Strengthening Access, Performance and Accountability of Primary Health Care Implementation Framework Template Central East LHIN Response

Strengthening Access, Performance and Accountability of Primary Health Care Implementation Framework Template Central East LHIN Response Advancing Integrated Systems of Care the Central East LHIN s Primary Care Strategy (CEPC) Date: October 9, 2015 Contact details Name: Brian Laundry Title: Sr. Director Organization: Central East LHIN Email: Brian.laundry@lhins.on.ca Phone: 905-427-5497 ext. 205 Endorsed by Name Deborah Hammons Dr. Paul Caulford Position (s) Signature (s) CEO, Central East LHIN Original signed by Deborah Hammons Central East Primary Care Physician LHIN Lead Original signed by Dr. Paul Caulford Date October 9, 2015 October 9, 2015 The responses contained in this document were developed in consultation with the Central East LHIN s Primary Health Care Advisory Group (PHCAG) 1 P a g e

Central East LHIN Health Link Communities The Central East LHIN will advance integrated systems of care - which include primary care - within each of the seven Health Link communities. 2 P a g e

Table of Contents Introduction to Central East Primary Care (CEPC) Strategy Three CEPC Pillars: (How, Partners, Measuring Success) Summary Tables Leadership & Engagement System Design and Reorganization Practice Level Improvements for Patients and Providers 1.0 Executive Summary 2.0 Recent or Ongoing Primary Care Engagement and Performance Improvement Activities 3.0 Implementation Snap Shot 4.0 Anticipated Sub-LHIN Regions 5.0 Performance Improvement 6.0 Data Needs 7.0 Leadership 8.0 Work Plan 9.0 Key Stakeholders 10.0 Strategic Linkages 11.0 Key Risks 12.0 Governance and Organization Appendix 1: Appendix 2: Appendix 3: Appendix 4: Appendix 5: Appendix 6: Introduction from the MOHLTC Provincial Template Key Messages (Appendix C) from the Provincial Template Forward Sortation Areas (FSAs) by Health Link community Workplan (GANTT) Provincially Identified Performance Measures Operational Definition LHIN Data Package to be provided by MOHLTC 3 P a g e

Introduction This document outlines the Central East Local Health Integration Network s (LHIN) framework and preliminary ideas to support Primary Care transformation. This document is a response to the Ministry of Health and Long-term Care s Implementation Framework Template questions. The approach and ideas outlined will advance the province s current direction with regard to primary care reform and the Central East LHIN s goal for the next three years namely, advancing integrated systems of care to help Central East LHIN residents live healthier at home. For most Ontarians, contact with a family medicine physician or nurse practitioner is the entry point to the health care system. Primary care/family medicine is a community based discipline and as such, influences care delivery within their local communities. International evidence shows that jurisdictions with strong foundations of primary care have better health equity and overall better health system performance. The LHINs can achieve optimal primary care access for patients by supporting performance improvement at the community and clinical (practice) level through local engagement, collaboration and innovation. Putting patients first by ensuring that primary care providers (pcp) and services are organized and more robustly resourced around the needs of the community populations is already a priority of the Central East LHIN. It is our belief that primary care providers in the Central East LHIN prioritize improving the health needs of not only their individual patients but also the health of the communities that they work and often, live within. This is the common ground we will leverage and build upon through a variety of methods: Patients and family caregivers will be invited to share their stories and health system experiences to inform improvement activities; Active engagement of primary care and allied team health service providers (HSPs) in each of the Health Link (HL) communities to dialogue on finding solutions at the practice and community level for patients and them as primary care providers; Primary care providers and their partner agencies (e.g. LHIN HSPs) will be supported to work together within the seven HL communities to improve the coordination of care through development of coordinated care plans (CCPs) that focus on the goals of the patient and family caregiver; Information on the health and community services or assets available in each HL community will be made available including a profile of services available and the interconnections between services identified; System and primary care practice performance information will be provided by the province and made available to support performance improvement dialogue and activities at the HL community and primary care practice level; Primary care providers will be provided regular (i.e. quarterly or semi-annually) snapshots or a dashboard of indicators describing their primary care practice performance across predetermined provincial key measures. Primary care providers will be able to review the same 4 P a g e

performance indicator scores for their practice, their HL community, the Central East LHIN and provincially. The province has identified access, integration, effectiveness and patient centred-ness as areas for performance improvement. Achieving improvement in these areas, will require focused effort of primary care providers and their health system partners at both the community and individual practice level. Further, it will be essential to simultaneously pursue and demonstrate improvements for patients and providers at the individual, practice and community level to increase buy-in to primary care transformation and build momentum for change. Effective engagement and involvement of the primary care sector and individual primary care/family medicine providers is integral to advancing local integrated systems of care within the Central East LHIN. With the support of our Primary Care Physician LHIN Lead, seven Health Link physician Leads and through robust communications and the undertaking of improvement activities at the Health Link community planning tables, collaborative and innovative strategies will need to be proposed and tested. The Central East LHIN has already identified our seven Health Link communities (I.e. Patient Care Groups) (see Map Page 2). The HL communities (geographic populations) will be focal points for system access and performance improvement. The development of mechanisms to support physician, Nurse Practitioner (NP), allied health, home and community service providers and patient/caregiver engagement are underway: Through HL Steering Committees/Design Teams and Quality Improvement working teams these stakeholders are informing system planning and identifying ways to improve their collaboration in care delivery; The Central East LHIN is seeking seven local primary care family medicine Leads who will work with the Primary Care Physician LHIN Lead and their Health Link community partners to champion change; With the support of the province, a common set of primary care/system performance indicators and data showing how regions are performing will be available. The Central East LHIN Primary Care Strategy (CEPC) is an action oriented platform supported by three pillars that will guide primary care transformation activities over the next three years: Leadership & Engagement System Design and Reorganization Practice Level Improvements for Patients and Providers 5 P a g e

Current Status Within Central East LHIN (2013), 1174 family medicine physicians and approximately 150 Nurse Practitioners work in various primary care models or independently. Primary care providers, often working in teams, carry out assessment and treatment as well as referral to secondary and tertiary care and community supports. How the primary care system performs often has an impact on other parts of the health care system. In 2014, 93.7% of Central East adults (aged 16 years and older) had a primary care provider. A high percentage (83%) of adults who had a primary care provider in Central East reported that their primary care provider always or often gives them the opportunity to ask questions, and 81.5% reported that their provider always or often spends enough time with them. This is consistent with the provincial averages. Central East physicians are older than the province as a whole, with 15% being over the age of 65 (2013). The rate of physicians/population in Central East is significantly lower than the province, at 74.5/100,000 people compared to 93.2/100,000 across Ontario. The past ten years of system and primary care reform has led to integration and patient attachment improvements. Yet gaps remain; just 39.0% of adults in the Central East LHIN were able to see a primary care provider on the same day or next day when they were sick; only 37.1% of Central East LHIN adults were aware that their provider offers an after-hours clinic, and almost half (49.5%) had difficulty accessing after-hours care without going to an emergency department. As a result, 13.9% of Emergency Department visits in Central East LHIN were categorized as best treated in alternative primary care settings. Only 37.1% of patients in Central East LHIN who had an acute hospital discharge saw a primary care physician within seven days of their discharge. Specifically, Central East LHIN patients who saw a primary care physician within seven (7) days of discharge from hospital was 40.3% for Congestive Heart Failure (CHF) discharges and 32.5% for Congestive Obstructive Pulmonary Disease (COPD) discharges. Notwithstanding the enormous efforts and successes of the past ten years to reform primary care (e.g. Electronic Medical Records (EMR), electronic connectivity, new blended payment methods, improved patient attachment rates, advanced after hours care, growth in allied providers, implementing Family Health Teams and creation of LHINs) gaps remain in our system and its ability to respond to what patients and family caregivers want and need. While our system is performing better than the province in many of these areas we can do better. Strengthening the primary care system for patients and providers requires a multi-year collaborative strategy including common objectives and measures for improvement in access, integration, effectiveness and patient-centred care including, but not limited to: 6 P a g e

Access: Attachment of patients to a primary care provider Access to the support of allied health providers for community based family doctors who are not presently part of a FHT or CHC Same day and next day access to primary care appointments Access to primary care in the evening or on a weekend Access to integrated and cohesive programming within HL communities that recognizes that complexity of care is most often influenced by the social determinants of health (SDOH) (e.g. income, education, employment, housing, food security, social safety and exclusion, aboriginal status, gender, race or disability). Integration Effectiveness: Efficiency: Primary care appointments within 7 days post-hospital discharge Reduction of readmission to hospital within 30 days for select medical conditions Reduction of avoidable emergency department visits Development of a single Coordinated Care Plan (CCP) developed based on patient and family caregiver goals is used by all care providers Increasing preventative care compliance rates, including cancer screening and immunizations Reducing repeated tests; Maximizing the use of technologies to provide more seamless communication and sharing of information on a client s needs between health team providers; Supporting practices to improve administrative efficiencies including office functioning as well as physical space planning. Patient-Centred care: Improving patient experience with system of care Delivering coordinated care delivered to patients The Central East LHIN Primary Care Strategy (CEPC) will provide guidance to the primary care sector in working collaboratively within their communities to focus their efforts and deliver on the four Central East LHIN strategic commitments in the next three years. Providing coordinated care to frail older adults so they can remain at home and in their communities; Providing options and support so that palliative patients and families can chose to die at home with the supports they need; Delivering integrated, wellness focused services for people with mental health & addictions; Promoting vascular health and prevention of secondary vascular events. 7 P a g e

Strengthening access, performance and accountability of primary care is a provincial commitment. The Central East LHIN will work together with primary care providers and their system partners to achieve this commitment. Collaboration between primary care providers and broader health system partners will support transformation toward a more seamless system for patients and families. Supporting primary care providers to be engaged in system design is a critical step to transformation and advancing integrated systems of care that put patients first. 8 P a g e

1.0 Executive Summary Provide an overarching summary of the LHIN s planned implementation framework to advance primary care access and performance. Access to a primary care provider for all persons is the fundamental goal to achieve; its achievement will facilitate success in integration, effectiveness and improved patient experiences. In the Central East LHIN implementation success will centre on agreement and reciprocity with all our primary care/ family medicine providers. We will implement attachment mechanisms toward the goal of having all of our Central East LHIN Family Medicine physicians having access for their patients to the range of interprofessional team resources now available to Family Health Team and Community Health Centre (CHC) physicians. Relationship and trust building will be developed through meaningful engagement and robust shared communication in the planning and implementation process for this significant transformation. Common ground with our patients, communities and providers is critical. This common ground will begin with a focus on the WHY of the transformation vision. Everything we do in this journey is dedicated to ensuring all members of our community receive timely, equitable access to medical and social healthcare. Focus will now include the health and wellness of their community all members of their community. Central East Primary Care (CEPC) Three Pillars 1 Leadership & Engagement How Through development and implementation of robust Stakeholder Engagement strategy (Stakeholder Matrix) and Shared Communication Plan Through identification of clinical, administrative and community leaders who bring public interest not self or sector interest as champions for primary care transformation. Partners Primary Care Physician LHIN Lead; Central East Primary Health Care Advisory Group (PHCAG); LHIN Physician Leads (ED, Critical Care, Palliative, Vascular, Seniors and Mental Health) Seven Health Link community Physician Leads; Nurse Practitioner Leaders; Community Health Centre (CHC) Executive Directors, Hospital CEOs, Provincial Primary Care and Physician Leadership tables (e.g. AFHTO, AOCHC) Central East CCAC, Public Health Unit Medical Officers of Health Measuring Success Updates 6 times per year to and from the PHCAG Gauging provider feedback on inclusivity, readiness, availability and engagement Quarterly Update to LHIN Board 9 P a g e

2 System Design and Reorganization How Partnership and collaborations between primary care providers and LHIN health service providers Through provision of system level metrics by Health Link community to provide foundation for dialogue across primary care and other health partners on improving system integration. Through pursuit of access for community based family doctors and their patients who are not part of a FHT/CHC to the support of an allied health team (e.g. mental health, social work, case management, system and social support, care coordination, navigation) Through application of tools currently available to LHINs to advance integration in the form of partnerships and collaborations Through a commitment to a rational approach to alignment and reorganization based on "best model" not necessarily existing structures Partners Primary Care Providers, HL Steering and Design Committees, Health Service Providers Municipal agencies public health units, service managers, EMS/paramedic services Health Analytics Branch MOHLTC, Decision Support HSPs and LHINs MOHLTC Primary Care Divisions Measuring Success Regular (quarterly and bi-annual) review of performance, monitoring and developmental indicators Patient experience and satisfaction improvements Improvements in confidence of patients, family caregivers and health service providers in the ability of system to deliver care needed at the right place, right time and in a coordinated manner 3 Practice Level Improvements for Patients and Providers How Identify, share, monitor system integration and performance measures at HL community level Include, as appropriate, system performance measures in Health Service Provider s Service Accountability Agreements Review primary care and health service provider Quality Improvement Plans (QIPs) and identify areas of strength and those for improvement Compile, share, monitor practice level data with primary care providers and support wider dialogue across primary care and HL community over-time Promote increased adoption and robust use of EMRs to manage patient care pursue shared EMR/HER tool for collaboration across providers and/or a patient portal accessible by involved service partners (i.e. alignment with the provincial Health Links electronic Coordinated Care Tool) Utilize Quality Improvement approaches to identify opportunities for improved office functioning including physical space planning Promote standardization of best practice through Quality Improvement Initiatives (e.g. Health Links, Quality-based Procedures) Collaboration with Health Quality Ontario through Health Link communities Regularly report on performance at a HL community level to HSPs, primary care providers, LHIN, province and public. Partners Primary care providers; patients, health service providers, LHIN, Health Quality Ontario 10 P a g e

Measuring Success Regular (quarterly and bi-annual) review of performance, monitoring and developmental indicators Regular (i.e. quarterly or semi-annual) reports to sub-regions and providers on key primary care performance dashboard indicators showing individual, local population and sub-region performance Patient experience and satisfaction improvements Primary care supported coordinated care plans Improvements in confidence of patients, family caregivers and health service providers in the ability of system to deliver care needed at the right place, right time and in a coordinated manner 11 P a g e

2.0 Recent or Ongoing Primary Care Engagement and Performance Improvement Activities Provide a brief summary of recent or ongoing primary care engagement, primary care performance improvement, or other primary care initiatives that will be leveraged to advance implementation of this strategy. Primary Care Engagement Primary Care Physician LHIN Lead (PCPLL) is in place (Dr. Paul Caulford) since June 2015 (replacement for two family medicine physicians who shared PCPLL duties across the LHIN since 2013). Activities include: Central East LHIN Primary Care communication plan including new web portal for input and feedback; Site visits well underway across LHIN; meet/greet, identify provider concern; hear concepts and ideas, gauge readiness and availability of providers; Building common ground for transformation. Connecting primary care providers together and with Central East LHIN wide Physician leadership. The Central East Primary Care work plan has been developed to ensure full and robust conversations among primary care providers and organizations - leading to a coherent and cohesive working relationship going forward: 15 member Primary Health Care Advisory Group (PHCAG) is in place and meets six times per (since 2007) year [2015 Membership is 1/3 physicians; 1/3 Nurse Practitioners; 1/3 primary care administrators and is representative of the three LHIN clusters (Durham, Scarborough and Northeast). Vision: The best primary care everywhere. [Timeframe: Since 2007 refreshed 2014] The Central East LHIN meets regularly with the Community Health Centre (CHC) Executive Leads. 2014 MSAA refresh included dialogue on various performance targets (See page 19) The Central East Primary Care (CEPC) Website with survey capacity is live www.central eastlhin.on.ca [Timeframe: August 2015] Seven Health Link community physician Leads (remunerated for 9-18 hours per month [Timeframe: by March 31, 2016] Informing and Joining in the Central East Primary Care Strategy in Central East LHIN survey launch https://www.surveymonkey.com/ (to be developed) [Timeframe: November 2015] 12 P a g e

3.0 Implementation Snap Shot Based on the commentary in the above two sections please provide a brief Snap Shot that describes in one or two paragraphs how the LHIN will approach the implementation of this strategy. The three Central East Primary Care (CEPC) Pillars provide the Framework through which implementation will proceed in alignment with the goal of the Central East LHINs Integrated Health Service Plan (IHSP 4) which is to advance integrated systems of care to support residents to live healthier at home. Pillar 1: Engagement and Leadership: Primary care reform will begin through dialogue across all communities and key informants in the primary care sector and Central East LHIN this builds on the initial consultation with the Central East LHIN Primary Health Care Advisory Group (PHCAG) and one to one / group engagements conducted with primary care providers by the Central East Primary Care Physician LHIN Lead (PCPLL) and former PCPLL physician leads during the early implementation of Health Links. Participation of physicians and other clinical team members is critical. A Stakeholder Engagement plan (See Page 26 for Stakeholder Matrix) and Shared Communication Plan will guide broad based engagement and communication. The Central East LHIN Communications Director, in partnership with PCPLL and LHIN staff is currently supporting these communications. Further, the Central East LHIN Communicators Network and Provincial Communication team will be consulted in the development and implementation of the Shared Communication Plan. Key Messages will be regularly posted to the web-site and a Frequently Asked Questions (FAQ) section developed. Primary Care Providers (pcp) and their administrative staff will be responsible for disseminating communications throughout their own organizations. Specialist physicians are an important stakeholder in primary care transformation as they are critical in their support of primary care providers. Effective Specialist engagement strategies will be identified through discussion with the LHIN Physician Leads and other medical leadership groups within the LHIN. Pillar 2, System Design and Reorganization will draw on the Local Health System Integration Act (LHSIA), 2006 that provides the fundamental tools to engage the broader primary care sector (beyond Community Health Centres) in dialogue on effective system design. With the understanding that review and potential revisions are underway to legislation governing LHINs the first and most appropriate phase of primary care system design and reorganization will: Develop a robust data profile and understanding of primary care provider practices challenges and opportunities within each of the seven Health Link communities [Timeframe: November 2015 March 2016]. Develop a profile of assets of organizations, associations, individuals and the community that can support primary care providers and the provision of primary care within each Health Link community The LHIN will enable dialogue between its Health Service Providers and primary care providers with early emphasis on the identification of opportunities and establishment of partnerships 13 P a g e

and collaborations which will build a foundation for further transformation of primary care. [Timeframe: April 2016 March 2017] It is anticipated (and requested) that provincial forums will be created for cross-lhin and MoHLTC dialogue on primary care transformation [Timeframe: January 2016] Pillar 3, Practice Level Improvement for Patients and Providers will support Primary Care Providers working collaboratively with Health Links Steering Committees/Design Teams to identify opportunities at the community and practice level which align with the identified primary care improvement indicators for access, integration, effectiveness & efficiency and patient centred-ness. For example, innovative initiatives are needed at the community level to ensure the social determinants of health ( e.g. housing support, settlement, employment support, Mental Health access, poverty and food security) are accessible and effective for the unattached and the most vulnerable populations within the HL communities. The Health Links Project Management Office working with Health Quality Ontario and engaging additional primary care QI facilitation expertise, as required, will implement quality improvement process cycles and make recommendations for improvements and spread of improvements across the system. Implementation Support: See Section 12 (Page 34) for description of organization and governance changes required to support primary care transformation. 14 P a g e

4.0 Anticipated Sub-LHIN Regions Clearly defining your sub-lhin boundaries is an essential foundational step to advance this reform strategy. These boundaries will become the focal point for data provision, performance improvement activities, progress tracking and reporting in addition to broader health service integration activities. Describe the boundaries of the proposed sub-lhin regions and the approach that was taken to define these boundaries. If these boundaries are different than those defined for Health Links, provide an explanation. Provide postal codes of these boundaries to support data extraction in addition to existing maps, where available, to be included in an appendix. The Central East LHIN will advance integrated systems of care aligned with the geographic boundaries of its seven Health Link communities and its three existing service clusters. (See Map on Page 2) See Appendix 3 for the Forward Sortation Areas (Postal Codes) for the Central East LHIN s seven Health Links. Primary care provider engagement in Health Links continues to grow; as of September 2014 enrollment was as follows: Health Link community % of physicians enrolled Peterborough City-County 98 Durham North East 66 Northumberland County 65 Haliburton County City of Kawartha Lakes 90 Scarborough North 49 Scarborough South 29 15 P a g e

5.0 Performance Improvement Performance improvement is a centrepiece to this strategy. The strategy relies on a common set of performance measures, the sharing and tracking of data against these measures, and community-based performance improvement activities. The common set of performance measures being used initially are as follows: Access: o Attachment to a primary care provider (key focus area) o Same day and next day access to primary care appointments o Access to primary care in the evening or on a weekend Integration o Primary care appointments within 7 days post-hospital discharge o Readmission to hospital with 30 days for select medical conditions o Avoidable emergency department visits Effectiveness o Preventative care compliance rates, including cancer screening and immunizations Patient-Centeredness Although it is acknowledged that detailed implementation plans to improve performance will depend on data that LHINs have yet to receive and the engagement of local providers, please provide general commentary on how the LHIN will approach improvement across priority performance areas against each of the identified indicators (see Appendix B for Operational Definitions) Core concepts that will support performance improvement activities include: Standardized Performance Indicators: Each Central East LHIN Health Link community will be a focal point for the advancement of system integration, access and performance improvement based on local evidence and focused on addressing patient need this includes primary care. Guiding system integration will be a common set of performance indicators and data showing how communities and practices are performing against these indicators. The indicators identified by the province for primary care transformation, will be included. Focusing on complex patients: Health Links are initiating with a focus on providing coordinated care to complex patients complexity is defined as 4+ co-morbid conditions and correlates to high use of health care services. It is estimated that there are close to 40,000 complex patients in Central East LHIN. Complex patients include seniors, people with mental health conditions and individuals with a life limiting condition nearing end of life (palliative/end of life). Recognizing that the composition of a care team to support complex patients will be varied and for some large, primary care coordination efforts will recognize and advance the concept of One patient = One care team (i.e. teams are assembled based on patient/family needs) Leveraging existing (trusting) relationship between provider and patient/family caregivers to inform performance improvement activities and achieve targets. Patients and providers must be aware of changing expectations for themselves and their primary care providers. Mutual support/accountability for achievement (i.e. appropriate use of ED, access to after-hours services, follow-up appointments and adhering to care plan implementation) will be essential. 16 P a g e

Recognizing practice level differences between communities. While local solutions will be required to address metrics determination on what needs to be standardized (to achieve equity across communities) and what can be customized is necessary. Practices will be asked to identify the specific issues that need to be addressed what is causing day to day challenges to access, integration, effectiveness and patient-centeredness? Access to Allied Health Provider teams: There are 7 Community Health Centres and 10 (11 including Carefirst Richmond Hill/Scarborough) Family Health Teams in Central East LHIN. These two primary care models which are funded by the province to provide access for physicians on the team and their patients to allied health providers. While the FHTs or CHCs are well distributed across our seven HL Communities the number of patients who are attached to these physician-allied health team models is low. Only 21% of patients in LHIN are enrolled in FHTs and Community Health Centres served approximately 14,000 patients in 2013. Incentives: It is recommended that the province identify and provide appropriate incentives for performance improvement. What is appropriate to incentivize change and reward improvement within the primary care sector is an area that will benefit from provincial expertise and standardization. Access to Primary Care: To date, the province has identified the following indicators to assess access to primary care: Within Central East LHIN the attachment rate is 94.5% or approximately 5.5% (88,000) people remain unattached to a comprehensive primary care provider. There were 7712 individuals registered to the Central East Health Care Connects list as of July 2015 - with close to 50% registered in Scarborough and Peterborough. To achieve 100% attachment new/innovative approaches to attach patients to primary care will need to be devised. Pursuing attachment to primary care physician practices which are already large, and in a LHIN whose physician to patient ratio is low, will continue to be problematic. Strategies to improve equitable access to inter-professional health team expertise for patients whose primary care provider does not work in an inter-professional care model, will be identified. The lessons learned and tools built by the Central East LHIN s Unattached Patient Project (UPA) (2009-10) will be re-assessed. The UPA project was a unique initiative in Central East LHIN which supported a physician and inter-professional team to locate, for a short time period (approximately 3 months) in underserved communities. The UPA 17 P a g e

team would provide comprehensive health assessments, triage and facilitated referral to existing physicians/practices for people who did not have a regular family medicine provider. Further, it will be important to understand the needs of and pursue attachment of patients using Walkin or Emergency Departments who identify they have no provider and desire regular access to one. The creation of virtual Hubs to link inter-professional/ allied health for non-fht or CHC family practices by HL community has been identified as a transformative advancement. Effort will be needed to identify the most appropriate scale for this within Central East to realize optimal access and provide opportunities for new physician and allied health grads to practice in inter-professional teams across the Central East LHIN. As such, within in the Central East LHIN - access for community based family doctors and their patients who are not part of a FHT/CHC to the support of an allied health team (e.g. mental health, social work, case management, system and social support navigation) will be a priority initiative related to improving access to care. A further challenge within Central East LHIN is supporting access to services for the uninsured population of new immigrants and refugees to Canada. A small amount of resources are provided to Community Health Centres to address the needs of those who are uninsured and the Canadian Centre for Refugee and Immigrant Healthcare operates in Scarborough (See page 34) Integration The Central East LHIN, has identified a number of system integration measures that will be introduced and assessed over the course of IHSP 4. These include, but are not limited to: Decrease hospital care through spending fewer days in hospital, reducing un-necessary ED visits and increasing ability of patients to be cared for at home with supports. Patients have a Coordinated Care Plan and the Plan (including patient goals) guides the interprofessional team care Patients and families experience seamless support at home, in community or in hospital; Patient and family diversity is supported by services that are culturally competent The provincially identified system integration measures below, once available, will be provided to the HL communities to support dialogue on collaborative improvement opportunities. To date the province has identified the following measures of system integration: In Central East LHIN, the further development of Rural Health Hubs in Haliburton and in Trent Hills provides opportunity for pursuit of further system integration with primary care in these communities. 18 P a g e

It will be important to take the necessary time to identify what models exist by HL community and explore what is working and can be built on e.g. Geriatric Assessment and Intervention Network (GAIN) teams, Palliative Care Community Teams (PCCT), Congestive Heart Failure clinic (The Scarborough Hospital (TSH); Community integration efforts such as the Virtual Ward (Carefirst for Seniors & TSH). Similarly, the identification of programs that are in place already but not widely known by or considered for clients by primary care providers (e.g. Rapid Response Nursing (CCAC), Community Care services, Adult Day Programs) is required. Improving collaboration and service planning between primary care and the CE CCAC and Mental Health and Addictions services (hospital or community) has been identified as a particular opportunity for improved integration for primary care providers and their patients. Effectiveness and Efficiency: Effectiveness: Community Health Centres currently report to LHINs (quarterly) and set performance targets through their Multi-sector Service Accountability Agreements (MSAA) related to the performance indicators below. It is expected that similar processes will be phased in over-time (with MOHLTC data support) for the primary care system as a whole. Within Central East LHIN, service accountability agreements with each community agency, including CHCs include the Alternate Level of Care (ALC) rate (based on closest hospital) as a performance indicator. This is intended to support system awareness and enable collaborative performance improvement on % ALC rate. Current CHC Preventative Care/Wellness performance indicators include: Cervical Cancer Screening Rate (PAP Tests) Colorectal Cancer Screening Rate Inter-professional Diabetes Care Rate Influenza Vaccination Rate Breast Cancer Screening Rate Periodic Health Exam Rate (to be removed in future years by province) Vacancy Rate (NPs and Doctors) Access to Primary Care - This is a new indicator for 2014-2017 which assesses the current number of clients provided clinical services as a percentage of the total number of clients the CHC is expected to serve. Where the expected client count or full potential of the CHC assumes a fully staffed clinical team and the client complexity is factored into the count. It is broadly accepted that wellness care provided by inter-professional teams (beyond physicians and NPs) and (as available) visiting home nursing and care delivered in community settings (vs hospital sites), is the preferred approach. The province has identified obesity rates (Adults aged 18+) as an indicator of focus for primary care providers. This is not currently an indicator which is reported through the CHCs. 19 P a g e

Efficiency: While efficiency is not identified as a focus for primary care performance per se examples of inefficiency will be noted and strategies proposed. For example, a reduction in repeated tests and more seamless communication and sharing of information on a client s needs between health team members is required. Maximizing the use of technologies, specifically EMR use and data mining as well as technologies such as OTN to enable care coordination/conferences are opportunities to improve efficiencies. This is particularly important to overcome travel distances for providers and patient and to access to specialist consultations. Supporting practices to improve administrative efficiencies is noted as an opportunity for Practice Level Performance improvements. This would include office functioning as well as physical space planning. Patient & Caregiver Centred-ness: Since its inception, the Central East LHIN has recognized the value of listening to the voice of patients and their caregivers. Taking action on the lived experience of patients and their caregivers resulted in the establishment of new programs, improvements to existing services and when warranted, the redesign or closure of services. Patients and family caregiver input, when combined with the perspectives of health service providers, portrays a more accurate picture of the quality of healthcare services. These insights help system planners and service providers to improve care. Understanding and taking action on the explicit goals of patients and family caregivers is recognized as highly valuable to delivering care that is effective. However, only 40% of respondents in the IHSP - Patient and Caregiver Engagement Survey agreed that patients and caregivers were working hand in hand with their care team. 20 P a g e

Additional Measures (under consideration) in Central East LHIN include: % of patients reporting their provider followed through on commitments and promises to their care in a timely manner (e.g. arranging specialist appointments, connections social agencies, follow up visits) % of patients who are comfortable following their providers advice (e.g. medications, referrals) % of patients reporting their provider took the time to understand the reason(s) for their visit Central East LHIN s Patient and Family Engagement Framework A variety of methods are needed to engage effectively with diverse and vulnerable patients and their caregivers. The Central East LHIN has adapted the Patient and Family Engagement Strategy (see below) to support the LHIN and its HSPs in implementation of IHSP 4 this Framework will extend to primary care settings. Fundamental to the framework is the recognition that universal, one-size-fits-all approaches to engagement will not enable diverse groups to participate in decision-making about programs and policies intended to meet their needs or enable planners to develop interventions with a diverse range of patients in mind. Engagement Approach for Vulnerable/Hard to Reach Patients and Caregivers: (Fraser Health, 2013) Through the duration of the 2016-2019 IHSP, different levels of engagement will be necessary. The level of engagement selected will be dependent on several factors, including the target population and the information the LHIN is seeking. Engagement methods will be designed based on the strategic aims and the diverse needs of the target patient and caregivers groups, including such examples as: in Health Links, early collection and learning from patient stories and involvement; bereaved caregivers engaged through interviews or peer support groups; 21 P a g e

graduates of the Cardiac Rehabilitation and Secondary Prevention (CRSP) program consulted through the program s evaluation processes and follow-up; and, The Excellent Care for All Act promotes expanded monitoring of patient experience to improve quality of care; for example, in the Mental Health and Addiction sector, implementation of the Ontario Perception of Care Tool, (OPOC). 22 P a g e

6.0 Data Needs Please identify any additional data needs beyond those noted in Appendix 6. The provincial proposed data set will provide a significant foundation to support primary care transformation at the HL community level. It is requested that the province confirm that these indicators reflect the most current and relevant (widely assessed) indicators within primary care practices settings It will be important that the province provide access for primary care providers (in the first instance) to their own practice level performance. This will be an important enabler to dialogue with their peers and system partners on advancing areas of access, integration, effectiveness and patient centred-ness. There is a lack of awareness of what is provided by individual primary care (e.g. clinics) and community services. Improved information will support more effective triage to appropriate resources in the community. Additional information requests (at this time) include: Provincial HHR Capacity information physician ratio, supply of physicians, nurses, NPs, pharmacists, midwives, social workers and location within sub-lhin areas with comparisons to Central East LHIN as a whole, other LHINs and the province. (the release of provincial HHR reports is expected) Distribution of Patient Rosters It would be useful to know the geographic distribution of patients within individual physician patient rosters, mapped for physician practices within given Health Link communities Specialized primary care models: Information on specialized care models operating in our LHIN Alternate payment models (e.g. Seniors, Palliative, Paediatrics) Physician practice settings/patterns: Information on the practice patterns of primary care providers in Central East LHIN would be helpful it is recognized that primary care providers are often working across multiple settings in particularly in smaller communities (e.g. LTCH, ED, own practice, home visits and seeing hospital inpatients) Physician Remuneration Models/ Codes: Knowledge transfer and training of LHIN teams on the existing/proposed remuneration models for physicians, including billing codes and practice model remuneration structures/levels will be required. Midwives and Midwifery Practices: The LHIN does not presently have information on Midwives and practices Enabling Technologies within Primary Care: o Use of Electronic Medical Records: There is a great deal of performance and improvement data available within EMRs; especially with the required specifications being defined provincially through Ontario MD and the new initiatives on utilization and more meaningful use of EMRs by Ontario MD. This needs analysis to provide common 23 P a g e

o o o o o o or core information that can then be extracted and used to improve system and practice performance instead of additional data entry / duplication of work. EMR Adoption and Capabilities: Information regarding primary care electronic medical record (EMR) adoption rates by Health Link, including information such as EMR vendor and version of system to support the planning and support to physicians in their readiness and adoption of technology. Provincial EHealth Assets: There is a need to understand and better plan the capability and readiness of physicians to make use of provincial assets such as patient and provider registries, ONEID secure email, Hospital Report Manager to receive discharge and consult reports, OLIS to receive lab results, Connecting GTA (to access the provincial aggregate patient record information from CCAC, Hospitals, FHTs etc.), coordinated care tool, notification tools such as e-notification and other tools being planned. The requirement to have the information on current state of physician readiness and use, as well as the issues and barriers to improve the access and adoption to these tools will be a key to support physicians to manage complex patients; book checkups/immunizations/follow-up appointments and track measures identified by the province. Ontario MD (OMD): The adoption and participation of the OMD program for meaningful use will be a key enabler of physician practice using electronic medical records in order to support through training and education physicians on best practice using the tools, as well as to support automated decision making and reporting for care delivery with their existing EMR. Secure Web-based Collaboration Supports (Ontario Telemedicine Network (OTN): Regular communication tools including collaborative spaces and forums for primary care through webinars would directly support their use of technology but also be leveraged to enhance performance and change management from legislation and practice. Examples would include discussion boards for a community of practice on various areas specific to physicians, and/or learning web-exs or recorded lectures / materials to provide on-demand education to the physicians on relevant topics (Incident reporting, indicators etc.) OTN Telemedicine: Access to the secure telemedicine network offered by the Ontario Telemedicine Network is a significant opportunity to support improve access to both specialist consultation for patients and collaboration across multiple providers. With the expansion of personal computer based video conferencing (PCVC) through OTN primary care providers can have secure web-based systems for collaboration with health service providers and, directly with their patients, through new initiatives such as OTN s web-link program. Support to primary care providers and our Health Link community partners to understand existing use and improve use and uptake of this provincially accessible network is requested. Econsult: Support to introduce use of electronic consultation (econsult) between family medicine and specialists would support practice level improvements in performance - Central East LHIN can join with the Champlain LHIN to implement if resources can be identified. 24 P a g e

7.0 Leadership Clinical and other local leaders will be critical in the implementation of primary care reform. These leaders will drive provider engagement and collaboration at the sub-lhin level and will be the central organizing element of each local network. Describe your approach to and criteria for identifying and engaging these leaders, as well as the expected role of these leaders. Where possible, identify likely lead individuals or organizations. The first Pillar of primary care transformation focuses on engagement and leadership. Core to this Pillar is the identification of seven HL community family medicine (physician) Leads who will work with their health service provider partners at the community level and the PCP LHIN Lead physician. See Leadership and Engagement Pillar summary (Page 9) 25 P a g e

8.0 Work Plan Provide a project plan which articulates your implementation approach and includes the following components: Identification of relevant work streams and deliverables. Planned start dates for these activities. See Appendix 4 for Workplan GANTT chart As of October 2015 Central East Primary Care Strategy ACTIVITY Pillar 1: Leadership and Engagement 1 Primary Care Physician LHIN Lead in place and engaging with primary care providers across the LHIN Jun-15 2 Central East LHIN Primary Health Care Advisory Group in place 3 PHCAG advises on development and implementation of Central East Primary Care Strategy (CEPC) Since 2007 Redesign 2013 - on-going September 2015 on going 4 The Central East Primary Care (CEPC) Website with survey capacity is live www.central eastlhin.on.ca 9/1/2015 - on-going 5 Seven Health Link community Family Medicine (Physician) Leads recruited October 2015 initiated March 2015 complete 6 Informing and Joining in the Central East Primary Care Strategy in Central East LHIN survey launch https://www.surveymonkey.com/ Nov-15 7 Development of Stakeholder Engagement Plan and Shared Communications Plan November 2015 ongoing 8 Regular updates on engagement and leadership pillar begin to PHCAG and LHIN Nov-15 9 Shared Communications Plan December 2015 onward 10 11 Engagement activities with primary care sector (e.g. face to face, focus groups, webinar/otn talks) - physicians, allied health Participation in provincial forums (as created) for cross-lhin and MoHLTC dialogue on primary care transformation November 2015 ongoing December 2015 onward 26 P a g e