CENTRETOWN CHC October 30, 2018 2018-2020 STRATEGIC PLAN

Approved by the Board on CENTRETOWN CHC October 30, 2018 2018-2020 STRATEGIC PLAN

Every One Matters. Chaque personne compte.

[email protected] 613-233-4443 www.centretownchc.org 420 Cooper St, Ottawa ON K2P 2N6 2

CONTENTS

2018-2020 Strategic Plan ______1 About Centretown CHC ______2 Our Mandate ______2 Our History ______3 Our Services ______4

Our Planning Approach ______5 Background ______5 The Collaborative Strategic Planning Process ______6 Centretown CHC’s Strategic Planning Process (2016-18) ______13

CCHC 2018-2020 Strategic Plan ______20 Our Vision, Mission & Values ______20 Our Strategic Directions & Goals ______21

Appendix I. Defining The System ______1 Appendix II. SWOT Analysis ______1

Centretown CHC Strategic Plan 2018-2020 2018-2020 STRATEGIC PLAN

“Health equity for all members of our communities.” Working as a collective to address the systemic barriers and

Collaborative challenges to accessing health services North Star

Our Vision Healthy caring communities where everyone matters.

Our Mission We lead the way in improving health and wellbeing for people and communities.

Our Values Equity ▪ Empowerment ▪ Excellence ▪ Respect

Our Strategic Directions

Enhance Access Demonstrate Leverage Enhance for People with Quality Through Collective Organizational Complex Needs Impact Capacity Health & Wellness

By 2020, we will…

1.1. Identify hotspots of 2.1 Review our data to 3.1 Undertake a joint 4.1 Implement an vulnerable individuals identify gaps in access review of primary improved performance in CHC catchment to programs and healthcare capacity to management system areas and target services for priority better understand for staff health inequities in populations © current gaps and our communities © opportunities for 4.2 Assess options to

2.2 Identify and address improved client care © improve our financial 1.2. Improve care inequities in the client sustainability coordination and experience and 3.2 Be proactive in health outcomes for outcomes of our mitigating clients with complex 4.3 Continuously improve diverse clients organizational risks © needs the CCHC staff

experience 1.3. Improve low-barrier 2.3 Adopt a social 3.3 Use EMR technology to access to primary prescribing model to improve client care and better integrate health health care and operational efficiency and social services, and addictions medicine for people who promote a greater

regularly use drugs sense of community

and alcohol belonging

ABOUT CENTRETOWN CHC

Centretown Community Health Centre

Figure 1. Centretown CHC's Catchment Area in Ottawa, Ontario.

Our Mandate We are a nonprofit, multi-service Community Health Centre serving the Centretown, Glebe, and Old Ottawa South neighbourhoods. Our interdisciplinary primary healthcare and health promotion programs support the health and wellbeing of over 13,000 Ottawa residents (including 5,300 regular primary care clients) who access our services every year. In a fair and just society, one’s skin colour, religion, income level, gender identity, and sexual orientation should not predict poor health outcomes. In ours, it sadly does. To bridge these health inequities, Centretown CHC offers a full range of healthcare services and health promotion programs, including specialty health clinics (i.e. urban health, newcomer health, trans health), mental health & addiction services, diabetes programs, early year programs, and community health promotion.

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These programs and services are delivered by a caring and diverse team of over 150 interdisciplinary health professionals, including doctors, nurse practitioners, nurses, social workers, counsellors, dietitians, community developers, health promoters, outreach workers, and peer workers. As a community-governed organization, we work hard to respond to the evolving health and social needs of our community.

Our History Centretown CHC has been playing an active role in improving its community’s health and wellbeing since 1969. Over time, we have built a strong reputation as: - an effective advocate for healthy policies at the municipal, provincial and federal level; - a committed ally to its LGBTQ+, Francophone, street-involved, vulnerable elderly, low income, and newcomer communities; - a high-quality provider of diabetes programs for the Champlain region.

Recent Developments at CCHC  2008 – Ontario launches Diabetes Strategy and expands CCHC’s Diabetes Education program, later adding screening, and chiropody services.  2012 – CCHC receives its ‘Baby Friendly’ designation for its adherence to World Health Organization (WHO) protocols that protect, promote, and support breastfeeding.  2016 – CCHC plays a leadership role in Refugee 613, providing outreach and low-barrier access to primary care for Syrian war refugees arriving in Ottawa.  2016 – CCHC introduces the Trans Health Clinic, providing wrap-around services and improved access to hormone therapy for trans individuals in the Champlain region.  2017 – CCHC receives its ‘French Language Services’ (FLS) designation from the Ministry of Health and Long Term Care.

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Our Services We believe in an integrated approach to care that is holistic, non-discriminatory, caring, and innovative. Our services are delivered in a variety of ways: 1-on-1 client care, personal development groups, and grassroots community involvement. As a French Language Services (FLS) designated Centre, we ensure high-quality programs and services in both official languages. In an effort to provide culturally- safe care, cultural interpretation services are also available for all clients who walk through our doors, and a number of groups facilitated by our diverse staff are offered in other languages frequently spoken in our catchment, including Mandarin, Arabic, and Somali.

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OUR PLANNING APPROACH

Background Given that the 6 Ottawa CHCs shared similar mandates, client profiles, and pressure points, a decision was made at the turn of the decade to formalize our partnerships by engaging in a joint strategic planning process. From 2012 to 2017, Carlington CHC, Centretown CHC, Pinecrest-Queensway CHC and South-East Ottawa CHC worked towards common strategic directions, including: i) enhancing the impact of their advocacy ii) improving social capital among priority populations iii) delivering high-quality programs and services, and iv) strengthening the health of their respective organizations The collaborative strategic plan allowed the 4 CHCs to join forces on a number of priorities while still allowing each Centre to specify Centre-specific goals to their plan, based on the unique needs and priorities impacting their communities. Building on the success of this collaborative process, 2 more community health centres (Somerset West CHC and Sandy Hill CHC) agreed to join the Ottawa CHC collaborative strategic planning process for 2018 and beyond. A request-for- proposals was posted in 2016 and Lansdowne Technologies Inc (LTI) was retained as a consulting partner to the 6 CHCs, to assist with planning facilitation, strategic plan development, and project management.

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The Collaborative Strategic Planning Process

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Phase 1: Literature Review and Environmental Scan (2016-2017) Phase 1 of the collaborative strategic planning process involved scanning the literature to identify best practices for planning within the context of primary healthcare. LTI conducted a thorough literature review and presented its recommendation that the 6 CHC Board of Directors adopt a planning framework grounded in complexity theory (‘5-Level Framework’).

Using A Complexity-Based Approach Understanding the domains to which managing healthcare resources in our changing context belongs is crucial to selecting the appropriate planning and management approach. As the Cynefin Framework tells us, complex problems are distinct from simple or merely complicated problems (see Figure 2).

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Problem Domains

 ‘known knowns’  there are rules in place (or best

practices), the situation is stable and the relationship between Simple cause and effect is clear: if you do X, expect Y  Approach: "sense–categorize–respond"  ‘known unknowns’  The relationship between cause and effect requires analysis or expertise; there are a range of Complicated right answers  Approach: “sense-analyze-respond”  ‘unknown unknowns’  Cause and effect can only be deduced in retrospect, and there are no right answers (but Complex instructive patterns can emerge)  Approach: “probe-sense-respond”  Cause and effect are unclear  Events are too confusing to wait for a knowledge-based response Chaotic  Approach: “act-sense-respond”

Figure 2. Cynefin Framework (by Dan Snowden)

The decision to use a planning framework adapted to complexity was informed by the fact that CHCs operate in a complex, unpredictable, and unknowable space. To illustrate the point, no amount of business intelligence could reasonably have forewarned the CHCs of the impacts of the Syrian crisis, of the OC Transpo bus strike, or of President Trump’s election and its effect on the cross-border migration of US- based refugees. Yet these are some of the major events, over the past 5 years, that have called upon the Community Health Centres to respond in significant ways.

Success in such an environment requires adaptable strategies built on first principles, timely data for sense-making, and agile collaborative structures to respond to emerging contextual factors. Only then can a course towards defined strategic outcomes be maintained, regardless of which way the wind blows.

“… CHCs operate in a complex, unpredictable, and unknowable space.”

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Applying a 5-Level Framework

Figure 3. 5-Level Framework

The 5-level framework was recommended by LTI and ultimately selected by the 6 Ottawa CHC boards as the framework for collaborative strategic planning. It was also recommended that planning timeframes be shortened to no more than 3 years, in keeping with best practices for managing organizations in complex environments. Finally, three options were presented for the implementation of the collaborative strategic plan at each organization: 1) Added Plan: The collaborative strategic directions and goals are added to individual CHCs’ strategic plans as needed, based on which Centres will be taking an active role on any given collaborative strategy. 2) Shared Plan: The CHCs’ strategic plans all share the same set of collaborative strategic directions and goals, and may add on other strategic directions based on their organization’s or catchment’s priorities. 3) Enabled Plan: The CHCs’ strategic plans reflect the collaborative strategic plan as subsidiary activities in their own strategic plans. These subsidiary activities may be reflected as a strategic goal (e.g. “strengthen CHC collaboration”) under one of their Centre’s strategic directions. It may otherwise be reflected as a set of enabling factors supporting all of their Centre’s strategic directions. Multi-board discussions held in January 13, 2018 resulted in consensus that the 6 CHC Boards wished to move forward with a Shared Plan.

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Environmental Scan In order to assess ‘where we are now’, LTI was commissioned to produce an environmental scan with support from CHC planners. Delivered in Fall 2017, this 80- page document helped to define ‘the system’ (see Appendix I), describe key trends at various levels of the system, and highlight a number of opportunities / threats facing Ottawa CHCs (see Appendix II). Population health statistics for Ottawa and findings by key themes are presented in Figure 4 and Table 1, respectively.

Figure 4. Population health statistics for Ottawa from the 2017 Environmental Scan.

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Table 1. Summary of Findings by Key Themes

• Regional conflict; religious, ethnic and LGBTQ+ persecution; and adverse weather Global events linked to global warming are driving increases in immigrant, refugee, and displaced persons. Many arrive in Ottawa with significant trauma loads and face Instability and barriers to integration. Trauma • The integration of trauma-informed healthcare, immigrant supports, and language/job skills development is essential to newcomer wellbeing.

• Patients First is rationalizing health systems within LHIN boundaries and newly defined sub-regions. CHCs will benefit from developing a shared future-state vision of sub- Health System regional systems and CHCs’ role within them, in order to operate from the same playbook when negotiating at sub-regional tables. Redesign • The risk of the current government being unseated remains high. CHCs will be well- served by monitoring provincial party platforms, engaging with all Ottawa MPP candidates, and planning contingencies as the June 2018 provincial election nears.

• On the business side, chronic disease management, dementia, and care coordination will increase encounter volumes and case complexity. • On the organizational side, the increasing threat of corporate memory loss will need to Ottawa’s Aging be monitored and planned for as a significant wave of front-line experts, care Population providers, and senior executives reach retirement age. • Strong succession planning, alongside forecasting and advocating for needed resources and supports (i.e. for care coordination and home care), will help mitigate these organizational stressors.

• The CHCs’ community governance model leads the way in promoting health equity, but no framework yet exists to leverage CHC data to systematically identify and address social disparities in: the determinants of health, access to care, patient experience, or clinical / population health outcomes. Health Equity • Adopting a health equity framework and investigating opportunities (e.g. patient portals) to expedite the collection of complete sociodemographic data for their centres would help CHCs maintain their status as system leaders in driving an evidence-informed health equity agenda.

• The 2012-2017 collaborative strategic plan demonstrated the value of collective action, allowing CHCs to make their mark while undergoing budget freezes. In light of recent health system funding reforms (Excellent Care for All Act), as well as the Auditor Value-For- General of Ontario (AGO) audit of LHINs/CHCs, the impetus for efficiency remains high. Money • By strengthening operational partnerships (together, and with key partners, e.g. Ottawa Public Health) and better monitoring their collective impact, Ottawa CHCs can continue to build on best practices, align resources to do more with less, and show value-for-money.

Big Data, GIS, • Ottawa CHCs are increasingly data-rich while analytic capacity lags. Meanwhile, the opportunity cost of not leveraging business intelligence increases yearly as software eHealth, and and capabilities grow. QI: Building • CHCs are encouraged to build pockets of excellence in GIS, big data, and eHealth to Learning glean new insights, spur efficiencies and champion innovations that will help CHCs meet the growing demands of an aging population. Short-term secondments could be Organizations used as a knowledge exchange pipeline.

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The environmental scan was circulated to all 6 CHC’s board members along with other key documents (see Table 2) to inform their efforts in Phase 2.

Table 2. Collaborative Strategic Planning – Key Inputs

Organization Key Document

 2012-2017 Collaborative Plan’s Strategic Outcomes CHCs  2017 Environmental Scan

 2016-19 Integrated Health Service Plan (IHSP) o Community Engagement Report for IHSP 2016-19 Champlain LHIN  Champlain LHIN Service Accountability Agreement (SAA) Indicators (2017-2020) Health Quality  Quality Improvement Indicators (2017-18) for primary care Ontario (HQO)

 Key province-wide initiatives led by AOHC Association of o Advocacy Priorities & Key Messaging (e.g. Elections) Ontario Health o ‘Vital 8’ outcome indicators Centres (AOHC) o ‘Count Every One’ data initiative

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Phase II: Strategic Planning (2017-2018) Phase 2 of the collaborative strategic planning process involved engaging the 6 Ottawa CHC boards in a collective visioning exercise to determine the strategic outcomes, guidelines, and directions that would guide our organizations.

Once the strategic directions were agreed upon by the 6 CHC boards, key stakeholders – including staff, clients, community partners at each Centre – were consulted in order to define, validate, and refine strategies to operationalize the collaborative strategic plan as well as inform any Centre-specific directions/priorities.

After an approval-in-principle in Spring 2018 and some further refining by the 6 CHCs’ executive directors and senior management teams over Summer 2018, three collaborative strategic directions were approved by the CHC boards in Fall 2018.

Our Collaborative ‘North Star’ “Health Equity for All Members of Our Communities” – Working as a collective to address the system barriers and challenges to accessing health services.

2018-2020 Collaborative Strategic Directions 1. Enhance Access for People with Complex Needs 2. Demonstrate Quality Through Impact 3. Leverage Collective Capacity

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Centretown CHC’s Strategic Planning Process (2016-18)

Throughout the Collaborative Strategic Planning process, Centretown CHC was concurrently engaged in a series of consultations with its staff, board members, community partners, and community members, in order to inform its input into the collaborative strategic directions, as well as to identify needs specific to its community members and its organization.

Client & Community Member Consultations - Summer 2016

 Between July and September 2016, clients were engaged with at over 20 group classes and community events across our various locations in Ottawa  Clients / community members were asked 4 key questions: o what needs/struggles they face o how accessible we are o how they hear about our programs & services o what it is that CCHC does for them (and how we could do this even better)  Consensus: o CCHC is a welcoming, inclusive space that clients value being able to access o Clients would find it difficult to replace CCHC in their lives o Clients typically come to the Centre for more than 1 service o Hear about our services/events mostly via word-of-mouth, staff, and posters

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Key Themes from 2016 Client Consultation

• Housing, food security and employment • Prejudice (not feeling accepted or valued as newcomers, people with mental health and/or addiction issues, LGBTQ+, Challenges senior citizens, etc.) Faced • How to access/navigate system for health & social resources • Social isolation: “if we are not explicitly included, we are implicitly excluded”

• Client orientation; health system coaching • Shorter wait times (Primary Care, Mental Health, Trans Clinic) Areas for • Translation supports (Arabic, Mandarin, Cantonese) Improvement • Better educate community partners about programs & services • More accessible (legible) posters in lobby

• Cooking classes (requested by wide range of groups) • More health promotion information (newcomers, seniors) • Longer term programs (>6 weeks) New Services • Physical activity/exercise classes (seniors (incl. LGBTQ), moms, newcomer women) • More outreach to social housing (seniors, other homebound)

While some of these key themes have since been addressed by Centretown CHC in CCHC’s 2016-17 and 2017-18 Operational Plans, other areas (i.e. decreasing social isolation, strengthening newcomer health supports, improving outreach efforts) were in need of a strategic focus, longer timelines, and/or more resources in order to effectively remove the barriers to health and wellbeing reported by our community members.

These themes received due consideration by CCHC’s Board and Senior Management during the formulation of our 2018-2020 strategic goals.

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Client Experience Survey – Spring 2018

 Between February and March 2018, clients waiting in our general or clinical reception area were asked to complete our annual Client Experience Survey  The anonymous 4-page questionnaire asks a series of demographic and service utilization questions, also inquiring about the quality and timeliness of the care experience, outcomes, and overall satisfaction with CCHC.  Consensus: o CCHC clients are highly satisfied with their care (99% agree) o Clients feel that their CCHC providers involve them in decisions about their care (96% agree) o Clients feel more connected with their community as a result of their involvement with Centretown CHC (90% agree)

Key Themes from Client Surveys [ themes mentioned by x% of sampled clients in comments ]

• High overall satisfaction with care experience and providers • While most individuals from marginalized groups felt welcome at our Centre (>90%), Homeless and Trans individuals were least likely to Key Insights agree that they always felt welcome and comfortable (83% each) • 9% of clients with a disability reported experienced some form of difficulty or discomfort when accessing Centretown CHC’s services

• Friendly, helpful staff [52%] • Quality of programs/services [14%] Areas of • Interdisciplinary care [9%] Excellence • Location (easy to access) [9%] • Warm welcome at reception [9%]

• Wait times (in clinic and for follow-up appointments) [6%] • Access to certain types of appointments [3%] Areas for • Sense of physical safety in the Centre, at times [2%] Improvement • Negative experiences at reception [2%] • Implement eHealth / electronic communications [2%]

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These findings were shared with CCHC’s board, senior management, and staff in Spring 2018 and received due consideration during the formulation of our 2018-2020 strategic goals.

Community Partner Consultations – Spring 2018  In April 2018, over a dozen community partners operating in our catchment were invited to attend a facilitated discussion to share observations about client and community trends in the Centretown neighbourhood  Facilitated discussions centred around 5 key questions: o What factors are most affecting your clients’ quality of life? o Which client groups is your organization struggling to serve well? o What key health issues/concerns require the most attention? o What is Centretown CHC’s role in the community? o What are the key opportunities for enhanced partnerships for 2020?  Consensus:

o Poor mental health, often accompanied by addictions, is a key driver of the health needs being felt in our community; agencies are struggling to serve clients with mental health issues well.

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o Traumatized refugees (especially families with children) have significant needs around trauma-informed and culturally-safe care, overcoming language barriers, employment, and early years/afterschool programs. o Social isolation and poverty are the hallmarks of poor quality of life in our catchment; seniors experiencing both are especially at risk. o Limited / segmented services available for LGBTQ+ health care and for mental health & addictions. o Lack of housing supports (e.g. pest control, hoarding) for vulnerable individuals lead to poor health outcomes and evictions. o Need to strengthen referrals for vulnerable people via ‘warm bridging’ and better awareness of each others’ services and key staff. o Centretown CHC is a community leader well-positioned to connect local partners, as well as a convenient place to refer people with complex needs, knowing that these needs will be met.

Board-Staff Consultations – Spring 2018

 In April 2018, two to three staff representatives from each program joined Board members in a facilitated planning session intended to identify potential goals under each Strategic Direction and strategies to achieve these goals.  Note: at the time, the Strategic Directions had not yet been finalized and were still known as ‘Access Leveling’, ‘Quality Improvement’ and ‘Strengthening Key Enablers’.

Strategic Issues Proposed Solution(s) Directions

- Lack of identified staff with - More Francophone (FLS) and culture, skills, language to Indigenous staff with lived meet needs of hard-to- experience (e.g. MHA, LGBTQ+, reach individuals homelessness) (Indigenous, people with Access addictions, Francophone) - Working with partners to better Leveling understand: - Lack of awareness about o Each other’s scopes and our programs among any gaps remaining clients and community partners o Data on who is falling through the cracks

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- Lack of continuity of care - Increase outreach and warm / wrap-around services for handovers for vulnerable clients homeless/marginalized populations - Stigma, social isolation, - More case management lack of mobility keep high- resources for complex clients need clients outside of our doors - Improve sense of belonging via programming that engages those most at risk of social isolation

- Need for high-quality - More Francophone (FLS) and Francophone primary Indigenous staff with lived healthcare (Haitian experience (e.g. MHA, LGBTQ+, refugees + existing homelessness) Francophone population + FLS designation) - Explore options for enhancing client engagement (e.g. client - Could do better at advisory group and/or or other engaging our clients mechanisms)

- Improve awareness of our - Integration between programs and services internally programs / teams could Quality and enhance strength of cross- be better program collaboration Improvement

- Not enough data (or lack - Collect better data on client of data flow) to respond needs and experience with quickly to different quality our services using health communities’ needs equity lens

- Review interdisciplinary primary - Offer a full continuum of healthcare assets and gaps in services across the community (take into CHCs/agencies instead of consideration hours of service, patchwork and eligibility, service type, duplication of basic geographic coverage) services

- Develop approaches to - Need better and more monitoring our client data over timely data time using an equity lens and

communicating this data to staff - Need to strengthen our

Key Enablers ability to tell our stories (i.e. - Better understand the gap advocacy, grants, brand between what we are seeing at reputation, influencing our Centre vs the true picture of system change) needs in our community (e.g.

who aren’t we seeing?)

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- Need to have more agile and collaborative - Flow data and stories from front- structures / resources to line staff / analyst / respond more quickly to management to emerging community communications to better tell issues our story

- Need better technology - Work with Communications to make healthcare specialist to coach key staff on processes more efficient strategy (e.g. social media) and client-centred and reduce burden on staff - CHC collaborative planning: Define core vs specialized/sub- regional services

- Plan across programs for priority populations (e.g. vulnerable MHA clients; isolated seniors; LGBTQ+)

- eFaxing, EMR, email reminders, tablets/kiosks for client forms/registrations

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CCHC 2018-2020 STRATEGIC PLAN

Our Vision, Mission & Values

Our Vision Healthy, caring, inclusive communities where every one matters.

Our Mission We lead the way in improving health and wellbeing for people and communities.

Our Values Equity / Empowerment / Excellence / Respect

Equity. We believe in recognizing and respecting diversity among people in our communities to provide them with appropriate services that meet their varying needs. We strive to break down barriers so everyone can enjoy access to the services they need to be healthy. Equity is about recognizing differences among people and treating people differently according to their needs in order to achieve equality of access.

Empowerment. We value participation and believe in our clients’ and communities’ right to play an active role in determining what services are offered and how they are delivered. To achieve this, we foster open and constructive dialogue and believe in engaging in respectful, honest and clear communications practices. We strive to provide all the support and information required to make informed choices and participate in meaningful ways.

Excellence. We are committed to providing excellent services and strive for constant improvement and innovation. We focus on best practices, evidence-based approaches and ongoing evaluation to deliver effective and comprehensive services that best meet our clients’ and communities’ needs. We ensure accountable, efficient and effective use of resources.

Respect. We are committed to fostering an inclusive environment where everyone is treated in ways that are fair, courteous and compassionate. We believe in valuing one another’s opinions and contributions and giving full considering to these views with an open and non-judgemental mind.

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OurDIRECTION Strategic 1: Directions & GoalsENHANCE ACCES FOR PEOPLE WITH COMPLEX NEEDS

Individuals with 4 or more chronic conditions are defined as medically complex individuals. If accessible, equitable and interdisciplinary primary healthcare is not available to these individuals, they are more likely to suffer from preventable complications, to frequent the emergency department, and to have poor quality of life. The CHC model of care is ideally suited to keeping these individuals healthy and well.

GOALS

1.1. Identify hotspots of vulnerable individuals in CHC catchment areas and target health inequities in our communities. © 1.2. Improve care coordination and health outcomes for clients with complex needs. 1.3. Improve low-barrier access to primary health care and addictions medicine for people who regularly use drugs and alcohol.

INITIAL ACTIVITIES

1.1. Develop a community profile of complex and vulnerable individuals in the community using a health equity lens. 1.2. Evaluate the implementation of Health Links and its impact on client outcomes. 1.3. Submit a funding proposal to Champlain LHIN for enhanced primary care and MH&A outreach resources for street-involved clients.

By 2020 …

CHCs will ensure that clients with complex needs have  2020 Target: 44 access to coordinated interdisciplinary care in Central Health Links Ottawa via Health Links. coordinated care plans (CCHC)

 CCHC will reduce 30-day hospital readmissions for clients 2020 Target: <9.5% 30-day hospital readmission rate for with complex needs. Health Links clients 2020 Target: 200  CCHC will improve client experience and continuity of more encounters/year with clients care for transient clients who use drugs and alcohol. who use drugs & alcohol due to enhanced wrap-around services Centretown CHC Strategic Plan 2018-2020 22

e DIRECTION 2: DEMONSTRATE QUALITY THROUGH IMPACT

Quality has many dimensions. While Centretown CHC excels at providing effective, safe, timely, and client- centred care to the most complex clients in our community, we have never formally studied how equitable the care that we provide truly is – at least not in a systematic way. This will change in 2018-2020.

GOALS

2.1. Review our data to identify gaps in access to programs and services for priority populations. © 2.2. Identify and address inequities in the client experience and outcomes of our diverse clients. 2.3. Adopt a Social Prescribing approach to better support collaborative practice and promote a greater sense of community belonging.

INITIAL ACTIVITIES

2.1. Develop a profile of clients served, including services accessed and client issues, using a health equity lens. 2.2. Develop a health equity report card to monitor access, client experience, care quality and outcomes for CCHC’s priority populations. 2.3. Develop a project plan for the implementation and evaluation of a Social Prescribing strategy.

By 2020 …

 Ottawa CHCs will have a system in place to monitor 2020 Target: Adoption of CHC performance dashboard inequities in access, client experience, and outcomes. with equity indicators 2020 Target: 4 out of 4  All Centretown CHC programs will have the information CCHC programs use access maps they need to set annual equity-seeking goals. and the health equity report card to set annual improvement targets 2020 Target: 75%  75% of clients involved in Social Prescribing pilot will report of monitored clients report an a greater sense of community belonging. improvement in their sense of community belonging

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DIRECTION 3: LEVERAGE COLLECTIVE CAPACITY

As the client journey and health outcomes of Central Ottawans becomes an increasingly collective and intersectoral responsibility, it is important to develop collaborative practices that enable the sharing of best practices, tools, and data systems so that our organizations can collectively rise to meet the needs of the community.

GOALS

3.1. Undertake a joint review of Primary Care capacity to better understand gaps and opportunities for improved client care. © 3.2. Be proactive in mitigating organizational risks. © 3.3. Use EMR technology to improve client care and operational efficiency.

INITIAL ACTIVITIES

3.1. Collaboratively define the scope and priority areas of the inter-CHC Primary Care capacity review project. 3.2. Educate senior management and board members on the use of Sandy Hill CHC’s risk management audit tool. 3.3. Undertake a cost-benefit analysis of potential EMR add-on services (e.g. eFaxing, client kiosks).

By 2020 …

 On-call providers will be able to access client records 2020 Target: Adoption of EMR data-sharing utility at the 6 and chart in the EMR when providing after-hours care. Central Ottawa CHCs

 Senior management will have adopted new tools and 2020 Target: Adoption of new risk management tools and processes to identify and manage organizational risks. processes captured in policies

 Collection of up-to-date client socio-demographic (SD) 2020 Target: 50% of active clients will have up-to- information will improve by +400%. date SD information in the EMR

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DIRECTION 4: ORGANIZATIONAL HEALTH & WELLNESS

Technological advancement, changes in government priorities, and the evolving nature of our work requires us to be constantly adapting to our context to maintain high quality, client-centred care. In order to deliver what the community expects of us, it is imperative that we continually look to strengthen our funding, our infrastructure, our processes, and our people.

GOALS

4.1. Implement an improved performance management system for staff. 4.2. Assess options to improve our fiscal sustainability. 4.3. Improve the CCHC staff experience.

ACTIVITIES

4.1. Finalize CCHC’s staff performance management tool in our HRM system. 4.2. Identify potential efficiencies and estimate cost savings. 4.3. Conduct a survey and consultations in order to better understand staff priorities.

By 2020 …

 # staff who report getting timely feedback on their job 2020 Target: 75% of staff agree that they get timely performance will improve by +50%. feedback

 # staff who report that there is strong support for training 2020 Target: 70% of staff agree that there is strong in their area of work will improve by +40%. support for training

 # staff who would recommend CCHC as a place to work 2020 Target: 70% of staff agree that they would will improve by +8%. recommend CCHC

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Every One Matters. Chaque personne compte.

420 Cooper St, Ottawa ON CentretK2P 2N6own * 613 CHC-233-4443 Strategic * [email protected] Plan 2018-2020 * www.centretownchc.org APPENDIX I. DEFINING THE SYSTEM APPENDIX II. SWOT ANALYSIS

Strengths Weaknesses • Ottawa CHCs generally report high client satisfaction. • Ottawa CHCs generally have limited analytical capacity and QI expertise • Ottawa CHCs are increasingly data-rich (EMR, Be Well Survey, to make use of their client data for equity-informed quality improvement Ottawa Neighbourhood Study, etc.). (QI). • Ottawa CHCs have access to a significant number of • Quality improvement is currently driven largely by a top-down (i.e. Health volunteers, many of whom have lived experience, as well as Quality Ontario) approach rather than via client engagement. cultural and linguistic competencies. • Low organizational maturity in program design, outcome evaluation, and • Ottawa CHCs are generally becoming more efficient or knowledge exchange make it difficult to identify, assess, and scale best maintaining their efficiency over time. practices in group programming across CHCs. • The practice of developing Centres of Excellence and referral pathways among CHCs promotes service high-quality clinical care.

Opportunities Threats • Greater use of eHealth tools like eVisits, patient portals, and • There is potential for already-high demand for newcomer health services hospital eNotifications could lead CHCs to better patient to be exacerbated by the recent trend of irregular crossings from US- outcomes, higher client satisfaction, and significant efficiencies. based asylum-seekers due to US ‘self-deportation’ policies. • The forthcoming integration of public health units within LHINs will • Ottawa’s aging population will significantly increase case complexity as allow CHCs to better align their community development and well as demand for chronic disease management, care coordination, health promotion resources with Public Health for greater and home-based care over the next 10 years. impact. • The high likelihood of political turnover in the June 2018 provincial • CHCs should explore the feasibility of becoming ‘Community elections casts doubt on the extent to which sub-regional healthcare Hubs’ (and related capital funding opportunities) in order to integration will proceed as planned. reduce barriers for clients needing access to social services. • The number of individuals approaching retirement age has begun to • Given the recent residential school apology, TRC Calls to Action, exceed the number entering the workforce. This trend will accelerate as and growing impetus to recognize the rights of indigenous the 65+ population segment grows by 28% as a share of Ottawa’s peoples to culturally-safe care, CHCs have an opportunity to population by 2026. CHC loss of corporate memory and expertise poses explore partnership with Wabano to promote a shared health a significant organizational risk. equity agenda in service of indigenous communities.