Coordinated care plans, or CCPs, have become integral to how DMHS provides client- and family-centred care. Introduced as a key component of Ontario’s Health Links approach to healthcare quality improvement, CCPs improve system integration and promote effective partnerships among the care providers supporting any individual client. A good outcome in terms of completing CCPs means better outcomes for clients.

A CCP is a written or electronic plan that is created and maintained by the client and their Care Team (i.e., family physician, care coordinators, specialists, community service providers, etc.) The CCP outlines short- and long-term client goals, coordination requirements, and contact information. It specifies who is responsible for each of the client’s care needs.

Not only formal healthcare services contribute to CCPs. The family’s role in support, if they and the client choose, is also captured and communicated.

“I think of CCPs in terms of three vital ‘Cs’,” says DMHS Program Director Sheri Rice. “Coordination (ensuring that the right services are in place and that everyone knows their role in the overall plan), communication (ensuring clear communication among all the contributing parties), and consistency (so that clients know what to expect from everyone involved). Clients have a right to well-coordinated, communicated and consistent service.”

Clients are saying that CCPs improve service access and reliability. Here are some reactions from DMHS clients:

· “Thank you for having a coordinated care plan as it helped me know exactly who (what worker from what organization) will help me accomplish all of my goals.”
· “I found the CCP experience to be informative and efficient.”
· “The service is great and always has been but the plan helped tailor the service to my needs so that I’m getting more consistent service and check-ins since the plan was developed.”
· “The CCP process helped me by bringing together all of my healthcare providers to develop a comprehensive team plan.”
· “I liked that I was able to explain what I needed to everyone all at once – we came up with a plan that works for me.”

HealthLinks provides a number of principles for optimally using CCPs:

1. The patient is informed of all information included in the CCP, who has access to the information and how the information is intended to be used.

2. Each CCP is developed with direct input from the patient. CCPs reflect patients’ stated goals, needs and preferences and are written in clear, accessible language, using patients’ own words where possible.

3. CCPs are accessible to patients and the circle of care in any setting where care may be delivered.

4. CCPs are actively used and reliably maintained according to the clinical practices established in each Health Link by all in the circle of care.

5. CCPs are based on current evidence and use generally accepted clinical guidelines.

Sheri Rice adds, “Our organization has been recognized as a leader in implementing CCPs because we have rolled it out across agency programs and have shown how it is a tool that benefits clients. We feel strongly that we will embrace any tool that keeps the client and their family at the centre of quality care.”

“Local Health Link networks are perfectly positioned to implement the action steps and directions articulated in the Patients First action plan and achieve the Central East LHIN IHSP4 Strategic Aims,” said Deborah Hammons, CEO, Central East LHIN. “As a Health Link network organization in the Durham North East LHIN sub-region (Health Link community), we are pleased to see Durham Mental Health Service’s active engagement in the coordinated care planning process which is a critical step to advancing integrated systems of care and putting patients first to increase their ability to live healthier at home.”

About Health Links:

Ontario is improving care for seniors and others with complex conditions through Health Links. This innovative approach brings together health care providers in a community to better and more quickly coordinate care for high-needs patients.

When different health care providers work as a team to care for a patient, they can better coordinate the full patient journey through the health system, leading to better care for patients. Health Links will help to ensure that patients with complex conditions:

• No longer need to answer the same question from different providers.
• Have support to ensure they are taking the right medications appropriately.
• Have a care provider they can call, eliminating unnecessary provider visits.
• Have an individualized comprehensive plan, developed with the patient and his/her care providers who will ensure the plan is being followed.

Health Links encourage greater collaboration between existing local health care providers, including family care providers, specialists, hospitals, long-term care, home care and other community supports. With improved coordination and information sharing, patients receive faster care, spend less time waiting for services and are supported by a team of health care providers at all levels of the health care system.