Integration Priority Report

Transcription

LHIN Integration Priority Opportunities
South East Ontario
LHIN 10
February 21, 2005
Table of Contents
A.
PATIENT CARE INTEGRATION OPPORTUNITIES .............................................................................................................. 4
1.
2.
3.
4.
5.
B.
ADDICTION SERVICES & MENTAL HEALTH SERVICES MUST BE INTEGRATED THROUGHOUT THE CONTINUUM OF CARE ............... 4
INNOVATION IN RURAL HEALTH .................................................................................................................................................... 10
URGENT MEDICAL TRANSPORT – TIMELY AND DELIBERATE ......................................................................................................... 11
CLIENT/PATIENT NAVIGATION AT TRANSITIONS ACROSS THE CONTINUUM OF CARE/HEALTH CARE JOURNEY ............................ 14
INTEGRATED PALLIATIVE CARE SERVICES PRIORITY..................................................................................................................... 18
ADMIN SUPPORT SERVICES INTEGRATION OPPORTUNITIES.................................................................................... 21
6. E-RECORD ..................................................................................................................................................................................... 21
7. NURSE PRACTITIONERS: IMPROVING INTEGRATION IN ALL SECTORS ............................................................................................. 24
8. RURAL COMMUNITY PARTNERSHIPS/VOLUNTEERS ....................................................................................................................... 28
9. PROVIDING MEANINGFUL GEOGRAPHIC INPUT TO LHIN PLANNING AND IMPLEMENTATION ........................................................ 30
10 ENSURING BETTER SYSTEM NAVIGATION FOR CLIENTS AT THE COMMUNITY LEVEL .................................................................... 34
C.
PRIORITY SETTING OF NEW INTEGRATION OPPORTUNITY ...................................................................................... 36
D.
CAPTURING UNIQUE CHARACTERISTICS OF EACH LHIN ........................................................................................... 43
E.
TRANSFORMATIONAL THINKING AND THE PROCESS.................................................................................................. 48
F.
REMAINING OPPORTUNITIES IDENTIFIED ....................................................................................................................... 50
1. DISTRICT WIDE PRIMARY, SECONDARY, AND TERTIARY MEDICAL MANPOWER PLAN ................................................................. 50
2. PHARMACY CARE .......................................................................................................................................................................... 52
3. PROFESSIONAL PRACTICE .............................................................................................................................................................. 53
4. HUMAN RESOURCES PLANNING, REMUNERATION, WORKING CONDITIONS................................................................................... 55
5. CHRONIC DISEASE PREVENTION AND MANAGEMENT – INTEGRATED MULTIDISCIPLINARY APPROACH ........................................ 56
6. BUILD A SINGLE SYSTEM FOR INTEGRATED REGIONAL SERVICE CAPACITY DECISION MAKING ................................................... 58
7. INTEGRATION OF COMMUNITY SUPPORT SERVICES ....................................................................................................................... 60
8. IMPROVING ACCESS TO CANCER SERVICES ACROSS THE CONTINUUM OF CARE THROUGH AN INTEGRATED ACCESS MANAGEMENT
SYSTEM.................................................................................................................................................................................................. 62
9. SHARING ADMINISTRATION RESOURCES........................................................................................................................................ 64
10.
LONG-TERM CARE – IT’S YOUR FUTURE ................................................................................................................................... 66
11.
DECREASING DUPLICATION OF COSTS ASSOCIATED WITH DELIVERY OF HEALTH SERVICES..................................................... 68
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12.
13.
14.
15.
16.
17.
18.
PLANNING AND REALIGNING HEALTH SERVICES BASED ON A POPULATION HEALTH MODEL ................................................... 70
SENIOR FRIENDLY FOCUS TO ACCESSING “GERIATRIC REHABILITATION PROCESSES”.............................................................. 72
MOVING CLINICAL PRACTICES INTO NON-CLINICAL LOCATIONS .............................................................................................. 74
ALL LHINS SHOULD BE ACADEMIC ORGANIZATIONS ................................................................................................................. 75
HOW CAN LHINS CONTRIBUTE TO FAMILY HEALTH TEAM DEVELOPMENT AND VICE VERSA ................................................... 77
STRATEGIES FOR IMPROVING ACCESS TO FRENCH LANGUAGE SERVICES .................................................................................. 79
HOSPITAL MANAGEMENT INTEGRATION .................................................................................................................................... 80
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A. Patient Care Integration Opportunities
1. Addiction Services & Mental Health Services Must be Integrated Throughout the Continuum
of Care
Description of Patient Care/Services Integration Initiative
Title of patient care/service initiative:
Type of integration (more than one box can
be checked)
Addiction services and mental health services must be integrated throughout
the continuum of care
Existing or new initiative?
Initiated/existing integration activity*
New integration opportunity
*Note: initiated/existing activities do not
need to be confined within LHIN
boundaries
Horizontal
Vertical
Other, describe:
Intersectoral
List of partners involved:
Mental health services and addiction services in the southeast district; providers of other
health and human services that impact on or are impacted by mental health and/or addiction
issues; district and local planning groups, eg. Mental Health Alliance of SEO and Alliance of
Southeastern Ontario Addiction Services.
See Appendix A.1 for list of participants
Please briefly describe the initiative:
It is proposed that addiction services and mental health services be integrated throughout the continuum in the health care system in SEO
LHIN area. Citizens deserve high quality, coordinated services located in their communities that address all of their needs in a seamless
system. Mental health and addiction problems do not exist in isolation from other health and social problems (e.g. housing, income,
education, social isolation and employment). The benefits of early, accessible, timely and appropriate interventions within a recovery
based philosophy provided in a complete continuum of health care by equal, collaborative partners cannot be over stated. The approach is
client directed, comprehensive, community based and cost effective.
If this is an initiated/existing activity…
What is the current status?
Incidence of addiction and mental health problems:
• 10% of Canadians report symptoms consistent with alcohol or drug dependence, 5% report problem or high-risk gambling
behavior and 50% report problems related to someone else’s drinking.
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20% of Canadians will experience a mental illness in their lifetime and 1 in 8 Canadians will be hospitalized for mental illness at
least once in their lives, more than are hospitalized for cancer or heart disease.
• 50% of the above segments of the population are estimated to have concurrent disorders (co-occurring addiction and mental
health problems) and, in addition to the aforementioned health problems, they also experience poor treatment outcomes, high
rates of relapse, suicide and homelessness.
•
Health, economic and social costs of mental health problems and addiction problems:
• Mental illness and alcohol and illicit drug abuse accounted for $13 billion in lost productivity due to illness and premature
death, and $10.2 billion in direct health care costs last year. Law enforcement costs related to substance abuse were another
$1.7 billion and while costs are unknown re mental health problems it may be speculated that is may equal or exceed that
amount.
• People with serious mental illness have higher rates of grave medical illnesses and premature death than the general population
and depression will become over the next 20 years the leading cause of workdays lost through disability and premature death.
• Heavy alcohol use raises blood pressure and increases risk of stroke, heart failure and liver, throat, breast and other cancers
and alcoholic liver disease is a major cause of illness and death in North America.
• Approximately one million Canadians are directly affected by problems related to their gambling and they are more likely to
experience physical and emotional health problems. Costs related to loss of work, court costs and treatment range from
$20,000 to $56,000 per person.
• 90% of suicide victims have a diagnosable mental illness or substance use disorder.
• Persons who experience long untreated psychotic episodes show greater evidence of brain damage versus those who
experience shorter more efficiently treated episodes.
• Significant declines in the use of health services are noted 2 years following treatment for substance abuse and between $4 $12 in long-term societal, economic and medical costs is saved for each dollar spent on the treatment of alcohol use disorders.
• Child and adolescent mental health disorders frequently persist into adulthood and lead to a downward spiral of school failure,
poor employment opportunities and poverty. No other set of illnesses so seriously damages so many children.
• Addiction and mental illness account for the greatest degree of disability worldwide.
Why is it a priority to integrate mental health and addiction services throughout the continuum of client health care?
• Planning reflects that mental health and addictions are logical but distinct partners with many shared clients and issues: further
integration with other health partners is an investment in population health and well-being.
• Despite the fact that credible planning documents commissioned by MOHLTC detail the prevalence and impact of addiction and
mental health problems and demonstrate the need to prioritize such problems, mental health and addiction services are
marginalized within the health care system. Service gaps and waiting lists for these services are no less important than other
health care priorities.
• The substantial impact of addiction and mental health problems on other health areas demands that the full continuum of
health care is able to recognize those with problems and those at risk and intervene more effectively than now happens.
• Identifying mental health and addiction issues as health care priorities significantly reduces the stigma associated with these
problems by giving them the same value as other sectors in the continuum.
• People with mental health and/or addiction problems (including problem gambling) comprise a significant proportion of the
population of Ontario and these problems represent a tremendous burden for those individuals, their families, the community
and the health care system.
• The needs of transitional age, children, youth, older persons and other populations (by age and specialization) are not
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•
•
•
•
•
•
•
•
recognized or adequately addressed in the current systems.
The funding crisis in the addiction treatment system in particular and in community mental health services in general greatly
inhibits the delivery of proven effective treatments/interventions.
The vast wealth of knowledge and expertise in the addiction and mental health systems of consumer, survivor, family, and peer
support groups and individuals are undervalued by the general health care system and require legitimacy and financial support.
The administrative infrastructure of community mental health agencies and addiction agencies has been eroded and weakened
by the failure to provide adequate funding for direct services and by a preset approach to determining organizational needs.
Development of vertical and horizontal integration of services would provide improved, standardized client information and
record keeping via a seamless system of electronic information sharing.
It enables the LHIN to build on existing planning and service integration initiatives within the mental health and addiction
systems and recognizes the commitments of the provincial government.
It provides an opportunity to develop a comprehensive mental health and addiction strategy within the health care system that:
•
secures dedicated funding for mental health services and addiction services
•
builds system capacity
•
ensures the availability of core supports and services throughout the SEO LHIN
•
develops mental health and addiction service delivery partnerships, with clearly defined roles, responsibilities and
accountabilities among community agencies, Schedule One and tertiary level facilities.
•
promotes client-directed and family-focused service that can logically collaborate with Family Health Teams.
It fosters collaboration within the health care system related to health promotion, identification and early intervention with at
risk populations across the life span.
It promotes integrated treatment of co-occurring mental health and addictions problems and integrated approaches to other
health problems that are impacted by mental health and/or addiction.
What are the outcomes/lessons learned (if any)?
Expected Outcomes of integration of addiction services and mental health services throughout the health care system:
Understanding of mental health and addiction issues is increased, including their influence on general health, and integration
will:
•
improve capacity to identify those with problems and those at risk
•
provide deserved legitimacy of mental health and addiction services,
•
increase awareness, acceptance and use of those services within the SEO district,
•
decrease stigma and discrimination of persons with addiction and mental health problems.
•
An effective response for people with mental health and/or addiction problems is provided from a complete health care
system that works together to ensure:
•
timely and appropriate referrals, service coordination and continuity of care,
•
more appropriate and cost-effective use of acute care services, e.g. bed utilization, use of ER and OHIP funded services.
•
standardized delivery of services (admission and discharge criteria, protocols, assessment tools and evaluation framework)
•
accessible, comprehensive, and client-directed services.
• Recovery oriented practices based on broad determinants of health are incorporated.
• Existing alliances, networks and partnerships are enhanced, whose expertise and experience is shared by the system.
• Standardized human resource practices are developed to reduce loss of staff and increase abilities to attract qualified staff.
•
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Cross-sectorial training (mental health, addictions, acute and tertiary care, etc) will increase understanding and awareness and
encourages linkages and exchange of data, documents and research to use evidence-based approaches that work.
• Inter ministerial collaboration is increased as the needs of people are addressed across their life span and in a variety of areas.
•
This government’s promise to transform the health care system in Ontario brings hope and expectation. The integration of addiction
services and mental health services throughout the continuum of care provides patient/client directed focus, multi entry points to the
system and coordinates care from admission to discharge. It will be a partnership of equals that clarifies roles and responsibilities,
guarantees strategic partnerships and stakeholder engagement, and substantially improves services to the residents of SEO.
References: Centre for Addictions & Mental Health [CAMH], Ontario Federation of Community Mental Health and Addiction Programs
[OFCMHAP] and Canadian Mental Health Assoc. [CMHA] Ontario, Health Canada, World Health Organization, Harvard University & World
Bank, Kirby Report, November 2004, Mental Health Implementation Task Force Report, “Making it Happen” and “Setting the Course.”
Lead contact person:
Name: Cate Sutherland, Executive Director
Telephone: (613) 969-0077
Organization: Addictions Centre (Hastings/Prince Edward Counties) Inc.
Email address: [email protected]
Name: Vicky Huehn, Executive Director
Telephone: (613) 544-1674
Organization: Frontenac Community Mental health Services
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Appendix A.1: List of Participants
Addiction Services & Mental Health Services Must be Integrated Throughout the Continuum of Care
Name
Larry Akerstrom
Gavin Anderson
Julio Arboleda-Flórez
Eva Barnett
Mary-Ann Beeby
Mary Boyce
Title
Executive Director
Organization
Salvation Army Harbour Light
Head of Department
Nurse Manager Psychiatry
Department of Psychiatry Queen’s University
Hotel Dieu Hospital
Options for Change
Addictions Centre (Hastings & Prince Edward Counties) Inc.
Gambling Counselor &
Addiction Counselor/Supervisor
Belia Brandow
Executive Director
Leeds & Grenville Rehabilitation and Counseling Services
Joan Cameron
Acting Manager
Providence Continuing Care Centre – Mental Health Services
[PCCC-MHS]
Karin Carmichael
Carole Cecchini
Community integration Program
Interim Administrator
Addictions Counselor -- Problem
Gambling
RNAO Executive, Kingston Chapter
PCCC-MHS
TriCounty Addiction Services
Kim Charlesbois
Executive Director
Sexual Assault Centre (Hastings/Prince Edward)
Bob Cunningham
Executive Director
Mental Health Services-Hastings Prince Edward
Dwight Druick
Janice Elms
Sheryl Ferguson
Franco Fragomeni
Agency Director
Psychometrist II
Employment Coordinator
Manager
L & A Community Mental Health Services
Ongwanada
PCCC-MHS
Crisis Intervention Program for Hastings/Prince Edward Counties
Marlo Gillis
Peer Support Coordinator
Mental Health Support Network -- H & PE Corp.
Gerry Gregory
John Hill
Peter Humphries
Director
Community Member
Hotel Dieu Detoxification Centre
February 21, 2005
Brockville Psychiatric Hospital, a division of the Royal Ottawa
Health Care Group
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Name
Dave Hunter
Board Member
Organization
SEO District Health Council
Vicky Huehn
Executive Director
Frontenac Community Mental Health Services
Sheila Irvine
Administrative Director
Brockville Psychiatric Hospital, a division of the Royal Ottawa
Health Care Group
J. Nicholas Kaduck
RN
Board of Directors, Pathways for Children and Youth
VP
Board of Directors, Children's Mental Health Ontario
Member
Limestone District School Board
Co-Chair
Coordinator
Special Ed Advisory Committee
Mental Health Support Project of Lanark, Leeds & Grenville (The
Link – Smiths Falls, South Link – Brockville)
Lisa Leveque
Title
Alan Mathany
Director of Operations
Frontenac Community Mental Health Services
Geoff McMullen
Executive Director
Developmental Services of Leeds and Grenville
Matt Melinyshyn
Roumen Milev
Jai Mills
Community Member
Clinical Director
Executive Director
PCCC-MHS
Mental Health support Network—H & PE Corp.
Stafford Murphy
Carole Nelson
David North
Janet Pearse
Mike Poulin
Diane Roberts
Pauline Sawyer
Marilyn Scott Harris
Colin Slack
Colleen Small
Nalini Stiemerling
Chris Sullivan
Cate Sutherland
Executive Director
Director
Executive Director
Executive Director
Executive Director
Assistant Executive Director
Executive Director
Executive Director
Executive Director
Program Director
Psychiatrist
System Planning Consultant
Executive Director
Lennox & Addington Addiction Services
Peer Support of Kingston
TriCounty Addiction Services
Options for Change
Lanark Community Mental Health
Youth Habilitation Inc.
Alwood Treatment Centre Inc.
Brock Cottage/Tennant House
CMHS – Leeds and Grenville
Kingston General Hospital
PCCC-MHS
Centre for Addiction and Mental Health
Addictions Centre (Hastings & Prince Edward Counties) Inc.
Carol Wannamaker
Director, CCC/Rehab/Mental Health
Quinte Health Care Corp
Cathie West
Sandra Willard
Kathy Barry
Executive Director
Youth Habilitation Inc.
Program Consultant
MOHLTC
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2. Innovation in Rural Health
Type of integration (more than one box can be
checked)
Innovation in Rural Health
Horizontal
Vertical
Other, describe:
boundaries
Intersectoral
Dorothy Broeders-Morin…..Saint Elizabeth Health Care
(co-chair), Kingston
Carlene MacDonald….Brockville General Hospital, Brockville
Tom Rankin…..Chair of Board , ACCC, Lanark, Leeds & Grenville
Nadia Zurba…..Portland Health Centre Portland
Carole Brearley…Business Development , Smiths Falls
Arlene Atkinson…Red Cross , Brockville
Barbara Courtney….Community Nurse, Maberly
To develop innovative strategies for cost effective, client centred, delivery of health promotion and health services in rural communities responding to the
needs of the clients who want to stay in their own community and have the ability to access a network of services to allow equity of services as we should not
be disadvantaged because we choose to live in a rural setting.
Name: Dorothy Broeders-Morin
Telephone: 613-530-3400 x222
February 21, 2005
Title: Manager Organization: Saint Elizabeth Health Care
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3. Urgent Medical Transport – Timely and Deliberate
Provide an effective, efficient, timely and safe system for urgent transfer of
patients between institutions in order to enable integration of, and access to,
patient care.
need to be confined within LHIN oundaries
be checked)
Horizontal
Vertical
Other, describe:
Intersectoral
Brockville General Hospital
Access Centre for Lanark Leeds-Grenville
Hotel Dieu Hospital
KFLA Public Health
Hastings Prince Edward Health Unit
Lennox & Addington County Hospital
Lanark Leeds Grenville Health Unit
Providence Continuing Care Centre
Queen’s University Faculty of Health Sciences
Perth Smiths Falls District Hospital
Southeastern Ontario District Health Council
Quinte Health Care
Cancer Centre of Southeastern Ontario
Kingston Frontenac Lennox & Addington CCAC
Health Care Network of Southeastern Ontario
Access Centre of Hastings Prince Edward
County of Frontenac EMS
County of Lennox & Addington EMS
Hastings Prince Edward EMS
The Ministry of Health and Long-Term Care has introduced a transformation agenda. Once of the top issues on this agenda is the
management of wait times. The wait time priorities require access to key services that are primarily located at the tertiary referral centre.
These are:
•
specialized cardiac services,
•
magnetic resonance imaging,
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•
•
•
24/7 computerized axial tomography (CAT) scan access,
complex cancer procedures, and
hip and knee joint replacements.
Timely access is currently compromised in Southeastern Ontario. This is due to the lack of an organized "just in time" urgent patient flow
model.
Upper tier municipalities are responsible for ambulance services. They have introduced Minimum Emergency Coverage (MEC) plans to
improve response time performance to meet provincial objectives. This has reduced the ability to coordinate the movement of urgent
patients between hospital sites. The net impact has been:
•
•
•
•
•
longer and inappropriate patient stays while they wait for transport to the referral hospital
longer and inappropriate patient stays while they wait for transport back to the home hospital,
increased risk to patients,
increased overtime for staff waiting for transfers and accompanying patients, and
increased missed appointments.
This has resulted in sub optimal situations for patients and a less efficient healthcare system. Annex A provides examples of actual cases
reported in Southeastern Ontario. The cost to the health care delivery system in terms of incremental operational cost estimates and
reduced clinical capacity are very close estimates. Examples of existing programs that depend on access to “just-in-time” urgent medical
transportation include:
•
The Southeastern Ontario Regional Stroke Program at the Kingston General Hospital
This has been a provincial landmark model of regional deployment for six years. The program has showcased an innovative regional
model that has documented many cases where the affects of acute stroke have been reversed or minimized due to rapid assessment
and prompt treatment.
•
The Kingston General Hospital’s same-day cardiac catheterization program
This program was introduced five years ago to improve timely and equitable access to specialized cardiovascular services. The initial
program reduced wait times for these services for in-patients outside of Kingston by up to 7-10 days. Due to its success, it was later
adapted to include pacemaker implants, rescue percutaneous coronary intervention (PCI) and other related cardiac services.
Creating a broader catchment area depends on the availability of appropriate emergent and urgent patient transport capacity into and out
of Kingston.
To resolve this issue, the establishment of an urgent medical transportation system is proposed that will manage the interface between the
hospitals, emergency medical services and the Ministry of Health and Long-Term Care services that are required to achieve enhanced
access to cardiac care, cancer care, joint replacements and diagnostic imaging, without adversely affecting other critical services.
Based on current utilization patterns, there is a need to move eight patients (round trip) from the Hastings – Prince Edward Counties area
towards Kingston and four patients (round trip) from the Lanark, Leeds and Grenville Counties area every weekday. Due to patient care
demands and risks, three paramedic staffed vehicles will be required.
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This would also include:
•
•
•
•
Door-to-door (vs. bed-to-bed) service, so that paramedics would not have to enter hospital in-patient units.
Coordination in Belleville (for Trenton, Picton and Bancroft) and Brockville (for Perth and Smiths Falls)
An RN-staffed marshalling area at the Kingston General Hospital to facilitate quick turnaround.
Regional one-number-to-call coordination between hospitals, transport vehicles and the central ambulance communications centre.
Key indicators for success will feature:
•
•
•
•
•
A reduction in admissions and patient-days associated with waits for urgent transport.
A reduction in missed appointments and cancelled surgeries or diagnostic procedures.
An increase in throughput, allowing better use of existing capacity for both the targeted services as well other patients and/or services.
Enhanced efficiency of EMS resources, along with greater capacity to support the extension of regional programs that require
emergency transport of patients
Expansion of urgent cardiac related programs such as regional Emergency PCI protocol
The partners have submitted a proposal to the MOHLTC Wait Time Innovation fund for funding consideration. A funding decision is pending.
[In the event that the initiative is not funded, the partners will revisit the proposal and consider funding alternate sources of revenue
internally and externally to establish this service due to the importance of access to urgent medical transportation].
That in order to integrate patient care across large geographic areas, access to a strong, responsive, just-in-time urgent medical transport
delivery system is imperative.
Name: Karen Gillan Title: Chair Organization: Brockville General Hospital Tel (613) 345-5645 Email: [email protected]
Name: John Hudson Title: Vice-Chair Organization: Kingston General Hospital Tel (613) 549-6666 Email: [email protected]
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4. Client/Patient Navigation at Transitions Across the Continuum of Care/Health Care Journey
Type of integration
Client/Patient Navigation at Transitions Across the Continuum of Care/Health
Care Journey
Initiated/existing integration activity
Horizontal
Vertical
Other, describe:
Intersectoral
See Appendix A.4.1
The initiative focuses on the creation of a client/patient-focused system that facilitates movement from one sector/service to another.
If this is an initiated/existing activity…What is the current status?
There is great variability in the present system resulting in delays, inefficient use of resources and confusion for the client/patient. There is
a general lack of knowledge and confidence about what should happen next, if it is going to happen and within what timeframe.
Clients/patients are being “admitted” to new services with gaps in information, need for repetitive information being asked and
reassessment being completed.
Navigation through the transition points requires managing a complex set of processes and resources that often are not clearly understood
by the client/patient and are not necessarily understood even by the referring/receiving health professionals/service providers.
Consequently, this results in an inefficient and costly system for clients/patients and professionals.
The objective of the client/patient navigation system is to have the clients/patients move back and forth along the continuum of care, in
what for them is a seamless system. This streamlined system will be more timely, efficient and subsequently cost effective will avoid many
of the present medical, clinical and financial inefficiencies and problems for providers, client/patients and consumers; as well as potential
undesirable health outcomes for client/patients. See appendix A.4.2
Without an integrated system, clients/patients have observed the following:
•
Excessive wait at one level of care because of incapacity at another level of care.
•
Repeat their health history for each service provider encounter.
•
Undergo the same test multiple times for different service providers.
•
Despite commonly having incomplete information they are often the main medium for informing their physician that they have been
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•
•
•
•
•
•
hospitalized or undergone diagnostic or treatment procedures; been prescribed drugs by another physician; not filled a previous
prescription; or been referred to a health agency for follow-up care.
Do not have 24-hour access to a primary care provider site.
Do not have easy to understand information about quality of care and clinical outcomes in order to make informed choices about
providers and treatment options.
Unable to make an appointment for a visit to a clinician, a diagnostic test or a treatment with one phone call.
Do not have a wide choice of primary care providers who are able to give them the time they need.
Client/patients of chronic diseases are not routinely contacted to have tests that identify problems before they occur; are not provided
with education about their disease process; and are not provided with in-home assistance and training in self-care to maximize their
autonomy.
Access to what is available depends on where and how knowledgeable you are in accessing the health system.
The following are a set of principles which must govern the development of the client/patient navigation system:
•
Health system must be client/patient-focused, meaning from the client/patient’s perspective it must be easy to access and move
through with a minimum of calls, visits, forms and assessments.
•
Continuity-of-care must govern the development of the client/patient navigation system and transmission of information.
•
An all-inclusive system, where clients/patients and providers can easily navigate through and the system meet the needs of all potential
client/patients (e.g. mental health, chronic disease management; diverse backgrounds e.g. rural, ethnic; and French-speaking (first
language-mother tongue).
•
A multiple access and entry point system, with each entry point providing full access to a range of health information and community
support services.
•
A system that expedites the use of e-health records and care plans to reduce duplication of documents.
•
A transition process that facilitates ease of movement between healthcare services.
•
Appropriate protocols developed for each unique transition point.
•
Recognition that all transition points are equally important (although some are used more frequently e.g. acute to community care &
vice versa).
•
A transparent system with an explicit accountability framework for all service providers.
•
A case management system with clear accountabilities that moves with the client/patient across the continuum of care.
•
Build on best practices to create new standards for transition to ensure an efficient and usable client/patient navigation system.
•
Maintain separate current databases for client/patient information and for professional/providers information containing relevant
information (including multilingual capabilities) of all available services within each LHIN area.
•
Establish privacy safeguards to ensure appropriate use and confidentiality of records.
•
Help information line (bilingual) available to assist all database users – a single telephone number staffed with live person to help
navigate client/patient through system.
•
Annual review of system and continual feedback for improvement (i.e. quality indicators, monitor indicators, outcome evaluation and
best practices).
•
The system terminology and language will be familiar to the client/patient rather than medical language often not understood by the
client/patient.
Name: Ms. Jackie Redmond
Telephone: 613 966-3530 x2206
February 21, 2005
Title: Executive Director Organization: Access Centre for Hastings & Prince Edward Counties
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Appendix A.4.1
List of Partners for Client Navigation
Name
Title
Organization
Email
Phone
Anne Jewell
Admin. Director/ SEO Reg. Geriatric Program
[email protected]
548-7222 x2350
Betty McIver
District Health Council
Executive Director
[email protected]
549-5253
Cally Martin
Carol Cooke
Victorian Order of Nurses
Regional Stroke Program Manager
Manager of Community Support Services / Site
Manager
[email protected]
[email protected]
549-6666 x3562
634-0130 x401
Debbie Moynes
Prince Edward Community Care
Executive Director
[email protected]
613-476-7493
Denise Hagerman
Director of Hildegard Centre
[email protected]
548-7222 x3118
Dr. John Puxty
Dr. Kenneth Le Clair
Chief of Staff, St.Mary's of the Lake Hospital
Executive Director, Geriatric Psychiatry Program
[email protected]
[email protected]
546-1101 x5645
548-5567 x5928
Elaine Johns
Independent
Contract Management Resource
[email protected]
546-9388
Georgina Thompson
All-Care Health Services Limited
CEO/President
[email protected]
613 962-3426
Greg Freeman
Owner Crown Ridge & Westgate Lodges
Owner/Operator
[email protected]
Jackie Redmond
Access Centre for Hasting & Prince Edward
Executive Director
[email protected]
613 996-3530 x2206
Janet Hunter
Admin Ass to Shalagh Nowlan
[email protected]
548-7222 x3130
Jeannine Proulx
French Canadian Association of Ontario
ACFO Mille-IIes -Thousand Island Region
[email protected]
546-7863
Jennifer Mills
Quinte & District Rehabilitation
Manager/ Occupational Therapist
[email protected]
613 476-7493
Joanna Nolan
The Canadian Paraplegic Association
Johanne Kot
Access Centre for Hasting & Prince Edward
Judith Norlock
Karen Gill
[email protected]
547-1391
Executive Secretary
[email protected]
613 966-4601 x2208
Stirling Manor Nursing Home
Administrator
[email protected]
613 395-2596
Alzheimer's Society of Kingston
Executive Director
[email protected]
544-6320
Patti Dixon-Medora
Kingston Geriatric Psychiatry Outreach
Team Manager
[email protected]
384-9088
Philip Ambury
Arthritic Society
Occupational Therapist
[email protected]
546-2546
Rick Conley
Shelagh Nowlan
[email protected]
Administrator, Providence Manor Site
Susan Shoniker
Executive Director
[email protected]
542-0559
[email protected]
613 966-2941
549-0112
Terry Richmond
Cheshire Home Inc
Vera Rabadi
ParaMed Home Health Care
[email protected]
Wayne Greenway
SEO District Health Council
[email protected]
William Gekoski
Ontario Community Support Association
February 21, 2005
Board Member (Eastern Ontario)
548-7222 x3130
[email protected]
[email protected]
532-7854
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Appendix A.4.2
February 21, 2005
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5. Integrated Palliative Care Services Priority
be checked)
Horizontal
Vertical
Other, describe:
Integrated Palliative Care Services Priority
boundaries
Intersectoral
The Priority Work Group members who developed the following submission are:
Amy Sager, Quinte and District Rehab.
Anne Smith, Cancer Centre of Southeastern Ontario at KGH
April Spatola, Cardinal Manor Residential Home and Heart of Hastings Hospice
Audrey Whitney, Hospice of Prince Edward County
Bonnie Delaney, Hospice Quinte
Cynthia Johnston, District Health Council (Co-lead)
Lesley Reynolds, Hospice Quinte
Margaret Webber, Heart of Hastings Hospice
Doris Bush, Heart of Hastings Hospice
Pat Cyr, Regional Pain and Symptom Management Program Coordinator, PCCC (Co-lead)
Betty Anne McGrath, Westgate Lodge Nursing Home
Peggy Sunstrum, Hospice of Lennox and Addington
Additional Collaborators (> 30) from across Southeastern Ontario had direct input into this
submission. A much broader group of organizations and individuals interested in
comprehensive palliative care provision are involved in the local initatives. (see attached list)
In 2003 more than 20 key providers of palliative related care and support in Southeastern Ontario came together and agreed to implement
a coordinated comprehensive system of palliative care beginning with implementation of the common assessment, collaborative care
planning and clinical guideline tools developed by Queens University and the Kingston, Frontenac, Lennox & Addington Palliative Care
Integration Project Steering Committee. The initial rollout of the PCIP across the district was supported by one-time funding from the
MOHLTC EO Regional Office. In addition, In 2004 the Ontario Minister of Health and Long Term Care identified quality comprehensive endof-life care as a priority for this province in accordance with Federal/Provincial/Territorial agreements on health care funding.
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Therefore, it is recommended that the Southeastern Ontario Local Health Integration Network (the LHIN) commit to ensuring that the
appropriate resources and supports be available to continue to develop and sustain the emerging Southeastern Ontario Palliative / End-ofLife Care Network and the Regional Palliative Care Integration Project. The district-wide network will provide the structure and process for
ensuring that the three developing local palliative /end-of-life care service delivery models (also part of the Minister’s end-of-Life Strategy)
and the Regional Palliative Care Integration Project are able to meet the goal of providing consistent, best practice, integrated and
exemplary Palliative/ End-Of-Life Care across Southeastern Ontario when needed and in the most appropriate setting.
The scope of the initiative is palliative care in the broadest sense. While the Ministry of Health and Long Term Care is using the term “endof-life care”, the workgroup feels strongly that this may result in a narrower scope than is needed. Therefore, the terms “palliative care”
and “end-of-life” for the purpose of this initiative are used to mean “a philosophy of care, which is the combination of active and
compassionate therapies intended to comfort and support the individuals and families who are living with life-threatening illness. During
periods of illness and bereavement palliative care strives to meet physical, psychological, social and spiritual expectations and needs, while
remaining sensitive to personal, cultural and religious values, beliefs and practices. Palliative care may be combined with therapies aimed
at reducing or curing illness, or it may be the total focus of care.” (from the CHPCA as quoted in the DHC EOL Resource Document, 2004:
pg.9) Palliative care services include all services and supports provided to improve quality of life for the individual and their
family/caregivers in adapting to life-threatening illness and in preparing for life closure.
The desired outcome is a system of comprehensive and coordinated services and supports whereby residents and their families will have
access to exemplary Palliative/ End-Of-Life care when needed and in the most appropriate setting through an interdisciplinary program of
care which focuses on quality of life, control of pain and symptoms and attends to the psychological, spiritual experiences of individuals and
their families in adapting to illness and in preparing for life closure.(adapted from the CHPCA as quoted in the DHC EOL Resource
Document, 2004: pg.9)
The intent is to build on, further integrate and enhance the five inter-related initiatives currently underway in Southeastern Ontario related
to improving palliative / end-of-life care in this district. The two regional initiatives:
•
•
•
•
•
The Regional Palliative Care Integration Project (see summary below);
The Southeastern Ontario Palliative/ End-of-Life Care Network part of the Ministers provincial End-of-Life Strategy (see summary
below); are both collaborative partnerships with the three local palliative care integration committees:
Lanark, Leeds and Grenville Palliative Care Council;
Quinte Regional Integrated Palliative Care Team; and,
Kingston, Frontenac, Lennox & Addington Palliative Care Integration Project Steering Committee; each of which are working on
designing and implementing local palliative/ end-of-life care delivery model with their respective Community Care Access Centres.
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The Existing Regional Initiatives Briefly:
The Regional Palliative Care Integration Project (RPCIP)
Started in 2001 in the KFL&A area under the leadership of the Queens University Department of Medicine Palliative Care Service and local
service providers, the RPCIP is now a district-wide project which promotes integration of efficient, high quality care delivery to palliative
patients and families, across disciplines and the continuum of care through dissemination of and training to use a set of resources to assist
individuals providing elements of the palliative/ end-of-life care continuum to use consistent assessment and care language, tools and
clinical practice.
The Resource components of the RPCIP include:
•
Standardized Assessment Tools
•
Collaborative Care Plans for three stages of palliation and a number of key related conditions
•
Symptom Management (Medical) Guidelines
Southeastern Ontario Palliative / End-of-Life Care Network
The Southeastern Ontario Palliative /End-Of-Life Care Network is being formed, with planning support from the District Health Council, at
the request of the Minister of Health and Long Term Care for Ontario. The Network will serve the residents of Southeastern Ontario. The
Network will provide leadership and structure to facilitate the development of plans and processes to optimize regional integration of
palliative/ end-of-life care and outcomes in Southeastern Ontario.
Inclusive of and building on the strengths of existing committees and organizations that coordinate and deliver palliative care, the
objectives of the SEO End-of-Life/ Palliative Care Network will be:
•
To plan and design a system of exemplary end-of-life care
•
To facilitate coordination and integration of end-of-life services at a system level
•
To assess and monitor community needs
•
To promote of identification and implementation of service innovations
The Network will be in place with formalized Terms of Reference by March 31, 2005 and will form an ideal forum for the LHIN to work with
the palliative / end-of-life partners in Southeastern Ontario.
Name: Pat Cyr
February 21, 2005
Organization: Regional Pain and Symptom Management Program Coordinator, PCCC
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B. Admin Support Services Integration Opportunities
6. E-Record
Description of Administrative Support Services Integration Initiative
Title of administrative support service initiative:
checked)
Electronic Health Record
Horizontal
Vertical
Other, describe:
*Note: initiated/existing activities do not need
to be confined within LHIN boundaries
Intersectoral
Joe de Mora, Kingston General Hospital
Dr. Roumen Milev, Providence Continuing Care Centre and Queen’s University
Bill Hart, Kingston General Hospital
Allan Katz, Health Care Network of Southeastern Ontario
To deliver better health care, fundamental changes to the health care system are required. In order to achieve this goal the government is
re-establishing a health care system in Ontario over the next few years that is patient-focused, results-driven, integrated and sustainable.
The plan for transforming the system is complex, but is anchored on a clear vision for health care in Ontario – healthy Ontarians in a
healthier Ontario.
It will enable the transformation in three specific areas:
•
•
•
reduced wait times for key services
more Ontarians with access to primary health care
a health care system that lives within its means
Information technology is a key enabler of this important initiative. The vision of the provincial electronic health (e-Health) strategy is to
develop information resources to drive transformation of healthcare delivery in Ontario into an integrated care system supporting timely
access to services, patient safety and accountability.
To this end, building on existing information technology investment and consideration expertise already in place throughout Southeastern
Ontario, the Information Technology and Communications Steering Committee of the Health Care Network of Southeastern Ontario has
developed a Regional Information Technology Strategic Plan (attached) consistent with the MOHLTC transformation agenda, the provincial
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e-Health strategy and other national health care informatics initiatives (i.e., Canada Health Infoway).
The plan outlines five main themes with associated projects aimed at achieving a consolidated or integrated health record that spans from
the primary care setting to the institutional environment. The plan also promotes the distribution of existing information to the right care
resource at the right time and the right place to support decision-making and enhance patient or client care.
Communication
•
In the initial phases the project will facilitate the implementation of Local Health Integration Networks through a planned and
coordinated rollout of SSHA connectivity and secure-email. The later phases will provide key secure patient information to health care
workers across the region.
Access
•
•
Assisting the implementation of the Government’s Wait Time strategy through the development of Waiting List Registries.
Enabling the establishment of the Government’s 150 Family Health Teams through a planned deployment of Physician IT.
Accountability
Enhancing accountability through the development and implementation of Accountability & Management Systems, starting with hospitals
and assisting the integration of services in LHINs through the development and implementation of IM/IT plans for each LHIN
In conjunction with its sixteen partners, the Health Care Network of Southeastern Ontario has developed a regional strategic plan
(attached) that focuses on five themes:
1. Regional Connectivity
o
Regional e-mail
o
Shared e-mail address books
o
Review and compliance with all pertinent security considerations
2. Electronic Health Records
o
Regional Picture Archiving and Communications System development
o
Identification of key patient information for sharing
o
Data sharing model
3. Telemedicine
o
Support linkage of all hospitals to regional telemedicine provider (CareConnect)
o
Continue to work with CareConnect to ensure linkages and access with key educational and community care providers.
4. Shared Infrastructure
o
Review opportunities for shared regional help desk functions
o
Explore opportunity for regional communication (telephony) initiative
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5. Community Physician Access.
o Develop model for community physician access with MOHLTC and OMA e-Physician project.
The plan was developed in consultation with key representatives from the e-Health Council and the Smart Systems for Health Agency as
well as health care providers from across Southeastern Ontario at a public forum – October 25, 2004.
The Network is now developing an implementation and communication strategy for the plan for presentation to government funding
agencies.
•
•
•
•
•
Before we talk electronic health record, we have to talk about secure connectivity among all health care providers regardless of
location.
There is no one magic piece of hardware and software that will create an electronic health record solution.
Any regional initiative must respect the investment in software and hardware capital, training and process development in each
organization’s legacy systems.
The common identification of specific data elements that are to be shared must be done first, followed by the development of interfaces
that will enable data to be shared among providers and with the client.
Security is a paramount issue in light of the enactment of PHIPA
Joe De Mora, President & CEO of Kingston General Hospital (613) 548-1322 Email: [email protected]
Dr. Roumen Milev, Psychiatrist, Providence of Continuing Care Centre & Queen’s University (613) 546-1101 x 5857
Email: [email protected]
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7. Nurse Practitioners: Improving Integration in all Sectors
checked)
Nurse Practitioners: Improving Integration in all sectors
Horizontal
Vertical
Other, describe:
Intersectoral
Acute Care: Kingston General Hospital, Hotel Dieu Hospital, Cancer Care Ontario
Primary Health Care: Sharbot Lake Medical Centre / Lansdowne Health Clinic
Long Term Care: Rideaucrest/Fairmount , City of Kingston
VON Hastings
Queens School of Nursing
North Kingston Community Health Centre
Kingston, Frontenac, Lennox & Addington Health Unit
ISSUE
•
There is currently a Health Human Resource (HHR) crisis in Ontario, which can be addressed in part by increased utilization of
nurse practitioners in all sectors of health care.
o Key stakeholders at the South East LHIN December 7th planning day, identified Nurse Practitioners (NPs) as part of the HHR
solution (see South East LHIN summary) - thereby supporting improved utilization and integration of NPs as a priority
planning and funding focus for the new LHIN.
o Adequate HHR is critical to the implementation of many of the other South East LHIN patient care priorities
o The healthcare partners involved believe that nurse practitioners can play a pivotal role in the delivery of health care to the
residents of the SE LHIN region.
CONTEXT/BACKGROUNDER
•
NPs are advanced practice nurses including but not limited to Acute Care NPs and Primary Health Care NPs.
•
NPs are highly skilled, and have the authority to function both independently and interdependently across the continuum of care.
•
In Ontario, up to 950 NPs practice in the various sectors of health care including: Primary Health Care/Family Health Teams,
Community Health Centres, Aboriginal Health Access Centres, Long Term Care, Community Care Access Centres, Public Health
Units, Ambulatory Clinics, Emergency Rooms, Acute Care specialized patient programs, NP managed clinics, Regional Cancer
Centres, and Academic Health Science Centres.
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•
•
•
NPs have the capacity and capability to lead patient navigation, facilitating the much needed collaboration, co-ordination and
continuity of care that ultimately leads to improved patient care and outcomes.
NPs enhance professional environments, improving recruitment and retention of nurses within their roles as educators, mentors
and researchers.
This advanced practice nursing role is helping to attract people into the nursing profession,
thereby stabilizing the workforce.
LITERATURE /RESEARCH TO SUPPORT THE ROLE
Research has demonstrated that Primary Health Care NPs consistently increase access to care, enhance quality of care, and improve
patient outcomes and patient satisfaction (Horrocks 2002). Similarly, Acute Care NPs have been shown to provide effective and fiscally
responsible care for a variety of patient populations (Genet et al 1995). NPs in emergency rooms decreased waiting time, improved access
to care and are associated with high levels of clinical efficiency and patient satisfaction.
OVERAL GOAL AND OBJECTIVES:
To improve health outcomes for residents of South East LHIN by increasing access to quality care.
1. Optimize HR planning and allocation of NPs
a. Enhance and promote collaborative models of care (e.g. shared-care)
b. Ensure accessibility to the most appropriate health care provider
c. Enhance existing NP capacity and utilization in all sectors
d. Identify existing capacity in SEO and potential for increased opportunities in SEO for NP employment
e. Address allocation and utilization of NP resources
f. Develop a recruitment & retention strategy
g. Ensure that current NPs are practicing to their fullest scope.
h. Ensure opportunities for continuing education
2. Improve client access to care in all sectors
a. Increase NP positions in Primary Health Care to increase capacity of current family physician practices (address the orphan
patient issue)
b. Identify and resource opportunities for NP positions that increase access for disadvantaged and vulnerable populations
(mentally ill, homeless)
c. Enhance mechanisms for cross-sector linkage of NPs employed in different settings
d. Increase specialty service NP positions, particularly in outpatient and Regional Cancer Care clinics that allow for appropriate
use of NP expertise while improving availability and access to the physician specialists
e. Plan, develop and implement an NP-managed wait-list pilot project for patients awaiting cardiac, cataract, and orthopedic
surgery
3. Improve quality of care
a. To improve patient access without compromising standards of care by empowering NPs in all sectors to function at their
fullest scope of practice
b. Recognize and optimize the NPs skill in case-management and navigation of the patient through the system.
STRATEGY/ACTION PLAN
•
Strike a steering committee/NP advisory committee
•
Conduct an environmental scan of existing supply and distribution and services. Look for areas ripe for capacity building (e.g.,
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•
•
•
•
•
•
•
acute care/ambulatory clinics that could increase number of patients seen in a timely fashion if an ACNP was working with
physicians on that service). COPD clinic referrals are out of control in the first year of that clinic being opened, patients wait a year
to see an endocrinologist.
Enhance existing supply, using a phased approach, with a focus first on acute care NPs
Develop & Implement a change management plan (public, providers, admin, other key stakeholders)
Align the regional NP strategy with provincial NP initiatives (consider NP Integration Final report of 2003, recommendations &
monitor task team progress)
Develop a NP recruitment and retention strategy
Provide support for networking of NP-NP and NP-other providers in all sectors
Create innovative models of NP care and outreach services (e.g. street health, high school clinics, Breast Cancer clinic, women’s
wellness centre)
Explore successful models of wait –list initiatives (e.g. Cardiac Care network, decrease in wait times to diagnosis for breast cancer)
ACCOUNTABILITY /EVALUATION
•
Utilize Queen’s School of Nursing, Practice and Research in Nursing (PRN) nurse researchers to plan and conduct an evaluation
component. The PRN group mandate is to facilitate the integration of practice and research initiatives across the practice and
academic settings. Parts of the activities involved in this process are process and summative evaluations to understand the barriers
and facilitators to integration. The PRN group comprises 3 career scientists (Dr. Jennifer Medves, Dr. Margaret Harrison and Dr.
Joan Tranmer) and 7 research associates. The group will conduct interviews and focus groups with key providers, decision makers
and clinicians to understand the settings. The PRN group will also undertake an economic evaluation of the cost to the health care
system of integration including estimating number of costs of visits “saved”, salary and support of the NP, and perceived savings of
patient time and satisfaction with the model of care from their perspectives. As the group is based at Queen’s University School of
Nursing, which is one of the PHCNP partners in the education program, they are ideally situated to transfer the knowledge gained
from the initiative into concrete recommendations for future education of PHCNPS.
The following examples demonstrate the effectiveness and successful integration of the NP role within the South East LHIN area:
•
A two-year analysis of the impact of an Acute Care NP working collaboratively with a cardiologist in the Hotel Dieu Hospital Congestive
Heart Failure clinic demonstrated an 80% decrease in emergency room visits and hospitalizations for 200 patients. Cost-savings are
estimated to be in the $422,000 range, not including physician and ambulance costs (Staples et al, 2004).
•
In the Long-Term Care sector of Southeastern Ontario, NPs improved quality of resident care including improved communication with
residents and families, improved skill level of other LTC staff and reduced Emergency Room visits (Commitment to Care: A Plan for LongTerm Care in Ontario (Smith 2004). These outcomes were demonstrated in a ministry-funded pilot project, of which two of the sites were
Rideaucrest and Fairmount Home for the Aged.
•
Approximately 14 Primary Health Care NPs are currently practicing in various PHC clinics across SEO. One example of NP integration
is within the Rural Kingston Primary Care Network, where two NPs provide comprehensive care in a collaborative team environment.
Unique features of this model include shared-care mental health services, and community outreach programs.
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Name: Mary Woodman, RN (EC), BNSc Title: PHC Nurse Practitioner
Organization: Sharbot Lake Medical Centre & Queen’s School of Nursing
February 21, 2005
Tel (613)-279-2102
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8. Rural Community Partnerships/Volunteers
Ensure equitable access to services for rural residents by partnering with
urban-based agencies and utilizing volunteers more effectively
be checked)
Horizontal
Vertical
Other, describe:
Intersectoral
Beth Freeland, Central Frontenac Community Services Corporation
Angela Ford, VON Hastings, Northumberland, Prince Edward Branch
Jennifer Binkley, CCAC and Central Frontenac Community Services Corporation
April McCann, Canadian Diabetes Association
Laura Hare, Alzheimer Society Belleville-Hastings-Quinte
Nadia Zurba, Country Roads Community Health Centre
Debbie MacDonald Moynes, Prince Edward County Community Care for Seniors Assoc.
Karla Weber, Kingston Frontenac Lennox & Addington Health Unit
This initiative ensures improved system integration and service coordination when the South East LHIN empowers any rural agency to offer
coordination of volunteers, service delivery space, marketing, and administrative support to partner with non-local health and social service
providers regardless of their funding source or service demographics. In return, area residents of all ages have community access to
needed services such as support groups, physiotherapy, outpatient surgical follow-up, dressing changes, blood pressure checks, health
promotion seminars, counseling and speech therapy in addition to those currently provided by the rural agency. Recognizing that there is
only one taxpayer, this also ensures that rented or owned community facilities meet the needs of a maximum number of area residents,
rather than a restricted demographic.
Rural agencies cannot be all things to all people however they can partner with more specialized service providers to improve the quality of
life of area residents by sharing rural community development and volunteer recruitment expertise.
This initiative marries not only urban with rural and social with health, it also provides an opportunity for the limited resources available in
rural communities to be effectively utilized across sectors and silos. Mental health agency clients can partner with community support
agencies to ensure that clients have transportation even if funding to cover the coordination of the volunteers providing the service comes
from a different pot. Space for community support groups can be provided no matter which arm or level of the government pays the rent.
Health promotion meetings - for groups or individuals, for all ages, healthy or not – can be offered close to home so that people are
encouraged and better able to attend. Health outreach services, for examples, physiotherapy, outpatient surgical follow-up, dressings,
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blood pressure checks, counseling and speech therapy, can be offered in local communities, maximizing the limited meeting space that is
available in the rural area, reducing service providers travel time, and increasing the role of volunteer drivers and escorts to provide
intergenerational services.
Currently, non-local health and social service providers may be willing to provide outreach services if space is provided free of charge.
Dependent on the sector or silo funding the space, rent may be a requirement of usage. Additionally, the expense of staff time to open and
close the building when the service is offered outside of normal office hours must be recognized. An integrated rural agency can provide
marketing, already having the trust of their communities, coordination in the forms of administrative support for booking appointments and
arranging service delivery space, and by accessing any additional Volunteer support that is needed.
There is a limited number of Volunteers in each area. With every health and social service agency requiring Volunteers, there is competition
for their time and skills. It needs to be recognized that not all Volunteers will be willing to serve all people or client groups but others may
choose to if additional program- specific training is provided. Rural agencies providing coordination of Volunteers for local and non-local
services, for example, local foot care appointments but non-local cancer treatments, can ensure that these valuable human resources do
not burn out and that those with the most appropriate skill set provide the service delivery.
•
•
•
•
•
•
Resident ownership of issues and solutions are very important: if the community views a building as serving all sectors of the
population rather than a specific demographic or economic sector, the community will provide additional resources.
Collaboration between organizations at a local level to address service needs and gaps happens more quickly than receiving
approval from varying funders to work jointly.
Volunteers are inexpensive but not free: there are standards that must be met for volunteer coordination including screening, risk
management, reimbursement for out-of-pocket expenses, and training.
Recruitment is most successful at a local level and becomes a focal point within the community.
Volunteering, in and of itself, improves health. The act of assisting others makes for a healthier community.
This initiative will be successful if Volunteers move beyond commitment to specific programs and specific agencies to the broader
community and if Funders, including the LHIN when established, look at supporting communities instead of defined people.
Name: Beth Freeland
Title: Executive Director
Telephone: (613) 376-6477
February 21, 2005
Organization: Central Frontenac Community Services Corporation
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9. Providing Meaningful Geographic Input to LHIN Planning and Implementation
checked)
Providing meaningful geographic input to LHIN planning and Implementation
Horizontal
Vertical
Intersectoral
Other, describe: Provides a vehicles to
include, sectors, communities and health
facilities, individual providers and provider
groups
Allen Prowse, KFL&A CCAC
Dianne Raby, CCAC Lanark, Leeds, Greenville
Dr. Peter Bell, Sharbot Lake Medical Centre
Scott Black, North Frontenac Community Services
Marnie Dahl, Associate Executive Director, Patient Care, and Chief Nursing Executive,
Hotel Dieu Hospital
Marg Atkinson, Director of Patient Care, Ambulatory Services, Hotel Dieu Hospital and
RNAO, Kingston Chapter
Mary Jo Dowker, Ontario Early Years Hastings-Frontenac-Lennox and Addington
Hersh Sehdev, North Kingston Community Health Centre
Marnie Dahl, Hotel Dieu Hospital (representing Marg Atkinson)
Cynthia Johnston, Southeastern Ontario District Health Council
Consultant:
Liz Fulton, Chief Administrative Officer, Frontenac County
Local communities within the LHIN region need to have input, ownership and confidence in the decisions of the LHIN. The initiative outlines
criteria, mechanisms and processes which may facilitate these objectives.
There are numerous sources of concern from both individuals and communities related to the call for greater transparency in decision
making and greater inclusion of the public in helping to make those decisions. In its December 2004 Research report on Transparency,
Trust and Citizen Engagement, The Canadian Policy Research Networks (http://www.cprn.org/en/doc.cfm?doc=1140) concluded that
Canadians are looking for meaningful input to influence decision making, and complement, not replace, the voices of experts and other
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stakeholders. These concerns echo the concern for greater integration outlined in the Romanow Report. This initiative is designed to
suggest both requirements and options available to the Local Health Integration Network to ensure that effective expectations, processes
and structures are in place to respond to this important community concern.
At its simplest, achieving effective community input involves; defining the community (ies), identifying who are the representatives, how
the representatives should be chosen and why these representatives would be effective. Describing these elements in more detail;
1.
Communities; may refer to geographic areas, communities of interest or service areas. Each of these has specific implications:
Geographic areas while easily defined and easily understood may not correspond to service areas or reflect how services are either
aligned or used. Defining community by service area will include some who actually use services outside the area and may not
ensure that the whole region is represented. In areas where there is a strong, existing network of services as there is in the North
Frontenac County area (outline and history included in an Ontario Trillium Foundation funded report, Our Strengths & Assets, Needs
& Issues: A Summary of Conversations about Community Quality of Life in Northern Frontenac 2004) there may be an opportunity
to achieve strong community input. A community may be defined as a cultural community, although this may not ensure effective
geographic or cultural representation based on how and from where the representative is selected. Lastly, community may be
defined as the community of active service users (patients or clients) who are rostered within the service area.
2.
Identifying the representatives; may refer to how many representatives are appropriate, whether they are formal or informal
representatives, who they may be allied to, what their function is and both whom they can and do represent as well as whom they
do not represent, as well as how often the membership should be rotated and renewed in order to ensure relevance and the
broadest possible representation of the communities of interest in Southeastern Ontario. Defining what and who can be considered
representative is as complex as defining the community. In addition, in order to maintain currency the representatives themselves
will need to be varied over time to ensure that all the voices which need to be heard are heard. (References:
www.cheshire.gov.uk/healthscrutiny/; http://ruralcommunitynetwork.unite.net/files/pdf/Community%20representation.pdf)
3.
How representatives are chosen will affect the communities’ sense of having effective input. While representatives may be selfappointed (citizen’s action groups, alliances, etc.), they may be appointed or selected through a democratic process. These
representatives may be selected by outsiders or from within their region. The opportunity exists to access existing networks,
where they exist, or to develop new ones (as England did in the creation of Patient and Public Involvement (PPI) Forums to advise
each health area www.cppih.org/abouthat.html). PPI Forums are made up of groups of volunteers in local communities who are
enthusiastic about helping patients and members of the public to influence the way that local healthcare is organized and delivered.
The history of the North Frontenac Community Services organization reflects the same type of history and direction in Southeastern
Ontario.
4.
What makes representatives effective includes a possible host of attributes some might include, the representative’s
accountability, legitimacy, communication practices (not just skills), and their ability to create capacity for action or impact
(involving social capital, influence, etc.) recognizing that although the LHINs need advice they also need the influence which
legitimate and effective support within each community can bring to create and support change.
(www.aifs.gov.au/sf/pubs/bull3/jb.html)
Critical Success Factors:
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LHIN Boards should……
•
Meet their skill based requirements with the broadest geographic distribution available. A good mix of rural and urban
representatives would be an asset.
•
Recognize that geographic representation is important but should be secondary to ensuring the effective representation of the
populations most affected by any decision.
•
Set expectations which require funded organizations to show evidence that community input/collaboration has been sought in
their submissions
•
Consistently acknowledge and incorporate a very broad range of organizations drawn from all sectors as part of their network
•
Utilize existing networks including intersectorial groups
•
Include representation from providers where appropriate. Providers bring important expertise to the table and, with the
possible exception of involvement in resource allocations which would confer a benefit to them, should participate equally with
representatives from the broader public. The expertise of providers will be crucial in the development of plans, priorities and
strategies submitted to the LHINs
•
Establish additional locally selected groups (similar to England’s PPI Forums) to augment its public consultation efforts. PPI
Forums consist of patient representatives drawn from rostered patient populations within the region (similar to the Community
Advisory Boards associated with Family Health Teams) and are, as a result, the representatives of direct consumers of care.
•
Ensure that representatives are not economically disadvantaged by their participation (e.g., physicians, volunteers, etc.)
•
Be broadly representative – fair and equitable representation or fair and equitable distribution of services
•
Establish permanent advisory structures (committees) similar to the Community Advisory Boards or Community Advisory
Councils mandated in Community Care Access Centres.
•
Work with focus groups with territory wide representation
•
Stipulate that providers show evidence that service is provided across the entire area for which they have responsibility and
that service plans, strategic directions and budget priorities have been developed with Community input.
•
Provide data collection, data dissemination and assistance to community groups to collect methodologically sound data to
support planning and decisions. All groups should be expected to base their work on available scientific evidence.
Options:
While the following alternatives represent different methods by which meaningful input may be sought, it is likely that the most effective
approach to accomplishing this initiative is to use the methods of representation which are most appropriate to the task or “task
appropriate methods”. If a task appropriate approach is used then all of these options will be appropriate and used at different times during
the creation and ongoing operation of the LHIN.
1.
Skill based panels: (panels or committees consisting of individuals with expertise in specific areas such as primary care, community
development, service delivery, consumers) the challenge is that from both the professional and the citizen perspective, the
representation cannot efficiently reflect all of the significant views and perspectives which exist within a large territory. While this
can be an efficient vehicle, challenges exist in identifying the experts as well as in ensuring a broad representation of views.
2.
Existing networks: using established networks can be efficient as it provides an infrastructure for consultations on specific
submissions. While this requires the questions directed to these groups to be well phrased, it can also provide efficient access to
significant expertise. Challenges will include the breadth of representation (i.e., what groups are included and what groups,
February 21, 2005
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institutions, sectors or territories are not represented in the networks). Questions direct to existing networks must reflect areas
where these groups can be seen as fairly and appropriately representative. The greatest liability of the technique if used in isolation
is that networks are often very issue specific or sector specific.
3.
Establish locally selected groups: Similar to the PPI forums or to the developmental process described in the history of the North
Frontenac Community services, these provide a very good opportunity to achieve representation from local communities including a
broad range of consumers and local organizations. Challenges will include the creation of appropriate committees. In addition,
consumer panels could be selected from amongst rostered patients receiving health services within the region resulting in a
community advisory board for a range of health services. Specific Community Advisory Committees (CACs) [similar to those
mandated in Community Care Access Centres] or Community Advisory Boards could provide a structured network supporting the
LHIN planning requirements.
4.
Surveys, polling, data sampling techniques: This approach will provide information concerning community opinions which is
perhaps the most scientific. It requires significant expertise in crafting questions, in sample selection and in statistical manipulation
in order to assure reasonable validity. In addition, unless it has its roots in personal health information it risks being somewhat
unfocussed as it will represent the views of both health systems users and non-users. Appropriately targeted surveys can yield the
most comprehensive and representative information. They also represent a potentially costly approach. Regardless of the approach
used to evaluate existing services, these approaches reflect a concentration on the evaluation of service and perceptions of service
quality aimed at assessing the quality of care.
While this represents a quick review of the major elements of various approaches to receiving meaningful input to decisions, the strengths
and weaknesses reflected in this high-level review suggest that in order for the LHIN board to consult both health experts and the people
affected by their decisions, that a range of approaches will need to be used and that these approaches will need to be tailored to achieve
the best possible level of both transparency and accountability in decisions-making.
Community Advisory Committees are mandated for all Community Access Centres in Ontario. District Health Councils and municipalities
have frequently used public meetings as a means to receive public feedback on proposals and changes in service. On a regional basis there
are varying practices both formal and ad hoc used to receive public, geographic and special interest input to decisions.
Name: Allen Prowse
Title: Executive Director
Telephone: (613) 544-8200 x126
February 21, 2005
Organization: Kingston Frontenac Lennox & Addington Community Care Access Centre
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10.
Ensuring Better System Navigation for Clients at the Community Level
be checked)
Ensuring Better System Navigation for clients at the Community Level
Horizontal
Vertical
Other, describe:
Intersectoral
Debbie Moynes, Prince Edward County Community Care for Seniors Assoc
Carol Weir, KFLA CCAC
Jeannine Proulx, ACFO Mille-Ilse
Joanna Nolan, The Canadian Paraplegic Association
Georgina Thompson, All-Care Health Services Ltd
Philip Ambury
Susan Shoniker
William Gekoski
Terry Richmond
The proposed initiative is designed to create a mechanism to facilitate communication among our LHIN area health system partners, and
between client/patient/caregivers and the system and its partners. The initiative is two pronged:
1. A one-number telephone information line will enhance the experience of clients/patients and their families as they search for health
information and services.
2. An interactive internet tool will help service providers to assist clients/patients. This internet tool that will enable service providers to
quickly and easily access and update information on health agencies & organizations so to provide care and support service contacts &
information to clients/patients and their families.
There is much variability in the present word-of-mouth system resulting in extensive confusion for the client/patient and a lack of
knowledge and confidence about what should happen next, if it is going to happen and within what timeframe.
Navigating through the system requires managing a complex set of processes and resources that often are not clearly understood by the
client/patient and are not necessarily understood even by the relevant health professionals/service providers. Consequently this results in
inefficiency and cost for clients/patients and service providers.
February 21, 2005
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The objective of this initiative is to prepare agencies for the smooth transition of clients/patients into the health system. This involves the
development of an interactive internet tool whereby service providers can share their services with other health care
providers/professionals so to provide timely information to their clients/patients. The result is an administratively seamless streamlined
system that is current, timely, and subsequently cost efficient and will help remove the existing disconnects between service providers.
The second part of the initiative is to provide clients/patients with one telephone number that would be answered in accordance with a
roster with each agency taking turns during a month. Using the internet tool in conjunction with this telephone line, the person answering
the phone would give clients/patients timely and relevant information and refer them to the appropriate provider.
The following is an outline of the interactive internet tool and the rostered telephone system:
•
•
•
•
•
•
•
•
•
•
•
•
•
The interactive tool will take the form of a website portal which contains agency information and their website links.
Users will easily search the portal for relevant information and then be transported to the appropriate website to attain this
information.
The website portal will be a secured user access only, so to protect the access of sensitive agency and service provider information
& contacts.
The website portal is intended for service provider and agency use only. Given their knowledge of the health system, they are the
best users of the interactive tool, and will disseminate timely and accurate information to their clients/patients.
The website portal will be client centered meaning it will be “one-stop-shopping” for all your service provider and community
agency services.
Keeping this information current will be the responsibility of service providers and agencies as information is sourced/linked from
individual service provider/agency’s websites.
The interactive tool will contain an information referral system drawing on the existing community service referral such as CCAC
information & referral databases and volunteer centre databases; it will also include information on availability and access to French
language services.
As privacy should not be a barrier to providing health services, common protocols and standards will be developed around the
transferring and referral of client/patient information between service providers.
Every community support agency and most of the other community agencies and service providers currently have access to the
Internet and thus will be easy to set up access to the website portal.
Service providers and agency staff/volunteers will be trained on this website portal.
The establishment of the “one number to call” system for clients will be established once the Internet tool is set up and tested;
advertising will be done and the technical requirements of having the number forwarded to agencies in accordance with a roster will
be attended to.
LHIN will be responsible to the initial set-up, funding and management of the website portal and the “one number to call” system.
For service providers and agencies without websites, LHIN will provide them funding to develop a website and to keep it current.
Name: Debbie Moynes Title: Executive Director Organization: The Prince Edward County Community Care for Seniors Association
Telephone: 613 476-7493
February 21, 2005
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C. Priority Setting of new Integration Opportunity
I. Patient Care/Services Integration Opportunities
Priority Opportunity
1 Addiction services and
mental health services
must be integrated
throughout the
continuum of care
February 21, 2005
High-Level Action Plan
1. The citizens of our communities require the full continuum of care to deal with mental and/or addictions
concerns through accessible comprehensive services. This requires the LHIN to appropriately resource a
continuum of accessible and effective addiction and mental health services, from early intervention to
specialized treatment and rehabilitation, to address the needs of all citizens across their life span.
2. An exclusive portfolio for mental health and addictions is assigned to a senior executive in the LHIN
management team.
3. A Stakeholder Advisory Committee for mental health and addictions is established, chaired by a member
of the LHIN Board of Directors. Membership would include equal representation from: local and district
mental health and addiction planning bodies and other coordinating groups in SEO; consumers; and
survivor, peer support, and/or family groups. Input from the Centre for Addiction and Mental Health
and MOHLTC is also needed. Strategic planning should commence with:
9 Review of all recent district and provincial system planning documents and key results of LHIN
population health review, and completion of a gap analysis to identify and plan implementation
of unmet and under-met needs.
9 An updated inventory of the current service system, its core services and capacity.
9 Identification of district needs and priorities with particular focus on rural versus urban issues
and equitable access to specialty services for all citizens across their life span, regardless of
LHIN boundaries
9 Review of the role, expertise, models of services and opportunity of other health care sectors
and other community services to provide services in partnership with mental health services and
addiction services.
4. Bi-level integration of the planning and delivery of mental health services and addictions services with
each other and with the planning and delivery of other health care services is critical. Based on existing
reports and existing integration efforts, the following items represent important opportunities should be
resourced to advance integration and enhance service delivery:
9 Plan and fund the delivery of integrated mental health and addiction services for concurrent
disorders.
9 Establish intra-and cross-sectoral service agreements that support integrated planning, issue
identification, problem-solving and protocol development to address the needs of people across
their life span with mental health and/or addiction problems who also need assistance from other
health care sectors or other Ministries (i.e. dual diagnosis, forensics, homelessness, oncology,
brain injuries, children, youth, seniors).
9 Formalize partnerships with consumer & peer support groups to ensure full, meaningful and
supported representation.
9 Ensure coordination and consistency between mental health and addiction sectors and other
health care sectors in the development and approval process for operating plans, budgets and
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2 Innovations in Rural
Health Care
accountability agreements.
9 Provide cross-sectoral training and consultation for other health care providers to increase
knowledge and skill levels in identification and intervention re mental health and addictions.
9 Implement shared care approach with family physicians & include mental health & addictions in
Family Health Teams.
9 Establish partnerships between mental health, addictions, community care and long-term care to
provide outreach assessment and intervention with seniors to prevent placement breakdown and
reduce hospitalization.
5. Addiction services and mental health services receive dedicated, needs based, sustainable multi-year
funding. As a first step, current funding levels are protected while the LHIN develops a strategic plan to
guide mental health and addiction funding decisions. The LHIN must also ensure that mental health &
addiction sectors, in keeping with its increasing important mandate in the overall health care system,
has a strong infrastructure and adequate resources to effectively participate and integrate will all other
parts of the system. This requires: attention to service delivery sites; resources to acquire/update
technology; and more importantly, resources to rectify compensation disparities and to recruit and
retain sufficient numbers of staff who are fully qualified and competent to work with a recovery based
philosophy in the challenging community setting.
6. The LHIN mandates and financially supports the development and implementation of: standardized
admission and discharge criteria and protocols; standardized assessment tools and evaluation criteria;
and, policy and reporting requirements and ensures that: services offered are consistent with best
practice and with evidenced-based research; and, formal linkages with universities and research
facilities are established.
7. The LHIN provides resources to both focus and strengthen diffuse prevention and promotion activities in
the existing system: coordinated collaboration between all health care sectors to plan and implement
health promotion strategies to reduce stigma and increase awareness of addiction, mental health and
related health issues; to promote early identification; and, to address socio-economic determinants of
health.
8. The LHIN fosters excellence in service delivery by mandating district wide training and professional
development programs and capacity enhancement programs through district wide specialized services.
E-Health
•
Promote e-health such as telehealth to expand this technology to allow rural clients access to
consultation, WOW wound care, tele-monitoring, web based online training, on line medical technology
support, on line access to medical/nursing technology support, on line caregiver support groups, telus
homesitter service where a video camera could monitor frail, elderly, or ill clients in their rural
environment
Education
•
Health promotion/prevention such as establishing a rural health network, interventions, new initiatives,
support group access by technology, on line resources such as links to health care libraries, sharing
February 21, 2005
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best practices, train health care professionals in the rural setting, foster dissemination of innovation
that has been practiced and works elsewhere such as the vast rural areas in Australia, establish
mandatory rural placement as part of professional training
Mobile Resources
•
Breast & cervical screening van, home dialysis or mobile dialysis van, MRI mobile van
Rural Health Department
•
Establish a rural health department at the ministry level to address rural innovative funding and
incentives
Rural Case Management
•
Intensive rural case management to identify and provide services required to keep rural people in their
community with adequate supports
3 Urgent Medical
Transport – Timely and
Deliberate
(Subject to change – note some items can occur in parallel)
1.
2.
3.
4.
5.
6.
7.
4 Client/patient
Navigation at
Transition Points
February 21, 2005
Create time limited multi-disciplinary, multi-stakeholder implementation team (hospitals, municipalities,
etc…).
Review recent urgent medical transportation trends within Southeastern Ontario hospitals.
Establish ambulance coverage schedules to address demand between hospital sites in Southeastern
Ontario using agreed operating schedule and response time indicators
a.
b.
c.
Establish incremental cost requirements and develop cost sharing models
Develop implementation plan for vehicle acquisition, staffing and scheduling
Develop hospital preparation teams to identify system activation policies, procedures and protocols
and schedule internal changes (i.e., preparation for door-to-door service, staffing)
d. Develop internal communication strategy featuring
e. Develop evaluation methodology.
Ensure sign-off by all parties.
Launch service.
Monitor and communicate results.
Steering Committee – established by LHINs and composed of representative from across the health care
continuum including managers, front-line staff and client/patients.
•
Mandate is to facilitate the expansion of best practices on client/patient navigation throughout different
sectors of the health care continuum. Use these best practices to identify and develop standards and
an implementation strategy for client/patient navigation.
•
Connect with other national, provincial and local groups regarding best practices, such as the Stroke
Strategy, that already have an infrastructure and can share lessons learned.
•
Establish task forces (composed of managers, front-line staff and client/patients) to develop:
o Navigational standards
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5 Portfolio of Palliative
and End-of-Life Care
o Customer requirements of system
o Inventory of service providers in SEO system (refer to Admin priority titled “Ensuring Better
System Navigation for Client/patients at the Community Level”)
o Dedicated funding from LHIN
Examples of how the Client/patient Navigation Infrastructure might work:
•
Readily Accessible Information: Information about services available within the system need to be
readily accessible to client/patients, patients, family, caregivers and service providers. A lack of
awareness about services and potential options handicaps the system and makes poor decision-making
more likely. Modern information technology such as the Internet can facilitate greater awareness and
informed decision-making (refer to Admin priority titled “Ensuring Better System Navigation for
Client/patients at the Community Level”).
•
Flexible Care-Management Process: A flexible case-management process needs to be in place, which
integrates the flow of client/patient information/care activities and actions. The system needs to
recognize there may be multiple agencies/agents involved for variable time periods.
•
Accountability: There needs to be accountability to client/patients/caregivers/service providers and the
system in terms of special needs of clients/patients.
•
Evidence-Based Care Plans: Where possible, evidence-based care plans should be the focus with
emphasis on unique and special needs of the client/patient.
It is strongly recommended that an exclusive portfolio for palliative and end-of-life care be assigned to a
senior executive in the LHIN management team and that resources are made available to:
1. Support a fulltime coordinator / facilitator for the developing Southeastern Ontario /Palliative /End--of
-Life Care Network. The coordinator/facilitator will provide leadership to the Network as it adopts its
vision and operationalizes its mandate, goals, and objectives.
2. Complete the roll-out (including training, implementation and evaluation) of the Regional Palliative
Care Integration Project tools across all sites of care and provider groups and individuals with 90%
compliance (with use and sharing of common language, assessments and clinical practices) upon
audit;
3. Complete the three (Lanark, Leeds & Grenville; Kingston, Frontenac, Lennox & Addington; Hastings &
Prince Edward) local service delivery model plans and implement the identified new processes and
protocols across Southeastern Ontario.
4. Conduct a formal evaluation, using a validated (by the consumer and family members using the
system) set of key indicators of success derived from the Key Objectives listed below.
5. Adapt the strategies as indicated by the evaluation results and implement changes;
6. Re-evaluate annually and adapt as indicated.
Key Objectives (to be validated through consultation)
The workgroup has identified the following as the initial Key Objectives for Evaluating the Integrated
Palliative Care Services System as derived from gaps and issues, identified by volunteers and visiting
February 21, 2005
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February 21, 2005
hospice organizations, in the current palliative and end-of-life system:
(i) Sufficient Resources in the system (financial, human, IT) to shorten length/time needed in
hospital; allow at-home/facility care services to provide comprehensive palliative support; and, ensure
rural care settings have equitable access.
(ii) Consistent and coordinated information transfer takes place from site to site; providing
consistency of caregivers (when possible); and mechanisms to both meet privacy obligations and
ensure appropriate information sharing to prevent confusion and disruption for the person and their
family.
(iii) Effective recruitment, retention and ongoing training of service providers to ensure sufficient health
human resources (nurses, doctors, volunteers, etc.) are prepared and available to meet
need.
(iv) Appriopriately planned and provided local service delivery to ensure flexible/timely access to services
as needs change (quickly); and on-call for crisis response 24/7.
(v) Appropriate Knowledge and Information is available to Patients and families to allow them
to know when and how to access services.
(vi) A District-wide Registry for Palliative Patients to ensure timely linkages and
support.
(vii) Physicians (at diagnosis) provide information and timely referral to palliative system/services to
begin appropriate support and relationship building.
(viii) Streamlined easy access to equipment to ensure appropriate care is available “when needed”, 7
days/week, for as long as needed.
(ix) Compassionate Care Leave (through Unemployment Insurance) to be more flexible, as needed and
repeatable to fit need.
(x) Common assessment tools, language and collaborative care planning to ensure consistency is used
across the district.
(xi) Care is provided as close to home as possible and informal supports are arranged to provide needed
support when it is not possible to stay in the home.
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II. Administrative Support Services Integration Opportunities
Priority
Opportunity
6 E-Record
Recommends the following action and budgetary investment to achieve the following deliverables:
1. Preparation for regional PACS submission to MOHLTC and Canada Health Infoway
2. PACS Regional submission
3. Identification of key patient information for sharing
4. Data sharing model
5. Develop costed application to fund regional EHR
7
Nurse Practitioners
8
Rural Community
Partnerships/
Volunteers
9
Providing
Meaningful
Geographic Input to
Planning &
Implementation
February 21, 2005
STRATEGY/ACTION PLAN
•
Strike a steering committee/NP advisory committee
•
Conduct an environmental scan of existing supply and distribution and services. Look for areas ripe for
capacity building (e.g., acute care/ambulatory clinics that could increase number of patients seen in a
timely fashion if an ACNP was working with physicians on that service). COPD clinic referrals are out of
control in the first year of that clinic being opened, patients wait a year to see an endocrinologist.
•
Enhance existing supply, using a phased approach, with a focus first on acute care NPs
•
Develop & Implement a change management plan (public, providers, admin, other key stakeholders)
•
Align the regional NP strategy with provincial NP initiatives (consider NP Integration Final report of
2003, recommendations & monitor task team progress)
•
Develop a NP recruitment and retention strategy
•
Provide support for networking of NP-NP and NP-other providers in all sectors
•
Create innovative models of NP care and outreach services (e.g. street health, high school clinics,
Breast Cancer clinic, women’s wellness centre)
•
Explore successful models of wait –list initiatives (e.g. Cardiac Care network, decrease in wait times to
diagnosis for breast cancer)
•
•
•
Policy statement developed by LHIN Board identifying demographics that can be served.
Establishment of LHIN working group to bring together all organizations reliant on volunteers.
LHIN must publicly support and recognize the value of volunteers in system integration and service
coordination.
•
Recommend widest possible geographic representation of the LHIN Board.
•
Professional planning and Community Development Ssaff will be essential supports to the LHIN process
and decision-making.
•
Establish structures focused on providing important as-needed advice on community issues and supporting
ongoing input, possibly based on a series of Community Advisory Boards. These Boards or committees could
be similar to those mandated in Community Care Access Centres. Where there are patient rosters, these
should be relied on to select patient/public representatives. Since Community Advisory Boards are essential to
the implementation of Family Health Teams, these should be incorporated into the LHIN Community Advisory
Board Structure to the extent possible. Providers should be expected to show evidence of community
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II. Administrative Support Services Integration Opportunities
Priority
Opportunity
consultation in the development of service plans incorporated into provider accountability agreements with the
LHIN Board and government.
•
Develop a data collection and analysis strategy capable of providing reliable information on the nature of
both the illness and the treatment provided under the existing and the transformed system.
•
Utilize appropriate technology/means to assure access/participation in decisions (transportation,
teleconference, moving meetings throughout the region “to the people”)
•
Evaluate first year decisions through appropriate community consultations (focus groups, informant
interviews, polling, etc.).
10
Ensuring Better
System Navigation
February 21, 2005
Establish a Steering Committee - composed of service-provider and agency representatives from across the
health care continuum including managers, front line staff, IT experts and clients.
•
Mandate is to oversee the development of the interactive Internet tool for service providers and
agencies and to establish a “one number to call” telephone system
•
Establish task forces on:
Inventory Assessment – conduct an inventory of all agencies and service providers involved in
providing services to clients/patients (i.e. disease based groups, community agencies). Identify
which agencies have websites and also which ones provide French language services.
Privacy Guidelines – develop privacy protocols/standards on client/patient information transfer
between service providers that allows service providers to provide referrals to better service
clients/patients.
Technology Committee – to make-it-happen: to set up the portal, and establish the telephone
forwarding system; for those service providers who do not have websites provide funding to
develop them; once website portal and telephone system is complete, provide user training to
all service providers/agencies.
To set up and manage procedures and processes built upon a computer platform to facilitate
communication between and among the parts of the health care system – this would take the
form of teleconferencing; video conferencing; “E-Rooms”; service provider list serves; etc.
Enhanced communication would be the result, with a reduction of time spent on traveling to
meetings. Hardware and software requirements would be determined and staff training would
be needed. Evaluation and continuous upgrading would be required.
LHIN will be responsible for setting-up and managing the information portal for 2 years, which is sufficient time
for a natural leader to emerge and take the lead role in managing the information portal.
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D. Capturing Unique Characteristics of each LHIN
What role Academic Health Sciences Centres and voluntary Networks (e.g. Emergency Network, Child Health Networks) play
within each LHIN (please limit your response to 2 pages)?
1. Academic Health Sciences Centres
The residents of Southeastern Ontario have benefited greatly from the presence of an Academic Health Sciences Centres within the
geographic area. The contributions of 3 distinct groups must be acknowledged. Theses groups are:
•
The health sciences program that includes medicine, nursing, rehabilitations and epidemiology
•
The non-health sciences programs which add to the body of knowledge available to district residents such as urban and regional planning,
public administration, business, geography with its CIT Laboratory and education.
•
Other educational institutions such as community colleges (2), private for-profit programs, and ongoing education programs from
provincial and federal services (i.e. Armed Forces and Corrections Canada)
It must be emphasized that this is seen as a two-way beneficial relationship. Health care is better because of the expertise of these academic
programs and the academic programs benefit from having a positive working relationship with the various service programs dispersed
through an urban and large rural area. Some academic programs extend outside the geographic area of the present district to such places as
Barrie and The James Bay Coast.
Presently, the academic programs provide formal training and continuing education opportunities that are accessible to all kinds of
practitioners. They also, on an individual basis, contribute greatly to the planning, implementation and coordination of health services and the
health services delivery system.
It will be important for these academic programs to establish linkages with the LHIN and to work at establishing a mutually beneficial working
relationship. Areas in which the academic programs could assist the LHIN include:
•
Conducting and sharing epidemiological, health care and system delivery research that will be used to assist service organizations in
standardizing evaluation and accountability efforts.
•
Supporting programs evaluations.
•
Providing “best practice” research and acting as consultants to make this information accessible.
•
Assisting the LHIN to identify the need for the types and numbers of future practitioners required to make upcoming human resource
system challenges.
•
Providing representation on the relevant LHIN committees.
•
Assist with the development and implementation of the evaluation of the LHIN.
February 21, 2005
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2. Voluntary Networks
Southeastern Ontario has a long history of establishing and working with voluntary networks. Some of these networks have resulted in
voluntary restructuring of organizations while others have focused on specific services between and among the independent partners. The
commitment to these networks speaks loudly to the desire to work together to improve client care and to facilitate joint activity between
urban and rural communities. Examples of these networks in Southeastern Ontario include:
•
The Health Care Network of Southeastern Ontario. This organization first began meeting in the early 1990s and was formally
established in 1993. It is a voluntary partnership, which includes 3 CCAC, IDHC, 3 Health Units, Queen’s University, and the 6 hospital
corporations of Quinte Health Care, Lennox and Addington County General Hospital, Kingston General Hospital, Hotel Dieu Hospital,
Providence Continuing Care Centre, Brockville General Hospital, and Perth/Smiths Falls Hospitals. It is designed to be an important venue for
the partner organizations to design, implement and monitor integrated health service delivery systems. Members have been effective in
rolling out the Stroke Strategy, same day cardiac catherization, and in developing a strategy for infection control. Recent initiatives include
linked information technology systems and an electronic health record. Work is underway to establish a Regional Urban Transportation
System Committee, which will include representatives from the six municipalities throughout the district.
•
Alliance of Southeastern Ontario of Addiction Services This alliance was one of the first such networks established in Ontario and
includes all the addiction services throughout the district. The emphasis is on planning and integration activities.
•
Southeastern Ontario Mental Health Alliance. The membership in this group includes any group funded by the MOHLTC for mental
health services and includes Queen’s University Department of Psychiatry. In their second year of operation, the group is focusing on specific
services such as crisis services and data collection.
•
Quinte Health Care Corporation Four hospitals in Hasting/Prince Edward became the Quinte Health Care Corporation.
•
Perth and Smiths Falls Hospitals incorporated into one hospital
•
Providence Continuing Care Centre St. Mary’s of the Lake Hospital in Kingston, St. Vincent de Paul Hospital in Brockville, Kingston
Psychiatric Hospital, and Providence Manor in Kingston became integrated as the Providence Continuing Care Centre.
•
Renal Dialysis. A number of communities requested that the local renal dialysis program be provided by an outreach from Kingston
General Hospital to facilitate optimal patient care. These communities include: Smiths Falls, Picton and Belleville with a proposed site for
Bancroft.
•
The Rural Health Services Network This voluntary network includes health agencies in Hastings and Prince Edward Counties. It
focuses on cooperative planning and integration efforts that are self-supportive. Their accomplishments include work on a Human Resources
Strategy.
•
The Southeastern Ontario Academic Medical Organization (SEAMO) Alternate Funding Plan is designed to allow Queen’s Faculty
of Health Services to fulfill its three-part mission – education, research and clinical care – while providing appropriate remuneration to its
physicians. The alternate funding mechanism is a significant benefit when recruiting physicians. However, it does not allow for spontaneous
growth in emerging clinical areas or as population needs change – without considerable lead time for negotiation with the funder.
•
The Stroke Network This group has developed a steering committee infrastructure that allows for representatives from across the
continuum of care (including community and support agencies) to come together to better manage transition. It has conducted transition
workshops and is piloting transition tools and care plans that cross the continuum of care.
February 21, 2005
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•
The Dementia Network This group has developed a common approach and framework for collecting and delivering work plans as well
as identifying clear roles and accountability that allow more effective working relationships.
•
The Southeastern Knowledge Exchange Network The mandate of this group is to make information and transfer of knowledge
relating to care of the elderly more accessible across agencies and the region. It includes representatives from PCCC, Academic Health
Sciences Centres, Regional Geriatric Program, Palliative Care and Queen’s University School of Business.
•
Quality Volunteer Management This project for East Region, funded by the MOHLTC, has developed standards and an agency audit
tool for community Support Service agencies.
•
Volunteer Transportation in Southeastern Ontario project funded by MOHLTC to study transportation provided by Community
Support Service agencies.
•
Palliative Care Network There have been three Palliative Care Networks operating throughout the district for a number of years and
they have formed together to complete specific projects. At the end of this fiscal year there should be one overall Palliative Care Network for
Southeastern Ontario.
•
Perinatal Partnership Program of Eastern and Southeastern Ontario (PPPESO) As an integral part of regional perinatal care for
over 20 years, the Perinatal Partnership Program of Eastern and Southeastern Ontario (PPPESO) works together with: Hospitals, Health
departments, Community agencies, Academic institutions and Private practitioners/consumers to promote optimum perinatal care of
childbearing families in Eastern and Southeastern Ontario in order to improve health and to achieve excellent perinatal health outcomes.
•
Three Community Support Services Agency Networks meet regularly in Hastings and Prince Edward Counties; Frontenac, Lennox &
Addington; and in Lanark, Leeds & Grenville. The agencies share best practices in the management of volunteers and work together so that
the rural and urban agencies can bring services closer to home for clients.
•
Community Support Services agencies in Southeastern Ontario meet 3 times a year to share best practices and hold joint educational
opportunities.
LHIN 10 is fortunate to have agencies/institutions that have a history of working together. Its challenge will be to build on this grounding to
make meaningful change and knowledge transfer. It will need to focus on inclusiveness and principled functioning. One key aspect of this
relationship will be whether the LHIN will be able to offer tangible resources to assist the various networks in this work. There will be the
added issue of two Health Science Centres and 2 LHINs in Eastern Ontario. The work of LHIN 10 will, by necessity, need to focus on the
system of services within its geographic areas and the associated academic health sciences programs. However, it will need to collaborate, as
appropriate, with LHINs 9 and 11 to ensure that residents who access specialty services from other Academic Health Sciences Centres are
also well served.
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Describe any unique characteristics/features of your LHIN that impact this process and/or future Integrated Health Services
planning activity (please limit your response to 2 pages.)
Unique Characteristics of Southeastern Ontario
The Local Health Integration Network will need to consider the following key components of the “context” for health services integration in
Southeastern Ontario:
•
A large geographic area, home to almost 500,000 people, 46% of whom live in dispersed rural communities (verses 14.5%
for the provinces). The northern two-thirds of the district is a mix of rural and small urban communities many of which are distant from the
main larger urban centres in the South. Rural areas of this size and with this low population density are particularly challenging for providers
of community and home care services. The larger centres are mainly along the 401 corridor. This geography presents challenges with factto-face networking; however it can present opportunities for electronic methods of communication and working together.
•
Demographically there is an older population in Southeastern Ontario as compared to the average in Ontario (25.5% 55
years and older verses 22.5%) with many communities having a significant part of their population in the older cohorts. Income levels
are also a challenge for many communities.
•
The special populations which include the francophone component in the two communities with Armed Forces bases – Trenton and
Kingston, and the aboriginal communities both on and off First Nation Territories.
•
Hospital Service Restructuring and Change – Many of the hospitals in the district were directed to undertake significant restructuring.
In Hastings & Prince Edward Counties the restructuring is largely complete, while the change continues to take hold. The restructuring
continues with the focus currently on site development in the Kingston and Brockville areas.
•
An under-serviced area for Primary Care Practitioners – The Southeastern Ontario District Health Council has identified access to
primary health care services to be a significant health care need in Southeastern Ontario and in response has outlined a framework and
initiated a process for community-driven and health-oriented primary care services.
•
A history and track record with Effective Vertical and Horizontal Health Care Networks, Alliances and Partnerships –
Community leaders and health care providers in Southeastern Ontario are great collaborators and work well through voluntary interorganizational groups to improve patient/client care and access. The work of the LHIN must build on these existing structures, support them
and demand continued excellence from the partners involved in them.
•
Health Status Profile suggests Risks of Chronic Disease – It is possible to identify a number of important risk factors (e.g. high
smoking rates, low physical activity, high BMI, aging, etc.) for developing chronic diseases (e.g. diabetes, kidney disease, cardiac disease,
etc.) among the demographic and health status data available.
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•
Transportation – This is a major issue for people accessing services. It is especially acute for people living away from the 401 corridor.
•
Presence of 6 Federal Penitentiary Facilities – creates issues for support services to these facilities as well as the need for primary
and ongoing care of family members who relocate to be near the incarcerated person.
•
The presence of Academic Health Sciences Centres – discussed earlier.
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E. Transformational Thinking and the Process
Please describe the approach and process used to complete this task (please limit your response to 3 pages)
Each of the 10 priority groups developed their own process for developing their initiative documents. The SEODHC assumed responsibility for
coordinating the 10 groups and early on organized a conference call. This call established the timelines for the development of the A, B and C
sections of the document. It was agreed that each priority group would assume responsibility for their own topic and the overall group would
not do a review or any modifications. Each group was asked to provide input for sections D and E with the overall group accepting
responsibility for developing the composite. It was agreed the 10 priority groups would have the A, B and C sections completed by February
7th, in order to meet the completion deadline of February 21st, 2005.
The process used by the various groups moved from a number of face-to-face meetings to all electronic and conference calls, to taking
material previously prepared and organizing it to meet the Ministry format.
Some groups had a large number of active participants as well as numerous more people who provided input/information and could have
participated had they so vested. Other groups had smaller numbers, which subsequently limited involvement with those outside the
immediate group.
Most groups used e-mail as the basis for communicating throughout the group. It was identified that this is a factor that prevents many
volunteers from actively participating in the process due to limited home computer capabilities. The positive side was it allowed those who
could not attend conference calls or meetings to receive the material with the opportunity to share their reactions and suggestions.
Conference calls were often used as a way to attain agreement on the material.
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Please describe key learnings that came out of this process (please limit your response to 2 pages)
•
This process provided the opportunity for stakeholders to understand more fully the system as it currently is functioning. It also allowed
the examination of our current networks with the realization of the work that has been accomplished in this district prior to any such
discussion of this policy direction provided by the LHIN planning.
•
For some people, this was the acknowledgement of the system strengths, which can provide a basis for further integration. This process
provided opportunities for discussion on moving forward on initiatives while awaiting the development of the LHIN.
•
The relative ease to address this priority opportunity for integrating addictions and mental health services across the continuum of care
(and the lifespan) is illustrative of our familiarity with/readiness for transformation. A key learning has been, once again, that there are many
of us who invest ourselves above and beyond the every day requirements of our jobs in order to promote better integration.
•
Another key learning would be the requirement to invest properly in setting up the channels and opportunities for inclusion of the general
public and broad representation from among "consumers" of our services in the integration process, including the proper resources for
program evaluation.
•
Found discussions on the principles insightful and helpful to the project.
•
It was interesting to learn the concerns of the group &/service providers were similar regarding.
•
Co-learning in rural areas is key to finding suitable service provision space in rural areas.
•
Collectively expanded our understanding of accountability for case management; learning that transition is not a point but rather a
reoccurring process within the continuum of care.
•
Our discussions revealed the need for a business case/financial plan to be developed to identify and determine the cost needed to put this
initiative into action and achieve the anticipated outcome.
•
A central co-coordinating body is required to provide infrastructure to move task ahead. Ideally the LHINs would be best able to provide
the level of planning and coordination needed to achieve this initiative.
•
Face-to-face meetings seem to be most useful when one desires to obtain a commitment early on in the process.
•
E-mail limits involvement of some volunteers.
•
Additional time could have allowed other participants in rural and urban communities in the South East to be consulted and could have
identified other opportunities associated with these initiatives.
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F. Remaining Opportunities Identified
1. District Wide Primary, Secondary, and Tertiary Medical Manpower Plan
Title of Integration Opportunity:
Type of focus
District Wide Primary, Secondary, and Tertiary Medical Manpower
boundaries
Patient Care Opportunity
Admin Support Opportunity
List of participants:
•
•
•
•
•
•
•
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Allan Katz, Healthcare Network of SEO
Carlene MacDonald, Leeds - S. Greenville Physician Recruitment Program
Carol Wannamaker, PCCC Health
Elizabeth McIver, SEO DHC
Hersh Sehdev, NK CHC
John Hudson, KGH
Ken Law, Leeds and South Greenville Physician Recruitment
Ray Marshall, BGH
Please briefly describe the integration Opportunity:
Analysis of the current state:
•
Location of Practice (area geographic/clinical),
•
Capacity (full/part time, other commitments),
•
Numbers,
•
Demographics,
•
Funding Incentives,
•
Practice Issues.
Population analysis with projected demand for 5 and 15 years
Describe preferred state regarding:
•
Numbers, ratio, ranges
•
Where services are delivered – consider population, workload, lifestyle issues, appropriateness for each secondary and tertiary
setting
•
Alternate providers/practices and changing roles and skills
•
Technology
•
Ownership of mandate
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•
•
•
•
Education system changes
Site of care (i.e. emergencies = hospitals, urgent care = CHCs, how use other parts of system)
Opportunities for growth and research
Funding incentives
Why is it a Priority?
•
•
•
•
•
Waiting times will continue to exist
Resources in some communities will continue to be underutilized while other sites will be overextended
Care at overextended sites will continue to be put at risk because of overload
People will continue to experience unnecessary travel and less family support / isolation
The “we and us here” will continue to exist with the resulting lack of coordination and integration
Topic Initiator:
Name: Elizabeth McIver
February 21, 2005
Organization: SEO DHC
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2. Pharmacy Care
Type of focus
Pharmacy Care
•
•
Hugh Graham, Hotel Dieu Hospital
Jack Gibbons, Quinte Health Care
boundaries
•
•
•
•
Pharmacists are primary contacts for medications (OTC, Rx) in the community setting and already play a key role in providing
health care.
Pharmacists must be integrated into the health networks in order to better collaborate and coordinate with other providers to
improve system efficiency and patient outcomes.
Pharmacists as the medication management experts have a key role to play in the LHIN regions beyond the Family Health Teams at
the community level. Currently pharmacists’ expertises are being underutilized.
Pharmacists will require IT support to connect to other health care providers such as public health, physicians, hospitals, long-term
care facilities, etc.. for information exchange in optimizing medication usage.
•
It is a priority because you must have a hand-in-glove operation between the patient and physician (or other health professional),
the patient and pharmacist, and then pharmacist and physician. This is at the community grass roots level.
Topic Initiator:
Name: Bruce Faulkner
February 21, 2005
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3. Professional Practice
Type of focus
Professional Practice
boundaries
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•
•
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•
•
•
•
•
•
•
Eleanor Rivoire, KGH
Gerogina Thompson, All Care Health
Joan Bennett, Sherwood Park Manor
Kathy Chesnick, KGH and HDH
Kathy McRae, Kingston Frontenac Lennox and Addington Health Unit
Monica Maly, OPA
Nicholas Kaduck, KGH
Sharon Mindle, CCCH
Shelagh Nowlan, PCCC
Shelley Huffman, Care Connect
Sue White, Public Health Unit
Susan Shoniker, Nurse
•
•
•
Horizontal integration of an administrative vehicle that supports the health care provider (regulated and unregulated) in the deliver
of safe, effective, ethical patient/family focused care that, for the regulated provider, is congruent with professional/regulatory
standards.
Professional Practice relates to standards of practice, scope of practice, credentialing, and education of health care providers.
Keys to success
o Formal infrastructure within partner organizations and within LHIN

Strong messaging by formal leaders throughout LHIN

Accountability framework and key outcomes measures
o Technology to support communication/education amongst partner organizations
o Culture of partnership across the continuum
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•
•
•
Professional practice is the basis of quality care.
Professional practice defines the professional and legal accountabilities of regulated providers in the delivery of care.
A LHIN infrastructure for professional practice that supports the communication and integration of professional practice activities
within and between disciplines will:
o Build relationships and capacity for problem solving across the continuum of care
o Facilitate consistency in practice based on the best available evidence across the continuum of care

By default this should ensure consistency of care from the perspective of patients and their families
o Reduce duplication of effort across agencies
o Maximize the sharing of intellectual capacity (i.e. knowledge transfer) for each discipline
Topic Initiator:
Name: Kathy Chesnick
February 21, 2005
Organization: KGH/HDH
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4. Human Resources Planning, Remuneration, Working Conditions
Type of focus
Human Resources Planning, Remuneration, Working Conditions
boundaries
•
•
•
•
•
•
•
•
•
Barbara Theman, Providence Continuing Case Centre
Bill Devries, Lennox and Addington Community Mental Health Services
Gavin Anderson, OPSEU/Pathways for Children Youth
Larry Norman, Provider Continuing Care Centre
Marg Atkinson, RNAO
Mike Seeger, MOHLTC
Ross Sutherland, Health Coalition
Sandra Willard, Kingston health Coalition, Personal Support Worker Association
Sheryl Ferguson, OPSEU l-431 PCCC, MHS
Integration of human resources planning, including remuneration and working conditions
•
•
•
•
•
This is critical for integrated management and policy change to be effectively implemented.
Employees have to be able to move within the system in a way that encourages change, provides new opportunities, and provides
as much stability as possible in employment security, and remuneration and working conditions.
It allows health care workers to deal with the key elements of change without facing chaos in their key employment conditions.
Security provides for increase quality of care, continuity of care, staff recruitment and retention and good moral.
Key recommendations:
o Negotiate an overall HR plan, preferably province wide
o Move toward equalization of remuneration across sectors and between urban and rural areas
Topic Initiator:
Name: Ross Sutherland
February 21, 2005
Organization: Health Coalition
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5. Chronic Disease Prevention and Management – Integrated Multidisciplinary Approach
Type of focus
Chronic Disease Preventions and Management – Integrated Multidisciplinary
Approach
boundaries
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
April Spatula, Cardinal Manor, Madoc Hospice
Betty McIver, SEO DHC
Bill Gekoski, Ontario Community Support Association – Board Member
Carole Brearley, St. Elizabeth Healthcare Kingston
Dorothy Ann Last, North Kingston CHC
Janet Siranni, SEHC
Joe Pemora, KGH
Lance Thruston, City of Kingston
Lyn Linton, Gateway Community Health Centre
Marg Atkinson, RNAO Kingston Chapter
Nadia Zurba, Country Roads Community Health Centre
Nam Bains, Health Information Partnership, Eastern Ontario
Philip Ambury, The Arthritis Society
Phoebe Collard, St.Lawerance District Medical Centre Lansdowne
Susan Hoche
Wayne Greenway, SEO DHC
•
•
•
Chronic disease prevention and management provide the single largest opportunity for LHINs to increase quality of care for
patients, shorten waiting times, and integrate all levels of care vertically, horizontally and intersectorally.
Current chronic disease prevention and management services are fragmented, contain many gaps, and are insufficient in many
areas resulting gin lack of access, unnecessary acute episodes, and discomfort for Ontarians (Arthritis, COPD, Asthma, Diabetes,
Stroke, Kidney, Blood disorders i.e. Hep C, HIV)
Integration at all levels and sectors (health, education, social services) is possible through this initiative. This process may be
staged as the LHIN develops. LHIN is uniquely positioned to initiate collaboration.
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•
•
•
•
Chronic disease is a huge, growing and not always quantified cost to the system and families.
Cost of disease prevention is less than the cost of treatment.
Cost of care for chronic diseases is unsustainable in the long-run.
There is an identified need for collaboration to share data and use this to plan health promotion and appropriate services.
Outcomes:
•
Creating an interdisciplinary and intersectoral model of care offers these potential outcomes to Ontarians living the SE LHIN:
o
o
o
o
o
o
o
o
o
o
o
Improved quality of life
Reduced health care costs
Access a network of services closer to home
Reduction in barriers
Reduced ER visits and acute admissions
More cost effective utilization of resources
Development of best practices in prevention, screening and treatment
Wellness focus
Appropriate use of disciples at appropriate places (i.e. interprofessional, interdisciplinary, community based)
Involvement of non-health care funded agencies and programs
Better education of consumers
Topic Initiator:
Name: Carole Brearley, St. Elizabeth Healthcare Kingston
Hersh Sedev
February 21, 2005
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6. Build a Single System for Integrated Regional Service Capacity Decision Making
Type of focus
Build a single system for integrated regional service capacity decision-making
coupled with individual patient/client navigation of service use within and
across services/organizations so that capacity is used both effectively and
efficiently to produce best possible health outcomes.
boundaries
Bernadette Byrne, COTA
Carole Weir, KFLA CCAAC
Cheryl Prest, All Care Health
Elaine Johns, Independent
Jeannine Proulx, ACFO Mille-Iles
John Proulx
John Puxty, PCCC Health
Mark Larratt-Smith
Nancy Sears, KOS
Shirley McLaren, All Care Health
Wayne Greenway, SEO DHC
•
Integrated service design and patient/client service us through integrated service capacity decision making by LHINs and
individualized patient/client navigation across services and organizational boundaries by case/care managers with either generalist
or specialist (programmatic) expertise.
•
•
•
Currently service capacity decisions are made by individual organizations or small groups of organizations, in consultation with the
MOHLTC, and the simultaneous emergence of related capacity plans may not emerge from other organizations/small groups. This
results in incompatibilities between the ability of different services to meet the needs as a patient/client tries to move across or
through the services offered by different sectors/organizations.
One regional accountability framework for full regional system capacity could end this fragmentation.
At the same time, the development of a navigation system for individual patients/clients that could guide their travel across
services and transition between services (possibly system wide care/care management services) that know the intricacies of this
system wide capacity could ensure effective and efficient use of the available services by each patient/client. In this way, the
“aggregate” planning is developed along with a mechanism for best individual use.
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Details
•
We need a way to use identified individual needs in a region to be used to both allow the individual to navigate through all of the
available services in an efficient way to produce effective health outcomes, as well as to integrate the data about individual needs
to build an aggregate information base of regional population needs. The former drives the use of services by individuals and the
latter drives capacity decision making for each service within and across the system. This marries with initiatives regarding
electronic data collection and an electronic information management system.
•
Individual patient involvement: This is the front end of the regional system. The case manager of individual access and use of
health care services was originally the family physician, and for CCACs and CCAC specific case manager. The new case manager is
system wide and a specialized service. There could be generalists as well as specialist case management practitioners. Every
patient/client in the system could opt into the case management model. The case manager moves across organizational boundaries
and moves the patient/client across services.
•
System Involvement: LHINs need to have the responsibility and accountability to develop integrated system and service capacity.
To do this, they will need to be able to exercise flexibility in funding and decisions both across and within funding cycles. When
making service capacity decisions, prevention needs to be one of the services with funding capacity managed by the LHIN.
•
Funding should first be geared to programs of services that cross organizational borders before it is subdivided into organization
funding to provide that organizations part of the program.
•
The program capacity needs to be set by aggregating evidence of need within the population for that service. Switzerland has a
model for planning of health and social services for seniors that could be used as a template for developing this system capacity
and service use mode
•
Current threats to developing an integrated planned and used system and remedies for these threats are:
o Agencies in the system not taking the LHINs seriously. Overcome this by giving the LHINs funding teeth early on such as
immediate allocation responsibility for new money entering the region.
o Labour agreements that restrict the ability of human resources to move across organizational or professional boundaries.
Overcome this by having a region-wide core for all labour agreements that allow transitional and temporary sharing of
networks and resources.
o Gaming of the planning system by organizations. Provide financial incentives for organizations tied to improved program
wide effectiveness of services demonstrated by improved patient/client outcomes and reduced need for organization
services.
Topic Initiator:
Name: Nancy Sears
February 21, 2005
Organization: KOS
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7. Integration of Community Support Services
Type of focus
Integration of community support services into the system and developing
culture of education regarding their central role in an integrated system
boundaries
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Ben Ginou, CNIB Ontario Division
Carole Cooke, VON
Diane Luck, Seniors Association Kingston Region
Doug Downer, CNIB Hastings PE – Kingston
Jack Gibbons, QHC
Jack Moore, QHC
Joanne Jenkins, Community Care for South Hastings Inc
Laura Hare, Alzheimer Society of Belleville-Hastings
Lin Spence, Sexual Assault Centre Kingston
Linda Jackson, Alzheimer Society of PEC
Lori Cooper, VON H and NPE
Marsha Stephen, East Region
Sharon Mindle, Community Care for Central Hastings
Susan Andrew-Allen, Land O’Lakes Community Services CSP
Tracey Bennett, MBQ Home Support
•
•
•
•
•
•
•
•
•
•
•
•
Opportunity to educate and create linkages across the system of the value of community support services to help people age in
place.
Increase community understanding of community support services (services & volunteer recruitment).
Community support services are the critical component of the system from beginning to end.
Review the coordination and integration opportunities within community support services.
Build on community support services to focus on client and caregiver needs.
Integration of back office services.
Simplify access to all health services (including discharge from Emergency Room).
Health system should have many entry portals.
Community support services (CSS) have the flexibility to respond to local community needs.
CSS provide prevention and wellness services (nutrition, mobility) and can divert from acute and primary care.
With the retirement of baby boomers, there is a potential for larger pool of volunteers.
CSS plays a huge role in medical transportation, which could be expanded.
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•
•
•
•
Community Support Services are an integral part in an effective health system.
CSS are truly community driven (grassroots) – often locally funded (under-funded) with minimal resources, supported by
volunteers and donated dollars.
The culture of the new system must include community support services and volunteer service provision.
The volunteer involvement in services is important and has an impact on diverting people from acute care.
Topic Initiator:
Name: Debbie Monyes & Lori Cooper
February 21, 2005
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8. Improving Access to Cancer Services across the Continuum of Care through an Integrated
Access Management System
Type of focus
Improving access to Cancer Services across the continuum of care through an
Integrated Access Management System
•
•
Dr. Anne Smith, KRCC
J. Sergey
boundaries
•
•
•
•
•
•
•
•
Fragmentation of care is a recognized issue for cancer patients with long wait times and variable access to cancer services.
Currently, there are no links between primary care, diagnostic assessment, surgery, or radiation/chemotherapy treatment.
A system is required to assist providers managing patients journey through the cancer system.
Such a system is readily available through the use of the latest web based technology that collects data from already existing
databases to create an at-a-glance easy to use application. This can link all of the various components of the cancer care journey.
Through the use of flags to alert providers when wait times are exceeded which allows interventions to occur, patients can be
managed through the system. Bottlenecks can be identified.
Such an access management system allows individual patients’ to be coordinated and also allows the system as a whole to be
looked at and modified as necessary.
Populations, such as by disease site, or by service needs, can be reviewed to look at access to the system as a while through
aggregate wait times. The reasons for waits and the standards for wait times, or accepted best practices, can be easily introduced
into the application.
The result of the integration is that there is an electronic tool which assists providers to manage patients through the cancer
journey, assists in transition from one part to another – resulting in improved access and reduced wait times.
This can truly integrate cancer services. It is an open-source concept, so easily adapted to patient care or other systems already in
place.
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•
•
•
Cancer incidence and prevalence continues to grow – an aging population, a growing population, and an absolute increase in
incidence for some cancers.
It is estimated that cancer will be the greatest burden to the health care system by 2010.
Cancer crosses all aspects of the health care system and lends itself to addressing integration across the continuum.
Topic Initiator:
Name: Dr. Anne Smith
February 21, 2005
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9. Sharing Administration Resources
Type of focus
Sharing Administration Resources
boundaries
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•
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•
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•
•
•
•
•
•
Belia Brandon, Leeds & Greenville Rehab and Counseling
Debbie Rollins, Hastings Manor LTC Facility
Dianne Raby, Access Centre Lanark, Leeds and Greenville
Gavin Anderson, OPSEU
Gower Bradshaw, L & A County Hospital
Ingo Ritums, ROHCG/BPH
Karen Gill, Alzheimer Society of Kingston
Linda Jackson, Alzheimer Society of PEC
Mike Poulin, Lanark County Mental Health
Paul Finner, SEO DHC
Rick Conley, ParaMed
Rose Bell, Rideaucrest Home
Shelia Irvine, ROHCG
Sherry Kennedy, Community
Vera Rabadi, ParaMed
•
•
•
Sharing non-clinical resources i.e.: human resources, management, purchasing, collocated sites, IT, hotel, payroll, finance,
accounting, education, insurance, information management, data collection.
Consolidate smaller agencies and bds and capitalize on expertise e.g. Quinte Health Care, larger agencies can sponsor smaller
agencies, contracting out discussions, centralize labour issues, forum to maintain and develop highly skilled labour, given ageing
work force at present, centralize bargaining, chance to challenge agencies to reduce administration costs,
Let agencies develop a model, which is target driven.
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Reduce
•
•
•
•
•
costs so to:
Increase efficiency to increase direct clinical care capacity to client
Provide affordable expertise for RFPs, business advice, etc..
Blend different corporate cultures
Harmonize wage, benefits, retirement, packages, etc..
Improve retention and recruitment
Topic Initiator:
Name: Belia Brandow
February 21, 2005
Organization: Leeds & Greenville Rehab and Counseling
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10.
Long-Term Care – It’s Your Future
Type of focus
Long-Term Care – It’s Your Future
boundaries
February 21, 2005
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Brenda Duffy, St. Lawrence District Medical Centre
Brett Gibson, Carveth Care Centre
Brian Smith, Lenadco Home
Carol Corcoran, Friendly Manor NH
Carole Irving, Kentwood Park, Picton
Charmaine Jordan, Stirling Manor Nursing Home
Constance Couch, Ongawanda
Darlene Murphy, Helen Henderson Care Centre
Deb Skeaff, OMNI Healthcare Maplewood Brighton
Debby Conroy, Lenadco Home
Dianne Fox, Lenadco Home
Elizabeth McGrath, Crown Lodge Health Care
Greg Freeman, Crown Ridge Place
Judy Merlock, Stirling and Friendly Seniors
Julie Shillington, Fairmount Home
Larry Gibson, The Gibson Group
Larry Norman, Providence Continuing Care Centre
Leslie Morrow, Maplewood Kentwood Park
Marilyn Benn, Extendicare
Marion Landon, Lenadco Home
Mary Lynn Lester, West Lake Terrace Picton
Shelia Langton, PCCC Health
Shelagh Nowlan, PCCC Providence Manor
Shelly Bender, Carveth Care Centre
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•
•
Vital provider in the continuum of care
Area long term care facilities would work together to utilize existing resources to improve the provision and delivery of services
through the following:
o Integration of our existing services to provide best practices/efficiencies
o Sharing of knowledge and education
o Areas of expertise – wound care, palliative care, nutritional care, pain and symptom management, family support and
involvement, restorative care, physiotherapy, infection control, dementia, spiritual care, supportive measures and life
enrichment.
o Work with acute care providers to increase the acute care services available in the community through long-term care
providers.
•
•
•
•
•
To provide equality in health care and services to seniors within the LTC home and the community through the integration of
existing services to provide best practices/efficiencies.
An increasing number of aging population
Improve cost efficiency
Improve quality of life
Improve sharing of resources
Topic Initiator:
Name: Linda Pierce
February 21, 2005
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11.
Decreasing Duplication of Costs Associated with Delivery of Health Services
Type of focus
Decreasing duplication in costs associated with the delivery of health services
and reinvesting in patient care.
boundaries
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•
Bill Devries, Lennox and Addington Community Mental Health
Carole Cooke, VON
Dot Broeders-Morin, SEHC
Elizabeth Fulton, County of Frontenac
Janet Sirianni, SEHC
Jim Garrah, Gananoque
Sue Munro, SEHC
•
•
•
Current models of Health Care Delivery create frequent incidents of duplication of activities/services across all sectors.
This creates additional stress on limited resources.
Identifying and developing strategies to eliminate this duplication will result in more of the total resources available being
reinvested into patient care.
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Incentives that result in improved quality and availability of client care, while minimizing risk and create opportunities for greater
utilization of resources at all levels should be a priority of the South Eastern LHIN.
Opportunities
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Single point of entry to care
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Leveraging technology solutions i.e. one electronic database/one client record that travels with client throughout their health care
career will:
o Minimize duplicity of interventions i.e. lab tests
o Encourage accurate “real time” information
o Improve the quality of information
o “Rules based” access meeting all privacy legislation
o Supports the planning process for resource allocation, funding and Public Health Initiatives
o Single tracking mechanisms
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RFP process-all services “bundled” where appropriate
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Evidence based/Standardized best practices
Coordinated approach to the development of education for all health care providers using “communities of learning” web based selfdirected learning.
Clear distinction of role of Case Management/single advocacy admin structure throughout the health care career and across all
sectors.
Coordinated wait list management
Topic Initiator:
Name: Dot Broeders-Morin
February 21, 2005
Organization: SEHC
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12.
Planning and Realigning Health Services based on a Population Health Model
Type of focus
Planning and realigning health services based on a population health model
boundaries
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Barbara Theman, Providence Continuing Care Centre
Bill Ryding, HPEC Health Unit
Denise Fraser, PCCC, St. Vincents de Paul Hospital
Denise Haggerman, PCCC Providence Manor
Georgina Thompson, HPEC Health Unit and ACHS
Jane Johnston, PCCC Regional Community Brain Injury Services
Joan Bennett, Sherwood Park Manor
Karen Gillan, Brockville General
Kathy MacRae, KFL and A Health Unit
Marcy Saxe-Braithwaite, PCCC
Patricia Brown, Hastings and Prince Edward Counties Health Client
Shelagh Nowlan, PCCC Providence Manor
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This group believes that if we used a population health model and health determinants we would be able to deliver more of a health
promotion and preventative model of care for residents of Ontario
Services need to be ALIGNED with the needs of the population
Required integration of services at a government level
Required linkages to key stakeholders within and outside of the traditional LHIN boundaries. For example: academic partners,
public health, dentists, school boards, community agencies, providers, municipalities, etc..
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Helps prevent crises
Avoid use of acute care services so acute care services are available for those that truly need access to acute care, i.e. prevents
road blocks
Uses health promotion model
System is ready for change in its VALUES
Supports a shift away from the traditional medical model
Supports a prevention model to address future wait lists
Can learn from existing successful models in other provinces and countries and know population health is the means for the future
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model
Is a new way of delivering health care in Ontario and it will energize and excite residents of Ontario to know it is based on
demographics and population health needs.
Topic Initiator:
Name: Marcy Saxe-Braithwaite
February 21, 2005
Organization: PCCC
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13.
Senior Friendly Focus to Accessing “Geriatric Rehabilitation Processes”
Type of focus
Senior friendly focus to accessing “Geriatric Rehabilitation Processes”
boundaries
List of
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participants:
Amy Sager, Quinte and District Rehab
Andy Quinn, Gateway CHC
Angela Ford, VON H and PE
Anne Jewel, PCCC – Reg. Geriatric Prgm
Barb Lovitt, Comcare Health Services
Carly Martin, Regional Stroke Program
Debbie Moynes, PE Country Communication Care for Seniors
Diane Luck, Ses. Assoc Kingston Region
Jennifer Mills, Quinte and District Rehab
Jaonne O’Keefe, COTA Health
Kelly Moore, Comcare Health Services
Patti Dixon-Medora, PCCC – MHS
Sandra Willard, KHG Personal Support Worker Association OPSEU
Sue Hache, SEO DHC
Tracey Bunnett, Community Care (Home Support)
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At present, there are large numbers of seniors and other vulnerable groups (e.g. Stoke survivors) accessing health care through
episodes of crisis.
Present rehabilitation planning is short-term and largely focused towards moving them out of the acute care system.
This results in premature decision-making, poor functional outcomes, increasing pressures on community and long-term care
services and recidivism and more pressure on acute care system.
Specialist services exist that are accessed by limited numbers of potential clients.
Rehab services are forced at act as “gatekeepers” of limited resources and fears of “bed blocking”.
There is opportunity to:
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Improve awareness and sharing of expertise currently within specialized services
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Develop system-wide approach to population health
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To move current planning out of silos, which respond only to part of the continuums’ needs.
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Opportunity to develop accountable case-management planning for vulnerable /frail populations
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Develop a system for transferring knowledge and competencies throughout the region using distance education and “train-thetrainer” models.
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Aging of the population is an established fact. Within 20 years, 1 in 4 will be over the age of 65 and at least as many in care-giving
roles. The majority of people age well and are part of the support system to the frail subgroup, however at present we know 10%
of the elderly population account for some 60% of acute care hospital separations over a 5-year period. Interventions that will
reduce or minimize frailty, disability and handicap will make an aging population more affordable and create a healthier community.
The LHINs provide the opportunity to move planning to a population needs focus and change an emphasis from increasing
investment in high profile acute care episodes to a more sustainable long-term community investment. Community care
investments result in better functional outcomes and reduced readmissions to acute care and are therefore better investments of
limited health care dollars.
The LHINs structure creates an opportunity to bring planners, specialists, health care providers and caregivers around a common
table to develop integrated effective care plans that the current silo based system cannot respond to.
If the LHINs had a discretionary allocation of even relatively small percentages of the present health care dollars (e.g. 2%) then
they could redirect this to community-based rehabilitation integration strategies with greater effect in reducing functional decline
and improving outcomes, keeping people at home and healthy.
Topic Initiator:
Name: John Puxty
February 21, 2005
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14.
Moving Clinical Practices into Non-Clinical Locations
Type of focus
Moving clinical practices into non-clinical locations
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Terry Kirkpatrick, Mills Community Support Corp.
boundaries
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Moving a variety of specialized clinical health, mental health, addictions, and other health-allied clinical services into nontraditional/non-clinical locations, i.e. rural locations, supported housing, community sites, etc..
Ways and Means:
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Technology i.e. telehealth, videoconferencing, internet linkups, etc.
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Using non-clinical mediators to transfer knowledge and skills, i.e. peers, volunteers, family members, personal support workers,
developmental service workers, etc..
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Traveling clinics (not new) but develop better infrastructure and support for organizing and implementing at more efficient levels
and more frequently
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Constraints the “professionalization / medicalization of everything”
Lowers the overall cost of delivering health care, particularly for people whose health care needs may be stable, predictable, longterm, and whose location is far from traditional clinical settings.
Brings the “community” into health care, and brings health care into the “community”.
Keeps family and non-professional resources in the picture longer than may presently be the case.
Topic Initiator:
Name: Terry Kirkpatrick
February 21, 2005
Organization: Mills Community Support Corp.
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15.
All LHINs should be academic organizations
Type of focus
All LHINs should be academic organizations in order to: promote best practices,
recruit and retain health professionals, assist in future supply health
professionals
Funding of providers should recognize the additional cost of educating health
professionals
boundaries
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Carlene MacDonald, Leeds – S. Greenville Physician Recruitment Program
Dale Kenney KGH/PCCC
Dan Hollan, QHC
Dwight Druick, L and A CMHS
Janice Elms, Ongwanda
John Hudson, KGH
Nadia Zurba, County Roads Community Heath Centre
Nalini Stiemerling, Psychol. CCC Health
Pam Carr, KFL and A Health Unit
Paul Rosenbaum, SEAMO
Peter Munt, Regional Chiefs of Staff Chair
Susan Shoniker, Nurse
It is more costly to provide care in an academic setting, but:
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Academic health organizations are better suited to adopt best practice/evidence based practice
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People tend to practice in locations in which they are trained
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Many health professionals are only willing to work within an environment that supports research interests
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LHINs should be mandated to support academic activities and funding by LHINs should recognize the costs of education and
research
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Best patient care requires staff to understand and adopt best practices
Recruitment and retention often dependent on academic support
Measuring and understanding patient outcomes are best done within an academic environment.
The LHIN can make the entire region academic.
All LHINs, whether they contain an Academic Health Sciences Centre or not, should be part of this academic environment.
Topic Initiator:
Name: Nalini Steimerling and Paul Rosenbaum
February 21, 2005
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16.
How can LHINs Contribute to Family Health Team Development and vice versa
Type of focus
How can LHINs contribute to Family Health Teams development, and how can
Family Health Teams contribute to LHIN development?
boundaries
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Alan Katz, Health Care Network of SEO
Andrew Quinn, Gateway CHC
Elaine Johns, Independent
Ken Law, Leeds and South Greenville Physician Recruitment
Lyn Linton, Gateway CHC
Mary Woodman, Sharbot Lake Med. Ctr., Queens School of Nursing
Ray Marshall, Brockville General Hospital
Ron Shore, Street Health Ctr. N. Kingston Community Health Ctr.
Ross Sutherland, Health Coalition
Sue White, SEO DHC
Tom Rankin, CCAC L LG
Wynn Turner, County of Lanark LTC
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We understand that LHIN and Family Health Team (FHT) development are proceeding on separate tracks. In order to maximize
efficiencies and opportunities, we believe that there should be early and frequent communication during their co-evolutions.
It was suggested that
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In the early period:
o LHINs should have multi-disciplinary professional advisory committees
o LHINs should get access to information on emerging FHT in their jurisdictions to ensure early communication and
coordination.
o Information on clients accessing FHT should be shared with LHINs
o Primary care reform planning should be devolved to a local LHIN responsibility
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In the later period
o FHT funding should evolve to be included in LHIN funding.
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If we were funding community based care in this manner, we risk establishing new silos that could impede the ongoing
development of an effective and efficient local health care delivery.
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Topic Initiator:
Name: Alan Katz
February 21, 2005
Organization: Health Care Network of SEO
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17.
Strategies for Improving access to French Language Services
Type of focus
Strategies for improving access to French language services
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Jeannine Proulx, ACFO Mille-Iles
Nancy Spears, KOS
Patricia Cyr, PCCC Health
boundaries
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Developing strategies for improving access to French language services in the area
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We have a growing Francophone population in the region, about 11,000 French speaking individuals according to the 2001 Census
in the Thousand-Island Region.
Need to address the linguistic issues/barriers to access services in the French language locally. Not all are willing to go to Ottawa to
be served in their mother tongue.
The aging population is among the Francophones as well.
Need to give support to health professionals by providing access to a list of other Francophone health practitioners to better serve
the clients.
Topic Initiator:
Name: Jeannine Proulx
February 21, 2005
Organization: ACFO Mille-Iles
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18.
Hospital Management Integration
Type of focus
Hospital management integration
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12 participants, however list not available
boundaries
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Efficiencies can be achieved by the integration of hospital management structures
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The integration of hospital management represents a significant opportunity for savings.
While there is some movement in place now, organizations within the region should number 2 or 3 having limited knowledge of the
suitability of the concept; this may not be the correct mix.
Some discussion of the common services and what does or does not fit this concept.
Boards will be a challenge.
The LHIN should tackle what can be accomplished. There are a lot of examples where this integration works well.
There are considerable cost savings that can be accomplished
Topic Initiator:
Name: Stan Collins
February 21, 2005
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