ONE CLIENT ONE TEAM. Advancing an Integrated System of Care Driving Transformation. Stacey Daub Chief Executive Officer

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1 ONE CLIENT ONE TEAM Advancing an Integrated System of Care Driving Transformation Stacey Daub Chief Executive Officer Toronto Central Community Care Access Centre Jodeme Goldhar Lead, Health System Integration for Complex Population and Primary Care Toronto Central Community Care Access Centre

2 What have we learned from leading strategy and changing delivery models to ensure integration? How do we continue to advance an integrated system of care for populations with complex needs?

3 A Debate About Reform and Which Road is Best Steadfast Despite Political Context Structural Reform? Layered On? Point of Care Functional Integration

4 Incremental Build Maturity Reached Over Time

5 Flip Our Thinking

6 Point of Care Integration

7 Our Aim Supporting populations with complex needs with better care at home in their communities, utilizing existing resources Our Approach: Creating One Team For the client/family Seamless care One team approach For the providers One team approach Built around client and family needs

8 Delivering integrated care requires integrated action within 3 key domains 1 3 At home, in the community 2 When necessary, the transition Acute, CCC or Rehab

9 Framework for Integration

10 Multiple Integration Initiatives Aim: One client, One team

11 Point of Care Integration Virtual Ward Kids with Medical Complexity

12 Palliative Care Point of Care Integration ICCP Older Adults

13 Point of Care Integration Integrated Home Based Primary Care (IHBPC) IMPACT Plus Integrated Community Care Team (ICCT) Hospitals Specialists Primary Care Allied Health Professionals Community Service Providers Long Term Care CCACs

14 Stop, Take Stock and Reflect What Have We Learned?

15 Deliberately being open Deliberately responding differently

16 I meet with my ICCP care coordinator every two weeks or so She speaks with my doctor. This is the first time the doctor ever came to my home. Client The Coordinator works with other professionals to collect information, so I just have one person to contact. It saves me time. Primary Care Physician Client and Family Experience Integrated Care Team The cross sector care we now provide is improving the patient experience as witnessed by shorter lengths of stay and improved patient satisfaction scores within these patient groups. Acute Care Partner If [Care Coordinator] had not helped arrange a specialist appointment for that patient, it would not have happened. Without her follow up, that patient would have gone to the ER. Primary Care Physician

17 Balance Approach to Evaluation Mixed Methods Research: Qualitative Longitudinal Research Developmental Research Secondary Data Analysis Case Flows & Client Trajectories Qualitative & Quantitative: Client and Caregiver surveys Stakeholder Interviews Retrospective Analysis Outcome & Process Metrics Qualitative: Quality Improvement 100 Process Changes PDSA Cycles Small Tests of Change

18 Process and Outcome Measures (Quantitative Information: Retrospective Cohort Analysis)

19 Walk a Mile or Two How can we work together differently? What do I need to do differently? How can we understand and experience different perspectives? How can we all work together on what is most important to the client/family?

20 Opposing Notions/ Tensions Integrated Solutions

21 Demonstrating Value Less Talk And More Delivery

22 Do not wait for complex solutions

23 There is no script Lead Through Ambiguity

24 Relationship Will Determine Success Trust Will Determine Success Safe Shared Accountability

25 Leadership Leaderful Greater Emphasis on EMOTIONAL INTELLIGENCE

26 Lift Up, Look out and Honour the Past

27 Policy Considerations How do we design our system to deliver the best value for clients and their families so that they experience the multiple parts of the system as ONE TEAM? How do we design incentives to ensure: capacity to deliver high performing home and community care? providers work in an integrated model? How do we look at accountability models so we move from organizational or sector accountabilities to integrated accountabilities tied to the client/family experience?

28 For more information, please contact: Stacey Daub Chief Executive Officer ont.ca Jodeme Goldhar Lead, Health System Integration for Complex Population and Primary Care ont.ca