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Hundreds gatherfor Minden ERclosure meeting

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Patrick Porzuczek told a packed house at the Minden Community Centre April 25 he’d never organized anything like the ‘Save Minden Ontario Emergency Room’ Facebook group.

However, he said since moving to the town seven years ago, he’d found a community and extended family. And that included the Minden emergency room after having twice had his abnormal heart beat return to a normal rhythm.

“My wife got in the car with our three kids and drove me to the ER while I was in an arrhythmia so I could be shocked. There’s many people in this room that know of, or have had, emergency services at the Minden ER. There’s many heart attack patients, cancer patients, patients that had an accident at home that used these vital services and saved our lives,” he said. He added his six-year-old daughter also received excellent care when she had a recent heart issue.

He urged the crowd, that numbered in the hundreds, to look around the room and asked, “if we didn’t have that emergency department in Minden, would that person sitting beside you be here today?”

The community came together to share stories of their life-saving interactions with Minden emerge, sign a petition, donate money, collect signs, and begin organizing next steps in their fight to keep the Minden ER open.

I want to create awareness. I want to get these signs on lawns. I want to get the conversation started. I want all of you to go out there and write your letters to [HHHS CEO and president] Carolyn Plummer,”

Organizers vow to fight HHHS closure decision

Porzuczek said. “Carolyn, we need you to come to Minden, face us face-to-face, tell us your plan. Tell us what you’re doing and why and how you’re going to handle it. We want to know how you made this decision, on all our behalf, without consulting any one of us.”

He added they’d like answers as to anticipated wait times at Haliburton emerge, for 911, or if there is a major car accident on Hwy. 35, “how they will get immediate care having to drive 25 minutes or more to Minden?”

He said Plummer and the hospital board had made a decision, “that is going to affect us here in Minden for the rest of our lives. We cannot let this hospital close. Let’s fix it. Not close it.”

He vowed his group would do whatever it takes to save the Minden ER. Porzuczek plans to drive the petitions to Queen’s Park this week.

Mayor Bob Carter said they “knew the decision was wrong” and he’s concerned about the timing, with the closure coming June 1, at the beginning of a busy County summer. He added it’s one of the oldest populations in Ontario.

“As you get older, you need those hospital services, so this decision in inexplicable.”

He said they had to continue the momentum in the hopes of pausing the decision. He noted Plummer and board chair David O’Brien will be addressing Minden council today (April 27).

Members of the crowd talked about the impact of COVID vaccine mandates on health care workers leaving their professions, the province mismanaging health care and allowing agency nurses and a move to privatization, while others said Haliburton’s ER will be greatly impacted and that Minden serves people living south of the town.

Richard Bradley said Minden has successfully fought daycare and Service Ontario planned closures.

“It sounds like a Moses thing here. We have done floods…we have survived all of those things …”

Former HHHS health care worker Christina Allore advised the group as to what to focus on.

“We are entitled as Canadians to accessible and safe care. Those are the two key points that you have to press because moving up to there [Haliburton] is not accessible and it is not safe.”

Go to Save Minden Ontario Emergency Room on Facebook for more information on the group.

Emergency department services to be consolidated in Haliburton

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Minden emergency slated for closure

The Minden hospital emergency department is closing, with emergency and in-patient services to be consolidated at Haliburton hospital, effective June 1.

Haliburton Highlands Health Services (HHHS) made the announcement April 20, saying Minden and the surrounding area will be able to access emergency services at the Haliburton site, and staff working in the Minden emergency department will be transferred to the Haliburton emergency department.

Chair of the HHHS board of directors, David O’Brien, said “this was an evidence-based decision, which was made in the best interest of our community. Today is an important day for HHHS, because it means that we will continue to be able to provide the high-quality health services that Haliburton County residents and visitors count on.”

President and CEO, Carolyn Plummer, added the move, “is really related to our health human resource crisis.” She said the shortage of nursing and medical staff has meant that the organization has needed to take “extraordinary” measures to keep both emergency departments operating, “which has required significant personal and professional sacrifices from staff.

“By bringing together HHHS’ emergency services at one site, there will be more staff available to help create a more stable and effective staffing situation overall.”

She said there would be no job losses and the service will still need to recruit approximately five to six full-time equivalent nurses.

HHHS has had to rely on agency nurses, which has contributed to an approximate $3 million deficit as of the last board meeting. Plummer said the decision isn’t about money but, “it will certainly reduce the need for agency nurses and the associated cost, but this is really about making sure that we’re making the best use of the resources that we have.”

Acting chief of staff, Dr. Norm Bottum said consolidations such as this are not new. They have occurred in Peterborough, Cobourg and Port Hope in recent times, and led to those consolidated sites being able to expand their services.

“There’s been a limit to maintaining services at both sites,” he said of Minden and Haliburton. “As medical staff, I’ve sat in on many strategic plans where we thought it would be ideal to be under one site. There’s lots of efficiencies.”

He added while the board has “gone above and beyond” to keep both Minden and Haliburton emergency departments operating, “the writings’ been on the wall.” He referenced the check-stop-go put in place in case of temporary emergency room closures and, “things have gotten worse over the last year rather than better. It’s something we anticipated would happen a lot sooner.” Dr. Bottum did not expect “shock, awe or surprise” among staff, who were being informed of the news today (April 20).

Difficult for Minden community

Plummer acknowledged the same may not be said for Minden.

“We know this is going to be a very difficult message for the Minden community. We’re very cognizant of that.

“This was a very tough decision in that regard. It certainly wasn’t made lightly. We’ve been talking about this and looking at options for quite some time but this is the decision that we needed to make in order to continue to provide health services in the County and make sure that every one in the County has access to those services and to give us the opportunity to build a really robust emergency department and hospital service and to give us the opportunity to grow and evolve in the future to meet the growing needs of our community.”

She said they needed to make sure their consolidated emergency department was attached to in-patient beds, and there are 15 of those in Haliburton. Shifting to Minden would have required ministry approval, delays, and costly renovations, she added. The Haliburton site will require a few minor alterations.

Plummer said Haliburton is also “a little more central in the County as well from an EMS response perspective and travel distance perspective.”

As for the future of the Minden site, Plummer said, “we’re going to look at lots of different opportunities for that site and what might help better meet the needs of the community.”

Dr. Bottum added, “in the long run, for the benefit of the organization, consolidating to one site and being able to optimize those services is going to be a bonus for the County for years to come. Instead of splitting money between two sites, which was politically nice, but from a medical standpoint, we’ve supported the idea of a single emergency department for 30 years.”

He also said it made sense to have a consolidated site to better recruit personnel and a primary emergency site to bolster the application for a CT scanner.

Plummer said since they have been planning for near closures for months, a lot of the legwork has been done for the transition. However, she said there would be adjustments for staffing, space, patient flow, equipment and parking, to name a few.

They are also rolling out a communications strategy that will include signage at Minden hospital and on highways, and staff on-site in Minden to redirect patients when needed.

“This decision is about maintaining the safety of our patients, the sustainability of our services and the care our patients receive, and the well-being of our staff teams,” Plummer said.

For more on this story, see next Thursday’s Highlander.

Troubadours to share music and stories with Highlanders

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Canadian roots powerhouse duo, The Small Glories, are headed to Haliburton County Saturday night, as the folk society presents Cara Luft and J.D. Edwards for the first time ever in the Highlands.

Hailing from Winnipeg, Luft told The Highlander this week, she and Edwards are musical partners only. “It’s like singing with a sibling, our voices work really well together. And we’re troubadours. We love to go from town to town and tell stories from other places we’ve been and share things with new audiences. It’s not just about the music for us. It’s about the whole thing.”

Like most musicians, the Small Glories did not tour for a couple of years due to the pandemic. However, they’ve had make up dates from cancelled shows that have recently seen them primarily in the United States.

In talking to their agent, Luft said, “we haven’t played Ontario very much. Because of the pandemic, the last time we were in Ontario was in 2019, so let’s look at spring of 2023.” The Haliburton County Folk Society, meanwhile, was looking to book in a spring show.

“So, our agent put the call out as we had a small timeframe that we could come to the province. And the Halliburton County Folk Society was one of the organizations and one of the communities that really wanted us to come.”

Luft added despite having played in larger towns and cities and in front of big crowds, they love playing for people, “no matter where they are, and no matter the audience size. We just want people to come who want to be there. It’s great to play for a full house but even when it’s not a full house, the people who are there, they get a unique experience.”

The Small Glories said fans can expect a lot of original material, but also some traditionals and covers.

“We’re really big believers in when you find a great song, regardless of who wrote it, it needs to be shared. So, we do a lot of interpretation that way. But we really love to engage with the audience. We love telling stories. We get people laughing, sometimes we get them crying, sometimes they get up and dance. So, it’s definitely really special.

“Every concert is unique and different and always very special. So, I think people will expect great music, a great respite and relief from whatever woes they may be experiencing, and just a really great time with community.”

The show is at 7:30 p.m. at the Haliburton Legion with opener Albert Saxby. Ticket information can be found at haliburtonfolk. com.

FoRT event focusing on cycling, environment

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The Friends of the Rail Trail (FoRT) is inviting County residents to attend an evening of socializing and education through the third iteration of its ‘Spokes and Species’ series.

Taking place in the clubroom at the Haliburton Legion April 26, the event will feature two guest speakers broaching subjects around cycling and the environment. Organizer Pamela Marsales said it will be a fun-filled evening jam-packed with information.

“We imagine there are lots of people out in the hinterlands in Haliburton County, cottagers and new residents who are interested in cycling, nature, rail trails or all of the above. This is a great opportunity for them to come out, meet new people and have a social evening,” she said.

Cara Steele, an ecologist at Abbey Gardens, will speak about the ecological restoration that has been ongoing at the site, touching on livable green spaces and habitat biodiversity.

The main presenter is Brendan Matheson, a coordinator with Tourism Simcoe County (TSC). Marsales said he’ll be talking about a new cycling tourism strategy he’s working on for TSC, with the key feature being a 160-kilometre rail trail loop connecting Barrie, Midland and Orillia with Georgian Bay, Lake Simcoe and Lake Couchiching.

“That would be of interest to many people here… the concept of cycling tourism is something that’s yet to be fully imagined and realized in Haliburton County,” Marsales said. “We’re excited to think about the possibilities. Brendan has helped create a loop trail that has become a real destination and economic driver for Simcoe County.”

Marsales said while the County has its own 35-kilometre rail trail, it’s often overlooked in favour of what she called better systems elsewhere.

She’s eager to see work continue on a proposed Toronto Algonquin Greenway (TAG) initiative that would connect the Highlands to Algonquin Park and the GTA. The 200-kilometre route would incorporate five separate existing trail systems and promote hiking, cycling and paddling.

“All the groundwork has been laid for this TAG concept to be developed as a sustainable, multi-community tourism product, but there’s still work to be done,” Marsales said, noting the project was put on hold in 2020 due to the pandemic. “I think that would really help to direct a lot of people to Haliburton County.”

The ‘Spokes and Species’ event will start at 7 p.m. Admission is by donation, with proceeds supporting FoRT. Attendees are asked to enter the Legion through the side door.

County seniors gearing up for 55-plus games

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Haliburton County’s district 11 organizers are looking forward to hosting Ontario Senior Games Association (OSGA) 55+ events this summer.

Spokesperson Mary Johnson said April 20 (today) is the last day for planners to receive mailed registrations prior to the games kicking off May 4 and running until June 20.

Johnson added the games are open to men and women who are 55-plus years of age as of Dec. 31, 2023.

The event features cards, including euchre, bid euchre, contract and duplicate bridge as well as cribbage, and sports such as golf, pickleball, shuffleboard, tennis and walking.

Johnson said the games are about being active and getting involved in the community, not necessarily competition.

“Do you have the time to have fun in a competitive, non-threatening setting? Are you seeking opportunities to socialize and meet new friends? Do you feel young and energetic?” she said of the OSGA mission statement.

However, people can qualify to go on to regional games and Ontario 55+ games. There are 36 districts across the province, with more than 9,000 participants and over 500 volunteers. The games were incorporated in 1997 and there are traditionally 18-plus summer and 10-plus winter events. District 11 comprises Muskoka and Haliburton.

This year’s schedule sees bid euchre first up, May 4 at 1 p.m., at the Cardiff Community Centre and then May 8 at 1 p.m. at the Minden Curling Club. The finals will be in Gravenhurst June 9.

Euchre will follow May 15 at 1 p.m. at the Minden Curling Club and June 1 in Cardiff. The finals are June 2 in Gravenhurst.

Cribbage is scheduled for May 18 at 1 p.m. at the Kinmount Legion. The cribbage finals will be played in Kinmount June 15.

Duplicate (9 a.m.) and contract (1 p.m.) bridge will be played June 5 at the Stanhope Community Centre.

Shuffleboarders will hit the courts in Minden June 6 at 9 a.m. The finals are in Gravenhurst June 8.

Golf will again return to the Blairhampton Golf Course, on June 7, with a shotgun start at 10 a.m. Walking then takes centre stage. It is slated for June 8 beginning at 9 a.m. from the docks in Haliburton. Tennis will be next up, at the Haliburton courts, June 13, with an 8:30 a.m. start.

And, finally, the ever-popular pickleball is slated for June 20 at the Haliburton courts.

For more information, contact Mary Johnson at 705-754- 1884.

The Music Room ‘hub or performances

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A new entertainment venue is coming to downtown Haliburton next month.

Partners Anna Lowes, Mark Christiano and Craig Titus have been working through winter to turn their dream of establishing a new musical space in the village into reality. The trio are launching The Music Room, a 150-seat event space inside Castle Antiques on Highland Street, in early May.

“We’ve been talking about this for quite a while now. It’s always been in the back of my mind to bring something new to the downtown scene… after working closely with Anna the past few months, the door opened,” Christiano told The Highlander.

For the past six months, Castle has hosted regular shows on Friday nights – providing an opportunity for local musicians to perform in front of a live crowd. The events, first dubbed ‘Friday Night at the Castle’ and later ‘Tacos and Tunes’, have been wildly successful, Lowes said.

“We ran shows almost every week through winter and it was great – people have had a lot of fun. Now we want to ramp things up,” Lowes said. “Friday nights was kind of the stepping stone, but after seeing how well everything was going, we knew the longterm goal was to have a permanent music venue and do larger concerts here.

“The goal of Castle has always been to be a destination and offer as much variety and things for people to do as possible. I think this is just another way of doing that,” she added.

Renovations are ongoing, with a new stage and sound system being fitted in the antiques side of the store. Christiano said he’s planning to incorporate many of the shop’s vintage musical items in his design for the space, showcasing classic jukeboxes, phonographs, and instruments.

“It’s going to be a really cool vibe,” he said. A first concert has been pencilled in for May 6, with Canadian country singer Marshall Dane bringing his talents to the Highlands. Tickets are $32 and can be bought at Castle and The Hair Lounge in Haliburton.

Titus said there are six further concerts confirmed for the summer, with Christiano adding he hopes to put on at least one show per week. This is in addition to the Friday night offerings, which Christiano says will continue, noting they provide opportunities and experience for up-and-coming local performers.

The space can also be booked for workshops, seminars, and corporate events, he said.

Lowes feels this new space has the potential to benefit all businesses in the downtown.

“I’m hopeful this will kickstart more of a lively evening atmosphere – bring more people into Haliburton during times when it’s usually starting to quiet down,” she said.

“We’re not limiting ourselves to one night a week – this will really be driven by public demand. If people want to see more, then we’ll do more.

“I think this is going to be really popular, and I’m just excited to see where we can take this,” she added.

For more information about The Music Room and upcoming shows, follow them on Facebook and Instagram @ themusicroomhaliburton. To enquire about tickets, email themusicroomhaliburton@ gmail.com.

HGTV designer ‘loves’ coming to the County

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Toronto-based designer Debra Salmoni said Haliburton County has long been one of her favourite destinations while filming material for HGTV’s hit show Scott’s Vacation House Rules.

Season four premieres April 23, with the first two episodes featuring properties in Coboconk and Algonquin Highlands. While filming last year, Salmoni said her return to the Highlands was something of a homecoming.

“I have such an emotional connection to Haliburton – my mother’s side of the family had a cottage on Eagle Lake, so I’ve been heading up there ever since I was in utero,” she told The Highlander. “I spent a lot of time in the County while I was growing up… I remember trips we’d take down into Minden, we’d go out to the dump just to see all the bears. Some amazing memories, for sure.”

Salmoni has offered her expertise on the hour-long show since its debut in 2020. Hosted by contractor Scott McGillivray, it provides a road map to renovation and rental success for homeowners, she said. The episodes often see the team transform a rundown property into something more befitting its natural surroundings.

In a previous interview with the paper, McGillivray said he tries to strike a delicate balance with every one of his redesigns.

“We don’t go and do anything that’s going to destroy the environment. We’re not interested in helicopter pads,” he said.

“We’re not a show that goes in and says, ‘let’s tear this down and build something that’s a 100,000 sq. ft. mega mansion’. Our show is way more grassroots than that.

“We’re here to support the local community, be balanced with what we do, be respectful about it, and find affordable ways for people to have a slice of that dream too,” he added.

Episode one features a cliffside cabin in Coboconk, owned by a long-time friend of McGillivray’s.

“It was quite a long renovation, it ended up taking us closer to six months to complete. We were fighting some of the elements throughout that project, but that’s what I love about the show. We’re not putting this high gloss vision of perfection out there, it’s all real-life stuff,” Salmoni said. “Scott encounters some major challenges with his renovations, and we like to show how we deal with those head on.”

The second episode captures a waterfront property overlooking Halls Lake in Algonquin Highlands. The owners are cottagers from the city, who wanted to spruce up the place so they can rent it out and help cover some of the costs associated with running it.

“I think their situation is very relatable for a lot of millennials,” Salmoni said.

The bungalow has been transformed on the inside to incorporate more of a “techie” theme, with local contractors assisting with the rebuild. The episode will air April 30. A third episode featuring a Highlands property will be released in the fall.

Aside from the lakes and natural beauty, Salmoni said a key attraction to filming in the County is the people.

“We have never had a bad experience up there. When we pull up to a property, the neighbours are always so gracious. A lot of times we don’t have running water, or space for parking, so we’ve had neighbours let us use their washroom, park in their driveway, offer to feed us,” Salmoni said. “This is a very welcoming community.”

Scott’s Vacation House Rules premieres April 23 at 10 p.m. on HGTV Canada, and is available to stream on StackTV.

Mindenites keeping eye on Gull

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Chris Kranyak stands on the front step of her Anson Street, Minden, home having a cigarette and warily watching the Gull River across the street.

Orange sand bags line the boat launch a stone’s throw away.

Kranyak has only lived in the house for two-and-a-half years, and not experienced a Gull River breach, but her sister, who lived in the home for 30 years, has.

“When they put the sandbags down the other day, our first thought was, of course, they’re expecting floods, but they put out on the Minden Hills website that it was just a precaution,” Kranyak said on April 18.

“But we watch the water go up and down every day,” she added. “I don’t think it will flood. We went through those torrential rains on the Sunday two weeks ago. It didn’t end up being anything.”

Nevertheless she is keeping an eye on the large culvert out front as well as water levels in the backyard. After all, it’s that time of year. Minden Hills and other County residents are watching the Gull and Burnt River for rising waters and other Highlanders are keeping an eye on lakes as the Trent Severn Waterway manages dams for spring run-off.

Minden Hills mayor Bob Carter said the township has another week or two to worry about potential flooding, but as of April 18 conditions were stable.

The MNRF gave notice April 14 of the potential for flooding based on weather forecasts calling for heavy rain, snow melt, high winds and other conditions. The water conditions statement – flood outlook bulletin remains in effect until April 21 at 4 p.m.

Carter, who has spoken with Parks Canada and the MNRF a number of times over the last week or two, said he’s been told there’s still a lot of snow in the northern areas. As a result, he said the melt has been significant but the good news is, “we didn’t have all of the rain that was forecast.

“So, as long as our rain levels remain somewhat normal, or slightly above normal, we’ll be fine.” However, if there is another big rainstorm like the recent one, the mayor said, “that would be problematic. So, we have another week or two to worry about it.”

Township staff confirmed they have placed sandbags across the boat launch on Anson Street as a precaution. The boat launch is closed until further notice.

In its statement, the MNRF advised of hazardous conditions near water, localized flooding on access roads, and told people to prepare accordingly.

“MNRF is closely monitoring the weather and developing watershed conditions. Further updates will be issued as appropriate,” they said.

Consultant suggests tax hikes for HE

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Highlands East received an asset management plan from consultants April 11, revealing the current replacement cost of all infrastructure totaled $101 million.

The township hired consultants PSD Citywide to prepare the plan, as legislated by the province, and Israr Ahmad and Sarah Craig presented it to council last week.

They looked at roads, bridges and culverts, water and wastewater distribution and treatment, vehicles, facilities, land improvements, and equipment.

The consultants said the plan provides important data on Highlands East’s assets, including replacement costs, condition and age information, short and long-term needs, current performance, where they are falling short on funding and how to close that gap.

Breaking down the $101 million, roads make up 38 per cent of assets, or more than $38 million, followed by buildings, at 31 per cent, or more than $31 million. Next were the water network (seven per cent), vehicles, sanitary network, bridges and culverts, each six per cent, machinery and equipment four per cent and land improvements, two per cent.

The consultants found that 58 per cent of the municipality’s infrastructure was in fair or better condition, with the remaining 42 per cent in poor or worse condition.

It was estimated that $16.1 million worth of roads were in poor shape, with $3.1 million very good, $7.8 million good and $10.4 million fair.

Bridges and culverts had $1.4 million rated as very poor and $300,000 as poor – with the remainder (nearly $4 million) very good, good and fair, as examples.

The consultants further said that, on average, $3.78 million is needed each year to remain current with capital replacement needs. However, “based on a historical analysis of available capital funding from sustainable sources, the municipality allocates $2.33 million annually – both for capital projects and to reserves. This creates an annual capital deficit of $1.45 million.”

It suggested to close those deficits over time as, “short phase-in periods to meet these funding targets may place too high a burden on taxpayers too quickly, whereas a phase-in period beyond 20 years may see a continued deterioration of infrastructure, leading to larger backlogs.”

The consultants suggested increasing taxes by 1.7 per cent per year over 10 years; increasing water rates by 3.3 per cent per year over 15 years; and increasing sanitary rates by 2.2 per cent per year over five years.

Ahmad said the township will have to continue to work on its asset management plan into 2024-25.

Deputy mayor Cec Ryall asked if Highlands East’s growth had been incorporated into the work thus far, and Ahmad said it had not, but would be.

Ryall commented when it comes to asset management planning, “once you stop, you will fall behind. So this asset management plan has to be maintained every year … it has to be improved based on intelligence and usage each year.”

Gooderham bridge works

Highlands East said on April 17 that an extensive rehabilitation of the Gooderham bridge, on County Road 507, just south of County Road 503 in Gooderham, has begun and is expected to be completed by late summer or early fall.

During construction, they said travel across the bridge will be reduced to a single lane of alternating traffic controlled by temporary traffic signals and drivers should be prepared for some traffic delays.

There will be a planned one-day full closure of the bridge to complete work that requires the entire bridge deck to be raised. The township said it’s working with the contractor to schedule the closure to minimize the impact.

A minimum of two weeks advance notice will be provided. In addition, the closure will have advance warning signage, a signed local detour, notification on the 511 system, and the County’s website, as well as media and social media announcements.

Plummer: health partnership to reduce confusion

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After a comprehensive, three-year review of all possible options, Haliburton Highlands Health Services announced April 12 it will become a partner with the Kawartha Lakes Ontario Health Team.

Introduced by the provincial government in February 2019, the OHT model was designed to improve the coordination of care and services for patients and their families across multiple health and wellness settings within their communities.

Teams can consist of municipalities, hospitals, primary care and community support providers, long-term care providers, public health, mental health and addiction agencies, and other service providers who all share resources and patient records.

Carolyn Plummer, HHHS president and CEO, said it made most sense to partner with Kawartha Lakes OHT considering how closely the organization works with many of its associate agencies.

“We know many people in Haliburton County already access services provided by members of KL-OHT and HHHS already has strong relationships with those providers,” Plummer said. “This means we can work more closely together to deliver better coordinated care to [our] patients.

Plummer told The Highlander the decision was delayed due to the COVID-19 pandemic, with negotiations with various OHTs put on hold.

She said there would be several benefits from the partnership, including improved communication between hospital staff and other agencies, and more referral options for patients.

“The Kawartha Lakes OHT aims to reduce confusion, support more efficient navigation between care settings and help keep people healthier for longer,” Plummer said. “Patients should have a more connected care experience as they move between different providers.”

She stressed there will be no changes to frontline care, with residents encouraged to contact their regular health providers if they have an issue, or report to the emergency department in Haliburton or Minden if in a crisis.

On its website, the Kawartha Lakes OHT states its primary mission is on enhancing coordinated care and services for seniors 65 years and older who live alone or have a poor support network, are frail with complex medical needs or are cognitively unwell, or have been hospitalized within the past year.