Toronto Preschool Speech and Language Program Redesign Implementation Update

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1 HL7.5 STAFF REPORT INFORMATION ONLY Toronto Preschool Speech and Language Program Redesign Implementation Update Date: October 6, 2015 To: From: Wards: Board of Health Medical Officer of Health All Reference Number: SUMMARY The purpose of this report is to provide the Board with an update on the status of implementation of the redesigned service delivery model for the Toronto Preschool Speech and Language Program. A program redesign was initiated in 2010 to address operational challenges such as growing and inequitable wait lists, wide variations in service levels across the city, inefficiencies in referral processes, and inconsistent program accountability. There were 4 key elements to this redesign. 1. Maintain a community-based service delivery approach through a reduced number of purchase of service contracts that ensure direct accountability to TPH as the funder and effective management of resources, including appropriate clinical supervision 2. Centralize intake and waitlist functions; streamline access to services for families 3. Establish an infrastructure that supports a city-wide approach to planning and service delivery 4. Integrate the funding of all preschool speech and language funding under TPH as lead agency The redesign process included extensive stakeholder consultation, business process analysis by an external consultant, and a city-administered Request for Proposal that resulted in the identification of five community-based service delivery agencies. Implementation of the redesign elements was done in a gradual and consultative manner that address impacts on exiting and new service delivery agencies and their staff and Staff report for information on Toronto PSL Program Redesign Implementation Update 1

2 service continuity for children and families. As of January 2015, all elements of the redesign have been implemented. Financial Impact There are no financial implications to the City directly resulting from this report. Toronto Preschool Speech and Language is 100% provincially funded through the Ministry of Children and Youth Services. DECISION HISTORY A report to the June 7, 2011 Board of Health regarding Public Health Programs funded by the Ministry of Children and Youth Services identified plans to initiate a comprehensive review of the PSL program as one of the strategies to address ongoing funding shortfalls. TPH reported to the Board on the status of the program review and redesign at its June 21, 2013 meeting A report to award purchase of service contracts for preschool speech and language services to community-based service providers identified through Request for Proposal No and to delegate authority to the Medical Office of Health to negotiate and enter into such purchase of service contracts was approved by Community Development and Recreation Committee at their April 3, 2014 meeting and subsequently adopted by City Council at their June 10, 11, 12, 13, 2014 meeting. ISSUE BACKGROUND The Preschool Speech and Language (PSL) Program is a province-wide program funded through both the Ministry of Children and Youth Service (MCYS) and Ministry of Health and Long Term Care (MOHLTC). Toronto Public Health (TPH) has been the lead agency for the Toronto PSL program since it began in 1998 and manages the MCYS portion of the PSL funding for Toronto. Toronto PSL is a city-wide service that provides speech and language services to children between six months of age and school entry. Service is based on an assessment of need by a clinical speech pathologist and treatment generally includes individual and group therapy, along with parent and caregiver training. The program is guided by the mission to provide exemplary identification and intervention service that is responsive to cultural and linguistic diversity, in partnership with community agencies, to enable all preschool children in Toronto to reach their highest communication potential. In its role as lead agency, TPH is required to ensure consistent access to evidence-based quality services across the city through effective use of available resources and integration of services that ensures equitable, timely access to service and avoids duplication and fragmentation for families. TPH leads a partnership of hospital providers Staff report for information on Toronto PSL Program Redesign Implementation Update 2

3 (funded by MOHLTC through the Local Health Integration Networks) and community providers (funded by MCYS through TPH) to ensure the effective implementation of the PSL program, meeting service targets as set by the province. TPH is not a direct provider of service, but rather contracts with local community agencies and a number of city-wide agencies that deliver specialized services. TPH provides city-wide co-ordination of the program, maintenance of the central data base, resource and website management, interpretation services and clinical professional development. MCYS base funding for this program has been flat-lined since 2008 and the related distribution of resources to service provider agencies has remained relatively unchanged since the program began in This resulted in growing and inequitable wait lists, wide variations in service levels across the city, inefficiencies in referral processes, and inconsistent program accountability. Consequently, TPH, as the lead agency, initiated a service review and redesign in The new Toronto PSL service model built on the strengths of the existing system and had the goal of effecting positive change in the areas of access to service, waitlist management, client flow, and service quality and resource utilization across the entire city. This model has four key elements: 1. Maintain a community-based service delivery approach through a reduced number of purchase of service contracts; contracts are constructed to ensure: i) direct accountability to TPH as the funder; ii) a sufficient critical mass of staff in each agency to effectively manage changing staff allocations and provide clinical supervision 2. Centralize intake and waitlist functions; streamline access to services for families 3. Establish an infrastructure that supports a city-wide approach to planning and service delivery 4. Integrate the funding of PSL resources by transferring MOHLTC dollars to MCYS' PSL funding envelope and thereby, have all PSL funding under TPH as lead agency. COMMENTS TPH provided the Board of Health with a detailed description of the redesigned Toronto PSL service model and related implementation plans and anticipated challenges in July 2013 prior to proceeding with formal implementation. The complexity of the funding model, the large number of community service partners, and the significant degree of change made implementation of this redesigned model a highly complex process. Considerable attention was paid to communicating regularly with all stakeholders, ensuring a transparent and fair request for proposal process, and supporting both exiting and new service delivery agencies through a transition process that endeavoured to maintain seamless service for children and families. The purpose of this report is to provide the Board with an update on the status of implementation of the redesigned model. Staff report for information on Toronto PSL Program Redesign Implementation Update 3

4 A Community-Based Service Delivery Five new geographic service areas (GSAs) were established using up-to-date demographics. These new areas reflect equitable need for service and are large enough to ensure a critical mass of staff in each area. PSL services in Toronto are now delivered by: five (5) contract agencies who represent approximately 90% of the funding in the community. Effective November 2014, each of the five (5) new community Geographic Service Area (GSA) agencies have service agreements with the City of Toronto that establish clear accountability related to staff qualifications and levels, service targets, service locations, participation in operational advisory committees and financial reporting. four (4) city-wide agencies for specialized services. These services are currently under review and it is anticipated that there will be revisions to these service contracts in the next year five (5) general hospitals and two (2) tertiary care hospitals continue to deliver speech and language services to preschoolers with MOHLTC funding. These services are primarily focused on clinic based services such as neonatal follow up, developmental assessment, and feeding clinics. Centralize Intake and Waitlist Functions Over 5,000 families contact the TPH intake line each year. Effective January 1, 2015, PSL intake was centralized for all TPH contract agencies and two general hospitals (the remaining general hospitals intake processes will be centralizing in late 2015). Families can either call TPH or complete an on-line intake form. Interpretation services are provided through TPH to ensure that all families have access to the intake process. In addition, TPH is currently piloting a service navigation function at intake for families of children who are deemed at risk for additional developmental concerns. Speech and language professionals contact families and review their intake information and make referrals for additional services when indicated. By putting this service navigation at the "front door", families can access additional services more quickly without having to repeat their story numerous times Centralizing intake has allowed TPH to also centralize the wait list and thereby realize equal access to services across the city. Wait times are reviewed on a quarterly basis and resources are flexed across the GSA agencies in order to match staffing capacity with need. The current wait times are approximately eight (8) months for assessment and (10) months for treatment. MCYS has recently introduced new service targets for wait times for PSL programs across the province. By 2016, wait times should not exceed three (3) months for assessment from date of referrals and five (5) months for treatment from date of assessment. A wait time strategy has been developed that will support PSL to achieve this target in Toronto by the end of City-Wide Planning Infrastructure Three levels of participation and accountability have been established for service delivery partners. The System Planning table engages senior leaders of service delivery agencies five times per year in discussions about broad system issues that impact on PSL service delivery and service integration. The Clinical Operations table includes agency managers Staff report for information on Toronto PSL Program Redesign Implementation Update 4

5 and meets monthly to discuss and problem-solve operational details in order to ensure service consistency, equitable wait times and target adherence. Best Practice tables are a mixture of front line clinicians and managers that meet regularly to research, design and pilot clinical best practices and make recommendations to the Clinical Operations table for city-wide implementation. In order to more effectively and efficiently manage the large budget, high volume of referrals, multiple service contracts, system accountability and the need for strong system leadership, TPH reorganized its internal management structure for the PSL program (including the related MCYS funded Infant Hearing and Blind Low Vision programs). Management responsibilities are divided by function versus program to enable program integration and facilitate communications and partnership building, data management, program design and evaluation, contract management and clinical operations. Integrated PSL Funding Through the review and redesign process, TPH called on the Province to consolidate and integrate all of the funding sources for PSL services in Toronto. TPH acknowledged that this was going to require negotiations between MCYS and MOHLTC, along with several Local Integrated Health Networks (LHINs), hospitals and community agencies and might need to happen in phases over an extended period of time. To-date, funding transfers from three hospitals and two community agencies have been completed. This has meant that a total of $561K has been transferred from MOHLTC to MCYS and, in turn, to TPH. Six (6) hospitals and one (1) community agency have opted to continue to deliver PSL services with MOHLTC funding. A Memorandum of System Participation has been developed in collaboration with these agencies to establish best practices, guiding principles and responsibilities they will adhere to as members of the Toronto PSL program. In addition, the Toronto PSL program received increases to base funding for 2014/15 and 2015/16 from MCYS for a total of $900K. This money has primarily been allocated to the service provider agencies to increase the number of clinical staff positions and service locations. While it is too early to report on exact service delivery levels with the redesigned model, TPH remains confident that service delivery levels will be higher within the new model and wait times will be reduced. Through the course of the review and redesign, there was some concern expressed that, in the new model, PSL service to junior kindergarten and senior kindergarten students would be reduced as a result of this redesign. While it is true that service has been limited for this age group, this reduction in service was initiated long before the redesign and is directly related to a number of factors, including the introduction of full day kindergarten and an evidence-based focus on early intervention prior to school entry. Implementation of the PSL review is also being influenced by the Children with Special Needs Strategy that was announced by the Province in October This is a joint initiative of the Ministries of Children and Youth Services, Health and Long Term Care, Education, and Community and Social Services and is meant to address a number of key issues to make services more accessible and coordinated for children and families. Each Staff report for information on Toronto PSL Program Redesign Implementation Update 5

6 community is required to submit two proposals regarding children and youth with special needs. The first proposal, due in June, addressed how families of children with multiple needs will have access to a coordinated service planner who will assist the family to navigate the system to get the services that their child needs and then pull the services together in order to develop a coordinated service plan. Toronto PSL participated in the development of the Toronto proposal. The second proposal, due October 30, requires communities to develop an integrated children's rehabilitation strategy that integrates speech-language pathology, occupational therapy and physiotherapy service access and delivery for children 0-21 years of age. Toronto PSL has been co-chairing this planning committee. This proposal will see TPH continue to provide speech and language pathology service for preschool children with the transfer of service delivery to the school boards when the child enters junior kindergarten. Finally, Toronto PSL is undergoing rebranding of the program. To most efficiently manage resources and co-ordinate services, the same intake line and website that are used to support PSL services also supports the Toronto Infant Hearing program and the Blind Low Vision program. Referring to this as the "PSL program" does not reflect the diversity of services provided and was confusing for parents. So, to support the new integrated model of service delivery for these three programs, a new program name has been created. These three programs will now be referred to as Early Abilities. A change management process is currently underway to support the rebranding. Significant progress has been made on implementing all four of the key elements of the Toronto PSL service model redesign. This would not have been possible without the commitment and dedication of all of the PSL service providers who consistently approached this change with a "child and family" first perspective. CONTACT Sara Koke Susan Makin Associate Director, Healthy Families Director, Healthy Families Toronto Public Health Toronto Public Health Tel: Tel: SIGNATURE Dr. David McKeown Medical Officer of Health Staff report for information on Toronto PSL Program Redesign Implementation Update 6

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