By Jessica Lovell
Guelph Tribune

Doing a better job of caring for Guelph’s most vulnerable people is the goal of a new health care plan created by local health-care providers – a plan that involves helping those people one patient at a time.
“Our thinking is if we do a good job with the people who use a lot of the health-care resources, everyone will benefit,” said Ross Kirkconnell, executive director of the Guelph Family Health Team.
The team, representing a significant number of family doctors in Guelph, is heading up the Guelph Health Link project, a pilot project that aims to deal with the issue of the unbalanced use of health-care resources. Guelph is one of 19 communities selected by the government to create and adopt these new Health Link plans.
The Ontario Ministry of Health and Long-Term Care estimates that patients with the greatest health needs – largely seniors and those with complex conditions – make up five per cent of the population but use about two-thirds of Ontario’s health-care dollars.
“For Guelph, this translates to a little over 6,000 people,” said Kirkconnell.
“Over the past couple of months we have met with patients and caregivers, front-line health-care workers, health-care and community leaders, and we have listened carefully to what they had to say,” said Kirkconnell.
“We heard a key message: there are a small number of people in Guelph who use a lot of health services. And with a bit of a different approach, we could help these people be healthier while reducing their use of costly health services,” he said.  The Health Link process has involved a couple of months of consultation with different health, social and community service providers to develop a business plan to be submitted to the Ministry of Health.
That business plan was submitted by the ministry’s Feb. 19 deadline.
They are not sure when or even if the plan will be approved by the ministry, but Health Link team members are already beginning to put the plan into practice, Kirkconnell said.
“The idea of this is to improve care for people one person at a time,” he said.
One step of the plan will involve working with primary care providers, as well as Guelph General Hospital’s emergency department staff, to try to identify the people who have complex care needs, explained Kirkconnell.
“Once identified, we believe these people can benefit from developing a personalized care plan that is driven by their needs and priorities,” he said.
For example, a patient may call an ambulance to make a trip to the emergency room, rather than making an appointment with a family doctor, because the cost of transportation to the doctor is too high, said Kirkconnell.
A personalized solution might involve creating a volunteer service that could provide transportation to the doctor’s office, he explained.
That is just one possible scenario, and there are thousands of patients the Health Link plan is hoping to help.
Of the estimated 6,000 high-needs patients in Guelph, the Health Link team estimates maybe half of them could be making better use of health-care resources.
The other half uses more health care dollars simply because their conditions require more expensive treatment, Kirkconnell explained. “For some of these people, it’s just expensive treatment; for some people, there’s little you can do,” he said.
So the team is setting 3,000 patients as its target, with the short-term goal of identifying 300 of these patients over the next three months, he said.
A steering committee of health-care and other community leaders has been assembled to guide the Health Link plan as it is implemented.
Guelph has an advantage in that there aren’t that many health and community service organizations in the city, but those that are there tend to work well together, said Kirkconnell.
But he recognizes there are still patients who are falling through the cracks in the system, including those who do not have family doctors.
It is not clear how many people in Guelph are without a primary health-care provider, but part of the Health Link plan will include a commitment to work with family doctors in the community to try to connect them with more people who are in need of their services, said Kirkconnell.