Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities

Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities Proposal for Voluntary Integration An Integration Proposal Submitted to the Toronto Central Local Health Integration Network by the Boards of Providence Healthcare, St. Joseph s Health Centre and St. Michael s Hospital For more information visit: www.oursharedpurpose.com Submission Date: April 11, 2017 Revised: May 12, 2017 Final Submission Date: June 26, 2017 Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities Page 1

TABLE OF CONTENTS 1. EXECUTIVE SUMMARY... 3 2. OUR SHARED PURPOSE: DELIVERING HIGH QUALITY AND SAFE PATIENT CARE... 6 2.1 OUR CHANGING LANDSCAPE: STANDING STILL IS NOT AN OPTION... 6 2.2 A NEW HEALTH NETWORK DELIVERING HIGH QUALITY, SAFE CARE... 7 2.3 SUSTAINING OUR SHARED PURPOSE CARE FOR THE DISADVANTAGED... 8 2.4 ENHANCING OUR ACADEMIC AND EDUCATION MANDATES... 10 3. OUR SHARED HISTORY OF PARTNERSHIP: A FUTURE FULL OF OPPORTUNITY... 12 3.1 OUR SHARED HISTORY OF COLLABORATION... 15 3.2 OUR SHARED STRATEGIC ALIGNMENT... 16 3.3 A NEW HEALTH NETWORK: STRONGER FOR PATIENTS... 17 3.4 HELPING TO ADVANCE ONTARIO S PATIENTS FIRST ACTION PLAN... 18 3.5 CONTRIBUTING TO THE TC LHIN S POPULATION HEALTH GOALS... 19 4. OUR SHARED ANALYSIS: FINDINGS... 21 4.1 MEDICAL STAFF... 22 4.2 INFORMATION SYSTEMS AND TECHNOLOGY... 24 4.3 HUMAN RESOURCES... 25 4.4 FINANCE... 26 4.5 BOARD GOVERNANCE... 28 4.6 FOUNDATIONS... 29 4.7 RISK MANAGEMENT ASSESSMENT... 29 4.8 DUE DILIGENCE... 32 5. OUR SHARED COMMUNITIES: INTERNAL AND PUBLIC ENGAGEMENT... 33 6. OUR SHARED ACCOUNTABILTY: PERFORMANCE REPORTING AND EVALUATION... 37 7. OUR SHARED PLAN MOVING FORWARD... 40 8. CONCLUSION... 41 REFERENCES... 42 APPENDIX A Overview of Programs and Services... 43 Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities Page 2

1. EXECUTIVE SUMMARY As members of Catholic Health Sponsors of Ontario, Providence Healthcare, St. Joseph s Health Centre and St. Michael s Hospital were founded by the Sisters of St. Joseph and continue to deliver on their long-standing mission of caring for the most marginalized or disadvantaged in our community Our Shared Purpose. All three organizations provide health care that begins with a deep respect for the intrinsic value and dignity of every human being. These are deeply rooted priorities founded in the mission of Catholic health care. The populations each organization serves are growing, more patients are presenting with complex medical and social needs, health human resources are aging, and health-care funding reform requires organizations to be innovative. St. Joseph s, St. Michael s and Providence recognize that to continue responding to the needs of their communities, standing still and standing alone is no longer a viable option. It is for this reason the three organizations are proposing the creation of a health network with a single governance and management model that will benefit the people they care for, the organizations respective communities and our broader health system. United, the three organizations will be better positioned to improve quality of care for all our patients, residents and clients ( patients ) by creating a new health network that offers the full spectrum of care. This integration will serve as a model of system integration between an academic health science centre, large community teaching centre and a post-acute organization providing rehabilitation, palliative care, long-term care and community care. High Quality, Safe Patient Care Providence, St. Joseph s and St. Michael s are confident this new health network will create positive gains for our patients and our organizations by: Helping patients and their families obtain better access to a more local and integrated health care network, by enabling consultative approaches to focus bi-directionally through primary care, acute, post-acute, residential care and community, putting our patients at the centre of their care improving their experience and delivering higher quality care. Making decisions based on value and quality, to sustain our network for our communities for generations to come by reinvesting in frontline care, making the best use of the skills and capacities of our clinical service providers, and by continuing the promise in all of our strategic plans to collaborate and engage patients, clients and residents in the care and services we provide. Expanding our research focus on urban health through increased activity in a larger communitybased network to study and better understand the determinants of health and their impact on the health of our communities. Recruiting and retaining outstanding physicians, health professionals, leaders, staff and volunteers by offering expanded clinical, education, research and management experiences across multiple sites. Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities Page 3

Enhancing our academic and education mandate by offering opportunities for medical, nursing and health professional learners to train in a variety of care settings. Using our roles as Toronto Central LHIN resource hospital partners to improve population health outcomes. Reinvesting in front-line care through a minimum of annualized savings and reinvestment opportunity between $8.8 million and $14.3 million. Quality and patient safety will also advance through the sharing and adoption of standard care protocols and best practices, improved care transitions and integrated IT systems that increase communication between providers. Instead of duplicating process design initiatives, we will be able to share and incorporate learnings that result from patient case reviews, and provide greater access to data that can inform quality improvement across the health network. Our knowledgeable physicians, clinicians and staff will work together to design a comprehensive network of care around the patient and family that spans the full spectrum of care from primary care, secondary community care, tertiary care, quaternary care services to post-acute through rehabilitation, palliative care and long-term care. By becoming an integrated health network, the organizations also believe we can become a stronger voice within the City of Toronto and Toronto Central LHIN for community population health specifically focused on patients social determinants of health like greater access to housing, nutrition and mental health and addiction services for the marginalized populations we serve. Together, the organizations are best positioned to deliver on the province s population health mandate to help patients and their families obtain better access to a more local and integrated health care system and improving the patient experience, thereby delivering higher-quality care. This integration will be the beginning of a new and stronger multi-provider health network that will be open to other partnerships enabling even greater improvements in coordination of care. A Collaborative Journey In September 2016, the boards of St. Joseph s and St. Michael s announced their intent to explore creating a health network that would provide value to patients, their communities and the broader health system. In February 2017, it was announced that Providence had joined as a founding member of the potential new network. A Joint Board Steering Committee comprised of members from the boards of directors of all three organizations was established to provide oversight and guidance on the integration analysis. The joint board formed working groups to assess the benefits and risks of integration, including in the areas of patient care, finance, information systems and technology, human resources, research and education, and medical staff models, the findings of which are outlined in this proposal. The joint board s work also included identifying a governance model for a new health network. During this process, the Joint Board Steering Committee and members of all three organizations senior management teams informed stakeholders of the integration exploration, and invited feedback on how a new health network would benefit patients and the system. Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities Page 4

The preliminary integration analysis and formal due diligence completed by the Joint Board Steering Committee and the three organization s boards is complete. There are no significant barriers or risks that would prevent the organizations from moving forward in creating a new health network. Based on the findings in the integration analysis and to realize these significant benefits for patients, partners and communities the three organizations serve, the boards of directors are proposing the new health network be led by a single governing body with a single management team, led by one president and CEO. An integrated medical staff model that complies with the Public Hospitals Act and maintains all legal requirements and current affiliation agreements and appointments will also allow for opportunities to share best practices and common quality improvement structures across an integrated organization while enabling physicians to maintain their current practice models at each site. The Toronto Central LHIN, Joint Board Steering Committee, the three organization s boards, Catholic Health Sponsors of Ontario and the Sisters of St. Joseph of Toronto have all endorsed this proposal. Final approval is sought by the Minister of Health and Long-Term Care, pursuant to the Public Hospitals Act. It is anticipated that the amalgamation will occur, at the earliest, on August 1, 2017. Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities Page 5

2. OUR SHARED PURPOSE: DELIVERING HIGH QUALITY AND SAFE PATIENT CARE 2.1 OUR CHANGING LANDSCAPE: STANDING STILL IS NOT AN OPTION Over the past 10 years, health care in Ontario has experienced great change. The pace of change will only continue to intensify, with a continued underpinning to put patients first. Today s patients want to be engaged, informed and active in their care more than ever before. As health-care providers, it is our obligation to continually evolve to meet the needs of patients while improving quality. This means keeping them safe, guaranteeing meaningful outcomes, enhancing access, providing patient-centred care with an optimal experience, and being good stewards of our precious resources. Additionally, our greatest resource the people who deliver care each day are aging and becoming increasingly more difficult to replace; the adoption of high-cost information technology to help deliver care is changing at a rapid pace; and funding mechanisms are changing the way we deliver care and how we optimize efficiencies. As a result, the pressure placed on our physicians, clinicians, leaders, staff and students to deliver high quality safe care, at a lower cost, has never been greater. The value of integration and partnership to meet these needs has become a major enabler of improved outcomes in access, quality and sustainability. At the system level, the provincial government is setting Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities Page 6

mandates, such as Patients First: Action Plan for Health Care and Health System Funding Reform to help break down siloes and improve patient care. In 2004, Local Health Integration Networks were also created with a mandate to support voluntary integration among health-care providers. Most recently, the Patients First Act, 2016 was introduced to broaden the scope of the LHINs from hospitals, long-term care and mental health to now include primary, home and community care. The need for, and benefits of, integration are clear at both a system and local level. 2.2 A NEW HEALTH NETWORK DELIVERING HIGH QUALITY, SAFE CARE The new health network will further enhance access and improve quality and patient safety through our shared commitments and the services we each provide: primary care, secondary community care, tertiary care, quaternary care services, and post-acute through rehabilitation, palliative care and longterm care. In the new health network, the needs of our patients will be better met by improving outcomes through a partnership that offers a broader spectrum of care, both within and across our respective organizations, as well as by building upon existing examples of coordinated care with each other and with our existing community partners. As Catholic health organizations, we share a common mission centred on caring for the most marginalized or those who experience disadvantage. We will continue to build on our existing commitment and further advance health equity and system-wide innovation through our shared expertise within the new health network. The benefits of this integration have been articulated through the lenses of: 1. Improving care for patients, residents, clients and their families through shared expertise; and 2. Harmonizing best practices and services to support care throughout the network; 3. Improving population health through an increased focus on community partnerships Improving care for patients, residents, clients and their families through shared expertise Working together and sharing our collective expertise across a network of care will provide a more seamless continuum of care to those we serve. We will enable consultative approaches within the network to focus bi-directionally through primary care, acute, post-acute, residential and community care. Between our three organizations, we will build on each other s strengths; for example, in Mental Health and Addictions, Rehabilitation, Dialysis and Palliative Care, to name a few. We will also leverage our full spectrum of care to advance alternate level of care (ALC) avoidance and ensure that care is delivered to our patients at the right place, at the right time and by the right providers. System fragmentation will be reduced by enabling interventions earlier in the patient s journey. For example, rehabilitation specialists from Providence would reach out to St. Joseph s and St. Michael s to become involved earlier in the patient s journey and support care planning that optimally prepares patients for rehabilitation and potential early transition whether to Providence, to other health service providers or to home. Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities Page 7

Harmonizing best practices and services to support care throughout the network Drawing upon our collective ability to share existing and develop new tools, we will improve processes and adopt best practices across the network. By doing this, we will further enable the high quality and safe care our communities deserve and expect. Efficiencies gained through the partnership will enable us to sustain and reinvest in services to better align care particularly for complex patients and those experiencing disadvantage. In a single organization, care will be optimized and streamlined through: improved access to tertiary and other specialty services leveraging a comprehensive network of consultation services a common information technology platform that will serve as an enabler of common care pathways, seamless transitions and access to the full continuum of care. These benefits are particularly valuable for patients with complex conditions and those needing to navigate multiple care providers across the network. We will create a network Quality and Safety Committee and develop common quality deliverables across all three sites. Improving population health through an increased focus on community partnerships Looking beyond the walls of our network and into the communities we serve, we will be well positioned to impact and become a stronger voice for population health. Our accountability to our patients does not start and end when they enter or leave our care. We can be proactive in improving the health of our communities, in order to reduce the burden of illness both in our network and in our neighbourhoods. We will also be better able to follow our patients and caregivers beyond the walls of the hospitals so as to monitor, measure and reconnect, if required. Our three organizations have a shared history of caring for the disadvantaged. Coming together will enable us to join forces in improving the lives of the marginalized or disadvantaged within our communities. Our new network will allow us to directly support the advancement of the Ministry of Health and Long- Term Care s Primary and Community Care transformation. We will develop common strategies, both within and across our sub-regions, to engage independent or small group physicians and improve access for their patients to our resources. Building on our existing community partnerships and leveraging our role as a system player will allow us to improve health and the social determinants of health for the populations we serve to a greater extent than we would as separate organizations. 2.3 SUSTAINING OUR SHARED PURPOSE CARE FOR THE DISADVANTAGED Social factors, such as income, education, housing and employment status, play a pivotal role in a person s health and well-being. These factors, known collectively as the social determinants of health, have been shown to particularly affect the health of inner city and urban populations. These issues are what inspire the work all three partners do in honour of our mission and founders, the Sisters of St. Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities Page 8

Joseph. Caring for, and being a voice for, the most marginalized or disadvantaged in our society is embedded in our day-to-day practices and a common purpose that unites the three organizations as we look ahead to integration. The new network will re-invest savings to protect and sustain programs and initiatives that help target and support our communities to manage the root causes of health inequity. Further, the integration will allow for greater sharing of health equity information and resources across our sites, helping us to design services that recognize diversity and enhance inclusiveness for all of those we serve, especially benefiting the marginalized or disadvantaged populations of our respective communities. Examples of programs that we have designed with a focus to address social determinants of health in the very diverse populations we serve include: The Transition to Community Fund at Providence supports those who are disadvantaged with the services and/or tools needed to safely return home or to the community following their hospital stay. Since it was established in 2010, the fund has helped close to 350 people transition home by paying for items such as: assistance from personal support workers; fees and subscriptions to services such as medical alert systems; equipment such as wheelchairs and assistive devices; home supports such as ramps, safety bars, beds and other furniture; and services for the home such as extreme cleanings. Without this support, many of these patients would remain in hospital in Alternative Level of Care. In partnership with the Toronto District School Board, St. Joseph s operates a paediatric clinic at Parkdale Public School to help give children in our community a healthy start. With specialties in family medicine, paediatrics and neurology, the team provides much needed support to families to identify and address health challenges that are having an impact on their child s academic performance. The clinic has seen more than 400 visits in its first year from students and their siblings who live in the diverse community of Parkdale. Recognizing that language can be a barrier to receiving care and that 60 per cent of students at Parkdale Public School speak a language other than English at home, the clinic uses the Health Centre s interpreter services during appointments to facilitate understanding and ensure all health issues are addressed. Recognizing that income plays a large role in a person s health, St. Michael s employs a full-time health promoter whose specific focus is to help improve the income security of patients living in poverty. Patients are referred to the health promoter by their doctor, and she helps them navigate the government s social services system, including programs such as Ontario Works and the Ontario Disability Support Program. She also helps patients reduce expenses, complete their taxes, set up bank accounts, access free programs, budget and save for emergencies. The IGNITE (addressing income security in primary care) randomized controlled trial will evaluate this position, the results of which can help inform policy makers about future interventions to address poverty as a health issue. Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities Page 9

2.4 ENHANCING OUR ACADEMIC AND EDUCATION MANDATES Together, all three partners will leverage our individual strengths in education and research to collectively increase activity in these areas and value for the broader health-care system, as well as for the people and communities we serve as a larger community-based network. Expanding our research focused on urban health will increase the wealth of information that can help us better understand the determinants of health and their impact on the health of our community. Clinically, we will offer opportunities for medical, nursing and health professionals to train in a variety of care settings across the full spectrum of care. As a new network, we will be able to recruit and retain outstanding physician leaders, clinicians, staff and volunteers by offering expanded clinical, education, research and management experience across multiple sites. EDUCATION Our organizations have similar commitments to improving care through education mandates that include a superior learner experience and educating all healthcare professionals, patients and their caregivers. The Fitzgerald Academy for training undergraduate medical students is managed through St. Michael s and supported by St. Joseph s through student placements and teaching. St. Michael s, Providence and St. Joseph s all have academic mandates through a number of established affiliation agreements with Canadian and international institutions. In the short term, these agreements would not need to fundamentally change under an integrated model. There are opportunities to maximize and innovate our approach to academic and community partnerships and streamline management of future academic affiliations across an integrated health network. Furthermore, integration would provide future trainees with a wider exposure of learning in diversified learning contexts across the health-care continuum. Continuing education, professional and faculty development are also priorities for all three organizations in order to ensure we provide high quality and safe care that is evidence informed, and education is provided by the most qualified staff and physicians. All three organizations have an articulated mandate to support patient and family education, as well as commitments to collaborative learning environments that include all health professions, patients and their caregivers. Overall, the organizations believe their academic mandates will be enhanced through integration and become a driver in attracting and retaining top talent at both trainee and staff levels. Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities Page 10

RESEARCH AND KNOWLEDGE TRANSLATION St. Michael s plays a critical research role within Canada and internationally, operating the Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, an international healthcare research and education centre developing innovative training programs, and helping translate knowledge into practice. St. Joseph s is beginning to define and establish a community-based research program. Providence has over recent years focused on rigorous evaluation and research that can quickly be applied at the bedside. All three organizations share a common interest in knowledge translation and research that aligns with the care we provide, ultimately bringing the applications of innovative research to the frontline of care. Each organization will continue to pursue research mandates that serve its communities. A new integrated health network would offer all three organizations opportunities to leverage shared research resources and processes, and provide access to an overall larger base of researchers and patients and populations while driving opportunities for innovation spanning community-based and international borders. In summary, the three organizations have a shared purpose to advance the health of our urban communities providing health services across the spectrum of care for all our patients from primary care, secondary community care, tertiary care, quaternary care services to post-acute through rehabilitation, palliative care and long-term care. As Catholic health organizations, our shared purpose is rooted in our common mission of providing excellent, compassionate care to all we serve, including those who experience marginalization or disadvantage. Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities Page 11

3. OUR SHARED HISTORY OF PARTNERSHIP: A FUTURE FULL OF OPPORTUNITY The three organizations have demonstrated a commitment to extend their reach beyond the walls of their respective institutions into the community, to improve health and the overall social determinants of health, rather than just treat disease a commitment rooted in our histories from the Sisters of St. Joseph. Providence Healthcare provides rehabilitation, palliative care, long-term care and community programs in Toronto. Through Providence Hospital s inpatient and outpatient programs, adults of all ages rehabilitate after strokes, orthopaedic surgery, lower limb amputations or other complex medical conditions generally associated with aging. The hospital s palliative care program offers seven days a week patient admissions for people approaching the end of life. Short-term respite admissions are available for palliative patients who require inpatient care before returning home to spend their final days. The Cardinal Ambrozic Houses of Providence long-term care home provides the highest standards of comfort, care and safety to 288 residents. An Adult Day Program for people with moderate to severe dementia cares for the most vulnerable clients, around the clock. Patients, residents, caregivers and families, as well as the general community, have access to the support and education resources of the Scotiabank Learning Centre. St. Joseph s Health Centre is a community teaching health centre affiliated with the University of Toronto that has served the communities of west Toronto and beyond for nearly a century. It is a vital resource for people and families at every stage in their lives, including family birthing, specialized paediatric services, family medicine and dedicated programs for the growing senior population. Its teams also help to diagnosis and manage chronic illnesses at its ambulatory clinics. St. Joseph s areas of specialty include mental health, cardiology, diabetes and nephrology, with St. Joseph s also being home to tertiary care programs in bariatrics, thoracic surgery and hepatobiliary surgery. These programs support not only our local community, but are a valued resource at a regional and provincial level. St. Michael s Hospital is a fully affiliated University of Toronto teaching and research-intensive hospital, and is a hub for care, ranging from primary and secondary care to highly complex tertiary and quaternary care for patients from across the province. St. Michael s is downtown Toronto s adult trauma centre an urban focal point for neurosurgery, complex cardiac and cardiovascular care, diabetes and osteoporosis care, minimally invasive surgery, and care of those who experience disadvantage. It is also one of the province s major sites of care for critically ill patients and runs provincial programs in the treatment of diseases such as multiple sclerosis and cystic fibrosis the largest of such clinics in Canada. Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities Page 12

The table below summarizes the organizations common mission, vision and values. Our Shared Missions St. Joseph s Health Centre St. Michael s Hospital Providence Healthcare St. Joseph s Health Centre is a Catholic community teaching hospital providing health care services that reflect the Gospel values of respect, dignity, and compassion. We are committed to fostering a healthy community for all. Working in partnership with our community, we reach out with the healing ministry of Christ to the sick, the disenfranchised and the disadvantaged. St. Michael s Hospital is a Catholic academic health care provider, fully affiliated with the University of Toronto and committed to innovative patient care, teaching and research. Established in 1892 by the Sisters of St. Joseph to care for the sick poor, St. Michael's Hospital remains dedicated to treating all with respect, compassion and dignity. Providence Healthcare, a Catholic healthcare organization, is inspired by the legacy of the Sisters of St. Joseph of Toronto to be a welcoming community of compassion, hope and healing. We provide rehabilitation, palliative care, long-term care and community programs. Our Shared Visions St. Joseph s Health Centre St. Michael s Hospital Providence Healthcare Advancing the Health of Our Community by being Canada s Best Community Teaching Health Centre World Leadership in Urban Health We will extend our community of expert care beyond our walls. We will give the people we care for the knowledge and confidence to stay healthy and safe at home, for as long as possible. Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities Page 13

Our Shared Values St. Joseph s Health Centre St. Michael s Hospital Providence Healthcare Human Dignity Each person is valued as a unique individual with a right to respect and acceptance. Human Dignity We value each person as a unique individual with a right to be respected and accepted. Human Dignity Everyone has intrinsic value and is worthy of respect. Sanctity of Life Every life is a sacred gift that has meaning and value. Excellence A commitment to strive for the best in care, education, research, and the quality of work life. Compassion A quality of presence and caring that fosters healing and wholeness. Social Responsibility Actions that promote the just use of resources entrusted to us for the enhancement of human life, both personally and corporately. Excellence We value quality in care, work life, education, and research. Compassion We value a quality of presence and caring that accepts people as they are and fosters healing and wholeness. Social Responsibility We value integrity and the promotion of the just use of resources entrusted to us for the enhancement of human life. Compassionate Service The needs of every person are attended to with thoughtfulness, understanding and sensitivity. Social Responsibility Accountability is demonstrated by the prudent use of the resources given to us in trust. Community of Service Communities of people working together in a climate of mutual support that enables healing and the fulfillment of human potential. Community of Service We value a work climate of mutual trust and harmony to enable healing, collaboration, and the fulfillment of human potential. Pride of Achievement We value our colleagues, our work and our accomplishments and take pride in bringing our rich tradition of hope and healing to every person in our care Social Justice Each person is treated in a fair and equitable manner, according to one s needs. Community People of diverse backgrounds gather together with a shared purpose and support each other in hope and celebration. Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities Page 14

3.1 OUR SHARED HISTORY OF COLLABORATION The three organizations have a strong history of partnership that has improved value for patients, residents and clients. Examples of the success we have already achieved by working together include: St. Joseph s, Providence and St. Michael s are part of the Hospital Collaborative on Vulnerable and Marginalized populations who work in partnership with other Toronto hospitals to promote cooperation and planning to address caring for these populations. The work looks at best practices and sharing resources with a focus on four common areas: those with addictions, the non-insured, elder care/seniors and health equity. The Centre for Clinical Ethics (CCE), the first ethics service of its kind in Canada, is jointly sponsored by Providence, St. Joseph s and St. Michael s. The CCE also provides ethics services to nine other institutions across the province, and is home to a fellowship program in clinical ethics which generates new leaders in this important area. By partnering, ethics leaders with specific specialties are able to assist staff and physicians across sites on many different ethical issues that rise in the course of care delivery. Staff from Providence work on-site at St. Michael s to help patients move in a more timely and efficient way from acute care to begin their rehab. Meeting with patients in acute care while still recovering from an illness or surgery has positively impacted patients subsequent discharge from rehab. At this early stage, we talk about how we can get them home through a combination of inpatient and outpatient care, and how we will help them achieve their maximum potential. Providence and St. Joseph s are part of the spread of the work of St. Michael s and others in sociodemographic data collection. Known as the Health Equity Survey, this collection of sociodemographic data allows the three organizations to better understand the people served. Toronto Heart Attack Collaborative, or THAC, an innovative alliance for patients having a type of heart attack known as a STEMI (ST segment Elevation Myocardial Infarction). Even if a patient is within the St. Joseph s catchment area, they will be taken by ambulance directly to St. Michael s from their home for interventional STEMI treatment a procedure that is not offered at St. Joseph s then returned to St. Joseph s for ongoing care. With this alliance, patients get the best and most appropriate treatment as fast as possible. Acknowledging that St Michael s did not have a thoracic surgical service, it signed a Memorandum of Understanding with St. Joseph s. With this partnership, patients requiring emergency thoracic surgery services now have access to the combined expertise of the thoracic surgery services at St. Joseph s and the respirology and general surgery services at St. Michael s for the management and treatment of lung cancer and benign thoracic surgical disease. Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities Page 15

St. Joseph s and St. Michael s partner to care for patients who experience a stroke. By transferring patients across sites, patients are able to access the most appropriate diagnostic treatments before returning to their local hospital to begin rehabilitation. St. Michael s and Providence work together as members of the South East Toronto Stroke Network St. Joseph s and St. Michael s are partnering to integrate and build a leading laboratory service that is advancing excellence in patient-centred care through a commitment to diagnostic excellence, collaborative care, research, and education. Currently there are 27 physicians who have privileges at both St. Joseph s and St. Michael s; they also share chief information and finance leadership positions, as well as a shared Information Services help desk. These partnerships demonstrate how the combined strength of each of the organizations improves the quality of patient care. In examining these collaborations, the organizations are confident their collective success is due to the fact they enhance the core role all three partners play within their communities, and clearly show the mutual respect their people have for each other. It is this vital foundation of mutual respect that will continue to be leveraged as a key success factor going forward in a newly integrated network. 3.2 OUR SHARED STRATEGIC ALIGNMENT Within the past three years, Providence, St. Joseph s and St. Michael s launched new strategic plans. Providence is aiming to help people flourish at Providence and at home, St. Joseph s is advancing the health of the community by being Canada s best community teaching health centre, and St. Michael s is striving for world leadership in urban health. Within the strategic plans, the organizations emphasize the importance of improving the patient experience through partnerships. By coming together and creating a new health network, the organizations will achieve significant progress towards each of their plans by aligning service and investing to improve quality, patient safety and the patient experience. The following table illustrates the strategic directions of each plan, which is publicly posted on the organizations websites. Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities Page 16

Vision Statement Strategic Plan Timelines Strategic Directions Success Factors St. Joseph s Health Centre St. Michael s Hospital Providence Healthcare Advancing the Health of World Leadership in Urban Providence Healthcare Our Community by being Health will extend our Canada s Best Community community of expert care Teaching Health Centre beyond our walls. We will give the people we care for the knowledge and confidence to stay healthy and safe at home for as long as possible. 2015-2020 2015-2018 2015-2020 Creating Seamless Transitions of Care Delivering an Exceptional Experience Shaping Care Through Teaching & Education People Information Management Physical Space Financial Health Partnerships Advanced Systems of Care for Disadvantaged patients Comprehensive Care for Entire Urban Community Excel in the Care of Critically Ill Patients People Information Management Infrastructure Fundraising Integration BEST Care Experience BEST Community of Experts BEST Relationships Beyond Our Walls Quality and Safety People Community Engagement Information Management Physical Space Financial Health 3.3 A NEW HEALTH NETWORK: STRONGER FOR PATIENTS Through integration, the new organization will become one of Canada s largest health networks. We will leverage our increased size to translate and innovate across the full spectrum of care from primary care, secondary community care, tertiary care, quaternary care services to post-acute through rehabilitation, palliative care and long-term care, while investing in world-class research and education. Together, we will provide an enhanced experience for everyone who works and studies with us and for those who we provide care to by specifically: Improving quality and patient safety through the sharing and adoption of standard care protocols and best practices. Expanding our research focused on urban health through increased activity in a larger community-based network to study and better understand the determinants of health and their impact on the health of our community. Leveraging the strengths of our spiritual care and ethics teams to ensure continued support for the mind, body and spirit of the people we care for. Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities Page 17

Recruiting and retaining outstanding physicians, health discipline professionals, leaders, staff and volunteers by offering expanded clinical, education, research and management experiences across multiple sites. Enhancing our academic and education mandate by offering opportunities for medical, nursing and professional practice learners to train in a variety of care settings. Using our roles as Toronto Central LHIN resource hospital partners to improve population health outcomes. Reinvesting in front-line care through a minimum of annualized savings of between $8.8 million and $14.3 million. As the table below illustrates, the organizations are large employers, significant providers of care and important centres of teaching and education in the province. Additional information about our programs and services is provided in Appendix A. Hospital Providence Healthcare St. Joseph s Health Centre St. Michael s Hospital New Network Inpatient Beds 245 392 463 1,100 Long-term Care Beds 288 - - 288 Emergency Visits - 101,077 73,750 174,827 Ambulatory Care Visits 32,000 254,755 507,825 794,580 Surgeries - 27,471 30,025 57,466 Births - 3,341 2,764 6,105 Employees 1,201 2,851 6,066 10,118 Medical Staff (physicians, 48 460 843 1,351 dentists, midwives) Volunteers 370 300 560 1,230 Medical Trainees & Health 793 1,010 3,976 5,779 Professional Learners *This table represents 2015/16 data 3.4 HELPING TO ADVANCE ONTARIO S PATIENTS FIRST ACTION PLAN Since 2014, the Ministry of Health and Long-Term Care has focused on putting patients at the centre the right care, right place, right time as a strategic priority and, more recently has been given a mandate to deliver coordinated and integrated care in the community and closer to home, including in the home. Our voluntary integration supports the ministry s Patients First Action Plan by improving access and connecting services. We will improve access to quality care for all our patients, residents and clients by creating a new health network that offers the full spectrum and seamless transitions of care from primary to post-acute through rehabilitation, palliative care and long-term care. At the same time, we can reduce system fragmentation by connecting services that enables interventions earlier in the patient s journey. For example, rehabilitation specialists from Providence will become involved earlier in the patient s journey Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities Page 18

and support care planning across the new network that optimally prepares patients for rehabilitation and potential early transition whether to Providence, to other health service providers or home. By becoming an integrated health network, the three organizations also believe we will be a stronger voice and source of information within the City of Toronto and Toronto Central Local Health Integration Network for community population health specifically focused on patients social determinants of health like greater access to housing, nutrition and mental health and addiction services for the marginalized or disadvantaged populations we serve. Together, we will make decisions based on value and quality, to sustain our network for our communities for generations to come by reinvesting in frontline care, making the best use of the skills and capacities of our clinical service providers, and by continuing the promise in all of our strategic plans to collaborate and engage patients, clients and residents in the care and services we provide. 3.5 CONTRIBUTING TO THE TC LHIN S POPULATION HEALTH GOALS Our voluntary integration aligns and supports the strategic goals and priorities of the Toronto Central LHIN, specifically addressing the needs of a highly complex patient population including the disadvantaged, improving the patient experience, and designing health care for the future that is innovative and delivers value and sustainability through more efficient use of resources. This network will create opportunities to enhance our collective roles as Toronto Central LHIN resource partners to improve population health outcomes. Together we will help make Toronto a healthier city by being proactive in improving the health of our communities by being able to better follow our patients and caregivers beyond the walls of our three organizations to monitor, measure and reconnect if required. We will help patients and their families obtain better access to a more local and integrated health care network, by enabling consultative approaches to focus bi-directionally through primary care, acute, post-acute, residential care and community, putting our patients at the centre of their care improving their experience and delivering higher quality care. Together, our organizations will also be able to enhance our academic and education mandate by offering opportunities for medical, nursing and professional practice learners to train in a variety of care settings, spreading innovation and new knowledge to the patient care we provide. We will re-invest savings into frontline care and in protecting and sustaining programs and initiatives that help target and support our communities to manage the root causes of health inequity. The integration will allow for greater sharing of health equity knowledge and resources across our sites, helping us design services that recognize diversity and enhance inclusiveness, especially benefitting the Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities Page 19

marginalized or disadvantaged populations of our respective communities. Please refer to the completed Health Equity Impact Assessment for further information. All three organizations have many referral partners, and this will continue into the future. We expect that through this integration, we will become a stronger partner for other health service providers in the TC LHIN and beyond. Improved access is a cornerstone of our proposal and we will continue to honor existing relationships with partner hospitals with regards to referrals, specifically for services such as rehabilitation at Providence Healthcare. The table below highlights referral patterns to Providence over the past three fiscal years from key acute-care partners. Admissions and Referral Sources to Providence Healthcare Michael Garron Hospital Sunnybrook Health Sciences St. Michael's Hospital Scarborough Hospital North York General Other Acute Home and Retirement Home 0 200 400 600 800 1000 1200 2014/15 2015/16 2016/17 Remaining Committed to the Integration Priorities of the TC LHIN The three organizations will also continue to support the TC LHIN s broader integration efforts with health care providers through its sub-regions. St. Joseph s and St. Michael s are Hospital Resource Partners and will continue to play leadership roles within the LHIN and assigned sub-regions to provide a local lens that will help LHINs better address patients needs at the local level. What sub-regions are supported? With a strong footprint in primary care through its Academic Family Health Team, St. Michael s Hospital is committed to continuing to support its partners in mid-east Toronto. Mid-East Toronto has the highest proportion of persons and children under 18 living below the low income measure (Low Income Measure After Tax) among the sub-regions and compared to Toronto Central LHIN. Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities Page 20

As stated above, Providence will maintain its hospital partner commitments in East Toronto. As a key community support service, Providence s Adult Day Program will continue to offer much-needed caregiver support, and its long-term care home, the Cardinal Ambrozic Houses of Providence, will continue to provide quality care for its residents. East Toronto has the highest rate of recent immigrants (8%), visible minorities (41%), and persons of aboriginal identity (3,540). As the most westerly acute care hospital in the TC LHIN, St. Joseph s is a hub for care receiving the largest number of emergency department visits in the city. In 2014/15, West Toronto sub-region had higher prevalence rates for Diabetes, Asthma, High Blood Pressure, Mental Health Visits & COPD compared to Toronto Central LHIN. Remaining Committed to the Communities We Serve As outlined, by entering into this partnership all three organizations believe there are significant benefits that will sustain and enhance quality of care for our patients. We recognize however that change can cause concern related to accessing service to any of our three sites. We remain committed to a three hospital model - consistently providing quality care to the communities we are located in. Patient flow to other referral partners will continue at all three sites. The organizations receive and refer patients from within and outside of the TC LHIN and enjoy strong relationships with the CCAC and other rehabilitation partners such as West Park Healthcare Centre, Runnymede Health Centre, Toronto Rehab and Bridgepoint Health. 4. OUR SHARED ANALYSIS: FINDINGS As the organizations began to discuss the potential of an integration, a Joint Board Steering Committee (JBSC) was established to provide governance oversight on the integration analysis. Guided by a Memorandum of Understanding, the goal of the JBSC was to identify a governance and management model that would meet the following objectives: enhance patient, resident and client care in the communities we serve. generate administrative and operating efficiencies to reinvest in patient/service delivery for the communities and populations we serve. create greater economies of scale to leverage investments and resources more effectively across both sites. advance sustainability locally and within the health system. leverage the strengths and distinct brands of each organization. respect each organization s history and identity. Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities Page 21

To facilitate its review, working groups were established to provide an analysis of the impact, benefits, and risks integration may have on: Patient Care Medical Staff Model Information Systems and Technology Human Resources Finance Research and Education Governance Due Diligence During this process, the JBSC also began a community and health system partner engagement exercise to seek advice on how a new health network would benefit patients and the system. A summary of our shared engagement is included in section 5 of this proposal. Scope of Work Underlying the analysis is the assumption all three organizations sites would remain in place and will continue to service each local community. Clinical program and medical department integration was not reviewed. Rather, the analysis examined whether the organizations could operate more efficiently under a common management structure thereby enabling further investment in frontline patient services. 4.1 MEDICAL STAFF Physicians play an integral role in the operations of a hospital providing not just front-line patient care but driving quality improvement, management of resources, and mentoring new staff and students as part of a collaborative care team. The majority of medical staff are independent professionals who are not employed by the hospitals, but are granted privileges by the board of directors to provide patient care within their licensed scope of practice. They also have varying payment arrangements and in the case of some physicians, teaching and/or research requirements through appointments with an associated school of medicine. St. Michael s is a fully affiliated teaching hospital of the University of Toronto. Full-time St. Michael s physicians are required to have an academic appointment. St. Joseph s and Providence Healthcare are community affiliated teaching hospitals whose medical staff members may have academic appointments. KEY PRINCIPLES Our Shared Purpose: Advancing the Health of Our Patients and Our Urban Communities Page 22