The South East Laidan Health Care Plan

Transcription

1 Health Care Tomorrow Putting Patients First Integrated Health Services Plan

2 Table of Contents Table of Contents 2 Executive Summary 3 The South East LHIN Mission, Vision and Values 5 Introduction 7 Local Health Integration Networks 7 The South East LHIN 7 Developing a Plan 9 Putting Patients First 9 Focus on Innovation 9 The Provincial Landscape 9 Health Links 10 Living Longer, Living Well 10 Bringing Care Home 10 Patients First: Ontario s Action Plan for Health Care 11 Integrated Health Services Plan 3 ( ) 13 Engagement and Consultation 15 Regional Capacity Analysis and Projections (ReCAP) 16 Health Care Tomorrow Putting Patients First - The Plan 19 Goals of IHSP 4 19 Hospital Services Project 20 Addictions and Mental Health Redesign 22 Older Adult Strategy 25 Creating a Strong Continuum of Care 26 Increasing Understanding of Care Options 26 Primary Care Tomorrow Putting Patients First 29 Health Links: One Patient, One Plan, One Team 30 Better Use of Technology for Greater Information Flow 31 Continuous Patient Engagement 32 Collaborative Governance 33 Building Comprehensive Services through Cooperation 33 Enhancing Indigenous and Francophone Health Services 34 Conclusion 37 2

3 Executive Summary This is the fourth Integrated Health Services Plan (IHSP) to be released by the South East LHIN. The IHSP is an essential component of our work. It not only helps keep Ontarians, the health care community and the provincial government informed about our plans for managing and funding health care in this region, it also serves as our roadmap. It reminds us of the obligation we have to ensure that people in the South East have the health care system they need, and of the various innovative ways we have determined that we are going to do so. This IHSP is called Health Care Tomorrow Putting Patients First. It builds on the foundation that we have laid over the course of the past decade through our first three plans, identifies our priorities for the coming three years, and outlines the various programs and initiatives that will help us achieve those priorities. It is a plan that will help us ensure that the needs of patients and communities across the region are being met. It is a plan that will help us ensure that we are delivering care equitably to all our patients. It is a plan that focuses on innovation and accountability. Most important, it is a plan that puts patients first. In creating this plan, we were dependent on extensive engagement and consultation with experts, health care stakeholders, community leaders and patients across our region. The plan was also informed by a number of recent developments in health care, including the successful launch of Health Links three years ago, a renewed focus on innovation, and several valuable reports into various aspects of the health care system. Our commitment to putting patients first is one that is shared by the provincial government, as evidenced by the release in February 2015 of Patients First: Ontario s Action Plan for Health Care. Our fourth IHSP is characterized by its commitment to equity, to innovation, to sustainability and to collaboration. It reflects our understanding that the goals we want to achieve will best be achieved in the context of a better integrated health care system that serves informed and involved communities. Health Care Tomorrow Putting Patients First establishes three overarching goals that will guide the work we do and define the direction for our region's health care system over the next three years: Three Overarching Goals 1. Achieving better patient outcomes through more equitable access to quality care When we talk about equity in health care, we are referring to a fair distribution of resources, based on need as opposed to volume of services. It is not necessary in health care to ensure that all patients receive the same number of services, or even the same services if they have different care needs. What is necessary is that all patients receive the services they require. If we want to ensure equitable access to care, we need to consider and address the various barriers that exist, whether they be financial, geographic or cultural. 3

4 2. Improving the health care experience through an integrated and patient-centred continuum of care Local Health Integration Networks, as the name implies, were created with a mandate to integrate health care. The past 10 years have seen tremendous progress in this regard. We have pressed forward with numerous integrations that have helped create more seamless care, but we know that there remains much more work to be done. Our third IHSP tackled that work head on, addressing what we call the "integration imperative." Simply put, it was an acknowledgement that everything we want to accomplish in health care depends on the vast array of providers and organizations working better together, sharing information, and wrapping the system around the needs of the patient. Integration remains the imperative today. We are committed to building an integrated and sustainable regional health care system that supports healthy communities with a patient-centred approached that is both timely and responsive. 3. Working with partners towards the achievement of an accountable, high performing health care system The key notion here is innovation. If we want a high performing and sustainable health care system, we must learn to do things differently. We must embrace new ideas. We must identify needs and take an innovative approach to meeting them. We also know that if we're going to be successful, we must work as a team. We share our mission of planning integrated health services for the residents of the South East LHIN with a wide variety of health service providers, stakeholders and communities. Because we know that better health depends on many factors outside the health care sector, such as housing, employment and food, we are casting our net wide. Our work is to foster a collaborative culture where all partners are involved and have a voice in the decisions that will affect the health care system in our region. We need to learn and understand more about each other s roles and how we can mutually support each other in an integrated system. 4

5 Programs and Initiatives Over the course of the next three years, we will be undertaking a number of programs and initiatives that will help us achieve our three goals. These include: Continuing to support a sustainable acute care system through the Hospital Services Project Moving ahead with the implementation of our Addictions and Mental Health Redesign Launching an Older Adult Strategy to strengthen the continuum of supportive care for older adults in the South East region Working with our primary care providers to build a solid and sustainable primary care system that is wellcoordinated and linked to other health care services, including hospitals, home care and long-term care Building on the success of Health Links, ensuring that process improvements that have been made are extended right through the entire primary and community care sectors Better Use of Technology for Greater Information Flow - expanding the use of technology to allow information and coordinated care plans to flow easily and more quickly between providers and across the system Continuous Patient Engagement - expanding the role of the Regional Patient Advisory Council, which was originally formed to support the Hospital Services Project, to serve as a regional resource for input on other Health Care Tomorrow Putting Patients First initiatives, as well as overall strategic planning Building Comprehensive Services Through Cooperation - aligning efforts for better performing, sustainable health care through cooperation with other partners in the region, including Public Health Units, municipalities, and other ministries, including the Ministry of Community and Social Services, Ministry of Children and Youth, Ministry of Justice Enhancing Indigenous and Francophone Health Services across our region, through cooperation, education and productive two-way communication 5

6 The South East LHIN Mission, Vision, and Values Mission Planning, accountability and funding that drive improved patient-centred health care performance in the South East Vision Achieving better health through innovative, proactive, integrated and accessible quality health care in collaboration with an informed and involved community Values Professionalism Respect Collaborative Engagement Transparency 6

7 Introduction Local Health Integration Networks We are the South East Local Health Integration Network (LHIN), one of 14 LHINs established by the government of Ontario in The creation of LHINs was in response to the need for a more integrated health care system, made up of providers and organizations working together in the best interests of patients. Located in communities across Ontario, LHINs are able to identify and respond to the needs and priorities of patients and providers across their regions. LHINs are mandated to manage the planning, integration, performance and funding of the health care system in this province. Although they do not provide health care services themselves, LHINs work with health service providers and members of their local communities to set priorities and plan health services in their regions. Ontario's LHINs are crown agencies that work in partnership with the Ministry of Health and Long-Term Care (MOHLTC) to address the health care needs of all Ontario residents. The MOHLTC provides strategy and oversight at the provincial level, and LHINs ensure that regional and system plans are in line with provincial priorities. As a result, Ontarians can expect the same level of health care wherever they live and they can also benefit from a system that is nimble and responsive enough to address their specific regional needs. LHINs are required by law to develop and publish regular three-year regional health plans. These are called Integrated Health Service Plans (IHSPs). These plans communicate each LHIN's vision and priorities, and describe the directions that the LHIN proposes to take over the following three years to make that vision a reality. This IHSP is the South East LHIN s fourth and covers the years We have chosen to call it Health Care Tomorrow Putting Patients First. The South East LHIN Our LHIN, the South East LHIN, covers 19,473 square kilometers and stretches from Brighton to Prescott, north to Smiths Falls and across to Bancroft. Our LHIN has a budget of approximately $1.1 billion, which we distribute amongst 76 health service providers in our region. Our LHIN is home to almost 500,000 people 3.6 percent of the population of Ontario. This makes us the third-smallest LHIN based on total population, and with 45 percent of our population living in a rural area, the most rural LHIN in southern Ontario. As we began planning our fourth IHSP, we were very aware of a number of factors within our LHIN that had to be taken into account. These factors include: Health Service Providers within the South East LHIN 7 hospitals across 11 sites 4 addiction and mental health agencies 1 Community Care Access Centre 37 long-term care homes 22 community support agencies 5 Community Health Centres operating 8 sites *This information reflects the number of agencies only and does not identify specific programs or the number of programs A high mortality rate. The death rate in our LHIN is approximately 970 per 100,000 people. That is the highest rate out of all the LHINs 7

8 An aging population. At 21 percent (aged 65+), our LHIN has the highest proportion of older adults in Ontario. By 2016 older adults will account for 22 percent of the LHIN s population, and by 2026 this proportion will rise to 28 percent A growing number of patients with chronic diseases A challenging fiscal environment in Ontario. This results in pressures in all areas, including limits on hospital revenue increases Increasing competition in the province for health professionals, making it harder to attract them to this region In response to these factors, we established three strategic goals that will inform the work that we do as we build the best possible health care system for the people of southeastern Ontario. These goals take into account the fact that health care, at its best, is a continuum a comprehensive array of services, ranging in intensity of care, delivered over time by different providers and organizations. Our job is to ensure that these services are delivered equitably, and that patients can count on having access to them, whenever and wherever the need may arise. Our three goals are as follows: 1. Achieving better patient outcomes through more equitable access to quality care 2. Improving the patient experience through an integrated and patientcentred continuum of care 3. Working with partners towards the achievement of an accountable, high performing health care system 8

9 Developing a Plan It has been 10 years since our LHIN was created, and this is the fourth IHSP that we have produced. We have learned that these plans work best when they are informed by a detailed analysis of data and demographics. We also know that they must reflect current and recent developments in health care. We know that they should be guided by feedback from the people we work with and the patients and families we serve. They must also build on past successes and be inspired by one overarching ideal. In the case of this IHSP, that ideal is putting patients first. Putting Patients First The notion of putting patients first may not seem, at first, like a new one. Health providers have been doing exactly that, on a one-to-one level, for as long as there have been patients and people who care for them. That is still the case. But from a system level, the focus on patients has not always been easy to sustain. As health care has grown in complexity, providers and organizations have tended to focus as much on their own place within the system as on the patient's. In an environment where health care resources are limited, there is often fierce competition amongst organizations for funding. In a system where there are so many different competing factors at play, the patient can almost seem to get lost in the background. More than anything else, this plan is designed to put patients in the South East LHIN back where they belong, at the forefront of a system that is built around their needs and concerns. Focus on Innovation The release of two reports, one in late 2014 and the other in the summer of 2015, highlighted the need for increased innovation in health care. The first report, entitled The Catalyst, was released by the Ontario Health Innovation Council and contained several recommendations on how to make Ontario a fertile ground for health care innovation. The second, entitled Unleashing Innovation: Excellent Healthcare for Canada, identified promising areas of innovation, in Canada and internationally, that have the potential to sustainably reduce the growth in health spending. These reports inspire us to be innovative in both our thinking and in our approach, to find new and better ways of delivering first class care to patients today, while ensuring that the system remains sustainable and able to serve patients tomorrow. The Provincial Landscape As we undertook the process of creating this IHSP, we were greatly influenced by a number of new developments in Ontario health care. These provincial reports and programs guide our thinking about, and approaches to, a regional system of integrated care. 9

10 Health Links Early in 2013, the Ministry of Health and Long-Term Care began rolling out the first Health Links across Ontario. Health Links are an excellent example of how health care can put patients first. We know that when different health care providers work as a team to care for a patient, they are better able to coordinate that patient's journey through the health system. This, in turn, leads to better health outcomes and a better overall experience for patients. Health Links encourage greater collaboration between existing local health care providers, including primary care providers, specialists, hospitals, long-term care, home care and other community supports. In the South East LHIN, every Health Link has a coordinating primary care partner, such as a Family Health Team, Community Health Centre or Family Health Organization. All health care providers in the Health Link share information, and they collaborate in order to better and more quickly coordinate health care services for patients with complex needs, such as older adults and others with multiple chronic conditions. As a result of this improved coordination and information sharing, patients receive timely care, are able to access the services they need, and feel supported by a team of health care providers at all levels of the health care system. Health Links also support the sustainability of the health care system by reducing costs. Through improved coordination of care in the community, and engagement of people in their own care, Health Links are reducing the need for expensive hospital visits and readmissions. There are now 82 Health Links in Ontario, with more being planned. Seven of the Health Links are located in the South East LHIN and cover the region's entire geography. Living Longer, Living Well In addition to the launch of Health Links, there was another extremely significant health care development in early 2013, with the release of Dr. Samir Sinha s report entitled Living Longer, Living Well. Dr. Sinha had been appointed by the Minister of Health and Long-Term Care to lead the development of the Older Adult Strategy for Ontario. Dr. Sinha's report contained numerous recommendations to help ensure that older Ontarians have access to the right care, at the right time and in the right place. Those recommendations included connecting older Ontarians with a primary care provider through Health Links, improving access to home care by expanding personal support worker services, and creating new physician incentives to care for high-needs patients. The Sinha report was important not only for its valuable recommendations but for the positive tone that it set in helping older patients live longer and live well. Bringing Care Home Another report that greatly influenced this IHSP was released in early Dr. Gail Donner headed an expert group on home and community care. They were tasked with making recommendations on improving the patient experience, promoting equitable access to a common basket of services in communities across the province, and identifying innovative opportunities to support a sustainable and accountable home and community care system. Dr. Donner's 16 recommendations, contained in her report entitled Bringing Care Home, focus on making it easier for patients and their caregivers to: 10

11 Navigate the health care system with services that are better coordinated and integrated Understand what to expect and how to access care Receive integrated home and community care after leaving the hospital Access more services that support patients and their caregivers Patients First: Ontario s Action Plan for Health Care The South East LHIN is not alone in its commitment to putting patients first. In February 2015, the Minister of Health and Long-Term Care released Patients First: Ontario s Action Plan for Health Care, which represents the next phase of Ontario's plan to transform its health care system. It builds on a strong foundation set by Ontario s original Action Plan for Health Care in 2012, and strengthens the government s commitment to put patients first by improving their health care experience. Like its predecessor, Patients First recognizes that Ontario must deal with limited financial resources for a growing and aging population. The way to do this is to focus on evidence-based practices, improved patient experiences, increased equity across the continuum, and patient-centred decision making. Patients First identifies four key objectives. Although LHINs are not accountable for all the initiatives within those objectives, our local priorities and initiatives here at the South East LHIN align with them very well. Ontario s LHINs all recognize the value of focusing our collective efforts on common challenges. For this reason, and to better align high-level objectives of Patients First with the work of local health service providers and community partners, the LHINs have developed the following provincial strategic initiatives: Transform the patient experience through a relentless focus on quality Tackle health inequities by focusing on population health Drive innovation and sustainable service delivery. And, working together, LHINs have agreed to build and foster integrated networks of care in and across each LHIN in the following priority areas: Mental Health and Addiction Services Health Links Home and Community Care Long-Term Care Redevelopment End-of-Life / Palliative Care "We have to approach the challenges facing health care from a different vantage point, which is that if we believe in such rights to health and health care as we do then the questions we really should be asking ourselves are how do we ensure universality, improve access and deliver the highest quality of care?" Dr. Eric Hoskins, Minister of Health and Long-Term Care Patients First: Ontario s Action Plan for Health Care 11

12 Patients First: Ontario s Action Plan for Health Care Four Key Objectives Access: Improve access provide faster access to the right care When patients take steps to prevent illness, become sick, or get injured, they need to be able to find the right kind of help, whether from a family doctor, nurse-practitioner, pharmacist, or a variety of different care providers. Connect: Connect services deliver better coordinated and integrated care in the community, closer to home The foundation has been set for the home and community care sector to meet the needs of today's population with an enhanced focus on older adults and chronic disease management. Inform: Support people and patients provide the education, information and transparency they need to make the right decisions about their health Health is about more than the care patients receive from providers. It is about living a healthier life, avoiding sickness, and learning about good ways to manage illness when it happens. Creating a culture of health and wellness will support LHIN residents in making educated, informed decisions about their care. Protect: Protect the public health care system make decisions based on value and quality, to sustain the system for generations to come LHINs operate under the fundamental premise that the health care needs of local communities are best understood by those who live in them. The local public health care system belongs to the residents who fund it and depend on it for their health and the health of their children. With an aging population that has a growing need for health care services, maintaining a sustainable health care system means controlling costs and targeting funding on preventing illness and improving results for patients. 12

13 Integrated Health Services Plan 3 ( ) Every IHSP builds on the plan that came before it. In this way, we can capitalize on our successes, while learning from those things that may not have worked as well as we would have liked. Three years ago, we released IHSP3, Better Integration, Better Health Care. It was a plan that sharpened our focus on integration on bringing the many parts of our health care system together in the interest of better patient care. Through Better Integration, Better Health Care, the South East LHIN set ambitious priorities, many of which are still being rolled out today. The setting of those priorities, and the many successes we have enjoyed as a result, have allowed us to sharpen our focus even more this time around. Health Care Tomorrow Putting Patients First is a plan that would not exist without its predecessor, and the two should be regarded as twin building blocks of an integrated health care system for South East Ontario one that is responsive, sustainable, and puts patients first. 13

14 Better Integration, Better Health Care Notable Accomplishments Health Links Established seven Health Links across the South East LHIN, resulting in more patient-focused, coordinated care Addictions and Mental Health Redesign - Amalgamated seven Addictions and Mental Health (AMH) agencies in the South East into three agencies, the first step in building a better system of addiction and mental health services that will deliver an Ideal Individual Experience for all patients SHIIP Launch - In collaboration with the South East LHIN and Kingston Frontenac Lennox & Addington Public Health, developed the South East Health Integrated Information Portal, allowing providers caring for the same patient to share information and thus improve the care they are able to deliver Physiotherapy Reform Clinic-based physiotherapy is now being offered in more communities across the South East LHIN Child and Adolescent Urgent Consult Clinic The clinic assesses and supports youth ages 6-17 with urgent mental health issues Behavioural Supports Transition Unit - Launched a 20-bed inpatient program for adults living with dementia or age-related cognitive impairments who need enhanced rehabilitative resources Non-Urgent Patient Transport Moved to a single regional provider, ensuring high quality, seamless and timely patient movement between hospitals and other providers icart Model for screening all emergency department patients over 75 years of age to identify and support highrisk older adults in hospital, and after they leave Assisted Living - Implemented the first phase of assisted living services in South East offering an important alternative to Long-Term Care Home placement Overnight Respite Implemented overnight weekend respite services that are community-based and provide a needed break for caregivers Napanee Acquired Brain Injury (ABI) Home Developed one of two planned sites in Napanee for residents who are living with an ABI and received approval for the second site to proceed Oral Health Initiated a program through our Community Health Centres (CHC) for low income older adults, adults and families who require oral health support but cannot afford it Patient Advisory Committees Patient Advisory Committees were created for both the Addictions and Mental Health Redesign and the Hospital Services Project, ensuring that patient views and concerns are always at the forefront Capital Investment Initiatives to improve infrastructure for health care provision, such as the Kingston Community Health Centre, Street Health, Napanee Community Health Centre and Acquired Brain Injury housing Convalescent Care Unit The first CC Unit in the South East LHIN located at Lennox and Addington County General Hospital, so that patients can continue receiving the care they need while no longer taking up an acute care bed Resource Matching & Referral Implemented in all seven hospitals to assist in better communication to access CCAC in home services and LTCH beds to ensure right care in the right place LHIN Repatriation Policy/Procedure and Tool The South East LHIN repatriation policy has been implemented to improve patient flow between hospitals 14

15 Engagement and Consultation Like everything we do at the South East LHIN, this IHSP is informed by the views and opinions of the patients we serve, as well as the providers with whom we work. LHINs exist to ensure that Ontario's health care system can respond to health care needs at a local and community level. We could not do that job without extensively consulting with patients and providers. Over the past three years, and specifically in the months leading up to the creation of this IHSP, we consulted extensively with many providers, patients, patient family members and other members of the general public in South East Ontario. We engaged with partners in addictions and mental health including patients, family members and primary care providers about weaknesses within the current system, and how it might change to better serve them. We conducted a survey that garnered more than 280 responses and hosted a Visioning Day that was attended by more than 180 addictions and mental health stakeholders including health care providers, judicial representatives, municipal government staff and service providers, first response workers, patients and members of the public. Similarly, our Hospital Services Project was initiated with a strong patient focus. To ensure that patients are a grounding force at this planning table, we formed a Regional Patient Advisory Council in Membership was established through the existing Hospital Patient Councils and an additional call out to the community for other members. The result was 24 council members with diverse backgrounds, representing different regions across the South East LHIN. These council members were active through discussions. They shared their stories and were particularly helpful in highlighting the various challenges they faced, as well as some of the positive outcomes they experienced when navigating the system. IHSP4: Engagement and Consultation Engagement responses tended to follow certain familiar themes. These themes included: The need for better access to a physician or primary care provider The need to retain 24-hour emergency services in local communities The need for in-patient beds close to home Identifying community support services as essential in rural areas When patients were asked what they found worked well in their health care system, some of the most common answers were: Caring staff who are knowledgeable Proximity to services Access to specialists When asked what did not work well, the most common responses were: Wait times that were too long Poor communication from care providers Some providers lack compassion and care, have no bedside manner, and are rude and unkind Services are disjointed, and there is no followthrough after discharge from hospital Broader public engagement was also conducted as part of our community consultation for this IHSP. Twelve community open houses were hosted across the South East in Bancroft, Trenton, Brighton, Smiths Falls, Picton, Belleville, Perth, Westport, Sharbot Lake, Kingston, Brockville, and Napanee. More than 250 members of the public attended. An online survey was also launched through the dedicated Health Care Tomorrow website. We received responses from over 1,750 residents across our region, our highest response rate ever for an online survey. 15

16 In addition, a focus group of informed Francophones was consulted in order to discuss preliminary results of the online survey, and collect their feedback. A more detailed breakdown of the engagement results can be found in Appendix A. Regional Capacity Analysis and Projections (ReCAP) This is the third of our IHSPs to be informed by what we call our Regional Capacity Analysis and Projections (ReCAP). This is a systemic analysis of the South East LHIN population and their health experience. The guiding principle behind ReCAP is that if programs and services are to meet the needs of our patients, then we need to better understand our patients their socioeconomic status, their health status and behaviours, and the ways in which they use the health care system. older. This is the highest percentage in Ontario. By 2016, that proportion is expected to rise to 22 percent, and by 2026, it is estimated that 28 percent of our LHIN's population will be over the age of 65. The impact of this aging population on our health care system is easy to predict, but extremely difficult to manage. The number of people living with chronic conditions will almost certainly increase, as will their need for services and care coordination. There will be an increasing need for palliative and end-of-life services as the larger older adult population reaches end-of-life. There will also be increased demand for long-term care services or alternatives like assisted living. Finally, as the needs for older adults are frequently met by many of our community support services, the demand for those services will also increase. ReCAP provides us with a clearer picture of current and projected demand for health services in our region, as well as a better understanding of emerging themes and opportunities. It is an invaluable tool in the development of plans like this one, and for the development of future local plans. A detailed breakdown of the ReCAP analysis can be found in Appendix B. As we created this IHSP, we were mindful of the many emerging themes and challenges revealed to us through the ReCAP process. These included: Demographics For the first time ever, there were more Canadians 65 and over than under the age of 15 in The South East LHIN reached that point in The simple fact is, ours is an older population. As of 2013, 20 percent of people in the South East LHIN were 65 years or Socio-Economic Status, Health Behaviors, and Health Status When looking at the South East LHIN overall, there may not appear to be large populations of certain socio-cultural groups compared to other areas of the province. However, there are areas in our LHIN where there are larger immigrant, Indigenous, and Francophone populations. As well, significant differences in income, education, unemployment, and numbers of people living alone can also be seen across the LHIN. Variation in all of these socioeconomic factors is important to keep in 16

17 mind when planning health services that will meet the needs of our population. We know that health service needs will likely increase as the population ages. However, many people in the South East LHIN already face health challenges, or have behaviors that will likely cause them to develop health issues. Almost half of the population is physically inactive, and more than half do not consume enough fruits and vegetables. Also, 20 percent of residents are daily smokers, and the same number reported heavy alcohol use. We have some of the highest rates in the province for many chronic conditions. And only three in five people in the South East LHIN said they had very good or excellent health. We need to make sure that the right services are in place to meet our population s health needs so everyone can live as healthy a life as possible. Hospital Funding Implications The ReCAP analysis makes it clear that hospitals in the South East LHIN spend more than similar hospitals in other LHINs, and under the province's health system funding reform, this will cause significant problems. This past year, hospitals in the South East LHIN experienced an initial reduction of $16.8 million in funding through the application of the province's Health Based Allocation Model (HBAM). This was as a consequence of the hospitals, collectively, performing at a higher than expected cost. Hospitals expect that the continued application of HBAM will further reduce budgets available to them in the future. It is imperative that hospitals find ways of improving service delivery resulting in improved quality, access, patient experience and lower costs. Until this happens, they will continue to face budget pressures. Health System Utilization Our analysis points to four key service areas where our LHIN seems to be underperforming or where we need to plan carefully for the future: 1. Rehabilitation services in the South East LHIN do not appear to meet the needs of our population. Currently, South East LHIN residents use inpatient rehabilitation beds less than other Ontario residents. However, with the high prevalence of certain health issues and the older and aging population in the LHIN, South East LHIN residents are expected to need more of this service. Furthermore, there are differences across the LHIN in the availability of inpatient and outpatient rehabilitation services, resulting in unequal access to these services. As an example, there is need for more inpatient rehabilitation beds in the Lanark, Leeds and Grenville area. We need to further examine the delivery of rehabilitation services across the region to ensure the service meets our population s needs. 2. Patient transitions between health care services and settings continue to be an issue in the South East LHIN. While much work has been done to make sure patients can transition smoothly from hospital to other care settings such as Long-Term Care, the number of days South East LHIN residents spend waiting in hospital for these transitions remains high. As well, wait times in the emergency department could be improved. While we are doing well compared to other parts of the province, ten percent of patients still wait more than 24 hours in the emergency department before being admitted to hospital. Finally, high demand for basic beds at certain Long-Term Care homes in the LHIN means that some residents 17

18 are waiting for a year or longer for these beds. Improving patient transitions will be one of our key priorities over the coming three years. 3. Home care services for clients with high needs must continue to meet the increasing demand for these communitybased services. The success of programs such as Home First has resulted in more frail older adults being able to leave hospital and recover safely at home. This, in combination with the projected increases in the older adult population, means that the number of high-needs clients requiring services in the community will continue to grow over the coming years. In the last six years alone, the volume of services for highneeds clients has increased by 113 percent. The South East Community Care Access Centre has already started to reduce the cost of delivering services to low- and moderate-need clients. Although other options will need to be considered, these efficiencies will help ensure that more resources are available to help with the increasing demand for high-needs client services. 4. The need for Community Support Services (CSS) has increased and will continue to grow into the future along with our aging population. To help meet this need, CSS agencies across the LHIN have worked hard to improve their efficiency and increase the volume of service they can deliver with modest funding increases. For example, the number of one-way trips to medical appointments increased by 22 percent over a three-year period, and the number of meals delivered increased by 54 percent in the same time frame. One important area of current and future need is Assisted Living arrangements. We have the smallest per capita spending in this area amongst all of the southern LHINs. Addressing this need will help ensure our frail elderly population is better supported in the community, and may also help as patients transition from hospital to community. Health Human Resource Planning Health care, like many industries, is faced with problems related to an aging workforce in this case, aging physicians. In the South East LHIN, there are a number of medical specialties with few younger practitioners. General Medicine, Geriatric Medicine, Hematology, Medical Oncology, Otolaryngology, Psychiatry, Respirology, Urology and Vascular Surgery were all identified with a noticeable number of physicians over the age of 50. In the not too distant future, this could have a significant impact on the provision of associated services, and the amount of time that patients have to wait for those services. 18

19 Health Care Tomorrow Putting Patients First The Plan As noted at the beginning of this report, the South East LHIN has identified three overarching goals that will guide us over the coming three years, as we work to realize our vision of Achieving better health through innovative, proactive, integrated and accessible quality health care in collaboration with an informed and involved community. These goals flowed logically from what we heard and learned during our engagement, as well as from our analysis of the current health care landscape in the South East. They reflect our thinking about health care, as well as the provincial priorities of which we always remain mindful. Above all else, we believe these goals put patients first. The following section of our IHSP explains the various initiatives and programs that will be used to achieve our goals. Goals of IHSP 4 Achieving better patient outcomes through more equitable access to quality care When we talk about equity in health care, we are referring to a fair distribution of resources, based on need as opposed to quantity. It is important to remember that we are not talking about equality. It is not necessary in health care to ensure that all patients receive the same number of services, or even the same services. What is necessary is to ensure that all patients can receive the services that they require. If we want to ensure equitable access to care, we need to consider and address the various barriers that exist, whether they be financial, geographic or cultural. Improving the health care experience through an integrated and patient-centred continuum of care Local Health Integration Networks, as the name implies, were created with a mandate to integrate health care. The past 10 years have seen tremendous progress in this regard. We have pressed forward with numerous integrations that have helped create more seamless care, but we know that there remains much more work to be done. Our third IHSP tackled that work head on, addressing what we call the "integration imperative." Simply put, it was an acknowledgement that everything we want to accomplish in health care depends on the vast array of providers and organizations working better together, sharing information, and wrapping the system around the needs of the patient. Integration remains imperative today. We are committed to building an integrated and sustainable local health care system that supports healthy communities with a patient-centred approached that is both timely and responsive. Working with partners towards the achievement of an accountable, high performing health care system The key notion here is innovation. If we want a sustainable and better performing health care system, we must learn to do things differently. We must embrace new ideas. We must identify needs, and take an innovative approach to meeting them. We also know that if we're going to be successful, we must work as a team. We share our mission of planning integrated health services for the residents of the South East LHIN with a wide variety of health services providers, stakeholders and communities. Our work is to foster a collaborative culture where all partners are involved and have a voice in the decisions that will affect the health care system in our region. We need to better learn about and understand each other s roles and how we can mutually support one another in an integrated system. 19

20 The appendices accompanying this report provide more detail about many of these initiatives. Over the course of three years, it is entirely possible that we may have to change our thinking about how to achieve this work. Such is the nature of strategic planning. What will not change, however, are the goals we have set out for ourselves. What will not change is the vision that guides us. And what will not change, ever, is our commitment to putting patients first. An aging population and patients with an increasing number of chronic diseases Fiscal constraints on all government funded health care programs, especially hospitals At the outset, the Hospitals Services Project identified a clear need for involvement of patients and residents in the overall process. Consequently, a Regional Patient Advisory Council (RPAC) was formed to bring together patients and family members to discuss and test ideas related to the future of hospital services across the region. The Council consists of 24 representatives from the South East, including Francophone representation. The members were selected from diverse backgrounds and locations The RPAC has passionately communicated that status quo is not an option for hospitals in the South East LHIN and change is necessary both from a financial perspective but most importantly, from a patient experience perspective. Hospital Services Project The Hospital Services Project was launched in It is a planning collaboration between Brockville General Hospital, Hotel Dieu Hospital, Lennox and Addington County General Hospital, Kingston General Hospital, Perth Smiths Falls District Hospital, Providence Care and Quinte Healthcare Corporation, as well as the South East Community Care Access Centre (CCAC), the Queen s University Faculty of Health Sciences and the South East Local Health Integration Network. These partners share a common commitment to support a sustainable acute care system in the face of significant challenges facing hospitals in our region. Those include: within the South East LHIN. The contributions of the RPAC members to this project cannot be overstated. They provided an invaluable perspective on the patient experience, including the current challenges faced by patients within the system, as well as personal insights into how the system can be improved. The first phase of the Hospital Services project focused on engagement, with a wide range of system stakeholders working to establish a vision and identify opportunities for improvement. That engagement process resulted in a report that was submitted to all hospital and LHIN Boards in June The report identified 10 opportunities that the hospitals and their partners including this LHIN must make to build a sustainable system of integrated hospital care. 20

21 The first seven opportunities identified are the responsibility of the hospitals: Develop a regional shared service to support finance, human resources, facilities/support services and information services Develop a regional laboratory system to serve all the hospitals in the South East LHIN. Develop a regional diagnostic imaging system to serve all the hospitals in the South East LHIN Develop a regional pharmacy system to serve all the hospitals in the South East LHIN Develop a regional system of care for highly specialized services Develop a regional system of care for urgent/emergent care to focus on process improvement and excellence that is evidence-based through an emergency department/urgent care community of practice Expand/standardize older adults care strategies across all South East LHIN hospitals, including primary, secondary and tertiary care, with regional specialization of behavioral supports and geriatric medicine/inter-professional resources Improve service delivery and the integration of care for complex patients/frail elderly through the development of automated and integrated coordinated care plans Moving forward, the Hospital Services Project will continue to explore the roles health care providers should adopt to improve access to high quality care within the current and projected financial environments. These roles will include new accountabilities at a system level including the integration of services across the region. The subsequent three opportunities require partnership and collaboration with community partners. The South East LHIN is committed to moving forward in these areas: Build capacity in community support services and optimize community resources to prevent unnecessary use of hospitals Develop an emergency department (ED) avoidance strategy that includes enhanced Emergency Medical Services (EMS) Services and care at home and in the community 21

22 Addictions and Mental Health Redesign During consultations for our last IHSP, we heard concerns from residents living in the South East LHIN about the delivery of mental health and addiction services in this region. Those concerns included: Duplication of services Multiple story telling or repetitive assessments Hurdles in transitioning between providers Difficulty in accessing services Insufficient volume of services to satisfy demand Stigma as a barrier to access services and other health services The concerns of our residents immediately became our concerns. By working with 22 addictions and mental health service providers, as well as patients and family users, we undertook a process to redesign a system that was clearly not serving the residents of the south east region as well as it could. Three years later, implementation is underway the journey towards the "Ideal Individual Experience" has begun. Ideal Individual Experience The Ideal Individual Experience is both a vision and a goal. It is what our system must provide for clients and their families. We knew that in order to redesign the system, we first needed an end state vision of the client journey throughout his or her life and throughout the continuum of care. We developed this vision with input from clients, their families and from providers, and it has been endorsed by providers across the region. The adoption of this Ideal Individual Experience across the region will not only help establish a South East LHIN Addictions and Mental Health Redesign - Individual s Experience Housing Primary Care AMH Services and Support Immediate Access and Re-entry Employment Police & Justice Seniors Services Children & Youth Central Service Access Developmental Services Addictions & Mental Health Municipal AMH Services and Supports I will work with you to support you along your journey I will reach out to you in your community (i.e. workplace, school) to work with you to bring you into the AMH system I will work with you to connect you to the right services and supports Individual AMH Role Family & Friends Screening and brief intervention, support and relapse management Short-term clinical intervention, support and relapse management Longer-term treatment, support and rehabilitation Promotion/Prevention Specialized treatment, rehabilitation and associated supports, and relapse management 22