from a patient-centered perspective. Coordinated care plans identify client goals and priorities which are to be integrated with their medical and service plan of care. This supports a team approach to care; promoting collaboration and service integration. Coordinated care planning helps improve client transitions within the system and helps ensure clients receive more responsive care that addresses their specific needs with the support of a tightly knit team of providers.

Health links are targeting the 1–5% of patients who utilize 66% of the total health care dollars spent in Ontario. Through data analysis, we have found that these patients predominantly have four or more chronic/high cost conditions, frequent hospital admissions, re-admissions and multiple emergency department visits and often experience barriers to health such as food security, transportation, housing or income insecurity. Clinical judgment is also important in identifying patients who would benefit from the health link approach.

Salmon River Health Link is led by Kingston Community Health Centres, with a multi-disciplinary team that understands the impact of social and economic deprivation on health outcomes. Recent research suggests that low socioeconomic status, high disease burden, low accessibility, greater healthcare coordination problems and low comprehensiveness of care contribute to high emergency department utilization (Hudon et al, 2016). Additionally, a recent review found that a disproportionate number of individuals with mental health concerns are presenting in emergency departments. Authors found a relationship between the continuity of care and frequent emergency department use for mental health concerns (Digel Vandyck et al, 2013).

Coordinated care offers a systematic approach to supporting people with chronic conditions that is responsive to their needs. While primary care-led, the Salmon River Health Link has worked closely with the Lennox and Addington County General Hospital as well as key community partners and health care providers to establish a central referral process for patients with complex needs. The majority of our referrals continue to come from primary care, hospital and community service organizations. A process has also been established to receive regular data pulls of patients who have 3+ emergency department visits within a three-month period as well as a readmission under 30 days. The SRHL care coordinator follows up with the primary care provider of identified patients to prompt a referral and obtain patient consent to engage the patient in developing a coordinated care plan.
The seven South East LHIN Health Links are in the process of integrating acute hospital utilization information to help identify the target population. Identifying patients with complex needs, who have high utilization of hospital services, or are at risk of hospitalization, will enable health links to target our efforts on this high-needs and vulnerable segment of the population.

III Methods

The Salmon River Health Link undertook an evaluation that measured client emergency department use and hospital admissions at the Lennox and Addington County General Hospital from September 2014 to July 2016. The primary objectives of this evaluation included:

  1. Assessment of the number of emergency department visits by each participant six months prior to enrollment with the health link and six months following engagement.
  2. Assessment of the length of stay within hospital for each participant six months prior to enrollment with the health link and six months following engagement.  

Evaluation methods included assessment of health link patient records (N=100) from the Lennox and Addington County General Hospital in Napanee. The records were used to quantitatively determine the number of emergency department visits and the number of days admitted in hospital for each client as well as the number of readmissions under 30 days.

IV Results

Objective 1: Emergency Department Visits – 31% decrease

Patients involved in health links visited the emergency department a total of 189 times in the six months before their involvement and a total of 131 times post-involvement. Results indicate an average reduction of 0.6 emergency department visits per person in the six months following health links enrolment. Overall, there were 58 fewer visits to the emergency department in the six months following health links participation, which resulted in a 31% decrease of emergency department visits. One individual, an outlier due to their unusual case, was removed from the data calculation because they visited the emergency department 21 days in a row to receive an antibiotic injection.

High Frequency emergency department presenters: A subset of individuals who visited the emergency department most frequently (4 to 11 visits) in the six months prior to health link involvement showed a decrease of 51% in emergency department visits in the six months following the intervention. This subset of 26 individuals visited the emergency department 138 times prior and 67 times post-health link involvement. The average number of visits changed from 5.3 visits per person pre-health link to 2.6 visits per person following health link involvement.

Objective 2: Length of Stay – 51% decrease

With one outlier removed, length of stay was reduced by approximately one day per person post-health links enrolment. This is a reduction of 51% with a total of 228 days in hospital pre-health link involvement and 116 days in hospital post-health link involvement. The one outlier patient stayed in hospital for 88 days, which is nearly three times as long as any other patient-stay within the sample population. As a result, this data point was removed.

Highest admission subgroup: Individuals with the most admissions before the health links intervention (four or more), showed the greatest changes in length of stay post intervention. Amongst this subgroup of 19 individuals, days spent in hospital decreased from 217 days to 67 days, a decrease of 69%.

Three Salmon River Health Link clients passed away during or shortly after their involvement. Two individuals were noted as deceased during the six-month period following initial involvement. In both cases, the length of stay increased in the post-involvement period (from zero days pre- to 10 days post-health links and from two days to three days). Both clients were close to the end of their involvement at their time of passing. A third client was noted as deceased one month after the post-enrolment period ended. All three clients were included in the data analysis.

Readmissions under 30 days: In the six months before health link involvement, five individuals were readmitted under 30 days while only one individual was readmitted under 30 days post-health link involvement.

V Discussion and Conclusion

This evaluation sought to assess how health link engagement might impact the number of emergency department visits and length of admission amongst participants. The results suggest a moderate reduction in emergency department visits and admissions once patients were involved in health links, and the reduction was most notable amongst those with the highest frequency emergency department visits and longest admissions. A limitation of the evaluation is that we were not able to access hospital utilization data for hospitals outside of our health link region. Overall, the health link approach may positively impact emergency department use and length of hospital stays amongst patients with complex needs. This small-scale program evaluation provides early evidence demonstrating the importance of coordinated care for more effective and efficient care of patients with complex needs. It also starts to help illuminate improvements around the patient experience and health outcomes while decreasing cost to the health care system.

VI Resources

Ontario Ministry of Health and Long-Term Care

SELHIN Sustainability Plan (2016)


Hudon, C., Sanche, S., and Haggerty, J.L. (2016). Personal Characteristics and Experience of Primary Care Predicting Frequent Use of Emergency Department: A Prospective Cohort Study. PLoS ONE 11(6): e0157489. doi:10.1371/journal.pone.0157489

Digel Vandyck, A., Harrison, M.B., VanDenKerkhof, E.G., Graham, I.D., and Ross-White, Amanda. (2013). Frequent Emergency Room Use by Individuals Seeking Mental Healthcare: A systematic Search and Review. Archives of Psychiatric Nursing. 20 (4). Pp 171-178.