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Toronto Central LHIN Community Transformation Report

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Toronto Central LHIN Community Transformation Report ADVANCING THE INTEGRATION OF HEALTH CARE THROUGH HEALTH LINKS ENHANCING CAPACITY TO CONNECT COMPLEX AND AT-RISK CLIENTS TO SERVICES TO INCREASE ACCESS, IMPROVE COORDINATION, AND ENHANCE CARE MANAGEMENT FINAL REPORT OCTOBER 2013 Executive Summary The Toronto Central LHIN’s (TC LHIN) 2012 – 2014 Strategic Plan has set out a clear system plan and priorities to build capacity within the community sectors that is guided by a person-centered approach to care. Resilient and sustainable community sectors, equipped to support a growing and increasingly complex client population to live with independence close to home is central to the health care plan. This plan is aligned with Ontario’s Action Plan for Health and the recent advancement of the Ministry’s Health Links efforts to enable primary care providers’ access to multidisciplinary providers, specialist care, chronic disease management programs and other community supports offered in their local community. To ensure the TC LHIN’s populations in greatest need of health care are supported, the Community Transformation Agenda has been established to bring forward system change to support people where they live. Over the past six months, working groups represented by sector experts have met to build a plan for how complex and at-risk populations can be better supported through greater alignment and linkages across sectors: primary care, community support, mental health and addictions, hospital, with support and guidance from the CCAC. Integrated Care can only be achieved by Sectors working together, across historic boundaries to provide appropriate care the client needs, by the right provider, at the right time. The Community Transformation agenda for more integrated care will be defined by the following five blueprints. Each blueprint describes a future model of care (e.g., access model, service model, and service enhancements) and explores recommendations to help to realize the model. Key highlights: For Mental Health and Addiction Clients: A Coordinated Access Point with enhanced hours will be established that supports intake and referral for community MHA clients supporting the principle of “no wrong door to care”. The Coordinated Access Point will ensure there will always be a clear point of entry for a client or referring provider. The work of the existing access points (e.g., Access1/CASH) serves as a model with a potential to expand to other community services. Access point will be integrated with other access points over time (e.g., Access CAMH, CSS, non-health). For the defined complex population, Care Coordination will be supported by integrated service teams that will be responsible for delivery of a consistent basket of services within each local area, tailored to meet the needs of the target clients. An integrated service team will be able to work with other teams creating a network of providers. Through service expectations, service provider organizations will be responsible to ensure appropriate and timely services are delivered to meet client needs. These organizations will also communicate any relevant information regarding a client status or situation to all other service providers within the client’s circle of care and be responsible to bring members of the integrated service team together as necessary to support the care planning to meet client goals. To ensure effective and efficient care delivery, Teams will work with other providers under an integrated partnership model. Future implementation planning will define the structure and necessary supports for this arrangement (e.g., shared communication tools and client information; ability to negotiate a shared plan, problem solve and clear accountability for outcomes, and service teams that are multi-disciplinary to enable immediate care response as required). Advancing the Integration of Health Care Through Health Links P a g e | 2 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy For Community Support Service Clients: A Coordinated Access Point with enhanced hours will be established that supports intake and referral for CSS clients supporting the principle of “no wrong door to care”. While clients can access the system through any door, the Coordinated Access Point will ensure there will always be a clear point of entry if a client or provider is unsure. Existing call centres (e.g., CNAP hub) and the CCAC Information and Referral function has been developed and is currently co-located crate a seamless interface between the sectors. This hub will be leveraged as the Coordinated Access Point with the potential to expand to other complex populations. This access point can be integrated with other access points over time (e.g., MHA). For the complex senior population, the Collaborative Care Model will be used with the CCAC taking the lead role for existing CCAC or new complex clients. A CSS agency can continue to provide the lead role for existing CSS complex clients or clients who choose not be part of the Collaborative Care service. Service enhancements for 2013/14 will be defined by the LHIN by October 2013. For the at-risk senior population, a CSS Lead Organization will be identified for every at-risk CSS client. The responsibility of the “Lead” is to ensure appropriate and timely services. The role of the lead is also to communicate any relevant information regarding a client status or situation to all other service providers and to bring the care team together as necessary to support care planning to meet client goals. To ensure effective and efficient care delivery, Leads will work with other CSS providers under a partnership model. Service enhancements for 2013/14 will be defined by October 2013. CCAC can also serve the at-risk population, especially when there is a prior relationship. For the transition senior population (populations moving up and down on the medically complex scale), CCAC and CSS organizations will assume joint accountability to work together to negotiate a care plan, identify a lead that is in the best interest of the client, seamlessly transition the client, and monitor and track the transition populations to ensure they receive the support and care required by the most appropriate provider(s). The LHIN will monitor a number of metrics including but not limited to: Client experience and satisfaction, volumes, costs, ability to reduce deterioration. For the general senior population, existing services will continue as they are critical to help clients and their families maintain independence in the community. For Clients and Primary Care Providers seeking access to Specialists: Timely access to specialist for our complex and at-risk clients will be enabled through standardized referral forms, streamlined processes and tools to efficiently search and identify appropriate specialists, and mechanisms to enable conversations between primary care providers and specialist where necessary. Proposed next steps include a feasibility assessment for: i) standardizing the specialist referral form; ii) collecting and making specialist information available to primary care providers; and iii) developing a tool to enable primary care providers to appropriately refer to a specialist/sub-specialist. For Clients and Primary Care Providers seeking access to Specialized Medical Imaging: Excessive delays waiting for specialized medical imaging procedures for complex and at-risk clients will be reduced or eliminated through the standardization of referral forms; clear processes and guidelines to ensure the right medical imaging modality is selected; and enhancing primary care providers access to imaging centre expertise to ensure relevant questions have been answered. Proposed next steps include a feasibility assessment for: i) standardizing the specialized medical imaging order forms; and ii) developing a tool to enable primary care providers to appropriately order medical imaging across TC LHIN hospitals. Advancing the Integration of Health Care Through Health Links P a g e | 3 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy Advancing the Integration of Health Care Through Health Links P a g e | 4 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy Table of Contents Executive Summary ............................................................................................................................. 2 Table of Contents ................................................................................................................................. 5 1.0 Setting Context – Aligning Priorities for Community Transformation ................................... 6 2.0 Confirming Focus – Advancing Care for the Complex and At-Risk ....................................... 7 3.0 Guiding the Community Transformation – Three Planning Tenets ...................................... 11 4.0 Building Blueprints for Integrated Health Care ..................................................................... 14 4.1 Enhancing Integration with Primary Care ....................................................................... 16 4.2 Community Mental Health & Addiction Blueprint......................................................... 19 4.3 Community Support Services Blueprint ......................................................................... 25 4.4 Access to Specialist Care Blueprint ................................................................................ 31 4.5 Access to Specialized Medical Imaging Blueprint ........................................................
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