Caring Communities, Healthier People
Integrated Health Service Plan (IHSP4)
for the Central Local Health Integration Network
2016-2019
ISBN: 978-1-4606-0555-4 (Print)
ISBN: 978-1-4606-0556-1 (PDF)
Table of Contents
CHAPTER 1...........................................................................2
Executive Summary
Central LHIN Vision
Our Strategic Priorities
CHAPTER 2.........................................................................10
Introduction: Insights and Inspiration from the Patient Voice
CHAPTER 3.........................................................................12
Provincial Context
CHAPTER 4.........................................................................15
LHINs’ Vision for the Health Care System
CHAPTER 5.........................................................................17
Overview of the Current Local Health Care System and
Achievements to Date
CHAPTER 6.........................................................................24
Strategic Priorities and Directions for the Local Health System
CHAPTER 7.........................................................................38
Conclusion
Appendix............................................................................40
Additional Resources
Central LHIN Integrated Health Service Plan 2016-2019
1
CHAPTER
1
Executive Summary
The Central Local Health Integration Network (LHIN)
is one of 14 LHINs established in 2006 by the Ontario
government to plan, coordinate, integrate and fund
health services at the local level.
LHINs are organized around geographic regions to
facilitate system-wide planning, with consideration of
local needs. Geography is not a barrier to service, and
patients may move freely between LHINs to receive
health care services.
The primary purpose of each LHIN is to improve health
care within the communities that are part of our region,
while creating a strong, integrated system of care.
Ultimately, patients and families should be able to
access care easily, and to transition from one type
of health care organization and/or service to another
without disruption. All the while, they will continue to
benefit from coordinated, quality care in a system that
supports their needs from birth to end-of-life.
The Central LHIN vision of Caring Communities,
Healthier People was launched when the first
Integrated Health Service Plan (IHSP) was developed
2
Central LHIN Integrated Health Service Plan 2016-2019
in 2007. Throughout the past three IHSPs, the vision
has remained compelling and relevant. Our vision
inspires the Central LHIN to work with patients,
families, Health Service Providers (HSPs), non-funded
partners such as municipalities, and the Ministry of
Health and Long-Term Care and other Ministries to
build a strong, sustainable system that will be here
to serve and to support future generations. This plan
represents the voices of our citizens and what is needed
to build a stronger system of care that focuses on the
needs of the diverse people living here, including our
Francophone population.
The process for IHSP4 is shaped by the continued
input we receive from our key stakeholders and
Health Service Providers including acute care,
community service agencies, long-term care,
community health centres and the Central Community
Care Access Centre (CCAC). As we developed the
plan, we kept these key considerations top of mind:
• Priorities of the Ministry of Health and
Long-Term Care, articulated through
Patients First: Action Plan for Health Care.
This is the next phase of Ontario’s plan for
changing and improving Ontario’s health system.
• An environmental scan provided to us by the
Ministry of Health and Long-Term Care Health
Analytics Branch. The scan gives a snapshot of
population characteristics and emerging health
care trends within Ontario, and specifically
within Central LHIN. This tool gives us a lens for
determining the priority areas that will make the
most impact on long-term health. This scan was
supplemented by data at a sub-LHIN geography
level where available.
• The voice of the patient and caregiver.
Experiences are shared with us through
engagement opportunities, surveys, consultations
with Health Service Providers and other forums.
• The influence and impact of primary care
providers including family physicians and nurse
practitioners. Although primary care is not funded
by the LHINs, we recognize and value the continued
role and commitment of this sector in creating a
seamless and coordinated system of care. Primary
care providers are an important gateway to care
for patients and families, and we will continue to
engage with this stakeholder group to develop
new solutions and breakthroughs in care.
• A shared commitment from all LHIN CEOs
to incorporate the directions of Quality, Equity,
Sustainability and Integration into all of the
IHSPs across the province.
• Continued engagement with Health Service
Providers, non-funded partners and other
key stakeholders who have the influence and
interest to contribute to a strong, sustainable
health care system.
Engagement Is Critical To Success
Engagement with key stakeholders is a core mandate
of the LHINs – and underlines our Central LHIN
philosophy of ‘Together, we’re better!’ Early in
2015, the Central LHIN began the development of the
2016-2019 IHSP. We used scheduled committees
and working groups to share the plan’s purpose and
process with as many stakeholders as possible, and
scheduled specific engagement sessions to capture
additional key populations and stakeholders.
As a result, we connected with hundreds of people,
culminating in a final engagement session with our
Health Service Providers and other key stakeholders.
Another initiative was the development and posting of
an online web survey to invite Central LHIN residents
to share their views and their health care experiences
with us. After each of our consultations, we noted
recurring themes and insights, and integrated them
into the plan as the content evolved.
Six key strategic priorities have been articulated
for the IHSP4. The priorities reflect provincial
directions for the Ontario health care system, as
well as local feedback on how best to strengthen
our capacity and commitment into the future.
‘Together, we’re better!’
The six strategic priorities, and their overall goals are:
• Better Seniors’ Care
Develop specialized strategies and support
systems to help older adults stay healthy and
independent at home for as long as possible.
Reduce reliance on acute care by exploring
and implementing other options that are
senior-friendly and cost-effective.
• Better Palliative Care
Provide holistic, proactive and continuous care
and support for patients with progressive,
life-limiting illness and for their families. Support
families through the entire spectrum of care
before and after death by helping patients to
live as they choose, and to die in their preferred
location of choice – with quality of life, comfort,
dignity and security.
• Better Care for Kids and Youth
Develop new partnerships and innovative
models to bring specialized care closer to home,
for children and youth.
• Better Community Care
Create stronger links to integrated community
services and to primary care, to help patients
recover and receive more of their health care at
home, with safety and independence.
Central LHIN Integrated Health Service Plan 2016-2019
3
• Better Care for Underserved Communities
Create organized, integrated systems of care to
improve early intervention and treatment of
disease in neighbourhoods where there are
recurring patterns of chronic and acute or
episodic health conditions. Develop
partnerships that will improve long-term
health by addressing the key factors that
determine healthy outcomes.
• Better Mental Health
Integrate a supportive system of programs and
services to enhance the wellness of people with
mental illness and addictions, and to promote
and sustain recovery.
For each of these strategic priorities, we have developed
measures that will help us to evaluate our progress
and our success.
Strategies for the Aboriginal and
Francophone Communities
There are two priority populations for all LHINs,
including the Central LHIN – the Francophone and
Aboriginal populations. Central LHIN is committed to
improve access to equitable and accessible programs
and services to both Aboriginal and Francophone
residents. This will support the improvement of
quality, safe care while providing a better patient
experience and reducing the impact of linguistic
and cultural barriers on health system performance.
A number of strategies have been developed as part
of the IHSP4 which will continue to engage both the
Francophone and Aboriginal communities, and
keep them involved as we implement effective
solutions for a long-lasting impact on the health
of these communities.
Here’s what we know about these populations in our
LHIN: Data from the 2011 National Household Survey
reveals that the Central LHIN geography is home to
approximately 7,000 Aboriginal people, representing
0.4% of the population. The Chippewas of Georgina
Island, comprised of approximately 200 residents, is
Central LHIN’s only First Nations and on-reserve
community.
4
Central LHIN Integrated Health Service Plan 2016-2019
While a portion of Central LHIN’s Aboriginal
population lives on Georgina Island, the majority
are living off-reserve, primarily in semi-rural and
smaller communities in northern York Region and
South Simcoe County. As well, within the North York
West community, there are approximately 2.15% of the
population who identify as Aboriginal. Central LHIN
recognizes that Aboriginal people have a greater
burden of illness than the general population, and that
this is exacerbated by barriers to equitable access to
health services.
The Central LHIN supports the Francophone population
through engagement with Entité 4, one of the provincial
French language health planning entities, and through
the implementation of the Joint Action Plan. The general
objective of the plan is to improve access to the right
French language care, at the right place and at the
right time within the following priority sectors: seniors’
care, mental health and addictions, primary care and
patients with chronic conditions.
Levers of Change
The Ministry of Health and Long-Term Care provides
leadership through a number of levers that drive
transformational change across the Ontario LHINs
and help us to reach our goals.
• Health Human Resources: The LHINs
will support the Ministry of Health and LongTerm Care in initiatives related to health care
human resources. By aligning with the work of
HealthForceOntario to meet local needs, there
can be improved human resource succession
planning including recruitment and retention.
• Health System Funding Reform (HSFR):
Health System Funding Reform is one of the key
pillars of Ontario’s Excellent Care for All (ECFA)
strategy, which seeks to change the culture of
health care by organizing the system around the
needs of the province’s patients. As HSFR is more
fully applied to the Community Care Access
Centre (CCAC) funding formula, Central LHIN
residents will move closer to the provincial
average for care provided. The LHIN will support
implementation of the care pathways for the
Quality Based Procedures (QBP) across the
LHIN, standardizing care processes to minimize
practice variation to provide patients with the
best care possible.
• Enabling Technology/Information
Management (ET/IM): Technology and
information management are key elements in
empowering patients, connecting the various
sectors of the health care system and enabling
patients to access services through technology.
ET/IM helps to eliminate duplication, allowing
patients, family caregivers and service providers
to share information and coordinate services
quickly and efficiently as people transition across
the care continuum. Leveraging information
management and information technology
investments made at the local, regional
and provincial levels will drive health care
transformation and enable informed system
planning decisions. Solutions implemented
in the next three years will be reflective of the
IHSP4’s strategic framework and are identified
in the Central Ontario Cluster Enabling
Technologies for Integration Business Plan.
• Capital Infrastructure: Central LHIN’s
population has been growing, and will continue
to grow – and this has strained the capacity of
our hospitals. There are initiatives underway
to address this challenge. Markham Stouffville
Hospital completed its capital project in 2014 in
which it doubled the size of the facility, tripled
the size of the Emergency Department, and
increased access to surgical, maternal health
and oncology services. Expanded services will
continue to be phased in over the next five
years. Humber River Hospital opened its new
site on October 18, 2015 with expanded services
in inpatient acute, emergency, and ambulatory
services phased in over seven years. This hospital
is recognized as the first fully digital hospital
in North America. Mackenzie Health released
a Request for Proposal (RFP) in the summer
of 2015 for a new hospital to be constructed
in Vaughan, and the associated planning,
development and fundraising strategies are well
underway. The LHIN will work with the Ministry
and Health Service Providers in continuing to
plan the necessary services for residents of
Central LHIN.
• Quality Improvement Plans and Quality
Reporting/Performance Management: Health
care quality is a provincial priority and Central
LHIN works in partnership with a large number
of other agencies and organizations such as the
Ministry, Health Quality Ontario (HQO), Cancer
Care Ontario and all Central LHIN Health Service
Providers in order to continually evaluate and
improve the quality of services delivered in
Central LHIN. The Central LHIN supports the
implementation of Quality Based Procedures
and care pathways across the LHIN, so that our
decisions for the care our residents receive is
based on the best available evidence.
With a focus on continuous improvement, Central LHIN
directs funding toward programs and improvement
projects that identify evidence-driven change ideas
that will have a high impact on the areas targeted for
improvement. Central LHIN cultivates accountability
for quality performance by monitoring and supporting
progress towards identified improvement targets.
As well, Central LHIN actively works with HQO and
Health Service Providers to address priority areas
for improvement through the use of formal Quality
Improvement Plans (QIPs). IHSP4 will advance the
Central LHIN from the current implementation of
single organization QIPs, to future plans that are
developed by several organizations working together
to improve care across sectors.
Central LHIN Integrated Health Service Plan 2016-2019
5
6
Central LHIN Integrated Health Service Plan 2016-2019
Central LHIN Integrated Health Service Plan 2016-2019
7
Our Strategic Priorities
8
Central LHIN Integrated Health Service Plan 2016-2019
Central LHIN Integrated Health Service Plan 2016-2019
9
CHAPTER
2
Introduction: Insights and Inspiration
from the Patient Voice
In the past year, we’ve worked with our Health Service
Providers and other stakeholders to develop the bold
breakthrough ideas and innovative thinking that will
drive the 2016-2019 Integrated Health Service Plan
(IHSP4) into the future.
Hundreds of people have had the opportunity to
provide their insights and ideas, as we confirmed the
six strategic priorities that are essential to build a
strong, sustainable health care system for future
generations: Better Seniors’ Care; Better Palliative
Care; Better Care for Kids and Youth; Better
Community Care; Better Care for Underserved
Communities; and Better Mental Health.
The innovative initiatives we are developing for
implementation over the next three years unite us in a
passion and purpose to advance the vision of Caring
Communities, Healthier People.
This experience has been a journey we’ve taken
together as we listened and learned … challenged the
status quo … discussed new ideas … and pushed back
boundaries and barriers.
10
Central LHIN Integrated Health Service Plan 2016-2019
To foster innovation and system-wide leadership to
benefit patient care, we have identified the priorities
that will improve and transform the way patients and
families access and navigate the health care system
across the Central LHIN. We will provide the right
care, at the right time and in the right place.
In our plan, we have embraced the provincial priorities
outlined in Patients First, the government’s action
plan to improve access; connect services; inform
people and patients; and protect our universal
health care system.
And we’ve responded to what we’ve learned about our
demographics and our population health in a recent
environmental scan of the Central LHIN.
But most important of all, our priorities continue to be
shaped by the voice and the experience of the patient
and the caregiver. Their insights are the catalyst to
transform care – and to create a legacy for future
generations.
As a result of our last Integrated Health Service Plan
(IHSP3), we have:
• Advanced the four quality-based system directions
of appropriateness; access; integration; and personcentredness. You will read more about these
shared achievements in Chapter 5 of this plan.
• Increased access to many programs and services
that promote recovery from mental illness and
addictions, and developed a multi-year action plan
to improve and sustain good mental health in
York Region. This plan will become a model that
can be spread to other areas of the Central LHIN.
• Supported our growing population of seniors
with the programs and services they need to
age safely and independently at home whenever possible.
• Launched an action plan that will create a
palliative care system of essential services for
patients and families within our region.
• Increased access to community services through
breakthrough initiatives that create linkages and
connections between home and community care.
• Made significant progress in the implementation
of eHealth initiatives that improve access to care,
and provide the information our care providers
need to make informed, evidence-based decisions.
We would not be able to achieve these accomplishments
without the partnership, purpose and passion of our
Health Service Providers and our other partners. Your
collective voice and vision has created our framework
for this IHSP – and will guide us towards its completion.
To highlight our strategic priorities for the future, we
have included the perspectives of our patients and
care providers. Although some of these insights are
positive, there are others that highlight gaps in our
system and the areas where we need to constantly
improve. This is our compass as we continually strive
to do more for the people we are privileged to serve.
We are honoured to share our collective work
with you, and we look forward to providing our
stakeholders with continued updates as we make
shared progress together.
Sincerely,
Warren Jestin
Chair, Board of Directors
Kim Baker
Chief Executive Officer
Central LHIN Integrated Health Service Plan 2016-2019
11
CHAPTER
3
Provincial Context
Ontario’s 14 LHINs plan, fund, integrate and monitor
local health care systems and also align their strategic
directions with provincial priorities. Accordingly, the
Central LHIN has aligned its strategic priorities for
2016-2019 with Patients First: Ontario’s Action
Plan for Health Care, and remains committed to
improving access to services in French for the
Francophone population within our geography.
Patients First: Ontario’s Action Plan for
Health Care
Released by the Minister of Health and Long-Term
Care in February 2015, Patients First represents the
next phase of Ontario’s plan to transform Ontario’s
health care system. It builds on a strong foundation
set by Ontario’s original Action Plan for Health
Care in 2012, and strengthens the government’s
commitment to put patients first by improving
their health care experience.
The 2012 Action Plan led to a number of important
successes. But there is still more work to do to
12
Central LHIN Integrated Health Service Plan 2016-2019
improve the patient experience; to make the health
care system more transparent and accountable; and
to ensure the universal health care system will be
there when needed for generations to come.
Like its predecessor, Patients First recognizes the
economic and demographic realities of finite financial
resources and a growing and aging population. It also
recognizes the need to approach such realities from a
different perspective, where we ask how we can
ensure universality, improve access, and deliver the
highest quality of care to people.
The answer is a matter of choice – choice rooted in
evidence-based practices; patient experiences; a
commitment to equity, access and universality; and
decision-making where patients come first. Guided by
four key objectives identified in Patients First, the
Central LHIN is working to understand and predict
the unique needs of people living within its geography,
supporting models that best serve local residents.
Although LHINs are not accountable for all the
initiatives within the four key objectives, local
priorities and initiatives align with the objectives
included in the Patients First plan, including:
Access: Improve access – provide faster
access to the right care
When residents take steps to prevent illness, or if they
experience sickness or an injury, they need to be able
to find the right kind of help, whether from a family
doctor, nurse practitioner, pharmacist, or a number
of different care providers. Improving access includes:
• More same-day and next-day visits to family
doctors or primary care providers
• Seeing a specialist sooner
• Providing the right care for mental health
and addiction
• Improving dementia support
• Expanding scope/removing barriers to
full practice
• More coordinated care for patients with complex
medical conditions
• Allowing nurse practitioners to prescribe
assistive devices
• Delivering coordinated, patient-centred public
services through community hubs
• Working in collaboration with our Health
Service Providers to incorporate the active offer
principles to their French Language Services
planning and delivery
Connect: Connect services – deliver better
coordinated and integrated care in the
community, closer to home
The foundation has been set for the home and
community care sector to meet the needs of
today’s population with an enhanced focus on
seniors and chronic disease management.
Connecting services includes:
• Transforming home and community care
• More rehabilitation therapy for seniors
• Inspections of long-term care homes
• Redeveloping older long-term care homes
• Supporting community paramedicine programs
• Improvements for personal support workers
• Additional convalescent care beds
• Enhancing palliative care at home or
out-of-hospital
Inform: Support people and patients –
provide the education, information and
transparency they need to make the right
decisions about their health
Health is about more than the care received from
providers. It is about living a healthier life, avoiding
sickness, and learning about effective ways to manage
illness when it happens. Creating a culture of health
and wellness will support LHIN residents in making
educated, informed decisions about their care.
Initiatives to support patients include:
• Menu labelling to support healthier eating
• My CancerIQ – online cancer risk assessment
and prevention tool
• Smoke-Free Ontario
• Healthy Kids Strategy to support healthy habits
from the start
Central LHIN Integrated Health Service Plan 2016-2019
13
• Expanding mental health programs in schools
and workplaces
• Strengthening the effectiveness of Ontario’s
immunization system, including better
informing parents about their school-aged
child’s immunization status
Protect: Protect the public health care
system – make decisions based on value
and quality, to sustain the system for
generations to come
LHINs operate under the fundamental premise that
the health care needs of local communities are best
understood by those who live in them. The local public
health care system belongs to the residents who fund
it and depend on it for their health and the health of
their children. With an aging population that has a
growing need for health care services, maintaining
a sustainable health care system means controlling
costs and targeting funding on preventing illness and
improving results for patients. Protecting the public
health system includes:
• Appointment of the first Patient Ombudsman
• More public reports on health system
performance
• More innovative approaches based on evidence
• More public information for patients
• Expanding patient engagement
LHINs and Patients First: Ontario’s Action
Plan for Health Care
Ontario’s LHINs recognize the value of focusing their
collective efforts on common challenges. For this
reason, and to better align high-level objectives of
Patients First with the work of local Health Service
Providers and community partners, LHINs have
developed the following provincial strategic initiatives:
• Transform the patient experience through a
relentless focus on quality
• Tackle health inequities by focusing on
population health
• Drive innovation and sustainable service delivery
14
Central LHIN Integrated Health Service Plan 2016-2019
And, working together, LHINs have agreed to build
and foster integrated networks of care in and across
each LHIN in the following priority areas:
• Mental Health and Addiction Services
• Home and Community Care
• Long-Term Care Redevelopment
• End-of-Life / Palliative Care
Each LHIN’s IHSP provides a clear picture of what the
LHIN intends to accomplish to improve the health
outcomes of the people and patients within local
geographies. With a mandate to engage the public,
health care providers, and other stakeholders, LHINs
are uniquely positioned to address the continued
transformation of the health care system across
Ontario through their strategic work, outlined in the
IHSP for 2016-2019.
CHAPTER
4
LHINs’ Vision for the Health
Care System
OUR VISION: Creating
Caring Communities and
Healthier People
The Central LHIN’s vision of Creating Caring
Communities and Healthier People was first
articulated in the original strategic plan and stayed
relevant through three consecutive Integrated Health
Service Plans (IHSPs), from 2007 to 2016. Throughout
our engagements for the 2016-2019 IHSP, we heard
that our vision still resonates with our patients and
communities and gives us a compelling reason to
strive for continued improvement.
As we continue to listen closely to what patients
and caregivers have to say, we’re gaining a richer
understanding and appreciation for the power of
caring communities – and the impact that this can
bring to good health.
Here are just three examples of how we’ve built
caring communities since our last IHSP, and in
partnership with many different organizations and
health care providers.
The Canadian Mental Health Association, South
Simcoe and York Region – through funding from
Central LHIN and the support of other partners – has
created a caring community for teenagers with mental
illness through an innovative mobile bus called Mobile
York South Simcoe, or MOBYSS. This health clinic on
wheels uses a smartphone app to communicate its
schedule of stops at shopping malls, recreation
centres and other locations where youth gather. Upon
boarding the bus, young people get access to a team of
professionals from across our LHIN who can provide
assessment, counselling, support services and
specialist referrals to improve their mental health as
soon as possible.
For patients with the most complex illness and disease
– usually seniors – we created a caring community
called a Health Link by bringing together a team of
Central LHIN Integrated Health Service Plan 2016-2019
15
health care professionals from many
organizations and with different areas of
expertise – social workers, nurses,
physicians, and physiotherapists just to
mention a few. Health Links professionals
work collaboratively to develop a plan of
care that wraps seamlessly around the
patient – coordinating and managing medical
appointments, health education, physiotherapy
and rehabilitation, at home care and social
supports. Central LHIN now has three
operational Health Links: South Simcoe and
Northern York Region; North York Central;
and South West York Region, with two more
(North York West; and South East York
Region) scheduled for launch in 2016.
Our last example profiles a caring community
we created for young adults who told us they
often felt socially isolated because of their
complex medical needs. An innovative
congregate model has been developed
through funding provided to March of Dimes
Canada – York, who worked in partnership
with the Central CCAC and with Reena, a
non-profit agency specializing in helping
adults with developmental disabilities.
Through this model, a group of young adults
with complex needs can now live and socialize
together in a safe and supervised residence that
provides onsite health care, support services and care
coordination. Funding collaboration with the Ministry
of Community and Social Services was a key factor in
the success of this initiative. This was an excellent
example of how Health Service Providers, the LHIN
and different government Ministries worked together
to achieve a common purpose and passion.
These examples support our vision for the future of
health care in our LHIN, and our commitment to
deliver on our Triple Aims of Better Care, Better
Health and Better Value. Together, we’ll develop
strategies, action plans and measurable indicators that
will guide us towards:
• Better Seniors’ Care
• Better Palliative Care
• Better Care for Kids and Youth
16
Central LHIN Integrated Health Service Plan 2016-2019
• Better Community Care
• Better Care for Underserved Communities
• Better Mental Health
Creating a better system of care can only be achieved
through partnerships that demonstrate our underlying
philosophy of ‘Together, we’re better!’ Every
person in our LHIN who works with us in some
way makes a difference in advancing our vision of
caring communities and making this a reality today.
This includes our patients, caregivers and family
members, Health Service Providers and their teams,
or our Board members, volunteers and LHIN staff.
Together, we’re united in our commitment to create
caring communities. And together, we’re privileged
to lead and to leave this life changing legacy for
the future.
CHAPTER
5
Overview of the Current Local Health
Care System and Achievements to Date
All data sources in this chapter are from the
2016-2019 IHSP Pan-LHIN Environmental Scan
MOHLTC Health Analytics Branch July 2015
unless otherwise noted.
Effective local health system planning begins with an
understanding of the health care needs of the people
who live and work within the Central LHIN. This
awareness is supported by meaningful data that gives
us insights into where we need to focus our efforts,
based on population trends, demographic information
and resident surveys.
The Central LHIN covers an area of 2,730 square
kilometres. Our Central LHIN region is segmented into
six sub-LHIN geographic areas for planning, health
care and service delivery. Each planning area has
varying populations, age structures, economic
conditions and health and social characteristics
that drive targeted approaches to local health care.
Our population has grown since the last IHSP – and
will continue to increase into the future. There are
1.9 million people – or 13.6% of Ontario’s population –
who live within the Central LHIN and this makes us
the most populous LHIN in Ontario. Most Central
LHIN residents (90%) live in a large urban centre with
a population of over 100,000, with just 5% living in a
rural area. Between 2010 and 2015, the Central LHIN
population increased by 8%, which is the second
highest growth rate among all of the LHINs. The
population is expected to increase again by 8%
between 2015 and 2020, and 17% between 2015
and 2025.
The city of Toronto is home to 40% of our population;
17% live in Markham; and 14% of the people choose
Vaughan as their place of residence. The remainder of
the population lives in other areas of the Central LHIN.
Central LHIN Integrated Health Service Plan 2016-2019
17
A Growing Seniors Population
As our vision implies, a caring community supports
people throughout all stages of life’s journey, and
particularly when they need help the most. Along with
the Ministry of Health and Long-Term Care, we are
strengthening care for seniors so that they can remain
at home and live independently for as long as possible.
In our strategic planning, a key consideration is our
current and future population of seniors. Among all
LHINs, Central LHIN has the highest absolute number
of seniors who are aged 65 plus, and projections show
that we will continue to have the highest number in
2020, 2025, 2030 and 2035.
Here’s the number and projected growth of seniors
aged 65 and over, after 2015:
2015 – 268,750
2020 – 333,730 (24.2%)
The low supply of affordable housing and the
percentage of people living in low-income
households is a growing area of concern. The
provincial rate of people living in these households
is 13.9%, and the Central LHIN has a slightly higher
proportion of residents living in low-income
households (14.5%, or 244,610 people). However, our
rate has decreased from the 18% noted in the last
IHSP – at that time the second highest in Ontario.
The supply of safe, affordable housing continues to
be an issue particularly in York Region, where the
demand is high and the waiting lists are growing.
The Regional Municipality of York’s 10-Year Housing
Strategy, Housing Solutions: A Place for Everyone,
identifies a significant lack of available and affordable
housing across York Region. Central LHIN has the
largest population of the 14 LHINS; however, York
Region’s social housing supply relative to its
population is the lowest in Ontario at 1.0 social
housing units per 1,000 households.
2025 – 412,344 (53.4%)
2035 – 570,487 (112.3%)
By 2035, there will be over half a million seniors living
within the Central LHIN, making up 23% or almost
one-quarter, of the total population.
Population Characteristics
Based on the 2011 Census, Central LHIN had the highest
proportion of residents who were immigrants (49% or
820,580 people), and had the second highest proportion
of residents who were visible minorities (49.6% or
792,290 people). These characteristics contribute great
depth and richness to our society, and remind us that
we need to continue to be mindful of integrating cultural
sensitivity and awareness into the care delivered by our
Health Service Providers. Respecting and integrating
culturally appropriate solutions into our health care
strategies is an important priority for the Central LHIN.
Just over half – 52% of our residents – report English
as their mother tongue, and 1.3% of the population
identify as Francophone, according to the provincial
inclusive definition of Francophone. Central LHIN has
the highest proportion of residents in the province
(5%, or 83,155 people) with no knowledge of English
or of French.
18
Central LHIN Integrated Health Service Plan 2016-2019
Population Health
By understanding the Central LHIN health profile,
we can make meaningful decisions about where to
focus our resources, identifying populations and
communities that can benefit from targeted initiatives
to improve overall access and health.
When compared to Ontario, the percentage of people
in Central LHIN who report their general selfperceived health as very good or excellent, is
consistent with the provincial average of 60%.
Self-perceived mental health is rated as good or
excellent at 74.9%, while the Ontario average is 70.9%.
Nonetheless, between 2010/11 and 2013/14 there was
a 23% growth in Emergency Department visits within
the Central LHIN where mental health/substance
abuse was the main problem diagnosis.
The number of people with chronic medical conditions
is decreasing within the Central LHIN. The rates per
100 population are also decreasing in arthritis,
asthma, diabetes, heart disease and multiples of these
conditions. Our rates were the lowest among all LHINs
and were significantly lower than the provincial rates
– however, there is an increasing trend in the
prevalence of high blood pressure which could be
linked to an aging population. Within this context of a
relatively healthy population, Central LHIN does have
pockets of higher chronic disease particularly in the
southwest and northern geographies of the LHIN.
Sources: 2013 Canadian Community Health
Survey (CCHS), Statistics Canada
In another area of note, we have the second highest
number of ‘birth days’ (total number of births) among
the LHINs.
Source: Better Outcomes Registry & Network
(BORN) Ontario. Canadian Institute for Health
Information (CIHI), Statistics Canada, and the
Ontario Registrar General
The Health Service Providers in our LHIN
The mandate of the LHIN is defined by the Local
Health System Integration Act, 2006, which also
describes the types of Health Service Providers
(HSPs) that fall within the LHIN mandate.
In 2014/15 the Central LHIN funded 96 Health Service
Providers, with some organizations offering services
in multiple sectors. These include:
• Seven public* and two private hospitals
• 46 long-term care homes
• One Community Care Access Centre (CCAC) –
the Central CCAC
• 36 Community Support Service (CSS) providers
• 23 mental health and addictions service providers
• Two Community Health Centres (CHCs)
Source: March detailed 2015 MLPA funding
documents
There are 109 accountability agreements in place:
• Nine Hospital Service Accountability Agreements
• 46 Long-Term Care Service Accountability
Agreements
• 54 Multi-Service Accountability Agreements
Note that Health Service Providers providing services
in multiple sectors will have more than one Service
Accountability Agreement.
* The public hospitals include West Park Healthcare
Centre, which is included because Central LHIN
funds ventilator beds.
Many services funded by the Ministry of Health and
Long-Term Care do not fall under our mandate as
defined by the Local Health System Integration Act,
2006. These include:
• Most physician services
• Nurse practitioner-led clinics
• Drug benefits
• Independent health facilities
• Laboratories
• Ambulance services, and
• Public health
Although the LHIN does not fund primary care,
there is increased engagement with physicians, and
collaborative opportunities to participate at tables
where system-wide issues are explored and addressed.
A full list of our Health Service Providers can be
referenced on our website at www.centrallhin.on.ca.
Budget for our Health Service Providers
For 2014/15, the Central LHIN allocated $1.949 billion
to a wide range of health care services. Hospitals
account for the majority of spending at 59.1%, or
slightly over $1.151 billion.
Achievements to date
The following key initiatives were achieved as a
result of the 2013-2016 strategic plan, Advancing
Excellence in Local Health Care Together, and
helped to significantly advance the four quality-based
system directions that are part of the plan:
Appropriateness; Access; Integration; and
Person-Centredness.
Source: Central LHIN MSAA/LSAA/HSAAs
Central LHIN Integrated Health Service Plan 2016-2019
19
Appropriateness – Improve the delivery
of safe, effective and timely care in the
right setting
Two active working groups – one focused on
Emergency Department pressures and the other on
Alternate Level of Care (ALC) – developed initiatives
to reduce the amount of time people spend waiting
in their local Emergency Department and ways to
discharge patients faster from the hospital, and into
a more appropriate level of care.
Key initiatives and breakthroughs to support these
goals included:
• Ongoing investments in Home First – an enhanced
care service offered in partnership with Central
LHIN hospitals and the Central CCAC. The
Home First philosophy helps older adults to
return home with the necessary post-hospital
supports they need to safely continue recovery
after their acute hospital stay. In addition,
Home First provides adults who may be facing
a decision to move to a long-term care home
with the time they need to make an informed
and thoughtful choice – from the dignity and
comfort of their home.
From September 2009 to March 2015, 4,529
clients were served through Home First.
Seventy-two per cent of Home First clients
remained in the community after receiving
enhanced care, reducing the need for longterm care.
• Funding for 103 transitional care beds in
Markham Stouffville Hospital – beds that support
patients discharged from the hospital so they
can quickly and safely transition out of an acute
care setting and into a more appropriate level
of care. Patients can return to their highest
level of independence through specialized,
restorative care.
20
Central LHIN Integrated Health Service Plan 2016-2019
• Expansion of physiotherapy services for
seniors in the community, helping them to stay
healthy, physically active and independent. At the
end of 2015, there were over 370 group exercise
classes and 247 falls prevention classes for
seniors at over 200 sites within the Central LHIN.
All 46 Central LHIN long-term care homes were
funded to provide one-to-one physiotherapy and
group exercise classes for residents.
• Expansion of Nurse-Led Long-Term Care
Outreach Teams (NLOT). These specialized
teams meet with staff in long-term care homes
to provide access to timely and appropriate
care with a goal of reducing avoidable resident
transfers to the Emergency Department, and
subsequent hospital admissions. All long-term
care homes within the Central LHIN have
access to NLOT services. A pilot project in
2014/15 saw the NLOTs in Central LHIN liaise
with Geriatric Emergency Management Nurses,
Patient Flow Navigators and discharge staff
across Central LHIN hospitals so that long-term
care patients in hospital could be readmitted to
their long-term care home in a safe, efficient and
timely manner. Also piloted was an automated
notification process to assist in the tracking
of patient admissions and discharges. NLOT
services have reduced the need for emergency
visits. Ambulance transport data for the first
quarter of 2014/15 showed that Emergency
Department transfers were avoided 89% of the
time on average across all long-term care homes
in Central LHIN.
• Implementation of the provincial Assisted
Living for High Risk Seniors Policy, providing
more access to Assisted Living services for
eligible seniors. Assisted Living supports seniors
with high needs who require services at a greater
frequency or intensity than regular home care.
Services include a combination of personal
support, and homemaking and security
checks provided 24/7 on both a scheduled
and unscheduled basis. From 2013-2015, over
$5 million was invested to serve an additional
625 seniors through assisted living.
• Implementation of Assess and Restore
Guidelines to enhance rehabilitative and
restorative care services to high risk seniors
with the goal of intervening and delaying the
loss of functional abilities.
• Successful transition of five Diabetes
Education Programs (DEPs) and two
Paediatric Diabetes Programs to the Central
LHIN, with responsibility for coordination and
planning. All DEPs now have a standardized
referral form; screening for diabetes through
partnerships with local pharmacies and
Welcome Centres for new immigrants; access
to telemedicine; and access to internet-based
community clinical pathways for Chronic
Obstructive Pulmonary Disease (COPD)
and Diabetes.
• Implementation of Quality-Based Procedures
(QBPs) for: Unilateral Hip and Knee Replacement;
Chronic Obstructive Pulmonary Disease (COPD);
Chronic Heart Failure (CHF); Stroke; and
Community Acquired Pneumonia. Through QBPs,
evidence-based best practices are used to align
patient care with Patient-Based Funding, and
patients receive a better understanding of their
care as they transition from hospital to home.
• Expansion to telemedicine capacity LHIN-wide,
including the implementation of telemedicine in
all 46 Central LHIN Long-Term Care Homes. This
has enabled residents to stay in their long-term
care home setting more often to receive care and
thus reduce the need for transfer to hospital for
follow-up care. From 2012/13 to 2014/15 there has
been a 70% increase in the use of telemedicine
for the provision of clinical care in Central LHIN.
Data Source: Ontario Telemedicine Network
LHIN-specific Site Activity Reports with
Therapeutic Area of Care
• Implementation of a LHIN-wide Telehomecare
program with demonstrated reductions in
Emergency Department visits and hospital
length of stay for patients with chronic diseases
such as congestive heart failure (CHF)
and chronic obstructive pulmonary disease
(COPD). Telehomecare allows clients to input
and transmit their vital health information
electronically from their home to a remote
monitoring care team who can help to interpret
the results and provide ongoing strategies for
prevention and treatment.
• Improvements in the LHIN-wide Resource
Matching and Referral tool (RM&R) resulting
in a reduction in wait times for placement in
rehabilitation beds and for CCAC services
after discharge from hospital. RM&R speeds up
the referral and matching process by replacing
a paper-based system and improving the
completeness of patient referrals.
Access – Continue to improve access to
hospital, community and primary care
• Development of a congregate care model that
addresses the needs of young adults who have
both medical and developmental complexities,
and are not able to direct their own care.
• Implementation of the Life or Limb Policy to
provide care for our sickest, most vulnerable and
critically ill patients with life or limb threatening
conditions. The policy improves access to timely
medical consultation, and supports transfer to
a hospital that provides the specialized clinical
services required within a window of four hours.
As well, the Central LHIN worked with other
GTA LHINs to develop a collaborative action plan
to implement the Life or Limb Policy across GTA
LHINs, and agreement on referral, acceptance
and repatriation processes.
• Increased access to Mental Health and
Substance Abuse Case Management and
Counselling supports in York Region for
residents living in Homes for Special Care
(HSCs), domiciliary hostels, shelters or social
housing through the Canadian Mental Health
Association, York Region and South Simcoe.
Central LHIN Integrated Health Service Plan 2016-2019
21
• Implementation of the Onsite Mobile Crisis
Co-Responder Model in York Region, so that
a social worker from York Support Services
Network can team up with York Regional Police
or York Emergency Medical Services (EMS)
to provide support and referral to specialized
services when a 911 call indicates a need for
mental health services.
• Expansion of peer support services to improve
Mental Health such as warm lines; peer
navigators in the Emergency Department; and
Wellness Recovery Action planning programs.
• Development of a Multi-Year Action Plan to
increase access to an integrated, coordinated
and efficient system of housing supports,
treatment programs and supportive housing
to promote and sustain recovery of those with
moderate/serious and persistent disability
in York Region. This plan was developed in
consultation with key stakeholders including
the Regional Municipality of York, Health
Service Providers, non-funded partners, and
consumers with lived experience and caregivers.
• Funding for the Mobile York South Simcoe
(MOBYSS) clinic, implemented through the
Canadian Mental Health Association, York
Region and South Simcoe. This travelling health
bus connects with vulnerable youth in the areas
where they congregate – recreation centres,
schools and malls. The clinic provides access
to physical and sexual health care and mental
health and addictions services, and is the first
of its kind in Ontario for transitional aged youth
ages 12 to 23. It also targets on-reserve and urban
Aboriginal youth.
Integration – Strengthen integrated
health care delivery from disease
prevention and primary care through
community, acute, long-term and
end-of-life care
• Development of an action plan that will create
a system of Palliative Care across the Central
LHIN. Through the Central CCAC, centralized
access to palliative care services and access
and referral to hospice beds in the region is
available. The Central LHIN worked with SYKES
(operators of Telehealth Ontario) to implement a
single telephone number (1-844-HERE4ME), now
available to support patients and families with
urgent health care situations at end-of-life.
• Continued strategic support and implementation
of two Health Links – South Simcoe Northern
York Region and North York Central – and the
addition of a third, the South West York Region
Health Link. Health Links improve the patient
experience. To better serve patients – usually
those with complex medical conditions – care
providers develop a coordinated care plan
with clear goals to match the right services and
actions to patient needs.
• Development of iRIDEPlus – a new regional
transportation model that gives patients and
clients across the Central LHIN coordinated and
equitable access to community transportation. By
calling one central telephone number, qualifying
seniors and adults with disabilities can receive
safe, consistent transportation to access medical
and other appointments.
• Refreshed the local vision care strategy for
ophthalmology services. Two regional highvolume eye-care centres managed over 11,000
cataract procedures at North York General
Hospital and Southlake Regional Health Centre.
In October 2015, the small volume of cataract
surgeries remaining at Humber River Hospital
were transferred to these centres.
22
Central LHIN Integrated Health Service Plan 2016-2019
• The expansion of current levels of specialty
eye surgeries such as glaucoma, corneal transplant and strabismus is underway. In 2014/15,
the wait time for cataract surgery in the
Central LHIN was 92 days – 69 days less
than the provincial wait time.
• Increased adoption of Electronic Medical
Records (EMR) by Central LHIN primary care
physicians from 60% to over 80% to enable
sharing of information across providers within
a patient’s circle of care.
• Implementation of Hospital Report Manager
(HRM) in all Central LHIN hospitals. HRM
facilitates the electronic transfer of hospital
reports from hospital records directly into
physicians’ electronic medical records allowing
the physician to be aware that his or her
patient has been in hospital and to receive the
information needed to manage their patient’s
care after discharge.
• Implementation and improved adoption of the
Integrated Assessment Record (IAR) for
all in-scope Central LHIN providers. The IAR is
an electronic application that allows providers
to view assessments done by other providers
to improve patient care, reduce the number of
assessments done and prevents patients from
having to tell their story multiple times as they
transition across the health care continuum.
• One Central LHIN hospital and the Central CCAC
Person-Centredness – Improve equity in
how people experience health care and
service delivery
• Funding for two Aboriginal Navigators who will
help the community to better understand and
navigate the system.
• Funding to provide Aboriginal Cultural training
for Central LHIN Board members, staff and
Central LHIN Health Service Providers.
• Enhanced collaboration with the Francophone
community through enhancements to the
French language services section of the
Central CCAC’s Centralhealthline website at
www.centralhealthline.ca. This is an online
platform with information on health care services
provided in the Central LHIN, including those
available in the French language.
• Establishment of a Citizens Health Advisory
Panel to bring a community perspective,
including that of the Francophone community,
to Central LHIN’s system planning, and provide
a forum for dialogue and input into ongoing
strategic initiatives.
• Embedding the patient voice in Central LHIN
planning activities through patient and resident
participation on planning groups such as the
Mental Health and Addictions Summit in York
Region, the Onsite Mobile Crisis Co-Responder
Model and the Palliative Care working groups.
is live on ConnectingGTA (cGTA), a step
towards having an electronic health record with
hospital and community data for all Ontarians.
cGTA is a clinical data repository where patient
information and records will become accessible
by providers in the Central Ontario Region.
Over 40 Health Service Providers or over 30,000
clinical users currently benefit from the cGTA
viewer portal.
Central LHIN Integrated Health Service Plan 2016-2019
23
CHAPTER
6
Strategic Priorities and Directions
for the Local Health System
The Central LHIN’s strategic priorities support our
philosophy of ‘Together, we’re better!’ The
priorities are shaped by these inputs:
• Priorities of the Ministry of Health and LongTerm Care, articulated through Patients First:
Action Plan for Health Care.
• A shared planning framework that articulates the
key elements that will advance our vision of
Caring Communities, Healthier People.
• The voice of the patient and caregiver, and
their shared experiences.
• The insights from our partners and key
stakeholders, including hospitals; Community
Health Centres; the Central Community Care
Access Centre; community support services
providers; long-term care homes; mental health
and addiction service providers; municipalities
and Public Health.
24
Central LHIN Integrated Health Service Plan 2016-2019
• The views and the insights of primary care
providers, including family physicians and
nurse practitioners.
• Shared directions from all LHINs to include
Quality, Equity, Sustainability and Integration.
• Continued engagement with Health Service
Providers, non-funded partners and other key
stakeholders who have the influence, interest and
inspiration to contribute to a strong, sustainable
health care system.
• An environmental scan provided to us by the
Ministry of Health and Long-Term Care Health
Analytics Branch and enhanced by population
health data at the sub-LHIN level.
Better Seniors’ Care
>> Priority: Develop specialized strategies and
support systems to help older adults stay
healthy and independent at home for as long
as possible. Reduce reliance on acute care by
exploring and implementing other options that
are senior-friendly and cost-effective.
What will change?
Seniors will have better and more
timely access to care in the community
to help them live safely and
independently at home
Seniors will have better outcomes
and will be less likely to decompensate
in hospital
Seniors with dementia or behavioural
issues will receive timely access to
appropriate care
The number and types of long-term
care beds will align to what the
community needs
What measures will we improve?
Percentage of home care clients with complex needs who receive their personal
support visit within five days of the date that they are authorized for personal
support services
Percentage of home care clients who receive their nursing visit within five days of
the date they are authorized for nursing services
90th percentile wait time from community for the Community Care Access Centre
(CCAC) in-home services
Alternate Level of Care (ALC) rate and percentage of ALC days
90th percentile Emergency Department length of stay for complex patients
Readmissions within 30 days for selected conditions
Eligible long-term care home beds for redevelopment are redeveloped as per schedule
“I moved to Tottenham to be closer to my adult children,
but eventually I found that I needed some additional help
and support. My assisted living team from CHATS helps
me with laundry and showering, will prepare a meal or
just chat over a cup of tea. My family and I have peace of
mind because we know that if I fall or have a health care
crisis that CHATS will be there for me. My team of two
rotates job responsibilities day to day – but they don’t
make me feel like I’m a ‘job’ to them. I don’t know what I
would do without their help. I’m sure I would have to go to
long-term care – but for now, I’m happy to be living right
here on my own and in my condo.”
Barbara, an assisted living client with CHATS
Throughout our consultations and our
conversations with older adults in the Central
LHIN, one thing is clear: most people want access
to supports and services that will help them to live
at home with independence and dignity for as long
as possible. Providing home-based care is not only
a compassionate choice, but is a transformational
solution that drives change across the system.
By providing the right care at home, reliance on
hospital Emergency Departments is reduced and
seniors spend less time waiting to be discharged
to another level of care – such as rehabilitation or
long-term care – when they are admitted to hospital.
Central LHIN Integrated Health Service Plan 2016-2019
25
Building on Ontario’s Strategy for Our
Seniors Population
Our strategy for older adults will align with: Patients
First – the Ontario government’s 2015 Roadmap to
Strengthen Home and Community Care; Bringing
Care Home, the report submitted to the Ministry of
Health and Long-Term Care from the expert group on
home and community care; and Living Longer,
Living Well – Dr. Samir Sinha’s seniors strategy for
Ontario. To plan for the growing and changing needs
of our seniors, the Central LHIN will undertake a
seniors capacity planning and strategy development
process to plan for the growing and changing needs
of our seniors.
This process will help us to identify alignment,
integration, and investment (as funding allows)
opportunities. Furthermore, we will collaborate with
our municipal partners including the Region of York,
the City of Toronto and Simcoe County to leverage
cross sector activities. This information will be used to
develop a multi-year action plan to address the growing
needs of our seniors and support four objectives:
• Keep seniors healthy – through rehabilitation
therapy, and self-management and education for
chronic diseases
• Provide care in the most cost-effective
manner – by transforming home and community
care, and providing as much care as possible out
of hospital
• Prevent functional decline, when acute
care is required – we’ll look at new options
that will get seniors out of hospital sooner and
into programs that will help to promote their
independence and maintain mobility
• Provide quality and cost-effective options
when living at home is no longer possible
– through exploring alternatives to long-term
care and helping people to live longer and
safely at home
As our Health Service Providers create senior-friendly
hospitals and more community services to help
seniors live independently and reduce their reliance
26
Central LHIN Integrated Health Service Plan 2016-2019
on acute care, we will continue to support assisted
living services, Adult Day Programs and respite
services. We’re also working closely with the Ministry
of Health and Long-Term Care on a provincial longterm care redevelopment initiative so long-term care
homes can meet best practices and standards of care.
As part of the Home and Community-based Care
Coordination Policy, the Central LHIN will implement
policy guidelines that will ultimately result in the provision
of more care in the home. The Ministry of Health and
Long-Term Care has developed policy guidelines that will
broaden the role of community support service agencies
to provide in-home personal support services to clients.
The guidelines will also strengthen linkages between the
Community Care Access Centres and community support
service agencies so they can work closer together to
provide integrated care to clients in the community.
Technology will continue to play a key role in helping
care providers to support seniors and their families on a
number of fronts. For example, health care providers
can connect with their patients remotely through
technology, and can support them to monitor and
manage their health care conditions. As well, health care
providers can increase access to services for patients
and speed up referrals to community services because
they are able to do these functions electronically.
Provincial electronic tools will promote sharing of
information across Health Service Providers for
patients – for example, a drug information system
will provide a comprehensive record of all the drugs
prescribed and provided to a senior as they move
through the system of care.
Technology will continue to play a powerful role as it’s
leveraged with long-term care homes and other system
providers to help residents get the care they need and
prevent unnecessary Emergency Departments and
hospital admissions. For example, the Ontario
Telemedicine Network (OTN) can be used to connect
residents in long-term care homes with specialists,
diabetes education sessions, stroke clinics, exercise
and falls prevention classes, and other virtual
appointments to keep them healthy and safe.
Better Palliative Care
>> Priority: Provide holistic, proactive and
continuous care and support for patients with
progressive, life-limiting illness and for their
families. Support families through the entire
spectrum of care before and after death by
helping patients to live as they choose, and to
die in their preferred location of choice – with
quality of life, comfort, dignity and security.
What will change?
What measures will we improve?
Patients have the choice to live their end-of-life period in their preferred location
Improved community access to essential supports and services, including
advanced care planning
Easier navigation system for patients and caregivers
Palliative residents in long-term care homes will benefit from care providers with
enhanced knowledge and skills to support them
Percentage of palliative care patients
discharged from hospital with home support
Percentage of palliative days in acute care as a
per cent of total patient days in acute care
Specialists will provide support and education to primary care providers to
support their patients through their end-of-life journey
“What keeps me awake at night? Our patients tell their health care team that they want to live
their last days at home. We’ll put as many resources as we can into place, but often what we see is
significant caregiver burnout because the families just can’t cope with the level of support they get.
So in the end, patients end up going to the hospital in a crisis situation and often they will end their
life by dying on a stretcher in the Emergency Department or in an acute care hospital bed, which is not
where they want to be. This is where the system has failed the patient because the caregiver didn’t
have the right support and the services weren’t in place. I see the action plan for palliative care as a
big step in the right direction, especially with the launch of the single crisis line for help with urgent
end-of-life situations.
Through this plan, we have the opportunity to help people to focus on living the best possible life with
whatever time is left to them. We see some beautiful things happening in hospices and palliative care
units – families who reconcile, people who have weddings. It’s important that we are able to give our
patients and families what they need to appreciate what is really important in life.”
Dr. Cindy So
Cancer Care Ontario Central LHIN Palliative Care Regional Lead
Central LHIN Integrated Health Service Plan 2016-2019
27
Talking about death can be difficult, but at the Central
LHIN we are opening up the dialogue about how to
improve palliative care in our region, and as a system.
The Central LHIN has engaged with our Central
Community Care Access Centre (CCAC), primary care
providers, palliative care teams, patients, caregivers
and other health care experts to develop a Palliative
Care Action Plan. The new solutions we will put into
place together will support Central LHIN residents so
they can live with quality, and die with dignity once
they have been diagnosed with a life-limiting illness.
Most patients say they would prefer to die at home –
but the reality is that only 22% of Central LHIN deaths
take place at home, giving us significant room for
improvement. Within the Central LHIN in 2012/13, 47%
of deaths took place in acute care hospitals; and 28%
occurred in the Emergency Department or in complex
continuing care and rehabilitation facilities. About 13%
took place in long-term care homes – which is
considered by many residents to be ‘home.’
(Data Source: Palliative Care in Ontario, February
2-14 Updates, Health Analytics Branch)
The work on our Palliative Care Action Plan began
with 14 service recommendations from the Regional
Hospice Palliative Care Program Council in 2013,
based on the Declaration of Partnership and
Commitment to Action (2011). This plan reflects
the Ontario government’s commitment to improve
our palliative care system across Ontario.
Changing the Delivery of Palliative Care
The recommendations of the Regional Hospice
Palliative Care Program Council continues through
a number of work groups and a Palliative Care
Coordinating Council (established in the fall of 2015).
The work of these groups has resulted in bold new
initiatives that are changing the way that palliative
care is delivered and sustained into the future within
the Central LHIN. For example, centralized and
coordinated access to palliative care services for
patients and families is now available by calling one
28
Central LHIN Integrated Health Service Plan 2016-2019
telephone number at the Central CCAC. Patients and
families may be referred by a physician, or they may
call directly and become part of the patient registry
for palliative care.
Also provided through the Central CCAC is an
online directory of palliative care and end-of-life
resources, available on the CCAC website at
www.centralhealthline.ca.
To provide urgent palliative support during the last
stages of life, the Central LHIN led the development
of a single telephone number for crisis palliative
care situations. The central telephone number –
1-844-HERE4ME – is managed and provided through
SYKES Assistance Services Corporation, also provider
of Telehealth Ontario. The calls are triaged through
Registered Nurses, and provide patients with an
integrated level of support that had not been available
in the past. Expertise is provided to manage emotional
or physical changes; worsening or changing physical
pain or symptoms; and to cope with medical equipment
and supply concerns.
Services Wrap around the Patient
and Family
The vision for palliative and end-of-life care focuses
on the development across Central LHIN of virtual
service regions where groups of providers work
together to deliver a basket of services available to
support palliative care patients, their caregivers and
families. The services may be provided by a number
of Health Service Providers – each one a particular
expert in a certain area – and will be organized around
the patient and caregiver. Through these ‘service
regions,’ services are delivered and wrapped around
the palliative care patient in the location where they
choose to receive their care through to end-of-life.
The ‘service regions’ will provide essential services
such as: advance care planning; pain and symptom
management; medical management and interventions;
care coordination and navigation; and grief and
bereavement services.
Continuing the conversation with patients and
caregivers will be enhanced through a continued focus
on education and training for health care providers,
including those in long-term care homes. With our
palliative care partners, we’ll provide primary care
physicians, nurse practitioners, family health teams
and other providers with the tools they need to
understand patients’ unique needs and to implement
care directives that will respect their wishes right up
to the end-of-life. This includes increased cultural
competency to support end-of-life care for Aboriginal
residents living in Central LHIN.
In alignment with the funding designated by the
Ministry of Health and Long-Term Care as part of the
2005 End-of-Life Care Strategy, the IHSP4 calls for the
implementation of 20 new residential hospice beds in
our region. Ten of these are earmarked for York
Region and 10 for North York, with a subsequent
integration of services to better serve the patient
and family.
In addition, we will focus on giving those who work in
long-term care homes, the support that they need to
help their residents live and die with dignity. This will
include ongoing education and standardized tools
that can help – for example, with pain and symptom
management and advance care planning.
The ongoing and broadened use of technologies such
as telemedicine and telehomecare will support the
provision of care in the home setting when desired,
and will enhance the skills of those who provide
palliative care. Technology will also help to create
enhanced awareness of the available services,
coordinate access to these services and speed up
referrals to services that support palliative care
patients. Using provincial eHealth tools such as
electronic consultation will facilitate timely referrals
from primary care to specialists because it will enable
information sharing and knowledge transfer.
Central LHIN Integrated Health Service Plan 2016-2019
29
Better Care for Kids and Youth
>> Priority: Develop new partnerships and
innovative models to bring specialized care
closer to home, for children and youth.
What will change?
Prevention of unnecessary hospital admissions and more efficient discharge from hospital
when hospitalization is required
Children and their families will benefit from paediatric care, in the Emergency Department
and in the hospital that’s closest to their home
More equitable access to hospital paediatric care, as close to home as possible
More community supports for children from birth to 18 who have complex medical needs,
and for their families
What measures will we
improve?
Decrease preventable or repeat
Emergency Department visits or
hospital readmissions
Outflow of Central LHIN paediatric
residents to other LHINs for
paediatric care
“I am so appreciative of Christopher’s placement within the new cluster care model. Congratulations
to the LHIN and its partners for getting this model into place, and for finding a way to meet the needs
of complex care young people like Christopher in a progressive, community-based environment.
Christopher has made great progress this year. Despite his ongoing and serious health concerns, he
has been an active participant in the day program and other Reena activities, has made new friends,
and is developing higher levels of confidence and self-esteem day by day.
Each of the staff selected by Saint Elizabeth Health Care and March of Dimes at Reena has been
competent and professional, as well as highly engaging for Christopher. The residence has a great
feeling of positive energy and this is reflected in many ways. I am delighted with the overall situation.
It takes a great deal of coordination and effort to bring all the aspects of Christopher’s care together,
and I commend everyone involved for an exceptional job.”
Jennifer, mother of Christopher, a Reena resident
30
Central LHIN Integrated Health Service Plan 2016-2019
Creating safe, effective care to protect our children
and youth as they transition into adulthood – and to
protect the generation after – is one of our most
compelling reasons for coming together to create
meaningful change.
To do this, Central LHIN has developed an innovative
congregate care model in partnership with the March
of Dimes, Central CCAC and the Reena Residence in
Vaughan, to address the needs of young adults who
told us they often felt socially isolated because of their
complex medical needs. Working with our partners
and Health Service Providers, we funded a model that
brought these young people together in a safe and
supervised residence that provides onsite health care,
support services and care coordination. The model
was so successful that it has been extended to
other locations within our LHIN with a broadened
focus to include those with developmental needs,
in partnership with the Ministry of Community and
Social Services.
The feedback from young adults ages 16 to 24 who live
in this residence and what we hear from their families,
shows that this new model is making a transformative
difference in their lives. Building on this success and
as part of our Integrated Health Service Plan, we will
look at evaluating the model and exploring other ways
to enhance care in the community. This is an initiative
that crosses government Ministries in the pursuit of a
common goal and brings together health, community
and social services, and children and youth services.
Working with our Health Service Providers, we’ll also
look to enhance access to paediatric care in Central
LHIN hospitals through partnerships that support the
provision of enhanced care as close to home as
possible for kids and their families in Central LHIN.
Technology will continue to play a key role, giving us
access to telemedicine consults and referrals that will
provide the best care possible, close to home.
Central LHIN Integrated Health Service Plan 2016-2019
31
Better Community Care
>> Priority: Create stronger links to integrated
community services and to primary care, to
help patients recover and receive more of
their health care at home, with safety and
independence.
What will change?
What measures will we improve?
Patient and family caregivers will understand what services to
expect and be better able to participate in the development of
their care plan
Percentage of home care clients with complex needs who
receive their personal support visit within five days of the date
that they are authorized for personal support services
Patient experience across transitions will improve, with
standardized assessments and care plans that are shared
across providers
Percentage of home care who receive their nursing visit within
five days of the date they are authorized for nursing services
Patients will have more timely access to home and community
care, with better outcomes
90th percentile wait time from community to the Community
Care Access Centre (CCAC) in-home services
Rate and percentage of Alternate Level of Care Days (ALC)
Services will be more consistent, efficient, aligned and
evidence-based across all providers
Per cent of acute care patients who have had a follow-up with
a physician within seven days of discharge
Transparency and ease of navigation will improve for patients
and families
Rate of Emergency Department visits for conditions better
managed elsewhere
Services will be delivered more efficiently
Hospitalization rate for ambulatory care sensitive conditions
Readmissions within 30 days for select conditions
“I get a ride from iRIDEPlus that takes me from
my home to my program (Adult Day Program).
It’s the best … I love the crafts and the exercise
and really like the people. We play music, make
decorations, bake and sing. iRIDEPlus is the
most comfortable ride ever. It’s on time and
takes me to my home away from home. If I
didn’t have my ride to this place, or if it ever
closed down … I don’t know what I would do.”
Barbara, an iRIDEPlus client
32
Central LHIN Integrated Health Service Plan 2016-2019
The Ministry of Health and Long-Term Care is
committed to act on the March 2015 recommendations
of Bringing Care Home – the report from the
expert group on home and community care. Patients
and caregivers across Ontario have shared their
experiences, and sent a clear signal that they want to
receive as much care as possible in their home and in
the community. To achieve this goal, they need access
to an integrated ‘basket’ of services that wraps
seamlessly around the patient and caregiver so that
care transitions are smooth and interruptions in
service are minimal.
The implementation of Health Links – currently three
in the Central LHIN – are one way that home care is
being strengthened in a very patient-focused way. The
Central LHIN will continue to partner with the lead
organizations in each of our Health Links to strengthen
this model. Through Health Links, high-needs complex
patients are identified – often the frail elderly, those with
mental health and addictions issues or palliative patients
– and health care professionals across the system are
brought together to develop a targeted plan of care. The
outcomes are better communication and coordination
of care; smoother transitions and handoffs across the
system; and better clinical outcomes for the patient.
Also, the LHIN will continue to collaborate with our
Aboriginal community to improve access to services
for residents living both on (Georgina Island) and
off-reserve.
Greater Collaboration with Primary Care
Technology will be an important enabler for both
Health Service Providers and patients by providing
enhanced awareness of available services, coordinated
access to services (including wait list management)
and speeding up referrals to services in the
community sector.
The patient experience will benefit from technology
because as they transition across the system, patients
will not have to share their health care story multiple
times. Relevant information will be automatically
shared across Health Service Providers within the
patient’s circle of care. Primary care providers will
have greater awareness of the patient’s journey and
associated information as they access electronic
tools such as notification of hospital admissions and
discharges, and system-wide drug prescriptions. This
will facilitate greater coordination in patient care.
Ontario’s Patients First: Action Plan for Health Care
(2015) commits to a plan “to ensure that primary care
providers are organized around the needs of our
population, such as those in northern, rural and
fast-growing communities, focusing on greater
accountability and access for individuals and families.”
The Central LHIN is working with the Ministry and
our providers to improve access, accountability
and performance in the primary care sector through
a greater focus on quality improvement.
Central LHIN Integrated Health Service Plan 2016-2019
33
Better Care for Underserved Communities
>> Priority: Create organized, integrated systems of
care to improve early intervention and treatment of
disease in neighbourhoods or populations (Aboriginal
and Francophone) where there are recurring patterns
of chronic and acute or episodic health conditions.
Develop partnerships that will improve long-term
health by addressing the key factors that determine
healthy outcomes.
What will change?
More equitable access to appropriate health services, including home
and community services, and mental health and addictions services and
supports, leading to better outcomes
Patients and their families will be able to manage their chronic conditions
Chronic conditions for these populations will be addressed in the most
appropriate settings
Patients will have an improved experience and more satisfaction with
their care
Increased access to culturally and linguistically competent services leading
to improved outcomes
Marginalized populations are better informed regarding existing resources
Increased access to housing supports for sustaining housing tenancy
for those living with mental health and addictions challenges
What measures will improve?
Rate of emergency visits for conditions best
managed elsewhere
Hospitalization rate for ambulatory care sensitive
conditions
Readmissions within 30 days for selected conditions
Reduce repeat emergency visits within 30 days
for mental health conditions
Reduce repeat emergency visits within 30 days for
substance abuse conditions
Emergency department utilization for mental
health and substance abuse conditions
“In my first month with Addiction Services for York Region, I attended the Health Fair on Georgina
Island. One of the women who lives on the Island was curious about our services, and asked what we
have specifically for Native people. Unfortunately, I had to tell her that we have very little.
Her point is valid. Traditional Native culture was based on honouring a person, and a person’s entire
family and community, in the four sacred directions of Body, Mind, Spirit and Emotion. From what I can
see, Addiction Services for York Region does pretty well in addressing all these four directions, but not
necessarily from an Aboriginal perspective. However, this deficiency is not limited to our organization.
From my observation, a part of this woman still pines for the loss of loving community which would
continually surround and support her at one time.”
Ken
Indigenous Outreach Counsellor, Addiction Services for York Region
34
Central LHIN Integrated Health Service Plan 2016-2019
Providing equitable access to care so that people in
all neighbourhoods are able to get the targeted care
they need is an important direction in the Central
LHIN framework for our IHSP4. By working with
municipalities, we are able to gather and analyze
data that helps us to better understand the unique
‘population health’ needs in various communities,
and develop targeted approaches.
care pathway to support primary care providers
serving this population.
• Work with Central East and Toronto Central LHINs
to improve access for Francophones to Mental
Health and Addictions services by strengthening
a mental health and addictions continuum.
• Continue to engage Francophones as part of the
Central LHIN’s continuous consultation process.
We know, for example, that within the North York
West communities there is an increased prevalence
of chronic health conditions, despite the lower overall
prevalence in the Central LHIN.
• Work in collaboration with the health services
To address this situation, we have identified an
opportunity to work closely with the City of Toronto,
local Health Service Providers, non-funded partners
and government ministries to develop new ways to
prevent and to manage chronic health conditions. In
doing this, we will align closely with our six sub-LHIN
geographic regions and our Health Links currently
in place, to provide care for patients with the most
complex conditions. Collaboration with primary care
providers will be essential for success. As well, we
will look to leverage the capacity of the Diabetes
Education Program to develop and implement an
integrated regional model that will deliver Chronic
Disease Prevention and Management Programs
seamlessly for the patient and family.
• Improve the quality of data on the Francophone
Focus on the Francophone Community
Other key ongoing elements of our strategy include
a renewed focus on both the Francophone and
Aboriginal communities, to identify services that
will better serve each of these populations.
The Central LHIN will engage with the Francophone
community as part of the LHIN continuous
consultation process and to identify the unique
needs of the Francophone population within each
of the six strategic priorities within this IHSP. We
will implement a number of initiatives in partnership
with Entité 4:
• In North York West, an area with a high proportion
of French-speaking recent immigrants, we will
work with the Francophone community to improve
access to the necessary health care services
and navigation of the health system. This will be
complemented by the development of a primary
providers to incorporate active offer principles
to their French Language Services (FLS) planning
and delivery.
population and on the provision of services in
French by supporting the development and use
of common FLS indicators.
• Continue to work with Entité 4 to identify the
needs of the Francophone population and the
gaps in the continuum of care.
Focus on Aboriginal Community
To respond to historical data that shows the Aboriginal
community has been underserved, we will continue to
provide Indigenous Cultural Competency training to
help Health Service Providers better understand the
unique needs of Aboriginal residents and the most
effective ways to begin and sustain important
conversations about care with Aboriginal people.
Aboriginal Health System Navigators assigned to
provide service in the South Simcoe Northern York
Region and North York West planning areas will
be monitored and evaluated to make sure that this
investment is resulting in more efficient, effective
and culturally appropriate care.
Technology – especially through mobile applications
on smartphones, for example – will help connect
patients with case managers and other health care
providers on a regular basis to improve their access
to service. Where applicable, the use of mobile
applications will link patients with providers and
information. The Ontario Telehomecare Network
will continue to play an important role in health care
delivery by giving patients the opportunity to monitor
their own care, and connecting with a health care
professional to discuss results, questions and
effective strategies.
Central LHIN Integrated Health Service Plan 2016-2019
35
Better Mental Health
>> Priority: Integrate a supportive system of
programs and services to enhance the wellness
of people with mental health and addictions,
and to promote and sustain recovery.
What will change?
What measures will improve?
More efficient discharge from hospital after an admission for mental health
and addictions
Repeat unscheduled emergency visits within
30 days for mental health conditions
Increased awareness of health care options, coordination and ease of navigation
Repeat unscheduled emergency visits within
30 days for substance abuse conditions
Increased access to housing supports for sustaining housing tenancy for those
living with mental health and addictions challenges
Increased ability for people with mental health and addictions to access needed
services in a timely way
“The winter of 2015 was one of the coldest on
record. For every day of that winter, I lived in my
car because I had lost my job and had nowhere else
to go. Having Crohn’s Disease and the constant
inflammation in my bowel made things even worse.
Living in a car? Well, there’s no sense of time and
the boredom is intense. I’m usually hungry. So I go
to sleep at 5 p.m. when it gets dark in the winter,
and wake up when it’s light. Sometimes I go into the
mall to warm up but they usually kick you out. I
can’t shower so personal hygiene is bad. Without
stable housing, there is no place to go and nothing
to do. I have constant thoughts of suicide. I am one
of the throwaway people.
* Helpline offered through York Support
Services Network
Things did change when I finally called 310-COPE*.
I was connected to a social worker at CMHA** and
had access to some temporary housing. 310-COPE
saved my life.”
People in Central LHIN who have experienced
mental illness and addiction challenges spoke candidly
with us during our consultations, sharing their
personal stories during an information-gathering
project and including their successes, challenges and
recommendations for change. We also engaged
John, a Central LHIN resident
36
Emergency department utilization for
mental health and substance abuse
conditions
Central LHIN Integrated Health Service Plan 2016-2019
** Canadian Mental Health Association of York
Region and South Simcoe
Stories like John’s remind us of the importance
of our continued partnership with The Regional
Municipality of York (York Region) and our ongoing
implementation of our multi-year action plan to
address one of the key determinants of health: safe,
affordable housing, with supports that enable
independence and recovery from mental illness
and addictions (for example – social work, ongoing
counselling and education).
managers of social and emergency housing, including
hostels and homes for special care; representatives
from Emergency Medical Services, York Regional
Police and United Way. From their voices – and from
our data – we learned that an increase in safe,
affordable housing with supports is urgently needed
across York Region and that we need to both help
consumers to understand how to navigate the system,
and how to access the services they need. The same is
true for addiction services, where we need to address
‘pockets’ of substance abuse and provide increased
access to addiction recovery supports, including those
for pregnant women and mothers of young children.
Enhancing our Mental Health and
Addictions Supports
In the spring of 2015, the Central LHIN co-hosted –
with the Regional Municipality of York – a bold and
innovative Mental Health and Addictions Planning
Summit. Over two days, we engaged stakeholders in
developing a multi-year action plan to direct future
investments to promote and sustain recovery from
issues that arise from mental health and addictions
challenges. Our stakeholders were diverse, but we
shared a common and compelling goal: “To enhance
the wellness of persons with mental illness and
addictions in York Region by optimizing access to
an integrated, coordinated and efficient system of
housing supports, treatment programs and supportive
housing to promote and sustain recovery of those
with moderate/serious and persistent disability.”
Our Multi-Year Action Plan will foster better mental
health and reduce addictions; improve health and
wellness; increase access to vital programs and
services; and reduce the number of times that people
with mental illness and addictions return to hospital
Emergency Departments for help.
We’ll do this by helping people to navigate and understand
the programs and services that are available to them
within York Region – and later within other planning
areas of Central LHIN – and to get the support they
need to find and sustain stable and appropriate housing.
We know that housing has a strong impact on improving
mental health, yet there is a severe shortage of affordable
housing within York Region despite a large population
of people with a demonstrated need.
Among the 14 LHINs, Central LHIN has the largest
overall population and the highest number of people
diagnosed with mental illness and addictions. Yet we
also have the lowest number of housing units where
people with mental health or addictions issues can
receive a supplement for their rental expense and
support services to give them the help they need.
Central LHIN has just 191 units per 1,000 people
diagnosed with mental illness and addictions issues.
One of our action plan solutions is the creation of a Service
Coordination Council, co-led by the Central LHIN and the
Canadian Mental Health Association-York Region and
South Simcoe (CMHA-YR), and launched in the fall of
2015. The Council is charged with operationalizing the
Mental Health and Addictions Action Plan in York Region.
The Council has a two-fold mandate – explore and
implement ways to improve patient/client services
within York Region, and establish a resolution process
for clients with complex and unresolved issues. The
Council will also oversee the development of a ‘one stop’
resource to centralize information about available
programs and services – giving clients what they need to
understand, navigate and access all mental health and
addictions and housing services available to them.
Technology plays a key role in the strategy for Better
Mental Health by enhancing access to services such as
psychiatry, counselling and case management. It will enable
enhanced awareness of services as well as coordinate
electronic access to services and speed up referrals to
services within the mental health and addictions sector.
Strategies can be targeted to specific age groups.
The application of technology will be rooted in our
philosophy of continually improving the patient
experience. The coordination of care will be strengthened
through technology – for example, by adopting community
clinical data repositories with standardized assessment
data that can be used across the system. Having access
to shared information can facilitate the sharing of
information with multiple Health Service Providers,
across a client’s circle of care. Provincial electronic tools
can also be adopted to provide additional important
benefits – such as electronic consultation/referral from
primary care to specialists, and the sharing of information
across Health Service Providers for complex patients.
Examples of this would be the Coordinated Care Tool
and the regional electronic health record.
Central LHIN Integrated Health Service Plan 2016-2019
37
CHAPTER
7
Conclusion
With the completion of the Integrated Health Service
Plan for 2016-2019, the Central LHIN and our key
stakeholders are poised for a time of transformational
change as together we advance our shared vision of
Caring Communities, Healthier People.
The framework for our plan, comprised of our Vision,
Triple Aims, Mission, Core Values, Goals, Future
Directions and Levers for Change – will act as our
compass and provide the steadfast direction we
need as we move forward during continued times
of change and challenge.
Together with our Health Service Providers, we’ll
bring our plan to life, implementing the six strategic
priorities in these ways:
• Development and implementation of an Annual
Business Plan to provide a detailed explanation
of key deliverables and action items
• Ongoing performance management and
monitoring of key indicators to help us
understand whether we are achieving systemwide improvement across the Central LHIN
38
Central LHIN Integrated Health Service Plan 2016-2019
• Development and communication of an Annual
Report, based on the March-to-March fiscal year,
to outline and communicate our achievements
relative to our Annual Business Plan
• Ongoing engagement and feedback from our
Health Service Providers, key stakeholders and
non-funded partners
Most important, our work will continue to be informed
by the voices of our patients and their families, and by
the Health Care Providers who deliver care each
day across the Central LHIN. The Central LHIN will
continue to work with Entité 4, our Health Service
Providers and other stakeholders in order to better
integrate the needs of our Francophone communities
within the planning activities and improve access to
quality services in French.
Throughout our plan implementation, we will continue
to be mindful of these important considerations:
• Patients First – the government’s plan and
priorities for health care
• The changing expectations and needs of
consumers, including the need for more
home and community-based care
• Fiscal realities, including the need to deliver
as much value as possible for the investment of
our taxpayers in our future
• Changing demographics including the needs
of culturally diverse populations, and the
Francophone and Aboriginal communities, and
• The potential and possibilities that new
technologies can bring to system-wide
health care planning and delivery
As the Central LHIN implements key deliverables in
the IHSP4, we are committed to remain engaged and
connected with the communities we are privileged to
serve – and we’ll communicate to you often about
shared successes and challenges.
And as we do so, we’re counting on each one of you
to help – together, we’re better!
Central LHIN Integrated Health Service Plan 2016-2019
39
Appendix
Additional Resources
Centre for Addiction and Mental Health. Improving Mental Health Services in the
Jane Finch Community. July 2012. www.loftcs.org/wp-content/uploads/2012/07/
JaneFinchReport-Web.pdf
Chiu, Maria; Maclagan, Laura; Tu, Jack; Shah, Baiju. Temporal trends in
cardiovascular disease risk factors among white, South Asian, Chinese and
black groups in Ontario, Canada, 2001 to 2012: a population-based study.
August 2015. http://bmjopen.bmj.com/content/5/8/e007232.full
Crighton, Eric; Ragetlie, Rosalind; Luo, Jin; To, Teresa; Gershon, Andrea. A spatial
analysis of COPD prevalence, incidence, mortality and health service use in Ontario.
March 2015. www.statcan.gc.ca/pub/82-003-x/2015003/article/14144-eng.htm
Ministry of Health and Long-Term Care. Bringing Care Home. March 2015.
http://www.health.gov.on.ca/en/public/programs/ccac/docs/hcc_report.pdf
Ministry of Health and Long-Term Care. Environmental Scan for Strengthening
Residential Hospice Care in Ontario. March 2015. https://www.oma.org/Resources/
Documents/EnvironmentalScanforStrengtheningResidentialHopsiceCareinOntario.pdf
Ministry of Health and Long-Term Care. Open Minds, Healthy Minds – Comprehensive
Mental Health and Addictions Strategy. 2011. http://www.health.gov.on.ca/en/
common/ministry/publications/reports/mental_health2011/mentalhealth_rep2011.pdf
Ministry of Health and Long-Term Care. Patients First: A Roadmap to Strengthen
Home and Community Care. May 2015. http://www.health.gov.on.ca/en/public/
programs/ccac/roadmap.pdf
Ministry of Health and Long-Term Care. Patients First Action Plan for Health Care.
February 2015. http://www.health.gov.on.ca/en/ms/ecfa/healthy_change/docs/
rep_patientsfirst.pdf
Ministry of Health and Long-Term Care. Strengthening Ontario’s End-of-Life Continuum:
Advice Regarding the Role of Residential Hospices. March 2015. http://www.oma.org/
Resources/Documents/StrengtheningOntarioEnd-of-LifeContinuum.pdf
Ministry of Municipal Affairs and Housing. Building Foundations: Building
Futures – Ontario’s Long-Term Affordable Housing Strategy. November 2010.
www.mah.gov.on.ca/AssetFactory.aspx?did=8590
Ministry of Municipal Affairs and Housing. Minister’s Forum on Affordable
Housing and the Private Sector. November 2014. www.mah.gov.on.ca/
Asset10906.aspx?method=1
40
Central LHIN Integrated Health Service Plan 2016-2019
Ministry of Municipal Affairs and Housing. Provincial Policy Statement 2014.
February 2014. http://www.mah.gov.on.ca/Page10679.aspx
Ontario Non-Profit Housing Association. 2015 Waiting Lists Survey. May 2015.
http://onpha.on.ca/onpha/CMDownload.aspx?ContentKey=224ea012-0fb2-47f4a13c-e6f3ebca63dc&ContentItemKey=cb12f5fc-3da1-4e09-98bc-fcfaad22ae94
Porter, Michael. Effective Health Care Policy: Improving Value for Patients.
November 2014. http://www.healthachieve.com/2014/Presentations%202014/
Official%20Opening_Michael%20E%20Porter.pdf
Sirotich, Frank; Durbin, Anna. Identifying the Needs of Complex Health
Populations Receiving Community Mental Health and Addictions Services:
An Analyses of Ontario Common Assessment of Need (OCAN) Data for
Case Management and Supportive Housing Programs. December 2014.
https://www.ccim.on.ca/CMHA/OCAN/Document/Unlinked/Identifying%20
Complex%20Health%20Populations_CMHA.pdf
Central LHIN Integrated Health Service Plan 2016-2019
41
Central Local Health Integration Network
60 Renfrew Drive, Suite 300
Markham, ON L3R 0E1
Tel: 905-948-1872 or 1-866-392-5446
Fax: 905-948-8011
Email: [email protected]
www.centrallhin.on.ca