Leading Integrated Systems of Care: The Experience of the East Health Partners

Presenters: • Sarah Downey, CEO, Michael Garron Hospital • Anne Wojtak, Lead, East Toronto Health Partners

@CCHL_CCLS #BCHLC2020 Realizing Integrated Care The Canadian Context

Across Canada, provincial and regional jurisdictions are viewing integrated care as an opportunity to improve the delivery and how care is experienced by patients and their family caregivers

Within , integrated care and population health planning are areas that poised to support and enable health system improvement.

Under the new Ontario Health Team delivery model, health care providers will work as one coordinated team – focusing on the needs of patients at a local level. Patients and families see the healthcare system as 1 entity

But the design forces patients and families to deal with components separately

How do we address the gap? The goal of the Ontario Health Team strategy is to move us…

from this…. to this.

Mental Health & Acute Care Addictions

Primary Care Long-Term Care

Home Care Patients & Caregivers

Patients and caregivers will receive all their care Patients & Caregivers from an integrated team.

An Ontario Health Team: Introducing the East Toronto Health Partners

EAST TORONTO FAMILY PRACTICE NETWORK 6 Our Story…. Health Hubs SCOPE MGH Virtual Examples of what we’ve achieved together… Home 2Day Ward Home 2Day reduces LOS with same clinical outcomes and saves approx. $1,500 per patient Bundled Community Care Surge $1.5 M invested in community surge in 2018 and $1.8M in 2019

70 family physicians signed up to SCOPE since February 2019, with over 200 calls to HealthLinks Interprofessional the nurse navigator Neighbourhood Care Teams Shared staffing resources across the partners

Shared Learning Management Partnership recognized as an Accreditation Canada leading practice

Community Referrals to EMS started in East 2001 – Solutions - East Toronto Health Network Toronto and spread across Ontario

1996 – East Metro Health Group/Partners for Health 7 Who We Are

An Anchor Partnership model with an evolving network of health, community care and social service providers with a long history of delivering East Toronto solutions together.

Engaged Engaged Partners Partners Community Hospital Support and Long- and Mental Term Care Health Services

Supporting 300,000 residents in 21 neighbhourhoods

EasT-FPN Home Community Health Care Fami Centres Family Engaged Physicians Engaged Partners Partners8 Overall vision for our Ontario Health Team

East Toronto Health Partners Vision: A System without Discharges: A Seamless Continuum of Care that is Population Health- focused, with Programs Tailored to Local Communities

Chronic Disease Integrated Coordinated Neighbourhood Community Integrated Management Mental Health Home Care Care Teams Support Surge and Home 2 Day and Addictions Services Response

Streamlined Access and Navigation, Enabled by Digital and Virtual Care

Coordinated Governance, Resource and Performance Management

“The East Toronto Health Partners share a deep commitment to serve our communities better”

9 Who We Serve in East Toronto

Population (2016) 275,385 (22.4% of Toronto Central LHIN) Population Density: 6,394.9 ppl / km2

Child/Youth (age 0-19): 23.1% Seniors (ages 65+): 13.7%

21 Diverse Neighbourhoods 5 Designated Neighbourhood Improvement Areas: , , Oakridge, and Taylor- Massey ”Every challenge that we face is the opportunity to become something more than we’ve been before”

Lyena Strelkoff

11 Challenge/Opportunity #1

The emergence of organized primary care

12  To be the go-to voice for family practice physicians in East Toronto  The first formally organized network that captures the interests of previously unaffiliated family physicians  70% of family physicians (200,000 patients) in East Toronto signed a letter of support for EasT-

FPN; goal is to represent all 270+ local family physicians 13  An equal partner in the Governance of the ETHP Our Joint Venture Agreement

14 Challenge/Opportunity #2

Sharing Scarce Resources

15 Integrated Surge Response: A Collaborative Investment

In response to winter surge, East Toronto invested $1.5M into a range of hospital and community- based services to better meet the needs of our local community:

• Expanded primary care after-hours clinics at Albany Clinic and in Thorncliffe Park

• Community outreach to vulnerable populations including shelter and other settings

• Neighbourhood-based flu vaccinations in several supportive housing areas

• Support to congregate food security enabling continued food services

• Enhanced weekend home-care services streamlining transitions home on weekends

• Local reactivation services in the community with coordinated transition and home care

• Expanded emergency department services reducing wait times and hallway health care

• Initiation of Home 2 Day for COPD patients a new hospital at home model in East Toronto

16 Integrated Chronic Disease Management: Home 2 Day provides seamless virtual care, transitions and navigation for individuals

Initial Hospital Integrated Acute Care at Program Discharge Admission Home (> Day 2) (5-7 days later)

Community 24 hr Supports Day 2 • Inter- O2 Transition professional Family MD & • Multi- Specialist F/U 50% COPD Patients Provider Eligible • Virtual Care Reduced Surge Navigation Evidence-based Screening (2 beds/week) and Identification • Technology- Enabled Solutions

17 Neighbourhood Care Teams: Taylor Massey is a community with high sociodemographic needs, requiring a tailored local approach

33.1% of Seniors Living Alone* Taylor Compared to City of Toronto rate of 26.7% Massey 2016 Listed 445 Seniors from 65 to 85 and 70 people 80+

77.2% live in Apartments 5 stories or Above* Compared to City of Toronto rate of 44.3%

11.5% Unemployment rate* Compared to City of Toronto rate of 8.2% Economic family income by decile group

47.4% Report Very Good or Excellent Mental Health ^ Compared to City of Toronto Rate of 73.4%

8 Challenge/Opportunity #3

A global pandemic

19 Year 1 Priorities

1. Seniors with chronic disease and their caregivers 2. Youth mental health and wellness 3. Adults with issues of substance use and health

20 Year 1 Priorities

1. Seniors with chronic disease and their caregivers 2. Youth mental health and wellness 3. Adults with issues of substance use and health

21 The East Toronto Health Partners Integrated Approach to COVID-19

Mobile Transitioning Supporting at- Planning and Supporting Problem-Solving physician post-acute individuals risk seniors in assessment patients the Together in shelters Weekly joint team from EasT- … to retirement community FPN) embedded and group planning calls home/home Community hubs across OHT in COVID-19 homes with CHCs, assessment care engaged partners, partnership FHTS, home and centre to support CHCs and community care LTC and seniors in long- MGH leading providing virtual retirement homes, term care and And we have nowintegrated launched an Eastand in -person and Family retirement homes …to home andToronto school support plancare to seniors in Practice, COVID+ Remote community response to high-density support supported by Patient Monitoring care housing and EasT-FPN and Establishing vulnerable across the MGH IPAC Mobile adults, youth, community Assessment Centres in and families Hotspots East Toronto’s COVID-19 Path ETHP Priority Recalibration and Future 2nd State Planning MGH On-site Launch of Mobile COVID-19 ETHP Planning Session Assessment support at St Kew Gardens 1st Mobile Assessment 3rd Mobile Wave 2 and Flu Jan. 16, 2020 Centre Clair- Atrium site Assessment Site opens Assessment Surge Planning opens O’Connor LTC Apr 14 Site opens Jun 4 - Sharing progress Site opens Jun - Aug Mar 12 Mar 27 May 25 - Assessing our partnership model Jun 11 - Future state planning TODAY COVID-19 Lockdown Mar 14 Start of Joint MGH/EasT-FPN Outreach Centralized Launch st COVID planning Jan-Feb to 1 Emergency 1st ETHP st st School re- • Monitoring global data 1 COVID+ patient Shelter 1 Shelter ETHP.CA weekly PPE opening • Researching best practices admitted to MGH Apr 14 partner launched partner distribution support plan (e.g. assessment centres) Mar 26 call June 2 call for LTC, CHCs, Aug-Sep • First Coronavirus Apr 20 Mar 11 Primary Care preparedness meeting Jan Jun 8th 30 IPAC/ EasT-FPN/CHCs - LTC/Retirement/Congregate/Shelters/Group Homes Outreach

Weekly Partner Calls Primary Care, Expanding to LTC, Retirement Homes, Group Homes and Shelters, All East Toronto partners and schools (as of Aug)

Primary Care/Community Hub development for homebound/at risk populations across East Toronto COVID-19 has forced all of us to pause….and rethink our priorities 25