Advancing Primary Health Care
Integration in the Toronto Central LHIN
A Strategy for Primary Health Care
Final Report
January 2013
Advancing the Integration of Primary Health Care in the Toronto Central LHIN (Draft Report)
A Strategy for Primary Health Care
1
Acknowledgements
A study of this magnitude cannot be successful without the input of time, energy and knowledge of many
individuals.
Corpus Sanchez International would like to extend special thanks to the project sponsors – the Toronto
Central LHIN, the Toronto Central CCAC and St. Michael’s Hospital – and specifically the lead individuals
from each organization:

Ms. Stacey Daub, CEO of the Toronto Central CCAC;

Ms. Camille Orridge, CEO of the Toronto Central LHIN; and

Dr. Doug Sinclair, Executive VP and Chief Medical Officer at St. Michael’s Hospital.
Your foresight in recognizing the importance of this project, and your guidance to the team cannot be
overstated.
We want to acknowledge the efforts of several staff at the Toronto Central LHIN including: Ms. Vania
Sakelaris, Senior Director; Ms. Ashnoor Rahim, Project Manager Primary Care; and Ms. Jasmine
Paloheimo, Administrative Assistant Primary Care. Your individual and collective interactions with the CSI
team and your unwavering support have been invaluable.
We also extend our appreciation to the Toronto Central LHIN’s Primary Care Advisors: Drs. Yoel Abells,
Phil Ellison and Tara Kiran. This work would not have been possible without your support and guidance.
We thank the participants of the Current State Working Group and the Design Working Group who helped
to frame and prioritize the current state issues and provided the foundation for the proposed future
primary care model. Your commitment to Primary Care in Toronto is applauded.
We want to acknowledge the people who helped gather the data used to inform the review Ms. Rachel
Solomon, Senior Director; Ms. Shirley Bryant, Epidemiologist; and Ms. Cynthia Damba, Epidemiologist,
and other staff at the TC LHIN who have dedicated significant time and energy in interpreting the current
state and conducting future planning analysis included in this report. We also thank Dr. Rick Glazier for
his valuable input and support. We recognize that this is only the “tip of the iceberg” in terms of
understanding the starting point. Your ongoing assistance will be invaluable.
Finally, our appreciation goes to the over 250 individuals who participated in interview sessions,
committee meetings, focus groups, and the Think Tank Session who shared their insights, and ultimately
gave this review an invaluable degree of robustness and depth.
To all those who participated, we hope you recognize the value of your contribution to the ultimate goal
of providing improved primary care services to the people who rely on all of the providers and agencies
within the Toronto Central LHIN to meet their needs.
Advancing the Integration of Primary Health Care in the Toronto Central LHIN (Draft Report)
A Strategy for Primary Health Care
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Table of Contents
EXECUTIVE SUMMARY
INTRODUCTION
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Setting Context
Understanding the Mandate
A CLEAR NEED FOR ADVANCING PRIMARY CARE
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Drivers for Changing Our Health Care System
UNDERSTANDING THE LOCAL CONTEXT
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Confirming the Case for Change
Understanding the Uniqueness of the Toronto Central LHIN
CONFIRMING KEY AREAS OF FOCUS
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Focus 1: Innovation in Care Delivery
Focus 2: System Leadership and Clear Vision
Focus 3: Building Enablers and Supports for Success
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VISION FOR PRIMARY HEALTH CARE IN THE TORONTO CENTRAL LHIN ERROR! BOOKMARK NOT
DEFINED.
THE PRIMARY HEALTH CARE MODEL
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Building the Network Concept
Confirming the Benefits of the Network Concept
Identifying the Networks
Defining Core Services for the Each Network
Evaluating the Impact of Networks
BUILDING A PLAN TO MOVE FORWARD
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Six Imperatives to Achieve the Vision
Imperatives and Supporting Recommendations
Philosophy for Moving Forward
Commitment from the Toronto Central LHIN
APPENDIX
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Current State Design Working Group
Design Working Group
Think Tank Participants
Learnings from the International and National Landscape
Identifying How to Measure Success
Proposed Network Maps
Framework for Evaluating Impact of Primary Care Networks (Draft)
References
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Advancing the Integration of Primary Health Care in the Toronto Central LHIN (Draft Report)
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Executive Summary
Setting Context
Health systems in countries around the world are struggling with the issue of system sustainability. While
all health care systems have their own unique characteristics, a common under-pinning of all reform
efforts is that they are grounded in a vision of a strong primary care system that ensures effective care at
a local level, while enabling access to higher levels of care through coordinated access.
In Ontario, primary care evolution has been under consideration for decades, with multiple models being
proposed over the years as part of successive governments’ ongoing desire to strengthen primary health
care. All of this work has been grounded in the realization that primary care is a, if not the, fundamental
building block of an effective care delivery system. Drawing on this rich history and willingness to explore
innovative models, Ontario’s Action Plan for Health Care reaffirms the importance of primary health care
and seeks to improve access to family health care, ensuring patients and families get the right care, at the
right time, and in the right place.
The Toronto Central LHIN (TC LHIN), along with its many providers, also acknowledges the need for a
comprehensive, system-wide strategy to establish sustainable primary care delivery models capable of
meeting the growing, diverse, and changing needs within the LHIN. In keeping with the LHIN’s strategic
aim to transform the system to achieve better health outcomes for people now and in the future, the
overarching goal is to ensure that the right primary care resources are in place and incorporated into an
integrated continuum of care that meets the needs of individuals requiring services now and in the future,
and creates a care system focused on the health of a population. The TC LHIN understands also that
primary health care is just one element of an overall solution to better serve populations, and that efforts
around Seniors Health and other important efforts like the Ministry’s Health Links initiative must
effectively work together.
Primary Health Strategy
Ontario’s
Action Plan
for Health
Care
Toronto
Central LHIN’s
Strategic Plan
2012 - 2014
Informs
Informs
February
February 2012
2012
Seniors Strategy
Guides
Guides
April
April 2012
2012
Accountable for
the Health of a
Population
Health Links Initiative
Initiated
Initiated in
in 2012
2012
A Multi-Year Plan
with Evaluation
Delivers
Delivers
2013
2013 -- 2015
2015
Building on Ontario’s Action Plan for Health Care and the TC LHIN’s Strategic Plan, the Toronto Central
Local Health Integration Network (TC LHIN), in partnership with the Toronto Central Community Care
Access Centre (TC CCAC) and St. Michael’s Hospital initiated a comprehensive review of the Primary Care
System in Toronto. To support the overall project goals, over 250 stakeholders were engaged in focused
discussions to better understand key issues and identify system-wide opportunities to advance primary
care within the LHIN. Stakeholders included, but were not limited to, patients and families, point of care
providers and navigators, primary health care provider organizations, community-based providers, family
medicine department leaders, system level informants, and institutional providers.
The report summarizes two important phases of work. Phase 1 focused on building an understanding of
the primary care landscape in the Toronto Central LHIN with a focus on primary care physicians, and Phase
2 transitioned into building a Primary Health Care Strategy for communities within the Toronto Central
LHIN.
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A Strategy for Primary Health Care
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Confirming the Need and Opportunity for Change
In Phase I, a clear understanding of the key issues impacting primary care were defined, confirming that
there are clear needs and drivers for changing our systems of health care. These include an understanding
that quality can – and must – be better for individuals requiring care; the growing burden of chronic illness
that is emerging within the LHIN’s aging and constantly changing population represents a major challenge
for many providers; a recognition that our health care system is not a system at all but rather a series of
silos; and the continued awareness of the need to manage the costs to ensure the ongoing sustainability
of the health care system.
Fortunately, as the Toronto Central LHIN providers move forward, it is starting from a position of strength.
Toronto Central LHIN is home to some of the very best primary care providers, CCAC, community
providers, hospitals, teaching institutions, and broader social service agencies. And as a collective, is
capable of providing the very best in health care. Providers in the LHIN have already initiated some
important foundational work in primary care that will be leveraged to ensure early and ongoing success.
Phase 1 confirmed that Toronto Central LHIN stakeholders and partners are in full agreement that change
needs to happen.
Establishing the Vision to Move Forward
In Phase II, the focus transitioned into establishing a strategy for primary health care for the Toronto
Central LHIN to guide its efforts over the coming three to five years. It was identified early on that to
advance primary care in the TC LHIN, the system must be viewed as part of the broader primary health
care continuum which includes the many providers who work together to contribute to the health of the
population. To achieve these goals, a vision for Advancing the Integration of Primary Health Care was
established:
The Providers of the Toronto Central LHIN will provide personalized, seamless, timely, comprehensive,
and high quality primary care to its population through collaboration across the system to advance
improved patient outcomes and improved patient experience in the context of a sustainable health care
system.
This vision for primary health care in the Toronto Central LHIN will ensure:

Every resident will have a primary care practitioner who provides them with accessible, high quality
care regardless of which practice model they are a part of;

Every primary care physician will have equal and equitable access to interprofessional teams in the
community to support their most complex patients and regardless of practice type;

A collaborative, interdisciplinary team supports all comprehensive family doctors and their patients;

Individuals requiring services and their families play an active role in directing plans of care;

Primary care services are integrated across a broader system of health care (e.g., acute care, long
term care, rehabilitation, end of life care), and other community health and social services including
public health and schools;

Primary care services are delivered in accordance with patient and community need with a view to
reducing health inequities;

Best practices, innovations and information systems are leveraged and spread; and

Patient outcomes and experience are measured at the practice and system level to support
continuous quality improvement.
Advancing the Integration of Primary Health Care in the Toronto Central LHIN (Draft Report)
A Strategy for Primary Health Care
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Designing the Network Concept
To deliver on the vision, a proposed Primary Health Care Model is established on the premise that
transforming primary health care cannot, and must not, be solely focused on primary care providers in
isolation of the broader care system. A broader, network approach must be leveraged that brings
together providers to jointly tackle the key challenges facing primary health care.
The idea of Networks is simple: Providers supporting providers to deliver the best possible care for people
and communities to ensure access to the core health care services in the communities and neighbourhoods
where they live their lives. This Network Concept will seamlessly bring together primary care, the CCAC,
community based services, hospital and specialized care, teaching and education, and linkages with social
and support services together. This will be achieved through the creation of smaller sub-LHIN boundaries
that create Networks that will build on local capacity to meet the health care needs of the population.
The result – the Networks come together to deliver better value for money, ensure higher quality of care,
improve access, support deeper engagement of individuals requiring services and family, and develop a
truly patient-centred focus.
To be successful, Networks must be grounded in the local needs of populations within a community; be
built on voluntary partnerships; be guided by local leadership; will focus on delivery comprehensive core
services to a population regardless of the existing family practice/general practitioner funding model;
must enable access to specialized services; be guided by a patient-centred approach to planning that will
focus on the complex, high need and high cost populations initially; and leverage existing successes and
partnerships which have been built on an inter-sectoral and interprofessional team approach, and through
an increasing degree of trust across providers.
Pursuing the Network model will result in a number of benefits for individuals requiring services.

Individuals requiring services will have improved experiences and will be at the center of the
transformation.

Individuals requiring services will have consistent access to required services reflecting the local needs
of the population.

Individuals requiring services will have equitable access to the same range of services and supports
regardless of who their physician is, and who their physician knows and has access to.

Individuals requiring services will be supported by interprofessional providers who will support their
transition and navigation to help access the care and services they need.

Individuals requiring services will have more options to receive their care when they need it, including
after-hours.
The Network model will also result in a number of benefits for providers. These include:

Providers will benefit from enhanced levels of flexibility to deliver services in ways that best meet the
needs of their communities.

Providers will have enhanced access to services and navigational support including access to primary
care, community, hospital and social services within and beyond their Network.

Providers will enhance their client’s experience through timely and smooth access to the services
clients’ need, when they need it through enhanced core coordination.

Referral patterns will be established to support the transition of individuals requiring services.

Providers will access care standards, information from across the system, and improved tools to
support delivery of the best care for their individuals requiring services.

Providers will have more support in caring for patients with complex care needs. Support for primary
care providers will leverage existing capacity and experience currently available.
Advancing the Integration of Primary Health Care in the Toronto Central LHIN (Draft Report)
A Strategy for Primary Health Care
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Building a Plan to Move Forward With
The TC LHIN has proposed the creation of nine (9) networks. Each network will have commonality in terms
of access to core services and expected outcomes, but will have a degree of customization based on the
needs of the local community. Specialized services will be available to all networks through a formal
referral process. Each network will be supported by robust information management practices to identify
and track improvements for defined efforts to improve the patient experience, quality of care received,
and timely access to services.
To realize our vision for personalized, seamless, timely, comprehensive, and high quality primary care that
are focused on collaborative approach that advances improved patient outcomes and patient experience,
the Toronto Central LHIN will take a phased approach to implementation. However the work must begin
and be completed in a timely fashion as residents of the LHIN cannot wait.
While it would be impractical to get all of the Networks up and running at the same time, our goal will be
to get all nine networks operational over the next three years. We will utilize implementation waves,
where subsequent Networks will learn from and build on the experience of networks that were
established before them to ensure future deployments will get easier. Every area of the LHIN and every
provider will be part of this. The first focus will start with Primary Care Providers and the CCAC as a
foundation. This is about ensuring primary care is available where clients live their lives.
While we know the next few years will require ongoing dedication and support to achieve the vision for
primary health care, we believe the Toronto Central LHIN as a collective of its providers and partners is up
for the challenge. Our providers have an abundance of talent, capacity and knowledge to make this
happen. We also understand the importance, and have the will and the courage to make difficult changes
for our clients and communities. With a planned and structured approach, we are more than capable of
delivering on what the Minister is calling on us to do.
Together, we can create the kind of system and experience that people tell us they want and that we
know they should be able to count on.
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A Strategy for Primary Health Care
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