Health Access Thorncliffe Park. Proposal for Creating a Primary Health Care Home in the Community - EXECUTIVE SUMMARY. Thursday, December 18, 2014

Transcription

1 Health Access Thorncliffe Park Proposal for Creating a Primary Health Care Home in the Community - EXECUTIVE SUMMARY Thursday, December 18, 2014 Prepared by:

2 Executive Summary The Thorncliffe Park neighbourhood is growing much faster than other neighbourhoods in the City of Toronto and has become a leading destination for newcomers to Canada. An estimated 30,000 people live in this community of high and low- rise apartments today more than the population of most Ontario towns. With the highest birth rate in the city, Thorncliffe Park s burgeoning population is expected to continue to grow and change in the future. It has become evident that there are insufficient local health services given the population s size, complexity and diversity and that there are striking health care gaps. People who live in Thorncliffe Park are in poorer health than other Toronto residents. For example, there are higher rates of diabetes and mental health issues in Thorncliffe Park. High rates of ED visits for seniors and low screening and immunization rates further point to the lack of comprehensive primary health care. Social and economic conditions in the community such as high unemployment / underemployment, isolation, language and cultural barriers, overcrowded living conditions and the stresses of resettlement contribute to the neighbourhood s health challenges. In 2014, the Toronto Central (TC) Local Health Integration Network (LHIN) supported Thorncliffe Neighbourhood Office (TNO), Flemingdon Health Centre (FHC) and South Riverdale CHC to undertake a health care gap analysis involving some 100 residents and stakeholder groups the Health Care Gap Analysis for Thorncliffe Park. At the same time, the City of Toronto identified Thorncliffe Park as a top Neighbourhood Improvement Area. The Gap Analysis concluded that: there is a need for comprehensive, coordinated primary health care that is responsive to the populations unique health and social needs and integrated in the neighbourhood. The most pressing health care gap is that the vast majority of people (an estimated 70%- 80%) do not have a regular family physician or receive comprehensive primary health care. A minority of residents travel outside Thorncliffe Park for primary health care, but community members would prefer to receive primary care in their own neighbourhood. Within four months of tabling the Gap Analysis, the TC LHIN, TNO and providers began working on a community- driven blueprint for primary health care in Thorncliffe Park, under the umbrella, Health Access Thorncliffe Park. Immediate action has been taken to address two hot spots: maternal care and primary care for homebound seniors. Organizations have joined together to create the Thorncliffe Park Pregnancy Clinic within the neighbourhood. When the clinic opens on January 12, 2015, women in the program will receive care from the clinic s physician- nurse team, or be referred to a midwife or an obstetrician at Toronto East General Hospital or Sunnybrook Health Sciences Centre. Seniors Health Services Thorncliffe Park is a collaboration of Family Health Teams (FHT), Community Health Centres (CHC), the Toronto Central Community Care Access Centre (CCAC) and other providers to expand medical visits to homebound seniors. The first teams will be operational in January To develop the long- term primary care blueprint, approximately 800 Thorncliffe Park residents and 100 stakeholders were engaged through facilitated sessions, interviews and other means. A Council made up of health and community service stakeholders provided expert guidance and validation. 1

3 Reflecting the evidence and the perspectives of community members and stakeholders, the Steering Committee has defined a vision for a primary health care home in Thorncliffe Park. Health Access Thorncliffe Park is a caring place where people meet. a neighbourhood health hub that helps the community stay well and cares for people when they are sick. The Steering Committee proposes the following guiding principles and goals to achieve the kind of primary health care that would make a difference in this neighbourhood. Guiding Principles and Foundational Goals for the Primary Health Care Hub VISION Health'Access'Thorncliffe'Park'is'a'caring'place'where'people'meet.a'neighbourhood' health'hub'that'helps'the'community'stay'well''cares'for'people'when'they'are'sick.' GUIDING PRINCIPLES ACCESS Comprehensive,'con;nuous'and' ;mely'primaryhealthcarethatis accessibletoallthorncliffepark residents. INTEGRATED Primaryhealthcareisagateway toarangeofhealth,'wellness,'and' community'services.integra@on withallhealth,socialand communitysectorsisseamless. Primarycarephysiciansandother providerswork'together'todesign anddeliverhealthcare improvements. EFFICIENT Con;nuous'evalua;on'and reflec@veprac@cewillensurethat servicesmeetresidents needsand adaptastheneighbourhood changes. Comprehensiveprimaryhealth careclosebywillachieve measurable'outcomesfor ThorncliffePark spopula@onsand thehealthsystem. POPULATION'HEALTH Servicesareflexible'and'culturally' sensi;vesotheyrespondtoeverj changingpopula;onneeds. PATIENT''CLIENT+CENTRED Residentsaremeaningfully'and' con;nually'engaged'inthedesign anddeliveryofhealthcarefor theirneighbourhood. Mul;ple'strategies'and'pathways' areac@vatedtoreach'thorncliffe Park sculturally'dis;nct' communi;es. GOVERNANCE''ACCOUNTABILITY Goodgovernanceand accountabilityensuresthat community'and'pa;ent'needsand experiencesguide'decisions'and allpartnersareclearabouttheir rolesandsharethesame'goals. FOUNDATIONAL GOALS OPTIMIZE'HEALTH'OUTCOMES'FOR' PATIENTS''POPULATIONS Buildingonthepilotservices (PregnancyClinicandSeniors HealthServices),ThorncliffePark residentswillhaveaccesstoa' comprehensive'primary'health' care'home'thatprovidestheright care,attheright@me,andinthe rightplace. Ensurecon@nuouscareby integra;ng'with'other'sectors, withinandbeyondhealthcare. MEET'PATIENT''PUBLIC' EXPECTATIONS Improve'literacy'about comprehensiveteamjbased primaryhealthcaresothat residentscanfullypar@cipatein andbenefitfromhealthand wellnessservices. Enhancethecultural'competency' ofprimaryhealthcareandother servicesforcommunitymembers. SUPPORT'A'SUSATAINABLE'HEALTH' SYSTEM Makethebest'use'of'exis;ng' rela;onships'and'capaci;es'while' crea;ng'a'primary'health'care' hometomeetneeds,reducegaps andpromotehealthypeopleanda healthyneighbourhood. Health Access Thorncliffe Park Service Model The model will follow Barbara Starfield s primary health care framework: Primary Care is the level of a health service system that provides entry into the system for all new needs and problems, provides person- focused (not disease- oriented) care over time, provides care for all but very uncommon or unusual conditions, and co- ordinates or integrates care provided elsewhere by others. Residents emphasize that primary health care must be within walking distance and delivered at a central location or Hub. Given the diversity of the population, there must also be multiple access points. In addition to the comprehensive services at the main site, primary health care services will be brought to where people are through mobile teams, virtual health care and 2

4 portable hubs in a variety of settings including homes, apartment buildings, schools, places of worship and meeting places. In accordance with the Starfield framework, there will be mechanisms and infrastructure to effectively coordinate and integrate primary and other levels of health care, and community and social care. It is also envisioned that the Health Hub will be scalable so that it can serve a critical mass of Thorncliffe Park s population and, ultimately, be co- located with community and social services in one site. There will be two phases for the creation of the Health Hub: Phase 1 is the start up, which includes the establishment of enhanced primary health care services delivered by an interdisciplinary team out of an interim location. There will need to be an initial investment in infrastructure to support comprehensive, interprofessional primary health care and integration with community services delivered through TNO and other agencies. This phase will also involve building on relationships and services that are already available to the community and maximizing existing resources. Phase 2 is the transition to a comprehensive and fully integrated primary health care home on a single site. Multiple access points to primary health care and other services The neighbourhood- based primary health care system will require core infrastructure and capacity to ensure that services are integrated, efficient and accessible. These include: Clear and effective referral pathways Integrated information systems Cultural and language- specific health services Health education and literacy support Navigation and care coordination Every door is the right door 3

5 Services during extended hours and weekends Ability to identify and connect non- insured/non- OHIP populations with providers serving these populations Long- range health service planning capacity Strong capacity to engage community members and patients Community- Centred Governance and Accountability The Hub will be founded on a leading practice primary health care governance model. This will include a formal method of involving community members and reflecting community interest and diversity in the direction and stewardship of the organization. Another important consideration will be the engagement of primary care physicians and potentially other clinicians in governance and decision- making to promote clinical accountability. Core Primary Health Care Services The Steering Committee envisages that the Hub will deliver the following core primary health care services. The planning assumption is that the primary health care team will grow to an estimated 10 to 12 family physicians and four to six nurse practitioners when the new site is fully operational to be able to serve a critical mass of the population, particularly those without a regular primary care provider. Additional professionals will be incorporated including, but not limited to, nurses, pharmacist(s), social worker(s), dietician(s), mental health worker(s), a care navigator/care coordinator, health promotions/outreach professional(s), chiropodist(s), physiotherapist(s), and a health planner/informatics expert. Specialists will be made available through sessionals, case conferencing and other approaches. Key services to be delivered and supported by the Health Hub: Maternal and pediatric care Identification and referrals for medically complex children and youth Frail and high- needs seniors support Caregiver support Diabetes prevention and management Cardiovascular disease prevention and management Respiratory disease prevention and management Pain management Prevention and health promotion Cancer screening Immunization Mental health and substance use Sexual and reproductive health Dental and vision care Medication reconciliation Labs and imaging Capital The interim space will likely need to be renovated while the Health Hub site is being developed. It is estimated that the Hub space for the size of the interdisciplinary team and the scope of services would be at least 14,500 square feet. The site will need to be scalable and have an appropriate footprint to allow the primary health care Hub to serve more Thorncliffe Park residents over time and to house a community service hub in the future. 4