A pilot project that takes aim at the small group of patients who are Hamilton's heaviest users of health care dollars has achieved two of most important first year goals.

The Hamilton Central Health Link has succeeded in reducing the emergency room visits and hospital admissions for the 322 patients who use up the majority of the city's health care expenditures.

Hamilton is one of 19 Local Health Integrated Networks (LHIN) across the Ontario attempting to tackle the top five percent heaviest users of the health care system, tasked at finding out why some people can't stay out of the hospital's beds and emergency rooms.

Top 5 per cent uses two-thirds of health care dollars: report

A 2013 report  shows the remarkable statistic that just five-per cent of health care users in Ontario use two-thirds of the health care dollar in the province. In Hamilton, that top five per cent is 322 people. The Hamilton area LHIN was one of one of several that signed on to tackle the top five per cent.

Last April, Dr. David Price, a professor at McMaster's family medicine program and lead of the Hamilton Central Health Link met with his varied team of health care and social service professionals to set out some goals for the first year of the project.

Price and his team would use "learning circles" of specialists from the hospital, as well as family doctors and social service staff, to try and reduce the number of visits for the heaviest users. 

A year into their pilot project, promising numbers show that their listening has paid off. 

"We're making progress with that group," says Price.  

Emergency room visits, hospital admissions down 10 per cent

The two primary goals set in a report to the City of Hamilton were to reduce emergency room visits and hospital admissions by 10 per cent for the cohort of 322 patients, the top 5 per cent in Hamilton.

"We have certainly achieved that in terms of those high users," Price said.

The study has also seen that of the 322, two thirds have moved off the list within the year.

"Almost 200 patients are off the list from one year to the next."

The carryover from year to year in in the five per cent cohort is now the focus of an extended six months of funding from the Ontario Ministry of Health and Long Term Care. 

Between 2012 and 2013, 55 people remained on the list, a return rate of 17 per cent. That's not to say the remaining 83 per cent moved out of the system - 26 per cent, or 83 individuals, died during the study. 

Price said the "vast majority" of the top five per cent were already in their last year of life, and that fact was also an important thing to learn about the group.

"What this number has demonstrated to us is we need to do a better job of care planning of those individuals who may well be in their last year of life," said Price.  

"We're now recognizing that we need to put more in place as a safety net for these kind of patients than just access to the emergency or admission" added Price. "And I think what we're recognizing is that a lot of these folks can remain in their own homes or in their own places of care without needing to be transferred to hospital if we have added supports."

Wesley hoping shelter services would be integrated at hospital discharge

While integration remains the buzz word for health care policy, the health link appears to be trying to put it into practice. 

Shelter services like Wesley Urban Ministries was looped in on the "Learning Circles" to help find out how they can help people who find themselves between costly hospital beds and expensive emergency shelters.

"We know we're working with the same person," said Wesley director of housing and homelessness, Dean Waterfield. "They're bouncing between hospital and emergency shelters… We have a difficult time ourselves, slowing then down enough to get connected with them to stabilize their housing."

Waterfield is looking for shelter services like Wesley to be part of the hospital's discharge services. He said keeping track of the patients through the entire process is paramount to their success.

"Traditionally it hasn't been part of (the hospital's) mandate," Waterfield said. "When their patient is our client…. we can plan and strategize better. Sometimes we know the individual far better."

"In the past, no one would have called us… It's a little step forward, but it's a significant step."

Dale Guenter, a co-director at McMaster Family Practice who was also in on the learning circles, said one of their earliest cases demonstrated gaps in the system that would require new policies to fix.

Identifying gaps in the system

Guenter recalled a patient who called for an ambulance every time she fell at home and couldn't get up.

"Due to our legislation, the ambulance is obliged to take her to the emergency room of the hospital," Guenter said. "We began to look at how ambulances are being used in this city… From that we have discovered some patterns of where might be able to change how ambulances are used and work along with the paramedic service to develop a proposal for a new program called Community Paramedicine. This will be trying a new approach to supporting people in the community with the paramedics rather than necessarily transporting people."

The "Learning Circles" process is the key to finding the solutions. 

After extended interviews with the patients in the top five per cent, their cases are discussed with a health workers, social cervices workers and paramedics.

"Learning Circles are based on individual patient stories but that's to get an idea of what to change in the system," Guenter said. 

And despite its success, Price said there are no plans to make this program permanent. It's meant to right the course for health care, but not let it navigate care.

Guenter, however, says the learnings from listening to patient stories is an important step into fixing health care in the city.

"As we get an understanding of what's most important to (those patients), it begins to make sense that what we've been doing doesn't work so well," Guenter said.