The 1 percent of greatest users of services in Ontario consume nearly 30 percent of health spending. To fix this, Ontario set up Health Links in 2012. The aim was to identify heavy users, make sure they get the services they need, improve their outcomes and decrease needs for services and costs. Coordinated, timely, appropriate care decreases waste and increases efficiency.
Health Links have been very effective and they are still growing. Over 12,000 people have been identified and are getting services so far. At the Ways and Means 2015 conference I heard success stories as well as some challenges in delivering the breadth of services people need.
Lee Fairclough from Health Quality Ontario explained she had heard in her evaluation that the social determinants of health were increasingly considered important. Housing, social isolation and the need for social supports were underlying some difficulties in optimizing outcomes for people. I also heard that it took very little time for services to recognize the importance of the social determinants, but getting social services and others to the table was more difficult.
It is often said that good artists copy, but great artists steal – Picasso, Steve Jobs and T.S. Eliot all endorsed that idea. This has been taken further in industry; they say that innovations usually come from taking an idea from one discipline and using it in your own. If you have an innovation that works, like Health Links, getting to the next level of effectiveness can be achieved by incorporating ideas from somewhere else.
A simple idea from an allied discipline brings into focus what many people in Health Links may already know. But it crystallizes it in a way that may be useful in identifying what needs to be done.
People often use the Million Dollar Murray story to support the need for a homelessness strategy. Murray cost the state $1,000, 000 over a 10-year period through use of emergency departments, hospital beds and jail. It would have been cheaper to house him and give him in-home support.
But, on deeper analysis, Murray had physical, psychological and substance misuse problems. When in the emergency department or in the hospital, he had good care. The high cost of care and the social costs were because the coordinated community care he needed to make a full recovery and stay well were not in place.
You could argue that a Health Link would have made a difference, but perhaps not. Coordinated care was not in place because it relied on him being housed. His medical care was not as effective as it could have been because of a key social determinant: homelessness.
When Ontario set up Health Links it noted that the top 1 percent were defined by a number of social determinants: their age, gender, low household income, their ethnicity, the presence of chronic disease and health behaviours.
So it is a little surprising that the initial program evaluations reported that acute care, primary care and community care providers are most likely to be regularly engaged in Health Links but complex continuing care, mental health and rehabilitation are less likely to be engaged.
At the conference, people also reported some difficulty in getting social and other support services to the table. Those developing and delivering Health Links called for the leadership of other Ministries to give the same support to Health Links as the Ministry of Health and Long Term Care. They wanted those in social care and others who target the social determinants of health to have the same passion and license to be creative as they did in their Health Links. Some questioned why better cross-ministry support was not part of the original design of Health Links.
Some may think this is desirable; but I think it is vital.
Unless the Health Links can ensure flow they will slowly accumulate more and more patients. They could fill up and become inefficient. Two ways they can improve flow are (1) to increase the number of people who get better and no longer need their services, or (2) to decrease the number of people with high emergency department visits and inpatient stays. In other words, they need to increase flow out and decrease flow into Health Links.
Social determinants such as racialization, income inequality, education, unemployment, housing, disability and social exclusion increase a person’s chance of getting ill and also decrease the chance of getting better. For Health Links to be maximally effective they have to have the ability to counter the impact of the social determinants of health in creating ill health and chronic illness. The best way to improve quality and improve outcomes is for service to align with needs.
Those on the ground want help to improve Health Links by incorporating effective action on the social determinants. The learning from Million Dollar Murray is that it is vital that they do.
The next stage is to think through whether there need to be policy changes to ensure that this happens.
To download Dr. McKenzie’s slide from his Health Links 2015 talk, please click here. Health Links, 2015 McKenzie