RESPONSE TO PATIENTS FIRST: A PROPOSAL TO STRENGTHEN PATIENT-CENTRED CARE IN ONTARIO

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1 February 29, 2016 The Honourable Eric Hoskins Minister of Health and Long-Term Care 10 th Floor, Hepburn Block 80 Grosvenor Street Toronto, Ontario M7A 2C4 Forwarded by and submitted to Dear Minister, RESPONSE TO PATIENTS FIRST: A PROPOSAL TO STRENGTHEN PATIENT-CENTRED CARE IN ONTARIO The Ontario Society of Occupational Therapists is pleased to have opportunity to review and provide comment on your discussion paper, Patients First: a proposal to strengthen patientcentred health care in Ontario. We applaud the bold commitment to transform our health care system to achieve greater efficiencies and, most importantly, better health outcomes for Ontarians. Our comments will confer both agreement with the necessity for change and our perspectives on the proposals circulated with a goal to inform your ongoing planning and decision-making with the perspectives of Ontario s occupational therapists. The Ontario Society of Occupational Therapists (OSOT) is the professional association of over 4100 occupational therapists and student occupational therapists who work across the province, across the lifespan and across the current sectors of our health care system primary care, acute care, rehabilitation, community care, long-term care. Occupational therapists (OTs) work with clients who experience barriers to managing day to day living skills as result of a health issue such as illness, injury, chronic disease, mental illness, learning problems, aging. OTs work with their clients to minimize barriers, finding solutions that enable function and participation in occupations that are meaningful for them, including such occupations as self care, managing at home, school or work, engaging socially, caring for one s family and/or home. 1

2 Occupational therapists are important resources to a health care system focused on enabling people to maintain health and safe independence so as to maximize their quality of life and minimize their need or dependence on the health care system. But OTs are also critical resources to patients and the health care system when illness, injury, mental health problems, etc. disrupt lives and ability to manage. Enabling people to restore, regain function or adapt to new functional abilities ensures that patients are able to return home from hospital, to manage with less dependence on caregivers and long-term care, to regain quality of life and engagement in their communities. As we understand the goals for and pressures on our health care system, we believe that the profession of occupational therapy has much to contribute. General Comments OSOT supports the articulated goals of the proposed change. Our members experiences as front line clinicians across sectors of our current system would echo the evidence provided in the document identifying a need for change. As professionals often working with clients as they transition from one sector of the system to another, OTs have long advocated for increased system integration. We offer the following general comments for consideration; We see the potential for proposed changes to be transformative and assert that as a province we need to be bold, to take opportunity to transform and reframe and not just tinker with structure. Many of the recommendations speak to transformative potential...change that could affect how people think about and experience their health care system. Many recommendations speak to defining a new system for health...and this reframing of how we see our system from a health care system towards a system for health is supported. In a system for health, medical attention is important but the current medical model needs to be replaced with a more integrative focus on health and wellness, interprofessional collaboration and integration of systems that may lie outside health care but that influence health and well-being. There need to be effective ways to integrate with other Ministries to assure integrated attention to well recognized broad determinants of health such as economic status, housing, etc. Occupational therapists propose that there is value in reframing how Ontarians see their health care system and what they expect from it. The opportunity to build in commitments to restorative/enabling approaches across an integrated system should be considered. This helps frame a person s role in their own health and recovery and moves away from the current focus on care. Sustainability will require that Ontarians effectively 2

3 share responsibility for their health and recovery and the maintenance of health and function as they age. An increased focus on function, restoration and enabling also directs health care providers to focus on functional outcomes. Proposed changes are driven by a challenge to create a system that achieves goals and is sustainable for the future, recognizing the changing demographic and health profile of Ontarians. We recognize the need to find efficiencies and potential for cost saving and concur that reframing the focus of our system on maintaining health and well-being, with an emphasis on primary care and supporting people to make healthy living choices informed by an integrated public health focus is critical to sustainability. This coupled with increased integration of public health service and planning is a sound investment. The commitment to integrate mental health services more effectively into other health services is critical. Mainstreaming mental health services into the health care system is an overdue step towards addressing stigma. Increasingly, mental health issues are comorbidities of other health problems. Patients dealing with physical conditions may be struggling to cope with their illness, change in physical status or pain. They may not have a formal psychiatric diagnosis but would benefit from increased access to mental health supports. While cost-savings and system efficiencies must be found, we urge government s attention to the need to effectively fund change and the change management process. Ontario s current health care system is burdened, health care providers are over-stretched: to effect real change we need to invest in the process to achieve the outcomes that will result in long-term savings Regionalized health service planning is valued but this needs to be embraced in the context of clear province-wide guidelines that assure consistent/equitable access to service. How services are delivered locally/regionally can vary but Ontarians need to feel that they have access to the same core services regardless of where they live, the language they speak, the culture they celebrate, etc. Determining core service elements and standards that Ontarians can expect to be able to access is foundational to assuring equity. IT and electronic health records that are fully integrated across the health care continuum are paramount to an effectively integrated system of care. This requires leadership and investment. For example, the ability of an occupational therapist in a hospital setting to have direct and timely accessibility to the clinical documentation of the community care (Primary Care & Post-Discharge) OT, and vice versa would enable significantly more 3

4 effective transitions from hospital to home. Ontario s system for health needs to be senior friendly now and into the future. Navigating the system needs to be easy, friendly and supported. Family and caregivers need to be recognized as key elements of the senior s health care experience. Ontario s hospitals, community health services and communities in general need to be senior friendly supporting physical, cognitive and social determinants of health and wellness across the continuum. Occupational therapists bring expertise and experience to these foci. Ontario s system for health can use occupational therapists far more effectively. The profession of occupational therapy is currently an under-utilized resource, particularly in the community where access to OT can assist people to live safely and independently with chronic disease, prevent hospital admissions and support family and caregivers to manage and support their loved one s abilities. We need to ensure that planners and service providers think about the value of a rehab/restorative approach across the health care system continuum. OT used only for "rehab" is valuable but missing the opportunity to capitalize on an investment that can truly save money - keeping people out of hospital and/or major personal support or long-term care. Interprofessional rehab teams grounded in the community (but not necessarily tied to CCAC) could be an efficient way to provide resource to primary care physicians' clients, people being discharged from hospital and even those living in LTCHs. There would need to be sufficient resource to enable development of expertise - e.g. therapists that address seniors' needs, stroke rehab, dementia care, hip/knee replacements, etc. Addressing Identified Inequities... Occupational therapists concur that inequities of access to services exist particularly amongst populations of indigenous peoples, Franco-Ontarians and other cultural groups and those experiencing mental health or addiction challenges. Increasingly the family and caregiver need to be considered as important components of how we define patient. While attention to caregiver needs is gaining more attention, we urge identification of families and caregivers as an additional group for whom services are not consistently delivered. We also note inequities of access to consistent health services across regions of the province. In the current CCAC system, patients access to a variety of services, including occupational therapy can vary greatly, in some cases services may be available through some CCACs but not 4

5 at all in others. OSOT members express concern when OT is accessible in one service delivery model in one CCAC but not in another. Furthermore, many CCAC clients or would be clients are affected by the variable funding of services such as therapy throughout the fiscal year. It is not uncommon for access to therapy services to be reduced or withdrawn in the CCAC s third or fourth quarter. Health professions need to develop capacity to address the needs of populations that have been marginalized. As a profession we also struggle to assure that we are best positioned to serve these populations and continue to explore how best we can serve the depth of diversity in Ontario. Occupational therapy s focus is extremely client-centred and cultural understanding and sensitivity is critical to meaningful outcomes. Our profession needs to address how we continue to promote diversity within the profession, amongst applicants to the profession and to promote graduate practice across the breadth of the province. A provincial strategy to address the human health resource needs to serve identified gaps is important. That said, this needs to be complemented with appropriate job opportunity to ensure graduates stay in the province. (For example, currently our province has a francophone occupational therapy program from which many graduates re-locate to different parts of the country). Support for the 4 Pillars of the Proposal... Patients First identifies 4 pillars of a proposal for change. OSOT supports these four components of a change agenda. While the proposal deals with structural change, the Society urges consideration of the need to critically review what health services will be delivered and how in a newly structured system. Integration of primary care and public health services into the planning and oversight functions of the LHIN, creating smaller sub-lhins, and transferring responsibility for home and community care service management and delivery to the LHIN are massive changes in a system. Ensuring that these changes include critical review of the substance of care that each component of a newly integrated system provides is critical to ensure that existing problems don t simply transfer to a different structure. This was a very strong recommendation of the Expert Group on Home & Community Care. We are concerned that the work on the Roadmap to Strengthen Home and Community Care may not be completed before these new changes are engaged. 5

6 RECOMMENDATION #1: To provide care that is more integrated and responsive to local needs make LHINs responsible and accountable for all health service planning and performance. Identify smaller regions as part of each LHIN to be the focal point for local planning and service management and delivery. OSOT extends a resounding YES to more effective system integration. Occupational therapy s focus often places OTs with clients at the transition points of today s existing silos. OTs witness the compromised outcomes, patient experience and cost-efficiencies that result from lack of fulsome collaboration and seamless integration of sectors. System navigation is problematic now...integration proposes to ease this but patients and their families will still require supports. System navigation housed in the primary care system would appear to best place navigators to support Ontarians through their life experience of the health care system. The introduction of smaller regions as part of each LHIN to be responsible for local planning and service management poses, in our opinion, both opportunities and risks. We offer the following comments: We recognize that regional differences and service delivery structures dictate that no one integrated team structure is likely going to work everywhere. The proposal of SubLHINs introduces potential for maximizing collaborative, engaged integration. While the notion of LHIN Sub-Regions would support the potential for formal and informal networks to function more effectively, we worry about the potential administrative overhead of the proposed LHIN Sub-Regions. A structure that imposes additional administrative/bureaucratic layering that has the potential to divert funding from direct client services is concerning. The more local service delivery models that exist may increase the potential for disparity from region to region. The notion of Sub-LHINs magnifies a need for clear provincial standards for core services. Access to specialty services needs to be addressed in a model that embraces SubLHINs in which there may not be equitable access to specialty hospitals, specialist physicians, specialized rehabilitation services, etc. LHINs would need to monitor and identify means through which LHIN constituents access these services outside of the SubLHIN or LHIN. 6

7 While stakeholder engagement is critical to successful local health planning, the number of smaller planning bodies may pose a barrier to the participation of some stakeholders such as community service providers that service many Sub-LHINs, advocacy organizations (e.g. Alzheimer s Society, Arthritis Society), professional associations, etc., simply because of the volume demand on their representation and input. How do we support care providers in a more integrated care environment? Integrated service delivery requires engagement of stakeholders in planning/development of local solutions. Integration may require flexibility and trust in re-allocating who does what and where. Clear philosophical underpinnings need to be developed to ensure that all providers are focused to the same way, building to clearly understood common goals. OSOT would advocate for inclusion of a more enabling, restorative approach to the focus of service delivery at every point in the health system to be focused on restoring function, enabling the patient to re-engage in the activity of the their life, to be as independent as possible. Engagement of front-line clinicians in consultation processes is critical when service provider organizations are negotiating integration of who does what...understanding the frontline experience will be critical to ensuring that new models of integration are most successful Clear provincial standards/service expectations will support consistency and equity across smaller regional planning units and provide clear guidance to health service providers. What do LHINs need to succeed in their expanded role? Significant change management process need to manage change implementation and fund it well to achieve buy-in and efficient/effective adoption Clear provincial standards/service expectations will support consistency and equity across smaller regional planning units and provide clear guidance to health service providers Authority to make integration decisions and to fund accordingly 7

8 IT solutions to enable integration of various electronic health record systems System navigation will need to be addressed early on to assure success. What other local organizations can be engaged to ensure patients are receiving the care they need when they need it? Engagement of the private sector is likely critical to support a truly integrated patient experience e.g. retirement homes, pharmacies There may be potential for integration/linkages with local health and fitness organizations whose focus would complement a wholistic approach to health Local community care agencies would be presumably be available through the LHIN What other opportunities for bundling or integrating funding between hospitals, community care, primary care and possible other sectors should be explored? Funding/service delivery options that may allow increased access to resources such as rehabilitation should be explored. For example, establishing regional rehabilitation teams (occupational therapists, physiotherapists, speech language pathologists, etc.) that may serve the integrated system in the community primary care, out-patient services, home based services, retirement homes, long-term care, etc. may enable increased resource and expertise that is shared as opposed to very limited resources available if individual service providers secure their own personnel. Rehabilitation is a service focus that transcends all sectors and is, in itself, a process, not a procedure so is often not complete in any one sector of the health system. A integrated approach to the deliver of rehabilitation would help bring to life a focus on restorative or rehabilitative care that would help the system focus on functional outcomes What areas of performance should be highlighted through public reporting to drive improvement in the system? Evaluation and monitoring of outcomes is critical. There is a need to measure clinical outcomes such as function, not just performance measures such as access and utilization Should LHINs be renamed? The name Local Health Integration Network (LHIN) doesn t have a lot of meaning for the average consumer. The Society would recommend that the values and philosophy of the 8

9 system be defined first and then consideration of whether the current name still fits could best be determined. The name should convey what they system is meant to be. Health Service Network focuses more on health than care and may begin to shape public attitude/opinion around the focus of maintaining health. RECOMMENDATION #2: LHINs in partnership with local clinical leaders would take responsibility for primary care planning and performance management. Set out clearly the principles for successful clinical change, including engagement of clinical leaders. OSOT supports the integration of primary care with other health care services and unifying primary care planning under the LHINs to facilitate improved access to interprofessional primary care across the province. We note with support the recommendations to provide interprofessional primary care teams across the province. We urge a commitment to a fulsome definition of interprofessional as is evidenced in Community Health Centres or many Family Health Teams. These deliver cost efficient access to a broad range of health professionals who can address client needs, relieving the physician to enable their attention to those patients with real medical needs or to expand the breath of their practice. We offer the following comments on this recommendation: Successful integration of primary care under the LHINs may be dependent upon transformation of other sectors. For example, currently patients of physicians working in FHTs or CHCs have access to interprofessional teams (to a limited extent), however, patients of the the vast majority of GPs do not. This is primarily because the CCACs have such restrictive eligibility criteria and there is no other option for access to many services such as OT, SLP, Dietetics, etc. in the community. The Price Report proposal speaks to Patient Care Groups that are supported by interprofessional teams. As mentioned above, exploration of how rehabilitation/restorative services could be provided across the community sector (including primary) care is needed. Current levels of funding and integration of OT into FHTs is under-resourced. While OTs are demonstrating value to the patients and teams they serve the limits of their service curtail the value they can add. To date, OTs have been integrated into only approximately 25% of Family Health Teams. 9

10 OSOT is not in a position to evaluate the impact of this change on family physicians, however, we would guess that if physicians could see their patients have access to more services that support their health, ability to age at home, manage mental health issues, etc. there would be support for this enhanced access to service. Ontarians may well identify their primary care provider as the first stop for system information and navigation. Thoughtful consideration of where to place system navigation/coordinator supports is needed to determine where best to place this service. Family physicians themselves need supports in guiding their patients to and through other aspects of the system. Well integrated electronic health records that enable integrated communication across the continuum of health care are critical to effectively engage primary care teams with other components of the system. A health technology strategy targeted to explore, identify and share best practices in technology based health service delivery would be a valuable investment to support this RECOMMENDATION #3: Strengthen accountability and integration of home and community care. Transfer direct responsibility for service management and delivery from the CCACs to the LHINs. Ontario s home care system needs fixing. OSOT supports the recommendation to strengthen accountability and integration of home and community care. We offer the following comments on the recommendation that the LHIN assume direct responsibility for service management and delivery: There is concern that transferring responsibility for direct service management of current CCAC services to the LHIN will simply create a different bureaucratic structure. More significant reform is required. OSOT questions whether the requirement of LHINs to be a service provider of one part of a multi-part system they oversee, fund and evaluate will create a conflict of interest or the potential of perceived conflict of interest amongst other system stakeholders. This situation is not healthy for collaborative integration success. 10

11 OSOT is concerned that major structural changes for CCAC services are being considered before the formative work, called for by the Home and Community Care Expert Panel, has been completed. The vision, values and Levels of Care Framework work that is proposed in the Roadmap to Strengthen Home and Community Care have not been addressed to date. There is a need to critically review the services provided by CCACs and determine reasonable core expectations that can be delivered across the province. Therapy services, including occupational therapy, have been minimized over the past decades as the more acute client requires nursing care in order to be able to be discharged home earlier. If therapy isn t happening in the hospital and it s not happening in the community, where does the patient have opportunity to regain/restore function and ability to get on with their life? Determining what services are to be offered by home care will assist the LHINs and other stakeholder providers to determine where those services that are not provided by the LHIN are accessed. While occupational therapists have long advocated for increased access to OT services in the CCACs, the more critical component of our advocacy is to identify the scarcity of access to OT services in the community. Occupational therapy has much to offer to enable clients to retain or regain function and to manage to live independently or with as minimal support as safely possible in their own homes. This relieves burdens on caregivers and on the public system which provides caregiving support. At this time of transformative change, there is an important opportunity to look at where and how OT services are delivered to achieve maximum benefit. Recent transfer of low needs clients from the CCAC to the Community Support Services system has been concerning for occupational therapists. While nursing care needs are reduced for these clients and personal support needs can be managed by the community support agencies, these agencies do not have access to therapy services, such as OT. Regretfully, it is sometimes these lower need clients that have the most potential to benefit from therapy services. The decision to transfer these clients to community support did not involve consultation with stakeholders such as therapy providers. If services are transferred to the LHIN to deliver, the time is opportune to review access to services such as OT in the community support component of the system. While reassurances have been offered to current service provider agencies who hold contracts with the CCACs, the uncertainty of the job market for front line workers in the 11

12 community sector is currently stressful. It is unclear how the human resource transfers will be undertaken in the short and long term. There is both a need to promote retention in the community sector and to attract professionals to work in the sector. Compensation has historically been lower, fluctuations of workload result in inconsistent earnings, limitations on visits which curtail ability to achieve goals with clients, etc. have all contributed to a skeptical and frustrated community sector workforce. The need to protect and attract frontline expertise is critical to the successful transfer of services to the LHIN. It is unclear what the implications of unionization in the CCAC sector will have on human resource reallocation. RECOMMENDATION #4 - Integrate population and public health planning with other health services. Formalize linkages between LHINs and public health units. OSOT supports integration of population and public health planning with other health services. This increases opportunity and potential for health and wellness focused orientation of our health system and supports the recommendation made previously that we consider development of a system for health rather than a health care system. The current positioning and role of public health in relation to the formal health care system has resulted in limited knowledge and use of the resources and knowledge of the public health system. Thank you for the opportunity to contribute to your consultation. Please do not hesitate to contact the Society should you have need to clarify or further explore any of our points. Sincerely, Christie Brenchley Executive Director Ontario Society of Occupational Therapists 55 Eglinton Ave. E., Suite 210, Toronto, Ontario M4P 1G osot@osot.on.ca 12