North Toronto May 31, 2016 Welcome

Strengthening Integrated Heath Care in the Toronto Central Local Health Integration Network

Moderator and today’s Presenters

• Tess Romain

• Susan Fitzpatrick

• Bill Manson

• Vania Sakelaris

• Alvin Cheng

2 Thank you all for coming

• Anne Johnston Health • Sunnybrook Health Station Sciences Centre • Baycrest • Toronto Central CCAC • COTA • Toronto Intergenerational • Hospice Toronto Partnerships in Community • Madison Community (TIGP) Services • Toronto North Support • Mood Disorders Association Services of Ontario • The Bob Rumball Centre for • Regional Geriatric Program the Deaf of Toronto • Warden Woods • Renascent • Yorkminster Park Meals on • St. Matthew's Bracondale Wheels House 3 A special thanks to …

• Toronto Central LHIN Citizens’ Panel – Audrey King

• Toronto Central CCAC – Gayle Seddon

• Primary Care Transition Steering Committee – Dr. Jocelyn Charles and Dr. Yoel Abels

4 Purpose of this first cross-sector session

11. Share the vision of how we will move forward through a population-health approach

22. Clarify our approach to planning

3. Discuss how locally integrated care relates to regional 3 and provincial systems of care

44. Provide an update on primary care

55. Looking forward – what’s next

5 Future sessions (summer / fall)

11. Discuss the role and contribution of hospitals within a new collaborative approach

22. Share collaborative work in home care, community support services, and community mental health and addiction services

33. Discuss vision for integrated Community-based care

44. Discuss how to formalize patient / client, family, caregiver, and community involvement

6 Everything begins with our Patients, Clients, and Community members

Please welcome Audrey King

7 Today’s agenda

11. Vision and approach for achieving 20 minutes local, integrated, and population-based health care

22. Vision for a regional approach to care 15 minutes

32. Update on Primary care 15 minutes

43. Get to know our local patients / clients 30 minutes and families • Population data

54. Table talk and feedback on next steps 20 minutes 8 Key messages to keep in mind

• We have much to celebrate • We all share a responsibility for the health of our communities • All of our efforts must build toward a systems approach to care – no longer sector-based • This meeting today is the start of a collaborative, continuous process • We don’t have all of the solutions right now • We are working together, and together we will define

a vision and prioritize work to achieve that vision 9 What has brought us here today

Research, Analysis, and Strategic Plan Community Engagements Expert Reports

10 What we have heard from patients, clients, families, and caregivers …

Want to be at home and healthy “I don’t care how you organize my health - ACCESS – care or about the rules – I just want care when Searching is stressful I need it, where I can get to it, and to feel - NAVIGATION / confident that it is going COORDINATION - to make me better.” - Toronto Central LHIN Act as one team resident - COMMUNICATION - 11 TC LHIN Strategic Plan A vision for local planning

Susan Fitzpatrick, CEO

12 Our Shared Goals

Community Our Strategic Goals Outcomes

Vision Prevention& Wellness A Healthier Toronto We are a healthy and active Transform the community system to achieve better Positive Patient We have timely health Experiences access to care that includes us

outcomes for Access & and meets our Equity people now needs and in the future Innovation & We receive the System right care and all of our health care

Sustainability Quality &

providers act as a Value team

13 Current patient experience

Health Link Primary Care / Family - Access - Physician / Walk-In Hospital / Acute Availability of core services may vary across Toronto

Home Care Families and communities CaregiversHussein Family - Navigation / Coordination -

CSS and CMHA Service Home Care Agencies Assessment Largely patient- and family- directed

LTC Home - Communication - Multiple care plans 14 Current system of sectors

1.2 M Citizens navigating sectors of care

22 Home Care Agencies Specialists 1200+ Family 58 Diagnostics Practice / 17 54 CSS 17 CHCs CMHA 36 LTCHs Independent Hospitals Agencies General 1 CCAC Agencies Health Physicians Facilities

Limited shared accountability across providers or sectors

Accountable to MOHLTC Individual accountability agreements Varying models Individual volume-based funding Varied access to inter- professional, team-based care 15 Note: Numbers based on unique HSPs. Note that an HSP may have a number of agencies across sectors What we have heard from providers …

• Build on successes • Pursue a population health approach • Integrate community service delivery • Partner to strengthen intersection with social determinants • Create consistency in core services across communities • Support providers to respond to community specific needs, including cultural competency • Map primary care capacity 16 Achieving a system for citizens "Every system is perfectly designed to get the results it gets"

Current incentives What we want to incent

Focus on individual patients Holistic care for an entire community needs (preventative and responsive)

Individual providers funded based Teams funded based on community on volumes of care need and their outcomes achieved

Individual provider accountability Shared, team accountability for for outputs outcomes

Sector care planning One patient care plan

Sector I&IT Shared I&IT

Organized pilot projects Front line innovation

PROVIDER CITIZEN

17 Desired patient experience “One team” approach to care

Emergency Care and Scheduled Procedures

Family and Primary Care

Caregivers Local care Information Sharing team and care plan, rooted in primary and community care Care Coordination / Navigation

18 How we will work together to achieve the vision of “one team”?

• A new process • Sector tables → Cross collaborative tables

• An enhanced way of organizing how we work together • We serve the same communities → a single team in the eyes of the patient

• A means to develop local, integrated, and population- based care • Plan and take action together

19 The motivation for this approach ...

Together, we will: • Understand the needs of E.g. the whole population and Identify local communities care models • Meet the needs of sub- populations (e.g. E.g. Address Francophone, Indigenous, health marginalized) inequities

• Tackle health inequities E.g. Work • “Get upstream” upstream (maintain and (prevent) prevent) 20 Taking a Population Health Approach with a focus on Equity

• A cross-cutting theme in the implementation of our strategic plan

• Planning to date has generally been focused on meeting the needs of those actively receiving health care, but our mandate is to deliver excellent care to all (reinforced by Ontario’s Excellent Care for All Act). 21 Population Health: What does this mean to our partners?

Focusing on sub-populations, understanding their unique needs and challenges and working with communities to find sustainable solutions:

• This will require collaboration and shared accountability between the LHIN and HSPs, public health, and other partners to implement targeted solutions that will improve the health status of unique ‘sub-populations’

• Successful implementation will require: • Greater integration with primary, hospital, home, and community- based care, • Enhanced performance measurement through more valuable data, • Engaging marginalized populations, and • Strategic partnerships with health and non-health entities.

• The LHIN will focus on strengthening local planning partnerships to advance a population-based approach while maintaining regional and provincial systems 22 Purpose of a new approach to collaboration

Establish local Create strength in collaboratives of diversity diverse providers, patients / clients, and Share accountability families that share a for change common vision for local, integrated, and Outline the steps we will population-based health take together to make care in the TC LHIN that vision a reality

23 Moving to “One Team”

Patients / Clients, Families, and Caregivers

Establish patient Deepen and caregiver understanding of involvement the community’s health needs

Align home & Build a strong community care community-based as one integrated primary care system network Long-Term Care Primary Care Practices Homes FHT Define a model of Housing with FHN CHC Supports care coordination Care Supportive Community Coordination/ FHG Share information and navigation Mental Health and FHO Primary Care Navigation Addictions Network across all Services Inter- Solo Home and professional partners Health Link Practitioner Community Other teams partnership Support Services Clinics Post-Acute (complex care) Short-Stay Emergency Community Department Care Coordinate access to Build partnerships to specialized and advance social Hospital(s) regionally-based care determinants of health 24 when needed What can the future look like for patients and clients …

• Play an active role • Their outcomes and feedback drive continuous quality improvement - Access - • Have equitable and reliable access to care in their community - Coordination / Navigation - • Single point access to choice of primary care • Access to navigation and care coordination that meets their needs - Communication- • Providers work as one team and information follows the patient 25 What can the future look like for providers …

• Co-design local solutions with patients / clients - Access - • Access to inter-professional team supports including local Health Link processes and partnerships - Coordination / Navigation - • Work with care coordination and navigation supports • Better coordination between primary care and community • Consistency in access to regional /specialized care - Communication • Access to information from across the system on care being provided to your patients / clients

26 Ways in which the TC LHIN will facilitate …

- Access - • Plan with primary care and build capacity • Apply an equity focus - Coordination / Navigation - • Support for integration • Collaborate on a population health model for care coordination and navigation • Develop framework for regional care - Communication - • Build partnerships with Toronto Public Health, City of Toronto, and other non-health partners 27 Supporting activities to move forward with

• Facilitated sessions for cross-sector tables starting this Summer and Fall 2016

• Bringing all of our work together as part of one intentional and focused plan

• Launch of a Regional Quality Table in partnership with HQO, which will support future integrated Quality Improvement Plans

• Share Integration Report outlining recommendations to the TC LHIN and our partners 28 Proposed process to realize “One Team”

1. Evidence-based needs assessment of communities and sub- populations 2. Define outcomes that are important to the needs of communities and sub-populations 3. Identify priorities “where will we start” and “who does what” 4. Co-design delivery solutions with patients / clients, families, caregivers, and other partners (building an intersection of health and social care) 5. Evaluate against defined outcomes and continuously iterate to improve

What is different? • Focus on population need (demand as opposed to supply) • Focus on outcomes and generating evidence based on local context • Joint solution development (co-design) and continuous engagement 29 2016/17 activities

Fall 2016 1. First facilitated planning session • Review evidence-based, core components of population-based systems • Deepen understanding of community health needs (ongoing stratification of populations by risk; focusing on improving equity) • Identify and confirm a shared vision

Fall / Winter 2016-17 2. Local community-based asset mapping 3. Identify priority areas for collaboration (based on review of evidence in #1) • Complete self-assessment against core components 4. Develop shared agreement (acknowledge individual and shared commitments / accountabilities)

Winter 2017 and onward 5. Co-develop and begin execution of local work plans 6. Work plans shared (cross-region learning) 30 Key takeaways

•1 Creating a one-team approach (cross-collaborative planning)

•2 Focused on improving population health through a local planning approach, while closing the gap for those most in need (equity)

•3 This is a collaborative process

Questions?

31 Organizing Regional Services

Bill Manson, Senior Director

32 Multiple systems of care are required to meet the diverse needs of patients / clients

Provincial Programs and Services

Region

24/7 Pain and Culturally Specialized Symptom Sensitive Manaegment Indigenous Care Residential Hospices Francophone Rehabilitation / Local Community CCC Long-Term Care Family and Homes Caregivers Primary Care Practices

Housing with FHT Supports FHN CHC

Specialized Care Community Coordination/ Supportive MHA FHO FHG Mental Health and Navigation Primary Care Addictions Network Services Inter- Solo professional Home and Practitioner Specialized Other teams Community Prevention Clinics Support Services Post-Acute Services Short-Stay Emergency Community Department Care Specialized Diagnostic Services

Surgery Hospital(s)

Speciality 33 What we have heard …

- Access - • Variability in access to regional and specialty care • Access is designed on a sector or provider specific basis • Improve access for marginalized groups both within and outside the LHIN - Coordination / Navigation - • Patients and families experience fragmentation in transitions of care • Service planning is done in silos - Communication - • Improve ability to share information amongst

providers (to improve coordination, safety, and quality) 34 Problem Statement

• As the health care system moves towards providing services closer to home, a subset of services will need to continue to be delivered regionally due to insufficient demand to sustain quality and efficient service delivery across the LHIN

• Regional services must be designed to ensure the services are easily and equitably accessible, meet client / patient needs, and improve client outcomes and experiences with the health care system

Desired Outcome

• One regional services framework to guide the development of a regional services system

• Quick, reliable, and equitable access to regional services as well as an efficient use of resources while strengthening quality and sustainability of services 35 What can the future look like for clients and patients …

- Access – • Connect clients/patients to specialized services that do not exist at a local level - Coordination – • Create seamless transitions between services - Communication – • Regional services need to be seen as an extension of a local team (a “one team” approach to care in the eyes of the client/patient)

36 Early and draft definitions of a spectrum of care

Access starting close to / at home and scaling up when needed

Local Services Regional Services Provincial Services •Available consistently • More specialized in • Highly specialized and equitably across nature (typically lower tertiary and quaternary communities volumes) services accessible to •Based on local • Not available in each all Ontarians population health needs community (e.g. sub- • Local / regional (meet volume of need) region), but accessible programming would be •Expertise and to anybody in TC LHIN, cost and quality equipment readily GTA, and Ontario prohibitive available locally

Accessing highly specialized care, if necessary, and get patients home as soon as possible 37 Examples

1. Adult with an Acquired Brain Injury

Provincial Regional Local Specialized In-home Neurosurgery Ambulatory Personal Therapy Support

2. Adult with Type 1 Diabetes Local Regional Provincial Dialysis Kidney Primary Care Care Transplant

38 Proposed Regional Services Planning – A Phased Approach

Phase 1 – Scope and service delivery Phase 2- Access System(s) Define scope, principles, criteria Phase 3 – Implementation Identify access **Convene ‘expert system(s) / model for Identify opportunities panel’ of HSPs, regional services partners and for improvement community to support Identify guidelines to development of ensure seamless regional framework transitions with sub- region services

39 Proposed 2016/17 Regional activities

Summer 2016 1. Regional planning session • Begin to draft principles for a regional framework that could be applied to all regional services / programs

Fall / Winter 2016/17 2. Draft regional vision that supports local and provincial needs • Begin to prioritize opportunities for improvement

Winter 2017 and onward 3. Develop framework for regional and specialized programs including improvement plan 4. Validate regional framework with sub-regions 40 Key takeaways

1.1 Resolving fragmentation

2.2 Focusing on • quick, reliable, and equitable access to regional services • efficient use of resources • strengthening quality and sustainability of services

3.3 Enabled by one regional services framework to guide the development of a regional services system

Questions?

41 Primary Care

Vania Sakelaris, Senior Director

Special thanks to:

Members of the Primary Care Transition Steering Committee

42 Working locally to connect a system of primary care with community partners

Family and Long-Term Care Homes Primary Care Practices Caregivers

Housing with FHT Supports FHN CHC

Care Supportive Community FHG Coordination/ FHO Primary Care Mental Health and Navigation Addictions Network Services Inter- Solo professional Practitioner Home and Other teams Community Clinics Support Services Post-Acute Short-Stay Emergency Community Department Care

Hospital(s)

43 Primary Care Strategy – Overview

• Transforming primary health care is a strategic priority of the Toronto Central LHIN’s Strategic Plan

• The primary care sector is both an entryway and point of continuity in the system

• As we develop our approach to strengthening primary care, we have been listening to providers, patients, and caregivers

• Consultations have been held with over 250 primary care providers to inform the vision, goals, and objectives

• The LHIN is now moving in to the implementation phase 44 TC LHIN Primary Care Vision, Goals and Objectives

To build a population-based, person-centred, and integrated health care system, with a focus on primary health and community care

Improved Patient Access: Improved Service Increase System Efficiency: Integration:  Reduce/Eliminate unattached  Increase timely availability of  Improve communication between patients – for all patients who hospital discharge summaries health care providers and between providers and patients using want/require a provider  Improve primary care provider enhanced and integrated and/or team follow-up within 7  Improve same day/next day information systems access to primary care days of discharge  Reduce primary care sensitive ER  Increase timely access for  Improve after-hours access to visits and hospital admissions primary care advanced diagnostic services,  Streamline access to specialists  Improve/streamline access to  Increase access to inter- and hospital diagnostics and clinics professional team care for home care  Improve health service planning and those who need it  Improve care co-ordination and delivery through effective and care transitions for complex  Increase access and reduce interactive use of population health patients wait times for urgent information and outcomes specialist consults  Improve bi-directional  Increase the percentage of family communications between  Improve matching of health physicians practicing in group primary care and ER and human resources with models community need hospital for complex patients 45 Primary Care – Identified 2016/17 Priorities

1. Improve attachment to primary care providers for all residents who want one • Assess current capacity within the LHIN • Propose and implement strategies to improve access

2. Provide access to inter-professional care teams for patients who need them. Currently, there is unequal access to team based care for patients depending on their physician’s model of practice. • Assess current capacity within the LHIN • Develop criteria for identifying patients requiring access • Propose strategies and processes for implementation (SPIN)

46 Primary Care – Identified 2016/17 Priorities - Continued

3. Improve access to urgent specialist consults and streamline access to specialists within hospital settings (e.g SCOPE). • Develop a database and implement tools such as a one-number or one place to call process 4. Improve timely access to quality discharge summaries to enable primary care providers to follow-up with patients post discharge and avoid unnecessary readmissions. • Build upon current initiatives: Connect GTA, e-Notification and HRM. 5. Connect all primary care providers and other HSPs through secure email. A later phase will develop secure patient to provider electronic communications building on existing initiatives such as

OneMail. 47 Primary Care - Roles and Responsibilities

• Primary Care Clinical Leads: Are local primary care physician leaders that champion primary care strategy implementation through local engagement, collaboration, development and implementation of strategies to improve access and service integration.

• Primary Care Co-ordinating Committees: Will be a committee representative of the primary care providers from the various physician practice models (FHT, FHO, FHG, FFS, Solo Practitioners, CHCs) that will be responsible for developing a local primary care work plans to implement approved initiatives to move forward on the achievement of the goals and objectives.

48 2016/17 Primary care activities

June 2016 1. Local Primary Care Clinical Leads to be announced

Summer 2016 2. Implementation of local Primary Care Networks

Fall / Winter 2016/17 3. Commence implementation of identified Primary Care priorities

49 Key takeaways

•1 We are implementing priorities informed by local primary care providers and their patients

•2 We are partnering with local clinical leaders to co- design primary care networks.

• Connecting primary care providers and their patients 3 to an integrated system

Questions?

50 Population Health Status TC LHIN population overview

Alvin Cheng, Director

51 What does it mean to take a Population Health approach?

• Population health allows us to address the needs of the entire population, while reminding us that special attention needs to be paid to existing disparities in health

• A population health approach:

• Considers the upstream causes of poor health outcomes – the Social Determinants of Health • Looks at the distribution of health across populations and communities and identifies patterns (Equity) • Requires intersectoral partnerships (especially at the local level) to address barriers to good health • Takes a long-term approach

(Population Health & Health Care: Tai M. Huynh, University Health 52 Network – Authored on behalf of CIHI) Toronto Central LHIN (2016)

Population: 199,051 HSPs: 21 FP/GP: 303

Population: 232,570 HSPs: 28 Population: 305,989 Population: 143,392 FP/GP: 237 HSPs: 56 HSPs: 50 FP/GP: 735 FP/GP: 231

Population: 269,756 HSPs: 28 FP/GP: 303

53 Health Service Providers in Toronto Central LHIN (2016)

HSPs with offices in a particular region may provide services for people in other regions of TC LHIN.

Residents of a certain community may receive care in other communities.

There are many other health and non-health partners in our region that play a role in influencing health outcomes of our population.

Total **Includes Family Practice/General Private Family Practice/General excluding Physicians currently in good standing CCAC CHC CMHA CSS Hospital LTC Physicians** Hospital FP/GP with the College of Physicians and Surgeons of Ontario (CPSO) with a East 2 5 11 2 1 8 303 29 valid billing number. They may or may not be using their billing number or actively submitting claims to OHIP. Mid-East 4 22 16 3 4 231 49 Number excludes FP/GPs in Focused 1 Practices, e.g. Sports Medicine, Mid-West 5 20 13 5 12 735 55 Psychotherapy. North 2 3 9 3 3 303 20 54 West 4 8 5 3 9 237 29 TC LHIN 1 17 58 54 16 1 36 1809 183 North Toronto Highlights Please note data presented is for discussion purposes only. Detailed information reports will be shared upon final data quality and citation review.

55 North Toronto Neighbourhoods (2016)

56 About North Toronto

Sunnybrook Health Sciences Centre Yonge-Eglinton Forest Hill

Anne Johnston Lawrence Square Sunnybrook Park Health Station Shopping Centre

• Bounded by Highway 401 Don Valley Parkway, Allen Road to the west, St. Clair West Ave. to the south, and Sunnybrook park to the east (between Bayview Ave. and Leslie St.)

• The region contains 13 neighbourhoods, with Leaside-Bennington being split between North and Mid-East communities, and Yonge-St Clair neighbourhood split between North and Mid-West communities 57 Understanding the Population: North Region Highlights

• North Toronto had the highest proportion of seniors above 65 years in 2011, and the 2nd highest rate of seniors living alone

• At the neighbourhood level, there is variation in levels of marginalization and other socio-economic indicators; Englemount-Lawrence neighbourhood in particular exhibits characterstics of a high needs population from a health determinant standpoint.

• There is diversity in languages spoken amongst the neighbourhoods. The most common non-English languages spoken at home include Tagalog, French, Persian (Farsi), Spanish and Russian.

• In 2014/15, one-third of ED visits for North Toronto residents were provided at Sunnybrook Hospital. In total, nearly 25% of ED visits were provided by hospitals outside of TC LHIN.

• There is better continuity of primary care for enrolled and non-enrolled patients for residents of North Toronto neighbourhoods compared to those in other sub-regions (2011- 2013). Continuity is measured as patients with < 50% of their primary care visits with the same physician or group (minimum 3 total primary visits over the 2 years period).

• North Toronto region has the highest rate of cancer screening (mammograms, Pap smears, and colorectal and combined) for eligible populations. However, there is variation amongst the neighbourhoods. 58 North Toronto: Seniors Population (2011)

North Toronto has the highest proportion of seniors above 65 years in 2011 (14.7% vs the TC LHIN average of 13.1%), and the second highest proportion of seniors living alone (38.0% vs 34.1% for TC LHIN).

% of Total population in private households that are 65+, living alone, Both sexes, 2011 TC LHIN Mount Pleasant West 58.2 Englemount-Lawrence 41.6 Most neighbourhoods in North Toronto have Mount Pleasant East 41.1 Yonge-St. Clair 40.4 a higher than average proportion of Forest Hill North 39.2 seniors living alone in their Yonge-Eglinton 38.5 Humewood-Cedarvale 37.7 neighbourhoods. Leaside-Bennington 34.2 Forest Hill South 34.0 Bedford Park-Nortown 32.9 Mount Pleasant West has a particularly high Lawrence Park North 31.2 proportion of seniors living in this Lawrence Park South 24.7 Bridle Path-Sunnybrook-York Mills 18.2 neighbourhood (58.2%). 59 0 10 20 30 40 50 60 70 North Toronto: Diversity Top 3 Languages for Non-English Speaking Households by Neighbourhood (2011) The proportion of visible minorities in Neighbourhood Name #1 #2 #3 the North region is lower than the TC Englemount-Lawrence Tagalog Russian Spanish LHIN average. Bedford Park-Nortown Tagalog Russian Spanish Bridle Path-Sunnybrook-York Mills Persian (Farsi) Cantonese Chinese, n.o.s. However, there is diversity in Leaside-Bennington French Finnish Chinese, n.o.s. Yonge-St.Clair Spanish French Russian languages spoken amongst non- Mount Pleasant East French Serbian Spanish English speaking households. The Yonge-Eglinton French Spanish Korean most common non-English Forest Hill South Serbian Spanish French languages spoken at home include Forest Hill North Tagalog Russian Spanish Lawrence Park South French Spanish Russian Tagalog, French, Persian (Farsi), Mount Pleasant West Persian (Farsi) Spanish Korean Spanish and Russian. Lawrence Park North Korean Russian French Humewood-Cedarvale Tagalog Spanish Portuguese

Aboriginal Identity French Speakers Visible Minority 950 5,495 22.2% TC LHIN TC LHIN TC LHIN 10,665 33.6% Note: Persons of aboriginal identity are most likely 33,015 undercounted due to limitations of the NHS 60 Neighbourhood Profile: Englemount-Lawrence

Englemount-Lawrence borders Marginalization (ON-Marg, 2006) on Central LHIN. It exhibits 3.5 3.2 3 characteristics of a high needs City of 2.4 2.5 2 2 2 Toronto 1.8 population from a health 2 1.4 1.4 1.6 1.6 1.6 1.5 1 1 determinant standpoint. 1 0.5 0

Indicator definition: A combined measure of 18 variables representing residential instability, ethnic concentration, dependency and material deprivation, 2006 Census, Ontario Marginalization Index. Source: Urban Heart, 2014 [2006 Census, Ontario Marginalization Index]

% of Population - Low Income (After-Tax) % of Population - Social Assistance (2012) City of Toronto City of Toronto Indicator definition: Percentage of the Englemount-Lawrence Englemount-Lawrence 12.4 population living with incomes below the after- 25.5 tax low income measures (LIM-AT) established Mount Pleasant West 19.4 Forest Hill North 5.1 in 2010 for the City of Toronto. The after tax- Forest Hill North 16.6 Humewood-Cedarvale 4.9 low income measure (LIM-AT) is the poverty Humewood-Cedarvale 15.4 Mount Pleasant West 4.7 measure used by the Ontario Poverty Reduction Strategy. Source: Urban Heart Yonge-Eglinton 12.7 Yonge-St. Clair 2.4 Toronto, 2014 [2010 TI-Family File, Statistics Bedford Park-Nortown 11.2 Bedford Park-Nortown 2.1 Canada Income Division] Yonge-St. Clair 9.6 Mount Pleasant East 1.8 Mount Pleasant East 8.8 Yonge-Eglinton 1.8 Indicator definition: Social Assistance: % of the Forest Hill South 8.2 Lawrence Park South 1.6 population that are recipients of Ontario Works, Bridle Path-Sunnybrook-… 8.0 Leaside-Bennington 1.4 persons on ODSP participating in OW Lawrence Park North 7.1 Forest Hill South 1.2 employment programs and non-OW persons receiving assistance with medical items, 2012, Lawrence Park South 6.7 Lawrence Park North 1.1 Toronto Employment & Social Services. Leaside-Bennington Bridle Path-Sunnybrook-York Mills 5.6 0.4 61 0 5 10 15 20 25 30 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 North Toronto: Patterns of Emergency Department Use % of Total ED Visits for MHA Disorders

20.0% Majority of visits to the ED by North Toronto 18.0% 17.2% 16.0% residents are to Sunnybrook Health Sciences 14.0% 10.9% 12.0% 10.2% Hospital (34%). Overall, 75% of all ED visits by 10.0% 9.0% 7.3% 8.0% 6.9% 6.6% residents occur in TC LHIN hospitals. A quarter 5.8% 6.2% 6.4% 6.0% 5.0% 4.8% 3.5% of visits are provided by hospitals in other 4.0% LHINs. 2.0% 0.0% % of ED Visits by Hospital of Visit (All LHINs) Humber River Hospital 2% TEGH Other NYGH - 2% 11% Branson Site 3% Visits to TC LHIN EDs St. Michael's There is a relatively high Hospital Sunnybrook proportion of ED visits 34% 5% 75.3% for mental health and UHN - TWH 6% Central LHIN EDs behavioural conditions, with a wide variation

North 17.3% across neighbourhoods. UHN - TGH York Mount Sinai 6% Hospital General Other EDs Hospital 11% Hospital for 7.4% Sick Children 11% 62 9% North Toronto: Primary Care and Prevention

% Low Continuity and Enrolled & Non-Enrolled 25.0 22.2 22.4 22.9 Primary care continuity and rates of 20.8 18.6 19.1 prevention screening are indicators 20.0 17.2 17.9 18.0 18.3 15.8 16.1 16.4 of positive health outcomes. 15.0 10.0 Residents living in Englemount- 5.0 Lawrence, Forest Hill North and 0.0 Humewood-Cedarvale experience higher than average levels of low-continuity.

All but one neighbourhood are Age-Adjusted % of total eligible population (men and women) aged 50- above the average rate of coloretal 74 having any colorectal cancer screening (2013-2015) cancer screenings in the TC LHIN. 90.0 77.1 75.2 80.0 74.4 72 71.5 71.3 70.7 69.2 68.6 67.7 64.7 63.3 70.0 59.4 60.0 “Continuity of care is one of the fundamental 50.0 building blocks of high-performing primary care 40.0 and is associated with improved preventive and chronic care services, patient and clinician 30.0 satisfaction, lower hospital utilization, lower 20.0 costs, and for elderly patients, lower mortality. PercentageScreened (%) 10.0 For patients, continuity means seeing their own 0.0 clinician, year after year, every time they need care.” (JAMA, 2013) 63 2016/17 activities

Summer / Fall 2016 1. Finalize and share initial population profile reports 2. Begin deeper dive into health status of the population and community health utilization 3. Support deeper understanding of community health needs (ongoing stratification of populations by risk; focusing on improving equity)

Fall / Winter 2016-17 4. Further investigation and analysis of sub-populations to identify needs and gaps 5. Stratify strategic plan indicators by communities / populations

Winter 2017 and onward 6. In partnership with local tables, determine additional evidence required to support successful execution of local work plans

64 Key takeaways

•1 We are using population need to drive local planning

There is considerable variation by neighbourhoods, •2 of potential health needs which will be important to consider during planning

Questions?

65 Getting to Know Each Other Round Table Dialogue

Tess Romain, Senior Director

66 Getting your conversation started …

• What opportunities do you see in moving to a “one team” approach to local planning and delivery?

67 Next Steps

• Facilitated sessions for cross-sector tables starting this Summer and Fall 2016

• Bringing all of our work together as part of one intentional and focused plan …

68 Recall – Working through the process together

Patients / Clients, Families, and Caregivers

Establish patient Deepen and caregiver understanding of involvement the community’s health needs

Winter 2017 and onward Winter 2017 and onward • Develop regional framework • Co-design and implement • Partner with cross-sector tables • Work plans shared, cross- collaborative learning platform Fall / Winter 2016/17 established • Local primary care work plans Fall / Winter 2016/17 Fall / Winter 2016-17 • Draft regional vision • Asset map Summer 2016 • Identify priorities • Implement local network structure • Develop shared agreement Summer 2016 • Regional planning session Summer / Fall 2016 • Facilitated planning session (review June 2016 evidence, pop health and equity • Local Primary Care Clinical assessment; confirm vision) Leads to be confirmed

Local Cross- Local Primary Regional Sector Care Networks Coordination Planning 71 Questions? [email protected]

72 Appendix

73 Primary Care Transitional Steering Committee Membership Chair: Dr. Phil Ellison

• Dr. Jocelyn Charles • Susan Fitzpatrick • Dr. Tara Kiran • Vania Sakelaris • Dr. Nicole Nitti • Greg Stevens • Dr. Pauline Pariser • Alvin Cheng • Dr. Yoel Abels • Tess Romain • Dr. Barbara Yaffe • Dr. Tia Pham • Dr. Patrick Safieh • Dr. Karen Weyman • Dr. David Tannenbaum • Dr. Lynn Wilson • Dr. Rick Glazier • Dr. Javed Aloo • Dr. Ho • Malcolm Moffat • Dipti Purbhoo 74 Data Limitations

• Population data is from 2011. This is the most recent census data available that allows a breakdown to sub-region levels. For all data, including health utilization data, the most recent available data was used.

• Information on visible minorities, immigration, education, labour, and Aboriginal identity were collected as part of the 2011 National Household Survey by Statistics (NHS) Canada. The National Household Survey was a voluntary survey and subject to non-response bias especially in areas where non- response rates exceeded 25%, the threshold for suppression for the 2011 Census. Non-response bias is a common issue with voluntary surveys and a reflection of the tendency that people who are inclined to respond to a survey have different characteristics from people who do not respond. Consequently, marginalized or underrepresented subpopulations are likely undercounted in the National Household Survey and comparisons between the National Household Survey and previous Censuses should be considered to be unreliable.

• Population estimates provided in the following profile should be considered as an approximate estimate of the population, rather than a true, full count of the population. 75 Population Overview (2011)

West Mid-West North Mid-East East Red = Highest Rate TC LHIN Toronto Toronto Toronto Toronto Toronto Blue = Lowest Rate Total population 232,570 305,989 199,051 143,392 269,756 1,150,758 0 to 4 years 5.5% 4.1% 5.5% 3.9% 6.6% 5.2% 5 to 14 years 9.6% 6.3% 10.8% 6.1% 10.9% 8.8% 15 to 24 years 10.8% 13.0% 11.7% 12.1% 11.1% 11.8% 25 to 44 years 32.1% 40.7% 30.7% 39.3% 31.1% 34.8% 45 to 64 years 28.3% 23.0% 26.6% 27.0% 27.9% 26.3% 65+ years 13.7% 12.9% 14.7% 11.7% 12.4% 13.1% 75+ years 6.8% 6.3% 7.6% 5.1% 5.9% 6.4% 85+ years 2.2% 1.8% 2.8% 1.3% 1.7% 2.0% % with no knowledge of English or French 3.4% 7.0% 1.1% 3.4% 4.3% 4.2% % immigrants 39.5% 41.6% 30.2% 37.9% 40.5% 38.5% % immigrants in last 5 years 6.1% 6.1% 6.3% 7.8% 8.0% 6.8% % visible minorities 28.6% 35.2% 22.2% 40.5% 41.0% 33.6% Aboriginal identity1 1,900 2,710 950 1,565 3,540 10,665 French-speakers 6,210 8,530 5,495 5,345 7,435 33,015 % persons living with Low Income (LIM-AT)* 17.5% 21.5% 12.7% 23.9% 23.5% 20.0% % lone parent families with female head 83.3% 82.8% 84.6% 84.5% 83.2% 83.5% % seniors over 65 that are living alone 34.0% 28.3% 38.0% 43.2% 33.0% 34.1%

Source: Census of Canada & National Household Survey, Statistics Canada, 2011 *Source: Tax Filer, T1FF, 2013 76 1Persons of aboriginal identity are most likely undercounted due to limitations of the NHS