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 ...... 33

Appendix ...... 35 A1 Community Mental Health & Addiction Working Group ...... 36 A2 Community Support Services Working Group ...... 37 A3 Hospital Specialist Working Group ...... 38 A4 MRI/CT Network ...... 39 A5 Think Tank Participants ...... 40 A6 Profile, Challenges & Impacts of Complex/At-Risk Populations in TC LHIN ...... 42 A7 MHA Population Descriptions ...... 47 A8 CSS Population Descriptions ...... 50 A9 Specialist Access Conceptual Model ...... 55 A10 Specialized Medical Imaging Conceptual Model ...... 56 A11 Primary Care Health Links ...... 57

Advancing the Integration of Health Care Through Health Links P a g e | 5 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy 1.0 Setting Context – Aligning Priorities for Community Transformation

The time is right to enhance care for our most complex and at-risk clients in their own community:  In Ontario’s Action Plan for Health Care, the government’s directions, policies, and metrics have been very clear on its goals for better patient care through better value from our health care dollars - Better Access, Better Quality, and Better Value. The Plan is deliberate in recognizing the important contributions that the community sector makes in enhancing navigation, enabling appropriate access to care closer to home, and reducing pressure on other areas of the system through an effective community-based response.  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.  In the spring of 2012, the TC LHIN, with the support of leaders from across the system developed and launched its Primary Care Plan to seamlessly bring primary health care, community based services, hospital and specialized care, teaching and education, and linkages with social support services together.  In the fall of 2012, the Ministry of Health and Long-Term Care (MOHLTC) launched Health Links, a plan to enable primary care providers’ access to multidisciplinary providers, specialist care, chronic disease management programs and other community supports offered in their local community. Health Links utilize collaborative planning across sectors to ensure local needs are met. The early focus of Health Links center on the complex populations, with a plan to broaden its focus over time. The TC LHIN has brought all of these changes under the umbrella of its Community Transformation Agenda – a plan to bring forward system change to support people where they live. To ensure success, the TC LHIN continues to work with its partners and clients to build a meaningful plan for fully integrating services under Health Links to achieve the following goals: . Improving the client/patient experience by meeting people’s needs as they define them; . Enhancing access to services when and where they are needed; . Ensuring equity of access regardless of where a person lives or population subgroups they represent; . Supporting providers to deliver services that are effective and reflective of best practices; . Building an efficient system that we can afford now and in the future; and . Promoting inter-professional teamwork to enable integration of care as required Gaining momentum through a collaborative, informed approach to design. Over the past six months, working groups and system leaders participating in a Think Tank (see Appendix 1, 2, 3, 4 and 5 for a list of members) have met to build a plan for how complex and at-risk populations can be better supported through greater alignment and linkages across the primary care, community support sector, mental health and addiction sector, and the hospital sector. This report summarizes the proposed frameworks (access model, service model, and service enhancements) to enhance community services, and establishes plans for moving forward. . Confirming need in Advancing Care for the Complex and At- Risk Populations (Section 2.0); . Setting the foundation for change in Building Blueprints for Integrated Health Care (Section 3.0); and

Advancing the Integration of Health Care Through Health Links P a g e | 6 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy . Pulling it together in Transforming Care Delivery Through a Focus on Integration (Section 4.0) 2.0 Confirming Focus – Advancing Care for the Complex and At-Risk

The need for focusing on Complex and At-Risk Populations are clear:  Individuals receiving care by family physician demonstrate better health outcomes and lower rates of premature death due to chronic diseases. Health systems organized on a strong primary care system demonstrate: improved health outcomes, more equitable health outcomes across the population, and lower health system costs (Sources: Starfield, B, Shi L, Miscinko. 1994, 1999, 2002, 2003, and 2007). While it is widely recognized that a strong, well-integrated primary care is the backbone of a patient-centered, high quality health care system, it is the area where there are the most gaps and challenges in Toronto (and Ontario). Evidence supports that complex and at-risk populations do not have equitable access to primary care services.  The most complex clients with the greatest needs are often the ones the health care system is failing the most. As the needs of complex clients often extend beyond any one sector or provider, there are greater challenges to ensure care is not fragmented. The immediate need and responsibility is to address population health and the cost of care by building a more integrated system of care where those with the greatest needs who use the most resources have improved access to the services they need, when they need it, where they need it.  The system of care is not truly acting as a system, but rather a series of silos where there is an opportunity for greater integration and partnership. There have been many successes to progress towards a system of care; however there is still work to do. While there is goodwill and support amongst providers to achieve this goal, it is time to remove system barriers, history, and dis-incentives to achieve a true system of care. While most health care systems’ core business has focused on managing hospitals and not the health of populations, there has been a recent emergence of focus and interest on the broader continuum from primary care, community care, long-term care and public health sectors. To meet the needs of this population, the TC LHIN started with some key tenets: . Transformation of the system must start with a person’s health and wellness. To ensure proactive health and well-being, care must be organized around the needs and wants of the individual. This new system must support both health needs (a reactive system focused on enabling individuals to compensate for deficits, alleviating suffering and offering comfort) and wellness needs (a proactive approach that enables individuals to pursue their own highest quality of life). . The outlook to the provision of care must change. It is no longer simply based on whether services were delivered but if they were the right services, if there was an acceptable outcome from a system and client/patient perspective, and were they delivered by the right provider. Patients, providers and governments are increasingly demanding greater health system accountability for quality, client experience, and cost. This focus is also shining a light on unnecessary utilization, the need to improve handoffs and transitions, and the need to build more collaborative systems of care across the continuum. Integration of care will be a fundamental. . No single organization can go it alone. This transformation of the system cannot be focused on any one single area, but must be grounded in multiple organizations, institutions, ministries, funders and levels of government coming together. For example, the MOHLTC, LHINs, Ministries of Education, Community and Social Services, Municipal Affairs and Housing, Attorney General, the City of Toronto, provider sectors, United Way, etc. To create a community that will support the

Advancing the Integration of Health Care Through Health Links P a g e | 7 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy person, partners must come together seamlessly to support one another and provide comprehensive, client/patient focused care. Fortunately, there is growing interest (e.g., sector providers, physicians, system leaders) to align care providers within one health system however this window is not infinite – quick action must be taken. To support planning efforts, the following details provide an overview of the TC LHIN’s population and providers, and establish a definition for the TC LHIN’s complex and at-risk populations.

The Toronto Central LHIN’s Population The TC LHIN is an urban LHIN with the highest population density of all LHINs. With a population of 1.12 million residents, the TC LHIN serves a highly diverse, multi-cultural population (2011 census data): . 41% immigrants, with 20% being new immigrants; . Reflective of 200 countries of origin, 160 languages and dialects, with 32% racialized groups; . 24% of people live below low income cut-off, (2006 Census); . ~ 5000 homeless (30% of Ontario’s homeless); . 22% with physical or mental conditions; . 14% are seniors, 21% are children; and . 2% Aboriginal, 2.9% Francophone.

The Toronto Central LHIN’s Providers . The TC LHIN’s operating budget is $4.4 billion, and is home to 168 Health Service Providers (HSPs) and 206 programs as of June 2013. 17 Hospitals (5 acute academic, 2 community, 3 specialty, 7 rehab/CCC). Over 528,000 ED visits, ~149,000 acute admissions; . 36 Long term care homes. 5795 LTC Residents and 1625 people on LTC Beds Waitlist (2011/12); . 1 Community Care Access Centre (CCAC). 69,763 individuals served, 861,498 visits and 2,626,249 hours (2012/13); . 17 Community Health Centres (CHC). 29,535 individuals served, (2012/13); . Other Primary Care Providers (~1,600 family physicians, ~3,500 specialists); . 66 Community Support Services (CSS). 133,981 individuals served, (52% 65+ years),1,084,772 visits (2012/13); and . 69 Community Mental Health and Addictions Agencies (CMHA). 92,721 individuals served, 1,252,623 visits. (2012/13). Note: Visits include face-to-face and non-face-to-face.

The Toronto Central LHIN’s Complex Population There are numerous definitions of complex users and high cost health care users in the literature and policy, as well as from experts. Strictly speaking, the highest users (1 - 5%) of health care resources are those who, when ranked, have the greatest expenditures associated with their health care utilization. The challenge is that high users also include individuals for whom costs cannot easily be reduced, and individuals who are complex but are not high cost users. Accordingly, the LHIN has taken an expansive view of the target population by considering complex users, frequent users, and the highest users of the system. TC LHIN has adopted a framework (Schaink et al., 2012) for describing and understanding complex patients which includes the following five dimensions:

Advancing the Integration of Health Care Through Health Links P a g e | 8 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy 1. Medical/physical challenges (e.g., multimorbidity, polypharmacy, physical functioning, clinical practice guidelines); 2. Mental health and addiction challenges (e.g., depression, substance use, cognitive capacity, psychological wellbeing); 3. Social health issues (e.g., social support, caregiver strain, socioeconomic status, relationships, etc.); 4. Demographic characteristics (e.g. age, gender, ethnicity, language, education) and 5. Health and social experiences (e.g. health care utilization, quality of life, self-management, health care system navigation). In addition, systemic and structural issues within the health care system add another layer of complexity. This could be related to access, coordination of care, or integration of services across sectors. Based on the above as well as feedback from other consultations, complex populations are those individuals who have a combination of the above issues: i.e. multiple medical/physical challenges, mental health challenges, social issues, high use of health care services or challenges with health and social service experiences. Certain socio-demographic characteristics and systemic and structural issues put them at risk for increased complexity. Generally, the higher the number of issues a person has, the higher the complexity/acuity of the person. Overall, complex populations fall into four groupings although the characteristics of the patients may differ among the populations served in the different health care sectors: . Frail seniors with complex needs (include older adults with chronic and unstable health issues and needs, as well as those with complex care issues (Sinha, 2012); . Adults with complex needs; . Children with medically complex needs and/or technological dependencies; and . Palliative care or end-of-life care.

The Toronto Central LHIN’s At-Risk Population At-risk clients are those who have needs associated with a specific condition and may be at risk of becoming complex if they do not receive appropriate supports and care in a timely manner. Focusing on this at-risk population allows early detection, prevention, and rehabilitation, thereby improving and stabilizing their conditions/health status and preventing progression to greater complexity, or preventing crisis situations that may require visits to the emergency department and/or subsequent hospitalization. For the population groups: . Seniors at risk of frailty include older adults with chronic and stable health issues and needs (may have at least one chronic health issue yet overall health remains relatively stable). They would benefit from routine primary care. They generally manage on their own but may require occasional support from home care, CSS or family and friends (Sinha, 2012). However, the at-risk population are also strongly influenced by a number of factors that extend beyond medical state (e.g., social-emotional, behavioural issues) that must be included in the planning of services. . For children, youth and adults, using the example of mental health and addictions, at-risk population would be those that have risk factors for mental health and or addictions but whose conditions are controlled. See Appendix 6 for a Profile of Complex at At-Risk Populations in the TC LHIN.

Advancing the Integration of Health Care Through Health Links P a g e | 9 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy In addition, each sector has also done further work in defining the specific Complex and At-risk populations they will focus on - See page 16 for CMHA and page 21 for CSS complex clients of focus.

Advancing the Integration of Health Care Through Health Links P a g e | 10 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy 3.0 Guiding the Community Transformation – Three Planning Tenets

The need for an integrated health care model is supported by some clear objectives:  The MOHLTC’s vision is to make Ontario the healthiest place in North America to grow up and grow old;  The TC LHIN’s strategic aim is to transform the system to achieve better health outcomes for people now and in the future, with a focus on preventing and delaying serious illness and injury among those who are at greatest risk of declining health; and  The TC LHIN’s transformation goals are to achieve better outcomes for people through quality care; high performing, accountable and an efficient health system; system transformation through integration; and ensure LHIN capacity to make it happen. To deliver on these objectives, the LHIN has grounded their thinking in three tenets to support planning. . Multiple Lenses will be Utilized to Ensure a Balanced Approach to Solution Development. To meet the needs of the diverse client-base and provider- base, new perspectives and approaches to addressing historical issues must be utilized. It is no longer acceptable to maintain a provider lens – evolving levels of accountability are pushing a system lens; and it is clear that a patient lens must be driving everything we do. As a result, change must be planned, implemented and evaluated from a combination of viewpoints/lenses: . The Patient. We shift from patients, caregiver, families who are not intimately involved in their care, and whose voice is not listened to, to where patients, caregiver and family are active participants and drivers in their care; who are informed; always listened to; and respected. . The Provider. We shift from providers operating with varying levels of alignment & standardization between each other, to where providers operate in a tightly aligned system of care where all providers know how to connect to others at the right time, with warm handoffs. . The System. We shift from situations where governments have little reassurance investments made will yield the expected benefit and impact, to where governments have concrete measures to assess impact, ensure resources are placed in areas of need; and can assess value for money. A collective approach is critical for success. To support this work, local transformation is incorporating: • Findings from literature, and best practices from other jurisdictions; • A review of local data and performance; • A review of client, provider and other key stakeholder feedback; and • A careful consideration of the Ministry’s guidelines and strategic aims.

Advancing the Integration of Health Care Through Health Links P a g e | 11 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy . A Clear Picture of the Future will be Grounded in Guiding Principles. To design future models for care delivery, a clear “picture” and the guiding principles for how complex and at-risk populations will access services in the future, and how will the various sectors work together to meet these needs was established by Working Groups. Principles were grounded in four key categories.

Client-Centered Care The client is valued by all providers through: Integrated Care Planning & • Listening to the voice of patient, “their story” and using this Person Coordination to develop the service plan; Centred Care Amongst • Culturally responsive approaches; Providers • Equitable, barrier free access to services and Enhancing information; Capacity to • Simple, standard processes for the client that minimize Connect Complex and At-Risk the number of times they must tell their stories; Clients to • Shift from a system of dependency to one of Services empowerment; and • Enable client education of illness and supports. Coordinated Clear Care Accountability Integrated Care Planning & Coordination amongst Planning Providers Providers will be better enabled to work together by: • Work and processes guided by best practice and/or leading practice; • An ongoing effort to ensure efficient and effective handoffs are maintained; • Ensuring transparent pathways for easy access /mobility within and between sectors; • Point of care coordination that enables shared planning, decision-making, commitment to the client; • Effective utilization of sector capacity by working understanding how to work effectively together; • Maintaining a determinants of health focus; • Standards will guide processes and common definitions will enhance understanding; and • Ensure information and tools support the flow of information and communication between providers.

Coordinated Care Planning Between a Provider and a Client Providers and clients interactions will be supported through: • Flow of information that is multi-directional between provider and client; • Timely access to information enabling providers and clients to make informed choices about services; • Navigation role - providers and clients work together to ensure appropriate/best services are delivered; • Effective, comprehensive coordination and case management for the client that extends beyond any single providers walls; and • Clear understanding of the services that are out there for both the provider and the client through the use of clear language and easy-to-understand information material.

Clear Accountability An enhanced level of accountability will be enabled through: • Access to the right services at the right time, that is grounded in equity based on need; • A system that is transparent and uses periodic reporting of quality measures that providers understand; • Empower problem solving within the system allowing sectors to work together to drive solutions; and • Frontline staff are clear of their roles and the roles of others to ensure they are not doing something that is more appropriately supported by another provider.

Advancing the Integration of Health Care Through Health Links P a g e | 12 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy . A Multi-Sector View will be used to build an Integrated Health Care Blueprint. To build the future model for care delivery for the complex and at-risk populations, it was understood upfront that a collaborative approach to design and development was required – no one sector could alone address the needs of the complex and at-risk populations. This approach required a two-pronged approach to planning and delivery of care that avoids duplication of services, improves efficiency, and enhances system accountability and transparency. • The first prong focuses on population-based care close to where a person lives. This translates to enhancing access to primary-based care services, using a sub-LHIN model. It is important to note that Primary Care should remain engaged and supportive of the care patients across the complexity spectrum (from low to high), regardless of the system-wide supports. • The second prong focuses on system-wide supports to ensure services at a regional level seamlessly support the primary care system and the needs of the client through integrated, coordinated access.

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As a result, the TC LHIN brought influential leaders together as Planning/Working Groups from various sectors to develop the conceptual models to better address the needs this population.

Advancing the Integration of Health Care Through Health Links P a g e | 13 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy 4.0 Building Blueprints for Integrated Health Care

Integrated Care can only be achieved through inter-related blueprints that define a new future of care 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. . Primary Care Strategy. The Ministry’s Health Links agenda laid the foundation for primary care renewal – both within the sector itself and in collaboration with all other sectors of care along the broader continuum of care. To date, four of nine TC LHIN Primary Care Health Links are currently being deployed with an additional two Health Links focusing on Mental Health and Addiction populations currently being planned (see Section 4.1); . Community Mental Health and Addiction Blueprint. Community Mental Health and Addiction services provide care to an important population of clients that is often overlooked. To date, a sector, consumer and literature informed model for improving access, increasing coordinated and integrated care and enhancing service capacity with a focus on complex MHA clients has been developed and will directly inform future planning (see Section 4.2). . Community Support Services Blueprint. Community Support Services is an important support to help keep people in their own homes while they receive appropriate services. To date, a sector, consumer and literature informed model for improving access, increasing coordinated and integrated care, and enhancing service capacity with a focus on complex and at-risk CSS clients has been developed (see Section 4.3). . Specialist Access Blueprint. Timely access to specialists/sub-specialists has been identified as a critical support for complex and at-risk clients and their associated providers to ensure care available when it is needed (see Section 4.4). . Access to Specialized Medical Imaging Blueprint. Streamlined access to specialized medical imaging has been developed to ensure complex and at-risk clients and their associated providers have timely access to diagnostics tests to support care planning decisions (see Section 4.5).

Advancing the Integration of Health Care Through Health Links P a g e | 14 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy To support the community transformation efforts, a number of critical supports and enablers were identified throughout the Health Links Working Group session work. These included but are not limited to: . A culturally responsive approach to service delivery, driven and respectful of the voice of the client, and guided by the determinants of health. . All providers know what is out there, how they can services to enable informed decision making. . Clients requiring services originate from multiple points of access as every door leads to service, with barrier free access to services. Clear pathways will enable informed choice. . Clients are not solely based on age, but include developmentally informed care and prematurely aged. . Value and support the inter-connected sector: health, housing, criminal justice, social services etc. . One number to call when it is unknown who to call to ensure timely & appropriate access. This does not take away from the ability to directly refer. . Facilitates a more holistic engagement and equitable access process through better screening, eligibility determination, capacity management supporting immediate prioritization and response. . Services will be coordinated to ensure the right providers are connected, shared accountability is established, accountability and standards are adhered to, and clients are effectively prioritized and triaged. Coordination extends beyond any single agency’s walls to enable better transition and handoffs. . Clients will move into and out of a Sector seamlessly, and services and access will be adjusted based on their changing needs. . Ensuring clarity for who is responsible for a client at any point in time, and building capacity to transition responsibility where required. . Build economies of scale that enable shared care models grounded in multi-disciplinary teams. . A care coordinator is assigned to prioritized complex clients to facilitate and support ongoing integration of assessments and service plan development to respond to changing needs of clients/caregivers. . Centralized, 24/7 point of access for complex MHA services directing to local provider networks. . Primary Care, CCAC, Hospitals, and other providers will not only be sources of referrals to MHA, but will also deliver services and will also receive clients back as required, and will need the capacity to support these clients. . Enhanced system capacity. Primary Care physicians able to take on clients, enhanced specialized expertise and capacity in FHTs and CHCs, improved access to housing, peer support, providers working together to support services (Nurse Practitioner/MD in shelters). . Building capacity and expertise to support the necessary shifts in culture, processes, and thinking through an enhanced change management capacity. . Public and caregivers are educated and informed, and programs are marketed in plain English. CMHA sector understand who provides what, and knows where to get answers from. Sector has trust that Primary care and hospitals have enhanced MHA expertise and capacity. . Technology will enable and integrate providers together to ensure information is pushed to all corners of the system to enable informed decisions.

Advancing the Integration of Health Care Through Health Links P a g e | 15 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy . Comprehensive data and information will be collected, shared, and used to support effective decision-making to continually adjust and improve the system where it is needed. System will be able to demonstrate benefits and support accountability requirements. 4.1 Enhancing Integration with Primary Care

The TC LHIN Primary Care Plan established a clear vision for primary care that was grounded in a larger objective of advancing the integration of health care. The result:

The Providers of the Toronto Central LHIN will provide personalized, seamless, timely, comprehensive, and high quality primary care to its population through collaboration across the system to advance improved client outcomes and improved client experience in the context of a sustainable health care system.

This approach clearly acknowledged that primary care could not be addressed in isolation, but rather, improving care for clients would only be achieved through inter-sectoral integration. This approach supports Ontario’s Action Plan to ensure the right care at the right time in the right place requires that clients and providers work together more closely than they have in the past.

The TC LHIN is leading a number of efforts to enhance Primary Care Services: . Enhancing Primary Care Services for the Complex and At-Risk Population. Using the TC LHIN’s primary care plan as a foundation for the Health Link Transformation, the initial focus started with the population-based care that has led to the definition of nine sub-LHIN Health Links, (see Appendix A11 for a map of the TC LHIN Health Links). To date, four early adopter Health Links have been launched with early work to confirm MOHLTC and TC LHIN expectations with respect to project scope, roles, targets and deliverables (Wave 1); two additional Health Links that will focus on Mental Health and Addiction clients are preparing for their readiness assessment (Wave 2); and the TC LHIN is leading pre-engagement of providers across the remaining three Health Links and is currently hosting physician engagement sessions in collaboration with the TC CCAC and OMA District 11. It is anticipated that one of the Health Links will develop a plan focusing on Children and Youth with complex care needs. Within each wave of activity, there is

Advancing the Integration of Health Care Through Health Links P a g e | 16 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy development of leadership capacity and a translation of learnings and tools to ensure Health Links learn from one another.

Advancing the Integration of Health Care Through Health Links P a g e | 17 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy . Enabling System-Wide Planning. In addition to the Health Links efforts focusing on the complex and at-risk populations, the TC LHIN has also initiated a number of activities to address the broader population. • The Health Education Network is a table convened to improve access to primary care in the community by increasing the number and quality of educational placements provided in a community setting for future health care professionals. The goal of the Health Education Network is to help influence and benefit future providers of care, and ultimately the work of the Health Links. Specific areas of focus include: exploring opportunities to enhance curriculum offered to health care professionals that would help to address identified issues (e.g. increased focus on community, integrated care, change management, interdisciplinary teams); and exploring opportunities to increase community based placements for health care professionals (e.g. identify and address current gaps and barriers). • The Strategic Advisory Council utilizes a population health approach to improve health outcomes and reduce health inequities among population groups. A Strategic Advisory Council table has been struck consisting of members with planning accountability for different populations, not limited to health care. The goal of the group is to optimize collective efforts and maximize health outcomes by focusing on short-term and long-term initiatives that will meet the needs of the at-risk populations with an emphasis on population health by identifying synergies, collaborative efforts, and approaches to resolve barriers and issues to collectively advance health care. Partners include: United Way, City of Toronto, Public Health, the TC LHIN Health Links leads, CAMH, Sick Kids, Ministry of Child and Youth Services, etc.. Addressing the needs of Children and Youth, promoting elder friendly communities and health promotion have surfaced as potential areas of focus. • Enhancing Change Management Capacity. To help support local system transformation efforts, the LHIN has initiated planning focused on enabling and sustaining the change management that will be warranted through its Health Links program initiatives. This has included a preliminary review of leading practices in other jurisdictions and discussions with thought leaders and academics. The LHIN has also commenced planning efforts in support of community health leadership capacity building to further support the development of skills that will be required to drive and sustain system changes. • Ensuring Alignment with Other LHINs. The TC LHIN continues to engage other GTA LHINs and share knowledge and progress to ensure LHIN boundaries do not hinder services or delivery, and to support opportunities for collaborative work. • Ensuring Alignment with Other Sectors. To ensure regional supports are aligned and integrated with the work in primary care, community based sectors (Community Support Services sector, CCAC and the Mental Health and Addiction sector) and the hospital sector (enhance access to specialist and specialized medical imaging) have been engaged to ensure development of an integrated system of care that supports the broader continuum of care. The goal is to streamline and improve access to services offered by these providers, with an early emphasis on the needs of the complex and at-risk populations.

Advancing the Integration of Health Care Through Health Links P a g e | 18 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy 4.2 Community Mental Health & Addiction Blueprint Many of the most complex MHA clients with the greatest needs are the ones the health care system is failing the most. The challenge is that the system is not set up to get great outcomes for these clients, nor is it meeting the expectations and wants of its providers for its own clients. The reality is that as the number of complex and vulnerable clients with MHA continue to grow, it is becoming increasingly difficult to keep up with the needs. The time is now to transform the system to address these issues. In February 2013, the Community Mental Health and Addiction (MHA) Sector Working Group was established to develop concrete plans and strategies to connect a population of complex clients to needed services resulting in improved access, increased coordination and integrated care, and enhanced service capacity. This work complements and supports the multiple efforts associated with the Health Links agenda to advance the integration of health care. Between February and June 2013, the Working Group met eight times to transition from principles and visioning, to a conceptual model development, to service enhancements, and ultimately to building recommendations to guide future implementation work. The MHA Working Group confirmed that the current system does not support strong transitions and connections between sectors (e.g., between primary care, community support services sector, housing, and the acute sector). These gaps impede a provider’s ability to get the client to the appropriate service in a timely way. This is particularly true for our most complex MHA clients. This results in the following challenges: . Sharing, communicating and transferring information across the continuum is not efficient, streamlined, or effective – this affects how decisions are made and creates duplication the system cannot afford; . Transitions within the sector and between sectors are challenging. It can be unclear who is accountable for creating and supporting a client’s service plan, and unclear who is ultimately responsible for helping clients to navigate the system – need for greater and clearer levels of system-wide accountability; and . Clear disparities exist in some communities and neighbourhoods that limit appropriate and timely access to community MHA, primary, and secondary care close to where people live – need to be able to get care to or bring clients to the appropriate services when they are needed. To develop a future model for community MHA care, the Working Group completed the following steps: . Confirmed the Population of Focus. An initial focus of the Community MHA Sector representatives and the TC LHIN’s Performance and Information Management team was to clearly define the population that would be served, and what services should be included under the new delivery model to support this population. (See Appendix 7 for the Attributes of Complex Community MHA Seniors, Adults, and Youth Clients). For the purposes of the Working Group’s work, the initial area of focus for the design centred on a MHA client with multiple and complex needs that was defined as an individual who: • Is at least 16 years of age; • Has co-occurring conditions: Multiple mental illnesses and/or mental health conditions; Substance misuse issues; Developmental disability; Acquired Brain Injury; or Chronic physical diseases. • AND Frequently uses hospital emergency department; Uses other urgent care services, such as crisis or emergency community services (e.g. shelters, hot meal programs, out of the cold programs); Is admitted to hospital; or Has contact with the criminal justice system (CJS) (e.g. police, courts, jails, correctional centres, forensic services). • AND has social capital issues such as currently homeless or insecurely housed; Little to no social support network; Overburdened caregiver; or Living in poverty (e.g. unable to secure adequate food, clothing, or housing).

Advancing the Integration of Health Care Through Health Links P a g e | 19 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy These clients have a specific need(s) for which there is no current effective service system response and they require a tailored, holistic, client centered and coordinated systems approach to service delivery. Generally, the higher the number of issues a client has, and the diversity of service required, the more complex they are. CMHA clients can be subdivided into four categories: children, transitional aged youths (16-24 years), adults (25-64 years), and seniors (65 years and over)/psychogeriatrics. The majority of complex clients fall into the 25-64 age group, however the youths and seniors also experience significant challenges that need to be addressed. Some population subgroups are more likely to be at risk for being complex CMHA clients (e.g. Aboriginals, refugees, etc.). Appendix 10 has detailed potential characteristics of the CMHA complex adults, seniors and youth populations. Due to the lack of comprehensive data for the CMHA sector as well as the nature of mental health and addictions illness (acuity and complexity may change over time), it is difficult to identify eligibility criteria that can comprehensively identify or quantify the complex or at-risk clients served by TC LHIN agencies or those who require these services. This task will become easier when Ontario Common Assessment of Need (OCAN) data becomes available through the Integrated Assessment Record (IAR), and linked data becomes available from the TC LHIN Community Business Intelligence (BI) initiative. Further work will be done in the implementation phase of this project to identify comprehensive eligibility criteria/tools for identifying complex populations. In addition, this process will be informed by results from further analyses currently underway related to complex populations. For example, the DATIS (Drug and Addictions Treatment Information System) team is currently working on analyses to understand complex clients using TC LHIN addictions services, and TC LHIN is also working on analyses of mental health clients who frequently use hospital emergency departments over multiple years. . Defined a Framework for the Complex MHA Population. A future MHA model for the complex population was pursued because the most complex clients with the greatest needs are the ones the health care system is failing the most. There was clear acknowledgement that the problem is not getting any smaller. There is also appreciation of the great work the MHA sector in the TC LHIN has led, and an understanding that this work must be leveraged in future solution development. The concept of “no wrong door to service” must be a foundation for the future model. Recommendations from the Cross-LHIN Multi-Service Access Model Report and projects undertaken in recent years to enhance infrastructure and capacity for MHA clients provide an important foundation for a framework which is divided into three key areas: Access Model, a Service Delivery Model, and key and immediate Service Enhancements for complex MHA populations. The following describes each of the proposed models and summarizes key recommendations to better support the complex MHA populations within the TC LHIN. 1. Over time, the Coordinated Access Point will be enhanced, building on the work of the current Access1, CASH and Coordinated Access to Addictions projects, to support referrals for all community MHA clients to ensure clients, families or providers always know where to call to access community MHA services. While clients can enter through any door, the access point ensures clients are supported by skilled staff who understand sector resources and can support: information and referral; screening, triage, eligibility determination; service matching and waitlist management; peer support; and data collection and reporting for all populations requiring and who are eligible for community MHA services.

Advancing the Integration of Health Care Through Health Links P a g e | 20 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy The Coordinated Access Point will: . Be a main point of information and referral for all referral sources including health and non- health providers, family and client. For primary care providers, an MHA access point can be the one-stop entry point. Consideration will be given to the role for provincial and city run information and referral lines. Linguistic diversity will need to be accommodated. . Use clear eligibility criteria and screening processes to identify the most appropriate care and services to meet the needs of a client. The Coordinated Access Point will be responsible for the client who comes into contact with the system during the referral phase, and will ensure clients are transitioned to the appropriate provider who will then assume responsibility for the client’s care coordination. The Coordinated Access point will be staffed by highly skilled and trained individuals to provide information, assess urgency, and support matching functions. . Determine priority and urgent access to services with wait lists. For “complex” clients with urgent needs, the access hub will provide a warm handoff of the client directly to an organization that will be accountable for ensuring access to the appropriate care. . Be supported by an electronic referral system that will assist with matching and capacity management/determination. . Provide leadership and be responsible for reporting/monitoring data for the referral system. During implementation, consideration will be given to integrate and/or coordinate important access services including Access CAMH, Concurrent Disorders Support Services, Early Intervention, Safe Beds, etc. In addition, linkages and integration between aligned access points for CSS services, youth and developmental services will be developed – all of which have evolving independent access models but shared clients. Selected recommendations from the Cross-LHIN working group report will be implemented in stages and incorporated into the implementation planning, including further developing the role of crisis services in the access system resulting in an access system that is linked between all points on the continuum – crisis, community, acute and specialty.

2. The Service Delivery Model(s) will focus on delivering services to complex clients with urgent needs. The key criteria for model design and implementation will include: . Timely Access to Service: Creating a mechanism and capacity that will ensure the client is connected to services immediately upon referral. . Service Coordination: The role of a service coordinator will be a critical feature and will lead the assessment of need, coordination and facilitation of a treatment or support plan, and key accountability for mobilization of resources to be provided to client. . Integrated team-based care: Models will ensure the availability of a continuum of integrated services that allow for flexibility of movement between levels of service to meet the immediate and changing diversity and intensity of mental health and addictions services required by the client. This will result in an integrated service team where providers will work with one another creating the concept of a network of providers. Available hours of service will need to be examined. Note: Networks are not a “one-size model”; different network models may be required based on needs; knowledge transfer between networks will be key to

Advancing the Integration of Health Care Through Health Links P a g e | 21 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy ensure clients access the right services, by the right providers which enables client to step-up and step-down from services based on needs. This would include: . Transitional and crisis supports; . Case management; . Psychiatry; . MHA nurses; . Harm reduction; . Addictions counseling; . ACTT/multi-disciplinary teams; . Peer support; . Social recreational, daily living skills and group programming; and . Integrated network of services to meet basic and physical health needs including: Continuum of housing and housing supports; Primary care; Social services; and other community services. The specific service models to be tested will be finalized through implementation planning within each Health Link and through the proposal building stage. In addition, there are a number of services that are specialized and currently not available across the geography of the LHIN. These would include residential addictions services, specialized clinical services, clubhouse etc. Access to these services would continue be to done through the Coordinated Access Points until a determination could be made, over time, as to whether capacity should be enhanced to provide increased geographical reach. As Health Links focus on the coordination and integration of care for the most complex and costly within the health care system, the MHA model aligns with the Health Links to ensure collaborative problem identification and solving, including both health and non-health providers. The MHA Access and Service Delivery Model will be adopted within the nine Primary Care Health Links within the TC LHIN. 3. Service Enhancements to better meet the needs of the complex mental health and addiction population, target services were identified and recommended as a focus for future TC LHIN community investments. The following provides potential areas for service enhancement for complex MHA populations: . Enhance Intensive Case Management and team-based or/and multi-disciplinary care (e.g., includes crisis); . Enhance Supportive and Supported Housing/Residential Services; . Enhance Peer and Family/Caregiver Programs; . Complete system planning to support immediate Addiction Services needs; . Complete planning for Dual Diagnosis residential service model; . Complete MHA Human Resource Planning; and . Support Health Links efforts to enhance Team based Primary Care with MHA specialization and/or support.

Advancing the Integration of Health Care Through Health Links P a g e | 22 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy

Advancing the Integration of Health Care Through Health Links P a g e | 23 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy Recommendations for the Complex MHA Population:  A Coordinated Access Point with Enhanced Hours will be established that supports intake and referral for all community MHA clients. 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 for the Coordinated Access Point with a potential to expand to other complex populations. Access point can be integrated with other access points over time (e.g., Access CAMH, CSS, non-health). Future implementation planning will establish a plan for advancing the Coordinated Access Point in addition to confirming supporting tools (e.g., clear eligibility criteria and screening processes; standardized information on all available services; communication protocols to ensure efficient communication).  For the defined complex population as confirmed by the eligibility criteria at the Coordinated Access Point, 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 the concept of a network of providers. Note: Networks are not a “one-size model”; different network models may be required based on needs; knowledge transfer between networks will be key.  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. Future implementation planning will establish accountability requirements for developing specific competencies and capacities within provider organizations.  To ensure effective and efficient care delivery, Teams will work with other providers under a 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). An important partnership will be establishing effective linkages between the MHA, primary care and CSS providers.

Advancing the Integration of Health Care Through Health Links P a g e | 24 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy 4.3 Community Support Services Blueprint The Community Support Services Sector is dedicated to building a plan of care that links community support services with the broader care continuum. This work is being initiated because: the most complex CSS clients with the greatest needs are the ones the health care system is failing the most; the problem is not getting any smaller – reality of demographics and the fiscal situation means investment must be found from within the system; and a true need exists for the system to shift towards keeping people healthy and addressing determinants of health. In February 2013, the Community Support Services (CSS) Sector Working Group was established to develop concrete plans and strategies to connect a population of complex and at-risk clients to needed services resulting in increased access, improved coordination, and enhanced care management. This work complements and supports the multiple efforts associated with the Health Links agenda to advance the integration of health care. Between February and June 2013, the Working Group met seven times to transition from principles and visioning, to conceptual model development, to service enhancements, and ultimately to building recommendations to guide future implementation work. This document provides a summary of the proposed model for complex and at-risk community support service clients. Like the MHA Working Group, the CSS Working Group also confirmed that the understanding for how the system links together from primary care to community support services is not well understood – impeding timely and appropriate access, especially for our most complex clients. This results in the following challenges: . Sharing, communicating and transferring information across the continuum is not as efficient, streamlined, or effective as it needs to be – this affects how decisions are made and creates duplication the system cannot afford; . Transitions across sectors is challenged because it is sometimes not clear who is accountable for navigating the client – need for greater and clearer levels of system-wide accountability; and . Clear disparities exist in some communities and neighbourhoods that limit appropriate and timely access to community support services close to where people live. To develop a future model for CSS, the Working Group completed the following steps: . Confirming the Senior Population of Focus. Client needs supported by the Community Support Services sector in the TC LHIN are quite broad and can shift between complex, at-risk, and those with more general needs. While all levels of need require a response, the response and the related supports will be different. While the focus of the TC LHIN in 2013/14 will be on service enhancements for the complex and at-risk seniors, planning will also be initiated for the other two groups – complex adults and palliative care populations to develop a clear plan for action in 2014/15. (See Appendix 8 for details of the complex and at-risk seniors, adults and palliative care clients). The following diagram leverages the Collaborative Care Framework developed in collaboration between CNAP (Coordinated Navigation and Access Project – 33 CSS agencies providing services to seniors) and the Toronto Central CCAC, and was used to further identify target senior populations for the CSS Health Links Working Group.

Advancing the Integration of Health Care Through Health Links P a g e | 25 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy Using the Framework, Medically Complex Senior High Medical High Medical populations are defined as senior clients with high Low Psycho Social High Psycho Social medical/low psycho social and high s d

e medical/high psycho social needs (see purple

e Medically Complex Medically Complex

N quadrants). Clients are generally over the age

l Population Population a

c of 65 years but include individuals who are i d

e prematurely aged. M

’ . The At-Risk Senior population is defined s t

n as low medical and high psycho social e i l needs (see green quadrant). C

g . The General Senior population is defined n i

s General Population At-Risk Population a as low medical and low psycho social e r

c needs (see blue quadrant). n I Low Medical Low Medical . The immediate areas of focus will Low Psycho Social High Psycho Social be on Medically Complex and At-Risk Senior Populations. The General population Increasing Clients’ Psycho Social Needs will continue to be cared for using existing models.

Further work will be done in the implementation phase of to fine tune the eligibility criteria for identifying complex populations. This will take into account evolving changes in the RAI assessments as well as emerging tools such as the DIVERT (Detection of Indicators and Vulnerabilities for Emergency Room Trips) tool that has been developed by the interRAI team.

. Defining a Framework for the Complex and At-Risk Senior Populations To guide future planning, a framework was developed which is divided into three key areas: an Access Model, a Service Delivery Model, and key and immediate Service Enhancements for complex and at-risk senior populations. The following describes each of the proposed model and summarizes key recommendations to better support the CSS populations within the TC LHIN. The concept of “no wrong door to service” must be a foundation for the future model.

1. A Coordinated Access Point will be enhanced building on the CNAP hub to support referrals for all CSS clients to ensure clients, families or other providers always know where to call to access CSS services. While clients can enter through any door, the access point ensures clients are supported by experts who understand sector resources, apply standardized screening and prioritization criteria, and support capacity management functions to ensure clients get to their needed services. The same expectations and level of support to a client expected from the Coordinated Access Point, must be provided by any other “doorway” through which a client is seen. The Health Service Providers intending to function as another doorway into the system must commit to this same level of service. Access decisions must incorporate other influencing factors (e.g., transportation). 2. For the at-risk populations, the Coordinated Access Point will receive prioritized access to services and ensure a warm handoff to care by ensuring receiving organizations have the necessary information to assume care management of the client. Existing call centres (e.g., CNAP) and the TC CCAC Information and Referral function will be leveraged as the coordinated access point initially. Over time, the CSS Coordinated Access Point may be integrated with other access points (e.g., MHA) to enhance care coordination across sectors.

Advancing the Integration of Health Care Through Health Links P a g e | 26 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy The Coordinated Access Point will: . Be a main point of information and referral to all referral sources including health and non- health providers, family and client. For primary care providers, a CSS access point can be the one-stop entry point. Consideration will be given to the role for provincial and city run information and referral lines. . Use clear eligibility criteria and screening processes to identify the most appropriate care and services to meet the needs of a client. The Coordinated Access Point will be responsible for the client who comes into contact with the system during the referral phase, and will ensure clients are transitioned to the appropriate provider who will then assume responsibility for the client’s care coordination. The Coordinated Access Point will be staffed by highly skilled and trained individuals to provide information, assess urgency, and support matching functions. . Determine priority and urgent access to services with wait lists. For “complex” clients with urgent needs, the access hub will provide a warm handoff of the client directly to an organization that will be accountable for ensuring access to the appropriate care. . Be supported by an electronic referral system that will assist with matching and capacity management/determination. . Provide leadership and be responsible for reporting and monitoring data for the referral system. Overtime, linkages and integration between aligned access points for MHA services will be developed – all of which have evolving independent access models but shared clients.

3. The Service Delivery Model(s) for the CSS complex and at-risk populations were pursued because the most complex clients with the greatest needs are the ones the health care system is failing the most; and there was clear acknowledgement that the problem is not getting any smaller. There is also appreciation of the great work the CSS sector in the TC LHIN has undertaken to date, and understanding that this work must be leveraged in future solution development. To best support the senior medically complex and at-risk populations, the future

s model will include 3 foci: d High Medical High Medical e

e Low Psycho Social High Psycho Social N

l . Medically Complex Population (Hi M,

a Medically Complex Medically Complex c i Population Population Lo and Hi PS) – CCAC will generally Lead d e CCAC Lead CCAC Lead in Coordination M

’ s t . At-Risk Population (Lo M, Hi PS) – CSS n e i l will generally Lead in Care Coordination C

g At-Risk Population n

i . Transition Population (grey triangle) –

s General Population CSS Lead with a

e CSS Lead Enhanced Accountability for clients which transition r c

n Coordination up and down will be jointly determined by I Low Medical Low Medical CCAC and CSS to work together to Low Psycho Social High Psycho Social identify a plan for care that will be in best Increasing Clients’ Psycho Social Needs interest of the client. .

Advancing the Integration of Health Care Through Health Links P a g e | 27 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy • For the Complex Senior Population, the Toronto Central CCAC in cooperation with 33 Community Support Service agencies (Community Navigation and Access Project – CNAP) jointly developed a community-based care model to build capacity and better support seniors and their caregivers in their homes. The result is the Collaborative Care Framework with supporting practice standards and guidelines. Under this model, the CCAC has overall accountability for ensuring the complex client’s outcomes and goals are met (defined as the “Lead Organization”). However, an organization defined as the Lead does not preclude involving other service providers (defined as “support organizations”) in the provision of care, and individual service providers involved in the client’s care retain their accountability for the service to the client. However, it is understood that in some situations, a complex client’s care may be managed by a CSS agency directly with little or no support from the CCAC. This care will continue under the current model unless change is suggested by the CSS agency or the client. Client choice must be included in the decision-making process. • For the At-Risk Senior Population, CSS agencies will take the lead in delivering care with the following key changes in the care delivery model. A Lead CSS Organization will be identified for every at-risk CSS client where the Lead assumes responsibility for ensuring appropriate and timely services, communicating any relevant information regarding a client status or situation to all other service providers, and bringing the care team together as necessary to support the care planning to meet client goals. While the Lead has the overall accountability for ensuring client outcomes and that goals are met, the CSS Lead organizations will work with other service provider partners in the provision of care who retain their accountability for service to the client. CCAC can also serve the at-risk population, especially when there is a prior relationship. • For the Transition Senior population Senior Transition Clients who move up and down on the medically complex scale will require joint accountability by CCAC and CSS to negotiate a care plan and identify a lead that is in the best interest of the client, and to seamlessly transition the client to the appropriate lead (CCAC or CSS) to support care coordination. These decisions will be made on a case-by-case basis. • The General Senior population receiving CSS services includes seniors with low medical and psycho social needs, or in receipt of visiting hospice service, or other specialized services. While there are no immediate plans for system transformation efforts for the general population, service providers are encouraged to observe the system transformation planning for the complex and at-risk populations, and engage with those providers as necessary. In addition to the focus on the Complex and At-Risk Senior CSS populations, a number of other strategies are being employed by the TC LHIN to support the CSS Sector. These include: • TC LHIN has adopted a multi-year approach with regard to commitments to initiatives and community investments as initiatives typically take more than a year to plan, implement and evaluate. As a result, staff resources from both TC LHIN and HSPs will be invested in over several years to properly deliver new initiatives. Similarly, investments necessary to expand or enhance service capacity in the community will be made over multiple years. For example, commitments to a service expansion in one year that may not take full effect until the coming year. • System transformation is a multi-year commitment that will focus on improving client access to needed services, as well as improving capacity of services to meet the changing needs of clients.

Advancing the Integration of Health Care Through Health Links P a g e | 28 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy The focus of our efforts will continue to be on clients and patients, and the services they need. Not on HSPs. 3. Service Enhancements to better meet the needs of the complex and at-risk CSS populations, target services were identified and recommended as a focus for future TC LHIN community investments. • The following provides potential areas for service enhancement for complex CSS seniors as defined by the Working Group: . Enhanced Adult Day Programs; . Assisted Living Services for High Risk Seniors; and . Caregiver support.

• The following provides potential areas for service enhancement for at-risk CSS seniors as defined by the Working Group. While there is no confirmation of the financial allocations as of yet, the following provides potential areas for enhancement:

. Transportation; . Crisis intervention & assistance; . Adult day programs; . Respite; . Supportive housing; . Caregiver support; and

. Food security through social and congregate dining, and meals on wheels.

Recommendations for the Complex CSS Senior Population:  The Collaborative Care Model with the CCAC taking the lead role will be leveraged 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.  All Lead organizations will be held to the same level of accountability functions (e.g., ensuring client outcomes and goals are met, providing a system navigation and liaison role where required, reporting data and information to the TC LHIN). Accountability functions will be defined as part of the next phase of implementation planning that is being recommended.  All support organizations will be held to the same level of accountability functions (e.g. ensuring capacity for prioritized complex clients). Accountability functions will be defined, in partnership with the lead organization, as part of the next proposed phase of implementation planning.

Recommendations for the At-Risk CSS Senior Population:  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

Advancing the Integration of Health Care Through Health Links P a g e | 29 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy 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). Future implementation planning will establish a plan for advancing the Coordinated Access Point in addition to confirming supporting tools (e.g., clear eligibility criteria and screening processes to identify complex, at-risk and general populations; standardized information on all available services; communication protocols to ensure efficient communication).  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. Future implementation planning will establish accountability requirements for Lead organizations that are defined based on provider specific competencies and capacities. CCAC can also serve the at-risk population, especially when there is a prior relationship.  To ensure effective and efficient care delivery, Leads will work with other CSS providers under a partnership model. A specific focus will be to develop strategies to integrate LHIN-wide providers (e.g., CNIB, Alzheimer’s Society) into the network of providers. Future implementation planning will define the structure and necessary supports for this arrangement.  Future implementation planning will include analysis and consultations to confirm the level and location for the selected service enhancements for both the Complex Senior and At-Risk Senior populations, and will incorporate suggestions from the CSS Working Group and other key stakeholders to refine components of the framework. Analysis should take into account the evolving changes to the definition and assessment criteria.

Recommendations for the Transition CSS Senior Population:  CCAC and CSS lead organizations will work together to 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.

Recommendations for the General CSS Senior Population:  Existing services will continue for this general CSS population. These services are critical to maintain independence in the community. Toronto Central LHIN is keenly aware that as system transformation efforts are implemented for the complex and at-risk populations, existing services must be maintained for clients who rely on them. Every effort will be taken to ensure that stable ongoing funding for necessary community services continues throughout the community transformation work.

Advancing the Integration of Health Care Through Health Links P a g e | 30 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy 4.4 Access to Specialist Care Blueprint An important focus to enable clients access the care they need is to ensure timely and appropriate access by primary care providers to specialist advice, guidance and referrals. There was agreement that access to specialists by primary care provider was an important area for improvement. In May 2013, the Hospital Access Working Group was established to develop concrete plans and strategies to connect a population of complex and at-risk clients to specialists. This work complements and supports the multiple efforts associated with the Health Links agenda to advance the integration of health care. Between May and June 2013, the Working Group met two times to transition from establishing principles and a vision, to conceptual model development, and ultimately to building recommendations to guide future planning work (see Appendix 9 for a conceptual specialist access model). This document provides a proposed model for enhancing primary care access to specialist for their complex and at-risk clients by: . Improving the consistency, simplicity and efficiency of the Primary Care Referral process by making it easier to identify appropriate specialists to refer to; . Establishing clear processes to appropriately identify complex clients and at-risk clients to ensure the prioritized access is not misused; and . Ensuring specialists get timely and appropriate information they need to ensure they are the right provider to see the client, and enable them to prepare to support the care of the client. . Building greater capacity and supports to enable accountability of providers through measurement. The result – complex and at-risk clients are appropriately referred to a specialist consultation with minimal unnecessary delays. This work is not intended to change referral patterns or client/patient choices for which hospital they will go to for specialty care; link a hospital to any Health Link; or disadvantage referrals from outside TC LHIN. In addition, all work must support patient choice, and a patient’s involvement in the process. To develop a future model for enhancing access to specialist care, the Working Group identified the following key questions to address: . How do we make it easier to identify potential specialists to refer to? A current challenge for many primary care providers is a lack of knowledge as to which specialists to refer to. The solution is the development of a tool/information that enables primary care providers to easily search for a specialist/sub-specialist based on the needs of the clients, identify the specialist, and efficiently contact the specialist in a manner that works for the specialist. . How do we ensure the neediest clients have priority access to services? To ensure the most complex needs are met in a timely manner avoiding unnecessary de-compensation of clients, referrals must be easily prioritized to ensure clients with the highest needs receive timely access to services. The solution is the development of clear criteria and processes to identify urgent referrals that are accepted broadly across the system, and where possible, base this criteria on clinical symptoms. . How do we ensure critical conversations between primary care providers and specialist are enabled when required? In some situations, a primary care provider may only need to speak to a specialist to receive clinical advice, and/or may need to confirm the appropriateness of the referral. To ensure appropriate consults that do not further bottleneck the system, efficient processes and tools to connect primary care providers to specialist must be developed to enable these critical conversations.

Advancing the Integration of Health Care Through Health Links P a g e | 31 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy . How do we leverage new approaches to accessing specialists to address system capacity issues? With the evolving changes to care delivery, new approaches to enable access to specialists that ensure effective and efficient use of resources must be pursued. For example, a solution may be to leverage existing and/or create new telemedicine consultation options through a partnership with OTN.

Recommendations for the Complex and At-Risk Population Requiring Access to Specialists:  Support the standardization of referral forms. TC LHIN will lead work to develop 2-3 standardized referral forms for use by referring physicians.  Collect and make accessible specialist information to populate the minimum dataset including a contact person name for follow-up. Overtime, this information should include specifics related to the referral process for each specialist.  Explore a standardized solution to enable primary care providers to efficiently search and identify appropriate specialists based on a client’s needs using automation technologies, and enable effective communication between primary care provider and specialist.

Advancing the Integration of Health Care Through Health Links P a g e | 32 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy 4.5 Access to Specialized Medical Imaging Blueprint To best support the needs of complex and at-risk clients, primary care providers should not have excessive delays to access specialized medical imaging services. In May 2013, the MRI/CT Network provided input into approaches to enhance access to specialized medical imaging with the goal of supporting the development of concrete plans and strategies to connect need populations to specialized medical imaging. This work complements and supports the multiple efforts associated with the Health Links agenda to advance the integration of health care. Between May and June 2013, the Working Group met two times to transition from principles and a vision, to conceptual model development, and ultimately to building recommendations to guide future planning work (see Appendix 10 for a conceptual specialized medical imaging model). This document provides a proposed model for enhancing primary care access to specialized medical imaging for complex and at-risk clients by: . Improving the consistency, simplicity and efficiency of the Primary Care Referral for specialized diagnostic imaging eliminating the need for hospital-specific forms in favour of standardized processes that span multiple organizations. . Establishing clear processes and leveraging guidelines to ensure the right medical imaging modality is selected ensuring appropriateness of the diagnostic test; and . Ensuring primary care providers have necessary supports to appropriately interpret the results. . Building greater capacity and supports to enable accountability of providers through measurement. The result – complex and at-risk clients receive timely and appropriate access to specialized medical imaging. This work is not intended to change referral patterns or client/patient choices for which hospital they will go to for specialty care; link a hospital to any Health Link; or disadvantage referrals from outside the TC LHIN. In addition, specific needs for certain populations (e.g., paediatric) will need to be incorporated into the proposed design of the process.

To develop a future model for enhancing access to specialized medical imaging, the Working Group identified the following key questions to be addressed: . How do we enhance the consistency and standardization of order forms and processes? Currently, order forms for medical imaging are generally defined by each hospital resulting in primary care providers having to select the right form. In the future, a single referral process and form for use by all Primary Care Providers independent of Imaging Centres will be used to order specialized medical imaging. . How do we ensure the appropriate test is ordered? An ongoing challenge within diagnostic testing is to ensure the appropriate test is ordered to ensure safety for the client and effective use of limited resources. Approved ordering guidelines and new technologies provide a critical platform to enhance the appropriateness, safety, quality, efficiency and effectiveness of the medical imaging ordering process. . How do we better connect primary care providers with imaging centres when there is an important question to address? When dealing with the needs of a complex or at-risk client, sometimes questions need to be asked to determine the best plan for care. In the future, Primary Care Providers will have the opportunity to speak with an imaging centre/expert to ensure any special needs or requirements are met.

Advancing the Integration of Health Care Through Health Links P a g e | 33 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy . What do you do when a primary care provider has a clinical question? For the more complex clients, there is sometimes a need for primary care providers to follow-up with the radiologist. To support this need, in the future, there will be improved access to results reporting, with a greater capacity to follow-up with the Radiologist directly as required. Recommendations for the Complex and At-Risk Senior Population requiring Specialized Medical Imaging:  Support the standardization of medical imaging requisition forms. TC LHIN will lead work to develop a single standardized medical imaging order requisition form for use by referring physicians.  Implement an order tool for specialized medical imaging across all primary care providers that is grounded in appropriateness guidelines to ensure the right test is selected, and the client is appropriately triaged. Explore options for leveraging the tool to support communication between the primary care provider and the imaging centre.

Advancing the Integration of Health Care Through Health Links P a g e | 34 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy Appendix

. A1 Community Mental Health & Addiction Working Group . A2 Community Support Services Working Group . A3 Hospital Specialist Working Group . A4 MRI/CT Network . A5 Think Tank Participants . A6 Profile of Complex and At-Risk Populations in the TC LHIN . A7 MHA Population Descriptions . A8 CSS Population Descriptions . A9 Specialist Access Conceptual Model . A10 Specialized Medical Imaging Conceptual Model . A11 Primary Care Health Links

Advancing the Integration of Health Care Through Health Links P a g e | 35 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy A1 Community Mental Health & Addiction Working Group

Overview of Activities/Meetings

Session One February 27th Session orientation and principles developed Session Two March 11th Developing a straw conceptual model Session Three April 9th Advancing a conceptual model Session Four April 23rd Building a Blueprint Session Five May 8th Reviewing and Elaborating on the Blueprint Client Engagement April 22nd Board to Board Engagement May 2nd Think Tank Session May 10th Session Six May 28th To review service enhancements Session Seven June 10th To confirm recommendations Session Eight June 27th To finalize the report

MHA Health Link Working Group Membership:

. Mohamed Badsha, Reconnect Mental Health Services . Dr. Philip Berger, St. Michael’s . Liz Birchall, Community Outreach Programs in Addictions . Nancy Bradley, Jean Tweed Centre . Paul Bruce, COTA Health . Dr. Carol Cohen, Sunnybrook Health Sciences Centre . Elizabeth Ferguson , The Hospital for Sick Children . Lana Frado, Sound Times Support Services . Tom Henderson, St. Michael’s . Jan Lackstrom, University Health Network . David Lemire, Community Resource Connections Toronto . Dennis Long, Breakaway Addictions Services . Susan Miekle, Toronto North Support Services . Linda Mohri, Centre for Addictions and Mental Health . Jim Nason, LOFT Community Services . Dipti Purbhoo, TC CCAC . Noel Simpson, Regeneration Community Services . Dr. Vicky Stergiopolous, St. Michael's . Victor Willis, Parkdale Activity-Recreation Centre . Brigitte Witkowski, Mainstay Housing . Linda Young, Toronto East General Hospital

TC LHIN Representatives:  Vania Sakelaris  Lori Lucier  Kendyl Dobbin  Cynthia Damba

Advancing the Integration of Health Care Through Health Links P a g e | 36 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy A2 Community Support Services Working Group

Overview of Activities/Meetings:

Session One February 20th Session orientation and principles developed Session Two March 4th Developing a straw conceptual model Session Three April 15th Advancing a conceptual model Session Four May 1st Building a Blueprint Session Five May 21st Reviewing and Elaborating on the Blueprint Client Engagement May 2nd Board to Board Engagement May 9th Think Tank Session May 10th Sector Review May 12th Session Six June 12th To review service enhancements Session Seven June 27th To confirm recommendations an finalize report

CSS Health Link Working Group Membership:

. Cathy Barrick, Alzheimer Society of Toronto . Claire Bryden, Bellwoods Centres for Community Living . Barbara Cecceralli, Centres D’Accueil Héritage . Maureen Fair, St. Christopher House . Amanda Falotico, Providence Healthcare . Elizabeth Forestell, Central Neighbourhood House . Keith Hambly, Fife House . Mary Hansen, Storefront Humber . Stacy Landau, SPRINT Senior Care . Kaarina Luoma, Mid-Toronto Community Services Inc. . Seonag Macrae, WoodGreen Community Services . Lisa Manuel, Family Services Toronto . Dena Maule, Hospice Toronto . Jim Nason, LOFT Community Services . Evelyn Pepe, The Canadian Hearing Society . Dipti Purboo/Gayle Seddon/Jodeme Goldhar, TC CCAC . Tatjana Radovanovic, The Canadian Red Cross Society . Bruno Scorsone, Good Neighbours’ Club

TC LHIN Representatives:  Vania Sakelaris  Nello Del Rizzo  Teresa Martins  Cynthia Damba

Advancing the Integration of Health Care Through Health Links P a g e | 37 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy A3 Hospital Specialist Working Group

Hospital Specialist Access Working Group Membership: . Dr. Charlie Chan, UHN . Dr. Phil Ellison, Primary Care Advisor, TC LHIN . Laura Forma, West Park Health Centre . Dr. Ian Fraser, TEGH . Dr. Tom Harmantas, St. Joseph’s . Dr. Kwame McKenzie, CAMH . Malcolm Moffat, Sunnybrook . Heather McPherson, Women's College . Peter Nord, Providence . Carmine Stumpo, TEGH . Dr. Jerry Teitel, St. Michael’s . Dinarte Viveiros, Sick Kids . Dr. Jeff Zaltzman, St. Michael’s

TC LHIN Representatives:  Vania Sakelaris  Bill Manson  Ashnoor Rahim

Advancing the Integration of Health Care Through Health Links P a g e | 38 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy A4 MRI/CT Network

MRI/CT Network Membership: . Albert Aziza, Sick Kids Hospital . Paul Cornacchione, University Health Network . Ellen Charkot, Sick Kids Hospital . Tim Dowdell, St. Michael’s Hospital . Masoom Haider, Sunnybrook Health Sciences Centre . Michael Heffer, St. Joseph’s Health Centre . Thien Huynh, University of Toronto . Harry Joseph, Toronto East General Hospital . Dawn-Marie King, St. Michael’s . Walter Kucharczyk (Chair), University Health Network . Erin Monteith, St. Joseph’s Health Centre . Harold Newman, Toronto East General Hospital . Henry Sinn, Sunnybrook Health Sciences Centre . Wendy Thurston, St. Joseph’s Health Centre . Catherine Wang, University Health Network

Toronto Central LHIN Representatives:  Bill Manson  Chris Sulway

Advancing the Integration of Health Care Through Health Links P a g e | 39 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy A5 Think Tank Participants

Think Tank Participants include: . Dr. Yoel Abells, Toronto Central LHIN . Dr. Howard Abrams, University Health Network . Reva Adler, Bridgepoint Health . Dr. Javed Alloo, Community Physician (East GTA FHO) . Helen Angus, Ministry of Health and Long-term Care . Mohamed Badsha, Reconnect Mental Health Services . Robert Bell, University Health Network . Dr. Philip Berger, St. Michael's Hospital . Pooja Bhatia, William Osler Health Centre . Rick Blickstead, Toronto Central LHIN . Nancy Bradley, Jean Tweed Centre . Sheila Braidek, Regent Park Community Health Centre . Maggie Bruneau, Providence Healthcare . Elizabeth Bryce, Leisureworld Senior Care Corporation, St. George . Kathy Bugeja, Ontario Medical Association, District 11 . Dr. Jocelyn Charles, Sunnybrook Family Health Team . Paul Davis, Hospital for Sick Children . JoAnne Doyle, United Way Toronto . Maria Elias, Belmont House . Dr. Phil Ellison, Toronto Central LHIN . Debbie Elman, Sunnybrook Family Health Team . Angela Ferrante, Toronto Central LHIN . Kasia Filiber, Four Villages Community Health Centre . Debbie Fischer, Mt. Sinai Hospital . Louis Fliss, Flemingdon Community Health Centre . Russ Ford, LAMP Community Health Centre . Kathy Gallagher-Ross, Toronto Central LHIN . Isabel Girard, Les Centres d’Accueil D’ Heritage . Jodeme Goldhar, Toronto Central CCAC . Robin Griller, Inner City Family Health Team . Aynur Gurbanova, University Health Network Toronto Western Family Health Team . Jane Harrison, Anishnawbe Community Health Centre . Maurice Hudon, Toronto Central LHIN . Seonag Macrae, WoodGreen Community Support Services . Faith Malach, Baycrest . Kate Malisani, West Park Family Health Team . Laurie Malone, St. Michael's Hospital Family Health Team . Lisa Manuel, Family Services Toronto . Notisha Massaquoi, Women's Health in Women's Hands . Alies Maybee, Patients Association Representative . Susan McIsaac, United Way Toronto . Stephanie McLaren, South East Toronto Family Health Team

Advancing the Integration of Health Care Through Health Links P a g e | 40 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy . Barry McLellan, Sunnybrook Health Sciences Centre . Andrea McLister, Leisureworld Senior Care Corporation, O'Connor Gate . Sarah McMillan, Patients Association Representative . Dr. Heather McPherson, Women’s College Hospital . Linda Mohri, Centre for Addiction and Mental Health . Jim Nason, LOFT Community Services . Anne Oakley, Women’s College Hospital . Jim O'Neil, St. Michael's Hospital . Dr. Pauline Pariser, Taddle Creek Family Health Team . Carol Perry, Toronto Central LHIN . Lynne Raskin, South Riverdale Community Health Centre . Carla Ribiero, Parkdale Community Health Centre . Adair Roberts, ER Alliance . Angela Robertson, Central Toronto Community Health Centre . Marilyn Rook, The Salvation Army Toronto Grace Health Centre . Hélène Roussel, Reflet Salvéo . Sandie Seaman, Health Quality Ontario . Gayle Seddon, Toronto Central CCAC . Jill Shaw, Ministry of Health and Long-term Care . Dr. Jose Silveria, St. Joseph's Health Centre . Dr. Vicky Stergiopolous, St. Michael's Hospital . Carmine Stumpo, Toronto East General Hospital . Susan Swartzack, Mississauga Halton LHIN . Lyndsay Tchegus, Anne Johnston Community Health Centre . Gary Thompson, Ministry of Health and Long-term Care . Dinarte Viveiros, Hospital for Sick Children

Toronto Central LHIN Representatives:  Camille Orridge  Vania Sakelaris  Nello Del Rizzo  Rachel Solomon  Janine Hopkins  Ashnoor Rahim  Cynthia Damba  Lori Lucier  Kendyl Dobbin  Wendy Nelson

Advancing the Integration of Health Care Through Health Links P a g e | 41 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy A6 Profile, Challenges & Impacts of Complex/At-Risk Populations in TC LHIN

The following section presents a profile of complex and at-risk populations in TC LHIN, their needs and challenges and their impact on the health care system. a) Highest cost users of health services: . A small proportion of the population account for a large proportion of the healthcare costs. In TC LHIN in 2009, there were at total of 450,465 users of health care services for a total cost of $2.774 Billion with an average cost of $6,000. The top 1% (4,505) super high users accounted for 29% of the costs ($806 Million). 5% (22,525) high users accounted for 58% of total costs and 10% (45,045) high users accounted for 73% of total costs. . A higher proportion of high users have ALC days associated with their acute care stays: 35% of the super high users and 29% of the high users had ALC days. . For the 5% and 10% high users the largest acute inpatient Major Clinical Categories (MCCs) were diseases of the circulatory system, followed by diseases of the blood and lymphatic system, respiratory system, and digestive system. . The highest proportion of 5% and 10% highest cost ER users were for mental disorders followed by digestive and circulatory disorders. . Among the 1% highest users, nearly, three-quarters (74%) had used acute inpatient care and 56% were high users of ER. In this group, average costs per patient were highest for inpatient mental health patients ($176,000) followed by acute inpatient patients ($145,500). Among the 5% highest users, 83% had used acute inpatient care and 62% used the ER. In this group, mental health patients ($78,500) had the highest average cost per patient followed by CCC patients ($73,000). . Among the high cost health care users, there is a high proportion of deaths. b) Health status of complex and at-risk populations. . Complex patients have a multitude of problems and the problems increase with age. With the aging population in TC LHIN, we expect to see more complex seniors with higher needs. These patients with multiple chronic conditions have poor quality of life and use considerable health care resources. According to the 2009 & 2010 CCHS, 37% of Ontario population aged 12 and over had at least one chronic condition, with 15.2% reporting two or more conditions (MOHLTC HAB, 2012a). A Canadian study showed that seniors were four times more likely to report having a chronic condition than adults age 18 to 24 (74% vs. 19%). Twenty-four percent of all Canadian seniors reported having 3 or more chronic conditions (CIHI, 2011). Furthermore, seniors with three or more chronic conditions had nearly three times the number of health care visits than those without chronic conditions (CIHI, 2011). . Several behaviours put people at risk of developing chronic conditions. Although TC LHIN residents did relatively well in terms of high risk behaviours compared to other LHINs, there is still much room for improvement. In 2009-10, 38% of adults were overweight or obese, 61% did not consume enough fruits and vegetables daily, approximately 18% of LHIN residents were smokers and 17% were heavy drinkers (MOHLTC HAB, 2012b). These behaviours need to be addressed. . In addition, some characteristics put people at risk – for example, people with low income, the homeless, certain ethnic groups, Aboriginal population, immigrants and refugees are at increased risk of having chronic conditions. These groups often experience further challenges accessing health services which worsen their health outcomes. This issue is particularly important in TC LHIN given its diverse population as described previously.

Advancing the Integration of Health Care Through Health Links P a g e | 42 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy . Due to the multiple chronic conditions, many seniors take multiple medications. There has been a significant increases in both absolute and per person prescription claims among primary care patients aged 65+ in Ontario, particularly among women 85 years and older (Bajcar et al, 2010). The increased medications increase the risk of patient non-compliance and adverse events. Medical adverse events have been identified as one of the most common causes of repeat ED visits and readmissions. There is a need a for medication reconciliation for patients seen in the various health care settings. c) Health system impact and use by complex and at-risk populations. . Complex populations have high rates of repeat emergency department visits. TC LHIN has the highest rate of repeat ED visits for mental health and addictions in the province and although rates have been declining, more still needs to be done to reduce them further. In Q1 2012/13, the rate of unscheduled ED visits for MH was 27.6% while that for substance was 38%. A certain proportion of repeat ED MHA clients are repeat users over multiple years. Analysis of FY 2010 and FY 2011 data showed that 1,130 patients had a total of 5 or more ED visits (with at least 1 visit for MHA) within each year. The number of ED visits for these patients ranged from 5 to over 100 per year. This group of clients would benefit greatly from integrated care especially since studies have shown that people with severe mental health and addictions issues who use the ED repeatedly may also have multiple chronic conditions and also have a reduced life span. . Complex populations also have high rates of repeat inpatient admissions. TC LHIN has the highest rate of unscheduled readmissions for selected conditions (19% in Q1 2012/13). Congestive heart failure and chronic obstructive pulmonary disease continue to be the clinical groups with the highest readmission rates (MOHLTC HAB, 2013a). . TC LHIN rates of ALC are relatively low compared to other areas; however, some groups are disproportionately affected. As of July 23, 2013, there were a total of 561 open ALC cases in TC LHIN hospitals. Of these, 239 were in acute, 203 in CCC, 89 in MHA and 30 in rehab. The most hard-to-place patients stay in ALC for a long time (over 40 days) due to lack of appropriate places in the community to place them. MHA had the highest proportion of long stay ALC - 90% of all inpatient MHA ALC patients were long-stay compared to 74% for CCC, 54% for rehab, and only 24% for acute inpatients (CCO WTIS, 2013). d) Some examples of challenges experienced by complex and at risk populations in accessing care

Primary care: . Accessing primary care remains a major challenge for some patients. Overall, 89% of TC LHIN residents report having a regular medical doctor (similar to the provincial average but lower than most other LHINs) (MOHLTC HAB, 2013b). The province established the Health Care Connect (HCC) program to assist people in getting access to primary care. Although rates have started to improve recently, TC LHIN’s performance remains low compared to other LHINs. As of April 2013 the overall attachment rate for patients registered with HCC was 54.5%. This rate was higher for the complex vulnerable population (93%) than that for non-complex vulnerable (52%). However, these figures only reflect patients with valid health cards. Therefore the attachment rate is actually lower when taking into consideration those individuals without OHIP coverage (HCC, 2013). . There is lack of a coordinated system for specialist referrals from primary care and subsequently, patients wait a long time to see specialists. In June 2013, the 90th percentile wait time for cardiac by-pass was 45 days, for cancer surgeries 50 days, knee surgery 197 days, for hip surgery 179,

Advancing the Integration of Health Care Through Health Links P a g e | 43 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy and for cataract surgeries 147 days (WTIS CCO, 2013). Similarly, there are long waits for medical imaging – In June 2013, the 90th percentile wait time for MRI was 51 days and for CTs was 31 days (WTIS CCO, 2013). These long waits put patients at increased risk of their conditions deteriorating as they wait for diagnosis. . Adequate follow up by primary care providers of patients discharged from hospital is essential in helping patients have continuity of care. However, this remains a weak area of performance in TC LHIN. In 2011 only 42% of patients discharged from inpatient had a visit to their primary care provider within 7 days after discharge. This proportion was lowest for those from mental health and addictions beds (with only 10.5%) compared to 51% for those from medical beds (ICES, 2013). . According to CIHI 2009, 40% of persons with one or more severe chronic conditions have not made a treatment plan with their primary care provider in over a year

CCAC . TC CCAC estimates that the complex population (with Maple score 3-5) has grown at a rate of 26% over the last 4 years and over the recent years, the CCAC has focused on improving coordination of care for complex patients with initiatives such as the Integrated Client Care Program (ICCP) for seniors and the collaborative care project with CSS agencies. However, the services are limited and there are waits for these services. Palliative and children cases are not included in these estimates. . Toronto Central CCAC has estimated that that overall, it supports approximately 6,400 frail older adults and caregivers and 1300 complex adults to remain at home each year, approximately 1,600 individuals to die at home with dignity, and approximately 375 children to remain at home and in the school environment (Goldhar, 2013). . TC CCAC has partnered with three CSS agencies through enhanced Adult Day Programs (eADP) to serve the needs of 148 complex clients (RAI score of 13) who are significantly frail and at-risk to regain some independence while enabling them remain at home (TC CCAC, 2013). TC CCAC is also working with two CSS agencies to advance Assisted Living for High Risk Seniors (ALHRS). At present, they are serving 61 high risk seniors. Both these programs have shown considerable benefits for seniors such as reduced unscheduled ED visits, however, they are only located in some areas of the LHIN. There is a need to consider similar services for seniors in the North and West areas of the LHIN that have high populations of high risk seniors (TC CCAC, 2013).

CSS . The CSS sector in addition to the above also serves a considerable proportion of complex clients. 2012 RAI-CHA assessment data from three CSS agencies in TC LHIN showed that approximately 70% of the clients had a Maple score of 3 – 5. 7 – 16% had CHESS scores of 3-4 and 7% - 35% had Depression Rating Scores (DRS) scores of 3 or higher (TC LHIN, Inter RAI Team, 2013). Complex clients may be housed in supportive housing (SH) and among these are some of the most complex who do not have social support or caregivers, have socio-economic challenges, and mental health issues, and they have a considerably high rate of hospital use. Currently, many CSS supportive housing agencies in TC LHIN have long waiting lists or are unable to accommodate the clients who require their support due to lack of capacity. Early results showed that there was a 39% rate of unscheduled repeat ED visits and a 20% rate of unscheduled readmissions for SH clients in Q3 2012/13 (TC LHIN Quality Indicators, 2013a).

Advancing the Integration of Health Care Through Health Links P a g e | 44 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy . Assisted living services also play a significant role in caring for complex adults with disabilities. However, province wide there are long wait lists with approximately 5,000 individuals waiting for these services (Ontario Attendant Services Advisory Committee, 2013). The long waits are costly to the health care system as they contribute to poor health outcomes for individuals as well as their using more expensive services such as ALC in hospital, inappropriate placement in LTC homes, ending up in the ED with secondary complications. An average cost per person for a hospital bed is $42,000/month or $500,000/year, compared to that for Assisted Living Services in Supportive Housing ($5,000/month or $60,000/year); Self-managed Attendant Services ($2,600/month or $31,000/year) and Attendant Outreach Services ($2,250/month or $27,000/year) (Ontario Attendant Services Advisory Committee, 2013).

CMHA . The challenges encountered by individuals with mental health and addiction issues are well documented. Among those with MHA, some subgroups have higher rates of ED use and hospitalization. For example, those with concurrent disorders and those with intellectual and developmental disabilities (IDD) (Lunsky, et al., 2012). . TC LHIN faces a number of issues related to access to mental health and addictions services, especially those most required for complex clients. For example, clients in need of supportive housing (SH), intensive case management (ICM) and assertive community treatment (ACTT) experience waits for access to care. As of Q4 2012/13, there were approximately 6,000 people waiting for SH and the average wait time was 389 days. There were a total of 402 people waiting for ICM and ACT teams, and the wait for the person who had waited longest was 240 days (TC LHIN Quality indicators, 2013). . A considerable number of referrals to MHA supportive housing are refused by the clients (58%) and some are declined by providers (13%), indicating the complexity of housing mental health and addictions clients. The most common reasons for SH providers to decline referrals were: support needs too high (24%) and person does not meet eligibility criteria (24%) (TC LHIN Quality indicators, 2013b).

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Advancing the Integration of Health Care Through Health Links P a g e | 46 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy A7 MHA Population Descriptions

Attributes of Community Complex MHA Seniors, Adults, and Youth Clients The following three tables below provide detailed characteristics of the three groups have been identified for focus regarding MHA (a) Complex seniors, b) complex adults, and c) youth clients. The latter group may not be complex; however, they experience considerable challenges accessing services and may be at risk of becoming complex if they do not receive appropriate care in a timely manner. The three groups are not homogeneous; however, the tables below provide some common characteristics of these groups. Clients may have different combinations of the characteristics. Characteristics of Complex Adults Supported by CMHA services Domain Characteristics Demographics . Between ages of 25 - 64 years . Language issues . High risk ethnic groups e.g. Aboriginal people, historically marginalized . Newcomers (in Canada less than 5 years) Medical /Physical . Have comorbidities - chronic conditions such as diabetes, asthma, heart and respiratory conditions, cancer, hepatitis, liver disease, HIV/AIDs, etc. . Multiple medications, difficulty managing medications and not adherent to the medications prescribed by physician . Have multiple unmet needs Mental Health . May have multiple mental health conditions (e.g. Schizophrenia, mood disorders, depression), especially comorbid personality disorder (e.g. Cluster B disorders like Borderline personality disorder (BPD), Antisocial personality disorder (ASPD)) . May have addictions (substance abuse (alcohol, drugs, smoking tobacco, others) or problem gambling) . May have concurrent disorders (mental health and substance conditions) . May have dual diagnosis (mental health and developmental disorders e.g. autism) . May have brain injury (Acquired brain injury – ABI) . May have high risk behavior (e.g. repeated suicide attempts, repeated self-injurious behaviour (e.g. cutting, overdosing, burning), sex trade involvement, involvement in criminal activities, impulsivity resulting in significant financial/social consequences) . Aggressive behaviour, or be verbally or physically abusive, wandering, socially inappropriate, resist care, lack of trust of health care personnel . May have difficulty with memory, decision-making and/or making oneself understood Social Capital Issues . May be homeless or have housing issues . Low income . Psychosocial vulnerability . May have multiple contacts with the criminal justice system . Trauma and abuse issues Health & Social . May or may have not multiple hospital admissions or multiple ED visits in past year Experiences . In and out of justice system . Difficulty accessing/being admitted to CMHA services . May not have a regular primary care provider or have difficulty seeing primary care physician . Difficulty accessing a psychiatrist and other specialists . May be completely disconnected to any services, except for shelters or drop-ins

Advancing the Integration of Health Care Through Health Links P a g e | 47 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy Characteristics of Complex Older Adults (frail seniors) supported by CMHA services Domain Characteristics Demographics . 65 + years . Language issues . Immigrant . High risk ethnic groups such as Aboriginal/First Nations Medical /Physical . Have multiple unmet needs . Have chronic conditions such as diabetes, asthma, heart and respiratory conditions, etc. . Multiple medications, difficulty managing medications and not adherent to the medications prescribed by physician . Physically frail Mental Health . Have schizophrenia or other mental health conditions . May have cognitive issues like dementia, Alzheimer’s disease, and mental health issues like depression . Have substance abuse (alcohol, smoking, etc.) . May have aggressive behaviour - be verbally or physically abusive, wanders, be socially inappropriate, resists care . Have difficulty with memory, decision-making and/or making oneself understood (dementia, Alzheimer’s) . High risk behaviour Social Capital Issues . May be homeless or have housing issues . Low income . May live alone or have no family contact . Psychosocial vulnerability . May not have social support or social supports experiencing fatigue or burn-out . Issues with the justice system . Social supports/family issues (fatigue, burnout) . Food insecurity . Social issues Health & Social . Have had multiple hospital admissions or multiple ED visits in past year Experiences . Difficulty accessing/being admitted to CMHA services . Denied LTC due to behaviour issues . Does not have a regular primary care provider . Have difficulty accessing a psychiatrist and other specialists

Advancing the Integration of Health Care Through Health Links P a g e | 48 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy Characteristics of Transitional Aged Youth supported by the CMHA services (At-risk population) Domain Characteristics Demographics . 16 - 24 years . Literacy issues Medical /Physical . May or may not have medical problems . Have multiple unmet needs . Multiple medication, difficulty managing medications and not adherent to the medications prescribed by physician . May have poor diet (malnutrition), oral health problems, sexually transmitted diseases, hepatitis, HIV, teen pregnancy . Undiagnosed FAE . ADHD, ABI, learning disabilities Mental Health . May have complex, high-risk neuropsychiatric disorders . May have clinically significant mental health issue e.g. depression, anxiety, first episode of psychosis, mood disorder, conduct disorder, Anorexia Nervosa, bipolar disorder, schizophrenia, bulimia nervosa . May have multiple psychiatric disorders . May have substance abuse (alcohol, smoking tobacco, drugs, etc.) . May have concurrent disorder or dual diagnosis . May be suicidal, or have a family history of suicide, and previous suicide attempts Social Capital Issues . Young people transitioning from adolescence into young adulthood may face challenges such as increasing expectations of adult competency and independence: for example, high school completion, finding stable employment, becoming self- sufficient and, at times, supporting a family of their own. . Coming from a high-risk background can add to the challenge . May have history of being in Children’s Aid Society (CAS) care . May have lower socio-economic status . Caregiver fatigue . Have a history of alcoholic family systems, or physically violent environments, or be victims of sexual abuse Health & Social . May not be receiving any MHA service Experiences . May have ED visit and repeat ED visits for mental health, substance abuse, and attempted suicide . Frequent outpatient visits to a physician, and admissions to hospital . May face legal barriers to secure treatment available for younger children . May disengage from services after experiencing barriers to accessing services

Advancing the Integration of Health Care Through Health Links P a g e | 49 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy A8 CSS Population Descriptions

Attributes of Complex and At-Risk Seniors, Adults, Palliative Care Clients The following three tables below provide detailed characteristics of the three groups have been identified for focus regarding CSS (a) Complex older adults (frail seniors), b) complex adults (also includes ABI), and c) palliative clients. Clients may have different combinations of the characteristics and generally, the more issues a client has, the higher the acuity/complexity of the client. Detailed Characteristics of Complex Older Adults (Frail Seniors) Supported by CSS services Domain Characteristics Demographics . Generally, over the age of 65 years with the vast majority over the age of 80, but include individuals who are prematurely aged.

Medical . Have 2 or more chronic conditions such as diabetes, asthma, heart, respiratory /Physical . Multiple medications, difficulty managing medications and not adherent to the medications prescribed by physician . Physically frail with impaired mobility . Needs assistance with dressing, toileting, transfer, locomotion, hygiene . Has difficulty with meal preparation, ordinary housework, managing finances, managing medications, phone use, stairs, shopping, transportation . Has pressure/stasis ulcers . Has a history of falls . May have physical communication difficulty such as expressive aphasia, augmentative or alternative communication needs Assessments:* . Have a MAPLe (Method of Assigning Priority Levels) Scores of Moderate, High or Very High (MAPLe 3, 4 & 5) . CHESS score (Changes in Health, End-Stage Disease, and Sign and Symptoms) of moderate, high or very high health instability (CHESS 3, 4 & 5) . ADL and IADL scales (difficulty in managing one or more ADL or IADL) Mental Health . May have cognitive issues like dementia, Alzheimer’s disease, mental health issues like depression . May be verbally or physically abusive, wanders, is socially inappropriate, resists care . Have difficulty with memory, decision-making, and/or making oneself understood Assessments:* . Have a CPS (Cognitive Performance Scale) score of moderate, moderate severe, severe or very severe (CPS 3, 4, 5 or 6) . Have some symptoms of depression (DRS = or >1) Social Capital . May not have caregiver or adequate support system Issues . Caregivers of these individuals provide a lot of care and are often at risk for burn out . May not be functioning safely in the current environment . Low income or living in poverty . Are at risk for abuse or currently being abused . May struggle with maintaining adequate housing . May have food security issues Health & Social . Have had a hospital admission or multiple ED visits in past year (Often in and out of hospital Experiences and use the emergency department frequently). . See multiple health care providers including medical specialists and primary care. . May have difficulties remaining connected to primary care providers due to mental health issues, lack of trust, etc. * Clients who have Low MAPLE scores may still be complex if they have other high risk characteristics Assessment scores will be informed & modified using feedback from interRAI-CHA group & LHIN interRAI-CHA analyses - underway.

Advancing the Integration of Health Care Through Health Links P a g e | 50 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy Detailed Characteristics of Complex Adults Supported by CSS services Domain Characteristics Demographics . Between ages of 20 and 64 years

Medical . Includes individuals with acquired brain injuries or long term disability such as spinal cord /Physical injury, multiple sclerosis or cerebral palsy . Have 2 or more chronic conditions such as diabetes, asthma, heart and respiratory conditions, HIV/AIDS etc. . Multiple medications, difficulty managing medications and not adherent to the medications prescribed by physician . Needs assistance with dressing, toileting, transfer, locomotion, hygiene . Has difficulty with meal preparation, ordinary housework, managing finances, managing medications, phone use, stairs, shopping, transportation . Needs assistance with dressing, toileting, transfer, locomotion, hygiene . Physical communication difficulty such as expressive aphasia, augmentative or alternative communication needs

Assessments:* . Have a MAPLe (Method of Assigning Priority Levels) Scores of Moderate, High or Very High (MAPLe 3, 4 & 5) . CHESS score (Changes in Health, End-Stage Disease, and Sign and Symptoms) of moderate, high or very high health instability (CHESS 3, 4 & 5) . ADL and IADL scales (difficulty in managing one or more ADL or IADL) Mental Health . May have cognitive issues like dementia, Alzheimer’s disease, and mental health issues like depression . May be verbally or physically abusive, wanders, is socially inappropriate, resists care . Have difficulty with memory, decision-making and/or making oneself understood Assessments:* . Have a CPS (Cognitive Performance Scale) score of moderate, moderate severe, severe or very severe (CPS 3, 4, 5 or 6) . Have some symptoms of depression (DRS = or >1)

Social Capital . Similar characteristics to complex seniors Issues . Caregivers experiencing distress . Low income or living in poverty . Living alone . Are at risk for abuse or currently being abused . Health & Social . Similar characteristics to complex seniors. Experiences * Clients who have Low MAPLE scores may still be complex if they have other high risk characteristics Assessment scores will be informed and modified using feedback from interRAI-CHA group and TC LHIN interRAI-CHA analyses - underway.

Advancing the Integration of Health Care Through Health Links P a g e | 51 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy Detailed Characteristics of Palliative Patients*

Domain Characteristics

Demographics . 20 years and older Medical . Living with or dying of an advanced illness /Physical . Majority may have a malignant neoplasm . Similar characteristics to complex seniors Assessments:** . Have a MAPLe (Method of Assigning Priority Levels) Scores of Moderate, High or Very High (MAPLe 3, 4 & 5) . CHESS score (Changes in Health, End-Stage Disease, and Sign and Symptoms) of high or very high health instability (CHESS 4 & 5)

Mental Health . Similar characteristics to complex seniors Assessments: . Have a Depression Rating Scale exhibiting major or minor depressive disorders (3 and higher)

Social Capital . Similar characteristics to complex seniors Issues . Desire to die at home with dignity . Caregivers experiencing distress or inability to manage

Health & Social . Similar characteristics to complex seniors. Experiences

*Adopted from work done by TC CCAC to define Palliative Complex Clients ** Assessments used by CCAC for complex clients

Advancing the Integration of Health Care Through Health Links P a g e | 52 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy Collaborative Care Framework Population Descriptions and Characteristics The following table provides client profiles from the Collaborative Care Framework.

High Medical/Low Psycho-Social High Medical / High Psycho-Social Complexity Complexity . Multiple medical conditions and . Multiple co-morbidities, multiple Complex medications medications . ED and hospital usage can be very . Multiple Emergency Department and high unless there is well engaged Inpatient admissions primary care . Difficulty in ADL, . Need for self-management and . Functional and cognitive impairments health literacy is high . Homebound, homeless or in . Require health system navigation for supportive housing / assisted living specialist management facilities . Service utilization varies with . Has difficulty accessing and exacerbation of disease maintaining relationship with engaged

Needs . Homebound primary care . Addiction and mental health issues . Social issues (housing, income, homelessness)

Low Medical/Low Psycho-Social Low Medical/High Psycho-Social Clients’ Medical Clients’ Complexity Complexity . Good overall health: fully functional . Lack health system knowledge, may and competent experience language isolation . May have single serious condition . New comers with limited which is well self-managed and opportunity/awareness to use health literate settlement supports . Have good social supports and can . May have some mild cognitive issues generally navigate the health system or mental health/Addictions issues on their own . May have other complicating . May require limited supports on socioeconomic issues: housing, income occasion and food security, unemployment,

socially isolated, poverty, abuse Low

Low Complex Clients’ Psycho Social Needs

Advancing the Integration of Health Care Through Health Links P a g e | 53 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy Suggested Changes to Descriptions or Characteristics Proposed by the CSS Health Links Working Group Working Group participants suggest a number of thoughts or ideas for consideration. High Medical/Low Psycho-Social complexity . ED and hospital usage bullet – need to add a point about strong engagement with CCAC and/or CSS agencies . System navigation should be expanded beyond specialist management, to also include multiple parts of the health care system and to other systems such as social services, legal etc. . Incorporate disability aspect by adding “high ADL and IADL needs” Low Medical/Low Psycho-Social Complexity . Point about a serious physical health issues which is always self-managed – this implies chronic illness that is stable. However, with “Serious” illness, there is often a chance of changes occurring. . Incorporate disability aspect by adding “Low ADL and IADL needs” High Medical / High Psycho-Social Complexity . Add a note that this group often encounters abuse due to their vulnerabilities . Incorporate disability aspect by adding “high ADL and IADL needs” Low Medical/High Psycho-Social Complexity . Incorporate disability aspect by adding “ High IADL, Low ADL needs “ Overall Framework . Incorporate contribution and impact of caregivers in the matrix. For high medical or high psychosocial clients, where caregivers are available, they may be overwhelmed, exhausted, perhaps ill themselves, experiencing adverse socioeconomic issues such as interrupted work, financial issues related to having to support care in the home etc. In some instances, caregivers may become abusive or client becomes abusive making it a very challenging situation.

Evolving Changes to the Definition and Assessment Criteria The definition and assessments of complex and at-risk populations will also be informed/refined using results emerging from different projects that are underway. Currently, complex clients served by the Collaborative Care group are assessed using the CCAC RAI-HC 18 point scale. With the increasing use of interRAI-CHA assessments for CSS clients, more data will become available to assess complexity of CSS clients using this data. The interRAI-CHA group (Dr. John Hirde’s team, including Leslie Eckel) are assisting TC LHIN to determine an algorithm to define complex populations by analyzing data from 5 TC LHIN agencies (interRAI-CHA data and data from Case Worker complexity assessments). As well, the group is working on developing a common algorithm to define complex populations across sectors using interRAI data. These results will help us to better determine the number of clients to be targeted and the needs of clients and they will be incorporated in the planning phase of this project.

Advancing the Integration of Health Care Through Health Links P a g e | 54 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy A9 Specialist Access Conceptual Model

A B Specialist receive referral directly Urgent from primary care provider as per Urgent Criteria Urgent Referral their instructions (e.g., electronic, Checklist Process phone, fax – with appropriate information). C D Note: All instructions are identified/ Referral controlled by a specialist/group Non-Urgent Specialist Language Waitlist Primary Instruction practice. Care Specialist Office books appoint and/ Provider or confirms details with primary care + office. Specialist are asked to meet a Patient service level agreement of responding to a primary care Situation: provider with an set time. Doctor wants to Goal will be to introduce automated send a patient to Specialist Office will periodically update scheduling tools to facilitate a specialist but is contact details. Over time, Offices will scheduling directly from Primary not sure who to provide scheduled updates for waitlist Care offices send them to, information. RM&R may be utilized. and may have some questions prior to referring

Situation: Urgent Referral. A process to validate the request is urgent will be supported by a defined criteria/checklist, after which a specialist is identified using the “Specialist Access Table” and a A different process is invoked to communicate the urgent request to the specialist to ensure timely referral and appointment scheduling.

Situation: Physician Consult. Doctor has ability to contact Specialist prior to referring the client for B selected specialities. The intent is to reduce potentially unnecessary referrals.

Situation: Non-Urgent. Doctor has access to a “Specialist Access Table” that provides an up-to-date, searchable list of specialists with additional key qualifying information to help the doctor decide C who they will refer to for non-urgent requests: language, location, special instructions for how to book, instructions for how to connect to specialist, next available appointment.

D Situation: Access to other new clinic models (e.g., group practice, telemedicine consult referrals)

Advancing the Integration of Health Care Through Health Links P a g e | 55 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy A10 Specialized Medical Imaging Conceptual Model

Doctor wants to send a patient to a MRI or CT but is not sure who to send A Electronic Order them to, and may Entry have some Appropriateness questions prior to Review referring

Primary Care B Medical Imaging Provider/ Call Centre Complete and Specialist + Reported Patient

Patient Flow Coordinator C

eConsult D

Situation: Electronic Order Entry with Appropriateness Review. A primary care physician or a specialist uses an electronic, web based application to order an MRI or CT, with appropriateness indicators that are based on A approved guidelines to ensure a procedure is required, and the right imaging procedure is selected. Order is directly communicated to the imaging site and a date/time is provided to the physician office. The result: efficient, timely, prioritized, appropriate referrals with little time wasted on phone or fax communications.

Situation: Call Centre. A primary care physician or specialist wishes to talk to an imaging centre to seek advice and support prior to ordering procedure. They are able to contact a call centre and speak to a person who is able B to answer their questions, and put them in contact with a radiologist to answer specific questions if required. The result: ensure the right decision is made in a timely manner reducing unnecessary delays.

Situation: Patient Flow Coordinator. A patient flow coordinator is available to ensure patients are put into the right queue through a triaging function, and assist in providing advice regarding appropriateness of procedures C for complex situations. The PFC is a single point of contact to get all information, assess needs as required, and escalate/re-prioritize as required. The result: complex situations have a clear escalation point to address needs.

Situation: eConsult. An eConsult option is an electronic tool to connect primary care physicians and specialists with radiologists in a rapid fashion to seek further advice from radiologist. Note: billing mechanisms for the D eConsult model have yet to be confirmed. The result: timely access to a radiologist to respond to questions resulting in less wait for patients and providers to determine next course of care.

Advancing the Integration of Health Care Through Health Links P a g e | 56 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy A11 Primary Care Health Links

Advancing the Integration of Health Care Through Health Links P a g e | 57 Final Report Submitted to the Toronto Central LHIN by CSI Consultancy