ENHANCING CAPACITY TO CONNECT COMPLEX AND AT-RISK CLIENTS TO SERVICES

Transcription

1 ADVANCING THE INTEGRATION OF HEALTH CARE THROUGH HEALTH LINKS ENHANCING CAPACITY TO CONNECT COMPLEX AND AT-RISK CLIENTS TO SERVICES TO INCREASE ACCESS, IMPROVE COORDINATION, AND ENHANCE CARE MANAGEMENT FINAL REPORT OCTOBER 2013

2 Executive Summary The Toronto Central LHIN s (TC LHIN) Strategic Plan has set out a clear system plan and priorities to build capacity within the community sectors that is guided by a person-centered approach to care. Resilient and sustainable community sectors, equipped to support a growing and increasingly complex client population to live with independence close to home is central to the health care plan. This plan is aligned with Ontario s Action Plan for Health and the recent advancement of the Ministry s Health Links efforts to enable primary care providers access to multidisciplinary providers, specialist care, chronic disease management programs and other community supports offered in their local community. To ensure the TC LHIN s populations in greatest need of health care are supported, the Community Transformation Agenda has been established to bring forward system change to support people where they live. Over the past six months, working groups represented by sector experts have met to build a plan for how complex and at-risk populations can be better supported through greater alignment and linkages across sectors: primary care, community support, mental health and addictions, hospital, with support and guidance from the CCAC. Integrated Care can only be achieved by Sectors working together, across historic boundaries to provide appropriate care the client needs, by the right provider, at the right time. The Community Transformation agenda for more integrated care will be defined by the following five blueprints. Each blueprint describes a future model of care (e.g., access model, service model, and service enhancements) and explores recommendations to help to realize the model. Key highlights: For Mental Health and Addiction Clients: A Coordinated Access Point with enhanced hours will be established that supports intake and referral for community MHA clients supporting the principle of no wrong door to care. The Coordinated Access Point will ensure there will always be a clear point of entry for a client or referring provider. The work of the existing access points (e.g., Access1/CASH) serves as a model with a potential to expand to other community services. Access point will be integrated with other access points over time (e.g., Access CAMH, CSS, non-health). For the defined complex population, Care Coordination will be supported by integrated service teams that will be responsible for delivery of a consistent basket of services within each local area, tailored to meet the needs of the target clients. An integrated service team will be able to work with other teams creating a network of providers. Through service expectations, service provider organizations will be responsible to ensure appropriate and timely services are delivered to meet client needs. These organizations will also communicate any relevant information regarding a client status or situation to all other service providers within the client s circle of care and be responsible to bring members of the integrated service team together as necessary to support the care planning to meet client goals. To ensure effective and efficient care delivery, Teams will work with other providers under an integrated partnership model. Future implementation planning will define the structure and necessary supports for this arrangement (e.g., shared communication tools and client information; ability to negotiate a shared plan, problem solve and clear accountability for outcomes, and service teams that are multi-disciplinary to enable immediate care response as required). Advancing the Integration of Health Care Through Health Links P a g e 2

3 For Community Support Service Clients: A Coordinated Access Point with enhanced hours will be established that supports intake and referral for CSS clients supporting the principle of no wrong door to care. While clients can access the system through any door, the Coordinated Access Point will ensure there will always be a clear point of entry if a client or provider is unsure. Existing call centres (e.g., CNAP hub) and the CCAC Information and Referral function has been developed and is currently co-located crate a seamless interface between the sectors. This hub will be leveraged as the Coordinated Access Point with the potential to expand to other complex populations. This access point can be integrated with other access points over time (e.g., MHA). For the complex senior population, the Collaborative Care Model will be used with the CCAC taking the lead role for existing CCAC or new complex clients. A CSS agency can continue to provide the lead role for existing CSS complex clients or clients who choose not be part of the Collaborative Care service. Service enhancements for 2013/14 will be defined by the LHIN by October For the at-risk senior population, a CSS Lead Organization will be identified for every at-risk CSS client. The responsibility of the Lead is to ensure appropriate and timely services. The role of the lead is also to communicate any relevant information regarding a client status or situation to all other service providers and to bring the care team together as necessary to support care planning to meet client goals. To ensure effective and efficient care delivery, Leads will work with other CSS providers under a partnership model. Service enhancements for 2013/14 will be defined by October CCAC can also serve the at-risk population, especially when there is a prior relationship. For the transition senior population (populations moving up and down on the medically complex scale), CCAC and CSS organizations will assume joint accountability to work together to negotiate a care plan, identify a lead that is in the best interest of the client, seamlessly transition the client, and monitor and track the transition populations to ensure they receive the support and care required by the most appropriate provider(s). The LHIN will monitor a number of metrics including but not limited to: Client experience and satisfaction, volumes, costs, ability to reduce deterioration. For the general senior population, existing services will continue as they are critical to help clients and their families maintain independence in the community. For Clients and Primary Care Providers seeking access to Specialists: Timely access to specialist for our complex and at-risk clients will be enabled through standardized referral forms, streamlined processes and tools to efficiently search and identify appropriate specialists, and mechanisms to enable conversations between primary care providers and specialist where necessary. Proposed next steps include a feasibility assessment for: i) standardizing the specialist referral form; ii) collecting and making specialist information available to primary care providers; and iii) developing a tool to enable primary care providers to appropriately refer to a specialist/sub-specialist. For Clients and Primary Care Providers seeking access to Specialized Medical Imaging: Excessive delays waiting for specialized medical imaging procedures for complex and at-risk clients will be reduced or eliminated through the standardization of referral forms; clear processes and guidelines to ensure the right medical imaging modality is selected; and enhancing primary care providers access to imaging centre expertise to ensure relevant questions have been answered. Proposed next steps include a feasibility assessment for: i) standardizing the specialized medical imaging order forms; and ii) developing a tool to enable primary care providers to appropriately order medical imaging across TC LHIN hospitals. Advancing the Integration of Health Care Through Health Links P a g e 3

4 Advancing the Integration of Health Care Through Health Links P a g e 4

5 Table of Contents Executive Summary... 2 Table of Contents Setting Context Aligning Priorities for Community Transformation Confirming Focus Advancing Care for the Complex and At-Risk Guiding the Community Transformation Three Planning Tenets Building Blueprints for Integrated Health Care Enhancing Integration with Primary Care Community Mental Health & Addiction Blueprint Community Support Services Blueprint Access to Specialist Care Blueprint Access to Specialized Medical Imaging Blueprint Appendix A1 Community Mental Health & Addiction Working Group A2 Community Support Services Working Group A3 Hospital Specialist Working Group A4 MRI/CT Network A5 Think Tank Participants A6 Profile, Challenges & Impacts of Complex/At-Risk Populations in TC LHIN A7 MHA Population Descriptions A8 CSS Population Descriptions A9 Specialist Access Conceptual Model A10 Specialized Medical Imaging Conceptual Model A11 Primary Care Health Links Advancing the Integration of Health Care Through Health Links P a g e 5

6 1.0 Setting Context Aligning Priorities for Community Transformation The time is right to enhance care for our most complex and at-risk clients in their own community: In Ontario s Action Plan for Health Care, the government s directions, policies, and metrics have been very clear on its goals for better patient care through better value from our health care dollars - Better Access, Better Quality, and Better Value. The Plan is deliberate in recognizing the important contributions that the community sector makes in enhancing navigation, enabling appropriate access to care closer to home, and reducing pressure on other areas of the system through an effective community-based response. The Toronto Central LHIN s (TC LHIN) Strategic Plan has set out a clear system plan and priorities to build capacity within the community sectors that is guided by a person-centered approach to care. Resilient and sustainable community sectors, equipped to support a growing and increasingly complex client population to live with independence close to home, is central to the health care plan. In the spring of 2012, the TC LHIN, with the support of leaders from across the system developed and launched its Primary Care Plan to seamlessly bring primary health care, community based services, hospital and specialized care, teaching and education, and linkages with social support services together. In the fall of 2012, the Ministry of Health and Long-Term Care (MOHLTC) launched Health Links, a plan to enable primary care providers access to multidisciplinary providers, specialist care, chronic disease management programs and other community supports offered in their local community. Health Links utilize collaborative planning across sectors to ensure local needs are met. The early focus of Health Links center on the complex populations, with a plan to broaden its focus over time. The TC LHIN has brought all of these changes under the umbrella of its Community Transformation Agenda a plan to bring forward system change to support people where they live. To ensure success, the TC LHIN continues to work with its partners and clients to build a meaningful plan for fully integrating services under Health Links to achieve the following goals: Improving the client/patient experience by meeting people s needs as they define them; Enhancing access to services when and where they are needed; Ensuring equity of access regardless of where a person lives or population subgroups they represent; Supporting providers to deliver services that are effective and reflective of best practices; Building an efficient system that we can afford now and in the future; and Promoting inter-professional teamwork to enable integration of care as required Gaining momentum through a collaborative, informed approach to design. Over the past six months, working groups and system leaders participating in a Think Tank (see Appendix 1, 2, 3, 4 and 5 for a list of members) have met to build a plan for how complex and at-risk populations can be better supported through greater alignment and linkages across the primary care, community support sector, mental health and addiction sector, and the hospital sector. This report summarizes the proposed frameworks (access model, service model, and service enhancements) to enhance community services, and establishes plans for moving forward. Confirming need in Advancing Care for the Complex and At- Risk Populations (Section 2.0); Setting the foundation for change in Building Blueprints for Integrated Health Care (Section 3.0); and Advancing the Integration of Health Care Through Health Links P a g e 6

7 Pulling it together in Transforming Care Delivery Through a Focus on Integration (Section 4.0) 2.0 Confirming Focus Advancing Care for the Complex and At-Risk The need for focusing on Complex and At-Risk Populations are clear: Individuals receiving care by family physician demonstrate better health outcomes and lower rates of premature death due to chronic diseases. Health systems organized on a strong primary care system demonstrate: improved health outcomes, more equitable health outcomes across the population, and lower health system costs (Sources: Starfield, B, Shi L, Miscinko. 1994, 1999, 2002, 2003, and 2007). While it is widely recognized that a strong, well-integrated primary care is the backbone of a patient-centered, high quality health care system, it is the area where there are the most gaps and challenges in Toronto (and Ontario). Evidence supports that complex and at-risk populations do not have equitable access to primary care services. The most complex clients with the greatest needs are often the ones the health care system is failing the most. As the needs of complex clients often extend beyond any one sector or provider, there are greater challenges to ensure care is not fragmented. The immediate need and responsibility is to address population health and the cost of care by building a more integrated system of care where those with the greatest needs who use the most resources have improved access to the services they need, when they need it, where they need it. The system of care is not truly acting as a system, but rather a series of silos where there is an opportunity for greater integration and partnership. There have been many successes to progress towards a system of care; however there is still work to do. While there is goodwill and support amongst providers to achieve this goal, it is time to remove system barriers, history, and dis-incentives to achieve a true system of care. While most health care systems core business has focused on managing hospitals and not the health of populations, there has been a recent emergence of focus and interest on the broader continuum from primary care, community care, long-term care and public health sectors. To meet the needs of this population, the TC LHIN started with some key tenets: Transformation of the system must start with a person s health and wellness. To ensure proactive health and well-being, care must be organized around the needs and wants of the individual. This new system must support both health needs (a reactive system focused on enabling individuals to compensate for deficits, alleviating suffering and offering comfort) and wellness needs (a proactive approach that enables individuals to pursue their own highest quality of life). The outlook to the provision of care must change. It is no longer simply based on whether services were delivered but if they were the right services, if there was an acceptable outcome from a system and client/patient perspective, and were they delivered by the right provider. Patients, providers and governments are increasingly demanding greater health system accountability for quality, client experience, and cost. This focus is also shining a light on unnecessary utilization, the need to improve handoffs and transitions, and the need to build more collaborative systems of care across the continuum. Integration of care will be a fundamental. No single organization can go it alone. This transformation of the system cannot be focused on any one single area, but must be grounded in multiple organizations, institutions, ministries, funders and levels of government coming together. For example, the MOHLTC, LHINs, Ministries of Education, Community and Social Services, Municipal Affairs and Housing, Attorney General, the City of Toronto, provider sectors, United Way, etc. To create a community that will support the Advancing the Integration of Health Care Through Health Links P a g e 7

8 person, partners must come together seamlessly to support one another and provide comprehensive, client/patient focused care. Fortunately, there is growing interest (e.g., sector providers, physicians, system leaders) to align care providers within one health system however this window is not infinite quick action must be taken. To support planning efforts, the following details provide an overview of the TC LHIN s population and providers, and establish a definition for the TC LHIN s complex and at-risk populations. The Toronto Central LHIN s Population The TC LHIN is an urban LHIN with the highest population density of all LHINs. With a population of 1.12 million residents, the TC LHIN serves a highly diverse, multi-cultural population (2011 census data): 41% immigrants, with 20% being new immigrants; Reflective of 200 countries of origin, 160 languages and dialects, with 32% racialized groups; 24% of people live below low income cut-off, (2006 Census); ~ 5000 homeless (30% of Ontario s homeless); 22% with physical or mental conditions; 14% are seniors, 21% are children; and 2% Aboriginal, 2.9% Francophone. The Toronto Central LHIN s Providers The TC LHIN s operating budget is $4.4 billion, and is home to 168 Health Service Providers (HSPs) and 206 programs as of June Hospitals (5 acute academic, 2 community, 3 specialty, 7 rehab/ccc). Over 528,000 ED visits, ~149,000 acute admissions; 36 Long term care homes LTC Residents and 1625 people on LTC Beds Waitlist (2011/12); 1 Community Care Access Centre (CCAC). 69,763 individuals served, 861,498 visits and 2,626,249 hours (2012/13); 17 Community Health Centres (CHC). 29,535 individuals served, (2012/13); Other Primary Care Providers (~1,600 family physicians, ~3,500 specialists); 66 Community Support Services (CSS). 133,981 individuals served, (52% 65+ years),1,084,772 visits (2012/13); and 69 Community Mental Health and Addictions Agencies (CMHA). 92,721 individuals served, 1,252,623 visits. (2012/13). Note: Visits include face-to-face and non-face-to-face. The Toronto Central LHIN s Complex Population There are numerous definitions of complex users and high cost health care users in the literature and policy, as well as from experts. Strictly speaking, the highest users (1-5%) of health care resources are those who, when ranked, have the greatest expenditures associated with their health care utilization. The challenge is that high users also include individuals for whom costs cannot easily be reduced, and individuals who are complex but are not high cost users. Accordingly, the LHIN has taken an expansive view of the target population by considering complex users, frequent users, and the highest users of the system. TC LHIN has adopted a framework (Schaink et al., 2012) for describing and understanding complex patients which includes the following five dimensions: Advancing the Integration of Health Care Through Health Links P a g e 8

9 1. Medical/physical challenges (e.g., multimorbidity, polypharmacy, physical functioning, clinical practice guidelines); 2. Mental health and addiction challenges (e.g., depression, substance use, cognitive capacity, psychological wellbeing); 3. Social health issues (e.g., social support, caregiver strain, socioeconomic status, relationships, etc.); 4. Demographic characteristics (e.g. age, gender, ethnicity, language, education) and 5. Health and social experiences (e.g. health care utilization, quality of life, self-management, health care system navigation). In addition, systemic and structural issues within the health care system add another layer of complexity. This could be related to access, coordination of care, or integration of services across sectors. Based on the above as well as feedback from other consultations, complex populations are those individuals who have a combination of the above issues: i.e. multiple medical/physical challenges, mental health challenges, social issues, high use of health care services or challenges with health and social service experiences. Certain socio-demographic characteristics and systemic and structural issues put them at risk for increased complexity. Generally, the higher the number of issues a person has, the higher the complexity/acuity of the person. Overall, complex populations fall into four groupings although the characteristics of the patients may differ among the populations served in the different health care sectors: Frail seniors with complex needs (include older adults with chronic and unstable health issues and needs, as well as those with complex care issues (Sinha, 2012); Adults with complex needs; Children with medically complex needs and/or technological dependencies; and Palliative care or end-of-life care. The Toronto Central LHIN s At-Risk Population At-risk clients are those who have needs associated with a specific condition and may be at risk of becoming complex if they do not receive appropriate supports and care in a timely manner. Focusing on this at-risk population allows early detection, prevention, and rehabilitation, thereby improving and stabilizing their conditions/health status and preventing progression to greater complexity, or preventing crisis situations that may require visits to the emergency department and/or subsequent hospitalization. For the population groups: Seniors at risk of frailty include older adults with chronic and stable health issues and needs (may have at least one chronic health issue yet overall health remains relatively stable). They would benefit from routine primary care. They generally manage on their own but may require occasional support from home care, CSS or family and friends (Sinha, 2012). However, the at-risk population are also strongly influenced by a number of factors that extend beyond medical state (e.g., social-emotional, behavioural issues) that must be included in the planning of services. For children, youth and adults, using the example of mental health and addictions, at-risk population would be those that have risk factors for mental health and or addictions but whose conditions are controlled. See Appendix 6 for a Profile of Complex at At-Risk Populations in the TC LHIN. Advancing the Integration of Health Care Through Health Links P a g e 9

10 In addition, each sector has also done further work in defining the specific Complex and At-risk populations they will focus on - See page 16 for CMHA and page 21 for CSS complex clients of focus. Advancing the Integration of Health Care Through Health Links P a g e 10

11 3.0 Guiding the Community Transformation Three Planning Tenets The need for an integrated health care model is supported by some clear objectives: The MOHLTC s vision is to make Ontario the healthiest place in North America to grow up and grow old; The TC LHIN s strategic aim is to transform the system to achieve better health outcomes for people now and in the future, with a focus on preventing and delaying serious illness and injury among those who are at greatest risk of declining health; and The TC LHIN s transformation goals are to achieve better outcomes for people through quality care; high performing, accountable and an efficient health system; system transformation through integration; and ensure LHIN capacity to make it happen. To deliver on these objectives, the LHIN has grounded their thinking in three tenets to support planning. Multiple Lenses will be Utilized to Ensure a Balanced Approach to Solution Development. To meet the needs of the diverse client-base and providerbase, new perspectives and approaches to addressing historical issues must be utilized. It is no longer acceptable to maintain a provider lens evolving levels of accountability are pushing a system lens; and it is clear that a patient lens must be driving everything we do. As a result, change must be planned, implemented and evaluated from a combination of viewpoints/lenses: The Patient. We shift from patients, caregiver, families who are not intimately involved in their care, and whose voice is not listened to, to where patients, caregiver and family are active participants and drivers in their care; who are informed; always listened to; and respected. The Provider. We shift from providers operating with varying levels of alignment & standardization between each other, to where providers operate in a tightly aligned system of care where all providers know how to connect to others at the right time, with warm handoffs. The System. We shift from situations where governments have little reassurance investments made will yield the expected benefit and impact, to where governments have concrete measures to assess impact, ensure resources are placed in areas of need; and can assess value for money. A collective approach is critical for success. To support this work, local transformation is incorporating: Findings from literature, and best practices from other jurisdictions; A review of local data and performance; A review of client, provider and other key stakeholder feedback; and A careful consideration of the Ministry s guidelines and strategic aims. Advancing the Integration of Health Care Through Health Links P a g e 11

12 A Clear Picture of the Future will be Grounded in Guiding Principles. To design future models for care delivery, a clear picture and the guiding principles for how complex and at-risk populations will access services in the future, and how will the various sectors work together to meet these needs was established by Working Groups. Principles were grounded in four key categories. Client-Centered Care The client is valued by all providers through: Listening to the voice of patient, their story and using this to develop the service plan; Culturally responsive approaches; Equitable, barrier free access to services and information; Simple, standard processes for the client that minimize the number of times they must tell their stories; Shift from a system of dependency to one of empowerment; and Enable client education of illness and supports. Integrated Care Planning & Coordination amongst Providers Person Centred Care Clear Accountability Integrated Care Planning & Coordination Amongst Providers Enhancing Capacity to Connect Complex and At-Risk Clients to Services Coordinated Care Planning Providers will be better enabled to work together by: Work and processes guided by best practice and/or leading practice; An ongoing effort to ensure efficient and effective handoffs are maintained; Ensuring transparent pathways for easy access /mobility within and between sectors; Point of care coordination that enables shared planning, decision-making, commitment to the client; Effective utilization of sector capacity by working understanding how to work effectively together; Maintaining a determinants of health focus; Standards will guide processes and common definitions will enhance understanding; and Ensure information and tools support the flow of information and communication between providers. Coordinated Care Planning Between a Provider and a Client Providers and clients interactions will be supported through: Flow of information that is multi-directional between provider and client; Timely access to information enabling providers and clients to make informed choices about services; Navigation role - providers and clients work together to ensure appropriate/best services are delivered; Effective, comprehensive coordination and case management for the client that extends beyond any single providers walls; and Clear understanding of the services that are out there for both the provider and the client through the use of clear language and easy-to-understand information material. Clear Accountability An enhanced level of accountability will be enabled through: Access to the right services at the right time, that is grounded in equity based on need; A system that is transparent and uses periodic reporting of quality measures that providers understand; Empower problem solving within the system allowing sectors to work together to drive solutions; and Frontline staff are clear of their roles and the roles of others to ensure they are not doing something that is more appropriately supported by another provider. Advancing the Integration of Health Care Through Health Links P a g e 12

13 A Multi-Sector View will be used to build an Integrated Health Care Blueprint. To build the future model for care delivery for the complex and at-risk populations, it was understood upfront that a collaborative approach to design and development was required no one sector could alone address the needs of the complex and at-risk populations. This approach required a two-pronged approach to planning and delivery of care that avoids duplication of services, improves efficiency, and enhances system accountability and transparency. The first prong focuses on population-based care close to where a person lives. This translates to enhancing access to primary-based care services, using a sub-lhin model. It is important to note that Primary Care should remain engaged and supportive of the care patients across the complexity spectrum (from low to high), regardless of the system-wide supports. The second prong focuses on system-wide supports to ensure services at a regional level seamlessly support the primary care system and the needs of the client through integrated, coordinated access. CSS and MHA Sectors Working Together to Support Common Clients CCAC Support Across Sectors Low Complexity Clients Highly Complex Clients At-Risk Clients Changing Needs Community Support Services Sector Enhancing Access to Specialist Enhancing Access to Specialized Medical Imaging Hospital Sector LTC Sector Primary Care Sector Supporting the Health Links Transformation Strategy Changing Needs Community MHA Sector Prong 2: System-Wide Supports Delivered at a Regional Level Prong 1: Population-Based Care Via Primary Care As a result, the TC LHIN brought influential leaders together as Planning/Working Groups from various sectors to develop the conceptual models to better address the needs this population. Advancing the Integration of Health Care Through Health Links P a g e 13

14 4.0 Building Blueprints for Integrated Health Care Integrated Care can only be achieved through inter-related blueprints that define a new future of care The Community Transformation agenda for more integrated care will be defined by the following five blueprints. Each blueprint describes a future model of care (e.g., access model, service model, and service enhancements) and explores recommendations to help to realize the model. Primary Care Strategy. The Ministry s Health Links agenda laid the foundation for primary care renewal both within the sector itself and in collaboration with all other sectors of care along the broader continuum of care. To date, four of nine TC LHIN Primary Care Health Links are currently being deployed with an additional two Health Links focusing on Mental Health and Addiction populations currently being planned (see Section 4.1); Community Mental Health and Addiction Blueprint. Community Mental Health and Addiction services provide care to an important population of clients that is often overlooked. To date, a sector, consumer and literature informed model for improving access, increasing coordinated and integrated care and enhancing service capacity with a focus on complex MHA clients has been developed and will directly inform future planning (see Section 4.2). Community Support Services Blueprint. Community Support Services is an important support to help keep people in their own homes while they receive appropriate services. To date, a sector, consumer and literature informed model for improving access, increasing coordinated and integrated care, and enhancing service capacity with a focus on complex and at-risk CSS clients has been developed (see Section 4.3). Specialist Access Blueprint. Timely access to specialists/sub-specialists has been identified as a critical support for complex and at-risk clients and their associated providers to ensure care available when it is needed (see Section 4.4). Access to Specialized Medical Imaging Blueprint. Streamlined access to specialized medical imaging has been developed to ensure complex and at-risk clients and their associated providers have timely access to diagnostics tests to support care planning decisions (see Section 4.5). Advancing the Integration of Health Care Through Health Links P a g e 14

15 To support the community transformation efforts, a number of critical supports and enablers were identified throughout the Health Links Working Group session work. These included but are not limited to: A culturally responsive approach to service delivery, driven and respectful of the voice of the client, and guided by the determinants of health. All providers know what is out there, how they can services to enable informed decision making. Clients requiring services originate from multiple points of access as every door leads to service, with barrier free access to services. Clear pathways will enable informed choice. Clients are not solely based on age, but include developmentally informed care and prematurely aged. Value and support the inter-connected sector: health, housing, criminal justice, social services etc. One number to call when it is unknown who to call to ensure timely & appropriate access. This does not take away from the ability to directly refer. Facilitates a more holistic engagement and equitable access process through better screening, eligibility determination, capacity management supporting immediate prioritization and response. Services will be coordinated to ensure the right providers are connected, shared accountability is established, accountability and standards are adhered to, and clients are effectively prioritized and triaged. Coordination extends beyond any single agency s walls to enable better transition and handoffs. Clients will move into and out of a Sector seamlessly, and services and access will be adjusted based on their changing needs. Ensuring clarity for who is responsible for a client at any point in time, and building capacity to transition responsibility where required. Build economies of scale that enable shared care models grounded in multi-disciplinary teams. A care coordinator is assigned to prioritized complex clients to facilitate and support ongoing integration of assessments and service plan development to respond to changing needs of clients/caregivers. Centralized, 24/7 point of access for complex MHA services directing to local provider networks. Primary Care, CCAC, Hospitals, and other providers will not only be sources of referrals to MHA, but will also deliver services and will also receive clients back as required, and will need the capacity to support these clients. Enhanced system capacity. Primary Care physicians able to take on clients, enhanced specialized expertise and capacity in FHTs and CHCs, improved access to housing, peer support, providers working together to support services (Nurse Practitioner/MD in shelters). Building capacity and expertise to support the necessary shifts in culture, processes, and thinking through an enhanced change management capacity. Public and caregivers are educated and informed, and programs are marketed in plain English. CMHA sector understand who provides what, and knows where to get answers from. Sector has trust that Primary care and hospitals have enhanced MHA expertise and capacity. Technology will enable and integrate providers together to ensure information is pushed to all corners of the system to enable informed decisions. Advancing the Integration of Health Care Through Health Links P a g e 15

16 Comprehensive data and information will be collected, shared, and used to support effective decision-making to continually adjust and improve the system where it is needed. System will be able to demonstrate benefits and support accountability requirements. 4.1 Enhancing Integration with Primary Care The TC LHIN Primary Care Plan established a clear vision for primary care that was grounded in a larger objective of advancing the integration of health care. The result: The Providers of the Toronto Central LHIN will provide personalized, seamless, timely, comprehensive, and high quality primary care to its population through collaboration across the system to advance improved client outcomes and improved client experience in the context of a sustainable health care system. This approach clearly acknowledged that primary care could not be addressed in isolation, but rather, improving care for clients would only be achieved through inter-sectoral integration. This approach supports Ontario s Action Plan to ensure the right care at the right time in the right place requires that clients and providers work together more closely than they have in the past. The TC LHIN is leading a number of efforts to enhance Primary Care Services: Enhancing Primary Care Services for the Complex and At-Risk Population. Using the TC LHIN s primary care plan as a foundation for the Health Link Transformation, the initial focus started with the population-based care that has led to the definition of nine sub-lhin Health Links, (see Appendix A11 for a map of the TC LHIN Health Links). To date, four early adopter Health Links have been launched with early work to confirm MOHLTC and TC LHIN expectations with respect to project scope, roles, targets and deliverables (Wave 1); two additional Health Links that will focus on Mental Health and Addiction clients are preparing for their readiness assessment (Wave 2); and the TC LHIN is leading pre-engagement of providers across the remaining three Health Links and is currently hosting physician engagement sessions in collaboration with the TC CCAC and OMA District 11. It is anticipated that one of the Health Links will develop a plan focusing on Children and Youth with complex care needs. Within each wave of activity, there is Advancing the Integration of Health Care Through Health Links P a g e 16

17 development of leadership capacity and a translation of learnings and tools to ensure Health Links learn from one another. Advancing the Integration of Health Care Through Health Links P a g e 17

18 Enabling System-Wide Planning. In addition to the Health Links efforts focusing on the complex and at-risk populations, the TC LHIN has also initiated a number of activities to address the broader population. The Health Education Network is a table convened to improve access to primary care in the community by increasing the number and quality of educational placements provided in a community setting for future health care professionals. The goal of the Health Education Network is to help influence and benefit future providers of care, and ultimately the work of the Health Links. Specific areas of focus include: exploring opportunities to enhance curriculum offered to health care professionals that would help to address identified issues (e.g. increased focus on community, integrated care, change management, interdisciplinary teams); and exploring opportunities to increase community based placements for health care professionals (e.g. identify and address current gaps and barriers). The Strategic Advisory Council utilizes a population health approach to improve health outcomes and reduce health inequities among population groups. A Strategic Advisory Council table has been struck consisting of members with planning accountability for different populations, not limited to health care. The goal of the group is to optimize collective efforts and maximize health outcomes by focusing on short-term and long-term initiatives that will meet the needs of the at-risk populations with an emphasis on population health by identifying synergies, collaborative efforts, and approaches to resolve barriers and issues to collectively advance health care. Partners include: United Way, City of Toronto, Public Health, the TC LHIN Health Links leads, CAMH, Sick Kids, Ministry of Child and Youth Services, etc.. Addressing the needs of Children and Youth, promoting elder friendly communities and health promotion have surfaced as potential areas of focus. Enhancing Change Management Capacity. To help support local system transformation efforts, the LHIN has initiated planning focused on enabling and sustaining the change management that will be warranted through its Health Links program initiatives. This has included a preliminary review of leading practices in other jurisdictions and discussions with thought leaders and academics. The LHIN has also commenced planning efforts in support of community health leadership capacity building to further support the development of skills that will be required to drive and sustain system changes. Ensuring Alignment with Other LHINs. The TC LHIN continues to engage other GTA LHINs and share knowledge and progress to ensure LHIN boundaries do not hinder services or delivery, and to support opportunities for collaborative work. Ensuring Alignment with Other Sectors. To ensure regional supports are aligned and integrated with the work in primary care, community based sectors (Community Support Services sector, CCAC and the Mental Health and Addiction sector) and the hospital sector (enhance access to specialist and specialized medical imaging) have been engaged to ensure development of an integrated system of care that supports the broader continuum of care. The goal is to streamline and improve access to services offered by these providers, with an early emphasis on the needs of the complex and at-risk populations. Advancing the Integration of Health Care Through Health Links P a g e 18

19 4.2 Community Mental Health & Addiction Blueprint Many of the most complex MHA clients with the greatest needs are the ones the health care system is failing the most. The challenge is that the system is not set up to get great outcomes for these clients, nor is it meeting the expectations and wants of its providers for its own clients. The reality is that as the number of complex and vulnerable clients with MHA continue to grow, it is becoming increasingly difficult to keep up with the needs. The time is now to transform the system to address these issues. In February 2013, the Community Mental Health and Addiction (MHA) Sector Working Group was established to develop concrete plans and strategies to connect a population of complex clients to needed services resulting in improved access, increased coordination and integrated care, and enhanced service capacity. This work complements and supports the multiple efforts associated with the Health Links agenda to advance the integration of health care. Between February and June 2013, the Working Group met eight times to transition from principles and visioning, to a conceptual model development, to service enhancements, and ultimately to building recommendations to guide future implementation work. The MHA Working Group confirmed that the current system does not support strong transitions and connections between sectors (e.g., between primary care, community support services sector, housing, and the acute sector). These gaps impede a provider s ability to get the client to the appropriate service in a timely way. This is particularly true for our most complex MHA clients. This results in the following challenges: Sharing, communicating and transferring information across the continuum is not efficient, streamlined, or effective this affects how decisions are made and creates duplication the system cannot afford; Transitions within the sector and between sectors are challenging. It can be unclear who is accountable for creating and supporting a client s service plan, and unclear who is ultimately responsible for helping clients to navigate the system need for greater and clearer levels of system-wide accountability; and Clear disparities exist in some communities and neighbourhoods that limit appropriate and timely access to community MHA, primary, and secondary care close to where people live need to be able to get care to or bring clients to the appropriate services when they are needed. To develop a future model for community MHA care, the Working Group completed the following steps: Confirmed the Population of Focus. An initial focus of the Community MHA Sector representatives and the TC LHIN s Performance and Information Management team was to clearly define the population that would be served, and what services should be included under the new delivery model to support this population. (See Appendix 7 for the Attributes of Complex Community MHA Seniors, Adults, and Youth Clients). For the purposes of the Working Group s work, the initial area of focus for the design centred on a MHA client with multiple and complex needs that was defined as an individual who: Is at least 16 years of age; Has co-occurring conditions: Multiple mental illnesses and/or mental health conditions; Substance misuse issues; Developmental disability; Acquired Brain Injury; or Chronic physical diseases. AND Frequently uses hospital emergency department; Uses other urgent care services, such as crisis or emergency community services (e.g. shelters, hot meal programs, out of the cold programs); Is admitted to hospital; or Has contact with the criminal justice system (CJS) (e.g. police, courts, jails, correctional centres, forensic services). AND has social capital issues such as currently homeless or insecurely housed; Little to no social support network; Overburdened caregiver; or Living in poverty (e.g. unable to secure adequate food, clothing, or housing). Advancing the Integration of Health Care Through Health Links P a g e 19

20 These clients have a specific need(s) for which there is no current effective service system response and they require a tailored, holistic, client centered and coordinated systems approach to service delivery. Generally, the higher the number of issues a client has, and the diversity of service required, the more complex they are. CMHA clients can be subdivided into four categories: children, transitional aged youths (16-24 years), adults (25-64 years), and seniors (65 years and over)/psychogeriatrics. The majority of complex clients fall into the age group, however the youths and seniors also experience significant challenges that need to be addressed. Some population subgroups are more likely to be at risk for being complex CMHA clients (e.g. Aboriginals, refugees, etc.). Appendix 10 has detailed potential characteristics of the CMHA complex adults, seniors and youth populations. Due to the lack of comprehensive data for the CMHA sector as well as the nature of mental health and addictions illness (acuity and complexity may change over time), it is difficult to identify eligibility criteria that can comprehensively identify or quantify the complex or at-risk clients served by TC LHIN agencies or those who require these services. This task will become easier when Ontario Common Assessment of Need (OCAN) data becomes available through the Integrated Assessment Record (IAR), and linked data becomes available from the TC LHIN Community Business Intelligence (BI) initiative. Further work will be done in the implementation phase of this project to identify comprehensive eligibility criteria/tools for identifying complex populations. In addition, this process will be informed by results from further analyses currently underway related to complex populations. For example, the DATIS (Drug and Addictions Treatment Information System) team is currently working on analyses to understand complex clients using TC LHIN addictions services, and TC LHIN is also working on analyses of mental health clients who frequently use hospital emergency departments over multiple years. Defined a Framework for the Complex MHA Population. A future MHA model for the complex population was pursued because the most complex clients with the greatest needs are the ones the health care system is failing the most. There was clear acknowledgement that the problem is not getting any smaller. There is also appreciation of the great work the MHA sector in the TC LHIN has led, and an understanding that this work must be leveraged in future solution development. The concept of no wrong door to service must be a foundation for the future model. Recommendations from the Cross-LHIN Multi-Service Access Model Report and projects undertaken in recent years to enhance infrastructure and capacity for MHA clients provide an important foundation for a framework which is divided into three key areas: Access Model, a Service Delivery Model, and key and immediate Service Enhancements for complex MHA populations. The following describes each of the proposed models and summarizes key recommendations to better support the complex MHA populations within the TC LHIN. 1. Over time, the Coordinated Access Point will be enhanced, building on the work of the current Access1, CASH and Coordinated Access to Addictions projects, to support referrals for all community MHA clients to ensure clients, families or providers always know where to call to access community MHA services. While clients can enter through any door, the access point ensures clients are supported by skilled staff who understand sector resources and can support: information and referral; screening, triage, eligibility determination; service matching and waitlist management; peer support; and data collection and reporting for all populations requiring and who are eligible for community MHA services. Advancing the Integration of Health Care Through Health Links P a g e 20