Hsd Blueprint Vision 2022 Final

A Healthier Tomorrow Health System Design Blueprint Vision 2022

South West Local Health Integration Network

Table of contents Foreword..................................................................................................................................... 1 Note from the South West LHIN Board of Directors .................................................................... 2 Executive summary ..................................................................................................................... 3 Background and introduction....................................................................................................... 8 Why consider health system design now? ............................................................................ 8 Project Scope and Objectives .............................................................................................. 9 Building a Blueprint for the future? ......................................................................................10 An overview of today – Case for change .................................................................................. 11 An understanding of the South West LHIN ..........................................................................11 Overview of health services and implications for the future .................................................14 Profile of our Health Human Resources ..............................................................................24 On the road to transforming the current health care system… .............................................26 A blueprint for the future............................................................................................................ 28 Overview of the Integrated Health System of Care ..............................................................28 Population-based Integrated Health Services ................................................................31 How is the Population-based Integrated Health Services approach delivered?..............32 Centrally Coordinated Resource Capacity .....................................................................34 Operationalize the Integrated Health System of Care ..........................................................41 Call to action ............................................................................................................................. 46 Supporting documents .............................................................................................................. 48

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Foreword All of us value our health care system. We also value the health service providers and professionals that care for us in times of need. However, accessing services or managing more complex needs can often be a challenge. Based on our conversations with our health service providers and the members of the public, we have heard clearly that these challenges most often relate to disconnects within the health care system. It is for this reason that the South West LHIN Board of Directors initiated the Health System Design Blueprint process so that the bold and necessary step towards system transformation through the development of the Health Services Blueprint, a future state vision for our health system, could be advanced. Informed by your input through various forums of engagement and building upon initiatives to date, we developed a Blueprint which outlines and sets a vision for an Integrated Health System of Care. The Blueprint, centered on individuals/families, describes a system which facilitates equitable access to services, more appropriate use of our resources, and better management of the health of our population. It will begin to address existing needs and gaps across the South West LHIN. Where we have previously been troubled by scarcity and competition for resources, I am hopeful that new understandings and flexibility will allow for new initiatives and enhancements. Health care is changing and how we deliver services and manage our health care system must also change if we are to continue to meet the needs of our communities. To ensure the Blueprint can be translated into action, I urge Boards, health service providers, communities and other partners to seek to understand how the transformation will impact you, demonstrate a willingness to lead change, and collaborate to develop an improved health care system. The Blueprint represents a strong first step towards realizing a better health care system that is essential to meet the needs and demands of our population. I ask that you join us on the road to transformation, the collective journey to ensure that our communities receive the care they deserve now and in the future.

Michael Barrett Chair Health System Design Steering Committee

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Note from the South West LHIN Board of Directors Development of the Health System Design Blueprint - Vision 2022 is a significant milestone for the South West LHIN. Building on the commitment and achievements of health services providers across the LHIN over the last several years, this document represents a shared vision for the future health and health services delivery for individuals in the South West LHIN. Moreover, the Blueprint provides the foundation from which all health services providers, communities, and other system partners can collaboratively and progressively work towards an Integrated Health System of Care. The South West LHIN Board of Directors has endorsed the direction set forth within the Blueprint, and also recognizes that this document represents a launching pad for future change. The Blueprint, informed by the input of providers and other partners from across the LHIN, provides a strong vision for the future of our health system and the work required in making that happen. If we are to realize meaningful change and transform the Blueprint from words to reality, we must all collectively work together. As a Board, we are committed to working with other Boards, providers, and community leaders across the LHIN to enable those tasked with driving change to realize success in their endeavours. As we embark on the next phase of our health system transformation journey, I would also like to take this opportunity to thank the Health System Design Steering Committee, LHIN staff, and all providers and other partners for their engagement and participation in the development of the Blueprint. It is because of your efforts that we now sit on the precipice of transforming how individuals who receive care in the South West LHIN manage their health and how health services are delivered. Change is upon us. We look forward to working with you to build an Integrated Health System of Care that will allow us to collectively enable a healthier tomorrow.

Janet McEwen Board Chair (A) South West LHIN

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Executive summary Since 2006, the South West LHIN (LHIN) has dedicated itself to building a future vision of the health care system, an Integrated Health System of Care. By bringing local people together, including both the community and providers, we are committed to creating “A health care system that helps people stay healthy, delivers good care to them when they get sick and will be there for their children and grandchildren.” Guided by the first Integrated Health Service Plan (IHSP), the past three years have resulted in a foundation upon which we, our providers and communities are poised to continue the next leg of our health system transformation journey. For this reason, we began the health services design initiative. After reaching consensus with health system partners regarding the approach to be used, the South West LHIN‟s Health System Design Steering Committee came together to develop the Health Services Blueprint. The intention of the Blueprint is to provide an overall framework and set a direction for future detailed health services design. Development of the Blueprint has reinforced the fact that health services are provided by a talented and dedicated group of service providers across the LHIN. Moreover, it should be acknowledged that care providers, while dedicated in their pursuit to deliver the highest quality care, also recognize considerable challenges do exist. As a result, there are many examples of the development of innovative partnerships and initiatives that have been completed in order to address system and service delivery related challenges. However, despite these successes, many challenges still persist. More specifically, across the sectors, health service professionals and South West LHIN residents consistently face challenges within the current system:  Inequitable distribution of health services across the LHIN pose access challenges for residents, particularly those in rural communities.  Resource constraints, both health human resources (HHR) and funding, present challenges to meeting current and anticipated health service demand.  Current funding and operating models reinforce a provider-focused vs. person-centred approach to health service delivery.  Access challenges continue to persist for marginalized populations across the LHIN.  Lack of integration across sectors and health service providers inhibits the seamless transition of individuals and families across the continuum of care.  The health profile of the South West LHIN necessitates the need for more appropriate, integrated screening and early identification of health risk factors and conditions.  Lack of integrated platforms across the LHIN inhibits seamless information sharing among health service providers across sectors and geography.

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In order to address these current and emerging challenges, the Blueprint has developed a vision for the future health system, an Integrated Health System of Care. Building on the work of teams that had previously come together and developed through the input and participation of providers and public engagement forums through the Blueprint development process, the future system seeks to address today‟s challenges, and adjust for tomorrow‟s needs.

Local Community

MultiCommunity

• Services provided close to • Service delivery by home • Delivery of high volume/low complexity services to broader population • Collaboration across local traditional and nontraditional providers • Emphasis on an individual‟s self-health management

geographic clustering of moderate volume/complexity services focused on targeted populations • Seamless referral relationships with local and LHIN providers

LHIN Community • Delivery of low volume/highly complex services to manage specialized populations • Support multi-community and local providers with accessibility to specialized services • May serve as a broader provincial resource • Manages referrals and refers out of LHIN as necessary

This system emphasizes the message that all health programs and services are part of a single, unified health system of care. A unified system clearly communicates the roles and responsibilities of the various health service providers and non-health organizations, and also delineates the interdependencies between the various stakeholders to enable a shared approach to service delivery. In acknowledging unique characteristics among community, longterm care, acute services, and primary care services, the Integrated Health System of Care is to be implemented through two integrated service delivery approaches:  Population-based Integrated Health Services which is tailored to the collective needs of a local population and its health service providers. It enables local communities to support the health and wellness of its catchment population enabling them to better manage their own health and maintain independence. The local community services are supported by the multicommunity services and have access to LHIN community services as needed. ‒ Throughout an individual‟s life, he or she may access primary care, home and community care, complex continuing care, long-term care, rehabilitation, palliative care, chronic disease prevention and management, mental health and addictions (MH&A), and emergency services coordinated through this service delivery approach.  Centrally coordinated resource capacity optimizes the use of targeted resources to improve access and complement the management of health and wellness at the more local level. ‒ Throughout an individual‟s life, he or she may access medicine, surgical, and critical care inpatient and ambulatory services coordinated through this service delivery approach.

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Realization of these future service delivery approaches provides an opportunity to enhance the roles and responsibilities of providers, health professionals, individuals, and other entities (e.g. ministries) to operationalize an optimal, person-centred approach to care. This system design represents a significant change for communities and providers, providing the opportunity to realize several benefits.

The Integrated Health System of Care provides an essential roadmap for all of us who lead and participate in change, something that is critical to the success of our South West LHIN health system. Tom McHugh, Tillsonburg District Memorial Hospital and Alexandra Hospital – Ingersoll

How is this different from today’s service delivery model?  Develops collaborative partnerships across health sectors, continuum of care, and beyond broader health sectors.  Equitably distributes services across the LHIN to enable care close to home as appropriately possible.  Establishes referral processes to enable seamless, connected transfer of individuals across the continuum of care.  Enhances collaboration among providers across the LHIN to ensure that the right individual is in the right place at the right time.  Expands provider roles across the continuum to optimize care delivery. Enhances capacity of direct service providers on knowledge, understanding of services and individual health needs.  Standardizes evidence-based approaches to care provision.  Increases access through multiple entry points so that “any door is the right door.”  Involves the individual as part of their care by consistently sharing information throughout the process to enable decision-making.  Emphasizes an individual‟s accountability through enhanced reliance on self-health management.  Requires modifications to existing organizational relationships and structures.

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This system realizes benefits for both providers/health professionals and individuals/families. What are the benefits? Individuals and Families:  Empowerment and accountability of individuals/family members in managing their own care.  Emphasis on providing care closer to home balanced with access to specialty services.  Early identification and management of the individual‟s needs in order to enable people to optimize their level of function and quality of life in their community and home environment.  Strengthened relationship among individuals/families and health service professionals. Providers and Health Professionals:  Further development of physician relationships through traditional and virtual networks of physicians across LHIN to collaborate and share best practices, education, and ensure quality monitoring.  Strengthened relationships among health professionals across health sectors.  Strengthened partnerships with other ministry partners who can influence the health of our communities (e.g. education, social services).  Seamless referral and linkage of individuals/families across health and other sectors.  Enhanced capacity of local communities to increase focus on prevention, screening and early identification of chronic illnesses and addressing mental health and addictions needs.  Optimize capacity as a result of precise navigation to appropriate health facilities.  Improved quality of care through the adoption of standardized care pathways from screening, assessment through to discharge guidelines.

Acknowledging the realities of today and potential pressures of the future, change is even more imminent and the success of the future health system is dependent upon our collective responsibility. The Blueprint builds upon your input and the work accomplished through the 2007-2010 Integrated Health Service Plan (IHSP), the Priority Action Teams, and other integration initiatives being led by South West LHIN health service providers. The Blueprint has been developed through a methodical process that has been specifically designed to engage you - a broad cross section of stakeholders, enable development of the Blueprint through an iterative process and integrate the insights gained through the “best available” data/information, and learnings from leading practices within other jurisdictions. In order to take the Blueprint from words to action, a collective commitment is required on the part of all provider organizations, direct care providers and communities. Together, working with our partners within the Ministry of Health and Long-term care, primary care, public health and other partners, we must keep the needs of our communities front and centre, and build and align all aspects of our system to work in concert with one another such that we are all collectively working towards the same objective – a healthier South West LHIN population.

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How are we going to get there? South West LHIN in Collaboration with its Health System Partners:  Developing future IHSP releases and accountability agreements aligned to the vision of the Health Services Blueprint;  Decision-making and prioritization based on the Blueprint as a key guiding document;  Incenting health service providers and partners for integration and innovation as able and deemed appropriate; and  Facilitating transparent processes with open lines of communication to enable easy collaboration. Health Service Providers and Health Care Professionals:  Seeking opportunities to integrate the local health system as they align to the Health Services Blueprint;  Transforming governance and leadership relationships to facilitate and oversee change;  Expressing interest in the success of everyone‟s organization, as well as your own; and  Demonstrating how you fit into the future vision philosophically and operationally to showcase the outcomes of your transformational efforts to inspire others to become the change.

In summary, in order to progressively work towards the realization of the vision set forth in the Blueprint, building on the initial guiding steps indicated above, we all must work together to undertake and implement a number of transformative initiatives. Transformative elements to realize the future health system have been identified and illustrated through a programmatic implementation roadmap which includes health program-specific initiatives as well as system-wide changes. It is this road map that will provide the necessary framework to guide the LHIN, its providers and community partners in taking the next steps along the health system design journey.

System change is required to allow our health service providers to do what they do best – deliver quality care within a dynamic, everevolving environment. We can only make it happen together. Michael Barrett, South West LHIN

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Background and introduction Why consider health system design now? Since 2006, the South West LHIN has been dedicated to its vision of “A health care system that helps people stay healthy, delivers good care to them when they get sick and will be there for their children and grandchildren.” With today‟s economy and HHR shortage, change is upon us whether we choose it or not. Thus, through the Blueprint process, we have proactively engaged you, our health service providers and partners, to help direct us in transformation and control our changes so that it aligns to our vision. Under the Local Health System Integration Act, 2006, providers now have an accountability to look for opportunities to integrate the local health system. With that said, it is our responsibility to collectively transform our health system through integration to enhance access, quality of care, and ultimately, the health of our population. What is the Blueprint? Building on the foundation of the IHSP, the Blueprint has been developed to guide the LHIN and health service providers in shaping the future design of our health system within the South West LHIN. The Blueprint will be fundamental in guiding the decisions to be made in transforming the way in which services are designed to meet the needs, and changing demands, of local populations. The Blueprint integrates and advances the work of the Priority Action Teams (PAT) through the development of service delivery frameworks that will guide health service providers in their shared quest to improve how people experience and interact within the health care system. This will improve the overall health of its residents and maximize the value realized through health care expenditures. The Blueprint describes the shared vision for the future design of our health system and the changes needed to make that happen. Seeking to understand how people experience their health care and the improvements that we must make to ensure optimum health for South West LHIN residents is at the core of our responsibilities. This is an enormous undertaking, but one that we have already begun through the creation and implementation of its first Integrated Health Service Plan (IHSP) 2007 – 2010, which articulated four strategic priorities:  Strengthening and improving primary health care  Preventing and managing chronic illness  Building linkages across the continuum for all seniors and adults with complex needs  Accessing the right services, in the right place, at the right time, by the right provider As an outcome of the IHSP 2007-2010, we launched the development of a Blueprint to guide the transformation of health services across the South West LHIN for the future.

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Project Scope and Objectives Guided by the Health System Design project charter, the Blueprint continues the journey of health care system integration for the LHIN by designing a future health system, which will be realized through a multi-year staged implementation. More specifically, in developing the Blueprint, the intent is to create a guiding framework to enable the LHIN, health service providers and communities to progressively work towards the South West LHIN health system goals:  A focus on outcomes that includes improved heath care for the people of the South West LHIN to enable a Healthier South West LHIN Community.  A commitment to evidence-based and leading practice literature in delineating service delivery changes to ensure Quality of Care and Service.  Acknowledgement of service distribution across the LHIN to enable Equitable Access to Services.  Significant engagement and input from a broad range of stakeholders including priority action teams, providers, volunteers, the community and consumers to ensure Sustainability of the Local Health System.  An understanding that while this project focuses on the South West LHIN, we will consider a number of other province-wide initiatives which will influence the options for integration and non LHIN-funded organizations which play a critical role in the health care continuum to enable Integration of Health Care Delivery. With these goals in mind, the Blueprint development has been guided by the following objectives: Blueprint Guiding Objectives:

   

Provide response to f irst Integrated Health Service Plan (IHSP) priority to ensure access to the right services, in the right place, at the right time, by the right provider Develop a f ramework f or how the system should be structured, across programs and geography, based on a detailed understanding of current services Facilitate health care providers and the LHIN to plan f or change rather than react to health system trends, challenges and best practices Broadly and collectively leverage our resources rather than reacting to single issues f aced by one organization, sector, or discipline

 Recognizing that health system transformation will not be a “quick fix”, the Blueprint will set a direction that will guide the work of the LHIN and health service providers (across disciplines and sectors including hospitals, long-term care, complex continuing care, and home and community care), in conjunction with the communities they serve, over a multi-year time frame.

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Building a Blueprint for the future? The Blueprint guiding objectives provided the foundation to the process that was undertaken for its development. In designing the approach, the intent was to create and execute a Blueprint development process that integrated a significant level of stakeholder engagement, iterative development cycles, was based on the “best available” data/information, and integrated insights of leading practices. Key activities have been included below.  The project began with assessing the LHIN‟s current service utilization patterns and projecting the overall future service needs. Consultations with over 150 key cross-sectoral stakeholders (e.g. existing taskforces and coalitions, clinical leaders, community leaders) helped develop a well-rounded profile balanced with data and qualitative findings.  This current state assessment complemented a cross-jurisdictional review of peer models of care to provide context into service delivery elements that should be incorporated into the development of future models of care. This enabled the Health System Design Steering Committee to understand the service gaps and set the stage for the next phase in developing a future state health services Blueprint.  The LHIN held two health system design symposiums over two days, with 400+ participants, which orchestrated the planning of future models of care for eight health program areas. Building on the work of priority action teams where available and informed by service utilization profiles and peer models of care research, participants were facilitated to work through a model of care framework to discuss, develop, and gain consensus on the components comprising a future model of care. Models of care were developed for Mental Health and Addictions, Long Term Care Services and Complex Continuing Care, Chronic Disease Prevention and Management, Women‟s Health and Paediatrics, Emergency Services, Surgical Services, Medicine Services, and Critical Care Services.  The models of care were then refined and enhanced through the facilitation of 12 refinement sessions with existing and ad-hoc taskforces and coalitions. This enabled concentrated clinical input and pivotal cross-sectoral conversations on the integrated approach to delivering these models of care.  An order of magnitude analysis was conducted to better understand the implications of the future models of care on today‟s service delivery models. Base-case future state projections were adjusted with future health system planning assumptions to better understand the realities of capacity, HHR, and infrastructure implications in year 2022.  17 community sessions were held to engage the public on the Blueprint and IHSP.  The LHIN and Health System Design Steering Committee developed a future health system with two service delivery approaches for the South West LHIN community based upon common underpinnings of the models of care.  This approach helped derive the implementation elements required to operationalize the health services Blueprint to inform the development of the 2010-2013 IHSP. Further details regarding the specific methodologies and assumptions applied throughout this process are provided in Appendix C of the report.

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An overview of today – Case for change Across the South West LHIN, health care providers and residents face challenges in both delivering and accessing services; these concerns are compounded when one considers the projected future demands that will be placed on a system that is already struggling on a number of fronts.  Inequitable distribution of health services across the LHIN pose access challenges for residents, particularly those in rural communities.  Resource constraints in terms of both health human resources and funding present challenges to meeting current and anticipated health service demand.  Current funding and operating models reinforce a provider-focused vs. person-centred approach to health service delivery.  Access challenges continue to persist for marginalized populations across the LHIN.  Lack of integration across sectors and health service providers inhibits the seamless transition of individuals and families across the continuum of care.  The health profile of the South West LHIN necessitates the need for more appropriate, integrated screening and early identification of health risk factors and conditions.  Lack of integrated platforms across the LHIN inhibits seamless information sharing among health service providers across sectors and geography.

These foundational issues are described in further detail throughout this section.

An understanding of the South West LHIN The South West LHIN health system serves approximately 944,852 residents across 8 counties spanning 21,865 square kilometres. For planning purposes, these counties have been segmented into three geographic clusters:  North: Bruce and 95% of Grey Counties  Central: Huron and Perth Counties  South: Middlesex, Oxford, Elgin, and 12% of Haldimand-Norfolk

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While today‟s health system is caring for its current population, emerging challenges may threaten its sustainability in the future.  The large geography of the LHIN and the rural nature of some South West LHIN communities continue to pose challenges for their residents in accessing health services.  The growing unemployment rate may have an adverse effect on select populations, increasing the need for mental health and addiction services beyond the current capacity.  The demands of an aging population significantly impact services and will continue to grow in the future.  The high prevalence of chronic disease throughout the South West LHIN may contribute to increased hospitalizations if managed inappropriately. If not proactively addressed, the current challenges of the health profile will be exacerbated in the future, straining our health system further as seen below.

Population density is the highest in the southern cluster with pockets distributed throughout the rest of the LHIN: Approximately 70% of the South West LHIN population resides in the southern counties, with London and Middlesex County having the greatest proportion of visible minority residents and residents with a non-official language mother tongue. The population distribution has naturally resulted in a concentration of specialized health services in the south, which has posed access challenges for northern and central residents. Socioeconomic indicators may contribute to an increase in health risk factors:1 Overall, the LHIN‟s population reflects a similar educational profile to the provincial average. Approximately, 45.3% of the LHIN population has completed post-secondary education, 28.5% did not complete high school, and 8.8% have less than grade 9 education. The South West LHIN unemployment rate of 5.4% is below the provincial average. However, the economic downturn experienced over the past year has increased this average and may have adverse population health implications for some residents within the LHIN. In September 2009, Statistics Canada reported an increase in unemployment for Ontario to 8.4%, an increase of 2.0% from 2006. Current unemployment data is not available for the South West LHIN as a whole although London‟s unemployment rate in September 2009 was 11.5%. LHIN residents are also noted to have a lower average household income compared to provincial average. Consultations revealed that these socioeconomic indicators may contribute to an increased prevalence of mental illness and addictions issues as well as other chronic diseases.

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Data in this section is from Statistics Canada 2006

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Health profile of the LHIN may contribute to an increased need for health services: The Canadian Community Prevalence of Selected Chronic Conditions* Health Survey (CCHS) in South West Ontario 2007 revealed an Health Indicator 2005 2007 2005 2007 increasing public Asthma 7.3% 7.8% 8.0% 8.1% awareness of chronic Arthritis & health conditions, along 18.7% 17.1% 17.1% 16.2% Rheumatism with a desire to Diabetes 5.2% 5.7% 4.8% 6.1% understand chronic High Blood Pressure 17.2% 17.9% 15.2% 16.4% disease prevention and management strategies. Obesity 18.1% 18.0% 15.1% 16.1% While the prevalence of Smoker 20.7% 22.7% 20.7% 20.6% chronic conditions is in line with the provincial average, we have not seen any substantial improvement over the past two years. Moreover, there are noted population variations across the South West LHIN with regards to the prevalence and management of chronic disease. In addition, recent findings from the Canadian Institute for Health Information report on Primary Health Care in Canada2 reported that 41% of the Canadian population has one or more chronic illnesses. As well, historical LHIN data in 07/083 has revealed that 2% of the LHIN population was dealing with a diagnosis of cancer. Overall, stakeholders reported an increase in mental health and addictions prevalence across the LHIN. More specifically, they reported an increase in:  Use of Mental health service needs within rural populations;  Complex issues within the adolescent population;  Addictions, mainly related to the increase in methamphetamine use, within the north and central geographic clusters; and  Alzheimer-related cases within the growing senior‟s population cohort. In addition to health conditions, South West residents reported a need for in-home care through the CCHS 2007, which reported that:  2.5% of South West LHIN respondents needed help with personal care. Of the 2.2% who indicated that they had self-perceived unmet home care needs, 1.6% indicated that they required personal care support.  Under the topic of “restriction of activities”, 3.4% of South West LHIN respondents indicated they needed help for preparing meals. This is comparable to the overall Ontario average.  Under the topic of “home care”, 2.2% of respondents over the age of 18 indicated that their home care needs were unmet, while 77.6% of those said their need was for meals.

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CIHI – Analysis in Brief: Experiences with Primary Health Care in Canada, July 2009 2007/08 South West LHIN Oncology Data

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Often, the unattached population rates provide an indication of the at-risk population within our LHIN. CCHS 2007 and the Primary Care Access Survey4 results revealed that approximately 711% of the population is unattached. Of this, Huron and London/Middlesex counties tended to have the highest proportion of unattached patients, which exceeded the provincial rate of 7%. The high prevalence of chronic conditions may lead to increased hospitalizations in the future if not managed appropriately.

While these health needs are evident today, service providers will be faced with growing pressure to meet future demands for these health services. This anticipated service gap is reinforced when one considers future demand based on projected population growth.

South West LHIN Population

Projected population growth may exacerbate the current health profile straining current capacity: South West LHIN Population Projections 1200000 1150000 1100000

1,054,804

1050000 1000000

944,852

950000

900000 2007

2012

2017

2022

By 2022, the population is projected to grow by 0.7% average annual growth rate to Projected Years 1,054,804 residents as seen in the next exhibit. Elgin County is projected to have the highest growth rates relative to the other counties at .98%, with Middlesex and Grey projected at .87% and .80% respectively. The population distribution relative to the LHIN geography also affirms the fact that the South West LHIN is largely comprised of rural communities. As well, the senior‟s cohort of over 65 years is projected to grow from 15% to 21% of the total population by 2022. The demands of an aging population have already had a significant impact on the LHIN and will continue to grow over the next 15 years. The largest growth of this age cohort will occur in the north, where it will grow from 11% to 16% of the total northern population. If not addressed, the growth in population will exacerbate the current challenges, further straining our health system. Factors such as demographics, population density, health status indicators, and growth contribute to determining the service needs of the future population profile, which will influence the type, location, quantity and model of how services are delivered throughout the LHIN.

Overview of health services and implications for the future To date, South West LHIN health service providers have implemented innovative solutions to address the evolving needs of its catchment population. While there have been great strides in enhancing services, emerging demands continue to pose systemic challenges that require a more coordinated approach.

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Primary Care Access Survey (PCAS) Results for the South West LHIN and Ontario, July 2007-June 2008

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Profile of South West LHIN Health Service Providers The South West LHIN population receives services from an array of LHIN and non-LHIN funded organizations across the community, long-term care, and acute health sectors. Residents rely on these organizations for a variety of needs including home/social support, episodic, chronic, and long-term care. The following LHIN-funded organizations play a critical role in delivering services to its residents:  19 public hospitals operating 33 sites and 1 private hospital  62 community support services  2 community health centres (plus 3 under development)  28 mental health agencies (including 1 children‟s mental health)  10 agencies providing addictions services (including 4 which also provide problem gambling services)  75 long-term care homes  1 Community Care Access Centre (SWCCAC) In considering the above organizations, a proportion of organizations have been active in advancing the health services integration agenda. This is reflected in the various governance structures that exist, shared leadership roles and the number of partnerships/coalitions that are in place – all with the purpose of driving system integration. In addition, non-LHIN funded organizations such as family health teams, family health organizations, family health networks, solo-physician offices, and public health units, play a critical role in the delivery of primary care services. While these providers are not under the LHIN‟s mandate, they play a significant role and have thus been captured in the health services Blueprint process. For purposes of analysis, this report summarizes LHIN-wide profiles of these health services through a sector analysis of 2007-2008 utilization. These summaries are based on current state and future state assessment findings which are provided in Appendix H. Community Sector The community sector plays a pivotal role in managing chronic illnesses, providing services to those with mental health and addictions needs, and providing support services that enable individuals and their personal support networks to manage locally. Examples of these services include, but are not limited to:  Homemaking, in-home personal support, meal delivery, programs to assist the hearing and visually impaired, transportation, social and congregate dining; foot care, visiting hospice services, day services; assisted living/supportive housing  Crisis intervention services, psycho-geriatrics; supportive housing, mental health case management, counselling, vocational/employment support programs, social/recreation/rehabilitation, consumer and family initiatives, peer support, addictions assessment, group sessions, withdrawal management  Nursing, occupational therapy, physiotherapy, social work, speech language pathology, nutrition

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The following table provides an overview of key observations regarding the state of the community sector today, implications for the future and the challenges that will need to be addressed as part of the future state design.  A number of organizations deliver community and in-home support services such as homemaking, in-home personal support, meal delivery proportionate to the population distribution across the LHIN.  Some services are reported to have inconsistency in the capacity levels across the LHIN. For example:

Observations

‒ A lower proportion of day services programs were delivered in the north relative to the population ratios in the other geographic clusters. ‒ Despite the high volume of transportation assistance provided through LHIN-funded groups, transportation challenges were raised during consultations across the LHIN, especially by rural service providers.  A review of community-based mental health and addictions services revealed inconsistencies across the LHIN: ‒ While community crisis intervention, case management services, and psycho-geriatric services were provided across the LHIN, capacity levels appear to be greater within the southern and central geographic clusters within the LHIN relative to the north. ‒ Community residential treatment and supportive services were provided by organizations mainly in the north and south. ‒ Services to support those with concurrent disorders were mainly provided in the south, which poses challenges in providing these specialized services to residents across the LHIN.  South West CCAC enabled a variety of interdisciplinary practitioners to deliver care that allowed clients to remain in their home environment. CCAC facilitated a variety of services, with nursing and personal care support comprising the largest proportions.  Reported long waitlists for community support services.

Key Challenges

 Increasing complexity of patients discharged to community which impacts the finite resources dedicated to meeting these needs.  Community organizations face challenges of managing multiple funding sources and expectations in service delivery.  Stakeholders revealed that a narrowing mandate of the role of community mental health services has compromised the ability to provide early identification and intervention for those with mild to moderate mental health problems, a population at-risk for more serious issues.  Consultations suggest a need for strengthened screening of mental health illnesses and addictions at the local level.  Reported transportation challenges hinder access of health services in rural communities.  Organizations heavily dependent upon volunteers are at risk due to increased need attributed to aging population.

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Implications for the future

 The aging population will likely be high users of home and community care, which will be important to helping seniors maintain independent living at home.  Current service gaps across community-based services will grow in the future requiring an integrated, coordinated approach to delivery of community-based services.  Sustainable HHR model to address capacity challenges.  Design of services to address current and projected service needs for specialized populations (e.g. psycho-geriatrics, concurrent disorders, dual diagnosis).

Long-term Care Home Sector The South West LHIN has 75 long-term care homes (LTCH), which provide a range of services for individuals with varying needs. These include Alzheimer secure units, ethno-cultural/religious services, short stay, convalescent, and psycho-geriatric beds.

Seeds of Transformation: Partnerships for integrated delivery of comprehensive mental health services via multi-agency mental health teams Mental health crisis intervention teams play a critical role in managing individuals with emergent mental health and addictions needs. While providing the most appropriate care, they also help avoid visits to the ED, which is currently 2.7% of total ED volumes. Strengthening the capacity of crisis teams can result in improving the management of these individuals, while diminishing their use of the EDs.

Ratio of Long-term care beds per 1,000 Population 75+ years FY 2007-08 Sub-LHIN Beds Beds per 1,000 people North 1,325 106 Central 1,331 119 South 4,163 94 (107 with new beds)

With the pending addition of 608 beds to the southern portion of the LHIN, it is expected that the relative access to these beds across the LHIN will increase the ratio of beds per 1000 population within the south to be more in line with the north and central geographic areas of LHIN.

In addition to services within LTCHs, residents have also benefitted from an array of health services provided by community agencies, as indicated in the services provided through the community sector and non-acute services such as Complex Continuing Care (CCC), rehabilitation, and transitional care units (TCU), currently located within hospitals. The following table provides an overview of key observations regarding the state of community sector today, implications for the future and the challenges that will need to be addressed as part of the future state design.

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 The South West LHIN‟s waitlist is 8% of the provincial wait list. In July 2009, 1,893 clients were on waitlists, with average time spent as 146 days. On average, 175 individuals get placed into a home on a monthly basis.

Observations

 The South West LHIN also experienced consistent LTCH admissions, 5.3-5.9%, for individuals between ages 18-65. This was reported to be mainly due to the lack of appropriate supportive housing and wrap around services in rural areas.  While additional convalescent care beds are projected to be provided in the LHIN in 2010, survey findings and consultations raised the concern for more specialized units, especially around Psycho-geriatrics, Alzheimer, transitional care and convalescent care.

Key Challenges

 For the 75+ age cohort, the need for long-term care beds are projected to increase across the LHIN, with the north having the highest increase due to the growth rate of this age cohort.

Seeds of Transformation: Improved management of population through crosssector collaboration and service coordination: The South West CCAC‟s Wait@Home initiative has provided a win-win option to patients and providers. It has optimized current acute capacity by letting patients wait for LTC services in the comfort of their own homes. It facilitates this by providing up to 24/7 personal support care for individuals to wait at home. In the last four months of 08/09, a shift in 67 patients was realized.

 Waitlists are abundant and growing across the LHIN. In any given month, 10-12% of acute care beds in hospitals are occupied by ALC patients. Up to 61% of the ALC patients in these beds are waiting for long-term care beds.  Increase in acuity of population, multiple co-morbidities, result in a need for homes to care for specialized populations (sub-acute, Complex Continuing Care (CCC), mental health, dialysis, dementia, etc).  Consultations reveal that residents often improve within a LTCH and can be discharged, but often are not due to lack of alternative services.

Implications for the future

 Survey findings and consultations speak to an increased need for LTCH or supportive housing to accommodate the 18-65 years of age population that need 24/7 support.

 Alternative models to provide long-term care services to address the projected need in services.  Need for more specialized services including dementia secured units, psycho-geriatrics, and TCU/convalescent care. Increase in acuity of population, multiple co-morbidities, result in a need for homes to care for specialized populations (sub-acute, CCC, mental health, dialysis, dementia, etc).  Need for supportive housing and wrap around services to address the 18-65 population.

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Acute and Non-acute Hospital-based Services Sector Across the South West LHIN community, there are 20 hospital organizations. These range from small rural to large urban sites. According to The Core Service Role of Small Hospitals in Ontario 2006, the majority of sites are considered small hospitals. These hospital organizations enable access to core hospital services either through multi-site or single locations. While these small hospitals are mainly located in the northern and central geographic areas within the LHIN, a few sites reside in pockets of the southern geographic area. All hospitals accounted for 94,118 separations within the South West LHIN. The southern institutions encompassed approximately 71% of total separations across the LHIN, of which London Health Sciences Centre (LHSC) and St. Joseph‟s Health Care (St. Joseph‟s) accounted for 57% and 16%, respectively. The South West LHIN has four major referral centres as depicted by the map in the next exhibit:  Grey Bruce Health Services-Owen Sound in the north;  Huron Perth Healthcare Alliance – Stratford General Hospital in the central area; and  LHSC and St. Joseph‟s in the south. The map illustrates that GBHS-Owen Sound appears to capture major market share, 50% of total separations. Huron Perth Health Alliance - Stratford General Hospital captures significant market share in the central area of the LHIN with the service patterns extending beyond LHIN borders, with approximately 54% of total admissions being derived from within its natural catchment area. Hospitals located in the southern portion of the LHIN managed the largest proportion of inpatient separations in the South West LHIN. LHSC and St. Joseph‟s have large catchment areas, which is consistent with their role as tertiary care providers. The following summarizes other key highlights related to acute care-based services:

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 The distribution of beds from designated Complex Continuing Care beds and rehabilitation beds appear to align with the LHIN population density. Of all the CCC patients, 67% of them were either in the clinically complex or rehabilitation category.  In evaluating rehabilitation services, the largest number of admissions occurred in the southern hospitals, 65% at St. Joseph‟s-Parkwood. While all organizations offered orthopaedic and stroke in-patient rehabilitation services, volume of orthopaedic rehab was the greatest in central, while stroke rehab was utilized the most in the north.  The south has the highest volume of ED visits, while north and central experienced a greater proportion of visits per population. Of the 29 sites that registered ED visits, 21 sites managed greater than 10,000 visits in fiscal year 2007-08, with LHSC-Victoria as the busiest ED with over 100,000 visits.  Although these services are widely distributed across the LHIN, 69% of surgical and 89% of medical ambulatory visits were captured in the south.  As well, 79% of total chemotherapy visits were provided at LHSC, of which a portion of these visits is attributed to northern and central residents. Overall, the hospitals within the South West LHIN provide the vast majority of acute care services to its residents. Approximately 6.7% of residents were admitted for acute services outside of the LHIN, mostly to Hamilton Niagara Haldimand Brant, Toronto Central, and Waterloo Wellington LHINs. Beyond servicing the residents of the South West LHIN, hospitals within the LHIN also provide care for a proportion of residents from outside the LHIN which account for 14% of the 94,118 separations. Of the 14%, Erie St. Clair accounted for 7.2% of the total admissions. The following table provides an overview of key observations regarding the state of acute and non-acute hospital-based services sector today, implications for the future and the challenges that will need to be addressed as part of the future state design.

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Emergency Services:  Overall, while the majority of hospitals fall below the provincial average for total time spent in emergency departments, the LHIN exceeds the provincial average of total visits per population. In 2007, on a quarterly average, the LHIN had 159 visits per 1,000 residents, while the provincial average was approximately 100 visits per 1,000 residents. This may be attributed to the largely rural nature of the LHIN and the fact that the hospital ED is often the primary source of after hours primary care in many smaller communities.  The South West LHIN continues to face human resources challenges related to physician ED coverage and staffing, often putting some sites at risk for closure. The LHIN is the highest recipient of physician coverage hours through HealthForce Ontario‟s Emergency Department Coverage Demonstration Project program.  Across the LHIN, approximately a third of visits are attributed to non-urgent visits, which were Canadian Emergency Department Triage and Acuity Scale (CTAS) Level 4 and 5.  Challenges in addressing ED visits attributed to mental health and addictions exist across the LHIN. Medicine and Surgical Services:

Current Observations

 Each geographic cluster seems to manage the majority of the medicine-related needs in its communities.  However, for surgical services, a significant proportion of northern and central residents receive care by the southern providers. Approximately 30% and 37% of central residents frequented southern hospitals for their orthopaedic and trauma needs respectively, while, 16% and 18% of northern residents frequented southern hospitals for their general surgery and trauma needs.  Due to relatively lower case volumes in the „smaller‟ sites, stakeholders report concerns/perceptions with scope of surgical services provided outside of London and the associated quality of care. Conversely, there are reported concerns regarding the ability to access services within London hospitals.  Overall, there is a sentiment that a “rebalancing” is required to further enable and build surgical services delivery capacity outside of London.  A proportion of stakeholders state surgical cancellations have increased at their sites as a result of ALC patients in acute care beds.  Northern hospitals tend to have the highest proportion of ALC days attributed to surgical services. This could be reflective of the availability of post-operative services. Critical Care:  In the smaller community hospitals, the volume of critically ill patients is low and it is therefore challenging for the local physicians/nursing staff to attain and maintain a comfort level in dealing with these critically ill patients.  Nine hospitals are capable of providing Level 3 mechanical ventilation making it challenging to provide immediate access to Level 3 beds, which are distributed over a large geographical area. Challenges with maintaining access to designated ICU beds, arise from staffing availability/overrun of critical care budgets, beds blocked by patients who no longer need them, high-acuity patients, and reported variable occupancy rates in critical care units across the LHINs. Mental Health and Addictions:  Across the LHIN, there is a stated gap in services related to children and youth with mental health needs.  Currently, the majority of paediatric and adolescent admissions occur at southern providers which are most likely attributed to the fact that designated paediatric MH&A beds are located at LHSC and St. Joseph‟s. This current bed distribution results in inequitable access to paediatric mental health services.

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Key Challenges

 Lack of availability of specialty services in rural areas is particularly challenged by the uneven distribution of specialists.  Shortage of generalists in rural communities due to impeding retirement challenges and the availability of physicians with broad experience and capacity of previous generations.  Lack of coordinated process to manage emergent surgical cases (i.e. emergent orthopaedics).  Inconsistent approach to identifying patients in CCC that would be appropriately served in an alternate setting, such as LTCH or home with appropriate supports, impedes timely discharges to other community environments.

Implications for the future

 Need to optimize current acute capacity in order to offset the projected increase in demand.

Direction for Transformation

 Alternative model to coordinate resource capacity across the LHIN to better manage upstream and downstream flow of patients.

Sustaining access through optimization of current capacity:

 Need to strengthen the health resource base outside of London to enable care “closer to home” where appropriate and create capacity for London-based services to better deliver upon their local, tertiary and quaternary care mandates.

Improve patient care and optimize current capacity through the creation of multi-site maternal networks across the LHIN. A network would consist of a larger site managing the majority of obstetrical cases, providing support to the local sites to ensure that they meet the appropriate standards as a collective body.

 Better use of visiting specialists requires adequate local resources to support care.  All geographic clusters will need to play a role in delivering oncology systemic therapy (e.g. chemotherapy) that meets quality standards and brings care closer to home.  Need for community-based chronic ventilation program to address needs of growing population and to alleviate ICU bed pressures.

Primary Care Services A significant proportion of primary health services are provided through public health units, community health centres (CHC), family health teams (FHT), family health organizations (FHO), family health networks (FHN), family health groups (FHG), Comprehensive Care Model (CCM), Blended Salary Model (BSM) and individual practitioners. While the LHIN funds two existing Community Health Centres and one Aboriginal Health Access centre, there are also organizations and practitioners not funded by the LHIN that are pivotal in the delivery of health services to its residents.

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The organizations in the next exhibit are the first point of access to the health system and provide an array of educational and early intervention services including:  System navigation for many communities;  Prenatal and sexual health screening services that often serve as the stepping stone into education and early intervention;  Health education and promotion services which can help reduce the incidence of chronic illnesses; and  Key contact for identification and early intervention for mental health and addictions challenges and associated risk factors.

North

Distribution of Primary Care Resources All other primary care Public Health Community Health Centre resources (FHT, FHN, Units FHO, FHG, CCM, BSM) 1 0 and 1 under development

Central

2

0

South

4

2 plus 2 under development

Total

7

2 plus 3 under development

Implications for the future

Key Challenges

 Reported inconsistency in the availability of primary care resources in general across the LHIN.  Inconsistent access to primary resources (e.g. those individuals who are on the rosters of existing FHTs have greater access to other inter-professional care resources as compared to those who may receive their primary care through a solo practitioner).  Primary care resources are first point of contact, but not often resourced with tools and skill sets to appropriately screen for mental illnesses and addictions.

 Enhance provision of primary care services through alternative service delivery approaches.  Need for development of personal relationships across health service providers and primary care to maintain connectedness across the continuum of care.

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Transformation in Action Improved population health management: Partnerships for Health, collaborative team-based approach, has experienced success improving management of chronic diseases and optimizing use of current resources, through working in a collaborative team-based setting that has strong relationships with CCAC, physicians, diabetes centres, mental health and addiction partners, and community pharmacies.

 Need for a stronger emphasis on health promotion and education at local level.

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Profile of our Health Human Resources The delivery of health services is dependent upon regulated and non-regulated health human resources across the LHIN. Regulated resources include disciplines such as physicians, nurses, occupational therapists, physiotherapists, speech language therapists, midwives, chiropodists, pharmacists, audiologists, dietitians, massage therapists, psychologists and respiratory therapists. Non-regulated resources such as personal support workers, acupuncturists, naturopaths, chiropractors, social workers, and mental health and addictions counselors also a play a critical role in delivery of health services.  Capturing data on health human resources is often a challenging exercise as there is no central database that exists. Professionals who are regulated are attached to professional bodies so some information can be gleaned. There are a total of 1,805 physicians registered in the LHIN, with 79% practicing in the south.

Current Observations

 Approximately 11% and 20% of physicians are registered in counties in the north and central portions of the LHIN, while 17% and 15% of the LHIN population reside in the north and central segments of the LHIN.  There is a relatively even distribution of Family Medicine physicians across the LHIN.  Specialist practitioners are however primarily concentrated in the South, aligned to the academic health centres, LHSC and St. Joseph‟s.  Consultations reveal a projected shortage of generalists in rural communities.  Given that 7% of the population of Ontario residents live in the South West LHIN, there appears to be alignment between the population and resources, with the exception of Nurse Practitioners.5

Overview of Ontario Distribution & Characteristics of Registered Professionals Registered Members

South West LHIN %

Chiropodists

480

n/a

Midwives

334

7%

Nurse Practitioners

594

5%

4,010

10%

Physiotherapists

6,080

10%

Registered Nurses

89,054

9%

Registered Practical Nurses

24,482

11%

Occupational Therapists

 One major noted concern is the age distribution of regulated professionals across the South West LHIN. The majority of professionals within the LHIN are over the age of 40 years, with the exception of Occupational Therapists; a profile that is consistent with the overall trend across Canada.

5

This chart does not include a comprehensive list of regulated and non-regulated resources. The proportion of chiropodists in the South West LHIN was not available.

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Anticipated high growth based on base-case population projections

Volume of HHR

Implications for the future

 In the absence of change to how services are delivered, it is projected that the resource base of physicians and other inter-professional resources would need to increase relative to population growth in order to meet future service demands. With the realities of HHR recruitment, a more moderate increase may be possible. The gap in services may need to be offset through alternative service delivery models (i.e. interprofessional care).

Moderate growth based on realities of HHR

Gap in resources addressed through alternative service delivery models

 Current education of physicians may not match the needs of communities.  Need for strengthened, personal relationships between health service professionals across/within sectors.

2012

2017

2022

 Collaboration with physician partners to illicit change in service delivery.

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On the road to transforming the current health care system… Recognizing the realities of today, health service providers have proactively undertaken several initiatives to progressively improve health service delivery. Stakeholders recognize the impending challenges and have embarked on initiatives to help improve the health system. In developing the Blueprint, it is important to leverage and build on the many initiatives that have either been previously completed or are underway and are already focused on advancing the system towards the LHIN‟s system level goals. Below is a sampling of various initiatives identified through consultations and survey findings currently underway within the LHIN. (Note: in summarizing, these initiatives have been aligned to their primary health system goal focus; however initiatives may positively influence multiple goals.) System Level Goal

Sampling of current initiatives  Primary care resources (e.g. FHTs, CHCs) are providing coordinated services to address patient needs, particularly those with several co-morbidities.

Healthier South West LHIN Community

 Alzheimer Society‟s “Remember me” program accommodates services according to client needs.  Several organizations have adapted delivery to cultural sensitivities to meet the needs of populations such as Mennonites, Aboriginals, Amish and other ethnic minorities.  Partnerships with schools and public health deliver wellness programs.

Equitable access to services

 South West CCAC‟s Advanced Home Care Team, a quick response team of community-based primary nurse practitioners who work in partnership with physicians and the home care team to provide “hospital in the home” care to keep people out of the hospital and avoid ED and LTC.  Distribution of Flex Clinics for mobile outreach approach to providing services.  Delivery of crisis services through collaboration of two Grey Bruce Mental Health organizations.  Huron Perth Transportation providing central access to services.  Community Stroke Rehab Teams operate as inter-professional teams that follow the patient through mobile, in-home, ambulatory care settings, local community sites, LTC homes, etc.

Quality of Care and Service

 Pathways for People with Stroke to Live Fully in the Community to ensure consistency of care.  First Link program educates physicians & other front-line staff on recognizing the early signs of dementia which has allowed for early identification.  St. Joseph‟s has launched a project which enhances primary care provider skills in managing depression.  Grey Bruce connection, an integrated information management system with evidencebased care program and clinical pathways.

Sustainability of the Local Health System

 Inter-professional Education Program at University of Western Ontario to ensure professions are planning for care collaboratively, through a person-centred approach.  thehealthline.ca‟s South West Career Network that supports recruitment for rural providers.  Rural medical on-call model for Obstetrics in north to address HHR challenges.

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System Level Goal

Sampling of current initiatives  Through Aging at Home strategy, Tillsonburg-based assisted living program facilitates the movement of people from hospital to community.  Tillsonburg & Alexandra share Director of Laboratory & Diagnostic Imaging, Manager of Health Information & Privacy.  Huron Perth Healthcare Alliance (HPHA) Bed Management System serves as a single bed management system for all HPHA hospitals.  MRI Task Team operates as a regional team coordinating MRI scans to improve wait times.

Integration of Health Care Delivery

 Grey Bruce Integrated Health Network, 10 hospitals, utilizes visiting specialties, common pharmacy services at Owen Sound and a shared lab system (IHLP).  Listowel/Wingham connects community and hospital through an Electronic Medical Record.  Caregiver Connect serves a web portal accessible to caregivers for educational services.  ConnexOntario serves as an integrated information source for mental health, addictions and problem gambling services.  thehealthline.ca provides a service inventory and information on service capacity / availability.  Mental Health Grey Bruce, legal partnership of three organizations, provides integrated mental health services through five multi-agency teams.

These initiatives and others represent a significant and positive launching pad from which the health system can transform the manner in which services are delivered. The Blueprint provides the framework for the next steps to be taken in order to progressively enable greater transformational change across the system. More details on the overview of today are provided in the supporting technical report documents.

While health service providers are doing a great job in addressing the pressures of today, it’s clear the needs of the residents of the South West LHIN and the challenges of the future mean we cannot continue to provide care the way we do today. We need to fundamentally transform how we provide care and work together in a far more collaborative way centered around the client. Sandra Coleman – South West CCAC

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A blueprint for the future Overview of the Integrated Health System of Care Grounded in the vision and system level goals of the South West LHIN, the Blueprint strives to optimize the delivery of health services in the future. With this foundation in place, the Blueprint has been developed on the basis of common vision elements and guiding principles that have been determined by service providers and communities across the LHIN. It aims to create “A health care system that helps people stay healthy, delivers good care to them when they get sick and will be there for their children and grandchildren” by:  Integrating the delivery of services to provide the right care, at the right time, in the right place;  Focusing on care that is person and family centered;  Ensuring efficient and sustainable health human resources; and  Providing and supporting equitable and timely access to services for individuals and providers. As well, it works to realize the system level goals through the guiding principles. Healthier South West LHIN Community through

• Empowering the individual and their family to play an active role in the management of their care.

Equitable Access to Services through a

• Focus on the philosophy of care „close to home‟ while ensuring quality care.

Quality of Care and Service through

• Embracing health care innovation; and • Practicing evidence-based health care.

Sustainability of the Local Health System by

• Ensuring transparency and accountability in the broader system; • Ensuring sustainability of health human resources in the LHIN; and • Delivering efficient and cost-effective services.

Integration of Health Care Delivery by

• Promoting and instituting collaboration across all disciplines and across the entire continuum.

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Consequently, the end result is a future South West LHIN health system predicated on an Integrated Health System of Care. This system emphasizes the message that all health programs and services are part of a single, unified health system of care. It clearly communicates the roles and responsibilities of the various health service providers and social services partners, and also delineates the interdependencies among various stakeholders to enable a shared approach to service delivery. In acknowledging unique characteristics among community, long-term care, acute services, and primary care services, the Integrated Health System of Care is to be accessed through two integrated service delivery approaches:  Population-based Integrated Health Services which is tailored to the collective needs of a local population and its health service providers. It enables local communities to support the health and wellness of its catchment population enabling them to better manage their own health and maintain independence. The local community services are supported by the multicommunity services and has access to LHIN community services as needed. ‒ Throughout an individual‟s life, he or she may access primary care, home and community care, complex continuing care, long-term care, palliative care, rehabilitation, chronic disease prevention and management, mental health and addictions services and emergency services coordinated through this service delivery approach.  Centrally coordinated resource capacity which optimizes the use of targeted resources to improve access and complement the management of health and wellness at the more local level. ‒ Throughout an individual‟s life, he or she may access medicine, surgical, and critical care inpatient and ambulatory services coordinated through this service delivery approach. It is important to note that these approaches are not mutually exclusive, but are truly integrated, recognizing that as an individual at various points in their lifetime interacts with the system, their needs will vary and the system will be able to respond in a seamless and coordinated manner. Services should be delivered and accessed in a manner that enables them to represent the unique characteristics of managing clusters of population segments. Underlying each service delivery approach are the specific characteristics of how care should be delivered and accessed within the various health service program groupings, such as mental health and addictions, chronic disease prevention and management and critical care. For the purposes of this report, the focus will be on the two overarching service delivery approaches that are focused on different components of the Integrated Health System of Care. A detailed description of how the future of specific health services will be delivered is provided in Appendix A.

Planning at the system level is one of the best ways of ensuring continued access to high quality healthcare into the future. Andrew Williams, Huron Perth Healthcare Alliance

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The system of care relies on coordinated and effective working relationships among providers within local communities, across multiple communities, and across the entire South West LHIN and beyond. It calls for providers to work with others outside the LHIN to ensure continuity of services delivered for our residents within and outside of the South West LHIN boundaries. The following provides further explanation in order to define the terms Local Community, Multi-Community, LHIN community as applied within the Blueprint:

Local Community • Services provided close to home

“Local Community” involves the coordination of provision of services provided „close to home.‟ These types of services include primary care, some secondary care, home and community care, inter-professional clinics for chronic diseases, and local hospital services. For these services, there will be many sites for service access across the LHIN, located in communities, connected through an inter-professional team.

MultiCommunity • Service delivery by geographic clustering

• Delivery of high volume/low of moderate complexity services to broader population • Collaboration across local traditional and nontraditional providers • Emphasis on an individual‟s self-health management

volume/complexity services focused on targeted populations • Seamless referral relationships with local and LHIN providers

LHIN Community • Delivery of low volume/highly complex services to manage specialized populations • Support multi-community and local providers with accessibility to specialized services • May serve as a broader provincial resource • Manages referrals and refers out of LHIN as necessary

Service Delivery Approaches

Population-based integrated health services: • Home and community care, long-term care homes, complex continuing care, rehabilitation services • Chronic disease prevention and management • Mental health and addictions • Emergency services

Local Community

MultiCommunity

Centrally coordinated resource capacity: •Surgical services •Critical care services •Internal medicine services

“LHIN Community” refers to those services where the resources and expertise are not widely available throughout the LHIN. These programs will be led by one identified organization and the organization will be mandated to provide appropriate access and care to residents across our LHIN. Travel to a location may be required to access these highly specialized services. These organizations may also serve as a provincial resource for certain services.

LHIN Community

“Multi-Community” is the coordination and provision of some specialized services that will be provided through service providers who serve both their local community, but also surrounding communities within a defined catchment area. Some travel to access services may be required; however services should still be accessible within the Multi-Community area. Services may be located at two or more sites to serve several clustered communities. These sites will serve a large proportion of individuals who may require certain types of subspecialty programs, yet do not need to travel to LHIN Community sites. 30

Population-based Integrated Health Services The Population-based Integrated Health Services approach exhibits the following characteristics:  This approach calls for health service delivery tailored to the local needs of its catchment population and health service providers. It builds local communities to be able to support the health and wellness of its catchment population. This approach will focus on total health management including prevention, screening, identification, assessment, treatment, follow-up and the necessary support.  There is an emphasis on individual‟s accountability in the management of one‟s own health.  The majority of service coordination and intervention will be delivered through local health and social service providers and coordinated through local health resources, integrated health services collaboratives. These collaboratives will be achieved through various delivery models such as co-located, mobile, and/or virtual settings depending on the health and social needs of the community and health service provider base.

A responsive, comprehensive health system is one that recognizes and responds to the needs of all populations, including those who are marginalized, those with complex needs and those who experience barriers to care. It is also essential that we provide person-centred care: care that focuses on the whole person within his/her context, and not just on the person’s illness or disease. Sandy Stockman, Grey Bruce Community Health Corporation

 Relies on care coordination and interprofessional support at the local level, including primary care, community, and public health professionals as part of the broader health care team.  As individual needs become increasingly complex, referral to specialist and subspecialist care at the Multi-Community and LHIN levels may be required and coordinated through the inter-professional team.

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How is the Population-based Integrated Health Services approach delivered? The services will be delivered and facilitated through integrated health services collaboratives (IHSC) through a variety of settings, including virtual, mobile, co-located settings. Depending on the geographic profile, current primary care resources (e.g. FHTs, FHNs, FHO, CCM, BSM, FHG, CHCs, and solo-physician offices) can be transformed into collaboratives connected by technological infrastructure and shared resources. Solo-physician offices will capitalize on this model through the access to inter-professional resources. These IHSCs will provide education, screening, assessment, treatment, navigation, and the necessary support services. Integrated health services collaborative Co-located setting

• Long-Term Care Homes • Supportive housing • Home and Community Care • Rehabilitation

Mobile setting

Virtual setting

Strengthened Relationships

Fitness programs

Substance abuse services

• Linkage to core hospital services (medical and surgical) • Emergency Services

Coordinated Community Care services

• Linkage to specialist services (Schedule 1, etc)

Mental health services Problem gambling services

Nutritional clinics

Physician Inter-prof essional resource

Inter-professional teams (comprised of regulated and non-regulated practitioners) will manage chronic illnesses (manage multiple conditions as directed by individual vs. diseasespecific), primary mental health and addictions needs and other less emergent cases as appropriate. They will focus on integrated screening of at-risk populations. These teams will also provide navigation services including tools for self-navigation, service coordination, and clinical case management which will involve family/caregivers as part of the process, which is further described in the Foundational Elements section. This will involve holistic assessment of the individual’s health and social needs to connect them to the most appropriate service. IHSCs will work to provide the appropriate preventive, promotive, and lower acuity services close to home and in the community setting while referring to Multi-Community and LHIN Community sites for higher acuity needs.

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Coordinated community care services will continue to play a critical role in managing chronic illnesses, mental health and addictions issues, general health and wellness related needs, rehabilitation services through a coordinated delivery model. This will enable care provision for mild and complex cases at home as appropriate. These community organizations will demonstrate a stronger partnership with primary care partners to ensure seamless referral of individuals based on needs with a stronger emphasis on coordinated capacity. This model also emphasizes the provision of care closer to home. These services include long-term care home placement as well as home and community care and palliative services. As needed, individuals will be connected with specialized housing capacity (e.g. mental health and addictions specialized housing and LTCH). There will also be a focus on advanced care planning accounting for health and social assessments. Local integrated health services collaboratives will play a critical role in coordination. Dependent on the geographic profile (size and demographics of catchment population), the coordination services (e.g. SWCCAC) may be housed within an integrated health services collaborative or attached as a virtual partner. The population-based integrated health service delivery approach realizes the following transformative elements which produce benefits to both providers and individuals. How is this different from today’s service delivery model?  Development of collaborative partnerships across health sectors, continuum of care, and beyond broader health sectors.  Inter-professional teams to maintain continuity for individuals as they access services across the health system.  Established referral processes to enable seamless, connected transfer of individuals across the continuum of care.  Integrated health services collaboratives to screen, assess, and provide early intervention (care coordination, and liaison to specialist services as needed).  Expansion of provider roles across the continuum to optimize care delivery. Enhanced capacity of direct service providers on knowledge, understanding of services and individual‟s health needs.  Standardized, evidence-based approach to care provision.  Enhanced reliance on self-management – involving individual as part of health care team.

What are the benefits? Providers and Health Professionals:  Increased focus on preventing chronic illnesses and addressing mental health and addictions needs within a local capacity.  Appropriate use of complex continuing care and long-term care home capacity.  Availability of standardized tools to aid health care professionals in care delivery.  Seamless referral of individuals/families across health and other sectors. Individuals and Families:  Empowerment of individual/family members in managing their own care.  Emphasis on providing care closer to home to the extent that is reasonable and feasible.  Early identification and management of individual‟s needs in order to enable people to optimize their level of function and quality of life in their community and home environment.

 Alignment of service distribution to population needs/location across the LHIN.

More details on this service delivery approach are provided in Appendix D.

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Centrally Coordinated Resource Capacity The Centrally Coordinated Resource Capacity service delivery approach does not intend shifting to a single owner of resources, but exhibits the following characteristics:  Approach focuses on optimizing the use of targeted resources to improve access and complement the management of health and wellness at the more local level.

We, as hospital partners, need to collaborate to better manage our resource capacity. This is the only way to ensure seamless flow of our patients upstream and downstream. Dr. Nancy Whitmore, St. Thomas Elgin General Hospital

 LHIN-wide coordination of medicine, surgical and critical care inpatient and ambulatory services to maximize our resident‟s access to services. Service delivery will be coordinated across local community, Multi-Community, and LHIN community providers.  Local providers will play a key role in primary and secondary identification, assessment, treatment, and follow-up services for their local communities. Providers will also focus on changing their practices to include the individual and their families as part of the care team to emphasize the individual‟s accountability in the management of one‟s own health.  Providers whose role will be to deliver services at the Multi-Community level will provide specialist services for a larger population.  South West LHIN-wide providers will be responsible for delivering highly specialized services for complex population segments.  It should also be noted that while in some cases tertiary hospitals will be expected to function as a LHIN-wide resource, it is also expected that they will also continue to function as the local care resource for the communities in which they currently operate today.  Development of shared physician on-call system and structure. How will a Centrally Coordinated Resource Capacity model be delivered? The service delivery approach emphasizes LHIN-wide management of capacity allowing individuals to flow through the system equitably, minimizing backlogs and optimizing use of available resources. It focuses on facilitating an individual‟s access to the right provider based on complexity of need. This will enable to appropriately react to planned and unexpected events. This is dependent upon strengthened partnerships across the service delivery levels which would enable seamless referral relationships across health service providers. In addition to clinical expertise, expansion of provider roles would include navigation and information/referral as appropriate. All health service providers and professionals would comply with standardized, evidence-based practices developed in collaboration across all levels. Vehicles, such as telemedicine and other enabling technologies, would be utilized to execute best practices, tools, and quality guidelines across providers at all levels.

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The approach ensures equitable access by delivering a network of visiting specialists or physicians at the multi-community or LHIN level as warranted by demand and critical mass. As well, vehicles such as telemedicine would be used to provide speciality services as appropriate. As a result, the service delivery model requires a balanced distribution and alignment of services to critical mass, which is required to maintain a required level of quality and clinical practice competency and includes the appropriate alignment to population/community needs.  Local Community: Sites providing core services as warranted by critical mass and managing repatriated individuals. These sites are supported by in-house or visiting physicians depending on the catchment area.  Multi-Community: A site or network of sites dependent upon the community to provide care for moderate cases and managing repatriated individuals. The north and central may institute multi-site network of resources that provide visiting services at a few locations. The south may have specific Multi-Community sites distributed based on spread of population.  LHIN Community: Single site providing specialized services for higher acuity needs. Based on utilization, and concentration of clinical specialists in the south, the expectation is that such a resource would likely be located in the southern portion of the LHIN. Critical care services would also require LHIN-wide coordination across small, rural hospitals to urban sites. The distribution of resources would be dependent upon medical and surgical capacity as well. This could result in:  Local Community: Sites managing lower complexity cases, repatriated individuals for MultiCommunity and LHIN-wide sites, and provide support to community-based ventilation services. These sites provide Level 2 beds that are sustainable and ensure critical mass.  Multi-Community: Distributed sites supporting the service delivery of moderate cases, management of repatriated individuals, and ventilation needs to community-based ventilation services. These sites also have respiratory therapists as needed to provide coverage and have a smaller inventory of Level 2 and Level 3 beds.  LHIN Community: Two sites managing complex ventilation needs, higher acuity individuals, acute dialysis, and respiratory therapy. They will have the bulk of Level 3 beds and a higher inventory of Level 2 beds. The Centrally Coordinated Resource Capacity model realizes the following transformative elements which produce benefits to both providers and individuals.

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How is this different from today’s service delivery model?

What are the benefits?

 Collaboration among all sites across the LHIN to ensure that the right individual is in the right place at the right time (consistent admission criteria).

Providers and Health Professionals:

 Development of coordinated physician on-call system and structure.

 Increased physician base within which on-call coverage can be shared; with the coordinated on-call system, all consults will be directed to an on-call physician.

 Unified point of access with common referral standards / process by specialty.  Consistent use of standardized, evidence-based care pathways across the LHIN.  Care close to home balanced with access to the right care.

 Capacity utilization in the LHIN will improve as a result of a shared and integrated approach to resource coordination.

 Improved quality of care through the adoption of standardized care pathways from screening, assessment through to discharge guidelines.  More dedicated time for direct patient care by leveraging telemedicine capabilities.  Virtual linking of physicians across LHIN to share best practices, education, and quality monitoring. Individuals and Families:  Strengthens relationship with individual, families and providers.  Improved equity, timeliness and access to care in the „right‟ place.  Direct engagement in health care decision-making processes through an enhanced information sharing and access.

More details on this service delivery approach are provided in Appendix D.

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Enablers to realize the Integrated Health System of Care The success of the Integrated Health System of Care is contingent upon four threads of enablers, highlighted within the green border in the diagram below, which will transform health service delivery across all health sectors. Stakeholders in the South West LHIN identified fundamental, systemic elements which are required to help transform the current system by:  Multi-level system of navigation framework  Integrated health human resource strategies  Enabling information and clinical technologies  Health Systems Blueprint implementation and accountability frameworks Planning and implementation of these elements, fundamental to system effectiveness, will require a long, continuous process, with cross-sectoral providers and health professional dedication. While it is a time-consuming process, benefits can be realized with interim milestones. These elements are described below.

Local Community

MultiCommunity

• Services provided close to • Service delivery by home

geographic clustering

• Delivery of high volume/low of moderate complexity services to broader population • Collaboration across local traditional and nontraditional providers • Emphasis on an individual‟s self-health management

volume/complexity services focused on targeted populations • Seamless referral relationships with local and LHIN providers

LHIN Community • Delivery of low volume/highly complex services to manage specialized populations • Support multi-community and local providers with accessibility to specialized services • May serve as a broader provincial resource • Manages referrals and refers out of LHIN as necessary

Multi-level system of navigation framework: As the underpinning to health care provision across all health programs, this framework consists of a balanced approach to self-navigation, service coordination, and clinical case management as required by the individual. These Development of services can be provided by direct service care plan providers (regulated and non-regulated) or dedicated, specialized resources such as a care coordination resource. Referral to  Self-navigation: Individuals will play an active role in managing their own health care, selfnavigation, as they are able. They will be able to navigate themselves and their family through the integrated system of care. To enable individuals to take on this role, there will be a requirement for individuals to have access to:

Information and education

System of Navigation

appropriate service provider

Health/non-health needs post services

‒ Health education resources and tools; ‒ Inventory of health services with knowledge and understanding of the service; and ‒ Access to local services for coordination and clinical case management as needed.  Service coordination will be provided by a collection of resources depending on the setting of care. This can be delivered by a direct service provider or dedicated resource.

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 Depending on health need, clinical case management services will be provided by clinical case managers and/or direct service providers: ‒ Assessment and development of care plans with appropriate health/non-health resources ‒ Referral and contact to the appropriate health/non-health service provider as needed ‒ Management of care needs post services in order to maintain continuity throughout individual‟s life cycle ‒ Provision of education, support and consultation to the individuals and their families ‒ This person ensures that their client‟s involvement in decisions regarding their care is maximized and that all parties are in good communication and share common understandings Navigation services will vary dependent on the needs of the individual. For the majority of the population who need self-care support/management, individuals may just require readily access to service coordination as these individuals may need a more collaborative relationship with a navigator for educational and coordination purposes as needed. For those individuals who are at higher risk, they may require a moderate presence of clinical case management and stronger need for service coordination for individuals with specific diseases or chronic illnesses. Individuals may be considered high risk due to medical and/or social conditions. These resources would assist the individual through health and medical needs across health sectors and social agencies. For more specialized populations who need high complexity case management, there is a need for strong presence of clinical case management and service coordination. This would involve a navigator and case manager that stays attuned and connected to the individual as he/she goes through health, medical, and social services.

Level 3 High complexity case management

Level 2 High risk disease / care management

Level 1 Self care support / management (70-80%)

Integrated health human resource strategies: The Integrated Health System of Care requires integrated, proactive HHR strategies to better equip LHIN providers with the resources needed to adequately deliver services. This includes:  Developing a sustainable workforce planning process based upon data collection and performance management  Creating collaborative networks within and beyond the LHIN to leverage best practices and drive policy changes

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 Building capacity and optimize the use of current and future HHR across the system through various initiatives: ‒ Institute inter-professional team models in settings across health sectors to increase collaboration and provide coordinated care for individuals. ‒ In collaboration with LHIN providers, develop a recruitment and retention strategy for HHR in both rural and urban communities. ‒ Leverage recruitment programs across LHIN providers. ‒ Incent organizations to create cultures that encourage retention and growth. ‒ Develop and implement training programs to enhance skillsets to include management of specialized populations.

Our health system needs to account for the lifelong journey of individuals. No matter the time or place, health care needs to be seamless to the individual and their family. Sue McCutcheon, Grey Bruce Health Services

‒ Set clear expectations of roles and responsibilities of HHR within the future service delivery models. ‒ Leverage current provincial and South West LHIN initiatives to manage HHR. Enabling information and clinical technology: The provision of health services can be enhanced through the use of information and clinical technology related solutions.  Examples of potential information technology related solutions: ‒ Health care professionals will be equipped with a centrally accessed repository of all South West LHIN health services (e.g. thehealthline.ca, ConnexOntario) which includes inventory of services to enhance health education and enable care coordination across organizations, accessible online or via telephone. This may also enable enhanced functionality of real-time capacity update and electronic appointment booking. ‒ Leverage existing infrastructure to create a real-time, easily accessible clinical information repository available to health providers LHIN-wide, across the continuum of care that can be accessed through various existing applications such as physician office electronic medical records, hospital-based clinical information systems, other care provider records systems, and shared clinical portal technologies. ‒ The clinical information repository, connected to a personal health portal, will enable individuals to access and share health information as needed (e.g. with alternative care providers). The personal health portal will be equipped with self-assessment, management, and scheduling tools.  Examples of Clinical Technology related solutions: ‒ Implementation of clinical technologies to enhance care delivery as needed across LHIN (e.g. Diagnostic Imaging, Lab) ‒ LHIN-Community or Multi-Community systems to coordinate acute care services capacity. This could be enabled through the expansion of Criticall system with enhanced functionality. Enhanced functionality would include communication and reporting of bed

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capacity status, facilitate communication between physicians and triage, which collectively would serve as a mechanism to receive physician consult prior to referral of individual, and facilitate physician consults.  Care coordination system to enable electronic appointment referrals and bookings for organizations across sectors (e.g. GPS-type system for ED) ‒ Telemedicine and telehealth services will provide health services. Specialized teleconsult services will be provided to enable treatment and referral as needed. This will play a major role in the rural areas of the LHIN and will help defer referral to LHIN-wide site for higher acuity needs. Health systems Blueprint implementation and accountability frameworks: The South West LHIN will need to establish an implementation and accountability framework in order to effectively enact and monitor the Blueprint. This would require establishment of a framework which enables:  Clear expectations of governance and leadership relationships which will facilitate and oversee change;  Stewardship through coordination of key stakeholders and driving the agenda forward;  Improved efficiency and clarity of decision-making;  Clarity of roles and responsibilities;  Clear conflict resolution pathways;  Adoption of established standards (e.g. project management, performance management, etc); and  Improved cross-sector, stakeholder coordination and communication. This framework would be operationalized through agreed upon policies and procedures around mandate, process and information needs, and system monitoring and evaluation.

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Operationalize the Integrated Health System of Care Recognizing that transformation takes time, the Blueprint project‟s planning horizon has taken into consideration the projected population and service demands out to the year 2022. In developing the road map, it is also important to acknowledge that some providers and parts of the system are more experienced in undertaking systems integration initiatives relative to others. The implementation roadmap recognizes this difference. For example, where there are existing working groups or entities that have already started to not only think about future change, but are acting on their plans (e.g. chronic disease prevention and management and mental health and addictions), these groups will be able to more quickly mobilize and take action on the Blueprint. Conversely, where such groups Change in health care is not do not exist, time will be required to establish new; we must continue to be these groups and build their readiness to take on the challenge of implementing the Blueprint‟s bold in our actions. vision. In order to take action and initiate the journey Sandy Whittall, London Health towards the direction outlined in the Blueprint, the Sciences Centre and St. Joseph's South West LHIN and health service providers need to progressively take on a series of Health Care implementation elements. Together, these elements serve as a roadmap to realize the Integrated Health System of Care. The implementation roadmap has been created based upon the characteristics of the future health system, which includes the current actions as documented in recently published IHSP 2010-2013. As seen in the next exhibit, the implementation roadmap will be realized through a multi-year journey phased over a few IHSP cycles. The upcoming cycle, IHSP 2010-2013, includes actions which serve as natural starting points to continue health system transformation.

IHSP 2010-2013

IHSP 2013-2016

IHSP 2016-2019

IHSP 2019-2022

Integrated Health System of Care

During these IHSP cycles, the LHIN and health service providers will work to align IHSP actions to further the Integrated Health System of Care and ensure progress is made in efforts of transformation. On a periodic basis, the LHIN and health service providers will revisit the detailed workplan and refresh it to account for environmental considerations (e.g. political interventions, changing priorities) to be fluid in planning and implementation. Therefore, as appropriate, the IHSP actions will align to one of the following three threads which provide a framework for implementation planning.

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Accelerate 2010-2013 IHSP strategic directions Initiate implementation elements Launch enablers

During the 2010-2013 timeframe, the LHIN and health service providers will focus on accelerating the IHSP strategic directions while initiating planning for the remaining threads, initiate implementation elements and launch enablers. Progress on these threads will be furthered through upcoming IHSPs and accountability agreements as deemed appropriate. These threads, which create a framework for implementation planning, include key processes that will be involved in operationalizing the Integrated Health System of Care. Accelerate implementation of the 2010-2013 IHSP strategic directions and actions: The IHSP strategic directions and actions have been developed and aligned to the health services Blueprint project. The identified actions are in progress or ready to be launched, have dedicated resources, and have engagement of health service providers. As well, the LHIN and Health Service Providers should continue to support the current initiatives and pursuits which have dedicated stakeholders and align to the Blueprint. This process would encompass performance measurement strategies so as to collect and measure performance indicators throughout implementation. A summary of these initiatives is provided below. Actions Related to Enhancing Capacity and Integration of Primary, Specialized and Community-based Care, with a Focus on the Following Populations: Seniors and Adults with Complex Needs

People Living with Mental Health and Addictions Challenges

People Living with or at Risk of Chronic Disease(s)

 Through Aging at Home (Year 3):

 Increase supportive housing for people with problematic substance use and concurrent disorders

 Implement Chronic Disease Prevention and Management strategies with an initial focus on the Ontario Diabetes Strategy and extend to other chronic illnesses where relevant

‒ Develop and implement an integrated model of care for high-risk seniors ‒ Develop and implement a coordinated system of care for seniors with behavioural issues ‒ Enhance services and supports for Aboriginal seniors ‒ Enhance capacity and coordination of transportation services

 Implement a screening tool to screen universally for concurrent disorders  Implement a training program to help people to develop personal wellness plans  Improve access to community mental health and developmental services for persons with a dual

 Leverage success of the Partnerships for Health project and extend to other chronic illnesses where relevant  Implement enabling technologies with an initial focus on the provincial Diabetes Registry and include other enabling technologies where relevant  Explore the applicability of the

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‒ Create additional convalescent care beds in long-term care homes  Define the role of and access to complex continuing care beds and rehabilitation services  Monitor results of all Aging at Home initiatives

diagnosis  Work with partners to facilitate the movement of specialty hospital services (Tiers 2 and 3 divestment)  Work with partners to enhance the availability of and access to children‟s mental health beds

Diabetes Registry to manage data for other chronic diseases  Continue with, and expand, implementation of selfmanagement strategy  Implement peritoneal dialysis in long-term care homes to align with Ontario Renal Network

 Continue to work with Aboriginal and Francophone communities to improve availability of and access to services Actions related to Enhancing Access and Sustainability of Hospital-based Treatment and Care Related to: Emergency Services

Medicine, Surgical and Critical Care Services

Based on the recommendations of the Emergency Department Human Resources Study, engage key local and multi-community stakeholders to initiate a process to develop and implement strategies tailored to their communities‟ emergency services needs, with a focus on:

Engage key local, multi-community and LHIN community stakeholders to develop an action plan for creating and implementing Centrally Coordinated Resource Capacity for medicine, surgical and critical care services, with a focus on:

 Emergency services recruitment and retention capability  Emergency services coverage with current resource pool

 A LHIN-wide resource capacity management system  A centralized coordinated referral system, evidence based care pathways and order sets, tools and quality guidelines

 Emergency services health care personnel capacity

The success of these actions will serve as a catalyst for further operationalizing future implementation elements. Initiate implementation elements: Integrated health services collaborative

Other implementation elements, outside of those included in the IHSP 2010-2013, will be initiated in a timely manner dependent on the status of supporting reference groups. The reference groups responsible for initiating implementation elements following those identified in the IHSP 2010-2013 would also be in a position to integrate key lessons learned from the initial IHSP opportunities.

Co-located setting

• Long-Term Care Homes • Supportive housing • Home and Community Care • Rehabilitation

Mobile setting

Virtual setting

Strengthened Relationships

Fitness programs

Substance abuse services

• Linkage to core hospital services (medical and surgical) • Emergency Services

Coordinated Community Care services

• Linkage to specialist services (Schedule 1, etc)

Mental health services Problem gambling services

Nutritional clinics

Physician Inter-prof essional resource

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Key implementation elements may include:  The development of Integrated Health Service Collaboratives (IHSC): transforming current primary care settings (e.g. FHT, FHN, CHC, solo-physician offices) into a co-located, mobile, or virtual IHSC which works with its health partners to provide education, screening, assessment, treatment, navigation, and the necessary support services; and  The development of a resource capacity plan to better coordinate surgical bed capacity across the LHIN to accommodate local, multi-community, and LHIN service delivery. The success of each of these elements is dependent upon the dedication of a reference group of key cross-sectoral stakeholders able to provide the expertise and guidance in fully operationalizing the element. In some cases, these groups may exist, or such groups may need to be created. This reference group would receive the appropriate support by the LHIN to facilitate the process, resources, and project management expertise as necessary. 

Development of work plan: These groups, with support of the LHIN, would be charged with developing the process/structure for implementation including a detailed work plan. This group would be tasked with determining the launch dates for the element.



Understand the environmental scan: As a key initial step, the expectation would be that the group understands the approach and quantitative/qualitative findings from the environmental scan as a source to provide directional insight into moving the element forward.



Identify champions and launch pilots: Once plans are in place, these groups should support the identification of initial “pilot” or launch sites which would serve as early adopters or champions for specific elements. With coordinated support from the LHIN, these pilot sites will be provided the resources to plan and enact change, measure it, and continue to refine the initiative. ‒ In serving as a pilot, the site will provide the necessary „lessons learned‟ as the initiative is rolled out to other sites. Implementation success would be dependent on the support of partnerships with Health Service Providers, social organizations, and broader non-LHIN partners as appropriate.



Implement across the LHIN: Once the initial pilots are completed, the next phase of the implementation process will be the roll out of a given initiative across the LHIN as appropriate. To do this, reference groups would lead the development of a detailed implementation plan which involves a phased approach to roll out the element. ‒ This process would encompass performance measurement strategies so as to collect and measure performance indicators.

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Launch enablers to realize Integrated Health System of Care: The four threads of enablers impact the entire health system and will require a longer journey to complete implementation. As a result, it is critical that these elements be kicked-off with the development of a cross-sectoral reference group which will clearly outline a phased approach to implementation. This reference group would receive the appropriate support by the LHIN to facilitate the process, resources, and project management expertise as necessary. 

Development of work plan: These groups, with support of the LHIN, would be charged with developing the process/structure for implementation including a detailed work plan. This would include the development of interim milestones which would translate into small successes to be rolled out across the LHIN.



Understand the environmental scan: As a key initial step, the expectation would be that the group understands the approach and quantitative/qualitative findings from the environmental scan as a source to provide directional insight into moving the element forward.



Phased implementation of the enabler: As defined by the detailed work plan, reference groups would lead the development of a detailed implementation plan which involves a phased approach to roll out the enabler.

Implementation success would be dependent on the support of partnerships with Health Service Providers, social organizations, and broader non-LHIN partners as appropriate.

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Call to action The Health Services Blueprint has set a transformational agenda for the South West LHIN to create “A health care system that helps people stay healthy, delivers good care to them when they get sick and will be there for their children and grandchildren.” Informed through considerable stakeholder engagement, it builds upon the successes to date, to outline a more coordinated, collaborative path towards system transformation. In order to take the Blueprint from words to action, a collective commitment is required on the part of all provider organizations, direct service providers and communities. Working with our partners within the Ministry of Health and Long-term care, primary care, public health and others, we must keep the needs of our communities front and centre, and build and align all aspects of our system to work in concert with one another such that we are all collectively working towards the same objective – a healthier South West LHIN population. How are we going to get there? Action is required. Without this, the Blueprint is destined to be simply „yet another plan‟. That said, we must take to heart our collective accountability per the Local Health System Integration Act, 2006, to look for opportunities to integrate the local health system. In doing so, we must collectively focus and take action immediately if we are to capitalize on the positive energy and system-wide anticipation that has been generated through the Blueprint development process. The time is now to take the critical initial steps towards change. Recognizing this, we must be prepared to move forward through our impending and future initiatives. To kick-start the venture, the Health System Design Steering Committee will immediately undertake the following key initial action steps:  Identification of leadership to guide and lead change efforts, both at the system-wide level and within targeted implementation initiatives.  Framework for implementation planning to be completed by March 31, 2010. This framework will guide the development of detailed implementation plans. As part of this process, we will work with stakeholders within the context of the IHSP 2010-2013 priorities, to identify those opportunities that are innovative, align to the blueprint, and can serve as “success stories” and in doing so be an example of positive change. While we will collaborate with health service providers to proactively identify these groups, we urge you to engage in seeking out opportunities as well. These “actions” are critical to continuing to build a culture and environment of partnership and change within our communities and build an understanding that transformation is real and can happen if there is a collective will. In addition to the above immediate next steps, we, the LHIN, in collaboration with its health system partners, will continue to provide overall direction to our health system design process. More specifically, we will work to take action on the following:

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 Development of future IHSPs aligned to the vision of the Health Services Blueprint;  Creation of incentives for health service providers and partners as able and deemed appropriate;  Maintaining a transparent process with open lines of communication to enable easy collaboration; and  Modification of future new accountability agreements to include elements of the health services blueprint. As appropriate, these agreements will reflect transformative elements which will prompt health service providers to enact change. These agreements will reflect the partnerships involved across providers in making change through joint accountability statements. Change is never easy. However, acknowledging the resource limitations of today and potential pressures of the future, change is even more imminent and the success of the future health system is dependent upon effective partnerships with our health service providers. Through a shared commitment, we can improve the health of our community, so, please join us in developing a better tomorrow.

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Supporting documents  Appendix A: Programmatic Chapter Summaries: ‒ Appendix A.1: Mental Health and Addictions ‒ Appendix A.2: Chronic Disease Prevention and Management ‒ Appendix A.3: Long Term Care Services and Complex Continuing Care ‒ Appendix A.4: Medicine Services ‒ Appendix A.5: Surgical Services ‒ Appendix A.6: Critical Care Services ‒ Appendix A.7: Emergency Services ‒ Appendix A.8: Women‟s Health and Paediatrics  Appendix B: South West LHIN Vision, Mission, Values, and System Level Goals  Appendix C: Approach and Methodology  Appendix D: Service Delivery Approaches  Appendix E: Implementation Elements  Appendix F: Glossary of Terms  Appendix G: Steering Committee Membership  Appendix H: Technical Report including current state report, future state report, and order of magnitude analysis  Appendix I: Peer Models of Care Report

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