September Sub-Region Collaborative Meeting: Bramalea September 13, 2018
Agenda Item # Agenda Item Action Lead Time 1.0 Welcome Call to Order, Introductions, Objectives Co-Chairs 5 min 2.0 Integrated Health Service Plan 3.0 Health Links Maturity Model 3.1 Introduction 3.2 Interactive Session Provide a high-level update on IHSP progress and overview of engagement results Provide an overview of the Health Links Maturity Model discuss the sub-region s progress towards maturity Break Provide an update on: Sharanjeet Kaur/ LHIN Co-Chair Home and Community Care Director Community Co-chair 30 min 15 min 30 min 15 min 4.0 Working Group Project Updates Mental Health and Addictions Palliative Care Integrated Care Working Group Co-Chairs 45 min 5.0 Sub Region Collaborative Reflections Reflect on Sub-Region Collaborative initiatives to-date Project Specialists 30 min 6.0 Next Meeting Discuss upcoming meetings and confirm next steps Co Chairs 5 min 2
Meeting Objectives Review IHSP summary and validate key themes Develop a collective understanding of the Health Links Maturity Model Discuss and highlight working group progress to date 3
Item 2.0 Context Setting: Integrated Health Services Plan 5 Central West LHIN s INTEGRATED HEALTH SERVICE PLAN (2019 2022) A Healthier Community for All 4
Project Approach and Timeline May June July August September October November December Planning Project Management, Monitoring, and Control Closeout Project Launch Project Steps Facilitated Workshops Engagement and Environmental Scan Focus on Engagement IHSP Validation Development of IHSP & Organizational Strategic Plan Final Public-Facing IHSP Board of Directors Workshop Special Board Meeting Governance & Leadership Forum Session Project Closeout Project Plan Stakeholder Engagement Plan Draft IHSP and Corporate Strategy Document Final IHSP & Corporate Strategic Plan Document Final Public- Facing IHSP Document 5
DRAFT IHSP Framework 6
Engagement Summary 7
Together, we have engaged over 400 stakeholders during the IHSP development process! 8
Key Highlights from Environmental Scan Strengths The Central West LHIN had the: Lowest percentage (9.6%, or 10,745 seniors) of seniors living in poverty. Most residents rating their self-perceived mental health as very good or excellent in the province. Highest life expectancy at age 65 overall Challenges and Opportunities The Central West LHIN had the: 2 nd lowest rate of residents (55%) who reported their health as very good or excellent, significantly lower than the Ontario percentage. Highest percentage of residents who self-reported as overweight 2 nd highest percentage of residents who were physically inactive, significantly higher than the Ontario percentage Highest prevalence of diabetes and the 2 nd highest prevalence of asthma compared to other LHINs. 9
Health Care Utilization LHIN ranking Mental Health ED visits The rate of emergency department visits for mental health conditions in our LHIN are second lowest in the province, at 15.1 per 1,000 visits 2 nd 1 st Acute ALC Days Our LHIN ranks first in the province with 20,270 days per year Walk-in Clinic Visits Our LHIN had the most residents who went to a walk-in clinic in the past 12 months, ranking us last in the province 14 th 14 th Home Care Service Visits Our LHIN had the lowest home care visits (540.6 per 1,000 population), ranking us last in the province 10
IHSP Strategic Priority Improve the patient experience To improve patient experience at the sub-region level: a) What actions are we doing at the sub-region level that we should continue doing? b) What actions are we doing at the sub-region level that we should consider changing or stopping? c) What aspects of this priority are relevant at the subregion level, versus across the LHIN? d) What will look different at the sub-region level when we are successful in 3 years?
IHSP Strategic Priority Reduce the burden of disease and chronic illness To reduce the burden of disease and chronic illness at the sub-region level: a) What actions are we doing at the sub-region level that we should continue doing? b) What actions are we doing at the sub-region level that we should consider changing or stopping? c) What aspects of this priority are relevant at the subregion level, versus across the LHIN? d) What will look different at the sub-region level when we are successful in 3 years?
IHSP Strategic Priority Build and foster healthy communities through integrated care networks closer to home To build and foster integrated care closer to home at the sub-region level: a) What actions are we doing at the sub-region level that we should continue doing? b) What actions are we doing at the sub-region level that we should consider changing or stopping? c) What aspects of this priority are relevant at the subregion level, versus across the LHIN? d) What will look different at the sub-region level when we are successful in 3 years?
IHSP Strategic Priority Drive innovation through sustainable new models of care and digital solutions To drive innovation through new models of care and digital health at the sub-region level: a) What actions are we doing at the sub-region level that we should continue doing? b) What actions are we doing at the sub-region level that we should consider changing or stopping? c) What aspects of this priority are relevant at the subregion level, versus across the LHIN? d) What will look different at the sub-region level when we are successful in 3 years?
IHSP Strategic Priority Drive efficiency and effectiveness To drive efficiency and effectiveness at the sub-region level: a) What actions are we doing at the sub-region level that we should continue doing? b) What actions are we doing at the sub-region level that we should consider changing or stopping? c) What aspects of this priority are relevant at the subregion level, versus across the LHIN? d) What will look different at the sub-region level when we are successful in 3 years?
Report Back!
IHSP Next Steps Next Steps Preliminary Draft Corporate Strategic Plan and IHSP (2019 2022) to Board Governance and Leadership Forum Draft Ministry Submission of IHSP (2019 2022) to Board Ministry Submission deadline Dates September 26 th October 1 st October 24 th October 29 th Refinement of Action Plans December 2018 Development of Public-facing IHSP March 2019 17
3. Health Links Maturity Model 18
Context Part 1: The Health Links Journey Where We Started Mid-Stream Improvement Where We Are Today December 2012 June 2015 2018 Low Rules Environment 26 Early Adopters One-time seed money to support coordination and project management Two indicators: complex patients and primary care attachment Introduction of the Guide to the Advanced Health Links Model Guidelines for complex patient identification (e.g. 4+ chronic/high cost conditions) HQO-enabled Quality Improvement Reporting and Analysis Platform (QI- RAP) Over 53,000 complex patients now connected with a primary care provider. Over 42,500 coordinated care plans completed. Foundational to sub-region geographies 19
Context Part 2: Health Links Measurement Development Historically, Health Links reported quarterly on two performance indicators to Health Quality Ontario (HQO): Number of patients with coordinated care plans (CCP); and Number of patients who were provided with regular and timely access to a primary care provider. Based on a 2016/17 response to Advanced Model LHINs and 7 Spread and Scale Strategy LHINs proposed additional indicators: The number and percentage of complex patients with regular and timely access to a primary care provider; The average time patients waited from referral (for CCP) to initial assessment; and The number of sectors and organizations involved in identifying and referring individuals who might benefit from a coordinated care plan. It is also important to note that not all Health Links patients were being tracked by a unique identifier. 20
What is the Health Links Maturity Assessment? Survey is conducted twice a year at Q2 and Q4 for LHINs to take stock of the current state of Health Link activities Current within Scale for each Healthsub-region. Links LHINs assess maturity based on core themes of the Patients First act objectives and the alignment of the Health Links approach as a foundation and core function of each sub-region. The results are subjective and in no way reflective of individual and/or team performance rather a single point in time assessment in the journey towards a fully matured Health Links approach. 21
Health Links Maturity Model Overview See Appendix for detailed description of each domain 22
Overview of Levels within Each Domain 23
Coordinated Care Planning: Current State Data 24
General Reflections Based on each of the four maturity domains, what does maturity look like in this Sub-Region? Are we doing the right things that will advance the health links approach? Do we have the right partners that will ensure success? 25
Break 26
4. Working Group Updates 27
Working Group Update: Mental Health & Addictions DESCRIPTION: This initiative will improve access to community mental health & addictions services by building a pathway will be consistent with best practice, provincial standards, and the LHIN vision for system access. PROJECT DELIVERABLES: A written pathway including all steps to appropriate community mental health and addictions services, and administrative and clinical decisions. PROJECT MILESTONES: Completion High Level Business Process Map of ED to Home Transition with best practices and standards built in Completion of Service Pathway for Bramalea with specific local resources attached Completion of Service Pathway for NEMWW with specific local resources attached Completion of Reference guides with each service pathway Completion of sustainability plan for service pathway LEGEND Completed Planned; On Track At Risk; Not Started INITIATING PROJECT HEALTH STATUS: Overall Project Health: Scope: Schedule: CLOSING PLANNING MONITOR AND CONTROLLING EXECUTING
Celebrating Successes and Shared Learnings Combined the two working groups to align similar goals and objectives Building on work already done including: MH&A System Access Model (SAM) report (March 2016) MH&A work group on repeat visits within 30 days Provincial reports and studies and LHIN-level work on pathways Establishing feasible pathways is dependent on input and buy-in from Osler s Emergency Departments 29
Working Group Update: Palliative Care PROJECT DESCRIPTION: The initiative will promote the use of standardized information and resources with the goals of broadening the knowledge of advanced care planning across sectors, and establish a shared understanding of palliative and end-of-life care. PROJECT DELIVERABLES: In partnership with the Central West LHIN Palliative Care Network, this project will: Identify and scope roles for cross-sector partners in this approach to care A consolidated tool kit containing standardized tools/resources An engagement plan to socialize the tool kit PROJECT MILESTONES: Palliative Care 101 and Advance Care Planning sessions completed A completed consolidated toolkit that meets the needs of cross-sectoral providers and is accessible to them Providers have a documented approach and are committed to establishing advance palliative care planning in their practices Primary Care engagement approach is documented and planned. LEGEND Completed Planned; On Track At Risk; Not Started INITIATING PROJECT HEALTH STATUS: Overall Project Health: Scope: CLOSING PLANNING Schedule: MONITOR AND CONTROLLING EXECUTING
Celebrating Successes and Shared Learnings Collaboration between the work group and the LHIN Palliative Care Network has been essential Cross-sector work group helping to shape a feasible approach to the spread of early identification and advance care planning in various settings Health Service Providers (HSPs) and Service Provider Organizations (SPOs) proactively seeking staff training in the 101 sessions Need to engage the Collaborative to ensure broad uptake 31
Working Group Update: Integrated Care DESCRIPTION: This initiative will improve integration of care for patients with complex care needs by promoting coordinated care planning across various system partners (health & social). PROJECT DELIVERABLES: Create and implement a standardized identification screener / tool to identify patients with complex care needs Design a registration form and process to support a systematic way of creating CCPs in HPG Transition providers on to the HPG platform (CCP in HPG Working Group) PROJECT MILESTONES: Value proposition developed for patient, primary care provider & health service provider for methodology Development of standardized identification tool for patients with complex needs (patient level) Implementation and testing of identification tool Shared understanding of roles & responsibilities in care planning for complex patients (i.e. who is the lead agency?) Development of data driven identification methodology (organizational health record level) LEGEND Completed Planned; On Track At Risk; Not Started PROJECT HEALTH STATUS: Overall Project Health: INITIATING Scope: CLOSING PLANNING Schedule: MONITOR AND CONTROLLING EXECUTING
Celebrating Successes and Shared Learnings Future state of Integrated Care is aligned to Health Links Maturity Model Identified the need for further screening questions. Co-designed Common registration form. Identified the need for clarity on determining Lead Agency (who is the lead agency in what scenarios) 33
5. Sub-Region Collaborative Initiative Reflection 34
Reflection: Sub-Region Collaborative Initiatives Reflecting on the planned initiatives, answer the following questions: Are we doing the right things? Are we moving any system-level metrics? Will we improve patient experience? 35
6. Next Steps 36
Next Steps: Working Group Portal All working group members have been requested access to portal If you do not have access, contact Hali.HarryPaul@lhins.on.ca One-stop location for all Work Group documents, tools, and events 37
Next Steps: Health Equity and Sub-Region Population Health Data In partnership with Join us on November 5 th and November 15 th to learn more about how health equity and population health work together to inform health system planning. Location: 199 County Court details to follow 38
You re Invited! A Year in Review Celebration Join us on November 15 th from 9 11 am to celebrate our collaborative successes and learn more about what s coming next! Location: 199 County Court Blvd Brampton, Dufferin and Caledon Rooms 39
Next Steps Summary Ongoing: Review working group progress via portal October 1 st : Attend Governance and Leadership Forum November 5 th and 15 th : Learning Series-Health Equity November 15 th :Attend Year in Review Celebration January 2019: Next Collaborative Meeting January 2019: Process related evaluation begins! 40
Thank You! Together, creating a healthier community for all!
Appendix A: Health Link Maturity Model Domains Reference Document
Domain 1: Identification of Complex Patients What population impact at scale could look like for identification of complex patients Current Scale for Health Links Level 1 Start-up Retrospective data analysis based on explicit criteria Expert review/ screening to identify patients from list Level 2 Evolving Explicit criteria (inclusion and exclusion) using MOHLTC data & identified complex patient target population Real-time prospective identification based on provider judgment Level 3 Functional Excellence Single list of Health Link patients viewable by Health Link care team members Standardized criteria & process for realtime identification across care settings Standardized tools/ processes for identifying patients; use of available technology and/or information systems Level 4 Integrated Excellence Patient identification at both the community & organizational level using same criteria & processes Defined process to improve identification, management & flow of Health Link patients Ongoing identification of patients across all care sectors/settings Defined outreach & rapport building to reach population Integrated protocols related to priority populations are in place & regularly utilized (e.g., BSO, palliative care, assess and restore, etc.) Level 5 Population Impact at Scale Iterative review of patient identification results to review data, look for trends, & adapt/adjust filters in retrospective & prospective identification tools Use of predictive algorithm tools 43
Domain 2: Coordination of Care What population impact at scale could look like for coordination of care Current Scale for Health Links Current Scale for Health Links Level 1 Start-up Fragmented care Identification of multidisciplinary team participants Level 2 Evolving Shared vision personal commitment from staff Multi-disciplinary discussions & case conferences are used Active engagement from partner organizations Level 3 Functional Excellence Clear roles, responsibilities & shared expectations for multi-disciplinary team within care model No duplication of roles across team Continued communication with patient Continuity of care includes named most responsible person for patients Level 4 Integrated Excellence Optimized care model with explicitly defined operational rules A multidisciplinary team of providers are involved in patient s care after the care plan has been created There is a strategy in place to rapidly scale & sustain coordination of care for complex patients Level 5 Population Impact at Scale The services available for complex patients have been identified, described, & information is available through established mechanisms (e.g., listed in a service directory or on-line resource) Inclusion of technologies that support virtual care planning teams & information sharing across organizations Capacity to provide care coordination for all complex patients is being fully utilized 44
Domain 3: Patient Centred-Care What population impact at scale could look like for patient centredcare Current Scale for Health Links Level 1 Start-up Patients minimally engaged in care planning Basic care planning tool/ template used Siloed & discrete documentation and interactions Current Scale for Health Links Level 2 Evolving Patient/caregiver is an active, empowered participant Care plans are driven by patient s goals and needs Standardized process for documentation & interaction Level 3 Functional Excellence Care plans are customized, regularly updated, & shared with patient & all team members Care plans reflect holistic focus on needs of patients & caregivers Empowered & engaged patients have an active role in their care Non-traditional forms of assistance are provided to support patient needs Level 4 Integrated Excellence Coordinated baskets of services available Patient-provider partnership across multiple settings & sectors Wrap around patient care consistently provided Strong education & coaching component for patients Use of follow-up mentoring & self-care promotion Build reliance among carers to alleviate stress & anxiety Level 5 Population Impact at Scale Tiered system with varying intensity care plans for different acuity levels Coordination between care teams & community resources Continuous familiarity with the patient over time Continuous proactive & responsive action between visits Patient outcomes & measurement Self-evaluating & benchmarking 45
Domain 4: Measurement and Continuous Performance Improvement What population impact at scale could look like for measurement and continuous performance improvement Current Scale for Health Links Level 5 Population Impact at Scale Level 1 Start-up Planning for performance measurement underway Level 2 Evolving Measurement plan developed Tracking & reporting on key indicators initiated Coordinated performance reporting based on reliable data from multiple partners Level 3 Functional Excellence Metric for measuring patient experience are incorporated Clear performance targets established Implementation of best practices ongoing Level 4 Integrated Excellence LHIN sub-region responsible for integrated performance reporting Ongoing process evaluation & benchmarking Identified Innovative practices embedded Achievement of performance targets demonstrated Significant impact on system level outcomes related to health system utilization & patient experience for health links population are demonstrated 46