Hamilton Niagara Haldimand Brant LHIN. Appendix XII: Strategic Health System Plan: Current State Synopsis

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1 Hamilton Niagara Haldimand Brant LHIN Appendix XII: Strategic Health System Plan: Current State Synopsis

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3 Table of Contents Introduction... 4 Environmental Scan Summary... 5 Provider Survey Summary Leading Practice Research Summary Appendix A: Provider Survey

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5 Introduction To support the vision, a health care system that helps people keep healthy, gets them good care when they are sick, and will be there for our children and grandchildren, the Hamilton Niagara Haldimand Brant Local Health Integration Network (HNHB LHIN) engaged PricewaterhouseCoopers (PwC) to support them in the development of a five-year Health System Strategic Plan. The objective of this plan is to build an evidence-based, integrated and person-centred health care system. The Health System Strategic Plan needs to be based on a robust understanding of the current state, which includes an understanding of the population living within the boundaries of the HNHB LHIN, their health, and their use of health resources. The plan is informed by input from providers and an examination of other high performing health care systems, to leverage successful strategies and initiatives employed by other jurisdictions. The Current State Synopsis is comprised of the following sections: Environmental Scan The Environmental Scan provides a detailed overview of the demographics, health status, health expenditures, health system utilization, and system performance in HNHB LHIN. This section also highlights the planning considerations related to each of these dimensions. Survey Report A survey of over 200 HNHB funded and non-lhin funded providers was conducted to gain providers perspectives on priorities, values, trade-offs and strategies that should shape the future state design. Leading Practices Report Five high performing health care systems were reviewed across the following five dimensions: structure, access, priority populations, quality, and value for money. Designed to address similar challenges as HNHB, the solutions proven in other jurisdictions could be built upon in HNHB LHIN to support an evidence based system. Together these three components provide an account of the current state within the LHIN, with an overlay of what providers have told us should be areas of focus when considering future state design and informed by the best practices in the health system literature. The Current State Report will be a component of the HNHB Strategic Health System Plan report. This document provides an overview and high-level findings for each section of the Current State Report. 4

6 Environmental Scan Summary 5

7 Table of Contents Environmental Scan Summary 5 Geographic and Population Profiles 7 Socio-Economic Status 8 Health Status 9 Community Services 10 Hospital Services 11 Ambulatory Care 12 Health Expenditures 14 Performance 15 6

8 Population Aged 65+ (Projected) CENTRAL WEST MISSISSAUGA HALTON CENTRAL WATERLOO WELLINGTON NORTH SIMCOE MUSKOKA CENTRAL EAST CHAMPLAIN SOUTH EAST SOUTH WEST ERIE ST. CLAIR HNHB NORTH-WEST NORTH-EAST TORONTO CENTRAL Thousands CAGR HNHB Strategic Health System Plan: Current State Synopsis Geographic and Population Profiles The HNHB LHIN encompasses Brant, Burlington, Haldimand, Hamilton, Niagara and most of Norfolk county. The LHIN stretches from Fort Erie to Turkey Point and Paris to Lowville and covers approximately 7,000 square kilometers. HNHB LHIN has the third largest population among Ontario LHINs and is geographically diverse. The LHIN has a mix of large urban, medium-sized communities and rural areas, which adds complexity to planning and delivering high quality integrated health services. HNHB LHIN is forecast to have lower than average population growth from 2012 to 2017 (0.8% annual growth compared to 1.2% for Ontario). Population growth in Ontario is being driven by four LHINs with large populations: Central, Mississauga Halton, Central West and Central East. Despite the lower than average growth rate, HNHB LHIN is still expecting to add the equivalent population of the Norfolk sub-lhin area, or a city the size of Welland or North Bay between 2006 and HNHB has the highest proportion of seniors of any LHIN in Ontario. Overall, the HNHB LHIN has a more senior population than Ontario, given higher percentages of individuals in all age cohorts over age 65. Compared to Ontario, the HNHB LHIN has a greater male to female ratio. Approximately 49% of the Ontario population is male compared to approximately 51% of the HNHB LHIN population. The gender profile of elderly seniors (age 75+) in HNHB LHIN is markedly different from the rest of Ontario (roughly 60/40, compared with 40/60 males to females). The high proportion of men is unusual and may account for some of the differences in patterns of health service utilization being experienced by the LHIN. This anomaly is expected to normalize by The rate of growth of the seniors population is slowing; however, the impact of the current and future total number of seniors will have major planning implications for the HNHB LHIN. By 2017, the number of seniors in HNHB will be greater than the entire population of Burlington and Brantford combined. Population Aged 65+, 2006 to % 5% 4% 3% 4% 4% 4% 4% 3% 3% 3% 3% 3% 1% 6% 5% 4% 3% 2% 1% 0% to 2017 CAGR 7

9 Unemployment Rate 15 years and over ERIE ST. CLAIR CENTRAL WEST CENTRAL EAST CENTRAL NORTH SIMCOE NORTH-EAST SOUTH EAST HNHB Brant City of Hamilton Haldimand-Norfolk Halton Niagara SOUTH WEST TORONTO CENTRAL WATERLOO MISSISSAUGA HALTON NORTH-WEST CHAMPLAIN ONTARIO HNHB Strategic Health System Plan: Current State Synopsis The Province of Ontario is adopting a population based funding methodology. Such methodologies favour population growth rather than decline and in an area with a population as large as HNHB the impact may be of some significance. Other variables will be considered such as disease state, acuity etc. In 2017, the HNHB LHIN s population is expected to represent approximately 10% of the provincial population. This is a decrease from a 10.5% share of the provincial population in Despite the lower growth rate, the LHIN population is still expected to grow by nearly 60,000 residents between 2012 and The high proportion of seniors, particularly those age 85 and older has significant health service planning implications, due to the higher cost for providing care to that population. There are approximately 25,000 people of Aboriginal identity in HNHB LHIN (1.7%). This is lower than the Ontario average (2.0%). Hamilton has the highest number of people that reported Aboriginal identity (7,625) and Brantford has the highest percent of the population with Aboriginal identity (3.9%). There are two First Nations reserves within the HNHB LHIN and approximately half of the Aboriginal population residing in the LHIN live on-reserve. There are few Aboriginal community support programs such as those that would provide transitional support following a hospital stay. Culturally appropriate care and support contributes to healing, recovery and good health.note that there are inherent limitations around the use of Census data as an estimate of the aboriginal population in any planning exercise; indeed, in the HNHB LHIN, some census subdivisions were incompletely enumerated or were suppressed and therefore the demographic information presented here is incomplete. There are over 28,000 Francophones in HNHB LHIN, which is the third largest number of Francophones in Ontario (after Champlain and North East). The percentage of the francophone population in the HNHB LHIN (2.2%) is approximately half that of Ontario (4.3%). This ranks the HNHB LHIN seventh among all 14 LHINs. There is some variability across sub-lhins; Niagara has the largest share of Francophones (3.6%, or approximately 15,000 residents). LHIN research suggests that there is unmet demand for services provided in French. The HNHB LHIN has a considerably lower share of visible minority population than the province on average (9.1% compared to 22.8% for Ontario). This ranks the HNHB ninth among all 14 LHINs. There is significant variation within the HNHB LHIN for this measure. The highest concentration of visible minority population is in Hamilton (13.6%), whereas visible minorities only accounts for 1.7% of the population in Norfolk and 1.3% of the Haldimand population. Socio-Economic Status The Environmental Scan reviewed and analysed a number of socio-economic indicators at the LHIN and sub-lhin levels, including educational attainment, employment rates, and indicators of income and housing affordability. HNHB residents have slightly lower than average education levels for both high school and university, particularly in rural areas of LHIN. The unemployment rate in HNHB LHIN in 2010 was slightly lower than the Ontario average, fluctuating over time. Variation exists among sub-lhins; Halton has sustained an unemployment rate under the provincial average from 2008 to Haldimand-Norfolk and Niagara have maintained rates over the provincial average. Patterns of employment are changing in the LHIN. There is a shift from a predominantly industrial employment base to a public sector employment base (such as health care and Unemployment Rate 15 years +,

10 education). In Hamilton, the University and hospitals are now the largest employers. The impacts of this shift on health services planning and future utilization are unknown. The population of economic families with incomes below the Low Income Cut-Off (LICO) in the HNHB LHIN (13.8%) is slightly lower than the Ontario average (14.7%). The cut-offs represent levels of income at which people must spend disproportionate amounts of income for food, shelter, and clothing. There is considerable variation in the rate among HNHB communities, ranging from 8.0% in Haldimand to 18.1% in Hamilton. Hamilton is the only HNHB community with a rate higher than the Ontario average. An unusual finding is that the two sub-lhin areas with the lowest rates of families below the LICO (Haldimand and Norfolk) also exhibit low educational attainment. Health Status The Health Status chapter highlights a number of indicators from Statistics Canada s Canadian Community Health Survey (CCHS, ). Indicators cluster around self-reported well being, health conditions, health behaviours, personal resources and environmental factors. CIHI-reported mortality rates are also discussed. Findings from the CCHS for HNHB are mixed in relation to the provincial average. Variations exist within the LHIN on many measures: Self-reported health status and mental health status is equal to Ontario and ranks 5 th among the 14 LHINs There is a higher proportion of overweight/obese residents than Ontario average Arthritis rates are higher but no significant difference in prevalence of other chronic conditions (diabetes, asthma and high blood pressure) Higher rates of heavy drinking Some areas of the LHIN have lower rates of low birth weight than the provincial average. None of the sub-lhins have a significantly higher percentage of low birth weight babies than the provincial average. The HNHB LHIN s age-standardized rate for injury hospitalization (falls, MVAs) is the fourth highest among all 14 LHINs and is statistically significantly higher than the rate for Ontario. Life expectancy is lower for residents of the HNHB LHIN than the average for the province. The agestandardized rate of potential years of life lost and the adult mortality rate are both higher in HNHB compared with the provincial average. 9

11 Community Services The range and availability of community services in the HNHB LHIN is examined, including descriptions of the availability of long-term care homes and utilization of CCAC, community support services and community mental health and addictions services. NORTH-EAST NORTH-WEST SOUTH WEST SOUTH EAST CENTRAL WEST ERIE ST. CLAIR CHAMPLAIN HNHB CENTRAL EAST NORTH SIMCOE MUSKOKA ONTARIO WATERLOO WELLINGTON TORONTO CENTRAL MISSISSAUGA HALTON Number of LTC Beds per 1,000 Population over 75, 2010/11 CENTRAL In 2010/11, the HNHB LHIN had 10,371 beds in 87 long-term care homes, which ranks the LHIN 8th in terms of rate of LTC beds per 1,000 population aged 75+. The rate of LTC beds per 1,000 population has been falling for past 3 years but remains higher than Ontario s rate. The distribution of LTC beds per 1,000 population is not aligned with the distribution of the seniors population in the LHIN. Hamilton has the greatest concentration of beds, but a lower than average percentage of the population over age 65. Conversely, Niagara has the second highest number of seniors as a percent of its population, but has the second lowest number of LTC beds per 1,000 population. The HNHB CCAC receives the largest amount of base funding in the province and provides 11.6% of total provincial CCAC volume. There are a variety of services provided by the CCAC and limited benchmarks are available for how much of each service should be provided. Rates of HNHB CCAC service utilization vary by type of service provided as measured by the percent of provincial volume. In most cases service levels are higher than would be expected if compared with the HNHB LHIN s share of the total population. This may be partially explained by the higher proportion of residents age 65+ in the LHIN (16.8%), compared with the Ontario average (14.6%) who are typically the most frequent users of CCAC services. There is a considerable breadth and variety of community support services available in the HNHB LHIN providing service to tens of thousands of clients and representing hundreds of thousands of hours of services. The LHIN funds 53 agencies (community support services, acquired brain injury, and supportive housing agencies) with total LHIN funding of $67M (3% of budget). These agencies contribute significantly to service delivery within their communities; however, there may be duplication of service and opportunity for consolidation/integration which should be explored. Community mental health and addictions services provided to at least 55,946 clients by 34 LHIN-funded agencies. Data to support accessibility and quality are limited. 10

12 HNHB has fewer family physicians per population than the Ontario average, but residents report similar levels of contact with medical doctors. Some areas within the LHIN have significantly fewer family physicians, which suggests potential access pressures in smaller communities. There is variance across sub-lhin areas in access to primary care physicians. For instance, Hamilton has high access whereas some other areas do not. There are fifteen Family Health Teams (FHTs) in HNHB LHIN. There is at least one FHT in each sub- LHIN area, including a FHT specifically for the First Nations community in Ohsweken. Uptake of CHCs and new models of primary care delivery are high in HNHB LHIN. There is high enrolment to new primary care models among HNHB LHIN residents (primarily attributable to the broad reach of the Hamilton FHT, which is the largest in Ontario) and there are 7 CHCs operating in 3 of the sub-lhin areas. Hospital Services The Environmental Scan includes an examination of utilization of inpatient hospital services for HNHB LHIN hospitals and HNHB LHIN residents. Inpatient hospital services include acute care (including ALC), acute mental health, rehabilitation and complex continuing care. Analysis of ALC and market share is also included. The HNHB LHIN has ten hospital corporations across 21 sites for a total of 3,384 beds1. Nine hospital corporations operate acute care beds. Residents of HNHB LHIN account for 14.1% of all inpatient days in Ontario, while comprising 10.5% of the population of the province. The two hospitals with the longest ALOS are the two smallest hospitals in the LHIN (Haldimand War Memorial and West Haldimand General). ALOS for HNHB LHIN residents (6.3 days) is slightly higher than the province (6.1 days). 1% 1% 3% 3% 9% 9% Share of Inpatient Separations by Hospital, % 29% Hamilton Health Sciences (29%) Niagara Health System (23%) St. Joseph's Healthcare Hamilton (16%) Brant Community Healthcare System (9%) Joseph Brant Memorial Hospital (9%) 16% 23% West Lincoln Memorial Hospital (3%) Norfolk General Hospital (3%) Haldimand War Memorial Hospital (1%) West Haldimand General Hospital (1%) Hospital outside of HNHB LHIN (7%) In 2010/11, there were 135,052 ALC days in HNHB LHIN hospitals, representing 18.0% of total inpatient days. The number of ALC days has declined at every hospital since 2008/09; nearly 30% overall. Most patients in acute beds waiting for an ALC placement are awaiting discharge home with home care; these patients tend to remain as ALC patients for long periods of time. 11

13 22.3% 20.0% 23.6% 25.2% 21.5% 18.1% 16.9% 15.8% 18.3% 18.4% 18.7% 17.5% 15.5% 15.6% 15.3% 14.9% 17.9% 21.7% 17.1% 16.9% 16.4% 17.3% 17.3% 16.3% 12.5% 11.9% 12.5% 12.2% 13.1% 13.6% 14.3% 17.1% 14.0% 16.0% HNHB Strategic Health System Plan: Current State Synopsis HNHB LHIN Acute ALC Rate (DAD) MLPA 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% % of ALC Days (MLAA) (DAD) Target HNHB hospitals provide nearly all of the inpatient services received by residents of the LHIN. Only 7.0% of all inpatient separations are provided by hospitals outside the LHIN, with slightly higher levels of outflow for mental health and rehabilitation patients. In 2011/12 there were 224 inpatient rehabilitation beds (including 15 temporary beds) at 5 locations sites in HNHB LHIN hospitals. Nearly 70% of rehabilitation beds are located in Hamilton; over half of the LHIN total are part of Hamilton Health Sciences Centre. HNHB LHIN hospitals provide 90% of the inpatient rehabilitation used by residents of the LHIN, a slightly lower rate than for all inpatient acute care services. Inpatient rehabilitation is a specialized resource that is largely concentrated in the two teaching centres and one specialized non-acute hospital (Hotel Dieu Shaver, St. Joseph s Healthcare and Hamilton Health Sciences). Complex care resources are widely dispersed within the LHIN; CCC is provided by all HNHB LHIN hospital corporations. There are currently 659 CCC beds in the LHIN, with a plan to reduce that number to 628. The case mix index for all LHIN hospitals is 1.07, suggesting that hospitals in the LHIN are treating patients that are relatively more complex. Ambulatory Care This section examines ambulatory care (clinic and same day surgery) and emergency department utilization at HNHB LHIN hospitals. There were over 400,278 ambulatory care visits / day surgery cases in HNHB LHIN hospitals in 2010/11. St Joseph s Health Care System in Hamilton had the greatest share of same day surgery of the LHIN (22.9%) of all HNHB LHIN cases. The nature of ambulatory care services varies substantially by hospital, with larger hospital corporations capturing a large share of same day surgery. Any planning related to ambulatory care should recognize the different areas of clinical focus, critical mass requirements to ensure quality of care and needs of various communities. Emergency Department (ED) activity is widely distributed at many hospitals sites. HNHB LHIN hospitals treated 604,258 Emergency Department visits in 2010/11, with 11 hospitals reporting over 30,000 annual visits. The ED at St. Joseph s Hamilton has highest volume and it represents 9.1% of LHIN volume. 12

14 Apr-08 Jun-08 Aug-08 Oct-08 Dec-08 Feb-09 Apr-09 Jun-09 Aug-09 Oct-09 Dec-09 Feb-10 Apr-10 Jun-10 Aug-10 Oct-10 Dec-10 Feb-11 Apr-11 Jun-11 Aug-11 Oct-11 Dec-11 Feb-12 ED LOS (Hours) HNHB Strategic Health System Plan: Current State Synopsis The median LOS for HNHB LHIN hospitals ranged from 3.0 hours to 3.3 hours while the median LOS for all hospitals in the province ranged from 2.7 hours to 3.0 hours. ED LOS (90th percentile) for HNHB LHIN hospitals has been consistently greater than for all Ontario hospitals from April 2008 to February The HNHB LHIN had the second longest 90 th percentile LOS in February 2012, after Toronto Central Total ED Length of Stay (Hours), April 2008 February th Percentile (HNHB LHIN) 90th Percentile (Province) Among top 10 hospital sites with the longest LOS (Feb 2012), half were located in HNHB LHIN. Two of 3 worst performers were HNHB, with 90th percentile LOS more than twice that of the province. Four percent of all HNHB LHIN emergency department visits lasted longer than 24 hours. Top 10 Sites with Longest ER LOS 90th Percentile LOS (hours) University Hospital (South West) Welland Hospital Site (HNHB) Hamilton General Hospital (HNHB) Ottawa Hospital General Campus Ottawa Hospital Civic Campus (Champlain) St. Catharines General Site (HNHB) Kingston General Hospital (South East) Joseph Brant Memorial Hospital (HNHB) Toronto General Hospital (Toronto Central) Juravinski Hospital (HNHB) Ontario

15 Health Expenditures HNHB LHIN is one of the most well-funded LHINs in terms of absolute dollars allocated but it is at the median of Ontario LHINs on the basis of per-capita funding. HNHB LHIN ranks 7th in terms of per capita spending overall and ranks among lowest in terms of per capita spending on Community Mental Health & Addictions and Community Health Centres; third highest for Long-Term Care Homes. Based on per capita spending and funding, the HNHB LHIN has a relatively strong focus on long-term care homes relative to other LHINs, as it receives the most funding among all LHINs for Long Term Care Homes and Community Care Access Centres. CMH (5) Assisted Living (3) CSS (2) CCAC (1) Long Term Care Homes (1) CHC (4) Funding Allocation and (Rank), 2011 Addictions Program (4) Operation of Hospitals (2) Acquired Brain Injury (2) Operation of Hospitals: $1,789 Long Term Care Homes: $432 Community Care Access Centres: $246 Community Support Services: $44 Assisted Living in Supportive Housing: $24 Community Health Centres: $24 Community Mental Health: $50 Addictions Program: $14 Acquired Brain Injury: $7 There are fewer family physicians but more specialist physicians per 100,000 population in the HNHB LHIN, compared with the provincial average, potentially reflecting limitations in access to primary care for some of the residents of the LHIN. 14

16 Performance Performance is examined in five domains: overall MLPA results, accessibility, appropriateness, effectiveness and safety. A number of indicators are discussed within each domain. Performance results are mixed. Performance results vary from quarter to quarter e.g. cardiac bypass and cancer surgery. Rates of influenza immunization, mammography, cervical cancer screening and caesarean section delivery are all similar to provincial rates. HNHB LHIN is experiencing challenges in achieving some of the targets as set out in the Ministry LHIN Performance Agreement, including targets related to Alternate Level of Care (ALC) and emergency room. The HNHB LHIN ranks first in the province for wait times for all scheduled Percutaneous Coronary Intervention (Angioplasty). HNHB s targets for cardiac and cancer surgery are aggressive, and while HNHB is not meeting these targets, their performance continues to be above the overall provincial target. In diagnostic imaging, MRI and CT wait times have been trending downwards since November This reflects the implementation of a quality improvement plan for diagnostic imaging addressing efficiency, appropriateness, capacity, and wait times. The percentage of ALC days in demonstrated improvement from a starting point of 17.88% to a low of 12.94% in the first quarter (the lowest rate reported since 2007). A focused strategy has resulted in the successful discharge of 169 individuals which accounted for over 30,000 ALC days in the third quarter of Age-Standardized Hospital Rates for Ambulatory Care Sensitive Conditions (per 100,000) NORTH WEST NORTH EAST ERIE ST. CLAIR HNHB SOUTH EAST NORTH SIMCOE MUSKOKA SOUTH WEST CENTRAL WEST ONTARIO CHAMPLAIN CENTRAL EAST TORONTO CENTRAL WATERLOO WELLINGTON MISSISSAUGA HALTON CENTRAL Hospitalization rates for ambulatory care sensitive conditions in HNHB (325 per 100,000 population) are higher than the provincial average (278 per 100,000 population). Admissions for ACSC vary by sub-lhin geography, with the highest rates observed among residents of Brantford and Fort Erie. The lowest rates were observed for residents of Burlington. HNHB LHIN is an average performer in terms of the rate of ED visits that could be managed elsewhere and is ranked eighth out of 14 LHINs. The share of HNHB residents that receive surgery for hip fracture within 48 hours of admission (80.8%) is higher than the provincial average (77.8%). HNHB ranked 6th among the LHINs. HNHB LHIN has the highest asthma readmission rate among Ontario LHINs. Acute Myocardial Infarction (AMI), hysterectomy, and prostatectomy readmission rates are similar to the province. 15

17 Provider Survey Summary 16

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19 Table of Contents Provider Survey Summary 16 Purpose 18 Approach 18 Findings 19 Demographics 19 Values 20 Priority Populations 20 Resource Allocation 21 Strategies to Improve Access and Coordination 22 Strategies to Enhance Value for Money 24 Summary 24 17

20 Purpose A survey was designed to elicit the perspectives of LHIN funded and non-lhin funded providers on both the current and future state of health services in the HNHB LHIN. The purpose of the survey was to inform the future state design, identify values and principles that should drive decision-making, and identify areas of priority for the LHIN to consider. Approach The survey was targeted across sectors (i.e., Community Health Centres, Community Mental Health and Addictions, Community Support Services, Community Care Access Centre, Hospitals, Long-Term Care, and Non-LHIN funded providers) at the executive-level. Recipients were selected by the LHIN to complete the survey, and contact information was provided to PwC. Survey recipients included senior leadership at: 10 Hospitals 1 Community Care Access Centre (CCAC) 25 Community Mental Health and Addictions Agencies 7 Community Health Centres 85 Long Term Care Homes 56 Community Support Services (CSS) 32 Non-Health Service Providers The survey was built and administered by PwC using Vovici, an electronic survey tool. The survey consisted of eleven mandatory close-ended questions and one optional opened-ended question (the responses to the open-ended questions are not within the content of this report), in the following five categories: Values Trade-Offs Access Coordination/ Integration Value for Money The survey was launched on March 27, 2012 and closed on April 13 th (See Appendix A: Provider Survey for survey questions and potential responses). Three reminders were issued to maximize the response rate. The survey was sent to 216 individuals and 155 responded (72% response rate). 18

21 Findings Demographics The graphs below indicate the responses by sector and sub-lhin area. By sector, the majority of respondents were from Community Support Services (31%) and Long-Term Care (34%). By sub-lhin area, the largest number of responses were from Niagara (59), and Hamilton (50). What Sector Best Reflects Your Organization? Community Health Centre (7, 5%) Community Mental Health and Addictions (20, 13%) Community Support Services (48, 31%) Community Care Access Centre (1, 1%) Hospital (10, 6%) LongTerm Care (52, 34%) 10 1 NonLHIN Funded Provider (17, 11%) What Sub-LHIN Area Does Your Organization Predominantly Serve? Hamilton (50) Niagara (59) Haldimand (22) 24 Brant (24) Burlington (10) Norfolk (14) LHIN-Wide (15) 19

22 Values Respondents were asked to rank the top values that should guide transformation. Both at an aggregate and sub-lhin level, the majority of respondents selected: 1. Person-centred (147/155) 2. Seamless service provision (95/155) 3. Equitable access to services (91/155) None of the sub-lhin areas prioritized contributes to system sustainability or value for money as values that should guide transformation. Values to Guide Transformation 1. Person-centred 2. Optimizes existing provider expertise in the LHIN 3. Builds on existing relationships/ partnerships 4. Evidence-based 5. Outcomes oriented 6. Shared accountability for outcomes 7. Seamless service provision 8. Contributes to system sustainability 9. Equitable access to services 10. Value for money Priority Populations Respondents were asked to select five priority populations for the LHIN to focus its health system transformation and care coordination efforts on. The table below outlines the priority populations selected by the majority of total respondents. At a sector-level, each sector prioritized the same populations, with the exception of Frequent Hospital/ED Visits, which was prioritized by all sectors for health system transformation except Community Health Centres. Priority Populations 1. Broad Population 2. High Risk Seniors 3. Mental Health and Addictions 4. Low Volume/ High Cost 5. Frequent Hospitalization/ ED Visits 6. End of Life/ Palliative 7. Infant/ Youth 8. Population with Barriers to Access 9. Population with Complex Medical Conditions Health System Transformation Focus for Care Coordination Efforts 1. High Risk Seniors (141/155) 1. High Risk Seniors (144/155) 2. Mental Health & Addictions (129/155) 2. Mental Health & Addictions (130/155) 3. Complex Medical Conditions (120/155) 3. Complex Medical Conditions (123/155) 4. Frequent Hospital/ED Visits (113/155) 4. Frequent Hospital/ED Visits (111/155) 20

23 Resource Allocation Respondents were asked a series of questions regarding funding allocation across sectors. As depicted in the following graphs, all sectors (including hospitals) suggested a decrease in funding to hospitals. All other sectors (excluding hospitals) allocated the largest share of funding increases to themselves. Community Mental Health and Addictions was allocated one of the largest increases in the funding reallocation. When respondents were asked to allocate a potential increase and decrease in funds, Community Mental Health and Addictions received one of the greatest percentages of additional funding and the lowest percentage for reduced funding. Current Allocation of LHIN Resources ($100) Suggested Allocation of LHIN Resources ($100) Hospital (68 to 51) LTC (16 to 19) CCAC (9 to 10) CSS (3 to 9) CMHA (2 to 7) CHC (1 to 4) Legend: CCAC = Community Care Access Centre, CHC = Community Health Centre, CMH&A = Community Mental Health and Addictions, CSS = Community Support Services, LTC = Long Term Care, Non-LHIN Funded = Non-LHIN Funded Providers. 21

24 Strategies to Improve Access and Coordination Respondents were asked to prioritize strategies to improve access, and to improve transitions between hospital and home. Strategies to Improve Access 1. Where cost effective and safe, more health care services should be provided at home. 2. The use of telemedicine should be expanded. 3. Optimize health care workers roles and productivity. 4. Expand the range of services and professionals currently offered in primary care. 5. Transition additional inpatient hospital services to an outpatient setting. 6. Strengthen the relationship between hospitals and community providers to enable more timely patient transitions. 7. Consolidate the provision of specialized care into centres of excellence in hospital or free standing clinics. 8. Sharing of evidence-based care pathways, processes and training should occur across organizations in order to optimize standardization of care and reduce variability. 9. Focus and target funding to programs and services that address the population with high priority health needs. 10. Facilitate the integration of program and services that will result in more direct care. Strategies to Improve Transitions 1. Transportation to Medical / Health Appointments 2. Telehomecare (e.g., Follow-Up Phone Calls from Heart Failure Clinics) 3. Ontario Telemedicine Network (OTN) 4. Mobile Health Teams (e.g., Nurse Led Outreach Programs, Psycho Geriatric Outreach Teams, Rapid Response Nursing Teams) 5. Assisted Living / Supportive Housing 6. Transitional Support Services (e.g., Programs Like Assess & Restore / Convalescent Care That Enable Patients to Go Home, as Opposed to Long Term Care 7. CCAC Case Management Services (In Emergency Departments, Hospitals, Community and Primary Care Settings) 8. Home Set Up (e.g., Stairs, Doorways, Equipment) 9. Home-Based Health Services (e.g., PSW, Nursing, Therapy Services) 10. Specialized Outpatient Clinics (e.g., General Internal Medicine Clinics, Heart Failure Clinics) 11. Congregate Care Settings (e.g., Nursing Clinics, Rehab Centres) 12. Care Coordinators / Navigators 22

25 The following table depicts the priority strategies selected by the majority of respondents: Improve Access Provide more services in the home (121/155) Strengthen relationship between hospital & community (110/155) Facilitate integration of services (100/155) Target populations with high priority needs (94/155) Optimize roles and productivity (82/155) Improve Transitions Home-based health services (116/155) Transitional support services (106/155) Assisted living/ supportive housing (104/155) Mobile health teams (99/155) 23

26 Strategies to Enhance Value for Money Respondents were asked to prioritize strategies to increase system efficiency and effectiveness. Overall, the top five strategies to increase system efficiency and effectiveness selected by the majority of respondents were: 1. Maximize scope of practice for health service providers 2. Community based health service integration by geography 3. Increased accountability for client/system outcomes 4. Enhanced use/sharing of evidence-based practice Priority Strategies to Increase System Efficiency and Effectiveness 1. Clinical program integration 2. Community based health service integration by geography 3. Community based health service integration by sector 4. Back office integration 5. Maximize scope of practice for health service providers 6. Enhanced use/sharing of evidence-based practice 7. Increased accountability for client/system outcomes 5. Clinical program integration Priority Strategies to Increase System Efficiency and Effectiveness Maximize scope of practice for health service Community based health service integration by Increased accountability for improved client/ Enhanced use/sharing of evidence-based Clinical program integration Community based health service integration by Back office integration Weighted Rankings Sectors varied significantly in their selection. The only strategy that was prioritized by all sectors was maximize scope of practice. The only strategy that was not prioritized by any sector was back-office integration. Summary The provider survey was designed to elicit the perspectives of LHIN-funded and non-lhin funded health service providers on both the current and future state of health services in the HNHB LHIN. Through the use of an electronic survey tool and timely reminders from both the LHIN and PwC, a 72% response rate 24

27 was achieved. Response rates differed by sector, and sub-lhin area. This may be attributed to the level of distribution of service providers across the LHIN, and should inform the interpretation of survey responses. Organized by the five question categories (values, trade-offs, access, coordination/integration, and value for money) the survey findings were presented at an aggregate level, and by sub-lhin area/ sector when meaningful for interpretation. Overall, the survey achieved its intended purpose to elicit input from HNHB health service providers on the identification of values and principles that should drive decision-making, and identification areas of priority for the LHIN to consider. 25

28 Leading Practice Research Summary 26

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30 Table of Contents Leading Practice Research Summary 26 Purpose 28 Approach 28 Comparative Analysis 30 Henry Ford Health System 30 Kaiser Permanente 31 Veterans Affairs 32 Australia 33 United Kingdom National Health Service 34 Implications 35 Organizational Overview 35 Access 35 Priority Populations 36 Quality 37 Value for Money 37 27

31 Purpose A jurisdictional scan was conducted to gather information on strategies being utilized in other organizations/countries to improve access to, and integration of, efficient and effective health services. This research was utilized to inform the future state design with evidence-based initiatives, designed to address similar challenges that HNHB is facing. Approach In determining the regions on which to focus the leading practice review, 10 international jurisdictions were examined at a high level: Henry Ford Health System, United States Queensland, Australia Intermountain Healthcare, United States New South Wales, Australia Kaiser Permanente, United States National Health Service, United Kingdom Veterans Affairs, United States Norway Japan Sweden Each of the ten jurisdictions was evaluated according to the following ten criteria: Population health based; Enhances the patient journey - quality and access; Value for money; Focus on rural; Innovative / leading approach; Integrated systems approach; Role of Primary Care; Relationship between regional programming and local service delivery (low volume, high complexity programs vs. high volume, low complexity programs); Aboriginal / cultural/ ethnic populations; and Seniors / Chronic Disease Management. Based on input from HNHB LHIN, the following 5 jurisdictions were selected for a more in-depth review: Henry Ford Health System, United States Kaiser Permanente, United States Veterans Affairs, United States Australia National Health Services, United Kingdom The research was conducted to understand the system and successful strategies for the identified priority populations of: high risk seniors, mental health and addictions, low-volume high cost, frequent 28

32 hospitalizations/emergency Department visits, end of life/palliative care, infant/youth, barriers to access (e.g., rural, Aboriginal, Francophone), and multiple complex medical conditions (chronic disease). The section includes a comparative summary of each of the jurisdictions followed by an analysis of the implications for the following components: Organizational Structure (Overview of Jurisdiction), Access, Priority Populations, Quality, and Value for Money. 29

33 Comparative Analysis Henry Ford Health System Key Points US Henry Ford Health System (HFHS) Overview Nationally recognized integrated health system serving South East Michigan. Comprised of: Medical Group (physicians); Health Alliance Plan (health insurance); Physician Network (physician community); Hospitals; Community Care Services; and Behavioural Health Services. Community partnerships include: Institute on Multicultural Health (examine/create solutions for healthcare disparities) and School- Based Education Program (health care access at school). Hard hit by the economic recession loss of health insurance income and high number of uninsured patients. Access Vertically integrated system (7 hospitals, community health services, and home health care). Developed a successful stratified approach to primary care with patient input targets appropriate intensity of services based on patients care needs. Priority Populations Developed award-winning approach to chronic disease: the Chronic Care Excellence Initiative. Emphasizes a pro-active approach to empowering individuals to manage their own health needs. Developed a highly successful initiative in collaboration with patients to eliminate suicide by redesigning depression care. Quality/ Value for Money Highly acclaimed for its focus on quality, and has been recognized by multiple organizations. Utilizes a performance reporting system tied to its strategic framework. Indicators include: financial performance, growth, turnover, patient satisfaction, quality and safety. Office of Clinical Quality and Safety system-level coordination of quality /infection control initiatives. Action-oriented quarterly Quality Forums are broadly attended by leadership from all HFHS organizations. Annual Quality Expo provides opportunities for staff to showcase initiatives, and celebrate quality. 30

34 Kaiser Permanente Overview Key Points US Kaiser Permanente (Kaiser) Largest non-profit, integrated health care delivery system in the US operating in 9 states. Comprised of: Kaiser Foundation Health Plans (health insurance); Kaiser Foundation Hospitals (16 hospitals/ 533 out-patient facilities); Permanente Medical Group (Kaiser physicians); and National Functions (administration). Access Closely integrated primary, secondary, and hospital care through integrated care pathways and electronic medical records. Comprehensive and multifaceted approach for chronic disease management (evidence-based guidelines, primary care led teambased population care, emphasis on self-management, Chronic Care Model s stratified approach to integrated care, etc.) Priority Populations Recognized by the Institute for Healthcare Improvement for its evidence reducing readmissions, the Chronic Care Coordination Model emphasizes multidisciplinary care, needs-based care plans, and seamless patient communication. Partnered with the Alzheimer s Association to develop an initiative to improve quality of care for patients with dementia (care-paths, coordination, education, supportive care, etc.) Developed an inter-disciplinary, home-based system of care for palliative patients. Emphasizes the integration of palliative care with curative care earlier in disease progression. Quality/ Value for Money Top-ranked health care organization for the National Committee on Quality Assurance s Quality Compass. Successfully implemented a national performance improvement system to mitigate quality variations. The system includes uniform quality measures for all providers, organization-wide performanceimprovement skill development, and support for quality initiatives. Developed evidence-based capabilities for performance improvement: leadership priority-setting, system s approach to improvement, measurement capability, learning organization, improvement capacity, and a culture of improvement. 31

35 Veterans Affairs Key Points US Veterans Affairs (VA) Overview Largest integrated health care system in the US. Underwent significant structural and operational transformation transitioned from a centrally-based organization to a system of 22 regional networks. System was reengineered to create a seamless continuum of highquality patient care, utilizing community-based primary care system with access to specialty services. Access Integrated system consists of 152 hospitals, 807 community-based outpatient clinics, and 288 Vet Centres (counselling, outreach, screening, etc). Optimized primary care through the Patient Aligned Care Teams an inter-disciplinary team-based approach. To optimize access while reducing costs the VA emphasises community based care including: Community Based Outpatient Clinics, and Outreach / Mobile Clinics (primary care, mental health services, etc.) in rural/remote regions. Priority Populations Comprehensive, inter-professional home-based primary care is offered to urban/rural chronically ill Veterans. Mental health services offered co-located indistinguishably within primary care setting with walk-in appointment availability. Developed an MOU with the Indian Health Service to foster collaboration and resource sharing. Provide telepsychiatry services to Aboriginals on/near reserves in collaboration with Tribal Veteran Outreach workers (tribe members trained and employed by the VA). Robust service offerings for seniors spanning a broad continuum of needs, and maximizing choices for care options (includes home, community, and residential services). Quality/ Value for Money Performance contracts were developed for each of the VA s networks outlining the goals and uniform measures for quality, cost, and access. Each network s Quality Management Officer prepares and disseminates performance data. Each network is required to perform root-cause analysis on adverse events, and provide the data to the National Centre for Patient Safety. Program evaluation is embedded in all activities, and is supported by a Corporate Analysis and Evaluation Service to enable evidence-based decision-making. 32

36 Australia Key Points Australia Overview National health insurance scheme (Medicare) provides universal coverage (prevention, primary care, hospitals, long-term care, etc.) Private insurance provides additional benefits (including private hospital care, choice of specialists, ancillary health services, etc.). The Australian government plays a strong role in national-policy making, regulation, and provision of funding. States/territories administer health services (subject to intergovernmental and funding agreements). Example of reforms at the State level: o NWS reformed its system governance to enhance local decision-making, transparency and accountability by transitioning Local Health Networks into Local Health Districts. The new Districts have greater autonomy in planning and purchasing services for their populations. o QSLD is transitioning its Health Districts into Local Health and Hospital Networks. Networks will be more autonomous, and run by governing councils (accountable for performance and maintaining effective systems to meet community needs). Access Australia s Reform Commission and National Primary Care Strategy identified the need to enhance the primary care infrastructure. The government commit funding to establish GP Super Clinics primary care clinics with an expanded scope of services and a focus on integrated service delivery with an inter-professional team. Priority Populations Quality/ Value for Money The government is also creating Medicare Locals groups of health care professionals whose role is to improve service access, promote seamless care delivery, support after-hours care, identify/mitigate gaps in service, and support quality improvement. The Commission is also focusing on hospitals by increasing the number of subacute hospital beds, reducing Emergency Department wait times, and improving access for elective surgery. Australia s government supports a national standardized approach for the assessment and provision of care subsidies for seniors. The purpose is to provide comprehensive assessment for frail seniors and provide them with access to the most appropriate care. The Home and Community Care Program subsidizes community services with an aim to support individuals in their own home. Australia s National Mental Health Strategy aims to deinstitutionalize and mainstream services. The Reform seeks to provide better care for people with severe mental illness, enhance prevention and early intervention, encourage economic and social participation, etc. NSW developed the culturally competent Chronic Care Model for Aboriginal People to improve health service delivery and access by rural/remote Aboriginals at risk for chronic disease. The Australian Commission on Safety and Quality in Health Care reports on the quality and safety of care against national standards. The majority of health care organizations are accredited (including hospitals, general practices, and aged care facilities). 33

37 United Kingdom National Health Service Key Points United Kingdom National Health Service (NHS) Overview Largest publically funded health care system in the world. NHS services in the UK are funded centrally through national taxation, but are managed separately by England, Northern Ireland, Scotland and Wales. The NHS is divided into two components, primary care and secondary care. Each is managed through a series of trusts (Primary Care Trusts, Acute NHS Trusts, Ambulance Trusts, etc). The NHS is undergoing large-scale National Reform. Through the reform, the Trusts are being redesigned. A NHS Commissioning Board will report to the Department of Health, and will fund/oversee the Clinical Commissioning Groups (CCG s) (formerly Primary Care Trusts). The CCG s will be comprised of mostly GP s, and through a consortium will control the budget and commissioning of services. All Acute NHS Trusts will transition to Foundation Trusts (hospitals run autonomously by local managers, staff, and members of the public). Access Primary care is provided through general practitioners with registered patient rosters. Primary care serves as gatekeepers for specialty services, and has a close relationship with community services (typically located within a close proximity to GP offices). At the request of the NHS, Sir Ara Darzi developed a 5-10 year strategy to meet London s health care needs. Strategies to improve access included: extended access to primary care, outpatient settings for routine diagnostics, day case-settings should be used for routine procedures, rehabilitation should be provided at home, specialized inpatient care should be centralized into specialty hospitals, and specialists should provide outreach to minimize patient travel. Priority Populations Quality/ Value for Money The Partnership for Older People Projects (POPP) was designed to develop services for older people to promote their health, wellbeing and independence. A broad range of initiatives (146 in total) were developed targeting different need levels, and the nature of services offered. Initiatives were categorized as community-facing if the purpose was to reduce social isolation and exclusion and/or promote healthy living, and hospital facing if the initiatives aimed to avoid admissions and/or enable earlier discharge. Recommendations for long-term conditions (chronic disease) were also suggested by Sir Darzi s report: prevention and outreach to the most deprived, provision of a web of services around people with long-term conditions, proactive community care to avoid acute service utilization, integration of services should be improved and system-wide care pathways should be developed. Quality Reform move away from centrally-driven process targets to a relentless focus on outcomes and quality standards to deliver them. The NHS Outcomes Framework outlines the five domains utilized to determine success, which are linked to the National Institute for Health and Clinical Excellence quality standards. Indicators and outcomes are being developed by the Commissioning Board to reflect the quality standards. 34