November 2018



I am pleased to feature Part Two of the guest blog by Martina Rozsa, Vice President of Home and Community Care for the Hamilton Niagara Haldimand Brant Local Health Integration Network (HNHB LHIN). In Part One, Martina wrote about the need for even greater collaboration with our health system partners, and how continued teamwork and new innovations are helping to ensure prompt access to care and smooth transitions for our patients and their caregivers.


Whether at home, in hospital, long-term care homes or through community support service agencies – transforming the health care system has to happen, and the Hamilton Niagara Haldimand Brant LHIN is making positive headway with modifications to our everyday business process and fundamental changes to our business and service delivery models to better support the people we serve.


In Part Two, Martina delves deeper into the embedded care coordination model and highlights the LHIN’s work with its local health system partners to improve communication and access to care for people in our communities. We are working better, smarter – and we are doing it together! I encourage you to read this blog to find out more about what the LHIN is doing to dramatically improve person-centred care.




Martina Rozsa

We are rolling out more exciting initiatives at the Hamilton Niagara Haldimand Brant LHIN  to transform how we deliver high quality patient-centred care together with our health system partners. Our focus is to improve how people move through the local health care system and to create exceptional patient experience.


We understand that for most people, primary care providers are the ‘front door’ to the health care system. That’s why it’s important for LHIN employees across the province to work differently and more effectively with their partners to deliver true patient-centred care. It is not surprising that more than 59% of all patient interactions in Ontario are with primary care and home care providers. By connecting these sectors, patients can experience many benefits including more convenient access to care, continuity of care and support for people with high/complex care needs.


The Hamilton Niagara Haldimand Brant LHIN is restructuring its community care coordination teams, aligning LHIN care coordinators with primary care, retirement homes and other partners to reduce the number of times a patient has to tell their story. Patients and caregivers across our LHIN have told us this is an area for improvement.


The structure and needs of primary care providers are unique. Family health teams, family health organizations, community health centres and solo practitioners all have different makeups – a varied number of offices, physicians, allied health – and cannot be painted with one brush. While we can’t put a LHIN care coordinator in every primary care office, there can be a single point of contact in primary care to help patients navigate the system – with the LHIN as part of the team.


Strengthening relationships between primary care and care coordination is foundational to transforming local health care. It’s also necessary to achieve our long-term goal of seamless and continuous patient transitions between providers and across the health care system over a person’s life span.


As I mentioned in the September Blog, Hamilton Niagara Haldimand Brant LHIN Home and Community Care has taken a phased approach to embed care coordination in primary care settings:


  • Phase 1 – Community Health Centres (CHCs) and Aboriginal Health Access Centres (AHACs)

  • Phase 2 – Family Health Teams (FHTs), large Family Health Organizations (FHOs) and Family Health Groups (FHGs)

  • Phase 3 – All other Primary Care not implemented in Phases 1 and 2


As part of Phase 1, 10 LHIN care coordinators are now located within community health centres and Aboriginal health access centres. Through a shared vision, the model developed between the LHIN and community health centres and Aboriginal health access centres features shared access to patient records, a single point of contact through the consultative model, and joint education and awareness for all members of the care team – primary care providers, allied health and LHIN care coordinators – to ensure a common understanding of the goals, objectives and solid partnerships needed to be successful.


By streamlining our efforts to begin operating as one cohesive team, we will improve communication with our patients and we will be able to work together differently to support our mutual patients with their care needs. Care wrapped around the person ensures:

  • A collaborative team – people the patient knows and can turn to when they need help
  • Joint health assessments – one assessment wherever possible involving the care team to reduce the number of times a person has to tell their story
  • Shared access to patient records – seamless communication between the care team and their patients
  • Interdisciplinary consultation – coordinated care planning to address a person’s care needs and health outcomes
  • Building system capacity – resources are freed up for patients to better access care and services.

By taking these approaches, we hope to break down silos and barriers within the local health care system and build up ‘neighbourhood’ models of care. This will give people access to the care and services they need from the most appropriate source – primary care, community health centres or community programs and services. It also leads to a number of possibilities to evolve models of service delivery.

The evolution of the Hamilton Niagara Haldimand Brant LHIN’s care coordination model is instrumental and will support other transformational changes. Specifically, in how we work differently with our partners by aligning our care coordination teams within smaller neighbourhoods to maximize service delivery. Doing this will improve our relationships and care planning with key system partners, and will help us work towards reducing the number of times a person has to tell their story as they navigate through a complex health care system.


These are just some of the early, positive changes being implemented by the Hamilton Niagara Haldimand Brant LHIN. We continue to improve our processes, models of care and service delivery to ensure patients and caregivers are getting safe, high quality, person-centred care and services across our health system. This is a journey on which we will be pausing to evaluate these changes and either moving forward as planned or making course corrections when needed.


If you’re a health care provider, I hope you’ll learn more about the work underway. If you’re a patient, family or caregiver, I hope you are seeing – or will see – a demonstrable change. And if you’re more of an ‘I’ll believe it when I see it’ person – watch us and just imagine what we can achieve together…when we care, listen and act.


If you or your organization would like to be featured in a future blog or share a patient story in one of our Voices in the Community videos you can reach us through our office, or if you’re on social media via our Twitter handle @HNHB_LHINgage or on Facebook. Your feedback and questions are always welcome.