Agenda Item 9 Integration Strategy Presentation to the Board of Directors
What is Integration? Our integration lens reflects a continuum of approaches from Informal Relationships to Structured Collaboration to Organizational Integration 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/coordinatio n 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 See Appendix A for additional context 2 Based on Kodner s model
Background In Spring 2016, recommendations were developed by a group of s to advance integration, and was presented to the LHIN Board of Directors In the report it was noted that, in the changing environment, the LHIN should seek new and better ways of thinking about pursuing integration Spring 2016 Fall 2016 LHIN management reviewed these recommendations and presented an implementation program to the LHIN Board in Fall 2016 In 2016/17, the Board approved 7 voluntary integrations and 1 funding transfer 3
Implementing an Integration Plan (October 2016) See Appendix B for published timeline 4
Progress Integration Knowledge Centre and toolkit posted on website and communicated through multiple platforms (see Appendix C) Ongoing annual integration report Communications roll-out completed Will undergo continuous improvement throughout 2018 based on ongoing feedback (e.g. from G2G s) Ongoing identification of integration opportunities through performance management process results 5 Local Collaborative formed in each Sub-Region; LHIN subregion leads are in place Hosted Governance to Governance (G2G) meetings (1 per sub-region throughout October and November): 75 87% reported that they are very likely to engage another agency to discuss the spectrum of integration 72 89% reported that they would benefit from attending another G2G session See Appendix D for evaluation
Early Summary of G2G feedback and recent submission by Board chairs (community-based) 6
Opportunity Identification and Prioritization 1. 1 Partnering and 22. Building shared 33. Setting standards for 43. Harmonizing funding sharing accountability capacity across services, ensuring for services for meeting local needs (creating an integrated health s (e.g. shared back office supports) positive client / patient experiences and outcomes (equitable funding and strengthening accountability) service delivery network) 7
1 5 4 Develop integrated service delivery networks that share accountability for meeting local need Population Health Populationbased goals are identified (include prevention and wellness) Outcomes Focused on health and experience outcomes that matter to people Quality Improvement Local continuous quality improvement and cocreation with citizens Access All providers are connected as one local network Primary Care Every community has access to local primary and interprofessional care (with clear access to specialized care) Care Communication Coordination Clients and their families have access to one number Clients have one care plan (inclusive of social determinants) Aligned Incentives Funding is based on outcomes and supports shared accountability 3 2 1 Sector-based view (i.e. understanding of own patients) Performance is measured by utilization See Appendix E for more detailed Maturity Model Quality improvement is focused on discrete performance objectives (e.g. wait times) Clients are connected only where information and referral is strong Primary care leadership is engaged in planning Care coordination for clients is sector / provider based Care planning occurs within sectors (meaning multiple care plans) Payments are made for activities and volume (fee for service) 8 Developed by the Toronto Central LHIN. Adapted from a combination of: Toronto Central LHIN Citizens Panel Visioning Session (May 25, 2016); Leatt et al. (2000). Towards a Canadian Model of Integrated Healthcare. Lavis et al. 2016. Building a Primary-Care Home for Every Ontarian; Baker, R. and Axler, R. (2015). Creating a High Performing Healthcare System for Ontario; and, McClellan et al. (2013). Focusing Accountability on the Outcomes that Matter.
As we progress through the maturity model, we also have an opportunity to improve system alignment through network development *specialist services CURRENT FOCUS Understand full complement of service assets within a sub-region Review against local population need Connect all agencies with a designated focus on local care to one shared purpose; build partnerships through Local Collaborative (sub-region) Establish Collaboration Agreement that establishes quality improvement focus Identify integration opportunities to improve health outcomes and experiences NEXT 6 24 MONTHS One aligned network approach for each sub-region Critical and appropriate mass of connected services and providers to meet local need Connect to regional and provincial specialist services* (provincial partners table) 9
Snapshot of our starting point (East Toronto) 32 different s in the East sub-region receive TC LHIN funding to deliver community-based services. Of the top funded communitybased services (not including home care): 12 different s in the East are providing the top 5 funded CSS services A total of 15 different SPOs are providing services to individuals that live in the East Personal Support: 10 different SPOs are serving home care clients that live in the East Nursing: 9 different SPOs are serving home care clients that live in the East 8 different s in the East are providing the top 5 funded CMHA services Total nursing volume distributed by SPO (hours/visits) Total personal support volume distributed by SPO (hours/ visits) 4 different s in the East are providing the top 5 funded CHC services 10
Action Plan 1. Refinement to SAA obligations (Q4) (continue) Ongoing participation in Local Collaborative and signing of Collaboration Agreement (new) Use of the Organizational Assessment Tool and integration to Local Collaborative conversations 2. Develop list of integration opportunities ( Report-back from G2G feedback) (Q4) Identify programs and services currently available in each sub-region Distribute to and SPO partners Customize reports to individual s and SPOs, identifying integration opportunities for Boards to consider / pursue 3. Local Collaborative assessment against Maturity Model (see Appendix E) (Q4 Q1) Facilitate integration conversations through Local Collaborative platform, focused on aligning services to meeting local need (health equity focus) 4. Prototype network governance approach starting in the East sub-region; in partnership with Dalla Lana School of Public Health (2018-19) 11
2 Build shared capacity across s through back office integration Initial Project Team Co-chaired by Woodgreen and Four Villages CHC Worked collaboratively with community-based s from across the Toronto Central LHIN Key inputs included: a) Environmental scan with existing six back office organizations (SE LHIN, NSM- LHIN, Plexis, etc) b) Surveys completed by 80 community s c) Interviews and analysis into nine community s 1) Limited standardization of back office functions currently among community agencies across the Toronto Central LHIN 2) Many community s have very limited back office capacity, evident in minimal dedicated staffing, low spending and few back office functions and activities 3) Some community s already successfully collaborate on the delivery of back office services 4) Successful back office integration occurs when s are encouraged to integrate in stages As a result of these findings, a recommended back office model and a implementation road map have been developed Goal: Optimize administrative back office capacity to improve service delivery, operations, and overall organizational performance 12
Approach Work with partners to pursue a vision for shared back office Achieve in stages, with accompanied evaluation Focus on an initial set of back office functions with a small number of s to support effective planning and evaluation Assess possible approaches (e.g. sub-region focus, etc) Current State: Large Variation Across s Back Office Integration of Community Functions Interim: Agency Sponsor Model Finance Sponsor Agency IT/IM Sponsor Vision: Single Shared Services Office Finance & IT/IM Shared Services Office Human Resources Sponsor Admin Sponsor Pursue for priority functions that are: Performed by the highest proportion of community S (nearly 100%) Highly transactional and commonly outsourced Proposed (Phase 1): Finance 1. General Accounting 2. Payroll & Benefits 3. Financial Reporting Proposed (Phase 2): IT/IM 1. Central Help Desk 2. Network Management 3. Hardware Support 4. Software System Admin 5. Access Provisioning 6. Decision Support Service 7. Data Entry & Data Quality Standards Human Resources & Administration 13
Action Plan 1. Use an Expression of Interest (EOI) process to identify s to sponsor back office functions (Q4) 2. Identify and approach s who may benefit from back-office support based on current state analysis (e.g. size of organization, performance, financial status, etc) (Q4) 3. Ensure alignment of final recommended approach integrated health service delivery approach (Q4) 4. Confirm one-time funding opportunities to support planning, implementation, and capacity building in support of back office integration for key back office functions (priority Finance and IT / IM services) based on G2G feedback (Q1) 14
3 Setting standards to improve quality, access, and experience The broad definition of some Functional Centres (services) have resulted in different levels of activity within the same service For example, Mental Health Case Management includes activity from linking clients to other providers to intensive case management Variations also exist in admission and discharge practice Resulting in variations in eligibility, etc. across the LHIN and from provider to provider For example, some addictions programs operate under an abstinence philosophy whereas others do not 50 CSS Providing 33 different LHIN-funded functional centres (FCs) 59 CHMA Providing 52 different LHIN-funded FCs 16 CHC Providing 24 different LHIN-funded FCs 177 distinct s* 206 programs 16 Hospitals + 17 home care SPOs** 2 Private Hospitals + 1359 PCPs^ * In the total count, 3 Hospitals that are part of the New Health Network are counted as one organization ** Excludes private schools and medical equipment providers ^ includes 10 PCPs practicing outside of Toronto Central LHIN at CHCs that have head offices within Toronto Central LHIN 36 LTC 15
Looking first at community-based services that receive the highest level of investment, 2017/18 Total # of FCs included in analysis* Estimated^ Total Budget for FCs included in analysis* % of Total Funding due to Top 5 FCs* List of Top 5 Functional Centres* CSS CMHA CHC Home & Community 33 52 24 28 $160,602,412 $162,972,824 $75,415,924 $234,337,865 55% $86,555,507 1. Assisted Living Services 2. Day Services 3. Personal Support/Independence Training 4. Transportation Client 5. Meals Delivery 50% $79,741,690 1. Case Management/Supportive Counselling & Services - Mental Health 2. Res. Mental Health - Support within Housing 3. Residential Addiction - Treatment Services- Substance Abuse 4. MH Assertive Community Treatment Teams 5. Crisis Intervention - Mental Health 80% $62,173,116 1. Clinics/Programs - General Clinic 2. Health Prom/Educ. & Com. Dev.- Chronic Disease Education, Awareness and Prevention- Diabetes 3. Clinics/Programs - Therapy Clinic - Counselling 4. Health Prom/Educ.& Com. Dev Personal Health and Wellness 5. Client Support Services 90% $212,863,902 1. In-Home Support - Comb. PS and HM Services 2. Case Management 3. In-Home HPS - Nursing Visiting 4. In-Home HPS - Nursing Shift 5. In-Home HPS - Occupational Therapy TOTAL 70% of Total Budget of FCs included ($633 M) Data source: Community Accountability Planning Submission (CAPS) - Budget, 2017/18 Functional centres highlighted in bold are also included in the list of 9 FC identified for service alignment and integration ^ Budgets for s who did not have an available CAPS submission are not reflected as no data were available to report * Includes the functional centres that are currently funded by Toronto Central LHIN, and excludes Administrative and Support Services (72 1*), Undistributed Accounting Centres (82*), and CSS Com Sup Init. - Self Managed Attendant Services (72 5 84 20) that have been categorized as inappropriate for integrated service sub-region analysis 16
Starting with case management for mental health, identify providers for initial engagement and opportunities for service integration throughout the process Ability to breakdown service analysis in several ways: Map of service locations by sub-region Service Locations Catchment Areas Map agency catchment area Client s served, client distribution, and funding received Identify client distribution at a sub-region level (which providers are servicing which sub-regions) Identify number of individuals served and budget 17
Action Plan 1. Identify current state of case management practices and levels of care (through targeted audit of selected service providers) (Q4) Define varying levels of need (e.g. high, medium, low) Define variation within levels of need Identify duplication 2. Engage experts to define standards of care within case management for mental health (based on audit results) that reflect levels of client need and equity (Q1) 3. Validate through engagement (2018-19) 4. Update SAAs to reflect evidence-based standards and identify opportunities for integration (2018-19) Repeat process for other services (utilizing current partnerships / tables where they exist) 18
4 Harmonizing funding for services (equitable funding and strengthening accountability) On October 24 th, Board chairs of several communitybased s submitted a letter requesting an increase to base funding The LHIN is proposing a detailed evaluation of current funding by functional centre to identify opportunities for harmonization This will ensure equity in future funding allocations and strengthened accountability for quality and value Future models will reflect population need, and leverage density and integrated service delivery approach 19
Action Plan 1. Evaluation of current state across all services (Q4) 2. Engage experts to identify appropriate harmonization approach (2018-19) 3. Validate through engagement and begin to harmonize rates (2019-20) 20
Voluntary Integrations Updated Approach Multi-step approach to Board approvals Early identification of proposed voluntary integrations in quarterly reports integration pipeline Board approvals based on combined operating budget and/or impact of integration Combined operating budget <$10 million consent agenda $10 million to $50 million briefing note (or presentation) >$50 million and all hospital integrations 2 part presentation to Board On a case by case basis, integrations will come forward identified by LHIN Add new outcome measures (patient experience, cost savings, etc) Alignment with integration strategy components (back office, service standards, local, other) Develop VOR of integration consultants funded by LHIN to support business case development 21
Connecting Board leadership to system design Strategy Component 1: Creating Integrated Health Service Delivery Networks Service Integration 2: Creating shared capacity through back office integration Strategy Component 3: Setting service standards Strategy Component 3: Harmonized rates Proposed Board Role Results of sub-region assessment against Maturity Model Identification of integration opportunities Proposed three-year investment strategy Results of EOI Ongoing implementation progress and evaluation Validated standards Updates to SAAs and Local Obligations Identification of integration opportunities Review recommendations for harmonized rates Updates to SAAs and Local Obligations Identification of integration opportunities Ongoing Voluntary Integrations Multi-step approach to Board approval Alignment with integration strategy objectives (including outcomes) 22
Integration Strategy Summary 1. Connecting all s 22. Building shared 33. Ensuring networks as part of one capacity across have clear quality network focused on meeting local need s standards and funding is equitable 43. Harmonizing funding for services Patient First System Value & Efficiency Capacity Quality, Access, & Experience Services Equitable Funding & Strengthened Accountability Funding Continuous knowledge translation, facilitation, opportunity identification, and support Ongoing and timely connection to Governors Focus on outcomes and evaluation 23
Action Plan Summary Integrated service delivery networks 1 Build shared 2 capacity across s through back office integration New SAA Obligations Collaboration Agreements signed Q4 Complete sub-region program and service list (opportunity identification) Local Collaborative assessment against Maturity Model Send customized reports to s EOI for sponsors Confirm potential investment support Facilitate integration conversations through Local Collaborative Identify candidates (align within network approach) Q1 Q2 Begin to prototype East governance model Standards to improve quality, access, and experience 4 Harmonize rates to improve equity and accountability Additional knowledge translation, facilitation, support 3 Select Third Audit Current Party State Select Third Party Communication follow up to G2G Audit Current State Ongoing improvement to Knowledge Centre Report Findings Engage Experts Define Standards (opportunity identification) Report Findings Engage Experts Define Rates (opportunity identification) Establish VOR to centralize resources Improve evaluation Ongoing Governance engagement Include in SAAs Begin rate harmonization 24
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Appendices 26
Appendix A: Context for moving forward Our clients and families deserve a more integrated experience System performance reflects the need to improve in areas of transitions We have a clear mandate from government We are guided by a strong foundation of evidence of high performing health systems 27
Appendix B: Timeline 28
Appendix C: Knowledge Centre http://www.torontocentrallhin. on.ca/goalsandachievements/ IntegrationKnowledgeCentre. aspx 29
Appendix D: G2G Evaluation Results Of the five G2G sessions, East, Mid-East, Mid-West, West and North, the areas of integration that were of most interest were A : integration and collaboration as a part of a network within a sub-region, as well as B : service integration of programs and/ or services, on average. Topic B was reported to be of most interest in the East, Mid-East and North compared to the Mid-West and West who reported to be more interested in topic A. 30
Appendix D: G2G Evaluation Results (continued) Of the individuals from the East, Mid-East, Mid-West, West and North G2G sessions who filled out a feedback survey, 79%, 80%, 75%, 87% and 70% reported that they are very likely/ likely to engage another agency to discuss the spectrum of integration, respectively N/A refers to those who did not complete this section of the evaluation survey, averaging approximately 6% of respondents Of the individuals from the East, Mid-East, Mid-West, West and North G2G sessions who filled out a feedback survey, 77%, 72%, 89%, 72% and 81% reported that they would benefit from attending another G2G session, respectively N/A refers to those who did not complete this section of the evaluation, averaging approximately 10% of respondents 31
Appendix E: Assessing progress 5 Population Health Outcomes Quality Improvement Access Primary Care Care Coordination Communication Aligned Incentives Goals are identified and stratified for the full population (and include prevention and wellness) Focus on health and experience outcomes that matter to people and communities; Targets / benchmarks are identified, publicly reported, and value / sustainability is tracked Local teams of providers and patients have access to real time outcome and experience metrics / results to drive ongoing CQI All community-based services are connected as one network and share accountability for improving health and experience Primary care providers are organized in medical homes that respond to local needs (population management) and share accountability for improving health and experience Patients can have access to one number to call when they are in need; Patient care plans are inclusive of social determinants of health Patients have one integrated care plan (designed and shared with them and across their care team) Funding is based on outcomes and supports shared accountability 4 Stratified understanding of the full population; Underserved populations are identified (health equity) Goals are adjusted to population types and risk adjusted; Enhanced focus on prevention and wellness Leading indicators (for advancing prevention and wellness) are identified and tracked Access is streamlined to specialized community services when needed Access is streamlined to specialized medical services when needed Model of needs-based care coordination is defined for system (i.e. across all sectors); Individuals are attached to coordinator / navigator based on their needs Real-time critical information and prompts are pushed to providers / care teams Funding / investment strategy is based on population need 3 Defined population (by sub-region geography) Population goals and outcomes are defined and comparable across geographies (sub-regions and neighbourhoods) Collaborative- Quality Improvement Plans (c- QIPs) are developed in each sub-region and are driven by outcomes Communities have services in place that meet local needs (capacity) Primary care capacity is planned to meet local need (geographical coverage) Patients are supported to self-manage / direct their care Direct provider-toprovider communication occurs in a timely fashion Funding follows the patient through an integrated pathway that crosses sectors (integrated funding project) 2 Highest risk health users are identified (Health Links) Clinical quality outcomes are defined for care pathways; Patient experience is inclusive of transitions in care Improvement capacity is increased; Providers are supported to work together to design collaborative-qips focused on improving outcomes Common standards and tools are in place to connect all providers into one system of care All primary care providers are connected to inter-professional teams and a network of local and communitybased services Highest complexity patients have coordinated care plans (Health Links) Basic viewing of important patient information is available across sectors and providers Reimburse providers for evidence-based pathways (sector- Quality Based Procedures (QBPs)) 1 Sector-based view of users of health care (i.e. understanding of own patients) Utilization-based performance measures; Patient experience is tracked by sector / provider System performance objectives are defined (i.e. access, coordination, communication) Providers use Information and referral to connect patients to services where they exist Primary care leadership is engaged in local and system planning Care coordination is provider / sector driven (coordinated within sectors) Communication and care planning occurs within sectors Payments for activities and volume (fee for 32service)