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 South East 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.

Please see the SHIIP Briefing Note for more information, or visit the SELHIN’s website: http://www.southeastlhin.on.ca/GoalsandAchievements/Technology/shiip.aspx