Overview The Central East Local Health Integration Network is one of 14 Local Health Integration Networks (LHINs) established by the Government of Ontario in 2006. LHINs are community-based organizations with the responsibility to plan, co-ordinate, integrate and fund health care services at the local level. LHINs provide funding for hospitals, longterm care homes, community care access centres, community support services, community mental health and addictions services and community health centres. This document outlines the process undertaken by seven health service providers (HSPs) to develop a DRAFT Integrated Service Delivery Model for LHIN-funded health services delivered in Northumberland County. The seven HSPs are: Campbellford Memorial Hospital (CMH) Campbellford Memorial Multicare Lodge (MCL) Community Care Northumberland (CCN) Branch 133 Legion Village ( Legion Village or LV) Northumberland Hills Hospital (NHH) Port Hope Community Health Centre (PHCHC) VON Canada Ontario Branch (VON) This group of health service providers has been meeting at the direction of the Central East LHIN since January of this year as part of a facilitated integration process. Similar discussions have been occurring concurrently in other regions of the LHIN, including Scarborough, Durham, Haliburton/Kawartha Lakes and Peterborough. The aim of the discussions was the development of a DRAFT Service Delivery Model(s) recommending how hospitals and community-based health services could be delivered in the future to improve client access to high-quality services, create readiness for future health system transformation and make the best use of the public s investment by identifying integration opportunities. Using a four-step process that has included looking at integration fit, pros/cons, risks and reinvestment opportunities, the seven Northumberland County HSPs (referred to collectively as the Northumberland Integration Planning Team, or IPT) have developed an initial DRAFT Integrated Service Delivery Model for consultation. The process is at the point of seeking broader input on whether the proposed DRAFT Integrated Service Delivery Model will improve people s experiences in accessing, receiving and/or delivering hospital and community-based health services. 1
Therefore this document is now being shared with the community - including patients, clients and family caregivers, staff, board members, community residents and other health care partners - in order to seek their comments and ideas. The feedback collected during this engagement process will support the development of a FINAL model which will be presented to each organization s Board of Directors and the LHIN Board in February 2014. Building on Success The current integration planning process extends and builds on processes that the area s HSPs have initiated over the past several years. To date there have been successful examples of integration in: Shared Clinical Management of Hospital-based Mental Health services through voluntary integrations (NHH, CMH and Ontario Shores Centre for Mental Health Sciences). Integration has significantly improved patient care quality and access. Formalization of the working relationship between CMH and Trent Hills Family Health Team Back office consolidation between Campbellford Memorial Hospital and Campbellford Memorial Multicare Lodge Integrated Chronic Disease Management program in Trent Hills Shared Lab resources between Campbellford Memorial Hospital and Ross Memorial Hospital Central Ontario Healthcare Procurement Alliance (COHPA) (supply chain management) Integration of hospice services with Community Care Northumberland (2010) Methodology The Northumberland IPT has been meeting since January 2013 to identify and assess opportunities for a more integrated delivery system to improve access, enhance patient care and achieve a more efficient delivery system. The Boards of all seven health service providers have also been extensively involved in the discussions. The Integration Planning Team has analyzed: Gaps and needs in current primary care, acute care and community services System shortcomings from a patient/client/caregiver perspective Opportunities for any new dollars realized to be reinvested in front line services Pros, cons and risks of a number of organizational structures The ability of new organizational models to contribute to the integration objectives Feedback from several community partners on options and opportunities. 2
Current State The seven organizations provide a wide range of services across all of Northumberland County. It is important to note that there is very little duplication of services between providers. The range of services is included in Appendix A. It is also important to note that under any proposed service realignment, all existing services will continue to be provided. Collectively, the seven organizations have a budget of approximately $94 million, of which $65 million is provided by the Central East LHIN. The balance of the funding comes from a range of other sources including fund raising and donations, municipal contributions, Ministry of Health and Long-Term Care, and fees and recoveries. Organization Northumberland Hills Hospital Campbellford Memorial Hospital Legion Village Cobourg Campbellford Memorial Multicare Lodge Port Hope Community Health Centre Community Care Northumberland VON Services Provided in Northumberland Acute and critical care services including; inpatient care, outpatient services, laboratory & diagnostics, restorative & rehabilitation Acute care services; inpatient care, outpatient services, laboratory & diagnostics, convalescent & rehabilitation Supportive housing Supportive housing Primary care services, wellness, prevention and education programs, diabetes programs Community Support Services: (ie Friendly Visiting, Meals on Wheels, Hospice Palliative Care, Transportation, etc.) Adult day programs SMILE Brighton; In Home respite Brighton and Private pay in Northumberland; SMART program; Nursing Services; Assisted Living for High Risk Seniors 3
Gaps and Needs in the Current State In assessing new models of care provision, the Integration Planning Team has attempted to address the following (not exhaustive) gaps and needs: Lack of access to some services (e.g., Adult Day Programming) Wait lists for some services (e.g., primary care, supportive housing) Transitions between home, hospital, community and primary care Difficulty for patients navigating through all of the programs, services and providers Lack of standardized service delivery and/or standardized clinical procedures across the system The need for patients to repeat their stories with every provider that they encounter Different access to services across the county. There are also significant financial pressures in today s health care system and service providers must find new opportunities to provide and maintain consistently high quality programs and services to meet growing needs and changing demands. The Integration Planning Team has identified a number of immediate priorities for service and/or system redesign in Northumberland County. Coordinated hospice/palliative care for Northumberland County residents Expanded in-home supports for seniors through development of a hub and spoke model for assisted living services Improved technology (e.g., common technology platforms; emergency response units; shared records and information) Expanded Adult Day Programming Improved referral system between services and more seamless referrals for clients between the Community Care Access Centre (CCAC) and Community Support Services Integrated and enhanced approach to chronic disease management, including more focus on self-management Access to standardized assessment information on clients, using Resident Assessment Instrument (RAI) tools that can be accessed by all providers. 4
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Key Elements of the DRAFT Integrated Service Delivery Model Through this DRAFT Integrated Service Delivery Model, the Integration Planning Team is recommending the following steps to lay the foundation for further system improvements and integration. Subsequent work would expand on these initiatives and identify potential for further integration. If approved as part of a FINAL Integration Plan, the seven Health Service Providers would pursue: 1. Continued Development of a Rural Health Hub in Trent Hills a. Transfer of accountability for LHIN-funded supportive housing services from Multicare Lodge to Campbellford Memorial Hospital b. Consolidation of one or more back office functions (Human Resources, Information Technology, Finance, Procurement) between Campbellford Memorial Hospital, Community Care Northumberland and Multicare Lodge 2. Development of Northumberland County-Wide (Regional) programs a. Integrated strategy for hospice/palliative care b. Integrated strategy for Diabetes Education, Care and Management 3. Development of an Assisted Living for High Risk Seniors and Supportive Housing Model in Northumberland 4. Development of a Strategic Alliance between Northumberland Hills Hospital and the Port Hope Community Health Centre 5. Improved Integration of Information Technology Capacity across the County 6. Creation of a Northumberland Health System Transformation Council. Phase 2 of this initiative would build on the experience and learnings of these initiatives, and would utilize the Health System Transformation Council to extend and enhance integration opportunities. 1. Continued Development of a Rural Health Hub in Trent Hills The health hub model, which is a model supported by the Ontario Hospital Association, is a highly successful model for providing health care and community support services in various communities across Ontario. In Trent Hills a rural health hub model has been successfully providing a range of local services including acute care, primary care (through a partnership with the Trent Hills Family Health Team), and supportive housing (through Campbellford Memorial Multicare Lodge) through their common health care campus. 6
The IPT is recommending the continued development of the rural health hub model through: The formal transfer of accountability for LHIN-funded supportive housing services from Multicare Lodge to Campbellford Memorial Hospital The consolidation of one or more back office functions (Human Resources, Information Technology, procurement, finance) between Campbellford Memorial Hospital, Community Care Northumberland, and Multicare Lodge. It is important to note that Multicare Lodge would still be accountable for the delivery of housing services overseen by its own board of governors. Rationale Formalizes an existing relationship between CMH and MCL Enhances the quality of back office/administrative functions at CCN Formalizes and sets a foundation for a closer working relationship between CMH, MCL and CCN Recognizes the uniqueness of the Trent Hills health care campus Provides a hub for care across the continuum (primary, acute and community) Remains responsive to local need Provides a foundation for further expansion and integration of health and community services into the hub model Provides an opportunity for integrated program leadership Provides an opportunity to consider further integration of Community Support Services delivered by organizations across municipal boundaries (e.g., collaboration with agencies in Peterborough and those in the SE LHIN). 2. Development of Northumberland County-wide (Regional) Programs IPT members are recommending the development and implementation of a number of high priority, County-wide clinical programs. The first two programs being proposed are hospice/palliative care and diabetes education, care and management. Integrated Strategy for Hospice/Palliative Care Under the Small Rural Northern Hospital Transformation Fund, work has begun to map the current state and to identify opportunities for a coordinated palliative care strategy. All seven of the HSPs have committed to continued work on this initiative. In doing so, the IPT would work closely with the Central East LHIN and Central East Hospice Palliative Care Network to align strategic planning priorities, goals and objectives. For example: Supporting patient choice and place of death Promoting consistent communication and care planning across settings 7
Leveraging and building upon current programs and services to support a holistic inter-professional palliative team approach Expanding education and training for primary, secondary and tertiary levels of care Optimizing palliative care delivery through hospitals including inpatient/outpatient palliative clinics Enhancing consistent access to community services, based on need The lead agency proposed by the IPT for this initiative would be Campbellford Memorial Hospital. Integrated Strategy for Diabetes Care and Management As a key enabler to county-wide chronic disease prevention and management, a Northumberland strategy for diabetes prevention, care and management would be developed. The existing programs across Campbellford Memorial Hospital, the Port Hope CHC, Northumberland Hills Hospital and Community Care Northumberland would work closely with the Central East LHIN to achieve the following goals, objectives and benefits: Support long term planning for diabetes care in alignment with the Central East LHIN and provincial priorities Engage primary care and other diabetes service providers to facilitate the adoption and integration of consistent, evidence based standards and best practices in diabetes management Coordinate services to support a more integrated, patient centered, accessible, equitable and effective system that offers best value for the patients Analyze and review quarterly report submissions (financials and indicators) comparing best practices and benchmarks to diabetes care i.e. wait times, number of patient visits per year, number of patients seen per year. Improve access to/navigation through programs and care by patients and clients (e.g., the possibility of centralized intake); ease of navigation Improve coordination of care Consistent use of clinical best practice Improve efficiency through human resource deployment, consolidating responsibility for program oversight and exploration of joint leadership. Improve consistency of communication across providers and to patients/clients and caregivers Standardize practice, protocols and education tools Coordinate (and expand) programs between acute care, primary care and community services. Expand programs to long term care and other settings. 8
3. Development of an Assisted Living & Supportive Housing Model in Northumberland Legion Village has been successfully delivering supportive housing programs and services to its residents in the Cobourg area for many years. It is currently funded by the LHIN to provide housing support to 70 clients. In 2013-2014, the VON will assume responsibility for the creation of new units of Assisted Living for High Risk Seniors in Norwood-Havelock, Campbellford and Cobourg. The VON program will enable the provision of more support to more clients, in their own homes. By transferring the of accountability for the delivery of personal support services from Legion Village to VON, potential efficiencies in service delivery and back office functions could be achieved. Again, it is important to note that Legion Village would still be accountable to provide housing services overseen by its own board of governors. A Service Level Agreement with the supportive housing in Campbellford would further strengthen the development of a County-wide supportive housing/assisted living strategy. Rationale Potential efficiency gains through the transfer of front line and back office functions to a larger entity (VON) Ensures delivery of consistent service across all supported living housing units Will improve access to community assisted living services Provision of support services to clients in their homes. 4. Development of a Strategic Alliance between Northumberland Hills Hospital and Port Hope Community Health Centre Linkages between primary care and acute care are critical to addressing such issues as effective transitions for patients, reducing Emergency Department visits, reducing readmissions, and effectively managing chronic disease to reduce the need for acute care. The IPT is recommending that the Port Hope CHC and Northumberland Hills Hospital develop a Memorandum of Understanding/Service Level Agreement that would 9
address specific strategies to improve transitions for patients between hospital and primary care and to enhance the delivery of care to patients. The Agreement would contain key accountabilities, time frames, and deliverables. Priority in Year 1 would include: Investigation, development and implementation of an IT strategy to support electronic health record connectivity between NHH and PHCHC. Clients of the PHCHC who visit the NHH Emergency Department would be flagged, and Emergency Department staff would be able to access and read clients charts at the PHCHC. Conversely, staff at the PHCHC would be able to access patient records from NHH to follow up after hospital discharge. Sharing and coordinating the strategy and resources for chronic disease prevention and management, beginning with diabetes. o Beginning in January, 2014 staff from the Port Hope Diabetes Education Centre (DEC) team would begin to provide education and support to patients and staff on the dialysis unit at NHH. (Approximately 40% of dialysis patients at NHH are diabetic). o Diabetic patients who are discharged from NHH would be directed back to the CHC for ongoing care and management of their diabetes as appropriate o The next phase of collaboration would involve the CHC DEC team offering complex diabetes education for admitted patients and providing the ongoing spread of diabetes best practices to all relevant health care professionals Sharing and coordinating the strategy and resources for a smoking cessation program o As one example, the team could focus on the development of a preoperative Smoking Cessation Program, with patients being referred to the PHCHC Smoking Cessation Program to reduce surgical risk and improve post-operative outcomes. Following surgery, patients would be directed back to the CHC for ongoing counseling and support. Continue to build on the collaboration that currently exists between the NHH Community Mental Health Program and the Port Hope CHC. The NHH Community Mental Health Program would refer lower acuity mental health patients from NHH to the PHCHC for initial counseling, with referrals back to the hospital if necessary. These are patients who fall outside of the service parameters for NHH, FourCast Addiction Services and the Canadian Mental Health Association. An agreement that NHH would provide advice on an as-needed basis to enhance the CHC s Human Resources and Organizational Development capacity. Agreement would extend the opportunity for CHC staff to participate in relevant education and training opportunities provided by NHH (e.g., process improvement/lean training; e-learning). 10
Rationale Share resources Standardize clinical practice, protocols and education through dissemination and application of best practice guidelines Improve knowledge transfer and dissemination Improve transition for patients from hospital to home/home to hospital Establish foundation for partnerships with other primary care models in West Northumberland Enhance use of staff resources; using scarce staff resources as efficiently as possible (diabetes program) Reduce Emergency Room visits; divert patients from the ED to more appropriate resources (mental health; diabetes program; seniors support) Decrease Length of Stay (LOS) and reduce post-surgical complications (smoking cessation) 5. Development of Enhanced Information Technology (IT) Capacity Robust information and data are key to informing system changes and to improving patient care and the patient experience. The Integration Planning Team is recommending a series of steps in the development of enhanced information systems and management that would facilitate data collection, data sharing and the use of common data sets to improve the quality of care. Use and Sharing of Common Data The Northumberland providers would also pursue the use and sharing of information to improve the patient experience and enhance patient care. The Resident Assessment Instrument (RAI) assessment and screener tools as well as the overarching Integrated Assessment Record (IAR) are useful clinical assessment tools used by the Community Support Service providers and the Central East CCAC. The RAI suite of assessment/screener tools and the IAR would be explored as an opportunity for more standardized assessment and collaboration between CSS, NHH, CMH and the PHCHC. The ability to share such information would reduce the need for patients, clients or caregivers to repeat their stories multiple times as they move across the system. All of the seven Health Service Providers would collaborate to assess what information systems are currently in use, what information can be shared using alternative mechanisms, and what interim steps can achieve improved sharing of patient data. 11
Rationale Patients will not have to repeatedly tell their stories every time they see a new provider Patient information will be up to date and accurate Patients will experience smoother transitions between hospitals and community Data quality and management will be improved. 6. Creation of a Northumberland Health System Transformation Council A Northumberland Health System Transformation Council would be established to continue the work of the integration initiative. The Council would identify further opportunities to improve the delivery of acute care, primary care and community support services for patients/clients and caregivers, and may identify further opportunities for consolidation, collaboration and efficiency gains between the organizations. The Council would include other LHIN- and non-lhin funded organizations such as Family Health Teams and the Central East CCAC. Preliminary interest in this Council has already been secured from the Northumberland Family Health Team, the Trent Hills Family Health Team, and the Central East CCAC. A Northumberland Health System Transformation Council would increase the likelihood of achieving sustainable change. Under the terms of a partnership agreement, the Council would have a (proposed) mandate to consider a range of health and community support service delivery issues, with a goal to improve the patient/client/caregiver experience and achieve system efficiencies. It would have agreed upon Terms of Reference, identified leadership, and a vision that is shared across its membership. Accountability would be secured through detailed MOUs. For LHIN-funded agencies, terms and conditions can be aligned with and monitored through health service provider accountability agreements (MSAAs and HSAAs). The Northumberland Health System Transformation Council would be a key mechanism to support the implementation of the Northumberland Health Link and the incorporation of PATH project learnings (Partners Advancing Transitions in Healthcare). The Council would assume responsibility for such initial priorities as Integrated IT solutions for Northumberland County providers, patients and clients Enhancement and coordination of non-urgent transportation Integrated care planning Strategic Leadership and Development of Regional Programs such as, o Comprehensive chronic disease management strategy 12
o Comprehensive hospice/palliative care and end-of-life strategy o Coordinated gerontology and seniors care strategy At start-up, the Council would be chaired by the CEO of Campbellford Memorial Hospital, and vice-chaired by the Executive Director of the Port Hope Community Health Centre. Benefits Establish a common vision for Northumberland Health and Community Services and a mission to support high quality care for Our Clients Longer term view and sustainability of solutions More robust solutions, County-wide Coordination of meal delivery programs in Port Hope A ready-made platform for the development and delivery of the Northumberland Health Link project (January 2014) A clearinghouse for the collection and dissemination of learnings from a wide range of projects and initiatives; reduce the potential for duplication of service development and delivery A clearinghouse for Requests For Proposals, to coordinate the rational development and delivery of programs and services A focal point for the coordination and delivery of regional programs and services A forum to pursue a regional IT strategy for system coordination and interoperability. Conclusion All of the Health Service Provider Boards reviewed the pros, cons and potential impact of a number of service delivery and organizational models. They have determined that the changes proposed above are an important first step in health system transformation that will improve patient/client care, be responsive to local health care needs, and will result in more effective and efficient delivery of services. The Boards of all seven Health Service Providers have expressed their commitment to continued exploration of opportunities for front line, back office, and/or governance and leadership integration through participation in and support for the Northumberland Health System Transformation Council. 13
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Appendix A 15