North Local Collaborative January 23, 2017

North Local Collaborative January 23, 2017

Get Social with your Local! Share thoughts, projects, and ideas about our North Sub-Region. Use the hashtag: #letsgetdowntolocal 2

Revisiting What to Expect October Session LHIN-wide subregion Framework (Nov Dec) January Session March Two activities: 1. Build framework for collaboration (vision, mission, success factors) 2. A Walk Around the Neighbourhoods (understand community & health data) Consolidate input across all 5 Local Collaboratives: Vision, mission, and success factors Working group: Review opportunity areas for Local Collaborative prioritization Next analysis of community data and experience Prioritize initial areas of focus at a sub-region level Refine output of Session 1 and confirm vision Confirm approach & next steps Refine output of January session Deeper dive on identified opportunity areas (January output) Establish measures of success & confirm joint commitment through collaborative agreement Confirm next steps 3

Purpose of this session Agenda Objective 1. Welcome 9:00 9:05 2. Progress update 3. Selecting initial opportunity areas for the North Local Collaborative Clarity of roles and responsibilities Confirm initial priorities for action planning 9:05 9:40 9:40 10:45 Networking Break 10:45 11:00 4. LHIN-Wide framework for Local Collaboratives 5. Next steps and action items Confirm the framework for collaboration Discuss appropriate structure for moving forward 11:00 11:20 11:20 12:00 4

PART 1: Welcome and progress update 5

Context setting Purpose of this section 1. Provide a progress update on key work streams that are currently underway 2. Clarify roles and responsibilities within these complimentary work streams 3. Initiate conversation on sub-region service alignment and integration Some context LHIN work streams represent a mix of system and local scope activities System scope: Local scope: Where there is a need for a common framework or standards to ensure consistency Priorities and solutions respond to a local context Capacity is planned to meet needs 6

Recall One Team, One Plan (Webinar, Sept 13) 1. Strengthen patient and community voice to drive One Plan 2. Use data and evidence to focus on population health and equity 3. Advance shared priorities with the City of Toronto 4. Create strong local partnerships to address community needs 5. Align primary care resources as local networks 6. Align community providers around a shared vision and plan 7. Enhance coordination and access to regional services 8. Leverage local leadership to improve clinical and community care 9. Create a high performing Toronto Central LHIN team; Communicate a public plan for integrated services; Aligning investment strategies, performance management and accountability, information technology, data and analytics, and policy to support One Plan

Foundation building to get us to a One Team approach Regional Services Framework (SYSTEM SCOPE) Specialized regional services Integrated Primary Care Strategy and Health Links (LOCAL AND SYSTEM SCOPE) Local primary care access, attachment System access to inter-professional teams, specialists, and discharge planning Local Collaborative Integrated Primary Care Health Links One Community Regional Services Framework Local Collaborative (LOCAL SCOPE) Partnership building, population based planning, service integration, and performance improvement One Community Strategy (SYSTEM SCOPE) Connecting shared community functions across CCAC, CSS, and CMHA 8

The role of the Local Collaborative, in closer detail: Delivering on Patients First our 5 sub-region planning areas are the focal point for: 1. Population based planning 2. Service alignment and integration 3. Performance improvement As part of the Toronto Central LHIN approach, we have organized Local Collaborative s of health service providers in each sub-region to: Work together to gain an in-depth understanding of the people that live in the sub-region (down to the neighbourhood level) Appropriately engage different populations to ensure all voices are heard across their entire subregion Integrate programs and services to best meet the needs of their populations Function effectively and efficiently as a collaborative of health service providers that serve common people Identify and work with partners that provide nonhealth services Select local priority areas for immediate improvement in health outcomes Monitor and measure improvement in local performance measures 9

Mapping our accomplishments and next steps: Visioning session (October) Consolidation of subregion feedback Refinement with working group Focus today: Finalize Collaboration Framework Sub-region profiles developed Population based planning Service alignment and integration Performance improvement *Partnership with Toronto Public Health Integration Steering Committee Report Initial identification of local opportunity areas (October) Neighbourhood profiles developed March focus: Form 2017/18 Work Plan Refinement with working group Focus today: Select initial areas Launching Population Health and Equity Leadership Table to inform local tools (January 31)* March focus: Form action teams 10

Planning for service alignment and integration 11

Preparing for a service alignment and integration work plan Integration Steering Committee Report and Implementation Plan (website) Integration as a continuum Next: Sub-region service alignment and integration work plan Opportunity for Local Collaborative leadership: 1 Issue specific: Look at alignment and integration services within the opportunity areas that we identify today 2 Sub-region level: As a Local Collaborative, look at the full set of services in the sub-region, and identify opportunities for alignment and integration 12

Integration is a spectrum of activities Degree of Integration Linkage (ad hoc) Coordination Structured Collaboration Program/Service Transfer Full Integration Limited or informal connections, network One time / ad hoc working arrangement Ongoing formal partnership/ coordination agreements within a system Program/service level No structural changes Ongoing formal collaboration agreements within a system Standardization along care pathway, shared services Brands remain separate Formal transfer, merge or amalgamation of program services May include back office services/ functions as well as clinical Creation of single system of care Based on Kodner s model 13 13

Examples of integration activity in the LHIN Degree of Integration Linkage (ad hoc) Coordination Structured Collaboration Program/Service Transfer Full Integration Health Service Provider initiated and led. Limited or informal connections, network. One time / ad hoc working arrangement. Based on Kodner s model Health Service Provider initiated and led. Ongoing formal partnership/ coordination agreements within a system. Program/service level. No structural changes. CAMH and Pilot Place Integrated services for Schizophrenia patients. Toronto Ride. Sherbourne Health Centre, CAMH, and Women s College Hospital Integrated services for Transgendered Community. Total of 12 Structured Collaborations since 2008/09. St. Michael s Hospital and Sinai Health System Transfer of Transitional Care Beds. Sunnybrook Health Sciences, Sinai Health System, St. Michael s Hospital and Kensington Eye Institute Transfer of Cataract Volumes. Total of 8 Program / Service Transfers since 2008/09. WoodGreen Community Service and Community Care East York. Toronto Rehabilitation Institute and UHN. Clarendon Foundation and PACE Independent Living. Total of 21 Integrations 14 since 2008/09.

LHIN identified opportunities for future facilitated service integration Identifying opportunities for Toronto Central LHIN led facilitation High volume Multiple providers Variation in performance metrics (volumes, unit cost) ~65% of total LHIN allocation to CSS, CMHA, CHC: 1. Assisted Living Services (27) 2. Personal Support Independence Training (3); 3. Clinic Programs in CHCs (16) 4. Mental Health Support within Housing Services (16); 5. Mental Health Case Management; Supportive Counseling Services (23) 6. Day Program Services for Seniors (2) 7. Residential Addiction Treatment Services Substance Abuse (7) 8. Health Promotion and Education Chronic Disease Awareness (14) 9. Crisis Intervention (14) 15

PART 2: Identify initial opportunity areas for the North 16

Prioritizing where to start Performance and Quality Improvement Sub-region profiles (available on website) Neighbourhood profiles (available on website*) Experience feedback ( A Walk Around the Neighbourhoods (October activity)) OpenLab exploration (Nomination card for People, Places, and Programs ) Initial list of opportunity areas identified (December working group) Objective today: Confirm initial priorities (1-2) for action planning March supports: Working group to propose planning tools OpenLab exploration focused on priority areas *Ongoing refinement through Population Health and Equity Strategy 17

https://medium.com/thelocal 18

Where we are starting, and what we are building toward over time Deloitte. Health Care Current: March 3, 2015 TODAY Phase 1 opportunities for the health system: Locate hot-spots of inequitable health outcomes (within neighbourhoods, sub-populations, etc) FUTURE Phase 2 opportunities for the health system: Locate at risk populations (further stratify the population pyramid and identify goals) FUTURE Phase 3 opportunities for the health system: Look at full population (fully stratify population and identify goals that include prevention and wellness) 19

Summary of pre-work (October Today) How initial opportunities have been identified Review existing sub-region data Identify opportunities for improvement Identify key contextual factors Potential Opportunity Areas Toronto Central LHIN analytics Toronto Community Health Profiles TPH Local Collaborative feedback What are the health issues based on the information that is available? High variance Alarming trends including significant growth Performance measures Who is experiencing these health issues (demographic, socioeconomic, cultural, etc.) Where 20

Several possible hot spots of high need have been identified for the North Mix of focus on: neighbourhoods, sub-populations, utilization A. Englemount Lawrence with high levels of marginalization, a large immigrant population, and high prevalence of chronic diseases B. Humewood-Cedarvale with a high number low urgency ED visits and low primary care continuity C. Mount Pleasant West with a high proportion of seniors living alone, high ED and inpatient usage for children, and relatively low primary care continuity and screening for adults seniors living alone, high ED and inpatient usage for children and relatively low primary care continuity and screening for adults 21

Opportunity Area Neighbourhood: Englemount Lawrence - High levels of marginalization with a large immigrant population, and high prevalence of chronic diseases Chronic diseases account for about 89% of all deaths in Canada Vulnerable populations such as low income people are at higher risk of getting chronic diseases Some immigrant and ethno-racial groups are at higher risk for specific chronic diseases, including diabetes and high blood pressure Why This Opportunity Was Identified Highest marginalization score in North Toronto sub-region: 4 3 2 1 0 1 1 3.2 2.4 1.4 1.4 1.6 1.6 1.6 1.8 2 2 2 Lawrence Lawrence Bridle Leaside- Bedford Mount Yonge- Mount Yonge-St. Forest Hill Humewoo Forest Hill Englemou Highest prevalence of Diabetes, and high prevalence of high blood pressure and COPD: Neighbourhood Diabetes (Ages 20+) High Blood Pressure (Ages 20+) City of Toront o: 2.4 COPD (Ages 35+) Englemount-Lawrence 10.5% 22.0% 9.4% North Toronto 6.6% 17.3% 7.3% Toronto Central LHIN 8.4% 18.3% 8.6% About the North Population (2011): 199,051 # Neighbourhoods: 13 Split: Leaside-Bennington and Yonge-St Clair Bounded by: Highway 401, Yonge St. and York Mills Rd. to the north, Sunnybrook park to the east (between Bayview Ave. and Leslie St.), St Clair Ave. W. and Moore Ave. to the south, and William R Allen Road to the west. Who is the population of focus? Population: 22,065 (ages 20+: 15,175, ages 65+: 4,040) Largest proportion of immigrants (47.2%) of which 26.3% are recent immigrants Visible minorities (38.8%) Top 3 languages other than English spoken at home: Tagalog, Russian, Spanish Many living below the low income measure, after tax (25.5%) Highest proportion on social assistance (12.4%) Percentage of seniors living alone: 41.6% High utilization of health services with high prevalence of chronic diseases and low screening rates High % low continuity (22.2%) High volume of ACSC hosp., 20-74yrs (2012/13 and 2013/14): 76 (higher in females) ED visits, all ages (2014/15): 7,174 (higher in females) Diabetes, 20(2014/15)+: 2,232 adults (higher in females) High Blood Pressure, 20+(2014/15): 4,802 adults (higher in females) COPD, 35+(2014/15): 1,321 adults (higher in females) Mammograms, women 50-69 yrs: 59.0% Any colorectal cancer screening, all 50-74 yrs: 59.4% Pap Smears, women 21-69 yrs: 53.0% Considerations MHA and adults aged 18-65 are needs in every neighbourhood High needs from SDH perspective High Tagalog speakers, likely paid caregivers Borders Central LHIN, may benefit from coordinated effort across LHIN boundaries

Opportunity Area Neighbourhood: Humewood-Cedarvale - High low urgency ED visits and low primary care continuity in the subregioncare continuity suggest Low urgency ED visits and primary inadequate access to a consistent primary care provider Consistent primary care providers play an essential role as the first points of entry into the health care system, providing ongoing prevention and treatment while knowing patients and their history Vulnerable populations face many barriers to primary care Barriers may include a lack of: personal resources such as child care and transportation, accessible services and after-hours care, and awareness of available health care options Why This Opportunity Was Identified Humewood-Cedarvale has the highest rate of low urgency ED visits for all ages. Age-Standardized Rate of Low Urgency Rate per 1,000 Population 100 50 0 ED Visits, Ages 0+ (2014/15) Toronto Central LHIN Rate: 92.4 Also, Humewoord-Cedarvale has highest percentage of low continuity in Primary Care. % Low Continuity Amongst Enrolled & Non- Enrolled (Total Population) About the North Population (2011): 199,051 # Neighbourhoods: 13 Split: Leaside-Bennington and Yonge-St Clair Bounded by: Highway 401, Yonge St. and York Mills Rd. to the north, Sunnybrook park to the east (between Bayview Ave. and Leslie St.), St Clair Ave. W. and Moore Ave. to the south, and William R Allen Road to the west. Who is the population of focus? Population: 14,015 (ages 20+: 11,425, ages 20-44:6,150, ages 65+: 1,610) One third of the residents in this neighbourhood are immigrants (33.7%), with 17.5% being recent immigrants Third highest percentage of population receiving social assistance: 4.90% Third highest marginalized Index in North Toronto: 2.0 Fourth highest percentage of persons living below low income measure, after tax:15.4% Top Three Languages Spoken at Home Other than English: Tagalog, Spanish, Portuguese Lowest proportion of seniors (ages 65+) in sub-region, however a relatively high proportion of seniors living alone (37.7%) High ED visits in Sub-Region High low urgency ED visits for all ages: 1,085 (higher in females than males) Highest rate of ED visits that are Mental Health Visits for transitional aged youth (ages 16-25): 35.7% Low Primary Care Continuity Highest rate of low continuity for Primary Care (22.9%) Low screening rates, especially for mammograms (59.9%), colonoscopy (47.2%) and colorectal cancer screening (64.7%) Asthma prevalence rate (13.1%) higher than Toronto Central LHIN rate (12.7%). Mental health visits (ages 20-44): 559 (higher in females than males) Considerations % with Low Continuity 25.0 20.0 15.0 10.0 5.0 0.0 Toronto 15.816.116.417.217.918.018.318.619.1 20.822.222.422.9 Central LHIN Rate: 21.3% MHA and adults aged 18-65 are needs in every neighbourhood High number of Tagalog speakers and immigrants, likely paid caregivers Lack of community / shared facilities

Opportunity Area Neighbourhood: Mount Pleasant West High proportion of seniors living alone, high ED and inpatient use for children and relatively low primary care continuity and screening for Seniors living alone may need adults in-home supports and community resources to ensure healthy aging in place and prevent isolation High ED and hospital use for children may be partly due to: lack of accessible and after-hours care, low caregiver health literacy and parents perceived advantage of a pediatric specialist hospital Vulnerable populations face barriers to primary and preventive care, including a lack of: personal resources, accessible services, after-hours care and awareness of available health care options Why This Opportunity Was Identified Highest percentage of seniors living alone in Toronto Central LHIN: 80% 60% 40% 20% 0% Percentage (%) Rate Per 1,000 Population Percent (%) of seniors living alone by Neighbourhood 58% 34%34%38%39%39%40%41%42% 18% 25%31%33% Bridle Highest low urgency ED rate for children ages 0-4: Rate of Low Urgency ED visits, Ages 0-4, FY2014/15 300.0 200.0 100.0 0.0 Toronto Central LHIN Rate: 34.1% Lawrenc Lawrenc Bedford Forest Leaside- Humewo Yonge- Forest Yonge- Mount Englemo Mount Toronto Central LHIN 78.888.1101.0109.0110.4111.7120.5129.5133.8143.9154.8 192.4211.7 Rate: 173.3 Lawre Bedfor Leasid Lawre Engle Mount Forest Forest Hume Bridle Yonge Yonge Mount About the North Population (2011): 199,051 # Neighbourhoods: 13 Split: Leaside-Bennington and Yonge-St Clair Bounded by: Highway 401, Yonge St. and York Mills Rd. to the north, Sunnybrook park to the east (between Bayview Ave. and Leslie St.), St Clair Ave. W. and Moore Ave. to the south, and William R Allen Road to the west. Who is the population of focus? Population: 28,615 (ages 0-4: 855, ages 0-9: 1,405, ages 20-44: 15,740, ages 65+: 3,840) Highest proportion of seniors living alone: 58.2% Highest proportion of families with children that are headed by a lone parent in private households: 39.1% Relatively high proportion of population living below the low income cut-off: 19.4% Relatively high proportion of immigrants (38.1%), of which 25.8% are recent immigrants High ED and inpatient use for children High number of 'high urgency' and low urgency ED visits in children ages 0-4 (high: 361 (higher in males), low: 181 (higher in females)) High number of hospitalizations for children ages 0-9 for all conditions: 556 (higher in males) Low continuity and screening rates for adults Relatively high % Low Continuity Among Ages 19+ (Enrolled and Not Enrolled) (20.8%) Lower mammogram (59%) and pap smear (55.6%) screening rates among neighbourhoods in North Toronto sub-region Considerations MHA and adults aged 18-65 are needs in every neighbourhood There is a lack of community / shared facilities in this neighbourhood; e.g. North Toronto Memorial to close down soon Providers also noted that there are few affordable grocery stores in area

Group Activity: Evaluating our Local Priorities Part 1: Current strengths, opportunities, and impact (20 minutes) 1. Review the data placemats on your table 2. Assign someone to write down the group s ideas on the template provided 3. Considering each of the potential priority areas on the list, answer: 1. What are some of the people, places, and programs that are making a difference to address challenges in this opportunity area? 2. What might be some of the symptoms of this opportunity area? What is the impact of the issue not being addressed? 25

Group Activity: Evaluating our Local Priorities Part 2: Evaluate the priorities (20 minutes) 1. Assign someone to write down the group s ideas 2. Using the second template provided, review the evaluation criteria and confirm the list, adding/changing as needed to create your group s evaluation framework 3. Considering each of the potential priority areas on the list and your previous discussion, evaluate the priority areas using the template and your group s evaluation framework Level of Agreement: 1 = Strong disagreement 3 = Neutral 5 = Strong agreement 4. Add up your columns and assign ranks to each priority area (high score to low) 5. Choose a presenter to report back key points 26

Group Activity: Evaluating our Local Priorities Part 2: Evaluate the priorities (continued) Impact: 1. This is a wicked problem 2. This priority supports provincial and LHIN priorities 3. There is a measureable gap in performance that needs to be addressed 4. An impact measure is easily identifiable 5. Impact can likely to be measured in the short-term (first year) 6. By addressing this opportunity area there is high potential to improve health outcomes (longer-term) 7. By addressing this opportunity area there is high potential to improve patient experiences 8. By addressing this opportunity area there is opportunity to improve value for money Effort: 1. Addressing this priority area will require partnerships among multiple HSPs (>3) 2. Addressing this priority area will require partnerships with non-lhin funded service providers 3. There are existing efforts in place already that we can build on 4. Presents an opportunity to support complex patients (Health Links) 5. Interventions would likely require no, or limited, new resources 6. There are proven or evidence-based solutions that we already know of that we can put in place 27

Group Activity: Evaluating our Local Priorities Part 3: Group Debrief For the group debrief, please report back: 1. Your group s ranking for the priority areas 2. Any relevant discussion points that could impact prioritization 28

PART 3: Collaboration Framework LHIN-Wide Framework for Local Collaboratives 29

Each Local Collaborative responded to 1. What do we as a Collaborative want to be recognized for in three years? 2. What MUST we focus on to achieve that recognition? 3. What is our role as a Collaborative? What is NOT our role? 4. What do our clients, patients, and residents expect of us? 5. What do our partners (HSPs, non-lhin funded providers, funders, etc.) expect of us? 6. What behaviours and values do we want to see recognized and rewarded? Analysis Consolidated Themes 30

Summary of feedback from all 5 sub-regions into one LHIN-Wide Framework for Local Collaboratives Collaborating Collaboration Together Success Factors Our mission is to change the way we work together to meet the needs of the residents of our sub-region. Improving Accessibility Access Vision Creating a healthier sub-region together Focusing People on Local Residents Focusing Solutions on Results Sharing Accountability Person-Centred Transparent Cooperative Inclusive Leading Change Values 31

LHIN-Wide Collaborative Framework: Success Factors Success factors provide focus and direction for the organization and guide strategic initiatives and activities. Resident Expectations Local Collaborative Response Success I expect factors my care providers focus to and direction for the organization We will partner with and residents guide in strategic listen initiatives to me and do and what s activities. best for me Focus On: Local Residents planning at all levels We will innovate and design together I expect my care providers to work together Collaboration We will collaborate and build partnerships around the needs of residents in our sub-region I expect to get the care I need when I need it Access We will make care easier to access and navigate I expect my care providers to fix what is not working Results We will actively make changes to address problems I expect my care providers to do what they say they will do Shared Accountability We will be responsible to our patients and to each other 32

Group Discussion: 1. Is this a framework that you and your organization would be able to commit to? 33

PART 4: Updates and Next Steps 34

Recap: Now to end of Fiscal Year Today: Selected initial opportunity areas based on available data and experience March: Team formation, initiate action planning, and identify improvement targets Invest in targeted action plans Fiscal Year 2017/18 A. Implementation of action plans for our initial opportunity areas: Local partnering and continuous improvement Monitoring and report back to Local Collaborative Sharing learnings across all 5 sub-regions B. Local Collaborative focus on sub-region service alignment and integration C. Ongoing population analysis (LHIN partnership with Toronto Public Health) 35

Proposed roles, responsibilities, and flexibility to deliver in 2017/18 Continue to build partnerships; Service alignment and integration; Monitor and measure local performance How are we doing? Where are our hot spots? Where do we focus on prevention? Population-based planning to drive improvements Local Collaborative (Quarterly?) Working Group Implement solutions for selected priority areas; Issue-specific partnership building and engagement; Quarterly updates to larger group (Local Collaborative)? Action Team (as identified) Action Team (as identified) 36

Updates One Community Strategy Regional Services Framework Integrated Primary Care Strategy and Health Links 37

Integrated Community Care TAKE AWAYS FROM ROADMAP SUMMIT (Dec 16) System is ready for change clear goals and Community leadership for implementation are essential Local community leaders are embracing sub-regions but needs tangible, actionable plans locally to prepare for change Need simple, easy entry points for clients, caregivers and other providers to access services (including Primary Care) Be specific about goals to improve access; tackle long-standing issues including wait times/wait lists, equitable access for key populations Ensure the right care coordination and navigation supports are available for the people who need them Align providers caring for clients to work as a single integrated care team, where clients and caregivers are partners in their care 38

One Community NEXT STEPS FOR INTEGRATED COMMUNITY CARE Action Teams to get underway in February with a focus on: Access, Seamless Assessment and Referral, Care Coordination and Navigation Defining and developing a detailed work-plan for the next phase of work Will specify goals with clear deliverables and timelines Developing a communications plan to ensure work-plan is effectively communicated with all community providers, clients and caregiver stakeholders Community-based Leadership working hand-in-hand with the LHIN Will include community leads from the sub-regions at each level and be directly linked to the work of the Local Collaboratives 39

Updates One Community Strategy Regional Services Framework Gillian Bone Integrated Primary Care Strategy and Health Links Dr. Curtis Handford 40

Updates One Community Strategy Regional Services Framework Gillian Bone Integrated Primary Care Strategy and Health Links Dr. Yoel Abels and Jocelyn Charles 41

Next Steps Working group* to meet in February to: Develop tool(s) for future Action Teams, to guide solution development and how we think about our current assets and partnerships Draft 2017/18 work plan for Local Collaborative, for discussion in March *North Working Group Debra Walco and Stacy Landau, Home & Community Leads Zulf Kassam, LHINC Kitty Liu and Kittie Pang, Primary Care Gayle Seddon, CCAC Malcom Moffat, Sunnybrook 42

Next Steps Feb 2017 Work Group Meetings - Finalize priorities - Outreach plan to compile activities End March/April 2017 Webinar (per LC) - Review activities and process - Community engagement plan - Share LC structure March 2017 Work Group Meeting - 5 WGs review activities for alignment - Validate LC structure 43

Thank You Contact Information: Zulf Kassam Senior Director (A), LHINC Toronto Central LHIN North Lead zulf.kassam@lhins.on.ca Tess Romain Senior Director, Communications, Corporate Affairs & Sub-Region Planning tess.romain@lhins.on.ca

Appendix

Integration Implementation Three-Year Plan 4