Central East Priority Project Summary Note: Summary to be completed prior to submission to LHIN Board or other Planning Partner for review

Version No: 0.8 FINAL Project Charter Version Date: 2009/06/18 Central East Priority Project Summary Note: Summary to be completed prior to submission to LHIN Board or other Planning Partner for review Project Name: Early Identification, Intervention and Integration of Chronic Disease Prevention & Management (CDPM) within the Chronic Kidney Disease (CKD) population in the Central East Local Health Integration Network (CE LHIN) Purpose of Board Review Project Charter Sponsor(s) For Information Only For Approval For Endorsement to Proceed with Further Planning/Refinement/Review Project Type Service Enhancement New Service / Program Integration Activity Demonstration Project Single Phase Project Multi-Phase Project Funding Required Funding Source Total $ = $ [2007-08] + $ [2008-09] Funding Year (s) 2007-08 2010-11 Funding Type Anticipated Project Owner (Accountability) CE LHIN CE LHIN Health Service Provider Assigned CE LHIN Project Team Project Deliverables / Goals To develop a Chronic Kidney Disease (CKD) CDPM model that could be implemented into the care and management of the CKD population within the CE LHIN. To develop this model to strive to meet the needs of patients with CKD by establishing an effective comprehensive management and treatment plan as well as offer a systematic carepath through early identification and assessment, diagnosis, timely interventions based on best practices, education on CKD, and follow up. Successful achievements will include the ability to reduce demand for acute care and hence, saving health care dollars, and building the necessary communication linkages and working relationships between primary care providers/physicians, specialists, in-home providers, pharmacists and other community health care partners for the CKD population within the CE LHIN. Report outcome indicators that measure impact CDPM has on patient and system outcomes. Project Timelines Start: March 31/ 2008 Completion: March 31/2012 Project Review: Health System Improvement Pre- Proposal (HSIPP) Networks: CE LHIN CKD Network Collaboratives: Care First Senior s Centre, The Scarborough Hospital, Peterborough Regional Health Centre, and Lakeridge Health Corporation s CKD Programs. Task Groups: CE LHIN CKD Joint Charter Group CE LHIN Staff: Jeanne Thomas CE LHIN Decision-making Framework: = Points and % Is there an HSIPP that relates to this Project Charter? Yes: Lakeridge Health Corporation s Renal Nephrology System has submitted an HSIPP requesting funding for an additional 2 years to support their CKD CDPM project. Page 1 of 21

Strategic Directions The LHIN Board will lead the transformation of the health care system into a culture of interdependence. Healthcare will be person-centred in safe environments of quality care. Create an integrated system of care that is easily accessed, sustainable and achieves good outcomes. Resource investments in the Central East LHIN will be fiscally responsible and prudent. Priorities for Change Enablers Seamless Care for Seniors Primary Care Mental Health and Addictions E-health CDPM Health Services Planning Wait Times and Critical Care Health Human Resources Diversity Back Office Transformation Moving People Through The System System Outcomes Accessible Safe Appropriately Resourced Effective People Centred Equitable Efficient Integrated Focused on Population Health Page 2 of 21

Project Name: Early Identification, Intervention and Integration of Chronic Disease Prevention & Management (CDPM) within the Chronic Kidney Disease (CKD) population in the Central East Local Health Integration Network (CE LHIN) Project Acronym or No.: Project Sponsor: CE LHIN Project Coordinator: Joint coordination among 3 CKD centres (TSH, PRHC, LHC) Project Lead/Project Manager: Joint Management (3 CKD Regional Centres within the CE LHIN) Target Project Completion Date: 2012/03/31 Version No.: 0.7 Version Date: 2009/05/20 Project Background Outline the context for the project by briefly explaining the current organizational environment. Provide necessary background to understand why the project was started. Under what circumstances was it initiated? Focus on relevant facts about the surrounding situation that are of importance to the project team, i.e.. Provide references to appropriate sections of the Business Case if one has been developed. The Central East Local Health Integration Network (CE LHIN) has identified Chronic Disease Prevention and Management [CDPM], as one of its three strategic priorities. According to findings outlined in the CE LHIN Integrated Health Services Plan (2006), chronic disease is the leading cause of death in Ontario and across Canada. The total cost of illness, disability and death resulting from chronic diseases is about $32 billion a year in Ontario. More than 80% of Ontario residents over 45 years of age are living with at least one chronic disease. Approximately 13% of the CE LHIN s population is over the age of 65. The prevalence of chronic disease within the CE LHIN is significant. As an example, diabetes is one of the leading causes of Chronic Kidney Disease (CKD). In 2004, 621,130 individuals in Ontario saw a physician for diabetes care; of these individuals 83,151 were from CE LHIN. This total was the highest of all 14 LHINs. This growth in prevalence of diabetes is contributing to the increasing growth in the prevalence of CKD. (CE LHIN Integrated Health Services Plan, 2006). Typically, patients living with CKD have multiple co-morbid conditions that require frequent intervention and support from the healthcare system. According to outcomes from the ICES Atlas Predicting the Growth in Dialysis Services in Ontario, 2006-2010, it is projected that the CE LHIN will have the largest number of people with End Stage Renal Disease (ESRD) using dialysis services of all LHINs in the Greater Toronto Area (GTA) by 2010. CKD, if detected early, can be managed to prevent progression of the disease; however, if not properly managed, patients with CKD can end up progressing to ESRD which requires costly, resource intense treatment (i.e. dialysis) which negatively impacts patient quality of life, may result in additional co-morbid conditions that develop as a result their progression to ESRD, and increases their risk of morbidity and mortality. One of the key challenges to optimally manage CKD is that the Ontario healthcare system is organized to provide acute/episodic care primarily based within the acute-care environment. As noted in Crossing the Quality Chasm, Care for the chronically ill needs to be a collaborative, multidisciplinary process. [that supports] coordinated, seamless care across settings and clinicians and over time (Page 11). The current system of work is clearly outmoded. There is need to shift the system s orientation from illness to wellness. As such, in keeping with the CE LHIN strategic priority of CDPM and recognizing the importance and need for a shift to a CDPM philosophy of care; one which is proactive and disciplined in its approach, the three Regional Nephrology Programs across the CE LHIN (Lakeridge Health Corporation (LHC), The Scarborough Hospital (TSH), and Peterborough Regional Health Centre PRHC)) will work jointly to develop and implement a CKD CDPM model into the care of the CKD population within the CE LHIN. The model will strive to meet the needs of patients with CKD by establishing an effective comprehensive management and treatment plan as well as offer a systematic care path through early identification and assessment, diagnosis, timely interventions based on best practices, education on CKD, and follow up. Successful achievements will include the ability to reduce demand for acute care and hence, saving health care dollars, and Page 3 of 21

Project Background building the necessary communication linkages and working relationships between primary care providers/physicians, specialists, in-home providers, pharmacists and other community health care partners for the CKD population within the CE LHIN. The key elements of this model: Early Identification, Intervention, Access and/or Provision to/of care are the foci of each of the Regional CKD Program s individual CKD CDPM projects (see project charters: Appendix A, B, & C). Collectively, the initiatives, processes, goals and objectives achieved within each individual project will develop outcomes that will inform the development of a comprehensive CKD CDPM model which can be implemented to better manage and provide care to CKD patients within the CE LHIN and potentially throughout all LHINs. The model may also help to inform/direct developments of other models that would support other disease specific CDPM models. Project Scope Project scope describes the work that must be done to complete the project. Define the scope of this project by documenting the project s purpose, benefits, as well as specific goals, objectives and deliverables in sections below. The information provided here will serve as the basis for making future project decisions and for confirming or developing common understanding of project scope among the stakeholders. Provide further scope details and explain how changes to project scope will be managed in the Scope Management Plan. Project Purpose Explain the purpose of this project by describing, at a high-level, what will be done. What is this project aiming to achieve? What is its vision? What need or opportunity will it address? What problem will it solve? Overall Purpose: The overall purpose of this project is to identify populations at high risk of developing CKD, prevent new and/or manage existing comorbid conditions and enhance health related quality of life and their health care experience in this specific CKD population; in doing so, overall health care costs within the CE LHIN will be reduced. Through the introduction and integration of the Ontario CDPM model and the tenets of disease management into the existing CKD care delivery model, patient s and their care givers will play a central role as active members of the care team in which they are engaged in shared decision-making, goal setting and care planning. The ultimate goal of this initiative is to develop a CKD CDPM care delivery model within the CE LHIN through the integration of the Renal CDPM work of each of the CE LHIN s CKD Regional Programs that enables early identification of people with or at high risk of developing renal disease, timely access to high quality, cost effective care/services needed to prevent and/or delay the progression of renal disease, and management of co-morbidities of renal disease along the entire continuum of care from stage one CKD to end of life. The basic elements of this CE LHIN CKD CDPM model include: Raising awareness of CKD and risk factors Identifying high risk people Improving access to services and care Preventing CKD and/or delaying the progression of CKD to ESRD Improving the experience of care Providing proactive patient care with a focus on co-morbidity management, seamless and coordinated patient care throughout the healthcare delivery system, Adopting and integrating patient self-management principles into CKD care management & delivery Increasing utilization of home-based renal therapies i.e peritoneal dialysis or home hemodialysis Improving clinical, program, and economic outcomes Page 4 of 21

Project Purpose Strategic Alignment Provide an indication of the project s strategic importance by describing the linkages to government priorities or organizational strategies. Also, show how this initiative is supported. The development and implementation of a CKD CDPM model in partnership with the 3 CKD Regional Programs within the CE LHIN will enable collaborative ties to each of the CKD Regional centres and the sharing of best practices and strategies for improvement. There is opportunity to strengthen consistency and integration of practices to better support patients living with or at risk of developing CKD within the CE LHIN. The development of this collaborative CKD CDPM model will also have strategic importance in facilitating the support of the following initiatives: Seamless Care for Seniors Diabetes Strategy (relates and supports the CE LHIN s goal of decreasing the burden of vascular disease) CE LHIN CDPM Strategy (in particular the CDPM Self Management Project) E-Health Kidney Foundation Mental Health (depression) Access & Wait times (including reducing wait times in Emergency) Triple AIM Seamless Care for Seniors: According to the CE LHIN Integrated Health Services Plan, the expected growth rate for persons 65 years or older within the CE LHIN from now until 2016 is projected to be approximately 47.5%. The cohort of patients over the age of 65 composes the fastest growing number of new patients starting dialysis. (CIHI, 2006) The growing cultural diversity and the continued inflow of aging new immigrants within the CE LHIN, gives rise to the need to ensure access to care in multiple languages, to care that reflects cultural values and the needs of the elderly. The CKD CDPM projects of TSH and PRHC include the development of methods for improved coordination among health care sectors to raise awareness and identify needs for early detection of CKD among high risk populations i.e. New immigrants, elderly, and First Nations populations. Their models also focus on developing enhanced referral, timely diagnosis, treatment, case management, and education through developed screening strategies and interventions that meet the unique needs of local seniors and First Nations populations. This search and rescue identifies CKD patients through their traditional points of contact with community partners, the health care system, Family Doctors and Community Health Nurses raising awareness within those arenas of the patient s risk for CKD and suggest a standardized referral algorithm for specialist follow-up and monitoring in the hospital s renal insufficiency clinic. TSH is unique in that this initiative is represented by a seniors organization outside of the hospital environment providing access to all services available through that organization. This model brings the focus out of the hospital and into the community. Development of patient-centered seamless and coordinated care through the full health care continuum ensuring integration of community, acute care and outpatient services (including those focused and geared to supporting the elderly) is one of the deliverables of the CE LHIN CKD CDPM Model. Diabetes Strategy: The Ontario Diabetes strategy recognizes the link between diabetes and CKD. The strategy includes early identification of CKD and efforts to prevent/delay kidney function deterioration for as long as possible. Diabetes is one of the major causes of renal failure. In 2004, 621,130 individuals in Ontario saw a physician for diabetes care; of these individuals 83,151 were from the CE LHIN region. This number was the highest of all 14 LHINs. Through the CE LHIN CKD CDPM Model, partnerships with the Durham Regional Diabetes Network (DRDN) and the Adult Diabetic Education Centres (ADEC) have been established to improve access to diabetic care and management. All programs have a connection/partnership with local diabetes clinics to support and manage diabetes clients with CKD. Page 5 of 21

CE LHIN Self Management Project Through the introduction and integration of the CKD CDPM model which is based on the Ontario CDPM model and the tenets of disease management, patients and their care givers are engaged in shared decision-making, goal setting, and care planning. This is facilitated by linking into the CE LHIN Self Management Project which looks to introduce a consistent, coordinated and sustainable chronic disease self-management model across CE LHIN. The CKD CDPM model has established a link into this project to enable CKD patients and their care providers to access self management training to empower them to develop skills to break the cycle of symptoms that can result from chronic conditions. In addition, training of health service professionals to the concept of self management will provide opportunity to help translate knowledge into effective actions and help to integrate self management into CKD care delivery processes; enabling patient s and their care givers to play a central role as active members of the care team. E-Health Initiatives: E-health is recognized as an enabler of CKD and CDPM initiatives. It is an area that has long been identified as requiring support and advancement. The Ontario Health Quality Council reports that better, more widespread and integrated use of technology will mean improved decisions about care, more effective diagnosis and treatment, fewer medical errors, greater safety, increased efficiency, better access to services, better research on health care and how to run the system and information to support continuous health system improvement. The CKD CDPM project will align with the CE LHIN E-Health strategy. The importance of e-health in CKD management is understood and encouraged. The ability to have clinical information flow for decision makers to be able to make decisions in a timely fashion improves population health and the experience of the patient. The CKD CDPM project has established key performance indicators that will measure the impact this project will have on CKD care delivery and outcomes from a clinical, operational, system, and economic perspective throughout the health care system. A Nephrology Electronic Documentation, Data Management, and Reporting System is being developed by LHC s RNS and will facilitate data collection, management, reporting, and analysis of outcomes and measurement of key performance outcomes. Successful development and implementation of this system will support and align with the aims of the E-Health Strategy. PRHC plans to leverage the local Family Health Team s electronic medical record system through pre-screening patients with CKD risk factors in a database search. Kidney Foundation: The Kidney Foundation s vision is kidney health and improved lives for all people affected by kidney disease. The Kidney Foundation of Canada is the national voluntary organization committed to reducing the burden of kidney disease through: funding and stimulating innovative research providing education and support promoting access to high quality healthcare increasing public awareness and commitment to kidney health and organ donation. The Kidney Foundation has expanded its constituency to include CKD patients at all five stages of kidney disease, has rolled out their Kidney Health Centre, a public awareness and kidney health promotion pilot, has built on existing relationships with Regional CKD Programs, and has increased opportunities for provision of information about kidney disease to diverse communities. The established partnership with the Kidney Foundation supports of the implementation of the CE LHIN CKD CDPM model and through their valuable work helps to enable many of the elements that are a part of the CE LHIN CKD CDPM model. CE LHIN CDPM Strategy: Common needs among people with chronic disease include education on their condition, eating properly, physical rehabilitation, peer support groups and supports for care givers. Everyone benefits when effective and coordinated chronic disease prevention and treatment programs are in place. Through the integration of the Ontario CDPM expanded model with particular focus on delivery system design, provider decision support, information systems and personal skills support the following goals of the CDPM model will be achieved: Activated communities & prepared, proactive community partners o Communities within the CE LHIN, through this project are collaborating across sectors and with health care organizations to identify and meet the needs of the CKD populations. Individuals and families are linked to community resources throughout the continuum of CKD care. Page 6 of 21

Prepared, Proactive Practice Team o At the time of the patient visit, processes are being developed to enable care providers to have the consumer information, decision support, people, equipment, and time required to deliver evidence-based clinical management, health promotion/prevention, and self-management support Informed activated individuals & families Mental Health: o Processes are being developed and implemented to enable individuals to understand the CKD disease process, are being made part of the care team, and are being educated to realize their role as the daily self manager. Family and caregivers are engaged in the individual s self-management. The role of the provider, through culture change and integration of the principles and concepts of self management are viewed as a guide on the side, not the sage on the stage. Mental health, in particular depression, is a major issue for the CKD population and can impact negatively on patients adherence to treatment regime and patient outcomes. The 2008 Clinical Practice Guidelines Diabetes estimates that 25% of diabetics are clinically depressed. Further to that, the Clinical Practice Guidelines of the Kidney Disease Outcome Quality Initiative (KDOQI) estimates that approximately 50% of dialysis patient are depressed and 50% have some anxiety disorders. Through the use of the KDQOL quality of life screening tool, mental health issues for the CKD patient will be evaluated with partnerships developed to address identified issues for our patients. Access & Wait times: Services are in great demand and people have long waits for therapy or treatment that would make a real difference to individuals and family distress and quality of life. Timely access to care is a high priority for people, health care providers and the public at large. Wait times can be seen as a proxy measure of how effectively, efficiently, and appropriately resourced a system is functioning. While not diminishing the importance of appropriate capacity, the LHIN recognizes that sometimes the flaws and delays are latent with the design and operations of a particular service. The CKD CDPM project will be looking to improve access by establishing strategies to: o o o o o Improve seamless referral and follow up i.e. CKD patients found in the early screening process without a primary care provider are referred to a Family Health team, reducing the number of unattached patients. Improve processes that deliver CKD education and culturally sensitive CKD screening and treatment services by bringing these services to high risk populations within the CE LHIN i.e. community clinics, etc. enabling and improving access to services. Expedite creation of dialysis access (i.e. vascular access or peritoneal dialysis catheters) to promote patient starts on home dialysis modalities. Improve risk stratification processes to ensure timely access to services by patients in high need. Reduce acute starts through Emergency department visits, thus reducing the number of Emergency Department visits that could be managed elsewhere The CKD CDPM project will be looking to improve access and wait times by aligning with: Triple AIM: o o The CE LHIN Unattached Patient initiative MOHLTC Health Care Connects The intent of the Triple Aim Initiative is to explore and develop a variety of models to identify different ways of achieving transformational results that balance the best possible performance in health, patient experience, and per capita costs of care by focusing on: Individuals and families; Redesign of primary care services and structures; Population health management; Cost control platform; System integration and execution. Page 7 of 21

As indicated in the background section of this document, the CE LHIN CKD CDPM joint project is being structured to achieve the 3 key aims of the Triple Aim Initiative. Focusing on the CKD population, the successful implementation of the CKD CDPM model within the CE LHIN will give rise to timely access to high quality, cost effective care/services needed to prevent and/or delay the progression of renal disease, management of co-morbidities of renal disease along the entire continuum of care, and enhance this population s health related quality of life and their experience in the delivery of care within the health care system. Project Benefits Identify specific results-based benefits that can be expected as a result of completing this project. List specific metrics and targets to be achieved, if known. Implementation of this initiative would be expected to show the following results-based benefits: 1. Improved Access to Care 2. Decreased number of unattached patients 3. Formalized, culturally sensitive screening approach/strategies to identify patients with or at high risk of developing CKD 4. Demonstrated disciplined approach to data capture, analysis, reporting, and quality improvement development designed to support evidence based guidelines. 5. Maintain or improve renal population health outcomes with a focus on co-morbidity management integration of risk stratification and self-management support. 6. Seamless patient care coordination, communication and integration of healthcare delivery throughout the patient renal lifespan 7. Operational savings through creation of workflow efficiencies. 8. Cost containment or cost avoidance through reduced acute and emergency hospitalization rates 9. A CKD CDPM model that can be shared with other programs across the CE LHIN and the province. Page 8 of 21

Goals, Objectives & Performance Measures GOAL: To develop, design and recommend a best practice CKD CDPM model within the CE LHIN that enables early identification of people with or at high risk of developing renal disease, timely access to high quality, cost effective care/services needed to prevent and/or delay the progression of renal disease, and management of co-morbidities of renal disease along the entire continuum of care from stage one CKD to end of life. Objectives Deliverables Performance Measures Objectives are clear statements of specific activities/tasks that must be performed to achieve the goals. Identify both project product/service and people/organization change objectives. Early Identification 1. Develop a process and core components of a CKD screening tool i.e. screening clinics, GP/FHT resources, etc. that are based on best-practice, and can be adjusted to be culturally appropriate to enable and support risk stratification, identification of needed services and coordination to access community services and supports. 2. Develop and implement a risk stratification process for CKD patients. Management 1) Develop service intensity guidelines for high risk groups, defining the services required for each level of risk. Deliverables are tangible, verifiable outcomes that signify completion of objectives. A. Development of a consistent process to identify patients at high risk throughout the CKD continuum of care (i.e. CKD, admission to hospital, emergency visits, mortality) B. Developed tools to help risk stratify patient populations A. Defined service intensity guidelines along the CKD continuum of care. Specifically for: Unidentified (community) Identified (Progressive Renal insufficiency) ESRD (RRT) Performance measures are used to determine if objectives have been completed. They check if the expected results have been successfully achieved. For each objective/deliverable, list the measures that will be used to evaluate success of results achieved. % of patients screened that were identified as high risk # of clients screened that were identified as high risk # of clients screened #/% of patients in each risk level throughout the continuum of CKD care #/% of patients who have a plan of care based on the service intensity guidelines 2) Recommend strategies to implement the service intensity guidelines A. A documented strategy supported by evidence based practice such as, but not limited to: KDOQI (Kidney Disease outcome quality initiatives) Guidelines CSN (Canadian society of Nephrology) Guidelines CDA (Canadian Diabetes Association) Guidelines CHEP (Canadian Hypertension Education Program) Guidelines Page 9 of 21

Objectives Deliverables Performance Measures 3) Promote patient empowerment and independence by: i) Developing a process of connecting patients to community services such as CE LHIN Selfmanagement program (Stanford Self- Management program), ADEC, etc. ii) Advising on the core elements for Selfmanagement support tools and skills for providers to enable patient selfmanagement. iii) Recommending core components for effective sustainable peer support. iv) Implementing the patient satisfaction survey Patient s Assessment of Chronic Illness Care (MacColl) 4. Promote timely access and seamless patient coordination during transition throughout the healthcare system where CKD patients access care. A. Tool kit for providers and patients: Materials A common CKD patient education curriculum with common core components. Community resources B. Documented Peer support strategy C. Conduct Patient Satisfaction Survey Patient s Assessment of Chronic Illness Care (MacColl) D. Analysis of patient satisfaction surveys E. Recommendations of action based on survey results. F. Developed consistent process of disseminating patient education materials i.e. identification of points in care where patient education material should be provided. A. Developed process flow maps, identified and prioritized transition points in CKD patient care. B. Recommendation for use and process for examination of process flow maps. C. Developed strategies to identify gaps at transition points. D. Developed referral processes to appropriate services (GP, Nephrologist, ADEC, Cardiac Rehab, Smoking Cessation, Mental Health, Health Care Connect, Unattached patient initiative, etc) %/# of staff attending self management support education %/# of CKD patients who attend Stanford Self Management Program (CELHIN, ADEC etc.) %/# of patients who become Self management Peer Leaders Baseline return rate for Patient satisfaction surveys Patient s Assessment of Chronic Illness Care (MacColl) of greater than 10% Demonstrated improvement in follow-up Survey Results Wait times at each transition and/or access to services. #/% patients without primary care provider #/%patients identified at risk of developing CKD #% of patients linked with follow-up services to manage CKD Patient s Assessment of Chronic Illness Care (MacColl) Patient Satisfaction Survey ( as noted above) Emergency Department/Admission/readmission rates 5. Identify strategies to provide most cost effective, high quality delivery process and key services needed to manage, prevent and/or delay the progression of renal disease A. Developed performance indicators and benchmark performance outcomes to CKD Clinical Best Practice industry standards and cost effective outcomes. Evidence based practice guidelines may include but are not limited to: KDOQI (Kidney Disease outcome quality initiatives) Guidelines CSN (Canadian society of Nephrology) Guidelines % growth in CKD % growth in ESRD % home therapies % ER/admissions/readmission as above # Acute starts to dialysis (known vs. unknown to program -separated by Acute Kidney Injury vs CKD) % patients meeting clinical BPG/targets Page 10 of 21

CDA (Canadian Diabetes Association) Guidelines CHEP (Canadian Hypertension Education Program) Guidelines B. Recommendations for Integrating/implementing established Ministry standards/targets into CKD CDPM care delivery. For example: Home therapy targets CKD referral targets Dialysis access targets Acute starts (targets) 6. Recommend a knowledge transfer/learning/sharing process that supports further development and dissemination of the CKD CDPM model. A. Developed report that synthesizes the approaches of all three CE LHIN CKD Regional CKD CDPM projects and an outline of how they could be combined to form a comprehensive CKD care delivery model. B. Developed communication plan to disseminate project learnings to: LHINs Other renal programs (other LHINs and provinces) Other chronic disease programs Primary care MOHLTC Other community programs # of downloads of the report or hits to the website where the report is housed. # of presentations and/ or requests for project presentations Page 11 of 21

add/remove rows in the above table to customize the number of goals to the needs of your project. Project IN & OUT of Scope Items Provide additional detail as to how the goals and objectives stated above will be met by documenting the specific in and out of scope items. Describe what is and what is not included as part of the work performed on this project. Consider specific features, functions, quality needs or other must have requirements and place them in the IN scope section. Spell out any exclusions, i.e. work that will not be performed, in the OUT of scope section. IN Scope Describe specific items that WILL be included as part of the work performed by this project. Early identification and risk stratification will be performed on patients with or at high risk of developing CKD within the catchment areas covered by the CE LHIN CKD Regional Program (LHC, TSH, & PRHC). Proactive patient care will focus on the prevention and management of co-morbid conditions known to establish patients at high risk of developing CKD i.e. Diabetes, Hypertension, Proteinuria, and other conditions outlined in the CKD Regional Programs charters. Identification of gaps within the health care system that are barriers to timely access and seamless care for CKD patient coordination and care. Aim to achieve the provincial targets related to the prevalence of home dialysis and ICHD therapies (40%:60%), established best practice CKD standards, and to improve the CKD care delivery of services. Write a comprehensive report to describe the recommended care path for management, prevention and delay of CKD. OUT of Scope Describe specific items that WILL NOT be included as part of the work performed by this project. Early identification and risk stratification will not extend to other populations outside of patients with or at high risk of developing CKD and to other catchment areas covered outside of the CE LHIN. Proactive patient care will not focus on other co-morbid conditions that are non-related to CKD. Resolving identified gaps within the health care system that are barriers to timely access and seamless care for CKD patient coordination and care. Decrease growth of CKD and ESRD within the CE LHIN. Balance the CKD budgets of each respective CKD Regional Program within the CE LHIN. Implementation of the recommendations from the project report. Project Timelines Indicate when the project will take place. Provide a preliminary estimate for the duration of the project by documenting the target completion dates for high-level project milestones. Milestones are significant project events that usually signify completion of project phases or major deliverables. Use the milestones and target dates provided below as a starting point for the development of the Project Schedule. High-Level Milestones List key milestones below. State milestones in past tense to signify achievement and completion. Include target dates for project kick-off and project end. Submission, approval, and sign off of Joint CKD CDPM Project Charter Established work plan that outlines the deliverables of each respective CKD Regional Program partnered with this Joint CKD CDPM project Target Completion Dates Provide preliminary estimates. Use Month, Year format. April 2009 April, 2009 Report to-date on program milestones March 2010 Completion of TSH s CKD CDPM Early Intervention and Screening project and achievement of key deliverables March 2010 Page 12 of 21

High-Level Milestones List key milestones below. State milestones in past tense to signify achievement and completion. Include target dates for project kick-off and project end. Completion of PRHC s CKD CDPM Early Intervention and Screening project and achievement of key deliverables Documentation of key processes and deliverables achieved by TSH and PRHC related to Early Intervention and Screening into the Joint CKD CDPM CE LHIN model report Target Completion Dates Provide preliminary estimates. Use Month, Year format. March 2010 March 2010 Quarterly performance indicator reports commencing April 1 st, 2009. March, 2012 Completion of LHC s CKD CDPM CE LHIN project March, 2012 First draft of the comprehensive CE LHIN CKD CDPM Model report completed March 2010 (close out of PRHC and SH projects) Submission and approval of the final CE LHIN CKD CDPM Model report March 31, 2012 (close out of LH project) Page 13 of 21

Version No: 0.8 FINAL Project Charter Version Date: 2009/06/18 Project Costs Indicate how much will it cost to complete the project. Provide a preliminary estimate of the project s budget by listing key expense categories and providing target cost figures. Indicate the fiscal years during which these costs will be incurred. Adjust budget categories to match the needs of your project. Note: benefits and ODOE are expressed as an estimated percentage of salaries and wages. Use the estimates provided below as a starting point for the development of the detailed Project Budget. Item Amount Description or Explanation Report Writer (Salary) $ Require a report writer to synthesize the reports from each of the CE LHIN CKD CDPM Projects into one joint report. Payment provided per hour(?) Printing Costs & Material $ Transportation $ Communication i.e. Long Distance, etc. $ TOTAL $ Funding Source Identify source of funding for this project (i.e. base, one-time, MB20 submission, etc.). Indicate whether project costs will be absorbed by an existing organization (i.e. covered by current Ministry or Division budget) or if separate source of funding is required. Total amount to be shared by LHC, TSH, & PRHC using each centres respective CE LHIN allocated CDPM project funding. Page 14 of 21

Project Team Identify who is needed on the core project team to complete project deliverables and achieve its goals and objectives. What skills, knowledge and experiences are required? Consider the need for special expertise to deal with people and organization change challenges. Use table below to indicate who will be part of the core project team and who will be brought-in as required. Provide further details, identify source of resources and explain how they will be recruited, hired, trained, developed and managed in a separate Human Resource Management Plan. Team Member, Organization (Examples Inserted) Role on the Project Estimated Duration Required Involvement Level of Effort Jeanne Thomas CE LHIN Jenny Burgess CE LHIN Denise Duffie Ashton, HarbourFront Health Group Dr. C.W. Ashton Project Management HarbourFront Health Group CELHIN Project Sponsor CELHIN Healthcare Planner PRHC Project Manager PRHC Project Manager 2012 2012 2010 2010 Monthly Monthly Bi-Weekly Bi-Weekly Emily Harrison LHC Ethel Doyle LHC Linda Kloosterman Baxter Canada Tracey Skov Baxter Canada Gail Chan, TSH Jay Wilson, TSH LHC Project Manger LHC Renal Quality Leader Project Manager, Disease Management, Baxter Project Manager, Disease Management, Baxter TSH Project Coordinator TSH Patient Care director, Nephrology and Diabetes 2012 2012 2012 2012 2010 2010 Weekly Weekly Bi-Weekly Bi-Weekly Bi-Weekly Bi-Weekly Janet Bick The Kidney Foundation of Canada Director of Policy & Programs, 2012 Monthly Project Partners Is this project carried out in partnership with other groups/organizations? Indicate who else, in addition to those listed as project team members above, committed to contributing to this project. Partners are individuals, groups or organizations who work together towards joint interests to achieve common goals. Identify shared, mutually beneficial objectives below and the contributions of each partner. Provide details of each partnership in a separate document, such as a Memorandum of Understanding (MOU) or Service Level Agreement (SLA). Partners Common Interests & Priorities Roles & Responsibilities Identify your partners. List names, groups or organizations. State shared objectives and identify priorities for each partner listed. List roles. What commitments have been made? Have MOUs or SLAs been signed? Page 15 of 21

Partners Common Interests & Priorities Roles & Responsibilities Identify your partners. List names, groups or organizations. CELHIN Renal Network Refer to individual project charters for list of other partners State shared objectives and identify priorities for each partner listed. To create strategies to implement recommendations made in this report as a means to better provide CKD care across the CE LHIN. List roles. What commitments have been made? Have MOUs or SLAs been signed? Project Stakeholders Stakeholders are individuals or organizations that have a vested interest in the initiative. They are either affected by, or can have an affect on, the project. Anyone whose interests may be positively or negatively impacted by the project, or anyone that may exert influence over the project or its results is considered a project stakeholder. All stakeholders must be identified and managed appropriately. Use the information provided below as a starting point to elaborate and provide further details explaining how project stakeholders will be managed in the Stakeholder Management Plan. Stakeholders Interests & Needs Management Strategies Identify your stakeholders. List names, groups or organizations. Why are they stakeholders? How are they involved? List interests. How will the project manage expectations & meet their needs and requirements? See Individual project charters Other Related Projects & Initiatives Are there dependencies with other initiatives or projects? If you haven t described them in the Project Partners or Project Stakeholders sections above, identify below the known interdependencies with other projects or initiatives currently underway in your branch, division, ministry, cluster or across the OPS. Identify related multi-ministry projects, inter-jurisdictional initiatives and/or public-private partnerships as well. Project/Initiative List the project or initiative. Interdependency & Impact State the dependency and indicate how the dependency impacts your project. See individual project charters Page 16 of 21

People & Organization Change Impacts Identify the impacts this project will have on both the people and structures of the affected organizations. Who will be impacted (both positively and negatively) as a result of or during the execution of this project? Will there be changes to the current staffing levels, reporting structures or position classifications? What impact will this project have on current organization core values, standards, business processes, policies, procedures, technology and finances? Are there any security, legal or privacy implications that need to be considered? Will the project result in the creation of a new organization? Elaborate and provide further details in the People & Organization Change Plan. Description of Impact List the people and organization change impacts this project will have. Identify who/what will be impacted and provide a description of that impact. See individual project charters Impact Management Strategies List the strategies that will be adopted on this project to minimize the negative and maximize the positive change impacts of this project. Project Communications Identify information needs of steering committee, project sponsor, project manager, team members, working groups, partners, stakeholders and others. List strategies for ensuring that right information is provided to right audience in most suitable and timely manner. Be sure to identify format and frequency of communication between the project manager and project sponsor regarding project status, performance, risks, issues, etc. Provide further details and describe how project information will be generated, collected, stored and communicated both internally within project team and externally with partners and stakeholders in the Communications Management Plan. Audience Information Needs Format & Timing Responsible To Whom? List recipients of the information. See individual project charters What? State what information will be communicated. How? When? How often? Explain method & frequency. Who? Identify who will provide information. Project Risks Consider what if Document high-level project risks apparent at this point that could either positively or negatively impact the achievement of project goals and objectives. Indicate initial likelihood and impact. Focus on risks that are likely to happen and have significant affect on project success. Be sure to consider risks associated with people & organization change, knowledge management and transition to operations. Provide further details and describe the approach that will be taken to identify, assess and respond to project risks in the Risk Management Plan. Risk Likelihood Impact Risk Response List high-level risk events that pose threats or opportunities to the project. Inability to recruit project writer See individual project charters Indicate Low/ Moderate/High Indicate Low/ Moderate/High Explain what will be done to avoid, transfer, mitigate or accept risks listed. Low High Early develop of role profile and communication of need to support recruitment. Worse case scenario, 3 project leaders from each respective project will need to work on the report together. Page 17 of 21

Critical Success Factors Define key factors that are critical to success of the project. These conditions must be satisfied to enable successful completion of project objectives and deliverables. Include significant events or decisions that need to take place. Whenever possible, ensure factors you list are measurable. Completion of the individual CKD CDPM projects Completion of the CKD CDPM Model report Assumptions & Constraints Assumptions are external factors that, at the time of writing the charter, are considered true, real or certain for purposes of planning. Certain unverified or unknown aspects that are likely to happen must be assumed as facts to proceed. Constraints are factors that are outside the control of the project team, that restrict or regulate the project. They limit available options and affect performance of the project. Assumptions List the assumptions made to date. What did you have to assume to be true to complete the charter? Individual CKD CDPM Projects from each CE LHIN CKD Program will be completed. Documentation of the outcomes and processes of these projects will be done in order to enable synthesis into one report. CE LHIN will continue to support the LHC CKD CDPM project and will continue to be the project sponsor of all respective projects Constraints List project constraints. Consider time, budget, scope, quality, availability/skills of resources, priorities, etc. Page 18 of 21

Sign-Off Project charter must be approved & signed-off by project sponsor before Definition Phase can be completed. Project manager, partners and team members also sign-off the charter. Once completed & signed-off, the charter forms the basis for detailed planning and future decision-making. It cannot be modified. Any changes to information contained in the charter must be documented using a formal Project Change Request and the associated process. Workstream Lead/Project Sponsor Sign-off by sponsor signifies that there is clear commitment on behalf of the sponsor to provide guidance & support and contribute necessary resources to complete project goals & objectives as outlined in the charter. By approving the project charter, the sponsor has understood what will be delivered and is in agreement with performance measures and success factors identified. Name & Organization Signature Date Jeanne Thomas CE LHIN Project Lead/Project Manager Sign-off by project manager signifies a commitment on behalf of the manager to plan, execute, monitor, control and complete the project in accordance with goals, objectives, requirements, assumptions and constraints outlined in the charter. By signing the charter, project manager has understood what needs to be done, what resources will be available, and how success of the project will be measured. Name & Organization Signature Date Page 19 of 21

Project Partners List names of project partners or representatives of partner organizations. Obtain appropriate signatures. Sign-off by project partners signifies that they have understood their roles & responsibilities as outlined in the Project Partners section and there is joint commitment and agreement to proceed. Name(s) & Organization(s) Signature(s) Date(s) Project Team Members List names of project team members. By signing the charter, team members confirm that they have understood their roles & responsibilities on this project and are committed to its successful completion. Name(s) & Organization(s) Signature(s) Date(s) Jeanne Thomas: CE LHIN Jenny Burgess: CE LHIN Denise Duffie Ashton: HarbourFront Health Group Dr. C.W. Ashton Project management Emily Harrison: LHC Ethel Doyle: LHC Linda Kloosterman: Baxter Canada Tracey Skov: Baxter Canada Gail Chan: TSH Jay Wilson: TSH Janet Bick: The Kidney Foundation of Canada Page 20 of 21

Charter Revision History Version Numbering: 0.x - internal draft - under development (Working copy for Project Coordinators) 1.x - document under review / internal draft (Begin 1.0 numbering when sent to Workstream Lead for comment) 2.x - document submitted for approval (Begin 2.0 numbering when sent to Oversight for approval) 3.x - document approved (Renumber to 3.0 after Oversight Approval) Revision No. Description Modified By Date 0.1 Development of first draft Project Background All November 21 st, 2009 0.2 Development of first draft Strategic Alignment E. Doyle & E. Harrison December 19 th, 2009 0.3 Development of first draft Project Benefits All January 26 th, 2009 0.4 Development of first draft Goals & Objectives E. Doyle & E. Harrison February 26 th, 2009 0.5 Development of first draft Goals, Objectives & PM All March 26th, 2009 0.6 Development of first draft Goals, Objectives & PM All May 19, 2009 0.7 Development of first draft Remainder of charter E. Doyle & E. Harrison May 20, 2009 Page 21 of 21