South West Lhin

South West LHIN

A Healthier Tomorrow: Integrated Health Service Plan 2010-2013 South West Local Health Integration Network November 30, 2009

Table of Contents Executive Summary

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1. Introduction What Do We Want to Build?

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2. Summary of Provincial Priorities Reducing Emergency Room (ER) Waits Alternate Level of Care (ALC) Diabetes Strategy Mental Health and Addiction Services An eHealth Framework

9 9 9 10 10 10

3. South West LHIN’s Vision for the Local Health Care System The South West LHIN’s Vision, Mission and Values South West LHIN’s System Level Goals

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4. Overview of the Current Local Health Care System What Does the Population Look Like in the South West LHIN? What Does the Health Care System Look Like in the South West LHIN? Profile of Health Human Resources in the South West LHIN What Did We Hear from the Community?

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5. Framework for Planning Where Are We Going? The Health Services“Blueprint”Describes It! How Are We Going to Get There?

22 22 26

6. Priorities & Strategic Directions for the Local Health System Key Enablers

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7. Rationale for Strategic Directions Rationale for IHSP Strategic Direction: Enhance Capacity and Integration of Primary, Specialized and Community- based Care Rationale for IHSP Strategic Direction: Enhance Access and Sustainability of Hospital-based Treatment and Care

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8. How We Will Demonstrate/Measure Success Why Do We Need to Demonstrate our Success? How Will We Measure Whether or not We’ve Been Successful? How Will We Know if We’ve Been Successful?

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9. Appendices and Supporting Resources

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10. Glossary of Key Definitions and Abbreviations

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Executive Summary Health care in Ontario has experienced year-over-year growth. Reasons for this growth include rising demand and use of services; an increasingly aging population; inflation and new, more expensive treatments and medications; increased public expectations; new diseases; and an increase in the prevalence of chronic diseases. Even though we have experienced considerable growth, it has not always resulted in improvements to how people experience their health care or the outcomes expected by that care. A primary reason for this is new health care resources are often aligned to service structures and delivery models that were created many, many years ago and no longer adequately serve our population. Over time, the health care system has become extremely complicated and difficult to navigate by users and providers of services. We have been continually adding services to a foundation that is based on historical approaches as opposed to current needs and best practices. Hence, it is imperative that over the next 12 years, we address the fundamental elements that need to be reconstructed to ensure that we have an “Integrated Health System of Care” built for 2022. Great care must be taken and effort made to ensure that accessible, quality and integrated services exist and will be there for South West LHIN residents, their children and their grandchildren.

Providers across health sectors face the following challenges: • Inequitable distribution of health services across the LHIN pose access challenges for residents, particularly those in rural communities • Current funding and operating models reinforce a provider-focused versus person-centred approach to health service delivery • Lack of integration across sectors and of health service providers inhibits the seamless movement of individuals and families across the continuum of care • The health profile of the South West LHIN necessitates more appropriate, integrated screening and early identification of health risk factors and conditions • Lack of integrated technology platforms across the LHIN inhibit information-sharing among health service providers across sectors and geography • Capacity limitations make it difficult to meet the increased demand for health services • Limited availability of health human resources make it difficult to meet the current and anticipated health service demand These issues must be addressed to improve the health system and ensure its sustainability in the future.

Health System of d e t a r g C Inte ULTI-LEVEL SYSTEM OF NAVIGATION FRAMEWORK are OG

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close to home • Delivery of high volume/ low complexity services to broader population • Collaboration across local traditinal 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

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

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South West LHIN: Integrated Health Service Plan

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EMEN HEALTH SYSTEMS BLUEPRINT MEWORKS TATION AN D ACCOUNTABILIT Y FRA

2010-2013

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In February 2009, the South West LHIN took the bold step of initiating the Blueprint project. The objectives of the Blueprint project included: • Provide a response to the first 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 • Facilitate health care providers’and the LHIN’s planning for change rather than reacting to health system trends, challenges and best practices • Develop a framework for how the system should be structured, across programs and geography, based on a detailed understanding of current services • Broadly and collectively leverage our resources rather than reacting to single issues faced by one organization, sector, or discipline

The Blueprint describes in detail what we want health service delivery to look like by 2022 and the IHSP 2010-2013 identifies the strategic directions and active steps we need to take in the next three years to begin to make it a reality. The Blueprint describes two overarching integrated service delivery approaches that detail how health services will be accessed and delivered by 2022: • Population-based Integrated Health Services 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 helping them to better manage their own health and maintain independence. The local community services are supported by the multi-community services and have access to LHIN community services as needed • Throughout an individual’s life, he or she may access primary care services, home and community care, complex continuing care, long-term 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 optimizes the use of targeted resources to improve access and

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complement health and wellness management 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 These approaches are not mutually exclusive, but are truly integrated recognizing that as an individual at various points in his or her lifetime interacts with the system, their needs will vary and the system must be able to respond in a seamless and coordinated manner. The IHSP 2010-2013, prioritizes our implementation efforts for the next three years through two strategic directions and their associated actions to work towards our Blueprint goal of an Integrated System of Care by 2022.

IHSP Strategic Directions 1. Enhance Capacity and Integration of Primary, Specialized and Community-based Care This first IHSP strategic direction aligns with the“Populationbased Integrated Health Services”integrated service delivery approach described by the Blueprint and is intended to move the first three years of this approach forward. It describes providing care coordination and inter-professional team based care at the local level to focus on prevention, identification, assessment, treatment, follow-up and providing necessary supports. Local care delivery will be very important to support those who need assistance with their health challenges such as diabetes, obesity, advanced age, mental illness or addictions issues. As care needs become increasingly complex for some individuals with conditions such as concurrent disorders, Alzheimer’s disease and multiple chronic illnesses, referral to specialist care at the multi-community and LHIN levels may be required and coordinated through the inter-professional team.

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The South West LHIN has chosen to focus on the following populations: • Seniors and Adults with Complex Needs • People Living with Mental Health and Addiction Challenges • People Living with or at Risk of Chronic Disease(s) We will focus on these populations for a number of reasons. Since the first IHSP, we have undertaken a great deal of planning and a number of initiatives have already been implemented that provide early starts to some of the Blueprint implementation elements. As with all LHINs, our actions related to seniors and adults with complex needs have been leveraged through the provincial Aging At Home initiative, Alternate Level of Care/Emergency Room initiatives and quality improvement initiatives such as the FLO Collaborative. The South West LHIN also remains committed to improving diabetes care by supporting the roll out of the Ontario Diabetes Strategy. In addition to being selected as one of the first three LHINs to implement the strategy in its first year, we are also one of two LHINs identified as an“early adopter”for the province’s eHealth Strategy. This puts us in the favourable position of fully enabling the provincial eHealth Diabetes Registry. The South West LHIN’s success with the implementation of the Partnerships for Health program has strengthened our position to be effective in improving diabetes care across the LHIN. Our involvement in the strategy, the registry and Partnerships for Health has given us real applications to test some of the Integrated Health System of Care elements described by the Blueprint. In addition, our learnings from the experiences with diabetes will help us to evolve systems of care for other chronic conditions.

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As our population characteristics and health status show, the South West LHIN has a significant proportion of seniors and people living with chronic conditions. Other data show us that South West LHIN residents have experienced challenges accessing coordinated addictions and mental health services. A substantial amount of work is currently taking place to facilitate divestment of mental health and addictions specialty hospital services and enhance capacity in local and multi-community settings. This is in addition to a number of mental health and addictions’early identification, health promotion and disease prevention initiatives across our LHIN. Generally, these populations tend to access and use a substantial portion of our health care resources. But the system doesn’t always support them to use these resources at the right time, in the right place and by the right provider which often leads to crisis intervention that could have been prevented if early identification, management and supports were in place. Currently, 58% percent of all emergency room visits in the South West LHIN are for non-urgent patients. 2. Enhance Access and Sustainability of Hospital-based Treatment and Care Related to: • Emergency Services • Medicine, Surgical and Critical Care Services The Blueprint development process included undertaking an assessment of the current state and future health care system in the South West LHIN. The information, insights and strategies profiled in the Emergency Department Human Resources (EDHR) Project Final Report, May 2009 (see EDHR study), commissioned by the South West LHIN, contributed greatly to the current state assessment. As for the future, the Blueprint’s“Centrally Coordinated Resource Capacity”integrated service delivery approach heavily influenced the IHSP action steps we will take in the next three years.

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The actions below will allow people to flow through the system equitably, minimize backlogs and optimize the use of available resources: • EMERGENCy SERVICES Based on the recommendations of the Emergency Department Human Resources Study and in full alignment with the Blueprint’s integrated service delivery approach, the LHIN will 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: • Emergency services recruitment and retention capability • Emergency services coverage with current resource pool • Emergency services health care personnel capacity • MEDICINE, SuRGICAL AND CRITICAL CARE SERVICES 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:

Recognizing that achieving an Integrated System of Care, as defined by the Blueprint, requires a dedicated journey involving planning and implementing, 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, the LHIN will work with stakeholders within the context of the IHSP strategic directions 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 work with health service providers to proactively identify these groups, we urge all stakeholders to engage in seeking out opportunities as well

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

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The LHIN, in collaboration with its health system partners, will also continue to provide overall direction to our health system design process. More specifically, we will work to take action on the following: • Developing future IHSPs aligned to the vision of the Health Services Blueprint • Creating incentives for health service providers and partners as we are able and deemed appropriate • Maintaining a transparent process with open lines of communication to enable easier collaboration • Modifying future new accountability agreements to include elements of the Health Services Blueprint and IHSP. As appropriate, these agreements will reflect transformative elements and initiatives which will prompt health service providers towards enacting change. These agreements will reflect the partnerships involved across providers in making change through joint accountability statements

IHSP 2010-2013

IHSP 2013-2016

Acknowledging the resource limitations of today and potential pressures of the future, transforming the health care system is even more imminent. Under the Local Health System Integration Act, 2006, providers now have an accountability to look for opportunities to integrate the local health system. We are a single health system and thus need to be vested in the“success of all”including people who deliver and receive health care, the success of organizations that we have an affiliation to, in addition to the success of other organizations and the services they deliver.

IHSP 2016-2019

IHSP 2019-2022

Integrated Health System of Care INTEGRATED HEALTH SYSTEM OF CARE

South West LHIN: Integrated Health Service Plan

2010-2013

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Introduction What do we want to build? Building an Integrated Health System of Care by bringing local users and providers together is vital to the work of the South West Local Health Integration Network (South West LHIN). We continually seek to understand how people experience their health care and the improvements that we must make to ensure optimum health for South West LHIN residents. This is an enormous undertaking but one that the South West LHIN has already begun through the creation and implementation of its first Integrated Health Service Plan (IHSP) 2007-2010. Over the past three years, through substantial participation, partnership and innovative thinking, Priority Action Teams completed Building the Case for Change reports for a number of priority populations and programs. The Priority Action Teams’comprehensive environmental scans, best practice analyses and recommendations have driven a larger and more integrated initiative nearing completion: a future “Blueprint”for an Integrated Health System of Care for our LHIN. The Blueprint integrates and advances the work of the Priority Action Teams by developing integrated service delivery approaches to help health service providers improve how people experience and interact within the health care system. That, in turn, will improve the overall health of residents and maximize the value of health care spending. The Blueprint describes in detail what we want health service delivery to look like by 2022 and why we need to take action today to make that vision a reality. The IHSP continues the planning and implementation efforts of our first IHSP and prioritizes steps towards the achievement of our Blueprint goal of an Integrated Health System of Care by 2022.

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The South West LHIN covers an area from Lake Erie to the Bruce Peninsula and is home to nearly one million people.

South West LHIN: Integrated Health Service Plan

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Summary of Provincial Priorities As part of the Ministry of Health and Long Term Care’s (MOHLTC) stewardship role in the provision of health care, it has identified a number of provincial priorities that LHINs have been engaged in for some time now. Due to each LHIN’s unique population needs, geography and service delivery infrastructures, LHINs often use different strategies to respond to these priorities (see Appendix A – Projects, Programs and Initiatives related to Strategic Directions). The MOHLTC is currently developing a 10-year strategic plan for Ontario’s health system but, in the interim it has put forward the following priorities for the health system. These priorities are: 1. Improve Access to Emergency Department Care by reducing the amount of time that patients spend waiting in the emergency department 2. Improve Access to Hospital Care by reducing the amount of time that patients spend waiting for an alternate level of care 3. Improve Access to Diabetes Care by supporting the roll out of the provincial diabetes strategy Two additional provincial priorities have also emerged: 4. Enhance Mental Health and Addictions Services 5. Implement Ontario’s eHealth Strategy

Reducing Emergency Room (ER) Waits Reducing ER wait times is one of the Ontario government’s top health care priorities. It recognizes that Ontarians deserve safe, reliable, appropriate and high-quality care when sudden injury or troubling symptoms take them to the ER. As part of its plan to improve ER performance, the MOHLTC has set provincial targets for ER waiting times and is moving forward with public reporting of the time Ontarians spend in the ER. Reducing ER waiting times is a complex issue that requires improvements across the entire health system. Important work is currently underway in Ontario to achieve operational improvements in emergency departments. In the South West LHIN, we recently completed an Emergency Department

South West LHIN: Integrated Health Service Plan

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Health Human Resources Study to understand how our emergency departments are functioning and what changes can be made to help provide the right level of service with current resources. A complementary opportunity that may have a greater impact is working to reduce the avoidable use of emergency services altogether. Fifty percent of ER visits are made by patients with non-urgent or less urgent needs. Reducing the number of non-urgent cases in the ER would enable emergency clinicians to focus on patients with critical needs. The South West LHIN, through the Blueprint’s Integrated Health System of Care, has identified ways to help people access appropriate health care services in places other than emergency rooms and to improve health care capacity in local communities.

Alternate Level of Care (ALC) Alternate Level of Care (ALC) refers to situations where hospital patients have completed the acute care phase of their treatment but remain in acute care beds waiting for discharge or transfer elsewhere. Some people cannot leave the hospital due to lack of access to other types of care. Other people await discharge due to inefficiency in the system. At times in the South West LHIN, up to 12% of hospitals’acute care beds are occupied by ALC patients. An ALC patient occupying an acute care bed can create a backlog in hospitals when there are no other beds available, causing people to spend a longer time in the ER. That’s why the provincial government is investing in a variety of initiatives that are working to relieve the ALC pressures in Ontario hospitals. LHINs will continue to invest time and money to reduce the number of people who stay in hospital when they could be at home or in the community getting services better suited to their needs. The South West LHIN has a number of strategies in place that have helped people receive care in the right setting.

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Diabetes Strategy Ontario’s Diabetes Strategy will help tackle a growing and expensive health care challenge. In 2008, about 900,000 Ontarian – 8.8% of the province’s population – were living with diabetes. The number of Ontarians with diabetes has increased by 69% in the last 10 years and is projected to grow from 900,000 to 1.2 million by 2010. Treatment for diabetes and related conditions such as heart disease, stroke and kidney disease currently costs Ontario over $5 billion each year. Focusing efforts on prevention programs and improving access to team-based care are central to the Diabetes Strategy. The provincial Strategy includes an online registry that will enable better self-care by giving patients and providers access to information and educational tools that empower them to manage their disease. The registry will also give health care providers the ability to easily check patient records, access diagnostic information and send patient alerts. It will result in faster diagnoses, treatment and improved management for Ontarians living with diabetes. The South West LHIN is extremely pleased to have been chosen as one of three LHINs to be an early adopter of both the Diabetes Strategy and the Diabetes Registry.

Mental Health and Addiction Services Mental health and addiction issues and concerns exist throughout all segments of society – all ages, cultures and backgrounds. Approximately one in five Ontarians will experience a mental health and/or an addiction problem during their life. The prevalence of mental health conditions among youth is increasing. As well, given the current economic situation, there may be a greater demand for adult mental health services in the coming years. Almost everyone knows someone who is affected. The cost to individuals and society is enormous.

South West LHIN: Integrated Health Service Plan

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That is why the Minister of Health and Long-Term Care established a Minister’s Advisory Group on Mental Health and Addictions to address the issue. This Advisory Group will help create a 10-year strategy on mental health and addictions needs and priorities. A South West LHIN environmental scan confirmed challenges in accessing coordinated addictions and mental health services (see Supporting Documents – South West LHIN Consultations for Mental Health and Addiction Strategy). There is a growing awareness that mental health and addiction integration needs to be within the whole system. The South West LHIN’s Blueprint describes the integration needed to achieve this. In addition, a number of actions will be implemented over the next three years to assist people to gain access to addiction and mental health service prevention, treatment and recovery programs.

An eHealth Framework On March 19, 2009, eHealth Ontario released Ontario’s eHealth Strategy, 2009-2012. The eHealth strategy is about improved health, health care, patient safety and quality of care for all Ontarians. It focuses on three clinical priorities over the next three years. They are: • Diabetes Management, including the Diabetes Registry • Medication Management, including complete drug history and dispensing information • Wait Times – ongoing enhancements to the Wait Times Information System and its expansion as part of the provincial Emergency Room (ER)/Alternate Level of Care (ALC) Information Strategy These clinical priorities will be supported by a foundation of information systems, as identified in the eHealth Strategy document.

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As the strategy evolves, with the patient’s consent, physicians, hospitals, community health care providers, labs, pharmacies and patients themselves, will gradually gain the ability to access and add to a single secure electronic record. However, this means that technology, business processes, registration, consent and privacy protocols have to be developed, implemented and adopted. The LHINs, the MOHLTC and eHealth Ontario are all partners in this important initiative, one that will enable us to transform health care delivery. As identified earlier, the South West LHIN is very pleased to pilot the implementation of the Diabetes Registry for the province in addition to having a number of information and clinical technology initiatives underway.

South West LHIN Alignment with Provincial Priorities The South West LHINs alignment with provincial priorities is evident throughout the IHSP. Specifically, the LHIN has prioritized a number of actions and performance measures that aim to enhance capacity and integration of primary, specialized and community-based care. There is a focus on seniors and adults with complex needs, people experiencing mental health and addictions challenges and people who have or are at risk of developing chronic diseases. In addition, the IHSP outlines actions and performance measures related to enhancing access and sustainability of hospital-based treatment and care with a focus on emergency services and medicine, surgical and critical care services.

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South West LHIN’s Vision for the Local Health Care System

South West LHIN’s Vision, Mission and Values

Working Together for... A Healthier Tomorrow Our Vision The South West LHIN shares the government’s overall direction for health care: “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.” Our Mission The South West LHIN brings people and organizations together to build a health care system that balances quality, access and sustainability. Our Values Compassion – We appreciate all our actions have real implications for people and communities Courage – We will make difficult decisions and challenge the status quo when required Evidence Informed – Our decisions will be guided by the best available information Innovation – We will encourage and support new thinking and the sharing of new knowledge Integrity – We will act in a fair, consistent and unbiased manner Trust and Respect – We believe in mutual trust and respect

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South West LHIN’s System Level Goals The South West LHIN strives to achieve five system level goals. The Blueprint and IHSP 2010-13 are grounded in these as well as the LHIN’s vision, mission and values. (see Appendix B – Health System Design – Blueprint Vision 2022, p29). 1. Healthier South West LHIN Community The South West LHIN has not been immune to the challenges related to the growing prevalence worldwide of people with multiple chronic conditions. Arthritis, high blood pressure, heart disease and diabetes are diseases that typically occur in combination with at least one other disease. The prevalence of depression is greater among individuals who have multiple conditions occurring at the same time. In addition, two of the major risk factors for chronic diseases are lower income levels and educational levels. Obesity and smoking are among two of the major contributors to developing diabetes, lung cancer, asthma and heart attacks. Achieving a healthier South West LHIN community involves increased attention on promoting healthy living, preventing illness and injury, enhancing the availability of better selfmanagement tools, practices and information to empower and support people and their care providers to manage their own care. It also involves enhancing team based care to screen, assess and provide early intervention strategies. The Blueprint identifies many of the strategies necessary to improve or maintain the South West LHIN’s population health. 2. Equitable Access to Services Our health care system has evolved over many years and there are many reasons why services in one area of our LHIN may not be as available or easily accessible to people living in another part of the LHIN. Some of these reasons include the timing, readiness and/or needs of a community that may have been evident in one part of our LHIN but not in another when a funding opportunity existed. At some point, additional communities may need the same service but the resources needed to provide the service are no longer available.

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Human resources challenges in some parts of our LHIN have also played a role in the inability to access services as close to home as possible. A system level goal that strives to achieve equitable access to services takes into consideration current and future service needs and the service delivery structures needed to meet those needs. The Blueprint provides substantial detail on the enhancements and modifications needed to be addressed to obtain equitable access to services across our LHIN. Strategies include a common system navigation framework for service coordination; case management and self-management; the creation of local integrated health service collaboratives unique to each community; standardized tools; health human resource strategies; and information and clinical technology. 3. Quality of Care and Service The most important element in defining quality of care and service is how South West LHIN residents individually and collectively reflect their experience of care with individual services and the health care system overall. At an individual level, it is defined by person-centred care that“encompasses respect for people’s values, preferences and their expressed needs; coordination and integration of care; information, communication, education; physical comfort; emotional support and alleviation of fear and anxiety; involvement of family and friends; and transition and continuity.” 1 A system level goal that strives to achieve a high quality of care involves increased attention to a person-centred approach, improving patient safety and the use of evidence to support practice, all of which are features of the Blueprint. In addition, legislation requires LHINs to develop Integrated Health Service Plans with input from the community and requires LHINs and health service providers to engage their communities. This community engagement plays a significant role in reflecting the public’s experience with the health care system (see Appendix C – Community Engagement Summary).

Externally Informed Annual Health System Trends Report: An Input for Health System Strategy Development, Policy Development and Planning Ministry of Health and Long-Term Care, 2009, p.6

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4. Integration of Health Care Delivery Similar to the discussion around equitable access to care, the way health care services are currently delivered has more to do with the fragmented way in which the system has evolved over time. This has been largely influenced by policy, legislation, diverse funding methods and educational systems. With the ever-increasing demand on health care services, it has become apparent that the current system no longer meets the needs of the population and certainly will not meet the needs of the future population in its current design. Adding to that is the health human resource shortages that challenge the system on a daily basis. Medical and technological advances, changes in scope of practice, increased evidence associated with the benefits of inter-professional teams and the availability of selfmanagement information and tools have more recently resulted in service delivery shifts. These, in turn call for a full re-examination of traditional structures and service delivery models to ensure that integrated care is delivered to individuals. A system level goal that strives to integrate health care delivery involves increased focus on redesigning the health care system, where needed, to achieve the intended outcomes. Integration is key to the transformative changes required to improve population health, people’s experiences and value for money. The Blueprint provides the framework elements required to create an Integrated Health System of Care for the South West LHIN.

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5. Sustainability of the South West Local Health System Health care spending in Ontario currently accounts for almost half of the provincial budget. It is projected to increase over the long term if steps are not taken to stem the year-overyear growth it has been experiencing. Reasons for this growth include rising demand and use of services; an increasingly aging population; inflation and new, more expensive treatments and medications; increased public expectations; new diseases; and an increase in the prevalence of chronic diseases. Given the current pressures faced by the health care system, particularly human resource pressures and an aging population, care must be taken and effort made to ensure that services exist and will be there for South West LHIN residents, their children and their grandchildren. A system level goal that strives to achieve sustainability of local health services focuses efforts on continuous quality improvement, improved efficiency and effectiveness of care and service delivery, maximizing our scarce human, financial and physical resources, and improved tools such as score cards and performance indicators to measure and report on productivity and quality. The Blueprint describes what we want health service delivery to look like by 2022 and the active steps we need to start taking today to make that happen.

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Overview of the Current Local Health Care System To better understand the South West LHIN population’s health care needs and the ability of the health care system in the South West LHIN to meet those needs, we looked at a variety of data and information including: • Characteristics and health status of the South West LHIN population • Health service utilization and capacity in the South West LHIN2 • Extensive engagement with the public and providers3 Given the large geography of the South West LHIN, three multi-community clusters have been identified to better understand local community needs and to allow for broader engagement with the public and local health providers. These areas are closely aligned to county boundaries and, in many cases, are served by networks and alliances of providers. The table below shows the distribution of the population across the three geographic clusters.

What Does the Population Look Like in the South West LHIN?

for northern and central residents. As well, close to 30% of the South West LHIN population resides in rural locations, which presents unique challenges for health care delivery and access. London and Middlesex County have the greatest proportion of visible minority residents and residents with a nonofficial language mother tongue. While the population of Francophones in the South West LHIN is small compared to the Francophone population in some other LHINs, the majority of Francophones in our LHIN resides in the south geographic cluster (see Appendix D - Francophone Population Profile). Francophone and newly immigrated individuals experience difficulty accessing health care services due to language and cultural barriers. The percentage of the Aboriginal population in the South West LHIN is slightly lower than in the province overall (1.7% versus 2.2%)5 (see Appendix J -Aboriginal Population Profile). Aboriginal communities face greater risk factors and higher prevalence rates for chronic disease and a variety of challenges to accessing care.

The South West LHIN health system serves approximately 944,852 residents, which is 7.4% of the provincial population. Approximately 70% of the South West LHIN population lives in the southern counties. The population distribution has naturally resulted in a concentration of specialized health services in the south, which has posed access challenges

Multi-Community Cluster

Consists of

Population (% of SW LHIN population)4

Square Kilometres

North

Bruce County, Grey County (excluding parts of Southgate Township, West Grey, and the Town of the Blue Mountains)

157,151 (17%)

8,663

Central

Huron and Perth Counties

138,529 (15%)

5,626

South

City of London, Middlesex, Oxford and Elgin Counties, Norfolk County (the southwest portions only)

649,172 (69%)

7,576

944,852

21,865

Total

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See Appendices E-I for more information on population and health services in the South West LHIN See Appendix C for a summary of the community engagement process and feedback 4 Ministry of Finance, 2007 5 Indian and Northern Affairs Canada (INAC) adjusted rate 3

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Socioeconomic Characteristics of the South West LHIN Population 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.6 The South West LHIN unemployment rate of 5.4% is below the provincial average.7 However, the economic downturn of 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%, a rise 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 the provincial average.8 Consultations revealed that these socioeconomic indicators may contribute to an increased prevalence of mental illness and addictions issues as well as other chronic diseases.

Health Status of the South West LHIN Population When developing a strategic plan for the health system, it is important to understand the population’s health status, which is likely to influence the health care needs of the population. The Canadian Community Health Survey (CCHS) in 2007 revealed that, while the prevalence of chronic conditions is in line with the provincial average, we have not seen any substantial improvement over the past two years. In addition, recent findings from the Canadian Institute for Health Information report on Primary Health Care in Canada9 reported that 41% of the population has one or more chronic illness. As well, historical LHIN data in 2007/200810 has revealed that 2% of the LHIN population was dealing with a diagnosis of cancer.

Prevelence of Selected Chronic Conditions* Health Indicator Asthma Arthritis & Rheumatism Diabetes High Blood Pressure Obesity Smoker

South West

Ontario

2005

2007

2005

2007

7.3% 18.7% 5.2% 17.2% 18.1% 20.7%

7.8% 17.1% 5.7% 17.9% 18.0% 22.7%

8.0% 17.1% 4.8% 15.2% 15.1% 20.7%

8.1% 16.2% 6.1% 16.4% 16.1% 20.6%

There has been a reported increase in mental health and addictions prevalence across the LHIN, specifically within rural populations, among adolescent populations, in addictions in the north and central multi-community areas, and in Alzheimer-related cases within the growing senior’s population. Often, the rate of the population without a primary care provider can offer an indication of the at-risk population within our LHIN. CCHS 2007 and the Primary Care Access Survey11 results revealed that approximately 7% to 11% of the population is unattached to a primary care provider. Of this, Huron and London/Middlesex counties tended to have the highest proportion of unattached patients, which exceeded the provincial rate of 7%. If not managed appropriately, the high prevalence of chronic conditions could lead to increased hospitalizations in the future.

What Will Our Population Look Like in the Future? In addition to addressing the health care needs of today’s population, service providers will be faced with continued pressure to meet future demands for these health services, particularly given the projected population growth. By 2022, the population is projected to exceed 1 million residents (see graph). 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.12

6

2006 Census of Canada Ibid 8 Ibid 9 CIHI – Analysis in Brief: Experiences with Primary Health Care in Canada, July 2009 10 2007/2008 South West LHIN Oncology data 11 Primary Care Access Survey (PCAS) Results for the South West LHIN and Ontario, July 2007-June 2008 12 Ministry of Finance, 2007 7

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16

South West LHIN Population Projections

What Does the Health Care System look like in the South West LHIN?

1,200,000 1,1500,00

1,054,804

1,100,000 1,050,000 1,000,000

944,852

950,000 900,000

2007

2012

2017

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.

2022

As well, the senior population (age 65+) 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.13

What Does This Mean for the Health of the South West LHIN Population? Factors such as demographics, population density, health status and growth contribute to determining the health care needs of our population and will influence delivery of health care in the South West LHIN. Challenges include: • 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 high prevalence of chronic disease throughout the South West LHIN may contribute to increased hospitalizations if not managed appropriately • The demands of an aging population have already had a significant impact on services and will continue to grow in the future If not addressed, these challenges will threaten the sustainability of our health care system in the future.

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 addiction services (including 4 which also provide problem gambling services) • 75 long-term care homes • South West Community Care Access Centre (CCAC) 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 services do not fall under the LHIN’s mandate, understanding them is crucial to developing a plan for integration and coordination across the health continuum.

Community Sector 14 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 within their local communities. Examples of these services include: • 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

13

Ibid See Appendix B – A Blueprint for the Future for a list of observations, challenges and implications for the future for each of the sectors presented.

14

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17

• 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 Compared to other services, a number of organizations deliver community and in-home support services (such as homemaking, in-home personal support, and meal delivery) proportionate to the population distribution across the LHIN. However, the service levels of others, such as day programs, transportation assistance and community-based mental health and addictions services, are reported to be inconsistent across the LHIN. Additional challenges for services in the community sector include long wait lists for in-home community support services, the increasing complexity of patients discharged to the community and funding issues.

In addition to services within LTCHs, South West LHIN residents also benefit 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. In July 2009, 1,893 people in the LHIN were waiting for a LTCH bed, with 146 days the average wait time. Approximately 175 people per month are admitted to a LTCH in the LHIN. Due to the lack of appropriate supportive housing and wraparound services in rural areas, individuals between the ages of 18 and 65 are consistently admitted to LTCHs. For those aged 75 and over, the need for LTCH beds is projected to increase across the LHIN, with the north having the highest increase due to the growth rate of this age cohort. An increase in the acuity of the population and multiple co-morbidities, resulting in a need for homes to care for specialized populations are another challenge for the LTCH sector.

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. RATIO OF LTC BEDS TO 1000 POPULATION 75+ YEARS South West LHIN

Beds

Beds per 1,000 people

North Central South

1,325 1.331 4,163

106 119 94 (107)

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 the LHIN.

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 Ontario15, most sites are considered small hospitals. South West LHIN organizations enable access to core hospital services either through multi-site or single locations. While these organizations are mainly located in the northern and central geographic areas within the LHIN, a few small hospital sites reside in pockets of the southern geographic area. The following are some key highlights related to hospital-based services: • The distribution of beds from designated CCC beds versus 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

15

A Summary Report to the Minister of Health and Long-Term Care From the Ontario Joint Policy and Planning Committee Multi-Site/Small Hospitals Advisory Group, December 18, 2006.

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• In evaluating rehabilitation services, the largest number of admissions occurred in the southern hospitals, 65% at St. Joseph’s Health Care – Parkwood. While all organizations offered orthopaedic and stroke in-patient rehabilitation services, the volume of orthopaedic rehab was the greatest in the central area, while stroke rehab was utilized the most in the north • The south has the highest volume of emergency department (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 2007/2008, with London Health Sciences Centre – 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, London Health Sciences Centre received 79% of total chemotherapy visits, of which a portion is attributed to northern and central residents Challenges for the acute and non-acute hospital-based services sector include a lack of available specialty services in rural areas, shortage of generalists in rural communities, lack of coordinated process to manage emergent surgical cases and an inconsistent approach to identifying CCC patients.

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 CHCs 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. The organizations in the table below provide an indication of some of the first points 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, which often serve as the stepping stone to education and early intervention

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• 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 DISTRIBUTION OF PRIMARY CARE RESOURCES

North Central South TOTAL

Primary Health Units

Community Health Centre

1 2 4 7

0 and 1 under development 0 2 plus 2 under development 2 plus 3 under development

All other primary care resources (FHT, FHN, FHO, FHG, CCM, BSM)

87

Challenges facing primary care services include inconsistency in the availability of and access to primary care resources across the LHIN. Primary care providers, although the first point of contact, often lack the tools and skill sets to appropriately screen for mental illnesses and addictions.

Profile of Health Human Resources in the South West LHIN 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 therapy, midwives, chiropodists, pharmacists, audiologists, dietitians, massage therapists, psychologists, and respiratory therapists. Non-regulated resources such as personal support workers, acupuncturists, naturopaths and chiropractors also a play a critical role in the delivery of health services. OVERVIEW OF ONTARIO DISTRIBUTION & CHARACTERISTICS OF REGISTERED PROFESSIONALS

Chiropodists Midwives Nurse Practitioners Occupational Therapists Physiotherapists Registered Nurses Registered Practical Nurses

Registered Members

South West LHIN %

480 334 594 4,010 6,080 89,054 24,482

n/a 7% 5% 10% 10% 9% 11%

19

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 is currently a total of 1,805 physicians registered in the South West LHIN, with 79% practicing in the south. Only 11% and 20% of them are registered in the north and central geographic clusters of the LHIN, while 17% and 15% of the LHIN population live in the north and central areas of the LHIN. Although there is a relatively even distribution of Family Medicine physicians across the LHIN, specialist practitioners are primarily concentrated in the south, aligned with the academic health centres, London Health Sciences Centre and St. Joseph’s Health Care, London. One area of concern is the age distribution of regulated health professionals across LHIN. Most are over the age of 40 years, with occupational therapists being the only exception. This profile is consistent with the overall trend across Canada.

What Does This Mean for the Health Care System in the South West LHIN? Providers across health sectors face the following challenges: • Inequitable distribution of health services across the LHIN pose access challenges for residents, particularly those in rural communities • Current funding and operating models reinforce a provider-focused versus person-centred approach to health service delivery • Lack of integration across sectors and of health service providers inhibits the seamless movement of individuals and families across the continuum of care • The health profile of the South West LHIN necessitates more appropriate, integrated screening and early identification of health risk factors and conditions

South West LHIN: Integrated Health Service Plan

2010-2013

• Lack of integrated technology platforms across the LHIN inhibit information-sharing among health service providers across sectors and geography • Capacity limitations make it difficult to meet the increased demand for health services • Limited availability of health human resources make it difficult to meet the current and anticipated health service demand

What Did We Hear from the Community? To inform and validate our priorities and to learn more about our health care system, we engaged people across the South West LHIN community through public meetings as well as telephone and online surveys (see Appendix C - Community Engagement Summary). We received valuable feedback regarding the development of our strategic directions. Community Sessions In July and September 2009, the South West LHIN hosted 17 sessions across the LHIN area to share information about current health trends and issues, listen to ideas and concerns about the health care system and get feedback on proposed priority areas for improvements. Targeted engagements were also held with representatives of Francophone communities and newly immigrated individuals. The majority of respondents felt that our proposed priorities would make a difference to them or people that they know. When asked if there were other priorities that the LHIN should consider, respondents suggested: addressing human resource shortages, health promotion, funding, system navigation and transportation.

20

At the Francophone community session, the group agreed that each of the priorities were of importance and stressed the need for health care services to be provided in French. They suggested additional ways to enhance access to French language services: the establishment of a Francophone Community Health Centre, enhancement of cultural and linguistic competency in health care, French speaking staff in the emergency rooms and housing supports tailored to Francophone seniors (e.g., long-term care homes). Those who provide services to newly immigrated individuals in and around the London area also took part in an engagement session. While participants agreed with the priorities, they highlighted the lack of access to languageand culturally appropriate health care services. It was noted that newly immigrated individuals struggle to know how and even when to use our health care system. Telephone and Online Surveys Telephone and online surveys were conducted with residents of the South West LHIN in September 2009. Telephone survey results showed strong support for our key priority areas. When asked what priority may be missing, the majority of respondents suggested the number and availability of doctors. Results of the online survey showed that most people felt that all the priorities were important. When asked what other priorities should be looked at, the desire for services close to home and doctor shortages were cited most often.

South West LHIN: Integrated Health Service Plan

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5

Framework for Planning Where Are We Going? The Health Services “Blueprint” Describes It!

Local Community, Multi-Community and LHIN Community are defined as follows:

Over the past year, the South West LHIN has worked to create a health services“Blueprint”. The Blueprint included the development of a project charter, a current and future state assessment and a Blueprint framework (see Appendix B – Health System Design – Blueprint Vision 2022). The LHIN has had the benefit of working on the current and future state assessment and the Blueprint framework over the past several months while the IHSP for 2010 – 2013 was also being developed.

• Local Community involves the coordination and provision of services ‘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

Creating the Blueprint framework now has allowed us to engage the public and health service providers about where we need to get to, based on the known practices and trends in health today (see Appendix C - Community Engagement Summary). Since the Blueprint has helped us understand our health care needs 12 years into the future, the second IHSP prioritizes our steps for the first three years of this journey so that we can achieve our Blueprint goal of an Integrated Health System of Care by 2022 The Blueprint follows the important work of the Priority Action Teams which helped define what an Integrated Health System of Care should look like at a population or program level based on the priorities identified in the first IHSP. The Blueprint takes these directions one step further by integrating common elements and creating a shared approach to service delivery that can be realized across priority populations and programs at local community, multi-community and LHIN community levels.

South West LHIN: Integrated Health Service Plan

2010-2013

• 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-wide sites • 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 and beyond. 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

22

ealth System o H d e t a f Car gr e t N A V F I O G A M T E I T O S N n e Y S FRAME I LEVEL W

LT IC A

G

• Delivery of low

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

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 IES

EN

A

IMPL

G

BL

I

• Service delivery by

close to home • Delivery of high volume/ low complexity services to broader population • Collaboration across local traditinal and nontraditional providers • Emphasis on an individual’s self-health management

RCE

• Services provided

STR AT E

NG

LHIN Community

MAN RESOU

N AND CLIN

MultiCommunity

TH HU EAL

M AT I O

Local Community

TE

DH

OR INF

IN

GY

EC

O OL

ORK

TE RA

HN

TIMUL

EMEN HEALTH SYSTEMS BLUEPRINT MEWORKS TATION AN D ACCOUNTABILIT Y FRA

Service & Delivery Approaches

Population-based integrated health services • Home and community care, long-term care homes, complex continuing care, rehabilitation services

• Chronic disease prevention

• Surgical services • Critical care services

and management • Emergency services

• Internal medicine services

Centrally coordinated resource capacity Local Community

South West LHIN: Integrated Health Service Plan

MultiCommunity

2010-2013

LHIN Community

23

Our Blueprint defines what our Integrated Health System of Care looks like through the description of two integrated service delivery approaches: • Population-based Integrated Health Services 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 facilitate access to LHIN community services as needed • Throughout an individual’s life journey, he or she may access primary care services, home and community care, complex continuing care, long-term 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 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 journey, 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 must be able to respond in a seamless and coordinated manner.

South West LHIN: Integrated Health Service Plan

2010-2013

Characteristics of the Two Integrated Health Service Delivery Approaches 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 capacity for these local communities in order 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 or integrated health services collaboratives. These collaboratives will be delivered 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 • Relies on care coordination and inter-professional 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 and linkage to specialist and sub-specialist care at the multi-community and LHIN community levels may be required and coordinated through the inter-professional team

24

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 • This approach focuses on 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

South West LHIN: Integrated Health Service Plan

2010-2013

In short, the Blueprint offers the South West LHIN the direction needed to improve people’s health care experiences, improve the health of particular populations and improve the value that we receive for the money that we spend on health care by: • • • • • •

focusing on individuals and families redesigning primary care services and structures managing the health of particular populations establishing a cost-control platform reinforcing system integration and execution building coalitions with other sectors

At a system level, the Blueprint: • Emphasizes that all health programs are part of a single health system dedicated to serving the larger South West LHIN population • Depicts how the various component parts of the health system need to adopt a shared approach to service delivery • Clearly communicates the roles of health providers and professionals within the broader health system. • Delineates the interdependencies between health programs which enables strategic planning and decision-making • Enables unified implementation of the IHSP.

25

At a service delivery level, the Blueprint: • Enables local, multi-community and LHIN-wide health service providers to critically evaluate the current state of their health services and identify the major issues and opportunities that exist for them and their specific population • Enables health care providers and the LHIN to plan for change by further developing and implementing a service delivery model customized to the specific health services and population needs at the local, multi-community and LHIN community level • Provides program-specific context to serve as the foundation for implementation planning at the local, multi-community and LHIN community level

How are we going to get there? Recognizing that achieving an Integrated System of Care, as defined by the Blueprint, requires a dedicated journey involving planning and implementing, the Health System Design Steering Committee will immediately transition to 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 strategic directions identified in the IHSP, to identify those opportunities that are innovative, align to the Blueprint and can serve as “success stories”and in doing so be examples of positive change. While we will work with health service providers to proactively identify these groups, we urge providers to engage in seeking out opportunities as well

South West LHIN: Integrated Health Service Plan

2010-2013

The South West LHIN, in collaboration with its health system partners, will continue to provide overall direction to our health system design process and will work to take action on the following: • Developing future IHSPs aligned to the vision of the Health Services Blueprint

IHSP 2010-2013

IHSP 2013-2016

IHSP 2016-2019

IHSP 2019-2022

Integrated Health System of Care INTEGRATED HEALTH SYSTEM OF CARE

• Creating 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 • Modifying service accountability agreements to include elements of the Health Services Blueprint and IHSP. As appropriate, these agreements will reflect transformative elements and initiatives which can gear health service providers towards enacting change These agreements will reflect the partnerships involved across providers in making change through joint accountability statements Acknowledging the resource limitations of today and potential pressures of the future, our need to transform the system is even more imminent. Under the Local Health System Integration Act, 2006, providers now have an accountability to look for opportunities to integrate the local health system. We are a single health system and thus need to be vested in the“success of all”including people who deliver and receive health care, the success of organizations that we have an affiliation to, in addition to the success of other organizations and the services they deliver.

26

A Strategic Improvement Approach can Help us! The Blueprint’s two integrated service delivery approaches provide the direction of where we are going but it will take substantial planning and implementation efforts over a number of years to move us towards experiencing health care differently in the South West LHIN. There are many examples of health care institutions and systems that have seen vast improvements in the provision of health care services and outcomes over the past decade. The MOHLTC is also interested in understanding the strategies and learnings in other parts of the world. Over the past couple of years, it has sponsored a number of events in partnership with the Centre for Healthcare Quality Improvement (CHQI) and The Change Foundation (see CHQI website) that have given LHINs and health service providers from across the province an opportunity to hear and learn from areas where health care advancements have been made. This has led many of the LHINs to investigate the Institute for Healthcare Improvement (IHI’s) compilation of tools and strategies that reflect much of the best thinking and evidence associated with improving health care. The IHI is a not-for-profit organization that collaborates with institutions and their leaders from around the world to capture the concepts, methodologies and tools to improve health care worldwide (see IHIs website). Approximately a year and a half ago, the South West LHIN solidified its vision, mission, values and system level goals and embarked on a strategic improvement approach to better align planning processes and investment strategies to obtain system level results. The strategic improvement approach provides a platform to support and measure the performance of projects through a continuous loop of “Plan, Do, Study and Act”that allows the LHIN to expand projects that achieve the results intended and modify or terminate projects that do not. As part of this approach, a portfolio of projects related to priority populations and programs based on the LHIN’s first IHSP, were mapped against the LHIN’s

South West LHIN: Integrated Health Service Plan

2010-2013

system level goals. By tracking performance measurements of these projects, the LHIN will better understand the contributions that these projects make to system level results over time. As the LHIN continues on this strategic improvement journey, other LHINs have also recognized the concepts, methodologies and tools that the IHI can bring to Ontario’s health care experience. In particular, CHQI and the Change Foundation hosted a“Triple Aim”forum in September, 2009 for all 14 LHINs. The LHINs have now committed to the“Triple Aim” approach in some capacity. Simply, Triple Aim is a framework that strives to improve three things at the same time: 1. People’s health care experiences 2. The health of particular populations 3. The value that we receive for the money that we spend on health care It does so by: • • • • • •

Focusing on individuals and families Redesigning primary care services and structures Managing the health of particular populations Establishing a cost-control platform Reinforcing system integration and execution Building coalitions with other sectors

27

TheTriple Aim framework embodies many of the core elements of the Blueprint’s integrated service delivery approaches. To track and understand the results of our efforts, the South West LHIN has also begun to apply the Triple Aim framework to its performance measurements. These measurements directly align with our system level goals.

BLUE PRINT

POPULATION HEALTH

Healthier South West LHIN Community Equitable Access to Services

EXPERIENCE OF CARE

Quality of Care and Services Integration of Health Care Delivery

PER CAPITAL COST/ COST CONTAINMENT

Sustainability of the South West Local Health System

The Blueprint includes a section on operationalizing the Integrated Health System of Care in addition to providing an implementation road map (see Blueprint Supporting Documents - Appendix E: Implementation Elements). The Blueprint’s integrated service delivery approaches will advance through planning and implementation, using a strategic improvement approach that tests small steps. This will result in small improvements in particular areas and then spread more broadly across the LHIN.

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28

6

Priorities & Strategic Directions for the Local Health System The Blueprint describes in detail what we want health service delivery to look like by 2022 and why we need to take active steps today to make that happen. The IHSP for 2010-2013 continues the implementation efforts of our first IHSP. It prioritizes the steps needed to achieve our Blueprint goal of an Integrated Health System of Care by 2022. The following chart provides a simple sketch of how our IHSP implementation efforts over the next three years align with our Blueprint directions and system level goals.

System Level goals Healthier South West LHIN Community

Equitable Access to Services

Quality of Care and Service

Integration of Health Care Delivery

Sustainability of the South West Local Health System

Blueprint Integrated Service Delivery Approaches, 2010-2022 Population-based Integrated Health Services Centrally Coordinated Resource Capacity Integrated Health Service Plan Strategic Directions, 2010-2013

Enhance Capacity and Integration of Primary, Specialized and Community-based Care, with a Focus on the following Populations:

Enhance Access and Sustainability of Hospital-based Treatment and Care Related to:

• Seniors and Adults with Complex Needs • People Living with Mental Health and Addiction Challenges • People Living with or at Risk of Chronic Disease(s)

• Emergency Services • Medicine, Surgical and Critical Care Services

Key Enablers Multi-level System of Navigation Information and Clinical Technology Integrated Health Human Resource Strategies Implementation and Accountability Frameworks

South West LHIN: Integrated Health Service Plan

2010-2013

29

What does the South West LHIN plan to implement over the next three years and why? The South West LHIN is in a very good position to identify the steps required over the IHSP 2010 – 2013 timeframe. The enormous engagement and consolidation of the Blueprint activities has set a detailed direction for what the Integrated Health System of Care will look like and how it will function in the South West LHIN. In general, we received public support for the actions related to the priority populations. This was through our community engagement process, which included community sessions, a telephone survey and an on-line survey (see Appendix C – Community Engagement Summary). In addition, we have examined the resources required and the readiness and ability of South West LHIN’s partner to action the following initiatives:

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 • Through Aging at Home (Year 3): - 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 - 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

People Living with Mental Health and Addictions Challenges • Increase supportive housing for people with problematic substance use and concurrent disorders • 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 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

People Living with or at Risk of Chronic Disease(s) • Implement Chronic Disease Prevention and Management strategies with an initial focus on the Ontario Diabetes Strategy and extend to other chronic illnesses where relevant • 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 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

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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 • Emergency services health care personnel capacity

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

Key Enablers

The following is a brief description of the key enablers.

A number of key enablers have been identified to ensure successful implementation of an Integrated Health System of Care. These include:

Multi-level System of Navigation A multi-level system of navigation underpins health care provision across all sectors. Elements of navigation include clinical case management, self-management and service coordination dependent on the needs of the individual. The intensity of navigation varies depending on needs and circumstances (including socioeconomic determinants of health) of the individual.

• Development, shared understanding and shared accountability for a multi-level system of navigation • Existence of robust information and clinical technology • Application of integrated health human resource strategies across our LHIN • Development of implementation and accountability frameworks

CL

Development of care plan

SELF

Referral to appropriate service provider

Health/nonhealth needs post service

ENT

Depending on health need, clinical case management services will be provided by clinical case managers and/or direct service providers and may include:

2010-2013

System of Navigation

C A S E M A N AG E M

Service coordination will be provided by a collection of resources depending on the care setting. While this can be delivered by a navigator and/or knowledge broker roles, it can also be delivered by health care professionals (primary care physicians, nurse practitioner, etc). Health care professionals will be required to provide information/referral services as deemed appropriate.

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C AL

N AV I G ATI O N

IN I

Multi-level System of Navigation Individuals will play an active role in managing their own health care, self-navigation, as they are able. They will be able to navigate themselves and their family through the integrated system of care. The system will empower individuals with centralized access to: • Health education resources and tools • Inventory of health services • Access to local services for coordination and clinical case management as needed

Information and education

SERVICE COORDINATION • Assessment and development of care plans with appropriate health/non-health resources • Referral to and contact with the appropriate health/nonhealth 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

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Modeled after the Kaiser Permanente concept, a multi-level system of navigation is needed to capture the following catchment populations:

LEVEL 3 High complexity case management

LEVEL 3: A strong presence of clinical case managament and service coordination for a small proportion of the population. This would involve a navigator and case manager that stays attuned and connected to the individual as he/she accesses health, medical and social services.

LEVEL 2: A moderate presence of clinical case management and stronger need for service coordination for individuals with specicfic diseases or chronic illnesses. These case managers and navigators would assist the individual through health and medical needs across health sectors and social agencies.

LEVEL 2 High risk disease/ care management

LEVEL 1

LEVEL 1: A strong presence of service coordination as these individuals need to develop a more collaborative relationship with a navigator for educational and coordination purposes as needed. This is roughly 70-80% of the population.

Self care support/ management (70-80%)

SOURCE: All Seniors and Adults with Complex Needs PAT; Prevention and management of chronic illnesses PATSource: ADAHPT Case Management Model. http://www.health.nsw.gov.au/resources/adahps/pdf/case_mgt_model.pdf; HRSA Clinical Case Management with Multiply Diagnosed Clients: Integrating Multiple Provider Roles, http://hab.hrsa. gov/special/integrating.htm; AZDHS Case Management and Clinical Team Services Plan, http://www.azdhs.gov/bhs/casemgtservplan.pdf

Enabling Information and Clinical Technology

E-health is a consumer-centred model of health care in which stakeholders can utilize information and communication technologies to manage their health care needs. E-health solutions are viewed as potential tools for modernizing the health care system, by making care safer and more cost effective.16 The internet and mobile phone technologies are not only important in people’s daily lives and in the delivery of health care services. They are also improving our access to health care services and health information. Some of the ways they are doing so include:

• Automated medication refills through the phone and online pharmacist care or medication purchasing • Telemedicine applications that, for example, record people’s weight, blood pressure and glucose readings and then transmit that information to awaiting health professionals to trigger responses, if needed • Automated physical activity programs like the Nintendo “Wii”that are accessible to people of all ages and varying abilities • Electronic health records that contain pertinent health information related to a particular person’s condition(s), treatment(s), medication(s) and service(s). This allows both providers and users to contribute to and access the record to ensure that all the individuals involved in that person’s care understand that person’s goals and the treatments and supports in place or that are still needed

• Web-based self-management programs that provide disease information, strategies and tools to better support individuals in assessing and managing their own conditions

16

Externally Informed Annual Health System Trends Report: An Input for Health System Strategy Development, Policy Development and Planning, Ministry of Health and Long-Term Care, 2009, p.13

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Magnitude of Change LESSER DEgREE

MODERATE DEgREE

• Health care professionals will be equipped with a centrally accessed repository of all South West LHIN health services (e.g. thehealthline.ca, ConnexOntario.ca) which lists services to enhance health education and enable care coordination across organizations - Enhanced functionality of real-time capacity update and electronic appointment booking - Accessible through online or via telephone • Enhance functionality of Criticall system (infrastructure already available) for: - LHIN-wide capacity management - Communicating and reporting of bed capacity status - Facilitating communication between physicians and triage - Serving as a mechanism to receive physician consult prior to referral of individual - Facilitating physician consults

gREATER DEgREE

• A real-time, easily accessible electronic health record (EHR) needs to be available to health providers LHIN-wide, across the continuum of care • A personal health portal will allow individuals to access their EHR 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 • Care coordination system will allow organizations to make electronic appointment referrals and bookings across sectors

• LHIN-wide or sub-LHIN management of capacity as appropriate: - Acute capacity - Complex continuing care - Specialized rehabilitation - Long-term care homes - Supportive housing service • Telemedicine and telehealth services will enable the provision of health services • Specialized tele-consult services will be provided to enable treatment and referral as needed. This will play a major role in the LHIN’s rural areas and will assist referral process to LHIN-wide services for higher acuity needs

The Blueprint describes the need for the above technologyrelated solutions to enable information flow, support the provision of care and facilitate communication to achieve an integrated system of care for the South West LHIN.

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When assessing potential eHealth initiatives, the South West LHIN will consider how they tie into the Clinical or Foundational priorities identified in Ontario’s eHealth Strategy 2009-2012 (see provincial eHealth Strategy). This will help ensure there is alignment with the provincial standards and direction. (See Appendix A - Projects, Programs and Initiatives related to Strategic Directions)

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Health Human Resources

“Health human resources (HHR) are a critical factor in health policy planning across Canada and internationally. The PanCanadian Health Human Resource Strategy states that: appropriate planning and management of HHR are key to developing a health-care workforce that has the right number and mix of health professionals to serve Canadians in all regions of the country”.17

As described by the Blueprint, an Integrated Health System of Care requires integrated, proactive HHR strategies to better equip South West LHIN providers with the health human resources needed to adequately deliver services. These include:

Magnitude of Change LESSER DEgREE

• Developing a sustainable workforce planning process based upon data collection and performance management to be available to health providers LHIN-wide, across the continuum of care • Develop a recruitment and retention strategy for HHR in both rural and urban communities in collaboration with South West LHIN providers • Leverage current provincial and regional initiatives to manage HHRs

MODERATE DEgREE

• Create collaborative networks South West LHIN to leverage best practices and drive policy changes

gREATER DEgREE

• Encourage organizations to create cultures that support retention and growth

• Leverage recruitment programs across South West LHIN providers • Set clear expectations of HHR roles and responsibilities within the future service delivery models (e.g. interprofessional collaboration) • Develop and implement training programs to enhance skill sets to include management of specialized populations

17

Externally Informed Annual Health System Trends Report: An Input for Health System Strategy Development, Policy Development and Planning, Ministry of Health and Long-Term Care, 2009, p.11

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The need to have the right number and mix of regulated health professionals and non-regulated health care staff and volunteers to deliver the required services has become a growing concern. The South West LHIN is not alone in its constant search for health care workers as the shortage is global. At the same time, the changing nature of practice of health professionals complicates our ability to predict our needs. Trends have shown that physician practices have changed over the years with them providing fewer hours of care. Yet, an increase in the elderly population, people with complex needs and those living with chronic diseases will most certainly require more health care resources. Implementation and Accountability Frameworks Achieving an Integrated System of Care is dependent on progressively initiating a series of implementation elements within a defined accountability framework. This requires the establishment of a framework which enables: • Clear expectations of existing governance and leadership structures that would 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) • 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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Recognizing that achieving an Integrated System of Care, as defined by the Blueprint, requires a dedicated journey involving planning and implementing, 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, the LHIN will work with stakeholders within the context of the 2010-2013 IHSP strategic directions 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 work with health service providers to proactively identify these groups, we urge you to engage in seeking out opportunities as well.

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The LHIN, in collaboration with its health system partners, will also continue to provide overall direction to our health system design process. More specifically, we will work to take action on the following: • Developing future IHSPs aligned to the vision of the Health Services Blueprint • Creating incentives for health service providers and partners as we are able and deemed appropriate • Maintaining a transparent process with open lines of communication to enable easy collaboration • Modifying future new service accountability agreements to include elements of the Health Services Blueprint and IHSP. As appropriate, these agreements will reflect transformative elements and initiatives which will prompt health service providers towards enacting change. These agreements will reflect the partnerships involved across providers in making change through joint accountability statements The actions that have been prioritized for the next three years, through the IHSP 2010-2013, are initiatives that contribute to achieving an Integrated Health System of Care. In many areas, a willingness and readiness has been demonstrated for some time and structures and incentives are already in place to enable a dedicated group of key cross-sectoral stakeholders to provide their expertise and guidance in fully planning and operationalizing the initiatives. For other actions, a dedicated group of stakeholders from different sectors and professions will need to be established to oversee more detailed planning and implementation efforts.

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7

Rationale for Strategic Directions In February 2009, the South West LHIN took the bold step of initiating the Blueprint project. The objectives of the Blueprint project are: • Provide a response to the first IHSP priority which was to ensure access to the right services, in the right place, at the right time, by the right provider • Facilitate health care providers’and the LHIN’s planning for change rather than reacting to health system trends, challenges and best practices • Develop a framework for how the system should be structured, across programs and geography, based on a detailed understanding of current services • Broadly and collectively leverage our resources rather than reacting to single issues faced by one organization, sector, or discipline As discussed in earlier chapters, the health care system faces a number of current and emerging challenges. The Blueprint addresses these challenges by describing an Integrated Health System of Care for the future where all health programs and services are part of a single, unified health system of care. The Blueprint clearly communicates the roles and responsibilities of the various health services within this unified system and delineates the interdependencies between stakeholders to enable a shared approach to service delivery. It does this through two integrated service delivery approaches: • Population-based Integrated Health Services • Centrally Coordinated Resource Capacity Through these two approaches, the Blueprint describes what we want health service delivery to look like by 2022. The IHSP identifies the strategic directions and steps that we need to take in the next three years to make it a reality, building on the implementation efforts of our first IHSP and the innovative partnerships and initiatives already in progress or ready to be launched (see Appendix A – Projects, Programs and Initiatives related to Strategic Directions)

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Rationale for IHSP Strategic Direction: Enhance Capacity and Integration of Primary, Specialized and Community-based Care This first IHSP strategic direction aligns with the“Populationbased Integrated Health Services”integrated service delivery approach and is intended to move the first three years of this approach forward. It describes providing care coordination and interprofessional team based care at the local level to focus on prevention, identification, assessment, treatment, follow-up and providing necessary supports. Local care delivery will be very important in order to support those who need assistance with their health challenges such as diabetes, obesity, advanced age, mental illness or addictions issues. As care needs become increasingly complex for some individuals with conditions such as concurrent disorders, Alzheimer’s disease and multiple chronic illnesses, referral to specialist care at the multi-community and LHIN levels may be required and coordinated through the inter-professional team. The South West LHIN has chosen to focus on the following populations: • Seniors and Adults with Complex Needs • People Living with Mental Health and Addiction Challenges • People Living with or at Risk of Chronic Disease(s) We will focus on these populations for a number of reasons. Since the first IHSP, we have undertaken a great deal of planning and a number of initiatives have already been implemented that provide early starts to some of the Blueprint implementation elements. As with all other LHINs, our actions related to seniors and adults with complex needs have been leveraged through the provincial Aging at Home initiative, Alternate Level of Care/Emergency Room initiatives and quality improvement initiatives such as the FLO Collaborative.

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The South West LHIN also remains committed to improving diabetes care by supporting the roll-out of the Ontario Diabetes Strategy. In addition to being selected as one of the first three LHINs to implement the strategy in its first year, we are also one of two LHINs identified as an“early adopter”of the province’s eHealth Strategy. This puts us in the favourable position of fully enabling the provincial eHealth Diabetes Registry. The South West LHIN’s success with the implementation of the Partnerships for Health program (see Partnerships for Health website) has strengthened our position to be effective in improving diabetes care across the LHIN. Our involvement with the strategy, the registry and Partnerships for Health has given us real applications to test some of the Integrated Health System of Care elements described by the Blueprint. In addition, our learnings from the experiences with diabetes will help us to evolve systems of care for other chronic conditions. As our population characteristics and health status show, the South West LHIN has a significant proportion of seniors and people living with chronic conditions. Other data show us that South West LHIN residents have experienced challenges accessing coordinated addictions and mental health services. Generally, these populations tend to access and use a substantial portion of our health care resources. But they don’t always use these resources at the right time, in the right place and by the right provider which often leads to crisis intervention that could have been prevented if early identification, management and supports were in place. Currently, 58% percent of all emergency room visits in the South West LHIN are for non-urgent patients.

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The IHSP actions related to enhancing capacity and integration of primary, specialized and community-based care with a focus on seniors and adults with complex needs; people living with mental health and addiction challenges; and people living with or at risk of chronic disease(s) will achieve the following objectives: • Increased availability of community care and supports for high-risk seniors, including Alternate Level of Care patients waiting for long-term care home placement • Enhanced service to clients with behavioural challenges in long-term care homes • Improved hospital bed utilization by: • Avoiding admission to acute care beds through prevention activity, facilitated discharge from emergency department to alternative settings with supports and provision of acute care in an alternative setting • Expediting discharge from acute care bed to subsequent care destinations whether at home, Long-Term Care home, Complex Continuing Care or Rehabilitation • Reduced emergency department demand – reducing the number of non-urgent cases that present at the ED will allow emergency clinicians to focus on patients with emergent needs • Early identification of and intervention for people living with mental illnesses and addictions • Improved access to and enhanced capacity of mental health and addiction services • Increased accessibility of Chronic Disease Prevention and Management team-based care close to home, particularly for those who traditionally face barriers to accessing care • Strengthened capacity for self-management among those with or at risk of, developing chronic disease(s) and for self-management support among providers • Improved ease of access to health education materials • Enhanced technological supports to manage chronic disease(s)

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Rationale for IHSP Strategic Direction: Enhance Access and Sustainability of Hospitalbased Treatment and Care: The Blueprint development process included undertaking an assessment of the current state and future health care system in the South West LHIN. The information, insights and strategies profiled in the Emergency Department Human Resources (EDHR) Project Final Report, May 2009 (see EDHR study) commissioned by the South West LHIN contributed greatly to the current state assessment. As for the future, the Blueprint’s“Centrally Coordinated Resource Capacity”integrated service delivery approach heavily influenced the IHSP action steps we will take in the next three years. Emergency Services The South West LHIN has faced particular challenges in accessing emergency services. Maintaining access to this very important service has been challenged by a number of factors, including: • A total of 27 emergency departments (EDs) within different-sized hospitals with varying capacity, volume and acuity of patients and catchment areas • Health human resources challenges in many of the 27 EDs related to consistent staffing • Shortages of family practitioners across the LHIN in part resulting in high numbers of patients who do not have a primary care physician • Demand by citizens living across a broad geography that is a mix of urban, rural and remote communities • Emergency department catchment areas that overlap LHIN boundaries influencing planning and coordination

resources (HR) strategies, the LHIN launched a project to review the current state of physician and nursing ED manpower. The project focused on developing ED strategies to be considered for implementation. Seven ED HR strategies were identified as a result of key findings and current state analysis associated with the EDHR study. They are to: A. Enhance recruitment and retention capability, activities and success at the local and LHIN levels B. Support local physician ED leadership C. Support nursing and physician workplace satisfaction D. Support local nursing and physician capacity E. Distribute hospital resources reasonably F. Maximize ED coverage within current resource pool G. Maximize integration of nurse practitioners (NPs) in primary care and community It is important to note that some strategies will apply to a few hospital sites, and others, to all sites. As identified in the EDHR final report, the next step in applying these strategies is to identify which strategies would be most appropriate for local and multi-community hospital sites. Based on the recommendations of the EDHR Study and in full alignment with the Blueprint’s integrated service delivery approach, the LHIN intends to engage key local and multi-community stakeholders to initiate a process to develop and implement tailored strategies to meet their communities’emergency services needs, with a focus on: • Emergency services recruitment and retention capability • Emergency services coverage with current resource pool • Emergency services health care personnel capacity

As stated earlier, many health human resource challenges currently exist and will continue to exist within the health care system. Over the past number of years, South West LHIN health service providers and municipalities have had variable results through focusing on increasing or supplementing physician and nursing resources in their communities. In an effort to be proactive and to develop sustainable ED human

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Medicine, Surgical and Critical Care Services The second IHSP strategic direction aligns with the Blueprint’s“Centrally Coordinated Resource Capacity” integrated service delivery approach and is intended to move the first three years of the plan forward. It describes the LHIN-wide coordination of medicine, surgical and critical care inpatient and ambulatory services to maximize access to these services for residents of the South West LHIN and beyond. Services will be coordinated across local community, multicommunity and LHIN community providers. Providers whose role will be to deliver services at the Multi-community level will provide specialist services for a larger population and LHIN community providers will be responsible for delivering highly specialized services for complex population segments from within the LHIN and beyond. This integrated service delivery approach emphasizes LHIN-wide management of resource capacity to allow people to flow through the system equitably. This will minimize backlogs and optimize the use of available resources. It will give individual’s access to the right provider based on complexity of need. This will help health service providers react to planned and unexpected events. The approach ensures equitable access by delivering a network of visiting specialist or physicians at the multicommunity or LHIN level based on demand and critical mass. It is expected that enabling technologies, such as telemedicine, would be used to execute best practices, tools and quality guidelines across providers at all levels.

The South West LHIN and health service providers have already launched some initiatives that aim to achieve similar results. Several Hips and Knees projects, stemming from the first IHSP and work of the Priority Action Team, have advanced the development and dissemination of standardized best practices for patients who need a joint replacement through creating and implementing an evidence-based joint replacement guideline in our LHIN. The current lack of standardization across our LHIN leads to variation in physician referral practices and has several potential impacts on surgical wait lists, including: • Patients being referred too early and getting lost in the system while they are waiting for their condition to worsen enough for a replacement • Patients being referred when their disease process is so advanced that by the time they see the surgeon, their severity has put them into the urgent priority • Patients who may not require surgery at all being seen by surgeons, impacting on their wait lists In addition, there is no standardized referral form in use across the LHIN. One form based on criteria of appropriateness for a joint replacement would aid in ensuring that only patients who need a joint replaced are referred to an orthopaedic surgeon. It would also aid in the triage process when referrals are received. A commonly used referral form that is linked to the evidence in the joint replacement guideline would streamline intake processes in surgeon offices and help surgeons in triage patients. This also lends itself to consistent elements of a“centralized intake”process recommended by the Hip and Knee Priority Action Team. The greatest benefit to people who need a total joint replacement will be that referrals are made at an appropriate time, based on evidence. Patients will receive orthopaedic care when they need it rather than too early or too late in the disease process. With a guideline to assist primary care physicians, patients can receive better care early on that could potentially avert or at least delay the need for a joint replacement.

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At the other end of the continuum, research indicates that if a patient is referred too late in the disease process, surgery cannot achieve optimal outcomes. An evidence-based guideline that helps physicians refer at the appropriate time will mean optimal surgical outcomes and quality of life for patients. The benefits of physicians using an evidence-based guideline in their clinical decision-making regarding care and treatment of patients with osteoarthritis will: • Possibly avert the need for some to have a joint replacement • Ensure that patients are referred to orthopaedic surgeons for a joint replacement when it is needed rather than consuming surgeon time caring for patients who are not yet ready for a joint replacement • Ensure that patients who do not need a joint replacement receive appropriate care Another initiative currently underway in the South West LHIN is the development of a Hospital Patient Flow Protocol. Currently some hospitals in the South West LHIN are experiencing patient access challenges that stem from patients requiring an Alternate Level of Care (ALC), limited access to long-term care home beds, human resource shortages and episodic higher emergency department volumes. These issues may then contribute to overcrowding in some hospital emergency departments, long lengths of stay, service delays and cancellation of surgeries. Adult tertiary acute care services are largely provided in London by the London Health Sciences Centre (LHSC) and to a lesser extent by St. Joseph’s Health Care, London. Current access issues in London have led to delays transferring patients to tertiary care which strains referring hospitals and can adversely affect patient outcomes.

or referral of patients who need urgent or emergency acute care beyond the mandate of Criticall. There is currently an initiative underway to develop and implement a Hospital Patient Flow Protocol in the South West LHIN. It will standardized patient access and flow procedures for hospitals and physicians across the LHIN to make patient referral and transfer more transparent, effective and efficient and understood by everyone. The objectives of the project include: • Implementing a standard LHIN-wide patient access and flow protocol for acute care hospitals to support patient access to specialist tertiary care and repatriation when tertiary care is no longer required • Developing LHIN-wide communication and education tools to facilitate the implementation of the protocol • Evaluating the effectiveness of the protocol These initiatives and others demonstrate our health service providers’desire to enhance access to and sustainability of hospital-based treatment and care. The South West LHIN is well positioned to engage key local, multi-community and LHIN community stakeholders to develop an action plan for the creation and implementation of Centrally Coordinated Resource Capacity for medicine, surgical and critical care services, with a focus on: • A LHIN-wide resource capacity management system • A centralized coordinated referral system, evidence-based care pathways and order sets, tools and quality guidelines These actions will allow people to flow through the system equitably, minimize backlogs and optimize the use of available resources.

Similarly, capacity constraints by some hospitals outside of London have led to challenges in repatriating patients back to their local community hospitals when they are ready to leave the tertiary environment. At present, the hospitals in the South West LHIN lack a uniform protocol for the transfer

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8

How will we Demonstrate/ Measure Success? Why Do We Need to Demonstrate Our Success? The strategic directions in our IHSP detail how we will advance our vision and system level goals, consistent with the needs of our local, multi- and LHIN-communities. Equally critical, the IHSP contains clear performance measurements to enable us to assess, monitor and report on the success of our initiatives and related actions. Performance measurements and reporting are fundamental components of strengthened accountability. As the foundation for the LHIN accountability framework with the Ministry, the LHIN reports its IHSP progress to the Ministry of Health and Long-Term Care. The IHSP also provides direction to the accountability agreements with health service providers that receive LHIN funding. Finally and most importantly, the South West LHIN is accountable to engage and report to the public on our progress in achieving our system level goals and strategic directions for the health care system.

How Will We Measure Whether or Not We’ve Been successful? The South West LHIN has identified performance measurements that will help us track our success in achieving our strategic directions. In the following table, we have included performance measurements for which: • We are currently accountable (e.g., through the Ministry-LHIN Accountability Agreement) • Data are currently collected, easily retrievable and can be summarized or are already summarized • Data are collected frequently enough to provide some measurements within the IHSP timeframe of 2010-2013 • Baselines are already established or could be established • Targets are set, or can be set, to measure our success

process or program related and linked to specific initiatives and projects will be reported in our Annual Business Plan. The broader IHSP performance measurements will be continuously tracked throughout the IHSP’s three-year timeframe and beyond. As we continue to develop ways to monitor projects and initiatives and improve how we evaluate information received, we are beginning to apply the Triple Aim framework to better track and understand the results of our efforts around: • People’s health care experiences • The health of particular populations • The value that we receive for the money that we spend on health care

How Will We Know if We’ve Been Successful? We need to know if we have improved people’s health care experiences, the health of particular populations and the value that we received for the money that we spent on health care. We have identified a number of indicators and measurements for each of our strategic directions and related priority populations and programs that we can measure on a regular basis and for which targets have been set, or will be set before 2013. By tracking our performance against the targets set for these measures, we will begin to understand whether or not our actions have been successful in moving us closer to our strategic directions and system level goals. Where we have achieved or surpassed our set targets, we will ensure that we continue to meet or exceed our achievements.

The three-year IHSP timeframe provides longer-term direction for our annual business planning. Although many of the performance measurements presented are not directly aligned to the actions we will take to achieve our strategic directions, the collective impact of the actions will affect the broader outcomes being measured. Measurements that are

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The measures listed below are based on those in the Ministry LHIN Accountability Agreement (MLAA), the service accountability agreements with health services providers in the South West LHIN and measures from the Ontario Health Quality Council.

What success will look like

What we will measure

What target we will try to meet

Measurements that will help us track our success in enhancing capacity and integration of primary, specialized and community-based care, with a focus on the following populations: Seniors and Adults with Complex Needs • Optimize their current level of health • Receive coordinated health services • Receive the right level of care in the most appropriate setting • Clients placed in long-term care homes with high or very high MAPLe* scores as a percentage of total clients placed

• Referrals from hospitals/ Community Care Access Centre to Community Support Services providers/programs • Median wait time to long-term care home placement for all placements

• Number of days from Alternate Level of Care designation to discharge by discharge to appropriate destination • reduced to 35 days

People Living with Mental Health and Addiction Challenges • People with early symptoms of mental health and/or addictions challenges are equipped to better manage their health condition • People with mental health and/or addictions challenges access coordinated services along the continuum of care • People with mental health and/or addictions challenges access the care they need where and when they need it

• Proportion of active cases by admission: self-threat; threat to others; unable to care for self; addiction problem; psychiatric symptoms; forensic • Contact with community mental health services in the previous year • Rate of re-admission to hospital for people with mental health and/or addictions challenges • Percentage of people with mental health and/or addictions challenges that report a positive experience with their care • Wait time for initial assessments • Wait time for treatment

Although this IHSP is a plan for performance, at this time there is no provincial strategic plan for mental health and addictions and no indicators to measure improvement. All LHINs will work with the Ministry to develop the best indicators. If necessary, the LHIN will modify its plans to reinforce provincial mental health and addictions priorities.

People Living with or at Risk of Chronic Disease(s) • Are identified, monitored and supported • Access a coordinated network of health services within their community • Manage their condition within targets

• Adjusted percentage of people (aged 66+) with diabetes for more than a year who had a serious diabetes complication treated in the hospital • Hospital admission rates per 100,000 population for diabetes • Use of peritoneal dialysis by all dialysis patients

• Adjusted percent of people (aged 66+) with diabetes for more than a year who had a serious diabetes complication treated in the hospital no greater than 7.5% • Hospital admission rates per 100,000 population for diabetes no greater than 75

*MAPLe – A Method of Assigning Priority Levels.

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What success will look like

What we will measure

What target we will try to meet

Across all Three Priority Populations Enhanced efficiency, effectiveness and integration of primary, specialized and community-based care

• Percentage of emergency room (ER) visits for low acuity patients (non-admitted CTAS** IV & V patients) • Number of ER unscheduled visits by quarter per 1000 population • Percentage of people who are registered with Health Care Connect and matched to a provider • Percentage of Alternative Level of Care days

• Number of ER unscheduled visits by quarter per 1000 population no greater than 120 visits • Alternative level of care days no greater than 9%

Measurements to help us track our success in enhancing access and sustainability of hospital-based treatment and care related to: Emergency Services People move swiftly and appropriately to receive the care required during and following a visit to emergency departments

• Proportion of admitted patients treated within the length of stay target of ≤ 8 hours • Proportion of non-admitted high acuity (CTAS I-III) patients treated within their respective targets of ≤ 8 hours for CTAS I-II and ≤ 6 hours for CTAS III)

• Proportion of admitted patients treated within the length of stay target of ≤ 8 hours greater than 65% • Proportion of non-admitted high acuity (CTAS I-III) patients treated within their respective targets of ≤ 8 hours for CTAS I-II and ≤ 6 hours for CTAS III) greater than 92%

Medicine, Surgical and Critical Care Services Improved access to medicine, surgical and critical care services at the local-, multi- and LHIN-community levels

90th percentile wait times for:

90th percentile wait times for:

• • • • • • • •

• • • • •

cancer surgery cardiac by-pass procedures cataract surgery hip replacement knee replacement diagnostic CT scan cancer surgery at 70 days cardiac by-pass procedures at 50 days

cataract surgery at 75 days hip replacement at 140 days knee replacement at 160 days diagnostic MRI scan at 100 days diagnostic CT scan at 28 days

*CTAS – Canadian Emergency Department Triage and Acuity Scale

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Appendices and Supporting Resources • Appendix A – Projects, Programs and Initiatives related to Strategic Directions • Appendix B - A Blueprint for the Future • Appendix C – Community Engagement Summary • Appendix D – Francophone Population Profile • Appendix E – South West LHIN Current State Profile • Appendix F – North Current State Profile • Appendix G – Central Current State Profile • Appendix H – South Current State Profile • Appendix I – Health Status of the South West LHIN Population • Appendix J –Aboriginal Population Profile Supporting Resources: • eHealth Ontario. (2009). Ontario’s eHealth Strategy: 2009-2012. Toronto. • Institute for Healthcare Improvement. (no date.) The Triple Aim. Retrieved November 2, 2009, from http://www.ihi.org/IHI/Programs/StrategicInitiatives/ TripleAim.htm • Ministry of Health and Long-Term Care. (2009.) Externally Informed Health System Trends Report: An Input for Health System Strategy Development, Policy Development and Planning. Toronto. • Morton, F., & Williams, A. P. (2009.) The South West Balance of Care Project: Summary of Findings. Toronto: Balance of Care Research Group, University of Toronto • Partnerships for Health: A Chronic Disease Prevention and Management Initiative. http://www.partnershipsforhealth.ca • South West Local Health Integration Network. (2009.) Emergency Department Human Resources Project: Final Report. London, ON. • South West LHIN Consultations for Mental Health and Addiction Strategy, October 2009 • Report on the Proceedings of the Aboriginal Meeting, London, Ontario, April 23, 2009

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Glossary of Key Definitions and Abbreviations Alternate Level of Care (ALC): Refers to situations where hospital patients have completed the acute care phase of their treatment but remain in acute care beds waiting for discharge or transfer elsewhere (e.g., Long-Term Care Home, rehabilitation, Complex Continuing Care, home care, etc.) Community: Includes any collection of individuals that is tied together by geography, common characteristics or a shared interest Complex Continuing Care (CCC): Relates to designated chronic care beds located in a hospital setting that provide continuing, medically complex and specialized services to both young and old, sometimes over extended periods of time Consumer: Includes patients, clients or user of the health care system Integrated Health System of Care: Future vision of the South West LHIN health system which unifies all health programs and services within a single, integrated health system of care that will allow individuals/families to seamlessly access and receive health services as required during the course of their lifetime. This future system of care will be delivered through two integrated service delivery approaches, population-based integrated health services and centrally coordinated resource capacity. Population-based Integrated Health Services: Service delivery approach 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 residents and surrounding communities, enabling them to better manage their own health and maintain their functional independence. Throughout an individual’s life, one 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 health services through this service delivery approach.

South West LHIN: Integrated Health Service Plan

Centrally coordinated resource capacity: Service delivery approach focused on a LHIN-wide approach to the coordination of access and management of specialized health service resources. 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. Through these approaches, local community services are supported by multi-community services and have access to LHIN community services as needed. This is defined as: Local Community: 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, and delivered through networks of inter-professional teams. Multi-Community: 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 may be required to access services; however services should still be accessible within the Multi-Community area. Services may be located at two or more sites to serve several communities within a defined geographic cluster/area. 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. 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 which 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.

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Integrated Health Services Collaborative: Virtual, mobile, or co-located settings where inter-professional teams (regulated and non-regulated practitioners) will deliver education, screening, assessment, treatment, navigation, and the necessary support services to manage the health needs of individuals within a given local catchment areas. These teams will provide a variety of services including preventive, promotive, and lower acuity services close to home while remaining connected to multi-community and LHIN community sites for higher acuity needs. Local Health Integration Networks (LHIN): Not-for-profit corporations that are responsible for planning, integrating and funding local health services in 14 different geographic areas of the province. LHINs determine the health care priorities and services required in their local communities, reflecting the reality that a community’s health needs and priorities are best understood by those familiar with the community. Partners: Include health care providers and consumers, public health units, and other partners such as university and colleges, and other community sectors (housing, environment, education, transportation, judicial) Priority Action Teams (PAT): Teams of providers, consumers and other partner representatives that defined what an integrated health system of care should look like at a population or program level based on the priorities identified in the first IHSP Providers: All health care organizations, professionals and workers providing care within their communities Transitional Care Unit (TCU): Units for alternate level of care (ALC) patients who no longer require acute care hospitalization and who will receive a more appropriate level of care in the TCU. In the TCU, patients are provided with restorative care to promote independence and maximize their potential to be cared for in retirement homes, long-term care homes, supportive housing or in their own homes with supports.

South West LHIN: Integrated Health Service Plan

2010-2013

ABBREVIATION

DEFINITION

BSM CCHS

Blended Salary Model Canadian Community Health Survey Canadian Institute for Health Information Computerized Tomography Canadian Emergency Department Triage and Acuity Scale Emergency Department Emergency Department Human Resources Emergency Room Family Health Group Family Health Network Family Health Organization Family Health Team Health Human Resources Integrated Health Service Plan London Health Sciences Centre Long-term Care Home Method of Assigning Priority Levels Mental Illness and Substance Abuse Ministry-LHIN Accountability Agreement Ministry of Health and Long-Term Care Magnetic Resonance Imaging South West Community Care Access Centre

CIHI CT CTAS ED EDHR ER FHG FHN FHO FHT HHR IHSP LHSC LTCH MAPLe MI & SA MLAA MOHLTC MRI SWCCAC

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