Transforming Primary Health and Community Care
Toronto Central Local Health Integration Network
Webinar
September 13, 2016
Welcome
•
Moderator
• Tess Romain, Senior Director
•
Presenter
• Susan Fitzpatrick, Chief Executive Officer
2
Purpose of today’s webinar
A special focus on two of our Strategic
Priorities:
•
Taking a Population Health
Approach (starting with subregion planning)
•
Transforming Primary Health and
Community Care
1.
Recap of activities to date
(9:05 – 9:10)
2.
Alignment of future activities
(9:10 – 9:30)
3.
Hear your input and feedback
(9:30 – 10:00)
3
Summer recap
•
Launched Local Collaboratives in May and June (transition
from sector-based tables to a sub-region approach); “Save the
Date” for October sessions have been sent
•
Confirmed sub-region planning area geographies (Webinar,
August 11th)
•
Announced leadership and developed our work plan for Primary
Care priorities
•
Reviewed reports, committee recommendations, and are starting
an ongoing dialogue with community providers to inform future
planning for integrating community care
4
5
5
Our Strategic Priorities in Action –
Year 2 Highlights
Taking a Population Health Approach –Services are reflective and are proportionate to
need (equity agenda)
1. Integrating the citizen voice in all that we do
2. Focusing on population health and equity
3. Creating strategic partnerships to advance social determinants of health
4. Building a strong local and collaborative foundation within sub-region planning areas
Transforming Primary Health and Community Care – Everyone has fair access to care
5. Creating an integrated system of Primary Care
6. Creating an integrated system of Community Care
7. Designing a coordinated Regional Framework when patients need access to specialized
services
Designing Health Care for the Future – All patients receive high quality care
8. Supporting clinical leadership throughout the system
Achieving Operational Excellence – Effective management that shapes health care for the
future
6
9. A strong Toronto Central LHIN team
One Team, One Plan
1. Strengthen patient and community voice to
drive One Plan
2. Use data and evidence to focus on population
health and equity
3. Advance shared priorities with the City of
Toronto
4. Create strong local partnerships to address
community needs
5. Align primary care resources as local
networks
6. Align community providers around a shared
vision and plan
7. Enhance coordination and access to regional
services
8. Leverage local leadership to improve clinical
and community care
9. Create a high performing Toronto Central LHIN team; Communicate a public plan for integrated
services; Aligning investment strategies, performance management and accountability,
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information technology, data and analytics, and policy to support One Plan
Today’s area of focus
1. Strengthen patient and community voice to drive
One Plan
2. Use data and evidence to focus on population
health and equity
3. Advance shared priorities with the City of
Toronto
4. Create strong local partnerships to address
community needs
5. Align primary care resources as local
networks
6. Align community providers around a shared
vision and plan
7. Enhance coordination and access to regional
services
8. Leverage local leadership to improve clinical and
community care
9. Create a high performing Toronto Central LHIN team; Communicate a public plan for integrated services;
Aligning investment strategies, performance management and accountability, information technology, 8data
and analytics, and policy to support One Plan
Strategic Priority:
Taking a Population
Health Approach
Services meet need (equity
agenda)
4 Local Collaboratives
(“Sub-Regions”)
9
Taking a population health approach…
• Understand the needs of
the whole population and
local communities
• Meet the needs of subpopulations (e.g.
Francophone, Indigenous)
• Tackle health inequities
• “Get upstream”
(maintain and prevent)
• Build partnerships to
address social
determinants of health
10
… with a focus on equity
•
We are accomplishing this by:
• Strengthening our population health analytics
• Engaging and planning with vulnerable and marginalized communities
• Creating strategic partnerships to support people with more holistic care
that will make a difference in their lives
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A sub-region approach supports local planning
around population need
Sub-region creation – Appropriate size to engage citizens and providers
and to reorganize care around local needs
1.2 million people → 74 neighbourhoods
→ North:13 Neighbourhoods
199,051 people
→ West: 14 Neighbourhoods
232,570 people
→ Mid-West: 18 Neighbourhoods
305,989 people
→ Mid-East: 8 Neighbourhoods
143,392 people
(2011 Census)
→ East: 21 Neighbourhoods
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269,756 people
The power of planning locally
1
Casa Loma has the rate of
highest income and a relatively
low marginalization rate.
Health system resource
indicators show lower utilization:
2
ALC Rate = 6.2%
Rate Inpatient Hospitalizations =
50.5 per 1,000
Kensington-Chinatown has the highest
rate of low income in the sub-region, and
the highest marginalization rate.
Health system resource indicators show
higher utilization:
ALC Rate = 15.3%
Rate Inpatient Hospitalizations = 75.5
per 1,000
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Linking local health outcomes and
system performance
Define outcomes
Common Toronto Central LHIN objectives
1
(Performance Dashboard)
Local population-based needs
2
(Local Collaborative / sub-region planning)
Identify balanced priorities where will we start, based
on our performance goals, both locally and LHIN-wide
One Team, One Plan
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GOALS
• Self reported health status
• Life expectancy
• Infant mortality
Positive Patient
Experiences
• Integrated patient experience
• Patient involvement in
decisions about their
care
• Change in trend of
proportion of funding
between community and
hospital care
• Achieve expected value
of integrations
• Unnecessary ED visits**
• Access for MRI*
• Access for CT*
• Access for hip*
• Access for knee*
• ED length of stay for
complex patients*
• ALC days*
• ALC rate*
With a focus on
marginalized / priority
populations, and in
partnership with Public
Health, municipal, and
other non-health partners:
• Smoking rates
• Diabetes
• Hypertension
• Childhood wellness
• Availability of housing
with supports
• Suicide rates
• Repeat unscheduled
emergency visits for
mental health*
• Repeat unscheduled
emergency visits for
substance abuse*
• Readmission within 30
days*
Transforming Primary
Health and Community
Care
• Primary care attachment
• Same day / next day
access to primary care
• Physician follow up within 7
days of discharge*
• Coordinated care plans for
complex patients
• Wait time from CCAC
assessment to in-home
services*
• 5 day target for personal
support *
• 5 day target for nursing
• Hospitalization rate for
ambulatory care sensitive
conditions**
• ED length of stay for
minor/uncomplicated
patients*
Achieving Excellence
in Operations
• TC LHIN performance
rating by HSPs
• HSP performance
against select
Accountability
Agreement
performance measures
• HSP current ratio
(consolidated)
• HSP total margin
(consolidated)
* MLAA Indicators
**MLAA Monitoring
Indicators
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Quality & Value
Taking a Population
Health Approach
• Age adjusted health
expenditure per capita
Access & Equity
Designing Health Care
for the Future
System Sustainability
Prevention & Wellness
STRATEGIC PRIORITIES
A Healthier Toronto
Strategic Priority:
Integrating Primary
Health and Community
Care
Everyone has fair access to care
5 Integrated Primary Care
6 Integrated Community Care
7 Coordinated Regional Services
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What we have heard from patients,
clients, families, and caregivers …
“
I don’t care how you organize my health care or
about the rules – I just want care when I need it,
where I can get to it, and to feel confident that it is
going to make me better.”
ACCESS
“Want to be at home
and healthy”
- Toronto Central LHIN resident
NAVIGATION /
COORDINATION
“Searching is stressful”
COMMUNICATION
“Act as one team”
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What will One Team look like?
Single point of
coordinated
access that can
link care
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Coordinated across the system
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Unifying streams of work that will build locally
integrated care
Identify
Leadership
Develop
Vision
Determine
Priorities
Develop
Work Plan
Integrated
Primary
Care
Integrated
Community
Care
Coordinated
Regional
Services
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How are we moving forward?
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Connected leadership across all providers
LHIN-wide:
Toronto Central LHIN CEO
Susan Fitzpatrick
Executive Advisory Committee
Anne Babcock, Woodgreen
Stacey Daub, TC CCAC
Dr. Phil Ellison, LHIN Primary Care
Lead
Terry McCullum, LOFT
Dr. Barry McLellan, Sunnybrook
Hospital
Dr. Barbara Yaffe, Toronto Public
Health
Executive Lead, Integrated
Primary Care
Dr. Phil Ellison, Chair
Executive Leadership,
Integrated Community Care
Within each
planning area:
Local Collaboratives
(Sub-Region Tables)
1. HSPs and other
community providers
2. Supported by Toronto
Central LHIN Leads:
Aleem Bhanji,
Gillian Bone,
Shez Daya,
Zulf Kassam,
Stephanie Lockert
Primary & Community
Care Committees
1.
2.
3.
4.
Primary Care Clinical Lead
CCAC Lead
CSS, CMHA Lead(s)
Hospital Resource Partner
To be announced
Regional Services Advisory
To be announced
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Primary Care Leadership
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Primary Care Work Plan Priorities 2016/17*
Through engagement with primary care providers, physician leaders have confirm 5 priority for system
improvement:
*See Appendix A (posted online following the presentation) for further details.
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Primary and Community Care Committee(s)
• A Primary and Community Care Committee (PCCC) is being established in
each sub-region planning area to advance the planning and integration of
primary care. The inaugural meetings are expected to be held in October
2016. The Primary Care Clinical Leads will chair each committee.
• PCCC responsibilities include:
• Initially, building a foundation and coordinated care network of
primary care clinicians and organizations, with active community
participation;
• Championing the development of a patient centric local primary care
system;
• Recommending and where approved overseeing implementation of
resources, processes and systems to improve access, continuity and
quality of primary health care;
• Facilitating and encouraging co-ordinated care for patients through
collaborative relationships with all health system providers.
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Plan for Local Collaboratives
(sub-region approach) 2016/17
Advance a Population Health Approach
In Fiscal Year 2016/2017, at our (sub-region) Collaborative Tables, we will:
1.
Begin by looking at robust sets of data that capture the unique needs
of the neighbourhoods and groups of people within our sub-region areas
2.
Engage patients and community members to confirm these
“community profiles” and to provide perspectives that cannot be captured
through data alone
3.
Identify unmet needs and health inequities, whether they be on a
neighbourhood basis, or within specific types of population groups
4.
Collaborative Tables will develop a framework for collaboration to
establish roles in responding to population need
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Launching Integrated Community Care
This fall, begin designing a high performing integrated system of care
• Aligned with Strategic Plan 2015-2018 and Roadmap to Strengthen Home
and Community Care
• Drive a one team, one plan vision for population-based integrated
system of community care that improves the experience, outcome and
value for clients
• Collaboration across CCAC, Community Support Services, and
Community Mental Health and Addictions to identify a common vision
and priorities
• Build on successful initiatives for improved collaboration and integration
across the community sector
• Undertake meaningful engagement of providers, clients and their
caregivers to inform strategy
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Next Steps
• Local Collaboratives (sub-region approach)
• Invites for October to follow
• Save the Dates →
Mid-West
Oct 11th, 1:00pm – 5:00pm
North
Oct 13th, 9:00am – 1:00pm
Mid-East
Oct 18th, 9:00am – 1:00pm
TBC
East
Oct 19th, 9:00am – 1:00pm
TBC
West
Oct 25th, 9:00am – 1:00pm
• Integrated Primary Care
• Formalize Primary & Community Care Committees (PCCC)
• Integrated Community Care
• Announce Leadership and engagement strategy to develop vision
and priorities
• Coordinated Regional Services
• Establish working group and begin engagement activities
• Save the Date → October 31st, 12:00pm – 3:00pm
• Webinar focusing on developments in Integrated Community Care
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Questions?
Megan Primeau
Manager, Communications
[email protected]
Tess Romain
Local Collaboratives (sub-region approach)
[email protected]
Greg Stevens
Primary Care
[email protected]
Gillian Bone
Regional Services Framework
[email protected]
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Appendix A: Primary Care Priority Projects
1. Attachment, Access and Continuity
2. Access to Inter-professional Teams
3. Access to Specialist Consultations
4. Discharge Planning
5. Secure Communication
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Lead: Dr. Curtis Handford, Mid-East PCCL
PRIORITY PROJECTS
1. Attachment, Access and Continuity
Objective: to improve access to primary care providers for all residents who want one.
Phase 1:
Unattached Patients
Phase 2:
Urgent/After Hours
Phase 3:
Continuity
Development of a baseline and
assessing success of various
initiatives (e.g. Health Care Connect
and Health Links); assessing current
capacity within the LHIN and
proposing and implementing
strategies to reduce/eliminate
unattached patients for all those who
want a provider.
To assess patient access to same
day/next day appointments with their
primary care team when they are
sick, at a sub-region level. Propose a
strategy for improvement.
Assess and evaluate the impact of
continuity of attachment and timely
access to services on the quality of
care and system efficiency using a
variety of measures. Where needed,
propose strategies for improvement.
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Lead: Dr. Geordie Fallis, East PCCL
PRIORITY PROJECTS
2. Access to Interprofessional Teams
Objective: to improve access to inter-professional care teams for patients who need them.
1. Current State
Assessment
Interprofessional teams are of most
benefit to complex patients with
chronic disease or co-morbidities.
Determine current baseline
information at a sub-region level on
teams, compositions, and access.
2. Assess Need
Current access is based largely on
practice models and not on overall
population need. Determine and
define which patients would benefit
most from team based care.
3. Propose Solutions
Assess current solutions and
innovations to improve access.
Propose a LHIN-wide strategy to
improve access to team based care
based on patient.
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PRIORITY PROJECTS
Lead: Dr. Pauline Pariser, Mid-West PCCL
Hospital Resource Partners: Mid-West - UHN & North – Sunnybrook
3. Access to Specialist Consultations
Objective: to improve access to urgent specialist consults and streamline access to community and
hospital-based specialists.
1. Assess
Current State
Access to specialist consults on an
urgent basis was identified as a high
priority for primary care physicians
during consultations. Assess current
access patterns, successes and
challenges in each sub-region.
2. Assess & Expand
Promising Practices
Assess and expand as appropriate
current practices and models
including SCOPE, eReferral and
eConsult.
3. Propose Strategies
for Improvement
Develop and implement a searchable
specialist directory and propose
strategies and processes to simplify,
streamline access to specialist
advice.
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Lead: Dr. Jocelyn Charles and Dr. Yoel Abells, North, PCCL
Hospital Resource Partners: East - Michael Garron and West St. Joseph’s and Mid-East - St. Michael’s
PRIORITY PROJECTS
4. Discharge Planning
Objective: to improve timely access to quality discharge summaries to enable timely primary care
provider follow-up.
1. Develop a Package of IT Solutions
Provide physicians with access to hospital and CCAC
information including discharge summaries and test results
(e.g cGTA, HRM and eNotification solutions).
2. Improve Quality and Processes
Work with hospitals to improve completeness, timeliness and
distribution of discharge information (including inpatient and
ER information and PODS).
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PRIORITY PROJECTS
Lead: Dr. Don Smith, West PCCL
Hospital Resource Partners: North – Sunnybrook,
West - St. Joseph’s and Mid East - St. Michael’s
5. Secure Communication
Objective: to improve communication between health care providers and between providers and patients using
enhanced and integrated information systems and reduce service duplication and inefficiency.
1. Provider to Provider
2. Provider and Patient
3. Patient Portals
Increase enrolment of physicians to
OneMail allowing for secure
communication across settings and
providers.
Assess benefits and policy
requirements to enable physicians to
securely communicate with patients
(within EMRs).
Support expansion of patient portals
to access hospital information
(e.g MyChart).
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