Welcome to the Governance to Governance and Leadership Forum. Please make your Name Tag and Table Tent Help yourself to dinner

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1 Welcome to the Governance to Governance and Leadership Forum Please make your Name Tag and Table Tent Help yourself to dinner

2 The IHSP was released officially on February 8, 2013 Our plan is fully aligned with the Ontario s Action Plan for Health Care and Pan-LHIN imperatives Each of your organizations will have received a soft copy of the plan and a limited number of hard copies are being distributed this week You will also find it on our website.

3 Why do organizations fail to achieve their strategy? Only 10-30% of Strategies Are Successfully Executed Awareness 95% of the typical workforce does not understand the strategy They Don t Manage Strategy! Resources 60% of organizations do not link budgets to strategy Incentives 70% of organizations do not link middle management incentives to strategy Executive Agenda 85% of executive teams spend less than one hour per month discussing strategy

4 4

5 Aligning and Cascading Strategy As important at a provincial level as it is at an organizational level Ontario s Action Plan 14 Integrated Health Services Plan Local HSP Strategic Plans 5

6 Health Links The Provincial Perspective Helen Angus, Associate Deputy Minister of Health and Long-Term Care

7 Moving Forward with Health Transformation Ministry of Health & Long-Term Care

8 Transformation Overview 8

9 $Billions The Fiscal challenge Health care spending since A C T U A L P R O J E C T E D 20 03/04 04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 12/13 13/14 14/15 9

10 < $Billions The Demographic Challenge Health costs by $24 billion

11 The Opportunity Health care is overflowing with opportunities for reform A system ready for change Technological advances Robust body of evidence 11 11

12 Current State Too many people relying on Emergency Rooms instead of receiving the right care in the community Too many people are having trouble navigating the system Too many ALC patients Too many people being readmitted to hospital within days of leaving hospital 12 12

13 Future State Vision: To make Ontario the healthiest place in North America to grow up and grow old A system focused on wellness Faster access to family health care that serves as the hub of their health care system Better integration and accountability 13 13

14 Dramatic Change is Needed We have a plan and we have a focus Targeting enhanced care to people with complex conditions with the poorest coordination of care can improve care and save money 1% of Ontarians account for one third of health spending, the top 5% make up 66% 14

15 Health System Transformation Health System Redesign allows for more flexible models of health care delivery which promote access and quality but also which allow for services to be provided in a fiscally sustainable manner Health System Transformation Health System Funding Reform Channel Management Health Links Paying for health care services based on the needs of the patient and on performance rather than basing it on the previous budget of the care facility and how much it costs to pay the provider Maximizing health care investments by shifting services into more appropriate and cost effective practice settings thus ensuring that the services are provided in the right place and the right time Forging ahead with a collaborative model of coordinated care which ensures greater access to existing health care services and minimizing waste in the system. 15

16 Health Links 16

17 17

18 18

19 19

20 Fred An example of a patient with complex needs 24 different conditions Treated by 16 doctors Cost of care was $900,000 in one year 20

21 Introducing Health Link: Patient Care Networks New model of care at the clinical level where all providers - including primary care, hospital, community care - are charged with coordinating plans at the patient level Initial focus on improving patient care and outcomes for people with complex health conditions (high users), while delivering better value for investment 5% of high users account for approximately $15.2 B in health care costs 21 21

22 Health Link Mandatory Requirements Minimum population of 50,000 Includes health care providers in the care of high use/high need patients Ability to identify and track high use/high need population Minimum of 65% of primary care providers in the region 22

23 Health Links Through the Province Hastings Rural Kingston Barrie South Georgian Bay Quinte Peterborough Timmins North Toronto E Southlake Temiskaming North York East Toronto Dufferin Guelph North Perth Hamilton SE Mississauga/West Toronto North Etobicoke/Malton Mid-Toronto W

24 A Broad Coalition and Diverse Leadership Models 19 early-adopter Health Links providing care to almost one million people, through the co-operation of 18 hospitals, 42 primary care groups and over 60 community service providers Cross section of coordinators 4 Hospitals 2 CCACs 8 primary care (FHT/FHO) 4 CHCs 1 Community Services Organization Cross section of partners Mental Health Agencies Public Health Units Food Banks Emergency Medical Services Educational Providers Community Social Service Providers Long Term Care Facilities Police Services 24 24

25 The Progression of Metrics for Health Links Year 1 Year 2 and Beyond Operational Metrics (Setting the Stage for Coordinated Care Straightaway) 1. Ensure the development of coordinated care plans for all complex patients 2. Increase the number of complex patients and seniors with regular and timely access to a primary care provider Results based Metrics (Moving the Needle) 1. Reduce the time from primary care referral to specialist consultation 2. Reduce the number of 30 day readmissions to hospital 3. Reduce the number of avoidable ED visits for patients with conditions best managed elsewhere 4. Reduce time from referral to home care visit 5. Reduce unnecessary admissions to hospitals 6. Ensure primary care follow-up within 7 days of discharge from an acute care setting Evaluation Based Metrics (How you ll know you ve arrived) 1. Enhance the health system experience for patients with the greatest health care needs 2. Achieve an ALC rate of 9 per cent or less 3. Reduce the average cost of delivering health services to patients without compromising the quality of care CONFIDENTIAL

26 Supporting the Change 26

27 Health Link Supports and Enablers Health Link Advisory Table Health Quality Ontario (incl. bestpath) Leadership training Removing barriers LHIN/Ministry expertise Funding Evaluation Communications support 27

28 Health Links aligned and mapped to ministry initiatives Aboriginal Health Care Research and Evaluation Health System Info. Mgmt. Specialized Clinics/ IHFs Health Prevention and Promotion Best PATH Mental Health Strategy Health Links OHIP / Ontario Drug Program Seniors Strategy Hospitals HHR F/P/T Public Health Strategy Primary Care Reform Excellent Care for All Rural and North LHIN Liaison Palliative Care Public Health Units Analytics and Data Sharing HSFR/ QBPs ehealth / EMRs OMA VDI COPD Labour Personal Support Workers

29 The Transformation Secretariat is providing change leadership and support for transformation Engagement To Mobilize System Drivers Leadership for Change Our Shared Purpose Spread of Innovation Improvement Methodology Rigorous Delivery Transparent Measurement 29

30 Questions of Clarification, Comments, Observations

31 Health Links in the Central West LHIN

32 Purpose of Presentation The purpose this evening is to spend some time talking about Health Links to develop an understanding about How Health Links are developing in Central West LHIN How they could work Your thoughts 32

33 Central West LHIN Chronology November Establish Steering Committee Look at high user data Identify first two Health Links Identify two Leads Identify co-leads Identify Potential partners Primary Care Lead meets physicians Submit early adopter Readiness Assessments December Early adopters establish advisory groups Identify next two Health Links and Leads, co-leads, partners Establish Leads working group Drill down into high users - utilization and location December 6 th Minister announces 19 Health Links including Dufferin Area and North Etobicoke - Malton January MOHLTC shares Business Case template Business Cases being prepared for two early adopters Draft Readiness Assessments sent to MOHLTC for comment Steering committee determines number and geographies of 5 Health Links Readiness Assessment for 5 th Health Link being drafted February February 22 nd Business Cases for two early adopter Health Links submitted to MOHLTC February 22 nd Readiness Assessments for next two health Links submitted to MOHLTC Readiness Assessment for 5 th Health Link Bolton-Caledon drafted and ready to submit for comment to MOHLTC 33

34 An Early Look at High Users 34

35 Health Links in the Central West LHIN Dufferin Area (Early Adopter) Bolton - Caledon Bramalea and Area Brampton and Area North Etobicoke - Malton - West Woodbridge (Early Adopter)

36 Health Links Model of Care Slide 36

37 Information Management /Technology will play critical roles - processes and technology will help flag patients in real-time as high users help with the development and maintenance of a care plan that is readily available to patient and their providers create an integrated portable patient record for these patients enhance communication amongst patients providers improve timely access to primary care providers, specialists and other services enhance the safety, quality and coordination at transfer of care points provide patients and their caregivers to better navigate the health care system Slide 37

38 Central West LHIN Health Links Governance Accountability Agreements for Lead and Partnering HSPs Central West LHIN Health Links Steering Committee Bramalea and Area Health Link Brampton and Area Health Link Dufferin Area Health Link Bolton - Caledon Health Link North Etobicoke Malton West Woodbridge Health Link Slide 38

39 Some challenges Time lines have been very tight - our ability to be nimble and strong existing relationships has been a strategic advantage to early success The strategy is evolving daily / weekly - the strategy is not fully baked Privacy and patient consent remains something to be completely addressed - this strategy requires providers to share patient information in a more open way in the circle of care Work is underway on understanding and dealing with cross boundary patients Need to ensure biggest impact of up to one-time $1 million investment per Health Link Slide 39

40 Your point of view Slide 40

41 Dialogue Let s Talk about Who Health Links are Intended to Serve

42 Bernice - a high user Bernice is 68 and lives by herself in her small home in old Brampton. Her children visit regularly. A PSW from the CCAC comes once a week. One day, she falls, cuts her arm and bruises her leg. She calls 911, is taken to hospital by ambulance, treated and sent home. Her family doctor isn t notified. The PSW is surprised by the bad cut and keeps an eye on it as it heals. A year later, Bernice falls again, and breaks her hip. She goes to hospital by ambulance. She waits 3 days in the ER, has surgery and waits to be transferred into a Toronto rehab hospital. She contracts Methicillin-resistant Staphylococcus aureus (MRSA), an infection common in hospitals. She spends 5 months in the hospital, most of it as ALC patient. One of the doctors at the hospital suggests she probably will not be able to manage on her own anymore, so she sells her house and moves into a Long-Term Care home. To care for Bernice for the next five years will cost the health care system close to half a million dollars. Could there be another end to Bernice s story? 42

43 Wilma - a high user Wilma is 70 and lives alone on government pension in a small apartment in Rexdale. She has one daughter in Burlington who works full-time to support her family. Wilma does not smoke or drink and minds what she eats. Wilma has 11 conditions including diabetes, hypertension and glaucoma. She sees her family doctor every 6 weeks, has visited 8 different specialists in the past year, and sometimes on weekends when she gets anxious about her health she goes to the local walk-in clinic. She has visited the ER 5 times, 2 times by ambulance, and been admitted twice, once when she was designated ALC and stayed nearly two months. She now receives 5 hours of home care per week from the CCAC. She is not interested in Long-Term Care. The cost of her care last year was nearly $750,000. Who is responsible for Wilma s journey? 43

44 Jack - a high user Jack is 79 years old. He lives in Shelburne with his wife, Nora, who is 78 years old and is doing well enough. One daughter lives in Toronto, one in Ottawa and one in Alberta. Jack has a small pension. Jack and Nora still drive. He likes to get to the Legion when he can. Jack suffers from chronic obstructive lung disease (COPD) and osteoarthritis. His left hip makes mobility a challenge but he toughs it out with his cane. He still smokes. In the last year, he has visited the ER on 4 occasions for exacerbation of COPD. He was admitted to the hospital once. He was put on home oxygen. During his most recent admission there was a discussion about Long-Term Care but he refuses to leave his wife and home. What do we do with Jack? 44

45 Report Back

46 Health Links Dialogue So, How Might Health Links Work

47 Moving Forward Identification Stage Define geographic areas Determine high users / seniors (local and cross-boundary) Determine local health service providers Develop Care Plans Engage health service providers Understand high users and their current care and what services they might most benefit from Engage patient and their care-givers Look at current tools and determine standards Establish individualized multi-organizational, multi-disciplinary Care Plans Identify Circle of Care and lead care coordinator for each patient Slide 47

48 Moving Forward Implement Care Plans Align current and additional services for each patient Provide Circle of Care Use communication / information technologies among providers to share information and smooth transitions Monitoring and Reporting Establish schedule of reporting by Circle of Care providers about status / progress for each patient using standard tools and measures Implement regular multi-organizational, multi-disciplinary case conferencing for each patient to evaluate impacts of interventions and re-set if necessary Evaluation Evaluate model, processes, tools, outcomes and impact on metrics for Health Links Slide 48

49 Health Links Dialogue For your Organization

50 From the perspective of your organization and the needs of your community 1. What key enablers will ensure the success of your local Health Link? 2. What role can your organization play to make your local Health Link a success? Slide 50

51 Report Back

52 Thank you!

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