Home and Community Care QUALITY Improvement Plan

Home and Community Care QUALITY Improvement Plan 2019-2020 1 Building a HEALTHIER Community for All

CONTENTS Introduction Overview Reflection Engagement Safe and Secure Workplace 3 5..11..14..17 2 Central West LHIN Home and Community Care Quality Improvement Plan 2019-2020

Introduction We are pleased to present the Central West Local Health Integration Network (LHIN) 2019-2020 Home and Community Care Quality Improvement Plan (HCC QIP 2019-2020), for fiscal year April 1, 2019 through March 31, 2020. A mosaic of geographic and cultural diversity and home to over 922,000 local residents, the Central West LHIN has a mandate, first established under Ontario s Local Health System Integration Act, 2006, to plan, fund, integrate and monitor health care services at the local level. Following introduction of the Patient s First Act, 2016, the Central West LHIN was provided with an expanded mandate to deliver home and community care services, strengthen local planning, and increase collaboration and coordination between the LHIN, primary care and Public Health Units. As a result, the Central West LHIN is uniquely positioned as a planner, funder and provider of health care services. With transition of home and community care services to the Central West LHIN, Accreditation Canada required the LHIN to submit an interim report, showing evidence of compliance against the selected standards and required organizational practices, in order to maintain its Accredited with Exemplary Standing status obtained in 2016. The interim report focused on Accreditation Canada s patient safety goals related to communication, risk, quality improvement, work life, medication management, and infection prevention and control. Most notably, one of the many achievements realized through this process was the successful training of all Home and Community Care staff (100%) in the newly-developed suite of Medication Management policies and procedures. Other notable achievements included the revision of the Adverse Event Reporting and Debriefing Process, Disclosure of Harm Guidelines, and Complaints Management procedure. Throughout this process, staff worked in partnership with and sought input from the Patient and Family Advisory Committee (PFAC) on development of various policies and procedures. 3 Building a HEALTHIER Community for All

Accreditation Canada accepted the Central West LHIN s interim report in September 2018 and awarded the Central West LHIN an extension of its Accredited with Exemplary Standing status through September 2019. In collaboration with health system partners, the Central West LHIN is improving the quality and efficiency of our provincial health care system while simultaneously transforming the local health care system through the development of new and innovative models of care that reflect the diverse health care needs of unique communities. The Central West LHIN prioritizes quality in all of its activities, and actively plans and delivers upon a variety of quality initiatives. The HCC QIP 2019-2020 is an example of how the organization is supporting system level change to further meet the needs of patients, caregivers and populations within its region. It is within the context of a changing health care landscape that the Central West LHIN remains committed to working in collaboration with a broad spectrum of health system partners to achieve excellence in health and health care. The HCC QIP 2019-2020 has been informed by and aligned with a variety of resources, including the Central West LHIN s Mission, Vision and Values; Integrated Health Service Plan (IHSP 2019-2022); Annual Business Plan (ABP 2019-2020); Integrated Quality Plan (IQP 2018-2022); and provincial and regional priorities. All of these resources have been developed in collaboration with our highly valued health system partners. The HCC QIP 2019-2020 is divided into four main sections: Overview Provides a line of sight to key areas of focus within HCC QIP 2019-2020. Reflection A look back on 2018-2019, this section reflects upon specific quality improvement achievements that had a positive impact on the health and healthy outcomes of patients. Engagement A review of the Central West LHIN s commitment to effective stakeholder engagement in consideration of its various quality initiatives. Safe and Secure Workplace A reflection upon the importance the Central West LHIN places on providing a safe and secure work environment. We all have a role to play in the development of a stronger, more vibrant, patient-centered and sustainable health care system. The Central West LHIN remains committed to addressing health system capacity challenges, hospital overcrowding, improving access to long-term care and mental health and addictions services, and making improvements in home and community care. Quality improvement and the HCC QIP 2019-2020 play an integral part in supporting these objectives. Together with our health system partners, we look forward to continuing to build on our quality improvement work inspired by the patients who live and work in the Central West LHIN. 4 Central West LHIN Home and Community Care Quality Improvement Plan 2019-2020

Overview In consideration of indicators that were included in the 2018-2019 HCC QIP and those identified as a priority by Health Quality Ontario (HQO) in 2019-2020, the Central West LHIN s HCC QIP 2019-2020 has been designed to support IHSP 2019-2022, ABP 2019-2020 and the IQP 2018-2022 by placing a spotlight on the following dimensions of quality: Effective, Efficient/Timely, and Patient-Centred. Effective: Within the effective dimension, two indicators will look to improve upon quality as it relates to chronic disease and, more specifically, wound care among patients with diabetes. WOUND CARE Improve Healing Time of Wounds Prevent Development of DFU My care needs are met using upto-date practices % PATIENTS DIAGNOSED WITH A HEALABLE DIABETIC FOOT ULCER WHOSE ULCER CLOSED WITHIN 12 WEEKS USING BEST PRACTICES TARGET: 65% % PEOPLE WITH DIABETES AND THEIR FAMILIES OR CAREGIVERS OFFERED EDUCATION ABOUT HOW TO PREVENT FOOT COMPLICATIONS AND WHO TO CONTACT IN THE EVENT OF A CONCERNING CHANGE TARGET: 50% Aligned with HQO s Quality Standards, wound care is a major strategic initiative for the Central West LHIN. With support from the LHIN s Senior Leadership Team and continued partnership with Service Provider Organizations (SPOs), the Central West LHIN has been able to realize and sustain marked improvements in patient outcomes. The Central West LHIN is meeting and exceeding the target for the percent of diabetic foot ulcers (DFUs) that healed within 12 weeks for patients with a healable diabetic ulcer with a 5 Building a HEALTHIER Community for All

Bates-Jensen Wound Assessment (BWAT) score of 31 or less. Moreover, the number of readmissions to acute care from Home and Community Care, for wound care-related issues, has significantly decreased as shown in the control chart below. As part of the Central West LHIN s improvement journey, the organization reformed and expanded the Wound Care Program measurement system by developing a comprehensive measurement framework that includes process and outcome key performance indicators (KPIs) such as wound healing time, average number of visits per week, and supplies cost per month. The new measurement framework has allowed the Central West LHIN and SPOs to have a more accurate evaluation of the effectiveness and efficiency of the Wound Care Program. Current research findings, along with a review of Central West LHIN s own patient population, informed the development of a predicted healing trajectory based on wound acuity which will help to expand understanding of predicting healing for population types (in this case patients with DFUs), as well as increase proper and timely referrals. In terms of quality patient care, this has resulted in improved healing times, efficiency in resources, effectiveness in the care provided, and the overall patient and family experience. The chart below illustrates the steady decrease in healing times for DFUs, venous leg ulcers, and pressure injuries. Project Start Time: April 2017 6 Central West LHIN Home and Community Care Quality Improvement Plan 2019-2020

The Central West LHIN is committed to evidence-based practices for wound care, with a continued focus on wound care policies, procedures and clinical pathways informed by current literature and practices, and in collaboration with SPOs and key stakeholders. The ongoing structural improvement of the Wound Care Program allows for continued multifaceted education for patients, clinical providers and the broader community. The goal of the HCC QIP 2019-2020 is to reinforce and educate care coordinators on how to use a systematic process to identify patients who are not within the expected wound healing trajectory and/or who are not on an evidence-based clinical pathway. The Central West LHIN will work with SPOs, care coordinators, community partners and other stakeholders to ensure referrals for wound care reflect an escalation of clinical hierarchy when necessary. Trigger enablers embedded into the current reporting process will enhance surveillance, reinforce the escalation process, and create a more timely response and intervention to meet patients clinical needs. Moreover, the Central West LHIN will strengthen the clinical governance structure of the Wound Care Program by establishing a quarterly reporting process where the SPOs will submit an action plan for the KPIs that are not meeting the target performance. This reporting process will enable the Central West LHIN to monitor progress in implementing change ideas on an ongoing basis and to identify system level improvement opportunities in the management of DFUs. Efficient/Timely: Within the efficient dimension, three indicators will look to improve upon quality as it relates to the integration of care and, more specifically, through coordinated care management. TRANSITIONS Decrease Hospital Readmissions Decrease Unplanned Emergency Department Visits Understanding drivers impacting Long Term Care Placement I receive my care in the right place at the right time % HOME CARE PATIENTS WHO EXPERIENCED AN UNPLANNED READMISSION TO HOSPITAL WITHIN 30 DAYS OF DISCHARGE FROM HOSPITAL TARGET: 16% % HOME CARE PATIENTS WITH AN UNPLANNED, LESS-URGENT ED VISIT WITHIN THE FIRST 30 DAYS OF DISCHARGE FROM HOSPITAL TARGET: 4.1% MEDIAN NUMBER OF DAYS TO LONG-TERM CARE HOME PLACEMENT (COMMUNITY) TARGET: COLLECTING BASELINE With a continued focus on reducing readmissions for patients with Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF), the LHIN will continue to leverage the Rapid Response Nurse (RRN) program. The program provides a visit within 24 to 48 hours from hospital discharge and focuses on customized health teaching, a review of the discharge plan and care plan, completion of medication reconciliation, and connecting patients 7 Building a HEALTHIER Community for All

with their primary care provider within seven days of hospital discharge. However, given that a subset of patients with COPD and CHF do return to hospital approximately 20 days post discharge, the LHIN implemented (in 2018-2019) a second RRN visit within seven to 10 days post initial RRN visit, for all patients with COPD and CHF. This has proved successful in reducing readmissions within 30 days of hospital discharge for this patient population, from a baseline of 21.4 per cent to 11.2 per cent. In order to further risk stratify this subset of patients for enhanced RRN follow up, a new Home and Community Care (HCC) assessment tool - Detection of Indicators and Vulnerabilities for Emergency Room Trips (DIVERT) - will be applied prior to hospital patient discharge. Patients identified with a DIVERT score that puts them at greater risk of a return visit to hospital, will automatically receive an RRN visit within 24 to 48 hours post discharge and a subsequent visit within seven to 10 days. Reducing unplanned, less urgent emergency department (ED) visits within 30 days after hospital discharge also remains a priority. Working collaboratively with contracted nursing service providers, the Central West LHIN will use targeted strategies to reduce the number of HCC Short Stay patients (patients requiring 90 days or less service) who return to the ED unnecessarily. In order to promote patient self-management and health system navigation, a patient-centered reference guide will be implemented within the first two weeks of nursing service visits for the Short Stay patient subset receiving in-home nursing services for wound care and IV therapy. In addition, this patient population will also receive a call from a care coordinator within 48 hours of home care admission to ensure linkage to primary care and follow-up appointments. Understanding key drivers to improve wait time for long-term care home placement will also be an area of focus that supports effective transitions in care. Patient-Centred: Within the patient-centred dimension, five indicators will look to improve upon quality as it relates to both the overall patient experience and specifically palliative care. PATIENT EXPERIENCE I felt involved in developing my plan of care My complaint was acknowledged in a timely manner My complaint was resolved in a timely manner Nothing about me without me % PATIENTS THAT FELT INVOLVED IN DEVELOPING THEIR CARE PLAN TARGET: 85% % COMPLAINTS ACKNOWLEDGED WITHIN TWO BUSINESS DAYS TARGET: 80% % COMPLAINTS RESOLVED WITHIN 30 DAYS TARGET: 50% 8 Central West LHIN Home and Community Care Quality Improvement Plan 2019-2020

Key strategies that support the patient experience and patient involvement in the design of their care plans remains a priority as it pertains to the development of Coordinated Care Plans (CCP) also known as Health Links and in regard to providing patients with access to their CCP. The Central West LHIN will also establish a reference tool designed to assist care coordinators in their discussions with patients and their families surrounding the development of care plans, and will offer mandatory training sessions to refresh staff on the foundations and processes of patient-centered care planning. Allowing a patient and their family to direct the goal-setting exercise ensures that the services and supports offered will meaningfully assist patients in maintaining or improving their health and independence with greater confidence. Patient and family complaint management is a key priority for HCC QIP 2019-2020. Recent efforts within the Central West LHIN have significantly improved the time taken to resolve complaints. Over the coming year, the LHIN will build on this work through the redesign of its electronic Event Tracking and Management System (ETMS), and by enabling system notifications to support the managers and SPOs in closing complaints within a designated timeframe. Training will support LHIN and SPO staff, and quarterly reports will be developed and distributed to track performance. The Central West LHIN will also leverage ETMS redesign to improve the time it takes to acknowledge complaints. PALLIATIVE CARE Patient died in preferred place of death Palliative Care Experience (VOICES Survey) You heard my wishes for dying % HOME AND COMMUNITY CARE PATIENTS WHO DIED IN HOSPITAL TARGET: 36% PALLIATIVE CARE EXPERIENCE (VOICES SURVEY, CAREGIVER RESPONSES) DO YOU THINK HE/SHE DIED IN THE RIGHT PLACE? TARGET: 95% Palliative care remains a priority within the Central West LHIN, with customized strategies having been developed to address sub-region population needs. These needs include the early identification of patients, and many initiatives have been informed by the impassioned efforts of practitioners and partners. With establishment of the Ontario Palliative Care Network (OPCN) and the refreshed Central West Palliative Care Network (PCN), partners have continued to work together to identify system gaps, and to create collaborative solutions that seek to improve both access to care and the lived experience of patients and of their caregivers. In Central West LHIN, there is a recognized need for a new palliative model of care. It is felt that the Dufferin sub-region is best positioned to be the initial site for development and testing of this new model. Under shared leadership - Central West PCN, Dufferin Sub-Region Collaborative and HCC - the Central West LHIN will collaborate and partner with key stakeholders to develop and implement a team-based approach between acute care, HCC, community partners and 9 Building a HEALTHIER Community for All

primary care to support a new model of palliative care in the Dufferin region with a plan for spread to other Central West LHIN sub-regions. This new model of care will leverage HQO s Palliative Care Quality Standards and the Palliative Care Health Services Delivery Framework (HSDF) developed by the OPCN. The HSDF aims to provide guidance on how to optimize the model of palliative care delivery, ensuring that the right provider provides the right care at the right time. Patients and their families have communicated that access to a consistent inter-professional palliative care team, 24 hours a day and in particular as patient progresses towards end of life, is critical to ensuring that patients and their families are supported in the home environment. This also supports the understanding that a majority of patients wish to avoid return visits to the ED, and wish to die at home. 10 Central West LHIN Home and Community Care Quality Improvement Plan 2019-2020

Reflection This year we are pleased to highlight the Central West LHIN Integrated Stroke Rehabilitation Program which has strengthened access and transitions related to helping patients receive the right stroke care in the right place, at the right time. In 2017, Central West LHIN collaborated with William Osler Health System (Osler) to develop an integrated approach to stroke rehabilitation for patients with mild stroke (Alpha FIM >80). Prior to this initiative, these patients were waiting in an acute care bed for an average of six days in order to access speech and occupational therapy, and be referred to inpatient rehabilitation. In addition, a three to four week waitlist for outpatient rehabilitation was leading to delays in discharge from the inpatient rehabilitation unit, and referrals to HCC did not occur consistently due to a lack of an interdisciplinary approach to rehabilitation. Such an approach is designed to address patient goals such as cognitive communication, executive function and instrumental ADL skill development. Furthermore, current services available did not align with best practices that recommend patients with mild stroke receive care in outpatient and community rehabilitation settings. A six-month collaborative pilot project, led by the Central West LHIN s Home and Community Care team in partnership with Osler, established an integrated team to deliver a Community Stroke Program that streamlined patient transitions into the community using a patient-centered approach. To ensure alignment with best practices, the project team invited the West GTA Stroke Network to assist with program design, development, and evaluation. To provide a community rehabilitation component to the project, the team also contracted with Service Provider Organization 1to1 Rehab. All partners worked collaboratively to use LEAN methodology to design this unique stroke rehabilitation program known as Community Outpatient Stroke Rehabilitation (COSR). 11 Building a HEALTHIER Community for All

Model Integrated Community Outpatient Stroke Rehabilitation (COSR) Stroke Care Coordinator Outpatient Clinic OT, PT, SLP, TA Community OTA, PTA, CDA Intake on Acute Unit and Goal Setting (COPM) Care Coordination including Service Planning Navigation Education Team Huddle Interprofessional Assessment and Treatment Plan Design interventions based on COPM goals TA Clinical oversight within cliinc and community setting Community Visits Reassessment Team Huddle Interventions based on COPM Goals Home and Community Settings Communication with Therapists (mobile access) Team Huddle This program has resulted in the following positive outcomes: Increased therapy intensity and scope provided to patients 12% percent decrease in patients admitted to inpatient rehab Decreased acute length of stay by three days Patient-centered goals drove interventions At least 2 point improvement in COPM performance and satisfaction scores 100% percent of survey participants were satisfied with their quality of care. 12 Central West LHIN Home and Community Care Quality Improvement Plan 2019-2020

Patients and their families noted: I learned a lot about stroke and about exercises. This program helped me relate to my wife better. I also gained empathy seeing other patients at the clinic and seeing their experiences and how stroke affected them. This program connected me with transportation, optometrist and exercise classes. These will all benefit me even after the program finishes! I have nothing but positive things to say about this program. [Having a stroke] has been such a big change to my life but I felt very well supported in this process and, while I'm still not at 100 per cent, I feel I have made great gains in the last few months. I'm playing badminton again! This program left me with more than what I came in with. I learned so much and I feel much better. There were skills that I have not used since I was in school and now they are coming back to me, how great is that? Physically I am stronger and steadier as well. I would give this program 100% percent. Key lessons learned include: Make the system fit the patient, don t make the patient fit the system Use available best practices and existing models to inform program design Innovation and collaboration between hospital and community care streamlines the patient experience Investing in outpatient/community rehab reduces stress on acute care while improving patient experience, satisfaction, and health system outcomes Incorporate patient focus group feedback (using caregivers in therapy, a more gradual transition from services, and improve linkages with other community resources). The program, now incorporated into regular operations in all three organizations, received a 2019 Central West LHIN Quality Award. The planning team continues to meet regularly to ensure sustainability. 13 Building a HEALTHIER Community for All

Engagement Quality improvement is central to work at all levels of the Central West LHIN. In particular, the LHIN actively seeks out voices of the patients, families and the communities we serve to guide our improvement priorities. Patients and Families LHIN transformation and the creation of LHIN sub-regions continues to provide an opportunity for HCC to expand patient engagement strategies more fully across the region. In October 2017, the Central West LHIN established a new Patient and Family Advisory Committee (PFAC). PFAC membership includes patient and family advisors from each of the five Central West LHIN sub-regions, as well as representatives from Francophone and Indigenous communities. These advisors bring a rich level of knowledge, experience, insight and wisdom to the next phase of the patient engagement journey in the Central West area. The Central West LHIN completed a fulsome engagement with the LHIN PFAC to guide the quality improvement efforts in priority areas, and to inform the change ideas for HCC QIP 2019-2020. The LHIN s improvement teams will continue to draw on insights obtained through this consultation to inform ongoing improvement work and to validate findings in 2019-2020. PFAC perspectives have also given the LHIN first-hand insights into lived experience as family members assisting loved ones navigate the health care system throughout various stages of illness or recovery. In consultation, caregiver considerations in support of a family member s end-of-life care plan were also highlighted as an area of priority. Given the broad skill set and diversity of PFAC members, the LHIN was also challenged to consider both system level considerations as well as the need to be attentive to the diversity of the communities in the Central West area. Opportunities exist to further incorporate patient and family voices as the improvement team implements the change ideas identified in the HCC QIP 2019-2020. 14 Central West LHIN Home and Community Care Quality Improvement Plan 2019-2020

In addition to the PFAC, HCC uses multiple mechanisms to engage with and obtain feedback from patients, families and caregivers. Of note, the LHIN uses feedback obtained through the Client and Caregiver Experience Evaluation (CCEE) survey to determine specific areas of improvement. The Central West LHIN considers patient engagement to be central to the next phase of its quality journey, and also an integral part of its Integrated Quality Plan. As the LHIN s PFAC establishes its annual work plan, the group s major focuses will align with priority areas related to Palliative Care, Chronic Care, Mental Health and Addictions, and Integrated Care. Community Partners The Central West LHIN s 2019-2022 IHSP, 2019-2020 ABP, and 2018-2022 IQP all highlight integration and strategic system partnerships as a way of building a patient and family-centered, high performance system of care within the LHIN. The establishment of the five Sub-Region Collaboratives and a Regional Quality Table provide the conduits through which we can drive system improvements to care. HCC QIP 2019-2020 priorities were developed by leveraging regional partnerships to improve the patient experience, wound care, effective transitions, palliative care and coordinated care management. Each priority improvement area will be achieved through a system-focused and partnership approach, with special attention to spread and sustainability practices. Accordingly, the Central West LHIN will continue to work with: Acute care partners at the point of transition and primary care providers at the sub-region level to develop Coordinated Care Plans that are current, sensitive to patients unique needs, and accessible to the team, including patients and families. Patients, families, community organizations, SPOs, physicians, health professionals, and vendors in order to continue to implement and sustain best practices for wound care across the Central West LHIN. Acute care partners and SPOs to implement the use of an assessment tool that will assist us to identify patients at risk of early return to hospital or emergency room visits. Clinicians, Leadership and Staff Led by the Vice President of Home and Community Care, approximately 100 HCC staff contributed to the development of HCC QIP 2019-2020 through a targeted engagement process that highlighted the link to organizational and system priority areas. This activity provided firsthand insights into the feasibility of the proposed change ideas, as well as many practical strategies to achieve improvement targets this year. With investments in professional development having been made over the years through the Improving and Driving Excellence Across Sectors (IDEAS) program, staff eagerly contributed to the change idea process, increasing the expected success and sustainability of the change ideas described in the HCC QIP 2019-2020. In addition, the Quality Secretariat and newly- 15 Building a HEALTHIER Community for All

established HCC Quality Council was also consulted in the development of the HCC QIP 2019-2020. To ensure the HCC QIP 2019-2020 reflects broader LHIN-level and provincial perspectives, inputs were used from work underway at the sub-region tables and the Regional Quality Table. The Central West LHIN also consulted its IHSP 2019-2022, ABP 2019-2020 and IQP 2018-2022. 16 Central West LHIN Home and Community Care Quality Improvement Plan 2019-2020

Safe and Secure Workplace In order to ensure compliance with all relevant health and safety legislation and best-in-class practices, and in accordance with the Occupational Health and Safety Act, the Central West LHIN has a robust Workplace Violence and Harassment Prevention program in place. In consultation with the Joint Health and Safety Committee (JHSC), the LHIN underwent a policy review in 2018 that resulted in implementation of a harmonized set of policies. As part of implementation, all staff were required to review related policies and complete mandatory e- learning refresher training related to workplace violence and a respectful workplace. The LHIN continually reviews operational strategies, amended and built into everyday controls, to mitigate exposure related to workplace violence. Current strategies include but are not limited to: Community Workplace Safety training - up to two training sessions are provided to all employees who are required to conduct their work in the community and in patient homes. Crucial Conversations training - provided to staff to arm them with the tools to communicate effectively when the stakes are high. Active investigation and the use of third party agents when events of harassment or violence have occurred. Ongoing training provided to teams as required, raising awareness of roles and responsibilities pertaining to workplace violence and harassment. New hire training for all staff pertaining to workplace violence and harassment. Home Visit Protocol in place to support employees conducting home visits so they can identify potential risks associated with the workplace before they go to the home. Proactive Workplace Violence Risk Assessment in the patient s home is documented in the patient s CHRIS record to ensure that SPOs are notified in advance of the home visit. Our community workers have the ability to access our Community Liaison partners and other partners to perform joint home visits when there is a concern pertaining to safety risks or hazards. 17 Building a HEALTHIER Community for All

Team huddles to discuss emerging trends and events related to violence and harassment. Consultation will the JHSC to discuss emerging trends and events related to violence and harassment. Approval The 2019-2020 Home and Community Care Quality Improvement Plan was approved by the Central West LHIN Senior Management Team on March 25, 2019. Scott McLeod CEO Kimberley Floyd VP Home and Community Care 18 Central West LHIN Home and Community Care Quality Improvement Plan 2019-2020

NOTES 19 Building a HEALTHIER Community for All

199 County Court Blvd. Brampton, ON L6W 4P3 Tel: 905-796-0040 Toll Free: 1-888-733-1177 www.centralwestlhin.on.ca The Central West LHIN Home and Community Care Quality Improvement Plan 2019-2020 is available in French upon request. 20 Central West LHIN Home and Community Care Quality Improvement Plan 2019-2020