` Overview of the Toronto Central LHIN Sub-Region Quality Improvement Approach: East Version 1.0 July 2017 1
Table of Contents Background: Toronto Central LHIN sub-region planning approach 3 Starting point: Quality improvement 4 Planning exercises 4 Sub-region profiles: 4 Neighbourhood level profiles: 7 Prioritizing where to start: 9 Detailed analysis 12 Capturing human experience: No data without stories, and no stories without data 14 Summary of process taken: 16 Snapshot of sub-region initial opportunity areas: 16 Next Steps: Supporting Collaborative Quality Improvement Planning (C-QIPs) 17 Future Vision 19 2
Background: Toronto Central LHIN sub-region planning approach The Toronto Central LHIN has established 5 sub-region planning areas to serve as the focal point for population based planning, service alignment and integration, partnership building, and quality improvement. We recognize and celebrate the diversity of our Toronto communities and we acknowledge that the path to improving health will be different for the diverse communities and population groups throughout the City. By honing in on five smaller, more manageable geographies, we can look at communities on a neighbourhood by neighbourhood basis, and plan care more appropriately. In May and June of 2016, we held an inaugural cross-sector meeting within each sub-region planning area. The purpose of these meetings was to bring all types of providers together, with our common element being the communities and people that we serve. This group of local providers within a sub-region planning area is our Local Collaborative. Why are Local Collaboratives important? No one organization or individual has the full set of resources, expertise, and capacity to ensure the best possible outcomes physical, mental, and social for all individuals. It is incumbent on all service providers to work together in and across sectors to support the holistic wellbeing of communities. 3
Starting point: Quality improvement Sub-region Local Collaboratives are the foundation for: Local population-based planning (meeting local need); Local service alignment and integration (improving access and communication); Locally based partnership building (influencing social determinants of health); and, Local quality improvement (beginning with a health equity perspective). Taking a health equity perspective to quality improvement meant beginning by identifying neighbourhoods or groups of people that are not receiving care that they need in order to be as healthy as the broader population around them. From our Strategic Plan: Health Equity is a state of health system design in which the provision of health and health care services is proportionate to nee Planning exercises To achieve this, the 5 sub-region Local Collaboratives worked through a series of populationbased planning exercises throughout the fiscal year (2016/17). Sub-region profiles: As a starting point, the LHIN developed comprehensive sub-region profiles that included population demographics, health outcomes, and rates of health care utilization down to a neighbourhood level (see East example on our website: About the East ). These profiles were introduced to the Local Collaboratives as a resource for local planning, and formed the basis of the population-based planning exercises throughout the year. 4
SAMPLE OF EAST SUB-REGION SNAPSHOT: East Toronto sub-region overview: Highest proportion (22.9%) of children and youth (ages 0-19 years) in 2011 among the Sub- Regions and relative to Toronto Central LHIN. Thorncliffe Park has the highest proportion of children and youth (32.2%) among all the neighbourhoods in Toronto Central LHIN. Highest proportion of recent immigrants (arrived between 2006-2011) with top three countries being: Bangladesh (17.9%), Pakistan (11.7%) and Philippines (8.9%). Most heavily represented visible minorities relative to Toronto Central LHIN are South Asian and West Asian or Arab. Thorncliffe Park, Victoria Village Oakridge and Flemingdon Park have particularly high levels of marginalization. Health status: Highest rate of total hospital births to women aged 15-49 rate: 47.7/1000 women (2012/13 to 2014/15). Highest number of deaths (1,712) and second highest crude death rate (634.6/100,000 population) among sub-regions in 2011. Highest prevalence rate for all chronic diseases among the Sub-Regions for 20+ years (for COPD 35+ years) (FY 2014/2015). Primary care and other health service providers: 230 primary care physicians, with 16% in Community Health Centres and Family Health Teams. Some areas with very few primary care physicians. Neighbourhoods with the lowest levels of continuity of primary care include Thorncliffe Park (27.8%), Flemingdon Park (24.3%) and Taylor-Massey (23.3%). Michael Garron Hospital is the main hospital in the area. 10 Community Support Services, 5 Community Mental Health and Addictions agencies and 8 Long-term Care Homes. Health service utilization: 27% (25,430) of a total 94,279 Emergency Department visits were of low urgency 2015/2016. 13.5% of the total number of hospital inpatient days were designated as Alternate Level of Care. 5
SAMPLE OF DETAILED SUB-REGION PROFILE CONTENT: 6
Neighbourhood level profiles: In the first planning exercise ( A Walk around the Neighbourhoods ), analytics were presented at a neighbourhood level. A number of neighbourhoods were selected based on high utilization (ED, ALC, etc) and variance in health status (such as chronic disease) (see East example on our website: About our Neighbourhoods). In the East, the following neighbourhood profiles were reviewed: Thorncliffe Park, Taylor-Massey, Oakridge, and East End-Danforth. As part of this exercise, participants rotated across each individual neighborhood profile, reviewing a detailed demographic and health service profile for each neighborhood. Participants were asked: how the data aligned with their experiences, what additional questions it raised, and the potential impacts on future planning. 7
SAMPLE OF A NEIGHBOURHOOD PROFILE: 8
Prioritizing where to start: Feedback from this session was used to further analyze opportunities within the sub-region. The LHIN reviewed the detailed sub-region analysis to identify areas of greatest disparity and variance in health outcomes and refined the list of initial opportunity areas in partnership with a sub-region working group. The following list of opportunities was identified in the East: This list was reviewed with the East Local Collaborative in a final exercise where Local Collaborative participants prioritized which opportunities may be the most appropriate starting points for initial quality improvement efforts. A sample is provided below. The full list of opportunities can be found on our website (East Area of Opportunity Profiles). 9
As part of this exercise, participants were divided into small groups to evaluate the opportunities based on criteria considering the potential impact of focusing on the issue and the expected effort required to create improvements. The specific criteria were: Impact 1. This is a wicked problem 2. There is a measureable gap in performance that needs to be addressed 3. Impact can likely to be measured in the short-term (first year) 4. By addressing this opportunity area there is high potential to improve health outcomes (longer-term) 5. By addressing this opportunity area there is high potential to improve patient experiences Effort 1. Will require partnerships among multiple HSPs (>3) 2. Will require partnerships with non-lhin funded service providers 3. There are few existing efforts in place already that we can build on 4. Interventions would likely require no, or limited, new resources 5. There are proven or evidence-based solutions that we already know of that we can put in place For each of the opportunity areas the criteria were rated on a scale of 1 to 5 based on level of agreement with the statement, with 1 indicating strong agreement, 3 indicating neutral and 5 indicating strong agreement. Once all the opportunities had been evaluated by each group, the scores were totaled to assign ranks to each one (high score to low). The scores were then mapped onto the graph below: 10
Prioritization feedback was reviewed by the East working group and it was recommended that Oakridge be selected as the initial opportunity area for quality improvement: Opportunity to focus improvements in a concentrated group of 5 Toronto Community Housing (TCHC) high needs buildings (high rises and townhouse complexes) High density area Low continuity of services Estimated that 35-40% of residents have complex seniors Few providers in area; services not coordinated Issue of equity to access of services, including hospitals high use of Michael Garron services High rates of chronic diseases, ED visits, and MH admissions for some age groups It was acknowledged that each of the opportunities needs to be addressed, and each require relatively high effort with the potential for great impact. The objective of this prioritization exercise was to help identify the one or two that the Local Collaborative can start with, where the group is best positioned to focus its efforts at this time on an issue or area that can be reasonably expected to see a positive impact as a result. The intention is that over time each opportunity will be reviewed and addressed. 11
Detailed analysis With initial opportunity areas confirmed, the LHIN completed a deep dive analyses of each initial area. For the East, the Oakridge analysis includes the following: 12
SAMPLE OF DETAILED ANALYSIS TCH Buildings: There are 5 TCH high needs developments in Oakridge (Warden Woods, Woodland Acres North, Woodland Acres South, Bying Towers & Teesdale Pharmacy) which range in size from 168 units to 556 units and have a resident population ranging from 171 to 1,248 residents Residents in all buildings are multicultural and speak a variety of languages Woodland Acres North has the highest proportion of males and residents aged 25-58 Byng Towers is a building with 100% seniors aged 59+ Overall and MHA ED Visits: Overall, there were 2,473 ED Visits by residents of high needs TCH Buildings with the top 3 most responsible diagnosis chapters being 1) Symptoms, signs and abnormal clinical and lab findings (23%), 2) Injury and Poisoning (18%) and 3) Diseases of the Respiratory System (8%) There was a total of, 198 MHA ED visits (FY2014-15 to FY2015-16) for patients who had a valid health card number with a total of 93 unique patients. The rate of MHA ED visits was slightly higher for TCH buildings (69.3 per 1,000) compared to Oakridge overall (68.1 per 1,000) Almost half of the ED visits (46%) were from residents in Woodland Acres North which has only 211 residents Majority of ED visits were for ages 25-58 (74%) with a higher proportion of males than females overall A large majority of patients who visited the ED for MHA conditions had a family physician (72%) A large proportion (89%) of the visits were for CTAS levels 2 & 3 indicating that residents are presenting to the ED when they are really sick A large majority of MHA ED visits were discharged home (69%) and less than one quarter (23%) were admitted Majority of ED visits were for alcohol (28%) and Schizophrenia, Schizotypal And Delusional Disorders (18%) and residents presented most at Michael Garron Hospital (44%) and Scarborough Hospital Birchmount Site (23%) 16 patients accounted for more than half (55%) of the total ED visits which ranged from 3 to 31 visits MHA Discharges: There were only 43 MHA inpatient discharges (FY2014-15 to FY2015-16) for patients aged 15+ in all TCH high needs buildings with a total of 27 unique patients, indicating an average of 1.6 discharges/patient Majority of discharges were for schizophrenia and other psychotic disorders (60%) and mood disorders (30%) and patients visited Michael Garron Hospital (42%) and Scarborough Hospital Birchmount Site (40%) the most The average annual rate of discharges for all TCH high needs buildings (745.0) was fairly similar to the overall rate for Oakridge (746.1) Given the small number of MHA discharges over 2 years for the high needs TCH buildings and the nearly similar rate compared to Oakridge, it can be concluded that mental health and addictions discharges is not as significant an issue for the selected high needs TCH buildings in Oakridge compared to the ED visits for MHA 13
Capturing human experience: No data without stories, and no stories without data At the same time that the LHIN was developing sub-region and community profiles, the LHIN also formed a partnership with the design centre, OpenLab, to launch a storytelling platform that would bring a human dimension to population health data in the Toronto Central LHIN. The Local was founded on the conviction that there should be no data without stories, and no stories without data. The objective is to capture and illuminate the voice of citizens and patients, gaining deeper insights into the unique needs of different communities, and to share these insights with planning tables as a compliment to data reviews. 14
The Local tells hyperlocal stories about population health issues and grassroots innovations happening within the Toronto neighbourhoods that make up the LHIN s five sub-regions. To date, these insights have included the lived experience of different segments of the population, including marginalized groups, as well as innovative approaches of different providers at the local level. It can be accessed here: https://medium.com/thelocal. With the initial opportunity areas identified, OpenLab will be working with the local QI teams in each sub-region to enrich community engagement and the citizen voice in quality improvement planning moving forward. 15
Summary of process taken: Snapshot of sub-region initial opportunity areas: 1. West Chronic disease in Rockcliffe-Smythe 2. Mid-West Low urgency ED use and primary care attachment in Kensington Chinatown 3. North Seniors living alone in Mount Pleasant West 4. Mid-East Mental health and addictions in Moss Park, with a focus on individuals who are precariously housed or experiencing homelessness 5. East Focus on mental health and addictions in Oakridge 16
Next Steps: Supporting Collaborative Quality Improvement Planning (C- QIPs) Across all 5 initial opportunity areas, the LHIN identified a need to ensure a consistent commitment to working in partnership with communities, level of support for building quality improvement capacity, and ability to measure what impact is being made as improvements are implemented. To accomplish this, the LHIN worked in partnership with the Toronto Central LHIN Regional Quality Chair and Table, Health Quality Ontario (HQO), and the IDEAS program to immediately launch quality improvement supports in each of the 5 sub-region hot spots. A two part process was designed to: Develop collaborative-qips focused on our 5 hot spots Build significant quality improvement (QI) capacity across a number of communitybased service providers within the sub-regions Model how HSPs implement quality improvement with community members and nonhealth partners Part 1: Build foundational QI capacity through a One-Day Regional Quality Forum (a QI level-set across all participants within each hot spot area) On June 14 th, 2017, the Toronto Central LHIN and Regional Quality Chair hosted an inaugural Regional Quality Forum. This was a full day forum facilitated by the IDEAS faculty. Invitees included partners within each hot spot priority area. Over 100 participants attended the Forum including: o Toronto Central LHIN Citizen Panel members o Front-line care providers (including nurses, nurse practitioners, physicians, pharmacists, care coordinators, and health coaches) o Representatives across the spectrum of service areas (including home care, community supports, mental health, addictions, hospitals, long-term care, CHCs, FHTs, indigenous and francophone health services, family services, newcomer and settlement services) o Administrative leaders including CEOs and Executive Directors Part 2: Support advanced QI within local QI teams to develop collaborative-qips (significantly accelerate action over a 6 month period) To achieve this, the LHIN has funded 4 team members per hot-spot (20 total) to attend the IDEAS Advanced Learning Program. 17
These core team members will work with co-executive sponsors to accelerate action within the larger hot-spot improvement teams. Classroom sessions begin in September 2017 and over the summer, Executive Sponsors and ALP members will o Engage and expand broader QI team o Work with the IDEAS faculty and coaches to focus the opportunity area o Undertake further information gathering and community engagement Over the course of the year, the local QI team will provide updates and report backs to the Local Collaborative 18
Future Vision A measured approach is necessary to developing mature integrated and population-based systems of health care. Three foundational components include: 1. Understanding the population 2. Defining outcomes that matter to people 3. Creating a culture of continuous quality improvement From a planning perspective, these components can be thought of in a sort of maturity model 1 where systems of care build capabilities that are required to progress through increasingly sophisticated levels of change: Through these initial sub-region quality improvement efforts, the LHIN is building system capacity to better stratify populations and understand underserved populations (health equity), identify goals that are person-centred, and integrate quality improvement approaches that respond to local need. 1 Developed by Toronto Central LHIN. Adapted from: McClellan et al. 2013. Focusing Accountability on the Outcomes that Matter. 19
Over the longer-term, the LHIN will continue to progress the focus toward at risk populations and move toward prevention and wellness. 20
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