Model of Health and Wellbeing. Evaluation Framework. Performance Management Committee

Transcription

1 Model of Health and Wellbeing Evaluation Framework Version 3.0 Performance Management Committee February 2015

2 Version control information Document version Author(s) Approved on: Approved by: Summary of changes for this version: 1.0 RDSSs Aug 2014 PMC Initial version 2.0 Arron Service February 2015 PMC PMC Feedback 3.0 Arron Service Final Version PMC Final Edits Table of Contents Model of Health and Wellbeing Evaluation Framework... 1 Version control information... 2 Table of Contents... 2 Background... 3 Purpose & Framework Components... 4 The Results Based Logic Model... 6 MHWB Domain #1: Team Based, Integrated and Coordinated... 7 MHWB Domain #2: Population Needs based MHWB Domain #3: Community Governed MHWB Domain 4: Accountable and Efficient MHWB Domain 5: Community Development Approach MHWB Domain 6: Anti oppressive and Culturally Safe MHWB Domain 7: Determinants of Health MHWB Domain 8: Accessible Glossary References P age

3 Background With evaluation and performance management playing a greater role in health care decision making, health service organizations need a method to demonstrate the value of their service models to their stakeholders. In the past, healthcare reforms were not always based on evidence and progress was often driven by political arguments or the interests of specific professional groups rather than by the results of sound evaluations (Watson, Broemeling, Reid & Black, 2004). Before we can demonstrate the value of our services, we need a common approach to describing the services we provide. At the provincial level, the common conceptual framework we use to describe our services is called the Model of Health and Wellbeing (MHWB). Figure 1. Model of Health and Wellbeing The role of the MHWB is to provide a common conceptual framework from which all services can be understood. Broadly speaking, the MHWB is based on a shared vision for the future: the best possible health and wellbeing for everyone. To achieve this, the MHWB revolves around eight domains that centres agree are critical components of the community governed primary health care, health promotion and community development programming we offer. Specifically, clients of our centres can expect that their care will be: 1. Interprofessional, integrated and coordinated 2. Anti oppressive and culturally safe 3. Accountable and efficient 4. Grounded in a community development approach 3 P age

4 5. Community governed 6. Based on the determinants of heath (DOH) 7. Population and needs based 8. Accessible With agreement and commitment to the common vision and the eight domains of the MHWB, the sector can move toward enhancing the evaluability of our model by developing an evaluation framework (the Framework). Although it is challenging to distill the services delivered by more than 85 unique primary health care organizations across the province into, first a single conceptual framework and then into a single measurement framework, this effort is critical in helping us understand what we are collectively attempting to achieve as a sector and will guide measurement of our progress along the way. Purpose & Framework Components With the recent revision of the MHWB, the Performance Management Committee (PMC) commissioned the revision of the Evaluation Framework (the Framework). The Framework is intended to support ongoing assessment and evaluation of our programs and services by providing a common starting point for more focused investigations. In order to conduct program evaluations on specific programs, investigators should use this sector wide evaluation framework as a first step in the development of more focused and detailed program based conceptual models and evaluation frameworks. The sectorwide evaluation framework is designed to be sufficiently generic enough to apply broadly across all programs and services. As a result, the Framework does not get into sufficient detail around any one single program for the purposes of evaluation and therefore should not be viewed as a program specific evaluation guide. For programs looking to evaluate their services, additional work will need to be completed at the program level to first, ensure programming is evaluable and anchored in a common conceptual framework and second, to identify appropriate indicators that might inform program outputs and outcomes. The current sector wide Framework will support these more focused evaluation efforts by providing information on our collective outputs and outcomes that we are all working towards, regardless of which program you support. All program specific evaluations should be able to identify outputs and outcomes from the sector wide Framework and use these concepts to drill down further to uncover specific indicators of outputs and outcomes that are meaningful within the context of their program. The Framework contains a series of discrete but associated components that can be used to evaluate the unique aspects of our MHWB. These components include the results based logic model (RBLM), evaluation questions, indicators (measures) and data sources appropriate to each indicator. 4 P age

5 The Results Based Logic Model Results based logic models linearly link resource inputs to activities performed, services delivered and outcomes achieved. In doing so, they identify the critical areas requiring monitoring (e.g., QI), evaluation and reporting. Deriving evaluation and performance measures from a common conceptual model of service (i.e., MHWB) improves the relevance of the (proxy) indicators and ensures good coverage of domains identified in the model. The results based logic model (RBLM) therefore serves an important function as a bridge between the conceptual (MHWB) and the operational (performance indicators and data entry manual). The RBLM was developed using previous logic models developed by the sector, consultation with sector decision makers, decision support specialists and centre staff with expertise in evaluation and performance management, the Treasury Board of Canada results based management accountability framework (2010), the results based logic model for primary care developed by the Centre for Health Services and Policy Research at the University of British Columbia (Watson, Broemeling, Reid & Black, 2004) and the Ontario Ministry of Health and Long Term Care primary care performance measurement framework (2013). The Evaluation Questions & Indicators A critical component of the Framework is the identification of strategic and overarching questions arising from the RBLM that are intended to guide evaluation activities and approaches. The following eight tables will provide potential evaluation questions and indicators for each of the eight domains of the MHWB. The evaluation questions and indicators were developed based on previous Community Health Centre (CHC) evaluation frameworks and the primary care evaluation literature. Each question will be associated with a number of indicators that are described in terms of indicator type (outcome=o and process=p), source of data, current use (at time of report) and a description of what is success? Process evaluation/measures Process evaluation examines the extent to which program implementation has taken place, the nature of the people being served and the degree to which the program operates as expected. Indicators of process are identified with a P in the following tables. Outcome (or Impact) evaluation/measures Evaluations of outcome can take on several levels of complexity. The most elementary level involves the assessment of the condition of those who have received the service; For example, are clients healthier? More challenging evaluations might attempt to demonstrate that receiving program services caused a positive change for the better (Posavac & Carey, 2010). Indicators of outcome are identified with an O in the following tables. Indicator Use Each indicator is identified as being in current use for particular reporting such as M SAA, others are categorized as possible if the data is available and others are future meaning that there may be potential to get this data and these provide ideas for continued work on assessing the outcomes of programs and services. 5 P age

6 Purpose Statement Highest Quality, People and Community Centred Health and Wellbeing Values Model of Health and Wellbeing Attributes Interprofessional, integrated and coordinated Commitment to health through the lens of determinants, community vitality and belonging, health equity and social justice Anti oppressive and Culturally Safe Accountable and Efficient Community Development Approach Community governed Based upon the Determinants of Health Population and Needs based Accessible Inputs Resources - Financial, Material and Human Community Knowledge Synthesis - Community and client input, Needs assessments, Environmental scans Activities Outputs Client and community driven health care programs, services and initiatives with particular focus on those who face barriers to health How do we deliver services? (i.e., 8 MoHWB Attributes) What services do we deliver? (e.g., primary health care with interprofessional teams, health promotion and community development) With Whom? (priority populations e.g., seniors, homeless, racialized) How Many? (Volumes) Direct Outcomes Reduced risk, incidence, duration and effects of acute and episodic physical, social or psychological conditions Reduced risk, incidence and effects of chronic diseases (e.g., diabetes, mental health & addictions) through health promotion Increased access for people who experience the greatest barriers Increased community partnerships Increased civic engagement and social capital Increased seamless delivery of services, appropriateness of time, place and interprofessional team through integration and coordination Increased community capacity building with empowered clients to address the determinants of health elements of their health needs Intermediate Outcomes Improved equity in access to CENTRE services by eliminating barriers and advocating for healthy public Improved capacity of communities to be involved in decision making about their health Reduced negative impact of SDOH on health and wellbeing of clients Longer term Outcomes Improved level and distribution of population health and wellness Improved functioning, health, resilience and wellbeing of Individuals, families and communities Improved Health Equity across Sectors 6 Page

7 MHWB Domain #1: Team Based, Integrated and Coordinated Definition: The provision of comprehensive primary healthcare services to clients by multiple healthcare professionals who work collaboratively to deliver care. The team is a collection of individuals who are interdependent in their tasks and share responsibility for outcomes. Team based care will be integrated and coordinated by ensuring that information flows easily both within the team but also as care is transitioned outside of the team to other community based agencies, secondary (specialists), tertiary (hospitals) and long term care services. Potential Questions Source Indicator Current Use What is success? 1.1 Is client information shared efficiently within Centres? Org or Staff Survey % of Centres reporting use of EHR to exchange health information with other providers over the past 12 months (P) Accreditation All health care providers share access to necessary client information 1.2 What factors facilitate health care providers working together to provide comprehensive primary care (scope of practice regulations, funding, training)? 1.3 Is there evidence of increased or appropriate use and support for interprofdohessional teams? CIHI Org or Staff Survey CIHI Staff Survey CIHI Client Experience Practice Profile % of Centres who report bidirectional electronic communication links with other HSOs over the past 12 months (P) % of Centre providers who report that their interprofessional team exhibits the characteristics of a highly effective interprofessional practice (O) Accreditation Health professionals are either co located or protocols / processes are developed to ensure a high level of integration Improved Client safety Formalized processes are developed to improve assessment and referral Increased access to teams by clients who are psychosocially complex Number of case conferences (P) Improved provider communications Improved client experience with accessing different team members Effective management of clients with diabetes (e.g., HA1c, retinal exam, etc.) (O) Number of clients accessing nonphysician/np provided services, that is, receiving more holistic care (P) Number of clients that access interprofessional teams, by provider type MSAA (Diabetes) MSAA (Diabetes) Improvement in management of clients with diabetes within the primary healthcare team Physicians and other health professionals better understand and appreciate the complementary role they can play in client care Client needs direct access to appropriate within team referrals 7 P age

8 1.4 Has the centre established practices that effectively utilize interprofessional teams? 1.5 Are team members working to full scope of practice (as per training and regulation)? Org Survey CIHI Client Exp. Survey Health Links Org Survey CIHI Provider Survey (P) Provider FTE per 100,000 population by type of provider (P) % of clients reporting that they (P): a) have access to a team b) are being managed by a team c) are satisfied with the team % of complex centre clients with coordinated care plans (P) % of centres reporting that they are making efforts to ensure providers are working to full scope of practice (O) (as appropriate) % of health care providers reporting that they are satisfied with the use of their skills by provider type (O) Increased access to interprofessional team providers Increased levels of satisfaction in both clients and providers Greater continuity of care for complex clients More seamless transitions for clients Increased number of providers working to full scope of practice Increased retention of staff 1.6. Is quality of work life acceptable to staff and providers? 1.7 Do clients experience continuity of care (e.g., coordinated and integrated)? Provider / staff Survey Provider Survey Provider Survey CIHI Client Experience Survey CIHI Provider Survey % of providers who report they were satisfied with the overall quality of work life over the past 12 months (O) % of providers who were satisfied with the duration of client visits over the past 12 months by provider (O) % of providers who had complete information (essential demographics and clinical) at the point of care, most of the time, over the past 12 months (O) % of clients who felt that unnecessary medical tests were ordered because the test had already been done, over the past 12 months (P) % of providers who repeated tests because results were unavailable, over the Increased staff work life satisfaction Improved provider satisfaction Health information is complete and follows the client throughout the health care system Decreased inefficiency of health system services Reduction in redundant testing due to lack of info availability 8 P age

9 1.8 Is there evidence that Centres improve communication between different levels of care? CIHI Practice Profile Practice Profile Health Links Practice Profile Health Links Practice Profile Provider Survey Client survey CIHI past month (P) Reduced number of 30 day readmissions (P) Primary care follow up within 7 days post hospital discharge (P / O) MSAA / QIP Improved community based health care Seamless transition between health services and sectors Improved client outcomes Improved timely access to specialty care Reduced time from PHC referral to specialist consult (P) # of specialist visits (P) Increased access to appropriate specialty care Reduced time from referral to home Improved timely access to specialty care care visit (P) % of ALC days (P) MSAA Improved access to appropriate care Provider satisfaction with coordination of care (O) % of Centres that can access reporting about the client following (P): a) consult b) emergency visit c) hospitalization % of eligible clients who report that they received case management services over the past 12 months include but not limited to (P): a) mental health b) cardiac care c) cancer care Improved communication to and from the centre and the ER, hospital and LTC Information technology used to facilitate the sharing of information Decrease duplication of services Reduced wait times for specialist services 9 P age

10 MHWB Domain #2: Population Needs based Definition: Clients and caregivers participate fully in their own care by goal setting and providing direction to services and programming. Communities are involved in directing, planning and governing centre services. Centres plan services and programs based on population and community needs. Potential Questions Source Indicator Current Use What is success? 2.1 Are clients actively Increased population needs based planning engaged in their care? 2.2 Are there process to obtain client, community and caregiver input regarding health care services and community programming? 2.3 How equitable are screening services to clients? Centre specific data HQO Client Survey Chart Review Program Review Org. Survey Org. Survey CI Tool % of centres who report that they received or collected information over the past 12 months about the characteristics of their catchment population that was used in planning (O) % of clients reporting involvement in care decisions # of policies in place that involve client consultation (P) # of program charters that demonstrate evidence of community needs assessment (O) # of PDG developed based on community input (P) # of CIs developed based on community input (P) % of eligible clients who received influenza vaccinations by DOH (P) HQO QIP MSAA Relative success can be assessed through comparisons to other HQO QIP involved centres Policies that contribute to a culture of clientcenteredness Community needs informed planning and increase in service appropriateness Improved community engagement for planning Improved community involvement in initiatives Increased prevention of influenza % of eligible clients who received breast cancer screening by DOH (P) MSAA Increased secondary prevention of breast cancer % of eligible clients who received colorectal cancer screening by DOH (P) MSAA Increased secondary prevention of colorectal cancer % of eligible clients who received cervical cancer screening by DOH (P) MSAA Increased secondary prevention of cervical cancer % of eligible clients who participated Improved services that address DOH of 10 P age

11 in self management programs or received resources from the centre by DOH (P) % of female clients who are pregnant or postpartum who have been screened for depression % of clients with depression who were asked by a provider if they had thoughts about committing suicide or hurting others particular communities 100% of eligible clients screened for depression 100% of clients living with depression screened for suicidal ideation 11 P age

12 MHWB Domain #3: Community Governed Definition: A method of community engagement that ensures effective involvement and empowerment of local community representatives in the planning, direction setting and monitoring of health organizations to address the health and wellbeing needs and priorities of populations within local neighbourhood communities. Centres are not for profit organizations, governed by community boards made of up members of the local community. Community boards and committees provide a mechanism for centres to represent and be responsive to the needs of their local communities, and for communities to develop democratic ownership over their centres. Community governance contributes to the health of local communities through engaged participation contributing to social capital and community leadership. Potential Questions Source Indicator Current Use What is success? 3.1 How well do centre boards understand and represent local community needs? Org. Survey % of board members that reflect socio demographic characteristics of centre priority populations (O) 3.2 How do centre community boards ensure local accountability? CI Tool / social planning councils Org. Survey Org. Survey Org. Survey AOHC # of public meetings or other community engagement activities where centre governance is the focus (P) % of centres with current organizational accreditation (P) % of MSAA indicators at or above target (P) Clear role and responsibility for board involvement in QIPs (P) % of board members satisfied with their ability to direct centre programs and services around community needs (O) % of centres that sign accountability agreements with LHINs (O) Centre boards that reflect the diversity and complexity of the community Greater alignment between centre programs and services and community needs Improved accountability to communities, boards and public in general Improved capacity to benchmark Increased governance accountability in quality improvement programs (QIPs) Increased community board involvement with population needs based planning Demonstrated accountability to local funder 12 P age

13 MHWB Domain 4: Accountable and Efficient Definition: Centres are high performing efficient organizations that are accountable to their funders and the local communities served. Centres strive to provide fair, equitable compensation and benefits for their staff. Capturing and measuring their work are essential parts of delivering Primary Health Care. Developing and implementing meaningful indicators based on our Model of Health and Wellbeing allows for reporting to all funders about services and programs delivered as well as the outcomes that follow. Potential Questions Source Indicator Current Use What is success? 4.1 To what extent is there provincial adoption of the AOHC / org. survey % of Centres that have signed the MHWB charter Increased ownership by organizations to the Model MHWB? Org. Survey CI Tool % of Centres that report evidence of activities that address at least 4 of the 8 domains in the MHWB (P) Improved comprehensive programming and services 4.2 To what extent is the MHWB evaluable? 4.3 To what extent do Centres participate in research and evaluation (including QI) activity? PMC Research Inventory Research Inventory Measurement of at least one process and one outcome indicator from each of the 8 domains of the MHWB reported annually by centre (P) # of centres participating in formal research projects annually (P) # of published peer reviewed research articles involving Centres (P) Improved committee governance over accountability of sector Increased understanding of sector s work on DOH Improved data sharing capacity Increased community based participatory research among sector & academic partners Improved visibility of sector within research community 4.4 What is the per capita operational cost of providing PHC in Centres? PMC Org. Survey Economic analysis OHRS # of AOHC Letters of Support to researchers seeking grant funding (P) % of centre staff that report participation in at least one formal research or evaluation (incl. QI) project annually Average annual cost per client for PHC services delivered by (O): a) Physicians Increased recognition by researchers to engage sector Increased participation in research and evaluation projects Improved efficiency of care for clients 13 P age

14 4.5 How well do Centres reduce non value added activity (waste)? b) Nurse Practitioners c) All other services OHRS % administrative costs (P) MSAA Increased efficiency of services for clients Client survey HQO % of Centres over 12 months that increased their panel size without additional PCP funding (P) % of clients that report their appointments start on time or clinic wait times (P) % of Centres that have active registries of clients with multiple chronic conditions (P) 4.6 Safety % of clients in last 12 months who have had their medications reviewed and discussed, including those from other physicians (P) 4.7 How appropriate are mental health services? Org survey Client survey Org survey Centre has a process in place to ensure current medication and problem list is recorded in the EHR (P) % of clients indicating that they had a side effect from a medication that required a visit to a physician or emergency room (O) Is there an incident reporting system to identify and address serious or potentially serious adverse events? (P) % of clients living with depression offered an effective/appropriate pharmacological or non pharmacological treatment % of clients living with panic disorder or generalized anxiety disorder who are MSAA Increased access to primary health care services Improved client services Improved primary care for clients with multiple co morbidities Clients with complex med profiles receive annual med reviews Increase in the identification of actual or potential drug interaction problems leading to a reduction in adverse events. Potential for reduction in client medications by reducing unnecessary ones Reduction over time in the number of clients reporting such events Indicates centre capacity to systematically identify and prevent serious adverse drug events Effective and appropriate treatment options provided to clients living with depression 100% of clients living with panic disorder or generalized anxiety disorder offered effective 14 P age

15 offered one of the following: Psychological services / referral Pharmacological therapy Psychiatry referral or; A psychosocial support group and appropriate therapy 15 P age

16 MHWB Domain 5: Community Development Approach Definition: Services and programs are driven by community initiatives and community needs; the community development approach builds on community leadership, knowledge, and the lived life experiences of community members and partners to contribute to the health and wellbeing of their communities. Centres increase the capacity of local communities to address their community wide needs and improve their community and individual health and wellbeing outcomes. Potential Questions Source Indicator Current Use What is success? 5.1 To what extent is community development and health promotion activity informed by community needs? CIHI Alberta Health Services % of Centres that report they used info on the composition of their catchment population over the past 12 months to plan CD or HP activities (P) 5.2 What is the impact of community development activity? Community Initiative Resource (CIR) CIR CIR Evidence demonstrating that community development activity is informed by community needs (P) How does the approach and design of the CI account for the history and conditions in the community? (P) Which DOH do centre CIs address? (P) Increased number of HP and CD activities developed based on population based need. Increased appropriateness. Increased number of HP and CD activities developed based on population based need. Increased appropriateness. CD activity that is designed to address barriers to access within specific communities CIs that work toward improving social conditions and thereby health in our communities Identification of audience allows for assessment of impact with that audience CD activity that is strategically aligned with CIR Is the CI reaching the appropriate audience? (P) CIR Is the CI addressing a priority issue for the centre s clients or community? (P) that of the centre or sector CIR # of community partnerships (P) Increase in the # of relationships among Org. Survey partners sharing similar CD goals CIR # of CIs led by the community (P) Increased sustainability of CD CIR # of staff involved in community Increase in interprofessional involvement in development (P) CD Community CIW Greater level of community engagement and survey reduction in social isolation Increase in % of community members reporting participation in organized activities (O) 16 P age

17 Community survey Increase in % of community members with a sense of belonging to the community (O) CIW Greater level of community engagement and reduction in social isolation Org survey Increase in # of centre volunteers (P) CIW Larger volunteer group Client Increase in % of clients that vote (O) CIW Increase in community civic engagement survey CIR # of community initiatives that involve a community impact evaluation (P) Greater understanding of the impact of CD activity CIR What new/useful community Increase in strategic partnerships relationships were developed? (O) Were any new policies or community structures developed as a result of the CI? (O) Change informed by CD activity. CD becomes an approach to test community based social initiatives CIR Did community leadership or identity emerge? (O) Did community stakeholders perceive initial goals/impacts of the CI were achieved? (O) Has the CI developed a sufficiently broad base of supports and resources for it to be sustainable? (O) 5.3 Evaluability CIR Has a clear goal(s) been identified for the CI? (P) CIR CIR Is there an opportunity for staff and community members to reflect on the CI s development and progress (i.e., midstream eval)? (P) What evidence is being used to support the development and design of the CI? (P) Increase in community leadership capacity and potential for CD sustainability Greater level of engagement by community in determining impact of CD activity (participatory and empowerment eval) Increase in likelihood for project sustainability Increase in the use and development of evaluation indicators tailored for specific CD activity that are based on CD goals Increase in participatory and empowerment eval approaches Evidence based planning and design approaches can lead to greater program success 17 P age

18 MHWB Domain 6: Anti oppressive and Culturally Safe Definition: The notion that healthcare services will be provided in an anti oppressive and cultural safe environment is an idea that moves beyond the traditional concept of tolerance or cultural sensitivity (acceptable to differences) to an activist orientation that seeks to eliminate the root causes of social inequity such as historic power imbalances and systematic discrimination. It is particularly important for those involved in systems that deliver healthcare services to understand the role that western medicine has and can play in the oppression of various ethnic, gender, sexual orientation, economic, religious and political groups to ensure our organizations do not perpetuate such discrimination (e.g., eugenics). Potential Questions Source Indicator Current Use What is success? 6.1 Do centre staff reflect the social diversity of the community? Org survey % of staff that reflect centre priority populations (e.g., culturally, linguistically, etc.) (O) A staff complement that reflects the diversity of the community thereby reducing cultural barriers of access Org survey Evidence of culturally specific programming (P) Program offerings that reflect the cultural values of the communities we serve Practice Disproportionate increase in % of Fewer ethno cultural barriers to accessing 6.2 Is the centre organized to support a culturally safe environment (sociocultural competency)? profile Client survey OHRS Chart review Org survey Client Exp. Survey Client Exp. Survey clients from vulnerable groups (O) Increase # of clients being offered services in their language of choice / use of translation services (P) Increase in % of encounters that involve discussion of a social issue (rather than only medical) (P) Evidence of staff education on social inequity or cultural safety (P) % of clients reporting that they receive services that align with their beliefs and values stratified by DOH (O) Client satisfaction stratified by DOH (O) care Increase in efficiency and effectiveness of practices (also an indicator of access) Demonstrates commitment to the DOH Majority of clinical staff with this training suggests greater capacity to effectively address client concerns in these areas Equitable consideration of clients beliefs and values Equitable treatment of clients regardless of client socio demographic conditions 18 P age

19 MHWB Domain 7: Determinants of Health Definition: The living conditions we experience through our lifetime that are shaped by the distribution of wealth, power and resources at global, national and local levels. The determinants of health are mostly responsible for health inequities which can be seen in the unfair and avoidable differences in health status seen between people. Examples of determinants of health include income, education, employment, working conditions, early childhood development, food insecurity, housing, social exclusion, social safety network, health services, gender, race, culture and disability. In most cases these living conditions are imposed upon us by the quality of the communities, housing situations, work settings, health and social service agencies and educational institutions with which we interact. Potential Questions Source Indicator Current Use What is success? 7.1 How well do we understand our client s % of clients that had the following updated in the EHR in last 12 months: (P) DQAT Improved data quality determinants of health? Ethnicity Language most comfortable speaking with provider Self identified Francophone Gender Sexual orientation Newcomer (Year of arrival in Canada) Employment status Household Income # of persons supported by Income Chronic conditions / disabilities Housing status Org survey Evidence that community needs assessments are being used to inform program planning (P) 7.2 How well do our services address the determinants of health? Increase in the ratio of social v medical issues addressed during encounter (P) Ability to accurately describe client population in terms of the DOH Dynamic programming that addresses emerging community needs Equitable consideration of social issues, particularly within medical practice Org survey # of formal partnerships that deal Increased community capacity to address the CIR specifically with the DOH (P) DOH NOD % of PDGs focused on DOH (P) Evidence of importance of DOH within health 19 P age

20 7.3 Does health promotion and prevention address the DOH? Org. Survey CIR Org. Survey Practice profile (ICES) NOD Centre specific data Centre specific data Org. Survey CIR CIW Practice Profile (ICES) Client survey Client survey promotion practice % of CIs focused on DOH (P) Evidence that community capacity building efforts incorporate the DOH Rate of ODSP participation (P) Evidence that we serve those we intend to serve # of centre policies that address DOH (P) Evidence of advocacy for healthy public policy (P) Reduction of % of homeless / precariously housed clients (O) % of uninsured clients who received a new health card number over the past 12 months (O) % of vulnerable clients who rate their health positively (O) % of clients screened for: (P) Diabetes Asthma Congestive Heart Failure Coronary Artery Disease Mental Illness Addictions % of eligible clients that report receiving specific help or info on: (P) Demonstration of organizational commitment to addressing the DOH Evidence that organizations are working to change systems to address the needs of our clients Evidence that organizations are working towards addressing social issues which correlate with poor health outcomes Reduction in the % of clients without insurance, except for new clients Increase in clients positive perceptions of their own health despite the social challenges they face Increase in screening rates over time or maintenance of high screening rates 100% of eligible clients are being provided with health promotion support 20 P age

21 NOD NOD Centre specific data Tobacco use Eating habits Physical activity Alcohol use High risk sexual practices Unmanaged stress # of internal referrals to health promotion education sessions over 12 months (P) # and attendance to health promotion education sessions over 12 months (P) # of health promotion programs that involve an outcome evaluation (P) Demonstrates effective health promotion referral and recruitment within centre Demonstrates effective health promotion activities 51% of health promotion programs involve outcome evaluation 21 P age

22 MHWB Domain 8: Accessible Definition: Clients should be able to get timely and appropriate healthcare services to achieve the best possible health outcomes. Access is multidimensional: affordability, availability (i.e., getting care when a person needs it), geographic accessibility (i.e., location of the care provider relative to where the client lives), accommodation (e.g., expanded hours of operation; ability to obtain an appointment in a reasonable time frame) and acceptability (e.g., physical access to the clinic, culturally appropriate services, receiving care from the appropriate health professional). Access is only achieved if all its components are ensured. Potential Questions Source Indicator Current Use What is success? 8.1 How accessible are Physicians and Nurse ICES Reduced number of avoidable ED visits (O) QIP Reduction in CTAS scores of 4 or 5 (nonurgent) Practitioners? ICES Reduced unnecessary hospital QIP Reduction in unnecessary hospital admissions admissions (O) Org Data Increase # of complex clients with regular and timely access (O) QIP Reduction in barriers to access for those who generally experience barriers to care Org Data Acceptable 3 rd next available appointment (P) QIP Reduction in average length of time between request for an appointment and the 3 rd next available appointment Org survey % of MDs and NPs that report they MSAA Increase in panel size NOD are accepting new clients (P) HQO % of clients who report same day QIP 100% of clients who need same day access get 8.2 How accessible is the interprofessional team? survey access (O) % of clients accessing interprofessional teams by type of providers (O) MSAA (diabetes only) it Equitable accessibility to the entire interprofessional team Org survey # of extended or on call hours (P) Increase in availability of services Client % of clients that report easy access Potential Increase in availability of services survey during regular hours using phone or Org survey Org survey (P) % of centres that offer: (P) a) liaison with home care or; b) the provision of home care services % of centres that report they provide the following: (P) Potential Potential Demonstration of the navigator function by organizations 100% of clients can access a comprehensive primary healthcare team 22 P age

23 Acute episodic care Non urgent care (e.g., well baby care, prenatal care, chronic disease management) Prevention and health promotion services Primary mental health care Psychosocial services (e.g., counselling advice for physical / emotional / financial concerns) Case management for vulnerable populations Referral to and follow up care from specialized services Rehabilitation and reintegration services Nutrition counselling Dental services End of life care 23 P age

24 Glossary Active Client A registered client who has had either an individual service encounter or was involved in a personal development group session within the last three years. Access Point An Access Point refers to the health services that are defined by: less than 21 hours per week health services delivery, perhaps in conjunction with a partner delivery of a specific health service or bundle of services staffing originate from the main centre or satellite no reception or administrative support staff administration and infrastructure support by the main centre. Baseline information Information collected at the beginning of a project that serves as the basis for comparison with information collected later Business Intelligence Report Tool is a bilingual, centrally hosted system that consolidates data and enables data analysis. Cognos is the reporting tool used to access, create and/or run reports on CHC data in. Community Initiative A community initiative is a set of activities aimed at strengthening the capacity of the community to address factors affecting its collective health. Data Miner Data Miner is a report/decision support tool that is being used to access individual centre NOD data primarily being used for reporting. The data management coordinator will primarily use this tool. Electronic Health Record (EHR) An EHR is a full electronic patient record, with a variety of data input capabilities, health maintenace tracking, clinical decision support with alerts interoperable with internal and external systems including interfaces to multiple practice management systems that complies with 24 P age

25 principles of documentation. The elements of an HER are health information and data, results management, order entry/management, decision support, electronic communication and connectivity, patient support, administrative processes, and reporting/population health management. Indicators Indicators are specific measures indicating the point at which goals and/or objectives have been achieved. Logic Model A program logic model is a diagram that shows what a program is supposed to do, with whom and why. Logic models typically include information on a program s target population, intended activities, intended inputs and intended outputs, and intended outcomes. Target populations Target populations include the individuals, groups, organizations or communities for and with whom a program s services are designed. They are a program s priority population or its intended reach. Inputs Include resources dedicated to or consumed by the program. Examples are money, staff, and staff time, volunteers and volunteer time, facilities, equipment, and supplies. Outputs The direct products of program activities and are usually measured in terms of the volume of work accomplished (eg. # of counseling sessions conducted, # of people served) Outcomes Outcomes are a change that occurs as a result of a project or program and show the benefits or changes in people or groups participating in a program. Outcomes are often associated with impact evaluations. There are different levels of outcomes: short term, intermediate and long term. Mandatory Data This data is necessary for a record to be valid. The field cannot be blank. The validation rules will check to ensure that all mandatory data is recorded. If there is missing data, an error message will appear on the screen after attempting to save. 25 P age

26 NOD NOD is Nightingale on Demand, the current Electronic Health Record that is being utilized by NPLCs, CHCs, and AHACs. NORA NORA is the Non Operational Reporting and Analytics work stream; it is a group of interrelated projects to integrate data from multiple systems and provide participating organizations with a holistic view of operations and clients served. Ongoing Primary Care Client Ongoing Primary Care Clients (OPCC) are registered clients who receive ongoing primary care from a GP/NP. This group forms the denominator for the MSAA accountability reporting. Outcome (or impact) evaluation: assesses what your project has achieved Performance Management Committee The Performance Management Committee (PMC) is the authoritative source for performance management activities that support and enhance the full scope of the CHC Model of Health and Wellbeing. PMC makes recommendations and provide strategic guidance to the Strategy Group and CHC /AHAC Provincial ED Network on provincial level initiatives related to the setting of performance and data standards, sector wide reporting, decision support, quality improvement initiatives, research, and accountability agreements to support the provision of better quality of care that improves the health of individuals and their communities. In order to complete the variety of work plan deliverables, PMC has four sub committees: Standards; Research; Clinical Advisory; and Health Promotion and Community Development. Personal Development Group A Personal Development Group (PDG) is defined as a series of time limited or on going sessions conducted, facilitated or supported by internal or external staff, whose purpose is to effect changes in participating individuals behaviour, knowledge or attitudes. Groups may have a specific purpose (i.e. Process evaluation Assesses what activities were implemented, the quality of implementation and the strengths and weaknesses of the implementation Referrals 26 P age

27 A referral directs a client from a source health provider to a target health provider, recommending the type and and length of care required by the client in a secure and efficient manner. The referral management process includes creating, sending, revising, updating and responding to a referral. Required Data These data fields must be completed for Ministry reporting, where possible. Missing data in the required fields will result in incomplete/inaccurate Ministry/CHCs local MIS reports. There will be no error message on the screen if field left blank. Satellite Satellite is a permanent location where health services are delivered outside of the main centre, characterized by: regular operations (minimum of 21h/week); fixed, accessible location, secured through ownership, a lease or a written agreement ongoing staff its own administrative and infrastructure support Service Event The term used to describe an encounter with an individual client, a session for a personal development group and a monthly report for a community initiative. The term encounter is often also used to signify a service event. Services Provided Services provided are those list of actions undertaken: Case Conference This is the attendance at a scheduled meeting with other providers and/or family members and/or the client to discuss and develop a plan of care to benefit the client. Encounter under Services Provided case conference. Case Management / Coordination This is the provision of support, counselling, coordination, advocacy and/or life skills instruction to long term clients with complex issues. Encounter under Services Provided Case management/coordination. Consultation A consultation is when two providers discuss the service(s) or quality of care being provided to the client, and the details of the discussion is significant enough to be charted. 27 P age

28 External External consultation means to request or provide an opinion of/for an external provider. Encounter under Services Provided consultation external consultation. Internal Internal consultation means to request or provide an opinion of/for an internal provider. Encounter under Services Provided consultation internal consultation. Referral External External referral is defined as a referral of a client made to a provider/service outside the centre. This includes written referrals. Encounter under Services Provided external referral AND Referrals. Internal Internal referral is defined as a referral of a client made to a provider/service within the centre. This includes written referrals. Encounter under Services Provided internal referral AND Referrals. Cultural Interpretation A service provided by a CHC an interpreter (volunteer or paid by the CHC), is used to provide language interpretation during a contact between a provider and a client. This is a service and should be collected as such. The interpreter is not captured as a staff involved. Cultural interpretation alone does not warrant an encounter. Note: the language of contact is always the language the provider spoke while delivering the service. Target Populations Target populations are the priority populations as identified by broad organizational, CI and groups objectives. They are often related to sociodemographic characteristics of the target population. Validation Rules A set of rules applied to each encounter to ensure that the minimum mandatory data set has been completed. An encounter should not be saved until all of the validation rules have been met and the encounter is complete. 28 P age

29 References A Primary Health Care Evaluation System for Nova Scotia. Nova Scotia Department of Health [Internet] 2006 October;[cited 2012 August 23] Available from: Health Care Evaluation Report 2006.pdf Alberta Quality Matrix for Health: User Guide. [Internet] September 2005;[cited 2012 June 4] Available from: Canadian Institute for Health Information. Pan Canadian Primary Health Care Indicator Development Project [Internet];[cited 2012 June 4] Available from: CIHI & Statistics Canada. The 10 th Anniversary. The Indicators Project. Report from the Third Consensus Conference on Health Indicators.[Internet] 2009; [cited 2012 June 4] Available from: XWE_e.PDF Government of Canada, Treasury Board of Canada results based management accountability framework (2010). Available from: outils/polrmaf polcgrr eng.asp Hoffman, K. (2009). A Decision Support System for Community Initiatives: Background and Recommendations for Action: Final Report. Submitted to the AOHC. Ontario Primary Care Performance Measurement Summit. Proceedings Report. (2012). Ontario Ministry of Health and Long Term Care & the Canadian Institute for Health Information. Posavac, E.J. & Carey, R. G. (2010). Program Evaluation Methods and Case Studies (8 th ed). Prentice Hall, Upper Saddle River, New Jersey. Primary Health Care Evaluation Framework. Primary Care Branch, Alberta Health, November 2013: Evaluation Framework 2013.pdf Program Evaluation Framework. Primary care initiative [Internet];[cited 2012 Aug 23] Available from: Raphael, D. (Ed.). (2009). Social Determinants of Health: Canadian Perspectives. 2nd edition. Toronto: Canadian Scholars Press Incorporated. The IHI Triple aim [Internet]; [cited 2012 July 11] Available from: 29 P age