Modeling Our New Way of Doing Business The five per cent of individuals who need and use health services the most are moving in and out of our health care system constantly. They are the ones whose care experience and outcomes can effectively mark out progress in creating a responsive health system. Improving system processes for the patients with the highest needs will exemplify, and be the litmus test of, the philosophical and practical changes behind the current health reforms already well underway. By its application, the high needs strategy will: help further define the new stewardship roles of the Ministries of Health; demonstrate the service delivery role of the health authorities; provide opportunities for clinical integration and innovation among our health professionals and; encourage the patients themselves to become informed partners in their own care Principles of Care Identification and monitoring of the population at risk Coordinated care that increases quality, integration and efficiency of care Stepped care that matches treatment to need Shared care that enables timely access to expert support Preventing the preventable, particularly intervening to stop the worsening of disease Supporting patient empowerment Tailored programs designed for specific purposes Increasing the capacity of primary health care service Examples of Programs Health Authorities May Decide Best Meet Patient Needs: End-of-Life Care: Advanced Directives and Community-Based Palliative Care All-inclusive care for the frail elderly: Full spectrum of community care for the frail elderly that improves health and quality of life and keeps them out of hospital. Assertive Community Treatment for people with mental illness: “ACT” teams provide outreach to people living with severe mental illness to improve health, manage other health problems and prevent hospitalization.