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COLLABORATION AGREEMENT EVOLUTION Primary Care Patient ISSUE 8 IN THIS ISSUE JANUARY 29, 2021 Collaboration Agreement Evolution - New primary care representation - Patient, Family & Caregiver representation Connected Care Halton Work Stream, Committee & Workgroup Updates Ontario Health Team - Mental Health & Addictions - Palliative Care Our Vision - Home & Community Care With the communities of Halton - Patient, Family & Caregiver Advisory Committee Hills, Milton and Oakville, we are committed to delivering an - Digital Health innovative, coordinated and Primary Care Corner connected health system that - Halton Physician Association enables better health and wellbeing - Collaborative Committee Representation & Work Streams of the population that we serve. - Public Health Update ANNOUNCEMENT: High Intensity Supports at Home Program Our Values Respect & Dignity Empathy & Compassion COLLABORATION AGREEMENT EVOLUTION Accountability, Transparency, Access & Diversity Primary Care During the Fall of 2020 the Connected Care Halton Ontario Health Team About Connected Care Halton moved forward with the planned expansion of its governance model. As The CCHOHT is guided by a per the CCHOHT terms of reference, primary care representation on the Collaborative Committee with equal Collaborative Committee has been expanded to include physicians from leadership representation from each community (Halton Hills, Milton and Oakville). Acclaim Health, Mississauga Halton LHIN, Halton Healthcare, Halton As of January 2021, six interim primary care physicians will serve on the Region and Primary Care. collaborative committee until March 30, 2021 at which time the newly organized Halton Physicians Association will appoint 3 physician The CCHOHT has received representatives to replace the interim appointments. See Primary Care expressions of interest from more Corner for more information on the Halton Physician Association. than 141 primary care physicians and service provider organizations Patient, Family and Caregiver representation representing a wide range of health In addition to the enhanced primary care representation, the newly care services in the communities of selected Chair of the Patient, Family and Caregiver Advisory Committee is Milton, Halton Hills and Oakville. now an active member of the Collaborative Committee. This is a very important milestone in the evolution of the CCHOHT as embedding the Our approach to health care Patient and Family voice is essential to achieving the vision of the transformation is founded on a CCHOHT. philosophy of patient-centered care and a population health approach. These are exciting achievements in the evolution of the Connected Care Halton Ontario Health Team. The CCHOHT Partners look forward to continuing to evolve their collaborative decision making arrangements with these voices at the table. WORK STREAM AND GROUP UPDATES The co-leads of the CCHOHT work streams (Mental Health & Addictions, Palliative and Home & Community Care) met in November to identify areas of focus and associated metrics on which to concentrate on in the upcoming year. The direction given to the work streams was to proceed cautiously due to the pandemic. As a result, each of the work streams identified priorities which they felt would be able to be accomplished during this time. Subsequent to this meeting, each of the work streams met with their full membership virtually in December to validate the identified areas of focus. Mental Health & Addictions Palliative Care The Mental Health & Addictions work stream The Palliative Care work stream has been focusing on expanding is currently focused on implementing a pilot the Community Palliative Program into Halton Hills. The program for a unified care plan. The purpose of a is modeled after the Milton Community Palliative Program which unified care plan is to bring coordination and enables community physicians to provide palliative care 24/7 in transparency across all service providers the patient’s home for as long as possible. Furthermore, work responsible for a patients’ care. continues on integrating the current Oakville Community Palliative Care Physician Program within Halton Healthcare to The pilot project will consist of the improve provider EMR access, allow for a common clinical chart, appointment of one care coordinator. This and streamline referral processes. individual will be the contact person for patients’ families and Primary Care and will The goals of this initiative are to decrease the number of ED visits be responsible for coordinating care in the last 30 days of life and to decrease palliative patient deaths between multiple service agencies. Each of in hospital when patient's wishes are more aligned with dying at the participating organizations will identify home. 5-6 patients that are currently receiving 2 or more services from different agencies to Due to a funding opportunity through Ontario Health, the enroll into this project. Mississauga Halton LHIN submitted a proposal and was approved This work stream is also working on rapid to implement the addition of Palliative Care Nurse Practitioners access psychiatry and counseling for primary on call 24/7 to support palliative care providers, patients and care and hope to see some success by end of caregivers in our community as well as assist in supporting the March 2021. 24/7 Palliative HELP Line. Home & Community Care The Home & Community Care work stream has been It is through the HISH program that the work focused on implementing a High Intensity Supports stream is also looking to advance other initiatives. at Home (HISH) Program. The HISH Program is done These initiatives include improved communication in partnership with the Mississauga Halton LHIN as between primary care physicians and community well as CANES Community Care (https:// service providers as well as escalation and resolution of challenges when they arise. www.canes.on.ca/). The objective of this program is to provide support The goal of this program is to decrease the average for up to 35 high risk seniors in the community who percentage of HISH program patients who present are on the wait list for long-term care placement. themselves in our Emergency Department. For more information on this program please see the announcement included at the end of this newsletter. WORK STREAM AND GROUP UPDATES (continued) Patient, Family and Caregiver Advisory Committee The Patient, Family and Caregiver Advisory Committee (PFAC) resumed meeting virtually in December 2020. The first order of business was the selection of Michele Sparling as Chair. Michele has over 18 years of experience as Chair for Boards, Committees, and Advisories at the local, provincial and national level in healthcare, education, social services, and knowledge mobilization. This experience includes being Chair of the Consumer Advisory Committee for Mental Health at Halton Healthcare, Chair of the Board of Directors for CMHA-Halton Region, and Chair of the Family and Youth League for Project Now at Trillium Health Partners. Upon its resumption, the CCHOHT PFAC adopted the Ontario Patient Declaration of Values for the CCHOHT. These can be found here: https://www.ontario.ca/page/ patient-declaration-values-ontario. In January 2021 the PFAC began the important work of developing a Patient Engagement, Consultation and Partnership Framework. This framework will function as the guide for engaging patients and family in co-designing the OHT activities in creating a seamless healthcare system for our communities. Once completed, the Framework will be endorsed by the Collaborative Committee and then sent to the Ministry of Health at the end of April 2021. Digital Health Membership for the Digital Health working group was finalized and the group held its first meeting mid-January. The working group was re-familiarized with Digital Health Appendix B of the full OHT submission where the objectives and the year 1 deliverables are outlined. Next steps is to develop Terms of Reference to help guide the exciting work ahead! Ontario Health reached out to the Regional Digital Health leads with a funding opportunity for Centralized Waitlist Management to address needs related to surgical backlog and COVID-19 in Ontario. An update on our submission is below. Expanded Central Intake for shoulders We applied, and received funding, to expand the Central Intake Program to include centralized referral management for shoulder assessments and surgical consults. A shoulder pathway will enable the backlog of patients waiting for shoulder surgery to be reassessed and prioritized according to standardized criteria. Some patients can be diverted from unnecessary surgery as their condition may be effectively managed through physiotherapy intervention or self-management. This model seeks to simplify and standardize the referral process for primary care providers, reduce initial assessment times for patients, as well as balance out and offer transparency to the wait-times per surgeons. PRIMARY CARE CORNER Collaborative Committee Representation and Halton Physician Association OHT Work Streams Since the last newsletter, the organization of the The CCHOHT Collaborative Committee has expanded primary care community has shifted, allowing for its primary care representation until March 30, 2021 exciting opportunities for the entire physician at which time the newly organized Halton Physicians community of Connected Care Halton, both primary Association will appoint 3 physician representatives care and specialists. The plans for the CCHOHT to replace the interim appointments.
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