Background

In the current state of the health care system, there is uneven access to primary care, and too many people are having trouble navigating the system, are receiving care in the hospital that would be better dealt with in the community, and are being readmitted to the hospital only days after leaving. To address these issues and improve efficient continuity of care, the Health Links program provides a new model of care at the clinical level, in which all of a patient’s health service providers in the community, including primary care, hospital, and community care, work together to create a coordinated care plan for the patient. The initial focus of Health Links is on high-cost users. To support Health Links initiatives, the custom web-application called Shared Health Integrated Information Portal (SHIIP) is being developed. The project is sponsored by the South East Local Health Integrated Network (South East LHIN) and delivered in collaboration with the Kingston, Frontenac and Lennox & Addington (KFL&A) Public Health that develops the solution and Kingston Health Science Centre as the host of the software application and Clinical Data Repository.

Purpose

Health Links, and primary care as a whole, require comprehensive data analysis to effectively support patients and providers. SHIIP is a portal-based technology solution that enhances individual patient care while providing real-time feedback and summarized data to help plan care. SHIIP automates the identification of complex/high needs patients, and the generation of patient risk scores to indicate the likelihood of hospital readmission. Through specific patient and provider matching, SHIIP makes this information available to providers in the circle of care to maintain patient confidentiality.

SHIIP benefits participating providers throughout the South East LHIN: hospitals will benefit from fewer faxes, fewer unnecessary emergency department visits, lower readmission rates, and reduced gridlock. Primary care, community providers, long-term care and other providers involved in the coordinated care of complex high-needs patients will benefit from accurate and timely patient health data for use in providing prompt and coordinated intervention.

The LACE index is described in:

van Walraven C, IA Dhalla, C Bell, E Etchells, IG Stiell, K Zarnke, PC Austin, AJ Forster. Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community. CMAJ. 2010;182(6):551-557. DOI: https://doi.org/10.1503/cmaj.091117

(Modified from abstract) Briefly, the LACE index is derived and validated to predict the risk of death or unplanned readmission within 30 days of discharge from hospital to the community. The LACE index was developed using a prospective cohort study (4,812 medical and surgical patients discharged from 11 hospitals in Ontario) using 48 patient-level and admission-level variables; the index was externally validated using administrative data from 1 million randomly selected Ontarians discharged from hospital from 2004 to 2008. The variables independently associated with death/readmission within 30 days included are L for length of stay, A for acuity of the, C for the Charlson comorbidity index score, and E for emergency department use (measured as the number of visits in the six months before admission). Scores using the LACE index ranged from 0 (2.0% expected risk of death or urgent readmission within 30 days) to 19 (43.7% expected risk).

Information regarding the HARP index is available here:

https://secure.cihi.ca/free_products/HARP_reportv_En.pdf

(Modified from Executive Summary) Briefly, Health Quality Ontario (HQO), the Canadian Institute of Health Information (CIHI), and other experts partnered to design a model that would identify an individual patient’s near and longer-term risk of future hospitalization. The Hospital Admission Risk Prediction (HARP) tool accounts for patient-level variables that are predictive of future hospitalization. HARP generates an individual patient risk score of hospital admission within two timeframes: 30 days, and 15 months. The variables included are: the patient’s age, the number of admissions and emergency department visits in the past six months, location where the patient was previously discharged to, the intensity of a previous admission, the presence of the 18 top conditions, whether a previous admission was through the emergency department, the Charlson co-morbidity index, select interventions during a hospital encounter, and previous length of stay.

Supporting Information:

What is SHIIP? Provides an overview of SHIIP, including a description of data included from acute care, community addictions and mental health services, and community support services, and outlines key benefits. Topics include: What is SHIIP?, What data is available in SHIIP?, Key data elements, What are the benefits of using SHIIP?, What are the upcoming priorities for SHIIP?, and How can I access SHIIP?

Supporting Primary Care Describes SHIIP’s support and benefits for primary care practices. Topics include: What is SHIIP?, How can SHIIP support Primary Care?, How can SHIIP benefit Primary Care?, How can SHIIP be integrated into Primary Care practices?, and How can Primary Care access SHIIP?

Supporting Service Planning for Community Support Services Describes SHIIP’s support and benefits for community support services, including how SHIIP can be integrated into workflows to enhance service delivery and improve client care. Topics include: What is SHIIP?, How can SHIIP Support CSS?, What are the benefits for using SHIIP to support care coordination in CSS?, and How can an agency access SHIIP?

Supporting Health Links Care Coordination Describes SHIIP’s integration into Health Links Care Coordination. Topics include: What is SHIIP?, How can SHIIP support Health Links?, How can SHIIP benefit Health Links?, How can SHIIP be integrated into Health Links Care Coordination?, and How can Health Links access SHIIP?