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Patient Lying on the Bed


Evaluation of the Implementation of Health Links in South-Eastern Ontario 

In Canada, approximately 5% of the population incurs approximately 66% of the healthcare costs. These “high cost” users tend to be elderly patients with multiple chronic conditions and low sociodemographic status, who experience fragmented care and system inefficiencies. In Canada, Coordinated Care Plans (CCPs) have been implemented to provide these patients with early assistance in transitioning with care providers and follow up care to reduce service gaps for complex patients, reduce hospital admission/readmission, and increase communication and satisfaction among patients and providers. Evaluations of the efficiency of CCPs for high-cost users have yielded mixed results. As a result, it is currently unclear what the effects of CCPs have been on decision-makers, CCP managers, healthcare providers, patients, and their families. 

To evaluate the impact of CCPs, this study adopts a sequential explanatory design, and uses in-depth health administrative data from the Institute for Clinical Evaluative Sciences (IC/ES) and data from the South-East Health Integrated Information Portal (SHIIP) to assess the impact of Health Links, the CCP in South-Eastern Ontario on patient outcomes in the South-East Local Health Integration Network (SELHIN). Focus groups will be conducted with decision-makers, healthcare providers, and a range of high needs patients and their families to explore their perspectives on the implementation of CCPs. Our objectives are to evaluate the impact of CCPs on enrolled patients compared to a control group with respect to healthcare utilization and costs, and to identify underlying causal factors of CCP costs and benefits through investigation of the lived experience of decision-makers, CCP managers, healthcare providers, patients, and their families. 

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