MANITOULIN—Manitoulin’s healthcare partners are working together on Manitoulin Health Link—a program designed to create a personal care plan for patients who are frequent users of the health care system.
Sheguiandah’s Nick Esposto has been leading the development of the program with the Northeastern Manitoulin family Health Team, Assiginack Family Health Team, Manitoulin Central Family Health Team, Mnaamodzawin Health Services, Noojmowin Teg Health Centre, Gore Bay Medical Centre, Wikwemikong Health Centre and M’Chigeeng Health Centre.
Two ‘coordinated care leads’ have been designated for each of the health care partners, Mr. Esposto explained, with those leads identifying two patients from each of the facilities to work with to develop a specialized care plan. In this first year, 16 patients from the eight partners will have personalized care plans developed for them with the eventual goal of adding more and more patients to that list.
Mr. Esposto, who holds an undergraduate degree in human kinetics and a master’s in business administration, explained that the care plans are “specific to each individual patient and designed to develop a plan for their care moving forward.” These plans will touch on everything, from physio, traditional healing, dental and any other health care items the patient can add about themselves.
At the onset, four or more of the enrolled patients have mobility issues, had 10 or more emergency department visits in the last year or three or more hospital admissions.
Mr. Esposto began the process in the fall of last year, educating all of the partners and then helping to identify the coordinated care leads.
“Everyone has picked their two patients and is currently gathering their information,” he added.
The group will meet regularly to discuss a course of action for their patients, which would be ever-changing just as the needs of the patients change.
“Right now, there’s no coordinated care on Manitoulin,” Mr. Esposto explained. “A patient could go to emergency one day, physio the next, have a dental appointment the day after and then an appointment with the family doctor. The doctor might treat you not knowing about any of the previous visits. (A personal care plan) allows for more educated and applicable decisions.”
Should one be approached by a coordinated care lead to develop a plan, one can expect a meeting, either at home or at the doctor’s office (wherever one feels comfortable). The coordinated care lead will: continue to work with the patient through home visits or phone calls; coordinate health care and social support services; help with the transition in and out of hospital; communicate with hospital staff and visit the patient post-discharge; assist the patient and the caregiver in accessing community support services; and provide health education to help the patient encourage healthy behaviours and actively participate in the patient’s care.
