Strengthening Integrated Heath Care in the Toronto Central Local Health Integration Network. East Toronto June 14, 2016

Transcription

1 Strengthening Integrated Heath Care in the Toronto Central Local Health Integration Network East Toronto June 14, 2016

2 Welcome to the first meeting of the cross-sector table for East Toronto Moderator and today s Presenters Tess Romain Susan Fitzpatrick Gillian Bone Vania Sakelaris Alvin Cheng 2

3 Thank you all for coming Access Alliance Alternatives East York Mental Health Counselling A-Way Express Bellwoods Bridgepoint FHT Chester Village COTA East End CHC East Toronto Health Link Flemingdon Health Centre Fountain View Care Community Fudger House Good Shepherd Non-Profit Homes Toronto Harmony Hall Centre for Seniors Nisbet Lodge Ontario Medical Association District 11 Physicians Providence Healthcare Reflet Salvéo Renascent Sinai Health System South East Toronto FHT South Riverdale CHC St. Clair O Connor Community The Neighbourhood Group Toronto Central CCAC Toronto East General Hospital The O Neill Centre Thorncliffe Neighbourhood Office Toronto Public Health Toronto Intergenerational Partnerships In Community YMCA of Greater Toronto Holland Bloorview Tobias House Attendant Care 3

4 A special thanks to Toronto Central LHIN Citizens Panel, Munira Khilji Toronto Central CCAC, Gayle Seddon Toronto Public Health, Jann Houston Primary Care Transition Steering Committee, Dr. Tia Pham Primary Care Transition Steering Committee Guest, Dr. Geordie Fallis 4

5 Purpose of this first cross-sector session 11. Share the vision of how we will move forward through a population-health approach 2. Clarify our approach to planning 3. Discuss how locally integrated care relates to regional 3 and provincial systems of care 4. Provide an update on primary care 4 5. Looking forward what s next 5 5

6 Future sessions (summer / fall) 11. Discuss the role and contribution of hospitals within a new collaborative approach 2. Share collaborative work in home care, community 2 support services, and community mental health and addiction services 3. Discuss vision for integrated Community-based care 4. Discuss how to formalize patient / client, family, caregiver, and community involvement 4 6

7 Everything begins with our Patients, Clients, and Community members Please welcome Munira Khilji 7

8 Today s agenda 1 1. Vision and approach for achieving local, integrated, and population-based health care 20 minutes Vision for a regional approach to care 15 minutes 2. Update on Primary care 15 minutes 4 3. Get to know our local patients / clients and families Population data 30 minutes 5 4. Table talk and feedback on next steps 20 minutes 8

9 What has brought us here today Strategic Plan Community Engagements Research, Analysis, and Expert Reports 9

10 What we have heard from patients, clients, families, and caregivers I don t care how you organize my health care or about the rules I just want care when I need it, where I can get to it, and to feel confident that it is going to make me better. - Toronto Central LHIN resident Want to be at home and healthy - ACCESS Searching is stressful - NAVIGATION / COORDINATION - Act as one team - COMMUNICATION - 10

11 Key messages to keep in mind All of our efforts must build toward a systems approach to care no longer sector-based This meeting today is the start of a collaborative, continuous process We don t have all of the solutions right now We are working together, and together we will define a vision and prioritize work to achieve that vision 11

12 TC LHIN Strategic Plan A vision for local planning Susan Fitzpatrick, CEO 12

13 Our Shared Goals Our Vision Strategic Goals Community Outcomes Transform the system to achieve better health outcomes for people now and in the future A Healthier Toronto Positive Patient Experiences Innovation & System Sustainability We are a healthy and active community We have timely access to care that includes us and meets our needs We receive the right care and all of our health care providers act as a team Prevention& Wellness Access & Equity Quality & Value 13

14 Current patient experience Families and Caregivers Hussein Family Health Link Hospital / Acute Primary Care / Family Physician / Walk-In Home Care - Access - Availability of core services may vary across Toronto communities - Navigation / Coordination - Home Care Assessment CSS and CMHA Service Agencies Largely patient- and family- directed LTC Home - Communication - Multiple care plans 14

15 Current system of sectors 1.2 M Citizens navigating sectors of care Specialists Diagnostics Independent Health Facilities Family Practice / General Physicians 17 CHCs 22 Home Care Agencies 1 CCAC 17 Hospitals 54 CSS Agencies 58 CMHA Agencies 36 LTCHs Limited shared accountability across providers or sectors Accountable to MOHLTC Individual accountability agreements Varying models Individual volume-based funding Varied access to interprofessional, team-based care 15 Note: Numbers based on unique HSPs. Note that an HSP may have a number of agencies across sectors

16 What we have heard from providers Build on successes Pursue a population health approach Integrate community service delivery Partner to strengthen intersection with social determinants Create consistency in core services across communities Support providers to respond to community specific needs, including cultural competency Map primary care capacity 16

17 Achieving a system for citizens "Every system is perfectly designed to get the results it gets" Current incentives Focus on individual patients needs Individual providers funded based on volumes of care Individual provider accountability for outputs Sector care planning Sector I&IT Organized pilot projects PROVIDER What we want to incent Holistic care for an entire community (preventative and responsive) Teams funded based on community need and their outcomes achieved Shared, team accountability for outcomes One patient care plan Shared I&IT Front line innovation CITIZEN 17

18 Desired patient experience One team approach to care Emergency Care and Scheduled Procedures Family and Caregivers Primary Care Care Coordination / Navigation Local care team and care plan, rooted in primary and community care Information Sharing 18

19 How we will work together to achieve the vision of one team? A new process Sector tables Cross collaborative tables An enhanced way of organizing how we work together We serve the same communities a single team in the eyes of the patient A means to develop local, integrated, and populationbased care Plan and take action together 19

20 The motivation for this approach... Together, we will: Understand the needs of the whole population and local communities Meet the needs of subpopulations (e.g. Francophone, Indigenous, marginalized) Tackle health inequities Get upstream (maintain and prevent) E.g. Identify care models E.g. Address health inequities E.g. Work upstream (prevent) 20

21 Taking a Population Health Approach with a focus on Equity A cross-cutting theme in the implementation of our strategic plan Planning to date has generally been focused on meeting the needs of those actively receiving health care, but our mandate is to deliver excellent care to all (reinforced by Ontario s Excellent Care for All Act). 21

22 Population Health: What does this mean to our partners? Focusing on populations and sub-populations, understanding their unique needs and challenges and working with communities to find sustainable solutions. This will require: Collaboration and shared accountability between the LHIN and HSPs, public health, and other partners Greater integration with primary, hospital, home, and communitybased care Enhanced performance measurement through more valuable data Engaging marginalized populations Strategic partnerships with health and non-health entities Strong local planning partnerships are needed to advance a population-based approach 22

23 Purpose of a new approach to collaboration Establish local collaboratives of diverse providers, patients / clients, and families that share a common vision for local, integrated, and population-based health care in the TC LHIN Create strength in diversity Share accountability for change Outline the steps we will take together to make that vision a reality 23

24 Moving to One Team Patients / Clients, Families, and Caregivers Align home & community care as one integrated system Define a model of care coordination and navigation Health Link partnership (complex care) Build partnerships to advance social determinants of health Establish patient and caregiver involvement Housing with Supports Community Mental Health and Addictions Services Home and Community Support Services Long-Term Care Homes Care Coordination/ Navigation Post-Acute Short-Stay Community Care Hospital(s) FHO Emergency Department Deepen understanding of the community s health needs Primary Care Practices FHN Solo Practitioner FHT Supportive Primary Care Network Other Clinics CHC FHG Interprofessional teams Build a strong community-based primary care network Share information across all partners Coordinate access to specialized and regionally-based care when needed 24

25 What can the future look like for patients and clients Play an active role Their outcomes and feedback drive continuous quality improvement - Access - Have equitable and reliable access to care in their community - Coordination / Navigation - Single point access to choice of primary care Access to navigation and care coordination that meets their needs - Communication- Providers work as one team and information follows the patient 25

26 What can the future look like for providers Co-design local solutions with patients / clients - Access - Access to inter-professional team supports including local Health Link processes and partnerships - Coordination / Navigation - Work with care coordination and navigation supports Better coordination between primary care and community Consistency in access to regional /specialized care - Communication Access to information from across the system on care being provided to your patients / clients 26

27 Ways in which the TC LHIN will facilitate - Access - Plan with primary care and build capacity Apply an equity focus - Coordination / Navigation - Support for integration Collaborate on a population health model for care coordination and navigation Develop framework for regional care - Communication - Build partnerships with Toronto Public Health, City of Toronto, and other non-health partners 27

28 Supporting activities to move forward with Facilitated sessions for cross-sector tables starting this Summer and Fall 2016 Bringing all of our work together as part of one intentional and focused plan Launch of a Regional Quality Table in partnership with HQO, which will support future integrated Quality Improvement Plans Share Integration Report outlining recommendations to the TC LHIN and our partners 28

29 Proposed process to realize One Team 1. Evidence-based needs assessment of communities and subpopulations 2. Define outcomes that are important to the needs of communities and sub-populations 3. Identify priorities where will we start and who does what 4. Co-design delivery solutions with patients / clients, families, caregivers, and other partners (building an intersection of health and social care) 5. Evaluate against defined outcomes and continuously iterate to improve What is different? Focus on population need (demand as opposed to supply) Focus on outcomes and generating evidence based on local context Joint solution development (co-design) and continuous engagement 29

30 2016/17 activities Fall First facilitated planning session Review evidence-based, core components of population-based systems Deepen understanding of community health needs (ongoing stratification of populations by risk; focusing on improving equity) Identify and confirm a shared vision Fall / Winter Local community-based asset mapping 3. Identify priority areas for collaboration (based on review of evidence in #1) Complete self-assessment against core components 4. Develop shared agreement (acknowledge individual and shared commitments / accountabilities) Winter 2017 and onward 5. Co-develop and begin execution of local work plans 6. Work plans shared (cross-region learning) 30

31 Key takeaways 1 Creating a one-team approach (cross-collaborative planning) 2 Focused on improving population health through a local planning approach, while closing the gap for those most in need (equity) 3 This is a collaborative process Questions? 31

32 Organizing Regional Services Gillian Bone, Senior Consultant 32

33 Multiple systems of care are required to meet the diverse needs of patients / clients Provincial Programs and Services Region 24/7 Specialized Care Rehabilitation / CCC Residential Hospices Pain and Symptom Manaegment Long-Term Care Homes Indigenous Culturally Sensitive Local Community Francophone Primary Care Practices Family and Caregivers Specialized MHA Specialized Prevention Services Housing with Supports Community Mental Health and Addictions Services Specialized Diagnostic Services Home and Community Support Services Surgery Care Coordination/ Navigation Post-Acute Short-Stay Community Care Hospital(s) FHO FHN Emergency Department Solo Practitioner FHT Supportive Primary Care Network Other Clinics CHC FHG Interprofessional teams Speciality 33

34 What we have heard - Access - Variability in access to regional and specialty care Access is designed on a sector or provider specific basis Improve access for marginalized groups both within and outside the LHIN - Coordination / Navigation - Patients and families experience fragmentation in transitions of care Service planning is done in silos - Communication - Improve ability to share information amongst providers (to improve coordination, safety, and quality) 34

35 Problem Statement As the health care system moves towards providing services closer to home, a subset of services will need to continue to be delivered regionally due to insufficient demand to sustain quality and efficient service delivery across the LHIN Regional services must be designed to ensure the services are easily and equitably accessible, meet client / patient needs, and improve client outcomes and experiences with the health care system Desired Outcome One regional services framework to guide the development of a regional services system Quick, reliable, and equitable access to regional services as well as an efficient use of resources while strengthening quality and sustainability of services 35

36 What can the future look like for clients and patients - Access Connect clients/patients to specialized services that do not exist at a local level - Coordination Create seamless transitions between services - Communication Regional services need to be seen as an extension of a local team (a one team approach to care in the eyes of the client/patient) 36

37 Early and draft definitions of a spectrum of care Access starting close to / at home and scaling up when needed Local Services Regional Services Provincial Services Available consistently and equitably across communities Based on local population health needs (meet volume of need) Expertise and equipment readily available locally More specialized in nature (typically lower volumes) Not available in each community (e.g. subregion), but accessible to anybody in TC LHIN, GTA, and Ontario Highly specialized tertiary and quaternary services accessible to all Ontarians Local / regional programming would be cost and quality prohibitive Accessing highly specialized care, if necessary, and get patients home as soon as possible 37

38 Examples 1. Adult with an Acquired Brain Injury Provincial Neurosurgery Regional Specialized Ambulatory Therapy Local In-home Personal Support 2. Adult with Type 1 Diabetes Local Regional Provincial Primary Care Dialysis Care Kidney Transplant 38

39 Proposed Regional Services Planning A Phased Approach Phase 1 Scope and service delivery Define scope, principles, criteria **Convene expert panel of HSPs, partners and community to support development of regional framework Phase 2- Access System(s) Identify access system(s) / model for regional services Identify guidelines to ensure seamless transitions with subregion services Phase 3 Implementation Identify opportunities for improvement 39

40 Proposed 2016/17 Regional activities Summer Regional planning session Begin to draft principles for a regional framework that could be applied to all regional services / programs Fall / Winter 2016/17 2. Draft regional vision that supports local and provincial needs Begin to prioritize opportunities for improvement Winter 2017 and onward 3. Develop framework for regional and specialized programs including improvement plan 4. Validate regional framework with sub-regions 40

41 Key takeaways 1. 1 Resolving fragmentation 2. 2 Focusing on quick, reliable, and equitable access to regional services efficient use of resources strengthening quality and sustainability of services 3. 3 Enabled by one regional services framework to guide the development of a regional services system Questions? 41

42 Primary Care Vania Sakelaris, Senior Director Special thanks to: Members of the Primary Care Transition Steering Committee 42

43 Working locally to connect a system of primary care with community partners Housing with Supports Community Mental Health and Addictions Services Long-Term Care Homes Home and Community Support Services Care Coordination/ Navigation Post-Acute Short-Stay Community Care FHO Emergency Department Primary Care Practices FHN Solo Practitioner FHT Supportive Primary Care Network Other Clinics CHC FHG Interprofessional teams Family and Caregivers Hospital(s) 43

44 Primary Care Strategy Overview Transforming primary health care is a strategic priority of the Toronto Central LHIN s Strategic Plan The primary care sector is both an entryway and point of continuity in the system As we develop our approach to strengthening primary care, we have been listening to providers, patients, and caregivers Consultations have been held with over 250 primary care providers to inform the vision, goals, and objectives The LHIN is now moving in to the implementation phase 44

45 TC LHIN Primary Care Vision, Goals and Objectives To build a population-based, person-centred, and integrated health care system, with a focus on primary health and community care Improved Patient Access: Reduce/Eliminate unattached patients for all patients who want/require a provider Improve same day/next day access to primary care Improve after-hours access to primary care Increase access to interprofessional team care for those who need it Increase access and reduce wait times for urgent specialist consults Improve matching of health human resources with community need Improved Service Integration: Increase timely availability of hospital discharge summaries Improve primary care provider and/or team followup within 7 days of discharge Increase timely access for advanced diagnostic services, Improve/streamline access to home care Improve care co-ordination and care transitions for complex patients Improve bi-directional communications between primary care and ER and hospital for complex patients Increase System Efficiency: Improve communication between health care providers and between providers and patients using enhanced and integrated information systems Reduce primary care sensitive ER visits and hospital admissions Streamline access to specialists and hospital diagnostics and clinics Improve health service planning and delivery through effective and interactive use of population health information and outcomes Increase the percentage of family physicians practicing in group models 45

46 Primary Care Identified 2016/17 Priorities 1. Improve attachment to primary care providers for all residents who want one Assess current capacity within the LHIN Propose and implement strategies to improve access 2. Provide access to inter-professional care teams for patients who need them. Currently, there is unequal access to team based care for patients depending on their physician s model of practice. Assess current capacity within the LHIN Develop criteria for identifying patients requiring access Propose strategies and processes for implementation (SPIN) 46

47 Primary Care Identified 2016/17 Priorities - Continued 3. Improve access to urgent specialist consults and streamline access to specialists within hospital settings (e.g SCOPE). Develop a database and implement tools such as a one-number or one place to call process 4. Improve timely access to quality discharge summaries to enable primary care providers to follow-up with patients post discharge and avoid unnecessary readmissions. Build upon current initiatives: Connect GTA, e-notification and HRM. 5. Connect all primary care providers and other HSPs through secure . A later phase will develop secure patient to provider electronic communications building on existing initiatives such as On . 47

48 Primary Care - Roles and Responsibilities Primary Care Clinical Leads: Are local primary care physician leaders that champion primary care strategy implementation through local engagement, collaboration, development and implementation of strategies to improve access and service integration. Primary Care Co-ordinating Committees: Will be a committee representative of the primary care providers from the various physician practice models (FHT, FHO, FHG, FFS, Solo Practitioners, CHCs) that will be responsible for developing a local primary care work plans to implement approved initiatives to move forward on the achievement of the goals and objectives. 48

49 2016/17 Primary care activities June Local Primary Care Clinical Leads to be announced Summer Implementation of local Primary Care Networks Fall / Winter 2016/17 3. Commence implementation of identified Primary Care priorities 49

50 Key takeaways 1 We are implementing priorities informed by local primary care providers and their patients 2 We are partnering with local clinical leaders to codesign primary care networks. Connecting primary care providers and their patients 3 to an integrated system Questions? 50

51 Population Health Status TC LHIN population overview Alvin Cheng, Director 51

52 Recall The motivation for a Population Health approach Taking a Population Health approach allows us to: Understand and address the needs of the whole population and local communities Meet the needs of sub-populations (e.g. Francophone, Indigenous, marginalized) Pay special attention to disparities in health tackle health inequities Get upstream through looking at the causes of poor health outcomes the Social Determinants of Health 52

53 Toronto Central LHIN (2016) Population: 199,051 HSPs: 20 FP/GP: 303 Population: 232,570 HSPs: 29 FP/GP: 237 Population: 305,989 HSPs: 55 FP/GP: 735 Population: 143,392 HSPs:49 FP/GP: 231 Population: 269,756 HSPs: 29 FP/GP:

54 Health Service Providers in Toronto Central LHIN (2016) HSPs with offices in a particular region may provide services for people in other regions of TC LHIN. Residents of a certain community may receive care in other communities. There are many other health and non-health partners in our region that play a role in influencing health outcomes of our population. East CCAC CHC CMHA CSS Hospital Private Hospital LTC Family Practice/General Physicians** Total excluding FP/GP Mid-East Mid-West North West TC LHIN **Includes Family Practice/General Physicians currently in good standing with the College of Physicians and Surgeons of Ontario (CPSO) with a valid billing number. They may or may not be using their billing number or actively submitting claims to OHIP. Number excludes FP/GPs in Focused Practices, e.g. Sports Medicine, Psychotherapy. 54

55 East Toronto Highlights Please note data presented is for discussion purposes only. Detailed information reports will be shared upon final data quality and citation review. 55

56 East Toronto Neighbourhoods Population (2011) 269,756 Males: 48.1% Females: 51.9% Children and Youth: 22.9% Seniors (ages 65+): 12.4% 56 Source: Toronto Community Health Profiles Partnership, Extracted: 2016; Census of Canada, Statistics Canada, 2011

57 About East Toronto Thorncliffe Park Flemingdon Health Centre The Beaches Danforth Toronto East Health Network WoodGreen Community Services Bounded by the Don Valley Parkway, Eglinton Ave, Warden Ave, and Lake Ontario, the East Toronto sub-region is the second largest region by land area and population. The region contains 21 neighbourhoods, 5 designated Neighbourhood Improvement Areas (Thorncliffe Park, Victoria Village, Oakridge, Flemingdon Park and Taylor-Massey (formally known as Crescent Town)) along with higher-income neighbourhoods such as The Beaches and North Riverdale. To note, South Riverdale neighbourhood is divided between East Toronto and Mid-East Toronto sub-region. The Don Valley Parkway and Taylor-Massey Creek physically separate the Thorncliffe Park and Flemingdon Park neighbourhoods from the rest of the region. The rail corridor south of Danforth Ave provides another natural boundary. 57

58 East Toronto: Population of Children and Youth (2011) East Toronto has the highest proportion of children and youth (ages 0-19 years) in 2011 (22.9% ) among the sub-regions and relative to TC LHIN (18.7%). All but two neighbourhoods in East Toronto have a higher than average proportion of children and youth in their neighbourhoods. Thorncliffe Park has the highest proportion of children and youth (32.2%) among all the neighbourhoods in TC LHIN. Source: Toronto Community Health Profiles Partnership, Extracted: 2016; Census of Canada, Statistics Canada, 2011 % of Total Population Ages 0-19, Both sexes (2011) Thorncliffe Park Oakridge Flemingdon Park Taylor-Massey O'Connor-Parkview Clairlea-Birchmount Blake-Jones East End-Danforth The Beaches Woodbine Corridor Victoria Village Danforth Birchcliffe-Cliffside North Riverdale Danforth-East York Greenwood-Coxwell Old East York Playter Estates-Danforth Woodbine-Lumsden Broadview North TC LHIN: 18.7% 27.5% 26.7% 24.4% 23.8% 23.5% 23.2% 22.5% 22.4% 21.9% 21.2% 21.0% 20.9% 20.5% 20.1% 20.0% 19.8% 19.4% 18.3% 18.0% 32.2% 0.0% 10.0% 20.0% 30.0% 40.0% 58

59 East Toronto: Diversity Percent (%) of Total population in private households that are recent immigrants: 8.0% TC LHIN 6.8% Visible Minority 41.0% TC LHIN 33.6% Top 3 Languages Other Than English Spoken at Home (2011) Neighbourhood Name #1 #2 #3 Victoria Village Arabic Persian (Farsi) Tamil Flemingdon Park Urdu Persian (Farsi) Tamil O'Connor-Parkview Greek Bantu languages, n.i.e. Tagalog (Pilipino, Filipino) Thorncliffe Park Urdu Persian (Farsi) Gujarati Broadview North Greek Serbian Albanian Old East York Greek Tagalog (Pilipino, Filipino) Cantonese Danforth-East York Greek Cantonese Italian Woodbine-Lumsden Cantonese Chinese, n.o.s.* Greek Taylor-Massey Bantu languages, n.i.e^. Urdu Tamil East End-Danforth Cantonese Urdu Bantu languages, n.i.e. The Beaches French Spanish German Woodbine Corridor French Cantonese Chinese, n.o.s.* Greenwood-Coxwell Cantonese Chinese, n.o.s.* Urdu Danforth Greek Italian Cantonese Playter Estates-Danforth Greek Spanish Cantonese North Riverdale Cantonese Chinese, n.o.s.* Greek Blake-Jones Cantonese Chinese, n.o.s.* Greek Clairlea-Birchmount Bantu languages, n.i.e. Tagalog (Pilipino, Filipino) Urdu Oakridge Bantu languages, n.i.e. Urdu Persian (Farsi) Birchcliffe-Cliffside Bantu languages, n.i.e. Cantonese Chinese, n.o.s. Aboriginal Identity 3,540 TC LHIN 10,665 Note: Persons of aboriginal identity are most likely undercounted due to limitations of the NHS East Toronto has the highest proportion of recent immigrants (arrived between ) with top three countries being Bangladesh (17.9%), Pakistan (11.7%) and Philippines (8.9%). Most heavily represented visible minorities relative to TC LHIN are South Asian and West Asian or Arab. The most common languages spoken at home other than English include Urdu, Greek and Bantu languages, n.i.e. * Chinese, n.o.s. (not otherwise specified) is comprised of a large number of persons who answered 'Chinese' to the question on mother tongue in the census, without any other specification. Source: Toronto Community Health Profiles Partnership, Extracted: 2016; These may, therefore, include persons with Mandarin, Cantonese or any other Chinese language as their mother tongue. Census of Canada, Statistics Canada, 2011 ^n.i.e. (not included elsewhere) 59

60 East Toronto: Marginalization Ontario Marginalization Index, per Neighbourhood (2006) City of Toronto: 2.4 There is variation in the levels of marginalization and socio-economic status in East Toronto neighbourhoods. Several neighbourhoods have particularly high levels of marginalization: Thorncliffe Park, Victoria Village Oakridge and Flemingdon Park. Indicator definition: A combined measure of 18 variables representing residential instability, ethnic concentration, dependency and material deprivation, 2006 Census, Ontario Marginalization Index. Source: Urban Heart, 2014 [2006 Census, Ontario Marginalization Index] % of Population - Low Income (After-Tax) (2010) Oakridge Crescent Town Flemingdon Park Thorncliffe Park Blake-Jones Clairlea-Birchmount Victoria Village Greenwood-Coxwell Broadview North O'Connor-Parkview East End-Danforth Woodbine Corridor Danforth East York Woodbine-Lumsden Birchcliffe-Cliffside Danforth Village - Toronto North Riverdale Old East York Playter Estates-Danforth The Beaches 9.8 City of Toronto: 22.2% Source: Urban Heart, 2014 [2006 Census, Ontario Marginalization Index] % of Population Receiving Social Assistance (2012) Oakridge Thorncliffe Park Flemingdon Park Crescent Town O'Connor-Parkview Victoria Village Blake-Jones Greenwood-Coxwell Broadview North Clairlea-Birchmount East End-Danforth Birchcliffe-Cliffside Woodbine Corridor Woodbine-Lumsden Danforth Village - Toronto Danforth East York Old East York North Riverdale Playter Estates-Danforth The Beaches City of Toronto: 10% Indicator definition: Percentage of the population living with incomes below the aftertax low income measures (LIM-AT) established in 2010 for the City of Toronto. The after taxlow income measure (LIM-AT) is the poverty measure used by the Ontario Poverty Reduction Strategy. Source: Urban Heart Toronto, 2014 [2010 TI-Family File, Statistics Canada Income Division] Indicator definition: Social Assistance: % of the population that are recipients of Ontario Works, persons on ODSP participating in OW employment programs and non-ow persons receiving assistance with medical items, 2012, Toronto Employment & Social Services. 60

61 East Toronto: A Tale of Two Neighbourhoods Early patterns suggest relationship between high marginalization, low income, and downstream use of health system resources. Further investigation is required. 2 Oakridge has the highest rate of low income in the sub-region, and the second highest marginalization rate. 1 The Beaches has the rate of highest income and the lowest marginalization rate. Health system resource indicators show lower utilization: ALC Rate = 9.8% Rate Inpatient Hospitalizations = 58.2 per 1,000 Health system resource indicators show higher utilization: ALC Rate = 11.7% Rate Inpatient Hospitalizations = 93.6 per 1,000 61

62 Age-Standardized Rate East Toronto: Prevalence of Chronic Diseases East Toronto has the highest prevalence rate for all chronic diseases (diabetes, asthma, high blood pressure, COPD and mental health visits) among the subregions and relative to TC LHIN. Chronic Disease TC LHIN Age Standardized Rate East Toronto Age Standardized Rate Neighbourhood Range Diabetes Asthma High Blood Pressure COPD Mental Health Visits Rate of High Blood Pressure for population 20+, East Toronto Neighborhoods (FY2014/15) TC LHIN: 20.1 Almost half of the neighbourhoods in East Toronto have higher than average rates of high blood pressure. Of the 9 neighbourhoods above the TC LHIN rate, 5 include Neighbourhood Improvement Areas identified by the City of Toronto. 62 Source: Ontario Community Health Profiles Partnership, Extracted: 2016

63 East Toronto: Patterns of ED Use More than half of visits to the ED by East Toronto residents are to Michael Garron Hospital (57%). Overall, approximately 12.8% of all ED visits by residents occur in hospitals in other LHINs. 28% 23% 18% 13% 8% 3% -2% % Change in ED Visit Volumes from FY 2010/11 to FY 2014/15 17%16% 15% 15% 14%14%14% 13% 12% 11%11% 9% 9% 9% 9% 7% TC LHIN Rate: 9.6% 4% 3% 3% 1% -1% UHN - TWH 2% UHN - TGH 3% Scarborough Hospital - General 4% Top 10 Hospitals - % of ED Visits by Hospital of Visit (FY2014/15) SJHC 1% NYGH 3% All Others 7% Visits to TC LHIN EDs 87.2% Several neighbourhoods have experienced increases in ED visit volumes since FY 2010/11: Mount Sinai Hospital 4% Sunnybrook 5% Hospital for Sick Children 6% St. Michael's Hospital 8% Michael Garron Hospital (TEGH) 57% Central East LHIN EDs 5.6% Other EDs in Other LHINs 7.2% Thorncliffe Park (increase by 17%) North Riverdale (16%) Woodbine Lumsden (15%) Flemingdon Park (15%) East End Danforth (14%) O Conner Parkview (14%) Source: NACRS (IntelliHealth), FY 2014/15 (Extracted: 2016) 63

64 Percentage Screened (%) Percentage Low Continuity (%) East Toronto: Primary Care and Prevention % Low Continuity of Care (2012/13) TC LHIN: 21.4% Primary care continuity and rates of prevention screening have historically led to positive health outcomes Six neighbourhoods in East Toronto have lower than average continuity of care. % of Eligible Population having any Colorectal Cancer screening (2015) TC LHIN: 60.8% Majority of neighbourhoods in East Toronto have below average rates of any colorectal cancer screenings relative to TC LHIN. 64 Source: Toronto Community Health Profiles Partnership, Extracted: 2016

65 2016/17 activities Summer / Fall Finalize and share initial population profile reports 2. Begin deeper dive into health status of the population and community health utilization 3. Support deeper understanding of community health needs (ongoing stratification of populations by risk; focusing on improving equity) Fall / Winter Further investigation and analysis of sub-populations to identify needs and gaps 5. Stratify strategic plan indicators by communities / populations Winter 2017 and onward 6. In partnership with local tables, determine additional evidence required to support successful execution of local work plans 65

66 Key takeaways 1 We are using population need to drive local planning There is considerable variation by neighbourhoods, 2 of potential health needs which will be important to consider during planning Questions? 66

67 Getting to Know Each Other Round Table Dialogue Tess Romain, Senior Director 67

68 Getting your conversation started What opportunities do you see in moving to a one team approach to local planning and delivery? 68

69 Next Steps Facilitated sessions for cross-sector tables starting this Summer and Fall 2016 Bringing all of our work together as part of one intentional and focused plan 69

70 Recall Working through the process together 1. Evidence-based needs assessment of communities and subpopulations 2. Define outcomes that are important to the needs of communities and sub-populations 3. Identify priorities where will we start and who does what 4. Co-design delivery solutions with patients / clients, families, caregivers, and other partners (building an intersection of health and social care) 5. Evaluate against defined outcomes and continuously iterate to improve What is different? Focus on population need (demand as opposed to supply) Focus on outcomes and generating evidence based on local context Joint solution development (co-design) and continuous engagement 70

71 Recall To advance shared objectives Patients / Clients, Families, and Caregivers Align home & community care as one integrated system Define a model of care coordination and navigation Health Link partnership (complex care) Build partnerships to advance social determinants of health Establish patient and caregiver involvement Housing with Supports Community Mental Health and Addictions Services Home and Community Support Services Long-Term Care Homes Care Coordination/ Navigation Post-Acute Short-Stay Community Care Hospital(s) FHO Emergency Department Deepen understanding of the community s health needs Primary Care Practices FHN Solo Practitioner FHT Supportive Primary Care Network Other Clinics CHC FHG Interprofessional teams Build a strong community-based primary care network Share information across all partners Coordinate access to specialized and regionally-based care when needed 71

72 Alignment of key deliverables Winter 2017 and onward Co-design and implement Work plans shared, crosscollaborative learning platform established Fall / Winter Asset map Identify priorities Develop shared agreement Summer / Fall 2016 Facilitated planning session (review evidence, pop health and equity assessment; confirm vision) Winter 2017 and onward Develop regional framework Partner with cross-sector tables Fall / Winter 2016/17 Local primary care work plans Fall / Winter 2016/17 Draft regional vision Summer 2016 Implement local network structure Summer 2016 Regional planning session June 2016 Local Primary Care Clinical Leads to be confirmed Local Cross- Sector Planning Local Primary Care Networks Regional Coordination 72

73 Questions? 73

74 Appendix 74

75 Primary Care Transitional Steering Committee Membership Chair: Dr. Phil Ellison Dr. Jocelyn Charles Dr. Tara Kiran Dr. Nicole Nitti Dr. Pauline Pariser Dr. Yoel Abels Dr. Barbara Yaffe Dr. Tia Pham Dr. Patrick Safieh Dr. Karen Weyman Dr. David Tannenbaum Dr. Lynn Wilson Dr. Rick Glazier Dr. Javed Aloo Dr. Ho Malcolm Moffat Dipti Purbhoo Susan Fitzpatrick Vania Sakelaris Greg Stevens Alvin Cheng Tess Romain 75

76 Data Limitations Population data is from This is the most recent census data available that allows a breakdown to sub-region levels. For all data, including health utilization data, the most recent available data was used. Information on visible minorities, immigration, education, labour, and Aboriginal identity were collected as part of the 2011 National Household Survey by Statistics (NHS) Canada. The National Household Survey was a voluntary survey and subject to non-response bias especially in areas where nonresponse rates exceeded 25%, the threshold for suppression for the 2011 Census. Non-response bias is a common issue with voluntary surveys and a reflection of the tendency that people who are inclined to respond to a survey have different characteristics from people who do not respond. Consequently, marginalized or underrepresented subpopulations are likely undercounted in the National Household Survey and comparisons between the National Household Survey and previous Censuses should be considered to be unreliable. Population estimates provided in the following profile should be considered as an approximate estimate of the population, rather than a true, full count of the population. 76

77 Population Overview (2011) West Toronto Mid-West Toronto North Toronto Mid-East Toronto East Toronto TC LHIN Total population 232, , , , ,756 1,150,758 0 to 4 years 5.5% 4.1% 5.5% 3.9% 6.6% 5.2% 5 to 14 years 9.6% 6.3% 10.8% 6.1% 10.9% 8.8% 15 to 24 years 10.8% 13.0% 11.7% 12.1% 11.1% 11.8% 25 to 44 years 32.1% 40.7% 30.7% 39.3% 31.1% 34.8% 45 to 64 years 28.3% 23.0% 26.6% 27.0% 27.9% 26.3% 65+ years 13.7% 12.9% 14.7% 11.7% 12.4% 13.1% 75+ years 6.8% 6.3% 7.6% 5.1% 5.9% 6.4% 85+ years 2.2% 1.8% 2.8% 1.3% 1.7% 2.0% % with no knowledge of English or French 3.4% 7.0% 1.1% 3.4% 4.3% 4.2% % immigrants 39.5% 41.6% 30.2% 37.9% 40.5% 38.5% % immigrants in last 5 years 6.1% 6.1% 6.3% 7.8% 8.0% 6.8% % visible minorities 28.6% 35.2% 22.2% 40.5% 41.0% 33.6% Aboriginal identity 1 1,900 2, ,565 3,540 10,665 French-speakers 6,210 8,530 5,495 5,345 7,435 33,015 % persons living with Low Income (LIM-AT)* 17.5% 21.5% 12.7% 23.9% 23.5% 20.0% % lone parent families with female head 83.3% 82.8% 84.6% 84.5% 83.2% 83.5% % seniors over 65 that are living alone 34.0% 28.3% 38.0% 43.2% 33.0% 34.1% Red = Highest Rate Blue = Lowest Rate Source: Census of Canada & National Household Survey, Statistics Canada, 2011 *Source: Tax Filer, T1FF, Persons of aboriginal identity are most likely undercounted due to limitations of the NHS 77