Mississauga Halton LHIN Community Consultation Feedback February 2016
Introduction On December 17, 2015 the ministry of Health and Long-Term Care (ministry) released a discussion paper entitled Patients First: A Proposal to Strengthen Patient-Centred Health Care in Ontario. The ministry requested input on their proposal and was looking to hear from providers, patients and caregivers from across the province.
In support of the ministry’s desire to engage Ontarians, the Mississauga Halton Local Health Integration Network (LHIN) undertook a six week community consultation process to gather feedback on the Patients First proposal. The consultation strategy consisted of three key mechanisms:
1. Face to face consultations, organized across the geography of the LHIN with primary care physicians, health service providers, patients and caregivers 2. An on-line survey and invitation to residents, primary care providers and health service providers to provide their feedback on the questions noted within the ministry’s discussion paper 3. Promotion of the ministry’s feedback link for community input
Over the past six weeks, 35 in person consultations were planned, organized and executed. The primary care physician community was reached through 14 separate consultations. Nine of these took place within the community, including one within each Health Link geography and two that were open to physicians from across the LHIN. The remaining five consultations included groups of physician leaders as well as hospital family medicine teams, solo practitioners and walk-in clinic owners. Representatives from the Ontario College of Family This report is a summary of Practioners (OCFP) and Ontario Medical Association (OMA) attended the feedback provided by 570 and participated in a number of the consultation sessions, and helped participants and does not advertise and encourage physician participation. imply endorsement from the Health service providers were engaged through a variety of meeting Mississauga Halton LHIN. The forums. A broad scale consultation with health service provider summary is broken down by governors was also conducted, soliciting input from close to 100 proposal and then again by the community leaders. Health service providers were also encouraged to questions posed within the share the survey links with their staff and patients/caregivers to invite ministry’s discussion paper. additional input from people providing and accessing care. Key themes that were voiced are noted in bold. Specific The broader public was reached in person at two community organized comments/quotes are noted events. Consultations were also conducted targeting specific in italics. A detailed populations within the LHIN, including the Indigenous, Francophone, breakdown of the consultation new immigrant/ethno cultural groups and patient/caregiver advisors. sessions, including a statistical summary is noted in the Following each consultation, participants were invited to provide Appendices. additional feedback via feedback surveys that were posted on the LHIN website. Three unique surveys were created targeting the public, primary care physicians and health service providers.
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PROPOSAL 1 – MORE EFFECTIVE INTEGRATION OF SERVICES & GREATER EQUITY
How can you/your organization be better supported to provide integrated care?
- Open dialogue with primary care and the LHIN and home and community care. There must be recognition that solo family physicians will need drivers to engage; their capacity to “integrate” as a team of one is very limited/counter-intuitive. Enhanced resources to support primary care would also help. Services need to be realigned around primary care – “Vertically integrate with primary care; we go to the primary care provider and provide our services there.” “Even at the Family Health Team we are still not resourced the way we would like to be.” “Please improve the communication and connections between primary health care providers, hospital, Community Care Access Centres (CCAC)/LHIN and the Service Provider organizations who will be providing the care in the community. Too often there seems to be a disconnect between hospital, primary care providers, CCAC and the service provider which ultimately delays service to the patient.”
- Clear communication from top down - any details about newly implemented programs should be communicated effectively to all stakeholders - not just management level but everyone in each organization. Better communication between agencies. More accountability and clarity in roles for service provision. Have clear guidelines to move the patient from one service to another (i.e. hospital to home) to make this move at the right time when the patient is ready. Have clear, up-to-date guidelines about each organization’s expected role. Each staff member should be telling the same story about what patient’s should expect from each organization. Have a communication guideline or technology that helps ensure the patient’s care is looked after at each step, especially when changing service or moving to another organization. “We are currently doing the role of care coordination for many clients which increases workload and takes away from our ability to provide quality dementia counselling.” - Bring the privacy commission to the table. Before we can have communication that works for patient and provider we need to focus on finding solutions to privacy issues. It is a huge barrier. “We can’t see who has been calling Emergency Medical Services three times a month to make sure that we connect with them to provide services – must be ways to do this better.” Make information available to entire circle of care.
- More integrated communications across the LHINs and service providers. Breakdowns in service, communication and accountability occur as patients cross LHIN boundaries. Open dialogue between all stakeholders to understand the barriers around funding. Tracking the way different initiatives intersect is important – to avoid duplication of services.
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- Technology has to be a solution to enable communication. Technology linkages – shared care planning without duplication. Use of existing open platforms to share information. Patient owned/driven and easily accessible. Leverage technology to support consistency between people at planning tables. Ensure the emergency room provides discharge instructions and medications or other treatments on the Hospital Report Manager form, as currently this information only comes on the handwritten report days to over one week later. Leveraging technology to view the patient's journey between sectors including primary care and lab. Access to specialists to support community providers through the Ontario Telemedicine Network for example.
- A health card with everything on it that people carry with them; “if a driver’s licence has all your driving history and the police can access it with a swipe of the card, why can’t health cards be the same?” “Patients need a card with a pin that would be associated with all of their reports – you can put in your pin and get all the reports. I have to call around and consent becomes a barrier – if they had a simple pin that could provide access, that would be easier.”
- Community Hubs: “I am most interested in this community hub model on a bigger scale – let’s take these places and collocate them so they are seamless.” “Have services a short staircase or hall walk away. This will make it easier to wrap services around the client. Geo-proximity of services will also help manage waitlists.” “The biggest barrier is that my patients can’t afford the services and they can’t get there. It would be nice to have a hub where everyone would go“. Create opportunities to collocate with other services to offer interdisciplinary care without the challenge of technology, carrying large amounts of resources, charts, signs, etc. and supporting the collecting of clinical interactions including care planning. Minimize the culture of competition for resources.
- Formally acknowledging the role of pharmacists and their services within the LHINs through enabling collaborative sharing of information between all health care providers, enabling pharmacists (and all health care providers) to practice to their fullest scope of training, and to establish a fair and reasonable funding model (which is likely the barrier right now to integration of pharmacists into the LHIN structure). Allow pharmacies to work with the LHIN. Many opportunities are only open to the non-profit sector. We would encourage focusing on delivery, costs and accountability rather than the corporate structure of the provider.
- Ensure sufficient resources exist (clinical) to meet growing demand in the region. Currently insufficient psychiatric resources available to community mental health services delaying access and timely discharge. Incentives need to be made to strengthen recruitment of psychiatrists to community based services. Improve access to crisis psychiatry care locally other than through an emergency room visit. Provide psychiatric nurse practitioners to community service providers. There are few programs and thus graduates in this specialty field - this needs to be
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expanded to enable dissemination of best practices and psychiatric expertise on complex cases. Align mental health/ addiction community services with existing hospital programs. Improve access to social workers.
- Within the long-term care sector, there is a higher acuity of residents, and subsequently, a shorter length of stay. Clients are coming in younger due to lack of sufficient supports in the community. There is also severe dementia. Supports in the community have to better align with long- term care by recognizing the shift in long-term care demands. The funding levels for long-term care need to reflect the increasing acuity of the people that we care for. The increase in behavioural clients is taxing the care of other clients. Opportunities for improvement include: . Enhanced supports in the community to meet the needs of complex residents and delay admission to long-term care . Resource mix needs to change in order to meet the needs of clients . Standardization between the LHINs . Flexibility to use funding in a non-prescriptive manner . Ability to expand programs that work well
- Reorganize - Home care services should be at walk-in clinics and Family Health Teams. This way family physicians would be able to connect their patients directly to services that could help them and possibly prevent hospital admissions or trips to the emergency room. Put CCACs back into hospitals to operationalize and steer patient outflow. “We can provide more timely care to our clients if we were given the ability to assess our clients for our supports and services. Currently this goes through the CCAC and the wait times are long and often services are not well distributed. We know our clients best and understand the disease process much better. Often the CCAC requests us to attend assessments to help provide this support. This is redundant and inefficient use of services. We are also able to contact clients often within 24 hours of referrals and make connections, follow ups and continue to provide supports when clients’ needs change. We don't close files.”
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How do we strengthen consistency and standardization of services while being responsive to local differences?
Consistency - Improve transitioning of individuals from the youth to adult sector. Focus on communication. Improve connections between all sectors (including primary providers, hospitals, and community care). - Implementation and consistency in application of policies and procedures by management. Designed provincially - customized to the local level.
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- “The same care offered by an agency no matter where I am. Some regions provide respite and some do not. This impacts my freedom to move across the province. Do I choose to be near family or the services I require?” - Proper assessments to identify the needs of clients would be the best first step. Better understanding of services available in the system as well as the referral processes. Care coordinators need to include regular referrals to much needed supports e.g. crisis services, geriatricians, psychiatrists, dementia supports etc. Awareness of the needs locally so differences can be accommodated for e.g. based on age, gender, culture etc. Ideally services to be provided by those that reflect the population being served (in terms of language, culture etc.). This is critical when supporting Indigenous peoples, Franco-Ontarians, newcomers, and people with mental health and addiction challenges. - Children’s mental health is funded by different bodies. Funding and boundaries create problems. The ministry of Children and Youth Services provides services to individuals 16-20yrs of age. Needs to be better integrated. Alignment of mandates between the ministries is key.
Standardization - Incentivize and mandate the use of best practices. Agencies know them but don’t use them. Set minimum outcome standards with relation to quality. Mandate accreditation then fund only those who are accredited. Set of recognized metrics/training modules – centralized approach to outcome measurement. - Standard Electronic Medical Record across the province. Too many Electronic Medical Records – technology issues need to be solved. Doctors shouldn’t be allowed to choose which Electronic Medical Record they are on. - Standardization can also be a barrier in discharge – limits choice to match services with patient needs. - Standardization of practices between Family Health Teams – when we hear another Family Health Team is doing something successfully we have limited mechanisms to implement the standardized process within our own teams. - LHINs need to be standardized. - Within the standardization, there needs to be flexibility to address local geographical needs. By definition, if services are responsive to local need they will be different and not standardized. The link between why they are different and what the local need is, is key. - Health profession regulatory authorities (College of Physicians and Surgeons of Ontario, Ontario College of Physicians, College of Nurses of Ontario, etc.) should be engaged to support patients given that their mandates are to protect the public and establish codes of ethics/conduct and standards of practice. - Common approaches for similar services will enable both predictable costs while at the same time we need to customize care based on local needs/issues. The tension often arises from 'standardization' which is funder/ministry focused, not client focused. Standardization inhibits nimbleness within the delivery system. Creating quality indicators that reflect system goals vs. service goals may support this. Creating self- directed funding envelopes may be helpful to those capable of navigating the complex service delivery system.
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- Feedback from consumers is necessary. While consistency and standardization have benefits, the policies and procedures put in place must allow for individualization of care plans that take into account the individual health needs of people in order to provide effective care. - Consider having a common form for all contracted services that are currently provided through the CCAC. - A clear set of recognized metrics/training modules assuring alignment. - Harmonize clinical pathways and referral options across similar providers, ensure equitable access even in non-urban areas. - Integrated access should be funded to evolve so all providers know how to get a patient referred rather than the many independent processes that currently exist. These need to transcend LHINs or sub-LHINs to be provincial. Responsiveness - Understand the needs of our communities first and respond to differences accordingly, including hiring professionals which match the needs of each community. - Involve community members on sub-LHIN planning groups that represent the diversity of the community. - Responsiveness to local differences is far more important than standardization. - The removal of clinical judgment by "standardization" is a risk to patient health and safety. Ensure greater clinical experience and exposure to variant clinical presentations as a "clinical practice", create hierarchies of clinical care and referral; circumvent referral delays (i.e., income for outcomes).
What other local organizations can be engaged to ensure patients are receiving the care they need when they need it? What role should they play?
A number of organizations were identified as key partners to ensure patients receive the care they need when they need it. These include: . Cultural centres - to enhance access to adequate culturally appropriate activities . Faith based groups; community groups . Education system/school boards . Emergency Medical Services - Paramedics play an important role in health care, although not recognized in the Patients First paper this needs to be recognized . Correctional services . Police
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. Transportation partners: “When it comes to transportation, a lot of my patients can’t get where they need to go – elderly in particular.” “Transportation continues to be a large gap in patient care that must be strategically embedded in all aspects of care. If patients can't reach our services then they cannot get the services.” . Physiotherapy clinics, occupational therapy services . Independent practices – Chiropractic, other private health care providers . Pharmacy . Non-profit organization such as the Cancer Society, Heart and Stroke Foundation, Alzheimer Society, The Diabetic Association of Canada and many others play a vital role in supporting patients and their families. They can continue to provide support and education to the patients and their families. . Private sector – broad partnerships, not just with health care charities or not for profit community partners . Hospitals - should include volunteer streams for fundraising as well as back office administrative duties. Given their expertise on complex care for all populations, hospitals should play a increased role in the Local Health Integration's delivery of services to this population. . Broader community human/social service sector that provides many other important supports in the area of mental health and addressing socioeconomic factors that are important for achieving positive health outcomes for people/patients . Other organizations that deal with social determinants of health such as income, housing and access to food. Safety should be included as well when these needs are not effectively met, otherwise well-developed health care plans for individuals will fall through. Examples of these organizations would include: housing shelters, women's and domestic violence shelters, food banks, community food programs, needle exchange programs, victim witness services, Ontario Works, Ontario Disability Support Program, clothing banks, and employment centres . Mental health partners including COAST, ROCK and others for further patient support . The OMA as well as the local Halton and Peel branches of the OMA
What other opportunities for bundling or integrating funding between hospitals, community care, primary care and possibly other sectors should be explored?
Identified opportunities for bundling that could be explored: . Complex patients such as medically fragile seniors . By sector of care, including prevention . By procedure, with funding flowing through the hospitals as lead agency
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. Bundle purchasing together to get better purchasing prices ex. Volume. Secondly, try to get bigger groups of physicians together in practice to improve total coverage. Then get each of these large groups to have a walk-in day and evening clinic for the group's patients which would ensure continuing good practice. This would also take a lot of pressure off the emergency departments of hospitals throughout the province. . More robust practices to support successful discharges from hospitals. This objective could be achieved by bundling services provided by hospitals, home care, mental health and addiction and community support services by having these collocated or available to support a sustainable discharge plan prior to discharge from hospital. . It would be good to bundle funding from a population health perspective. For example, in regional health authorities there has been project funding to support shifts in services and care that is more aligned with pay for performance. An example would be Fraser Health which incentivized the staff to adopt chronic disease prevention management (CDPM) practices in home care at the coordinator level. The number of CDPM goals and the reaching of these goals were used to provide a small amount of funding to a department to make and sustain this change. Identified opportunities for collaborative work across sectors: . Training opportunities could be shared . Case coordination – follow the individual and ensure they have a constant connection . Look at specific populations . Understand the barriers to providing care for the individuals along the continuum . Mental health funding should be reviewed because of the unique clients that come into long-term care. A joint effort to care between the hospitals and the long-term care homes needs to be explored - The opportunity to look at a basket of services that long-term care could provide to clients would be ideal in addressing needs of patients waiting for long-term care. Funding for long-term care needs to be reexamined. “Feels like long-term care gets what is left after hospitals get the bulk.” - Funding and resources need to be aligned. Can’t have one without the other. - Integrated, CDPM programs (such as those that have been funded in inter-professional teams and focused on conditions like diabetes and Chronic Obstructive Pulmonary Disease) are an excellent model for our health care system going forward.
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What areas of performance should be highlighted through public reporting to drive improvement in the system?
- Wait time for specialists and tong-term care - Primary care physicians that are taking new patients; number of patients on a primary care roster; number of primary care physicians in each hospital - Create dashboards for public transparency. Understanding what best performers are doing - There should be a clearly defined method of providing feedback as well as insurances that patient/family complaints won’t result in withdrawal of services.
What does the LHIN need to be successful in its expanded role?
- With the right leadership and thinking, the potential to remove some of the governance distractions that we've experienced in the past is there. An opportunity to make sure decisions are anchored in what makes the most sense for individuals - ensuring patients are put first. Looking at singular leadership - stewardship of the system from a regional perspective. Similar to a regional health authority model, supported by provincial boundaries and public health. Look at other jurisdictions and integrated systems with public health, etc. - Planning tables around social determinants – federal, provincial and municipal. Better connections with non LHIN funded agencies or groups (i.e. Wellspring, United Way agencies). - Increased internal knowledge capacity related to new partners (e.g. Public health/primary care). The LHIN may be given a new mandate before they even know who we (primary care) are. The relationship needs to be built first. - Need more accountability and transparency at the LHIN and ministry level. LHINs need to ensure service delivery is focused on its role and is accountable. Accountability of providers and measurements of public satisfaction need to be in place. - Government and health care need to get together to become better aligned. - Planning should include a pilot process and ingrained evaluation. Best practices have to be identified and developed - Quality improvement is proposed through the LHINs, yet the ministry holds the purse strings. “Even if there are many great ideas, how much can the LHIN actually do without the ability to alter funding?” If given a wider mandate, LHINs need to be given the ability to affect incentives. Currently “no teeth” in the proposal. - For this to work, the commitment has to be there. It cannot be one priority now and then a change in direction the following year. It has to be seen through.
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- Ensure that included in its role are coordination and holding providers accountable. Involve care providers. Create a centralized system for care coordination and service access where someone's role is to take responsibility for the care of the client. - Understanding of their HSPs, frontline staff, patients and doctors by continuing to engage on an ongoing basis to let them guide the way forward - The LHIN will need to be able to integrate more of the planning tables, clarify roles, have a better clinical understanding of care and care practices, bring providers together to enact and build opportunities for integration. - More understanding and expertise of direct service function. Establish measurement, performance and evaluation metrics and provide platforms for review and discussion of metrics to ensure consistency. - Ensure that their new structure has new clinical leaders who have the expertise to move the organization towards effective care delivery. - Acknowledge care as a province and make a commitment to all residents of Ontario, no differentiating between postal codes. - It needs to be able to control all the pieces of health care so they work under one vision. Should LHIN boundaries be redrawn?
- We don't know about the boundaries and we don't care - we refer the same way anyways. - Consider/base changes in patient flow when discussing boundary changes. We should spend more time understanding the boundaries and the issues that stem from them. If you change the boundaries, make sure you standardize services across them. Should be consistent with hospital referral patterns. - LHIN boundaries should better align with regional and municipal/other ministry boundaries. One LHIN for all of Halton. This would support better integrate opportunities, less client confusion, reduce administrative burden (e.g. keep Peel whole, keep Halton whole). Align boundaries to some current system boundaries that make sense – Public health; political? Look at Burlington/Etobicoke boundaries. Etobicoke is currently serviced by a number of LHINs. - Burlington should become part of the Mississauga Halton LHIN. Bring Burlington, which is in the Halton region, into the Mississauga Halton LHIN to support more seamless planning. The current boundaries create barriers to integration of care because it fractures the community. Residents in Burlington are often coming to Mississauga Halton LHIN for services. “Working with the Coast Program, it would have been so much easier if the LHINs and municipalities were aligned.” “Anybody who provides service in Halton would say that Burlington should be a part of the Mississauga Halton LHIN”. “Burlington is a natural fit with Halton because most GTA services end with Burlington as the outward boundary.” - When you live in Burlington you have priority over some cardiac services at Halton Healthcare Services and therefore I have to tell my patients who don't live in Burlington that they need to be referred to a community clinic. What will happen if they change the boundaries again?
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- Malton should become a part of the Mississauga Halton LHIN. Malton (which is part of the city of Mississauga) is currently part of Central West LHIN. There are gaps in service, especially in south Asian languages. Clients circulate info but are not eligible for service depending on where they live - “Mississauga and Halton are very different – splitting Mississauga Halton in two might make more sense – merge Mississauga Halton with Central West.” - The LHINs must accurately map out boundaries by profiling each area based on the social determinants of health, complexity, as well as language and culture. One cannot easily follow the patients and transfer payments. You can’t have zones like schools that connect people to doctors. - “Recommend blurring the boundaries as much as possible. I have many clients with mental health problems and I have no idea where to send them. Being stuck in the corner of a number of boundaries is like being stuck in no man’s land.” - “Will boundaries be set and applied with the "patient" in mind (i.e. where the patient lives) or will it be "provider" based (i.e. Where the provider works)? I ask because patients who reside in a particular LHIN (i.e. Mississauga Halton LHIN) may need to access a provider that is based in another LHIN (i.e. downtown Toronto). How will that work?” “ I like sub-LHIN as long as you remain flexible to cross boundary funding” - Must address cross LHIN barrier issues such as transportation. Transportation for disability won’t move beyond the boundaries of the municipalities. Public transportation needs to be looked at (availability of) - “Almost more important is the sub-LHIN planning levels. I don’t think there is any ideal way to divide the LHINs. In Halton the Health Link areas are natural – they are all municipality based which I think works very nicely.” - The number of LHINs should be reduced - Should not be based only on geography. Should examine cultural needs as well.
SubLHIN Regions - If sub-LHIN regions are created, each needs a clearly defined lead agency. There also needs to be a clearly defined process on how we respond to patients that access services from another sub-LHIN region. Lead agencies within each sub-LHIN should hold accountability. The lead agency must have the capacity to deliver on the outcomes to which they are accountable. - “I want to be able to refer patients to the services that I would like to refer to, regardless of the sub-LHIN boundaries.” Aligning resources by sub- LHIN region is a good idea but you have to increase resources or you will just get a bottleneck. “I want to be assured that if my patient doesn't fall in my sub-LHIN region then they get access to the same services that are available in my sub-LHIN.” - Equity must be kept front of mind when determining distribution of services within each sub-LHIN. Particularly areas of high need. - We should use the Health Link framework as the concept for wrapped care - everyone should belong to a sub-LHIN and within that sub-LHIN should be a group that wraps around the individual.
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- Patients access physiotherapists near their work and near their home. Their lives encompass two geographical areas. I would like to know that patients are able to access the services where they need them and not be locked into a sub-LHIN region near their home. - Communication has to be the focus to ensure any integration between sub-LHIN regions is successful. - Sub-LHIN planning levels are better able to respond to local needs (LHIN-wide initiatives are sometimes not efficient and not needed). Concerned about introducing another level of administration and cost. - Create a position whose role is to problem solve integration issues between sub-LHIN regions. - Both sectors are incentivized right now to push clients back and forth. With high demand for resources, it makes financial sense for providers to defer costs to other sectors. - At the sub-LHIN level it would be interesting to know what the patient patterns are - utilization of services. Are there any other patterns that we should look at? - Sub-LHIN work is great from a relationship point of view, but when planning etc., can't do it at that level. With Health Links, both large and small organizations have a challenge in meeting a number of sub-LHIN needs (as the organizations cross boundaries). It is difficult for a hospital to participate on seven steering committees, let alone a small organization. Sub-LHINs may have different needs but most things don’t only relate to one neighborhood. Patients will cross those sub-LHIN boundaries and there is risk that coordination is actually more complicated; the system is already complicated enough to navigate. - Starting to build referral patterns because all the sub-LHINs are live now. - Engagement at the sub-LHIN level, particularly with primary care (leveraging the primary care advisors) can work but planning at that level is very challenging especially since there's no structure for that planning. Do not create another layer of bureaucracy under the LHIN. - Ageism is rampant. We need to focus on equity before we focus on more localization. - Would like to see funding formulas that accommodate for population growth and changes in demographics. - “Worried it will be another form of red tape and will hold up decision making further.”
Feedback from the local Indigenous Community
- “Going through the process, the challenge is building the capacity at the beginning – having places to go to that the community will know will be open to their needs – then you can begin the process of properly engaging – “come on out – community event - questionnaire – a forum for doctors to learn from the aboriginal community – a dialogue.” - “There is a need to understand the way that traditional medicines interact with more traditional processes/medications. There is a knowledge gap with the physicians around this concept. Often they will agree to take the medication home that they have said they don’t need or that they don’t want to use, so they will offer it to others who are sick or possibly sell it. They need to take the time to get to know who we are.”
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- “I get told a lot about the fears related to prescriptions – someone goes on medicine for high cholesterol; then experiences side effects they weren’t told about because it interacted with a herbal treatment they were using. They didn’t share the herbal treatments they were using because they felt the doctor would judge them. Then when they get afflicted with something else, they are more reluctant to take medication because of previous experiences. They then move back to their roots and stick with a more natural management program. At this point you have already lost your opportunity to do it right the first time. I need a doc that will work with me. Not provide me treatments that I don’t want.” - “Doctors can be transient. When this happens I generally have to start again. The new doctors that are coming in, do they know anything about our medication? Particularly up north, many will walk by doctors’ offices because there is no trust – there are a number of herbs and plants and roots we take but they don’t understand it. I would like to be able to have a conversation with my doctor about the medicine I use.” - “When you are doing homecare, why do you not have some aboriginal or indigenous medicine there for the doctors that come in? What if the doctors had little packages with them that they could offer to clients who wanted them?” - “The northern medical university, when you look at their program, the last time I read material from them their funding is being cut back; it is not being increased to encourage more indigenous people to come in and learn to serve their community – it is not just the indigenous community it is the greater community that is learning from us.” - “You won’t get all the doctors to become experts in aboriginal healing so I think that having elders and medicine men working side by side with some doctors will promote translation of information and they can both learn.” - “I would like an aboriginal elder there to talk to me and he will listen to me. I can’t argue with the elder. If they tell me that I have to go (see the doctor) then I will. I have to listen to our peers. He can then speak with the doctor and myself about what the options are and what is best. The elder could provide the cultural teaching that otherwise wouldn’t be there.” - “Even something like aboriginal art in the doctor’s office – trees – plants – in the medical space, would make me feel more comfortable. Health places should have a room for smudging – where students or the patient can do a prayer or smudge and then go to wait for the doctor.” - “We approach health from a less physical manner. We identify environments that create health issues that are not conventional in nature. It is more healing sessions and gatherings – these are the things that we do well but they are not on your radar at all.”
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PROPOSAL 2 – Timely Access to primary care, and Seamless Links Between primary care and Other Services
How can services be organized differently to ensure better access to primary care for same/next day, evening and weekend appointments?
- Equitable access to allied services within primary care teams. Many patients can’t pay for physiotherapy, dieticians or chiropodists and their access to these services shouldn’t depend on the model of practice their physician has chosen to work. - Funding models shouldn’t impact a patient’s access to primary care – Some physicians only allow patients to discuss one topic per appointment. The length of the appointment should align with the needs of the patient. “Access to me is the patient being able to sit with me (the physician) and talk for a while.” “Access to me is having more time to spend with my doctor. Particularly as a newcomer. I need to time to explain what is going on.” - Patients want the flexibility to access primary care when it’s convenient. Patients can’t always take time off to see their physician during office hours. “If I look at my patient population, when I’m open is generally when they’re at work – and they would like to seek care after 5 and on weekends - primarily when I’m not there. Walk-in clinics are open during those hours.” - Accessibility and convenience need to be differentiated. Physicians should not be financially penalized if their patients choose this convenience. Physicians cannot control how patients choose to access their care. Patients may select a walk-in clinic when their physician is in their office with availability, yet physicians get penalized for this. - Access to allied health should become part of the definition of access to primary care. The definition of access should be changed from “Could you see your doctor?” to “Could you see the appropriate health care resource?” - Home visits should be available for those patient populations who cannot travel to the primary care office such as frail seniors and palliative care. This care needs to be routinely and equitably available across the LHIN, not depend on your individual physician. Physicians need to be compensated appropriately to provide this care. - Patient barriers to accessing appropriate care include non-health related issues such as transportation, income, ability to take time off work to access care. “You can have all the physiotherapy you want, but if they can’t get there, it’s useless!” “It’s hard to treat someone medically when they can’t afford the treatment they need. This ties the doctor’s hands – they know what the patient needs, but it can’t be accessed.” Health care needs to factor these issues into planning for services. - Access to primary care 24/7 is unrealistic. Sustainable staffing models for improving access need to be developed. “If we need to be available 24 hours a day we will burn out.” “I went into family medicine to avoid doing shift work. Integrating that kind of access is not acceptable as a life choice.”
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- Finding a primary care provider is challenging. Populations such as newcomers and those with mental health and addictions issues experience even greater challenges finding a primary care provider. Patients would like to have more choice in who their primary care provider is and the option to change physicians if there is not a good physician – patient fit. - Having timely access to primary care is critical. “It doesn’t help to have a primary care doctor if you can’t get in to see them.” Access to care should be available when you need it – this includes evenings and weekends. Physicians should organize coverage when they are away. - Access to care should be consistent across all primary care providers. Similar after hours and weekend availability should be available regardless of physician or their practice model. - Alternative forms of access - of the patient’s choice (i.e. telephone, email, Skype) should be available to improve access. - Need to consider whether continuity of care is an important concept within access. Is it important for the patient’s history to be known when seeking care? Define “access”. “Own” MD vs. group access where PTs chart/history is known. What role are walk-in clinics playing in the issue of access? - Long term care needs a primary care Resource – Long Term Care often has difficulty accessing primary care because they are too busy to come out to see patients in the homes.
How can primary care be supported as the system works together to create a more integrated care environment?
Improve Access to Resources - Integrated access to allied health providers is required within all comprehensive models of primary care. This includes access to: mental health care, psychiatry, counselling, psychology, GEM nurses and physiotherapy. Even within existing Family Health Teams, there are long wait lists for allied health resources which delays timely care. Increase access to social workers and physiotherapists. Often we experience repeat visits that could have been prevented had a physiotherapist been able to provide treatment. This is critical, particularly when doing prevention work in long-term care. We are lucky to have a speech and language pathologist and dietician on staff. Many other physicians do not – we need more. - We all need access to psychotherapists on our team that are OHIP funded.
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Nurse Practitioners - There needs to be a nurse practitioner on every team. “Nurse practitioners need to be better used within family practices. In our Family Health Team I am the only nurse practitioner. More of us and less doctors could solve a lot of the resource issues. Right now things are top heavy. I am stretched in terms of what I can do. If there were more of us we could take more of the load off the doctors and leave them to the critical care.” - Nurse practitioners can be best used to help relieve access to episodic care – providing same day service to improve access – we can be on call because the doctors are so busy as it is. I am envisioning a resource where you can just call up a nurse practitioner and access service by phone. - If the nurse practitioners want to be more independent they can’t be held to the same rules as physicians – their scope of practice would have to be defined in a different way – provide services to lower acuity patients etc. - Need to have shared care service for frail elderly and other complex patients – nurse practitioners can organize care and prepare the patient when docs are taking over their care provision.
Improve Linkages To Specialists - Distribution of specialists is not equitable across the LHIN. There is limited to no access to public transportation to support travel to where specialists are located. Alternate care delivery models should be considered for these areas. - Wait times for specialists are too long. Providing support to patients during wait times places a strain on family physicians. “I don't know how to get a psychiatrist involved without referring to the hospital.” - Wait times for specialists should be available to inform referral choices. Physicians refer to the same specialists over and over because it is what they are familiar with. They get locked into referral patterns which can create backlogs. Tools are needed to support the navigation of available specialists who have shorter wait times. - Access to specialists should not depend on where a referring physician practices or has privileges or where a patient lives. Flexibility is required to enable referrals province wide. - Technology such as eConsult should be leveraged to decrease wait times.
Access To Health Records - Patients want to be able to access their health records. Mychart used at Sunnybrook should be used throughout all sectors of the health care system. - Patients want professionals involved in their care to have access to an integrated health record regardless of where they are in the system.
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System Navigation - Tools and resources are required to support primary care to navigate both health and social service resources. There is no website that has a list of services that I can refer to. “I could navigate these services effectively if I had the time to do it. Currently I have no time.” - Connecting Care Coordinators to primary care would be beneficial. These roles have existed in Family Health Teams and Community Health Centre models, have proved to be effective and should be expanded. Both patients and primary care Providers should have one person to contact within the practice as their service navigation expert. - Primary Care Advisors are a useful resource to inform primary care about what is happening in the LHIN. Greater access and role development is needed for this resource that supports primary care to learn about available resources. “I'm shocked at the amount of resources we have - need someone to tell us more about them.” - Central intake for all services will simplify navigation. All referrals get sent to one place and gets triaged over to the appropriate “neighborhood”. Wait times should be available and a tracking system so primary care doesn’t have to constantly chase these down.
Leverage Technology to Enhance Communication - Technology needs to enable linkages and communication between different components of the health care system to create a coordinated and integrated health record. This should be inclusive of all levels of health care providers from Personal Support Workers to physicians. - Primary care needs to be informed about where their patients have accessed care throughout the system. Patients expect this. Patients always say “it’s in my file” – even though I have zero information or access to what has happened beyond my office.” Primary care needs to understand if service has been received following referrals, what happened to their patient during a hospitalization - Technology should also be leveraged to improve communication with patients. This includes email communication, and online appointment booking.
Physician Accountability/Capacity Building - Liability needs to be adjusted when working in team settings. When working with allied health providers, the liability needs to be shared so physicians feel they can relinquish control. - Capacity building opportunities for primary care providers. Various areas of care were identified including mental health, palliative care, Alzheimer’s and elder care, developmental disabilities and social determinants of health. Creative models such as creating memory clinics accessible to any physician will help to build capacity. - Primary care should have accountability agreements with the LHIN.
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Patient Accountability - “If the system is to be patient-centred, then put the patient at the centre in terms of accountability as well.” Make the patients accountable by giving them a finite number of dollars to spend every year and then they use their primary care Physician as a consultant to help them decide how they should spend it. - Patients need to be held accountable for their use of the health care system. Patients should be able to make choices about care that is important to them (i.e. when they want to choose a specific specialist) or when it’s more convenient for them. When patients make choices based on what is more convenient (i.e. walk-in clinic), they should be held financially accountable. - Patients need to be educated about the finite resources within the health care system. Use the media to demonstrate how tax dollars are being spent on health care. Inform the public about the limits to funding and the fact that long wait times are not the fault of the doctor. This should not be the responsibility of the physician. - Patients need to be educated on how to be responsible for their own health care. Provide education on how to ask questions, how to keep their own health care records, apps or tools that are available to ensure they have the information needed following an episode of care, when to stay home and when to see a doctor, the difference between a walk-in clinic and a comprehensive care family physician. - Patients need to be educated on when continuity of care is important. - Patients need greater awareness of how the rostering system works. Patients are asked to sign sheets at blood testing clinics which result in them being derostered from their primary care physician without the patient understanding what this means.
Integration - Remuneration needs to support the integration that is being proposed for primary care. If more collaborative approaches are expected, physicians cannot be financially penalized for referring to another primary care provider with a focused practice. - With fewer primary care physicians having privileges in hospitals, enhanced communication is required between the “Most Responsible Physician” in hospital and the primary care provider in the community. Doctors with a presence in the hospital who connect with patients while in hospital have a high rate of seeing patients following discharge. - Joint metrics & targets across sectors will foster enhanced cross sector collaboration. - Improved linkages and collaboration between primary care and community health services are required. There needs to be a true integration to create multi-disciplinary teams to best meet patient needs. - Primary care Electronic Medical Records need to be integrated with other health record systems including Walk-In clinics. - Services in the community that have been delisted could be integrated with primary care. - Shared care models are important to consider with a range of providers. Improved linkages with Primary and Specialty Care is an opportunity to have specialists offer clinics within primary care practices.
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Relationships - Relationships are a critical component to the primary care physician-patient dyad. Patients commented that the quality of the relationship they have with their doctor represents the level of access they have.
Improved Relations between the ministry of Health and Long-Term Care and Physicians - The LHIN needs to encourage the ministry to get back to a time when physicians were involved at the ground level. - Family physicians need to be engaged in a more positive way. The challenge is there has been such a breakdown in trust, that a ton of goodwill needs to be generated. Happy people work better – the government is always hammering doctors down. We want the government to say we understand you are trying to do a good job, but you are getting burned out. The government needs to address the human needs of physicians, otherwise this is just shuffling the deck. - The government and doctors need to communicate better with each other - stop blaming one another.
How can we identify, engage and support leaders in primary care?
- Clinical leadership will be key. “We can’t move forward if we don’t have the right minds moving us forward.” - Who in our community is doing that extra continuing medical education type work? - Leverage existing leadership within Family Health Organizations. - Clinical leadership needs to be paid. - Leaders need to be empowered with levers to create the proposed changes. We cannot just ask them to use powers of persuasion. There will need to be a push to enable the group of physicians within a geography to say we’re in this together. A physician academy such as the one found in Hamilton would provide a good forum for connecting with other doctors. - The governance structure will require clarity to allow leaders to do the work. Identification of the team and the support they can provide will be important in engaging leaders. - Physicians will self-identify.
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How can physician resources be better planned for at a sub-LHIN level? (Under serviced areas, retirements, short term leave, etc.)
- We have to design the system with consideration for those doctors who will be working in it for the next 30-40 years. Limitations on new grads will create an increase in fee-for-service doctors. How will this encourage them to practice in the team style models where they were trained? - Risk of creating shortage of family physicians. New grads are leaving the province due to restrictions on how they can practice. Many physicians in this area are nearing retirement. No one wanted to go into family medicine a decade ago and following reforms, it improved. We have moved away from those reforms and it now feels like history repeating itself.
How should primary care be structured within a sub-LHIN geography model?
- Different funding formulas create different cultures across primary care. Fee for Service incentivizes doctors to pump patients through the office, potentially risking quality of care. - Leverage alternate, more efficient ways to provide care. Providing care over the telephone or via email should be a funded option for care. - All clinics should be using advanced access. - All primary care should be part of team-based practices. Family physicians who have niche practices or specific clinical expertise should be leveraged to provide expertise within each neighbourhood. Physicians interested in providing home visits should be identified and paired with patients requiring this care. Allied health and connections to community support services will create a fluid continuum of care. Team based practices will create fewer touch points and simplify navigation for patients and providers. Similar to the UK model, within one team, all needed services for primary care should be provided to alleviate patients from having to be referred to multiple locations. - Maximize scopes of practice within the team – medical doctor should not be delivering all of the services. - Collocation of physicians in groups will improve access through the creation of teams who can provide cross coverage. - Create funding structures that support integrated and collaborative health care. - Create a management structure that supports primary care to focus on what we need to do and not spend our time with administrative tasks. The management will support development of new initiatives and facilitate integration with others. - Health care providers in private practice need to better understand the goals and needs of the community within the LHIN and understand how they can help and work in a more integrated fashion.
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- Family medicine needs to be rationalized to one single model to create more cooperation across the sector. Consider the goal to be achieved and create the model that will move us towards that goal. - Increase the availability of Nurse Practitioner Led Clinics. - All physicians should practice in a Family Health Team model. Without rationalizing the models, a two tiered primary care system will be sustained within the province. Both the patients and physicians practicing in these models don’t have access to the same level of resources. If all patients belonged to a Family Health Team, then physicians would not be reluctant to take on complex patients as they would have the team resources to support the patient. - Need to explore how to make Family Health Team resources available to the broader community and ensure there are ample resources available to serve the population. - Family Health Teams don’t have the same struggles with access because the resources are readily available - physiotherapy, psychiatry and dieticians. While in other practices, it takes six months to get in to see some of these resources. - The physicians in the LHIN should all be within one Family Health Team or FHO. This would enable physicians who have part time practices or take time off to ensure their patients are seen by others. - Community hubs need to be developed that house a range of health care services that are available to all primary care providers. Along with the centralized team of allied health and community support services for the neighbourhood, an urgent care centre for after hours would be contained within the hub. Urgent care centres would help bridge the gap between primary care and emergency room services. The hub would also service long-term care. Staffing within the hub would provide one stop shopping for navigation to health care services for both patients and providers. Services could be dispatched to individual physician offices as needed. Having a hub would create opportunities to reach a critical mass to make some service models sustainable. Ample resource will be required to meet the demand of the community otherwise services will be saturated very quickly.
How can the services offered by walk-in clinic physicians be leveraged and integrated into comprehensive care models?
- Feedback on walk-in clinics demonstrated the full continuum, from acknowledging the important role they play within the system in providing access when a person’s regular provider is unavailable to the belief that walk-in clinics are detrimental to the health care system. Physicians acknowledged the “us” and “them” mentality needs to end. - Leverage the human resource within walk-in clinics to join comprehensive care practices. To integrate physicians working in walk-in clinic models, funding models would have to be the same.
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- Create a super walk-in clinic site within each region/neighbourhood for all the physicians to work from which is supported by nursing staff, has security in the evenings and has access to resources to allow primary care to treat issues such as lacerations, etc. - Need to establish regulations that limit the scope of walk-in clinics practice – Requirement that walk-in clinics communicate back to primary care provider about the care provided to the patient. Prevent them from ordering tests/investigations unless they are emergent or making referrals to specialty care. The number of walk-in clinics in an area should also be limited to avoid them from popping up on every corner. - Walk-in clinics need access to a patient’s records so they can make educated decisions about care based on a patient’s history. No matter how good or qualified a physician in a walk-in clinic is, they cannot provide the same quality of care as they don’t have the right information and records, and most times patients don’t have that information at their fingertips. Without this information, health care is less efficient as it takes twice as long for the physician to gather the information required to attempt to make an appropriate recommendation. - Walk-in clinics need to be required to report back to the patient’s regular primary care provider. Without this the patients are at risk of receiving a duplicate medication and overdosing or having a negative drug interaction. - Look at methods to triage within a walk-in clinic and redirect the patient back to their family doctor is it’s not urgent. - Need to find a way to disincentivize new doctors from joining walk-in clinics. - Walk-in clinics are a duplication of the services we are already required to provide in terms of after hours. “It’s in direct conflict with the higher quality funded service patients can receive, so why is the government promoting the lower quality clinics?” - Walk-in clinics are not beneficial to a health care system if they are not integrated into a full comprehensive primary care system. “Be cautious about how you frame what you want, if everyone starts accessing walk-ins that aren’t integrated for patient convenience quality of care will plummet.” - Quality and outcomes must be measured within walk-in clinics. Funding should only be allocated to clinics demonstrating good quality, accountability and tracking. - Create a formal connection between a set of walk-in clinics and specific physician practices within the Sub LHIN region geographies. By developing relationships with the physicians who provide this additional coverage, better relationships could evolve. Liability issues would need to be addressed. - Walk-in clinics should be required to partner with hospitals to coordinate better access to low acuity care needs 24/7/365 especially during “surge” periods. Walk- in clinics are expensive but cheaper than the emergency department, so they need to be integrated into the system and leveraged appropriately. - Nurse practitioners should be running walk-in clinics - the least complicated things should be completed by the least expensive professionals.
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What quality indicators would your recommend to showcase the work of primary care?
- The following metrics were suggested as methods of evaluating the performance of primary care: the hours of service provided by a physician, number of people who receive vaccinations, timely access, community health (instead of individual health metrics), accountability for expenditures in Family Health Teams, ability to find a physician, metrics related to system integration. - Satisfaction scores are poor indicators of performance. When physicians tell patients a test/referral is inappropriate, it will impact negatively on the patient’s satisfaction but it doesn’t mean it was poor quality care. - Quality indicators should be areas primary care can influence. If a quality indicator is keeping patients within an A1C range but they don't have access to medication or can't afford them - how is this a good metric? If my patient declines a flu shot, why does that reflect on my quality of care measure? - Performance measurement should be managed at a peer to peer level. - Chronic disease management programs should be measured in terms of the improvement seen in the patient’s outcome scores. These are interdisciplinary programs and Family Health Teams need team measures vs. physician focused measures. If moving into team based care, need to ensure measures aren’t physician centric. - When you know that someone is a horrible care provider there is nothing that you can do about it. It is a private industry that owns primary care. For example, the most highly financially remunerated physician may provide the least integrated care or has the worst access. - How do you measure resource stewardship? Each year, a physician/neighbourhood should receive a bill demonstrating the average cost of health care by neighbourhood. - Resources are needed to support primary care providers to implement quality improvement projects – clinicians don’t have this training and only Family Health Teams have the resources to support these initiatives. - Measuring access needs to consider all methods of communication with patients. For example, if a physician is accessible to patients by phone, this may be adequate even if they aren’t available in their office. - Consider AFTO’s D2D measurement system.
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PROPOSAL 3 – MORE CONSISTENT AND ACCESSIBLE HOME & COMMUNITY CARE
How can home care delivery be more effective and consistent?
Standardization of a number of elements/areas, including: . Care coordination model that is well understood and standardized. . Personal support worker training could benefit from more standardization. “In Halton a number of agencies provide it and there are a number of inconsistencies in training on how to handle dementia. English as a second language is a large problem for many of the seniors; a lot of complaints that they don’t understand what their Personal Support Workers are trying to say to them.” . Quality – to ensure that services provided are quality and helpful; minimum standards should be set in place . Back office standardization . Services provided; grouping based on need but allowing for specialization . Cost of home care – too many layers . “Team” of providers – have the same nurse, Personal Support Worker, from the same agency . Have clearly mapped standards of care to follow with set expectations of the results. Clearly plan out the number of patients and their needs. . Simplified assessment process. Accountability for service agencies who discharge clients with alternative supports in place. . Better accountability for care by the service provider organizations; standardized clinical pathways for wound care, etc. that goes across sectors and reporting requirements. . Setting consistent standards of practice and communication with all levels of service providers and sharing those standards with the clients at the time of referral.
Feedback Mechanisms that support enhanced communication, including: . Improved CCAC patient experience/satisfaction survey – need to allow for constructive feedback and demonstrate issues identified and how the system has responded to these challenges. Use of questionnaires that seek constructive feedback; CCAC survey asks questions that don’t allow you to elaborate on issues/concerns. “It seems like they don’t want to hear any feedback that is not positive”. . “No one calls me up and asks: is this particular service and time helpful to you? Instead they just slot me in whenever they have a free space. The quality of service is not checked.” . Consultations with the family around the services they are receiving would help.
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. Acquire feedback from user that is used for delivery funding. . Report cards – send the clients these cards to get ideas about how things can be improved; Make sure there is a section on the card to register complaints. “One of the things that I did with Red Cross was have a card that included a space for clients to talk about services – what can change to make things better.” “Clients are frustrated as they do not get enough support at home. They report finding CCAC quite difficult to work with.” . “Feedback on services and needs does not feel welcomed. I had to call numerous times and keep pushing with questions/comments, and often did not get a response. Extremely tiring and time intensive. Interestingly noted that when a client satisfaction survey was being conducted was the only time I received a timely response to issues raised.” . Consult with the client to find out the client's need and make sure the care meets the client's expectation. Evaluation of care by the client should be done regularly.
Client/Family Directed Care - not provider-centred: . Independent care delivery model – allow caregivers/family to decide how and when home care can be provided; supports their quality of life better. Challenging when it’s on the providers clock. Supports for Daily Living is a great model. . “The agencies that CCAC is hiring – they think they’re doing us the favour – we’re almost told what our needs are.” . “We are the clients – it’s our health that we’re dealing with, not their schedules.”
Consistency . There is a fair bit of inequality within our region. In one neighbourhood I can’t even get a nurse to visit and investigate; in another region it is happening with ease. They are simple things that will benefit the person and prevent a number of other issues, but it is not currently in place. . Consistency of provider to really know and understand the needs of the client. . There are currently inconsistencies in what home care is available to patients. The availability of providers to support patient needs should be based on competency and patient need, and not along professional boundaries. This will also avoid the need for an additional layer of bureaucracy. . Have a process in place so that each agency is not asking each client/family the same questions previously asked by CCAC. Consistent documentation forms/charts in client's home no matter which home care agency is servicing them. . Too many CCAC workers involved. We need one consistent worker who can provide clear feedback about what services the patient is entitled to once discharged. This is missing! Service via CCAC is very limited. Not everyone needs activities of daily living care. People with dementia need to be considered when CCAC is assessing what support to provide.
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. Home care agencies need to be accountable. . “Grouped care: If there are several families in the same geographical area with different care needs, can the same Personal Support Worker support these families? Consistent Personal Support Worker support: I have families now that have a different Personal Support Worker every day providing support. Consistent support for the family instead of by person. More timely response time: Allowing the Personal Support Worker to access more support as things change. Often supervisor or Case Manager may not see a family for a year or an assessment is not re-done in a timely fashion or there are multiple changes of the Case Manager at CCAC and families lose track of who their connection is and how to contact them. Friendly and courteous: It’s a human service and should be supported by people who like people.” . Have clear guidelines for roles and responsibilities that every health care member must follow, whether they work in primary or acute care.
Best Practices to support quality care delivery: . Recognition that the entire patient’s needs are all responsibilities and not just an issue/task the provider is there to attend to. This requires a culture change from how care is currently delivered. A holistic approach to care is best practice. . Flexible service delivery – providers must be flexible to the needs of the patient/family, not rigid in what they can or cannot do. . More responsive, person-centred care – needs of caregivers and family members should not be dismissed, but respected and listened to. . Personal support worker registry was stopped – we need something like this to keep the focus on the quality of care.
Coordination of Services/Integration of Care: . Better communication between staff. Personal Support Workers come in during the day, they take on the bathing, diaper changes, transferring, etc. These tasks do not require different agencies and personnel to do these jobs (i.e. someone different to help bathe, cloth, and feed). Linking them all together so they can be more organized when delivered and ensure the patient/family/caregiver needs are better met would be ideal. . Health Care Coordinator that follows you along your continuum of care. I refer to three different CCACs because of the location of my practice. This has to stop. . Bring together community support service agencies - too many small agencies - integrate those who do not have critical mass. . Need greater collaboration with service providers and regional partners to lower duplication in service delivery. . The shift to Personal Support Worker care being offered through the LHIN and CCAC is a nightmare. It is confusing; CCAC is confusing enough. Is it the CCAC or the provider – home care has to be delivered through one system. . Have community workers communicating with family doctors ' offices. . Many Care Coordinators require clinical skills development in order to support interventions and care planning. Currently they are focused on service planning. So supporting their development in this regard would be beneficial to patients and the community sector. Also, definitive performance and accountability of service provider organizations is required to ensure quality.
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. Family physicians coordinating across, along, and throughout the patients' life cycle. . Timely and complete communication from the referral source to the provider; include all health care team members in communication process. . Have the hospitals act as a HUB. All patients know their hospital. Hospitals to act as central navigation. . In regard to hospice palliative care, create a centre of excellence using hospices as the centre and hub. Have outreach teams, care coordination, Advanced Practice Nurses/Nurse Practitioners, pain and symptom management and education (reorganize/restructure). Each hub area will have an outreach team. Have consistent services across the LHIN. . Family physicians aren’t very trusting of other providers with their patients - promoting inter-sectoral learning.
Care Provider Roles - Definition/Scope: . “There is a lot of resistance to performing duties outside of job descriptions. Very strict guidelines on who the dietician or chiropodist will see. This is similar with personal support workers in the CCAC - no customization. They will only perform roles in a specific basket of services - not the services I needed.” . Service can be more comprehensive if a Personal Support Worker has a broader scope - i.e. with a frail patient, sometimes the Personal Support Worker is the only person who's seeing the patient. They may not have the training to deal with or to report on the patient’s condition. . “Care provided by the Personal Support Worker through CCAC is very strict on what they will do and how they will do it. Not always sensitive to patient needs and usual way of doing things (i.e. typical process for a person with dementia). If they feel they are not okay with the typical way of transfer/handling, they refuse to participate/provide care, and then sit for the rest of the visit as they state they are not able to do any house making/activities of daily living support if they don’t do the key task they were assigned to do.” . Standardize training for care providers going into clients’ homes e.g. dementia training and mental health training for service providers going into clients’ homes and supporting older adults. Increase interactions with regulated health care professionals e.g. Occupational Therapist/Physiotherapist/Registered Social Worker/Registered Nurse. . Improved training, lower case loads for front line workers.
Funding . Funding should follow the patient, so that when they need home care, there is money; create pathways for the patient with funding that follows. Let the families have money to purchase their own services. Assist families more, as wages for Personal Support Workers have gone up, so too has private care costs, which makes the financial strain on families even higher. . “So much of our funding is tied to contracts that haven’t changed. We have moved away from CCAC.”
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. Support workers need more money to make service better; more staff with better salaries. . LHIN budgets delivered on time and in a timely manner so that organizations can better plan for staffing and salaries. . Appreciating the difficulty of caregiving in the community and providing the resources that allow for patient/family success, rather than based on individual allocation. . Cover 90 per cent of home care costs; 10 per cent needs to be covered by patient. . In Halton Hills, further infrastructure is required: supportive housing, long-term care beds, and respite and transitional beds. Need to provide funding to meet these needs.
Evaluation . Proper evaluation and measurement of services to enhance quality improvement measures. . Reduce evaluation to patient-driven indicators and cross sector integration. Right now there is unwieldy measurement and unnecessary structures in place.
Reduce/Streamline Administrative work . Providers are so burdened with paperwork and accountability that they're doing more of that than care these days; not sure if its increasing the quality of care in clients’ homes anymore. . “We fill out so many forms. If the information was there on the Electronic Medical Record, then we would have to fill way less forms” . Amount of reporting is crazy. We need help to respond to these duel reporting systems. How can we allow people to focus on their care delivery? . Often agencies are too busy doing the work to standardize practices that promote consistency. . Vertical integration of the back office at the sub-LHIN level. . Too much administration and not enough caregivers. . Advance work being done on bundled care.
Patient-Centred irrespective of where you live . Understanding what the needs are for the residents, based on neighborhoods. . “Sometimes our patients need more than standard 10 visits from the CCAC - where is the flexibility?” . Patient ownership of their health status needs to be a component. . A big component is maintaining a high level of patient engagement – refocus attention on the patient. . Recognize that people want their care between the times of seven and 10.
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. “CCAC provides three weeks of wound care but patients need six – so they tell them to go downtown for the rest of the treatment. They can’t get downtown, so they come to my office.” . Need to ensure that as we develop hubs/teams that the client AND caregiver/family is engaged and included.
Technology – leverage it! . Telehomecare is still not available in Mississauga Halton. o Required as a communication tool – would make things so much more person-centred, while at the same time enable providers to do their job in a much more efficient and effective manner. . Create technological systems to support efficiency in home care - standardize equipment, shared care plan. Let expertise lead - i.e. hospice/palliative organizations lead end-of-life work.
System Navigation . Increase the awareness of services at the primary care level. Have primary care providers identify patients who need supports well in advance of their declining health. Often times we are putting services in place when discharged from hospital when the patient could have benefited from those services years ago. The public needs to be aware of these services as well so they can be part of a proactive process.
How can home care be better integrated with primary care and acute care while not creating an additional layer of bureaucracy?
Communication . “I would like them to call and have a conversation as opposed to sending notes.” . “We need a list of staff and contact numbers of those involved with our patients so that we can call them for follow-up.” . Better communication channels between primary care and CCAC. . Too many assessments – keep care team current and all involved informed and up to date on communications. . The CCAC represents a middle man that is a block between primary care physicians and providers. “Right now I have no idea what the CCAC does - I just get a little form with some boxes ticked off.” . “My patient leaves the hospital and the discharge communication is lacking. The hospital changes the medication of the elderly and then they come in to my office and can’t remember. Then there are mistakes and they end up back in the hospital.” . Better and timelier communication between the acute care sector and the primary care sector. Allow hospitals to refer directly to the community for services to improve the timeliness and quality of home care.
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. Enhance communication channels so issues raised by clients are addressed directly with primary care/acute care through the service provider rather than relying on the client/family to relay this information. . Communication should flow freely from home to physicians to hospital to agencies. Sometimes confidentiality and privacy is taken too far and becomes a barrier to care. Use of the same referral form, electronic shared files or portals, one person managing the family and dictating or communicating with all other players are all ideas to improve communication. . “Client centred care is not what is happening now but it is what is talked about. Deciding what and when care is to be provided should be put into the hands of the family. A huge barrier is asking the person with dementia to consent to services. They most often won’t and CCAC can then not provide any care. The caregiver is then left with no help and no options.”
Care Coordination . “We need CCAC back in primary care offices - when they used to be there I could liaise with them, keep up to date and plan the care for the individual. It was great because I felt as if I was talking and integrating with home care. Embedded care coordinators can’t just be case managers - they have to be nurses with clinical skills. A background in clinical nursing would be valuable - we need to have a personal relationship with them that trumps everything.” (NB: Frequent point made by primary care). . “My communication with the CCAC is great. I have no issues at all. Whenever I need them I can pick up the phone and get updates on my patients. They reach out to me to let me know what is going on as well.” . Have CCAC case coordinators assigned to doctors (Family Health Team) or to a group of independent doctors. Dedicated case manager for every CCAC patient. Being able to pick up the phone to speak with them directly. Look to Health Links as a model. Consistent care coordinators should work with a patient as the system care-coordinator, fixed to a medical doctor – acts as navigator, flu compliance and effectiveness, moves info etc. . “Connecting care coordination to primary care is critical because when something happens to me, my physician finds out from me the next time I go in. Physicians are the last to know and sometimes they never find out and when they are sometimes that anchoring person to help navigate their patients to the right resources they need to know - covering that gap is huge.” . CCAC has a very large bureaucracy – at an individual care level, if there’s an ability for primary care to work with care coordinators in an easy way, we would likely have better integration. . Keep coordination and service delivery separate. . Create case managers to navigate and advocate for patients so they do not fall through cracks. . Navigating the system is very important. “Can CCAC help coordinate access to all kinds of services whether they have them or not?” . Already exists but catchment areas are too small so if the patient situation changes, the coordinator must change and we start all over again. . Fix home care first (fragmented, least cost/most profit drives service).
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. Having home care coordinators either embedded in Family Health Teams and/or having a direct line to a care coordinator may enhance efficiencies to enable patients of primary care providers to have easier and more responsive access. One primary care coordinator to coordinate all care needs for an individual patient is ideal. . Care coordinators moving to clinical case managers with specific clinical focus would be most helpful. This would enable interdisciplinary care planning and rounds. It would also carry forward as part of a patient’s hospitalization and discharge planning. . Have discharge planners communicate directly with community workers. Patients are often provided the services recommended and then have the services reassessed two weeks later. Have community workers see patients in a timely manner, within 48 hours of going home. . Improved case management; the current model does not work well.
Acute . “When patients come out with different medications it leads to a waste of time while I have to sit with them and have a discussion. Make hospitals responsible for home care to align goals.” . “Wait at home patients, or patients going to a senior residence – things are falling through the cracks! The doctor doesn’t know when the patient is admitted or discharged from hospital; many notes initially, but none in rehab; no discharge medication list – this goes to the pharmacist and the docs never see it. Don’t get timely discharge notes. Once admitted they need all this testing i.e. TB which has to go thru the CCAC, but CCAC won’t do this. There is no RN support in retirement homes – no supports for doctors. We need to know when they are going home, we need discharge meds and discharge summary faxed to the office - with direction on how to proceed with care plan. We need help with paperwork - not covered currently thru remuneration - this is a mess.” . Advanced access to rehabilitative care in hospitals for primary care physicians - for those patients whose decline is foreseeable and preventable (NB: raised by primary care a number of times). . The role that ambulatory care services in hospitals play have been largely ignored; need to figure out how to better integrate into the system; home services should be for patients who are non-ambulatory. . CCAC should not have to require hospitals to begin IV in hospitals instead of in the home. . Need to address the current disconnect between community CCAC and hospital CCAC. Confusion for families about which CCAC worker they have. . Good relation between hospitals and health care providers, to ensure fast services for patients when the patient goes home. . User fee. Open up private options. . “When we are discharging patients we need to have more access to the services directly. The current gatekeeper, CCAC often puts up road blocks to offering services into the home and causes an extra layer of bureaucracy that is not necessary. We need to have open access to services in the community. We need to be able to have better access to long-term care beds.”
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Technology . Leverage the HRM system to include systems from the CCAC so that primary care has access to all this information. The patient needs control of their electronic information so that they can provide access to the CCAC, community and primary care physician when needed. Maximize the scope of the professionals going into the home and have them report back to us (primary care). . On the integration side, see the importance of pushing the electronic medical piece because coordination is dependent on every care coordinator’s ability to pick up the phone and speak with other providers - deal with privacy barriers. . “We want the information that downloads from hospitals straight into CHRIS to come into our Electronic Medical Records as well.” . “The CCAC tells us that they have all the information so we should access it from them. We don’t want to access your information - we want our own information.” . Technology enablement - virtual care conferences, e-consult. . Hospitals should have access to CCAC records to know what has been arranged and where the family stands in regards to services. . Transmission of client information (likes/dislikes/triggers if there are behaviours) is essential. Ultimately improved communication. . “If there was some way of allowing home care, acute care and primary care to be intermingled and properly funded, I think that with the Electronic Medical Record being connected on a "Health Care Network," instant communication between these providers could be accomplished.”
Boundaries/sub-LHIN . I really like the idea of the CCAC moving to sub-LHIN regions. Sub-LHIN regions can focus on the local nuances of each area. . If we have new boundaries, the CCAC has to be willing to work together to decide who takes the referral. Right now it seems to just be an excuse to say no to providing service. . If you move forward with the plan for geographic sub-LHIN alignment of CCAC care coordinators with medical doctors, it will only work where patients live and receive primary care in the same geography.
Home Care Functions Moved into the LHINs . We need to be given a better picture upfront of how this will lead to efficiency. A better understanding and trust in governance. . “Change doesn't necessarily mean better when it comes to the CCAC going to the LHIN.” “What will change? Everything from the CCAC will get transferred and all the problems will remain the same.” . The CCAC is too large and complex. It makes sense to bring them together because the amount of money lost in transaction costs is shocking. Better to try and fix then replace.
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. “Not happy about the CCACs going to the LHINs. I don't see the change. You just have a new boss running an old broken ship. More has to change than just ownership.” . “Don’t understand why CCACs would move to the LHINs - how does that translate into change? You lose boards but does that save any money?” . Integration from the community perspective has huge potential. The role is planning, not direct service. The opportunity is exciting. Some governance changing if integrated, working differently, planning and operations piece comes together - has potential. . “I am very pleased to see the recommendation that home care services come under the LHIN tent. It has endeavoured to align with acute care over the past number of years, however, home care's business model is laboured, administratively driven (vs. patient driven) and seen to try to control the service delivery landscape in the community health sector. It is very slow to respond to changes in the service delivery environment. Having care coordinators embedded in the community and integrated with other services may be helpful, though not overly successful when collocated in hospitals.” . “I think that adding to the LHINs tasks without them having a budget is crazy. I have had patients at home who have been doing quite well with visits several days a week who have been cut to once a week. Then these people have had to be readmitted to hospital because they cannot be cared for at home. I would say that this tactic is akin to cutting off one’s nose to spite one’s face. So the budget needs to be increased to account for the increases in the elderly and infirm and the population increase in general. Home care is very important to the community; the old and infirm of which there are more in South-East Oakville population than in the majority of the province. This is a better way of caring for people than putting them in hospital in ALC or in a chronic care facility of which there is a deficit of about 330 beds in Oakville.”
Access . Accessibility to CCAC needs to be more than a 9-5 setup. If I refer wound care on a Friday afternoon - the person is lucky to see them by Monday - faster turnaround is needed. . Home care delivery is more attached to social determinants of health than it is to primary care delivery – the library van coming out, the friendly visitor, the fall prevention individual – all of these things reduce the volume of primary care services – the wrap around model. . Single point of entry: taking Canada post as a model – imagine you have one envelope to send and have 17 boxes – where should it go? There should only be one box and everything is sorted there – best economical investment of resources. Increase central registry for patients requiring home care. . Self or family referral for home care.
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. Retirement homes are filling a niche, they are the interim level between home and long-term care – they are creating physician coverage which cuts the family physician out. We need to form a relationship with nurse practitioners in long -term care who connect with family physicians versus breaking up the relationship.
How can we bring the focus on quality into the homes of patients?
Staffing: Empower, Educate, Train . Focus on the education of front line staff. We have staff with limited education who are being asked to do big jobs. . Give staff the authority and empower them to expand their authority. . Educate/empower front line workers to take responsibility for quality. . Ensure that front line staff have the ability to report on someone who is “higher” in the medical hierarchy (e.g. Personal Support Worker should be able to speak out about bad nursing care). . Staff competency: build relationship. . “Bedside manner” vs cold, mechanistic, precise care service. Trust is critical to quality of life, healing/recovery. Better education with better quality bedside manner . Education around home care should be standardized. . Everyone should feel they’re all part of a team. . Listen to front line staff who are actually involved in providing direct care to patients including Care Coordinators.
Patient Focused . By acknowledging the patient’s true care needs, rather than just assigning "3hr/day". . Empower clients to speak out about appropriate care. . Educate them with respect to what they can expect. . Education of what services are available. . Communicate expectations and manage client expectations. . Family caregivers are not currently part of the system – include them. Patient and caregiver should be treated as a team. . Relief through the income tax system for caregiver and volunteers. . Patient is number one; caregivers are critical. They must be recognized as such. . Improved communications to patients “health champion” so that they have all necessary information.
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. Simplify the process for patients/families to provide feedback, particularly caregivers. If patients can’t advocate for themselves, it is challenging. The concerns raised by caregivers must be listed to, and we must not drain them with complex processes – otherwise the patient will suffer.
Necessary/Adequate Resources . Occupational therapists, speech and language pathologists, physiotherapists should be available.
Transitions . Improve integration i.e. transitions to and from long-term care from community and acute settings. . Quality in home – ensure information for each provider and representative is available/shared; introduction of self to patient to support smooth transitions, adjust based on needs. . Adjust style for seniors – health service providers require strong skills and training to adjust care approach. . Prioritize continuity of care workers or ensure an effective hand-off. Hand-off between agencies should be seamless; need to evaluate why current system isn’t seamless. . Transfer of trust is key in circle of care. . Care managers need to engage caregiver at time of discharge. . Home care plans for each individual prior to being released from hospitals. Electronic transmission of self-care information.
Patient Navigation . Need a client navigator or patient health champion. . Map services on internet so that public understands how services connect together.
Evaluation . Objective outcome measures. Have third party conduct evaluation to ensure quality. . Surveys, including patient/family experience and satisfaction surveys.
Define . Be sure there is a clear understanding of what quality means to our clients. . Hierarchy in inter-disciplinary care. . Strong system stewardship.
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. Consistency across the system. . Community quality network is positive with a standard definition in place. CCAC has shared patient bill of rights, which is great.
PROPOSAL 4 – Stronger Links Between public health and Other Health Services
How can public health be Better Integrated into the System?
Playing a larger role in health promotion - Helping to address the risks associated with weight gain by finding ways to engage and provide education to primary care doctors and patients directly – helping doctors to understand how many diabetic patients are in their community. Education on long term chronic disease management – Public health can create the link between disease prevention and health promotion. - They also need to represent the voice of social determinants of health – lead our efforts to keep them front and centre in health care planning - we do not use social planning councils to the extent that we should in helping us understand population health.
Boundaries/SubLHIN planning levels
- Regional public health boundaries should be aligned with LHIN boundaries. “Aligned regions would mean not having to share staff between public health units in long-term care.” Population health planning should be integrated at a sub-LHIN level. This will help us to understand public health nuances at more detailed level. Public health resources should match with local need – “In the South East Asian community there is a lot of heart disease. Public health needs to match local needs because I refer for more diabetic coaching or teaching.” - Public health should be at all planning tables and be a part of broader LHIN wide planning – it would ensure that there is no duplication of services ex. smoking cessation/falls prevention. Public health experience with policy making at a macro level positions them to be excellent advisors. They can take on responsibility for advanced care planning. The connection between the LHIN and public health used to be much stronger. Public health should be at all tables including: . CCAC . School system
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. Emergency Medical Services . Department of recreation - We need public health’s ear to the ground so they can help us plan in a more preventative upstream way.
Data
- “Anyone can give the flu shot now, but no one keeps a record. We need a universal portal for records.” - Public health data is crucial to the LHIN and primary care. - Get the data into primary care - Public health can provide population health data that can influence practice, such as smoking rates and alcohol use. - More involved in health promotion and population analysis – “Whenever I need any information on population data, I go to public health.” - Barriers to data - I couldn’t get the information I needed because of restrictions caused by circle of care. - There must be coordination of data between regions, school boards, municipalities and the LHIN to provide a clear data picture of health areas. - Public health epidemiologists can inform the LHIN about population health needs - the LHIN then has the tools to plans around those needs with primary care executing. - Sharing of information between public health Units. - Data to inform population health planning across the LHIN. - Create info/data sets at sub-LHIN level. - Connecting the public health work and how it impacts the health of people and how it saves on other health care services. - Track the community for immunization rates/flu shot rates.
Public health Programming
- More direct service provision: . Post natal classes to understand child development - More public health nurses in the community. - Provide workshops in the community: . Obesity . Stress
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. Anxiety . Healthy eating . STI prevention . Exercise - Affordable health promotion programming: . Neighbourhood activities/swimming - Community based antibiotic stewardship. - Provide programming in long-term care: . Falls prevention . UTI prevention . Delirium prevention
Education - Teach the public about responsible health care use – when to go the emergency room vs family physician. - Public health should focus on education from a community development perspective. - Education in schools on health promotion activities. - Internet safety. - Computer literacy.
Immunization & Flu Shots - Public health should offer vaccination clinics – a place you can take your baby for a range of health promotion activities that is inclusive of but not limited to vaccinations. - Public health should maintain responsibility for providing flu shots. - Public health Nurse should be available to do home visits to promote vaccination use for those at risk and disconnected from the health care system.
Communication - Determine who owns the immunization record. - Implement processes to share immunization records more freely which includes accountability for recording and reporting information to relevant providers of care. - Require that pharmacists report back to primary care after administering a patient their flu shot.
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- Alberta has a central registry for immunizations which are all delivered by public health. - “Immunization is the single most important factor in good population health and prevention.” - We need a single patient record to understand who is immunized and who is not. - This process is something that needs to be streamlined. - Primary care needs to be informed when the school system’s immunization schedule is changed.
What should the role of the Medical Officers of Health be in informing or influencing decisions across the health care system?
- The Medical Officer of Health should be at planning tables to advise on new proposals – particularly in areas of prevention such as diabetes and cardiovascular disease. - Extremely important role in communicating any community wide concerns or issues and should have a role. - The Medical Officers of Health should take on an expanded leadership role by educating both health care providers and the public on best practices and evidence-informed care. Making sure the information reaches each household. - Promote the engagement of physicians. - “The Medical Officer of Health should have increased visibility in the community through social media and direct public engagements. The increased visibility would help to emphasize the focus on prevention and health promotion.” . Sit at hospital planning tables to bring a community perspective to issues.
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Appendix 1. Summary of Engagements
Group Committee/Region Number of Participants
Aboriginal Peel/Dufferin Aboriginal Networks - Credit River Metis 7 Council
Cross Sectorial Health System Strategy Council 11
Diabetes CDPM 13
FLS Providers and public 20
Health Links Halton Hills/Milton Steering Committee 11
Health Links Oakville Steering Committee 10
Health Links NW/SW Mississauga Steering Committee 17
Health Links East Mississauga Steering Committee 8
Health Links South Etobicoke Steering Committee 11
Rehab RCA working group 6
MH&A SIGMHA 15
Primary Care PCN Meeting 20
Primary Care PC Steering Meeting 14
Primary Care Halton Hills 4
Primary Care Milton 5
Primary Care Oakville 11
Primary Care NW Mississauga 3
Primary Care SW Mississauga 6
Primary Care East Mississauga 1
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Primary Care South Etobicoke 4
Primary Care Oakville Hospital Family Medicine 35
Allied Health Physios 7
Primary Care Summerville Family Health Team 10
Primary Care LHIN WIDE 7
Primary Care LHIN WIDE 7
Primary Care THP family rounds 18
Pubic Patient/Caregiver Advisory Group 12
Public Government and Community Services Fair 20
Public Georgetown Market Place 25
Public Governance to Governance 100
Public Nucleus Board of Directors 8
Newcomer Employment Language Training Class 10
Seniors/LTC Senior Steering Committee 15
Seniors/LTC LTC Admin Meeting 3
System Planning LHIN 25
Survey Monkey Primary Care 15
Survey Monkey Health Service Provider 40
Survey Monkey Patient/Caregiver 16
Total 570
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Appendix 2. Summary Statistics
Number of Engagements
Primary Care 14
HSP 12
Public 6
Other 3
Total 35
Number of Participants Suvey Face to Face Monkey Total Primary Care 152 15 167 HSP 147 40 187 Public 175 16 191 LHIN 25 0 25 Totals 499 71 570
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