Appendix C: Environmental Scan

Socio-Demographic Profile

Notes: Analysis based on the 2006 and 2011 Census of Canada (Statistics Canada), 2011 National Household Survey, as well as population estimates and projections from the Ministry of Finance. Results are presented for Ontario and for Local Health Integration Networks (LHINs). ONTARIO

Demographics . Ontario is home to 13.8 million people, an increase of 5.1% since 2010. . Ontario’s population is projected to experience growth over the next 5 and 10 years, increasing 5.3% between 2015 and 2020 and 11.1% between 2015 and 2025. . Seniors aged 65 years and over represent 16.1% of the Ontario population. . In 2011, 69.3% of the population of Ontario lived in large urban population centres (100,000+), while 14.1% lived in rural areas. Across the province’s LHINs, the rural population ranged from 0% in Toronto Central to almost 45% in the South East LHIN. . The overall population density in Ontario was 14.1 persons per square kilometre, ranging from 0.5 for North West LHIN to and 5,984.6 persons per square kilometer for Toronto Central LHIN. Population characteristics . In 2011, 70% of the provincial population reported English and 4.4% reported French as their mother tongue. 2.3% of the population reported no knowledge of either official language. . In 2011, almost 30% of the Ontario population were immigrants and 4% were recent immigrants, having arrived in Canada between 2006 and 2011. Across the LHINs, the proportion of the population who were recent immigrants in 2011 ranged from 0.3% in the North East LHIN to 7.3% in the Central West LHIN. . Using the after-tax low income measure, the proportion of residents living in low-income households varied across the province, from 11.5% in the Waterloo Wellington and Mississauga Halton LHINs to 18.5% in Toronto Central. The proportion for Ontario was 13.9%.

Socio-demographic characteristics, Ontario Ontario Range across the LHINs Population, 2015 13,809,683 235,870 - 1,874,907 % population age 65+ 16.1% 12.1 - 21.2% % population age 75+ 7.1% 4.8 - 9.2%

Population growth, past 5 years (2010-2015) 5.1% -1.2 - 8.9% Projected population, 2020 14,546,659 235,955 - 2,030,737 Projected population, 2025 15,342,512 236,208 - 2,195,401 % growth forecasted, 2015-2020 5.3% -0.6 - 9.3% % growth forecasted, 2015-2025 11.1% -1.0 - 19.2%

% living in a rural area (2011) 14.1% 0 - 44.8% % living in a large urban centre (2011) 69.3% 19.3 - 100%

Socio-demographic characteristics (% population) English Mother Tongue 70.4% 51.7 - 91.9% French Mother Tongue 4.4% 1.2 - 23.2% No knowledge of English or French 2.3% 0.2 - 4.9% Immigrants 28.5% 5.6 - 48.6% Recent immigrants (2006 - 2011) 4.0% 0.3 – 7.3% Visible minorities 25.9% 1.8 - 57.3% Aboriginal identity 2.4% 0.5 – 18.3% Labour force participation rate (age 15+) 65.5% 59.7 – 69.8% C1

Unemployment rate, 2011 (age 15+) 8.3% 6.7 – 9.8% Without certificate/degree/diploma (age 25-64) 11.0% 7.0 – 16.0% Completed post-secondary education (age 25-64) 64.8% 57.0 – 47.1% Living in low-income 13.9% 11.5 – 18.5%

North Simcoe Muskoka LHIN

Demographics . The North Simcoe Muskoka LHIN is home to just under 475,700 people, or 3.4% of the population of Ontario. . 38% of the population of the LHIN lived in a large urban population centre (100,000+), while 32% lived in a rural area. 31% of LHIN residents lived in Barrie. . Between 2010 and 2015, the population of the LHIN increased by 5.5%, similar to the provincial growth rate of 5.1%. . Seniors (aged 65+) accounted for 19% of North Simcoe Muskoka LHIN residents, an increase from 16% in 2006. . The LHIN’s population is projected to increase by 5.1% between 2015 and 2020 and 10.7% between 2015 and 2025. These growth rates are comparable to those for Ontario for the same time periods.

Population characteristics . Among all LHINs, North Simcoe Muskoka LHIN had the 2nd largest proportion (90.2%) of residents who reported English as their mother tongue. 2.8% of LHIN residents reported French was their mother tongue in 2011, while 0.3% reported having no knowledge of either English or French. . In 2011, 10.4% of North Simcoe Muskoka LHIN residents were immigrants, compared to 28.5% for Ontario. Less than 1% of LHIN residents were recent immigrants, having arrived in Canada between 2006 and 2011. . Only 4.1% North Simcoe Muskoka LHIN residents were visible minorities, compared to 25.9% in Ontario overall. . Compared with Ontario residents aged 25-64, a smaller proportion of North Simcoe Muskoka LHIN residents had completed post-secondary education. . The proportion of North Simcoe Muskoka LHIN residents who lived in low-income households (12.0%) was smaller than the provincial average (13.9%).

Socio-demographic characteristics, North Simcoe Muskoka (NSM) LHIN NSM LHIN Ontario Comments†

Population, 2015 475,676 13,809,683 2rd smallest % population age 65+ 18.8% 16.1% % population age 75+ 8.2% 7.1%

Population growth, past 5 years (2010-2015) 5.5% 5.1% Projected population, 2020 500,151 14,546,659 2rd smallest Projected population, 2025 526,486 15,342,512 3rd smallest % growth forecasted, 2015-2020 5.1% 5.3% % growth forecasted, 2015-2025 10.7% 11.1%

% living in a rural area (2011) 32.0% 14.1% 3rd largest % living in a large urban centre (2011) 37.9% 69.3% 3rd lowest

Socio-demographic characteristics (% population) English Mother Tongue 90.2% 70.4% 2nd highest French Mother Tongue 2.8% 4.4% No knowledge of English or French 0.3% 2.3% 3rd lowest Immigrants 10.4% 28.5% Recent immigrants (2006-2011) 0.8% 4.0% Visible minorities 4.1% 25.9% Aboriginal identity 4.3% 2.4% 3rd largest Labour force participation rate (age 15+) 64.5% 69.5% Unemployment rate, 2011 (age 15+) 8.5% 8.3% Without certificate/degree/diploma (age 25-64) 12.1% 11.0% Completed post-secondary education (age 25-64) 59.5% 64.8% Living in low-income 12.0% 13.9% C2

†Ranking in the province, compared to other LHINs.

Births and Mortality

Notes: This document and the accompanying workbook contain analysis of births and maternal outcomes from the Better Outcomes Registry & Network (BORN) Ontario, and the Canadian Institute for Health Information (CIHI); and analysis of mortality and potential years of life lost (PYLL) using data from Statistics Canada and the Ontario Registrar General.

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Births and Maternal Outcomes . In FY 2011/12 there were 139,386 births in Ontario hospitals to Ontario women. . Provincially, 3.2% of the women who gave birth were under 20 years of age and 22.0% were aged 35 years or older. These proportions varied greatly across LHINs. In North West LHIN, 10.9% of women giving birth were under 20 years age, compared to 1.1% in Mississauga Halton LHIN. In Toronto Central LHIN, 33.4% of women giving birth were 35 years or older, compared with 10.8% of women in North East LHIN. Teen mothers and their infants may be at greater risk for pre-term deliveries 229-943 and/or low birth weight and increased perinatal mortality due to factors such as inadequate prenatal care, increased likelihood of social deprivation, drug use and smoking, poor nutrition resulting in poor maternal weight gain and anemia and premature termination of education. Higher maternal age is associated with increased maternal morbidity (including gestational hypertension and diabetes), Caesarean delivery, multiple gestation pregnancy, and adverse pregnancy outcomes (including chromosomal abnormalities, miscarriage, low birth weight, being small for gestational age, pre-term birth, perinatal mortality, and serious neonatal morbidity). . In FY 2011/12, Caesarean deliveries accounted for 28.4% of all births. The highest rate of Caesarean deliveries occurred in the Central West LHIN (32.3%) and the lowest rate was found in the South West LHIN (23.4%). In addition to Central West LHIN, three other LHINs also had rates of Caesarean delivery of 30% or higher (Toronto Central, North Simcoe Muskoka, and North East). The rate of Caesarean deliveries has important implications on service requirements and capacity issues. . In Ontario, women have a range of care providers whom attend hospital births. Provincially, most hospital births were attended by an obstetrician (84.7%) although this varied greatly among the LHINs, ranging from 41.2% in the North West LHIN to 93.1% in the Erie St. Clair LHIN. Family physicians attended 8.6% of hospital births provincially and this also varied greatly among the LHINs with the largest proportion of family physician hospital births occurring in the North West LHIN (43.7%) and the smallest proportion occurring in the Erie St. Clair LHIN (2.2%). Provincially, 5.2% of women had their hospital birth attended by a midwife, with the highest proportion of midwife-attended births occurring in the North West LHIN (12.2%) and the lowest occurring in the Central West LHIN (2.8%). . 8.0% of births in Ontario hospitals were pre-term (less than 37 weeks gestation) ranging from 5.7% (in Waterloo Wellington) to 11.5% (in Toronto Central). Babies who are born pre-term are more likely to die or experience health problems during the first year after birth. There are immediate costs associated with intensive hospital care that is required at birth, as well as additional costs related to long‐term complications such as respiratory problems, motor and sensory impairment, and neurocognitive impairment. . Provincially, 9.4% of newborns were classified as “small for gestational age”, and 10.0% were “large for gestational age”. Infants who are small for gestational age are at increased risk for morbidity and mortality in the perinatal period, childhood, adolescence, and beyond. Infants who are large for gestational age are associated with adverse perinatal outcomes such as episiotomy, operative vaginal delivery, Caesarean delivery, shoulder dystocia, infant fracture, and brachial plexus injuries in the newborn. . Provincially, the rate of exclusive breastfeeding at discharge among term live births was 63.2% with the highest proportion in the Central East LHIN (73.6%) and the lowest proportion found in the Central West LHIN (48.2%). Breastfeeding offers numerous short term and long‐term benefits for infants (e.g., growth, immunity, and cognitive development) and for mothers (e.g., reduced postpartum bleeding, delayed resumption of ovulation, and improved bone demineralization. . The 30-day obstetric readmission rate for Ontario residents was 1.7% but ranged from a low of 1.1% for Erie St. Clair LHIN residents to a high of 2.7% for North West LHIN residents. . Births and Maternal Outcomes 2011/12 Indicator ONTARIO Range across LHINs Total births in Ontario hospitals to Ontario women 139,386 2,448 - 20,432 Distribution of maternal age (%) < 20 3.2 1.1% - 10.9% ≥ 35 22.0 10.8% - 33.4% Rate of Caesarean delivery (%) 28.4 23.4% - 32.3% Distribution of care provider who attended the hospital birth (%) Obstetrician 84.7 41.2% - 93.1% Family physician 8.6 2.2% - 43.7% Midwife 5.2 2.8% - 12.2% C3

Rate of pre-term birth (< 37 weeks) (%) 8.0 5.7% - 11.5% % births small for gestational age 9.4 6.8% - 11.7% % births large for gestational age 10.0 7.7% - 16.3% Rate of exclusive breastfeeding at discharge among term live births (%) † 63.2 48.2% - 73.6% 30-day obstetric readmission rate, LHIN of patient (%) 1.7 1.1% - 2.7% † Between 10% and 30% of records and missing information were excluded from calculations in HNHB and Central West LHINs. Individual hospitals in Waterloo Wellington, Toronto Central, Central, Central East, and North East LHIN that did not collect information on breastfeeding at discharge from hospital or had more than 30% of missing records on this variable and were excluded from the denominator used for these calculations.

Maternal smoking, alcohol and drug use during pregnancy among all women who live in Ontario and who had a live birth or stillbirth (LHIN of maternal residence), 2013/14 (BORN) . In 2013 there were 138,120 births in Ontario to women who were Ontario residents regardless of birth location (hospital, home, birth centre, other) †. . Provincially, the rate of women who reported smoking at first prenatal visit was 10.8% (n= 13,173) with the highest proportion in the North West LHIN (34.7%) and lowest proportion found in the Central LHIN (3.5%) (with the exception of the Mississauga Halton LHIN)††. . The prevalence of smoking at first prenatal visit ≥20, 10-19, and 1-9 cigarettes per day were 0.6 percent, 3.6 percent, and 6.0 percent, respectively. . 89.2% (n= 108,619) of the women were nonsmokers in their first prenatal visit. . The proportion of women who reported smoking at time of admission was 8.4% (n=11,330) with the highest proportion in the North West LHIN (30.9%) and lowest proportion in the Central LHIN (2.5%). . The prevalence of smoking at admission for birth ≥20, 10-19, and 1-9 cigarettes per day were 0.4 percent, 2.8 percent, and 4.8 percent, respectively. . 91.6% (n=122,876) of the women were nonsmokers at time of admission for birth. The rate has increased since at first prenatal visit by 13.1% from 108,619 to 122,876††. . 1.6% (n=2,072) of the women reported drinking alcohol and 2.0% (n=2,610) using drugs during pregnancy. . There is a considerable variation across LHINs in the proportion of women who reported drinking alcohol and using drugs. The proportion was lowest in the Central LHIN (0.7% and 0.6%, respectively) and highest in the North West LHIN (5.3% and 13.4%, respectively).

Maternal smoking at first prenatal visit ONTARIO Range across LHINs All pregnancies with live birth or stillbirth (LHIN of residence) † 121,792 2,490-16,874 Number of women who reported smoking >20 cigarettes/day 765 11-142 % women who reported smoking >20 cigarettes/day 0.6% 0.1% -1.5% Number of women who reported smoking 10-20 cigarettes/day 4,352 61-691 % women who reported smoking 10-20 cigarettes/day 3.6% 0.5% -9.6% Number of women who reported smoking <10 cigarettes/day 7,288 229-943 % women who reported smoking <10 cigarettes/day 6.0% 1.8% -23.6% Number of women who reported unknown amount of cigarettes smoked/day 768 8-163 % women who reported unknown amount of cigarettes smoked/day 0.6% 0.2% -1.3% Number of nonsmokers 108,619 1,626-16,276 % nonsmokers 89.2% 65.3% -96.5% Maternal smoking at time of admission All pregnancies with live birth or stillbirth (LHIN of residence)* 134,206 2,483-16,865 Number of women who reported smoking >20 cigarettes/day 593 9-109 % women who reported smoking >20 cigarettes/day 0.4% 0.1% -1.2% Number of women who reported smoking 10-20 cigarettes/day 3,703 40-605 % women who reported smoking 10-20 cigarettes/day 2.8 0.3% -8.3% Number of women who reported smoking <10 cigarettes/day 6,407 177-783 % women who reported smoking <10 cigarettes/day 4.8 1.3% -22.3% Number of women who reported unknown amount of cigarettes smoked/day 627 8-133 % women who reported unknown amount of cigarettes smoked/day 0.5 0.2% -1.0% Number of nonsmokers 122,876 1,715-16,438 % nonsmokers 91.6 69.1% -97.5% Self-reported consumption of alcoholic beverages during pregnancy All pregnancies with live birth or stillbirth (LHIN of residence)* 129,793 2,442-16,757 Number of women who self-reported consumption of alcoholic beverages 2,072 80-360 % women who self-reported consumption of alcoholic beverages 1.6 0.7% -5.3% Self-reported drug and substance use during pregnancy All pregnancies with live birth or stillbirth (LHIN of residence)* 130,158 2,438-16,967 Number of women who self-reported drug or substance use 2,610 95-326 % women who self-reported drug or substance use 2.0 0.6% -13.4% All pregnancies for women who were Ontario residents were included regardless of birth location (hospital, home, birth centre, other). †Records with missing values for any variables required to calculate the denominator were excluded. C4

The sum of the LHIN pregnancies will not add up to the Ontario total. Missing LHIN of maternal residence is due to missing maternal address or unmatched postal code and are included into ON total. †† The Mississauga Halton LHIN had >30% of records with missing information on maternal smoking at first prenatal visit therefore were excluded from the analysis.

Mortality and PYLL . 88,967 Ontario residents died in 2011, an increase of 2.3% in the number of deaths from 2007. . The crude all-cause mortality rate in 2011 was 670.8 per 100,000 population for Ontario residents; a decrease of 1.3% since 2007. Across the LHINs, this rate decreased by 9.4% for Champlain LHIN residents and increased by 15.6% for North West LHIN residents. . The leading causes of death for Ontario residents overall were ischaemic heart disease, dementia and Alzheimer disease, and cancer of lung & bronchus. The top 10 causes of death accounted for 54.0% of the total deaths in Ontario. . 37.2% of Ontario residents’ deaths in 2011 were premature (occurred in those aged younger than 75 years). . In 2011, 536,071 potential years of life were lost by Ontario residents. Potential years of life lost (PYLL) is an estimate of the average years a person would have lived if they had not died prematurely. A premature death is considered one before the age of 75, so a death at the age of 55 represents 20 ‘potential’ years of life lost. High PYLL rates indicate elevated levels of premature mortality. There was a decrease of 3.4% in PYLL in 2011 since 2007 for Ontario residents. . The PYLL rate per 100,000 population aged less than 75 was 4,327.0 in 2011 for Ontario residents, ranging from 2,963.9 for Central LHIN residents to 7,437.7 for North West LHIN residents. . The leading causes of PYLL for Ontario residents in 2011 were ischaemic heart disease, cancer of lung & bronchus, and intentional self-harm. . For Ontario residents in 2011, ischaemic heart disease was the leading cause of both death and PYLL.

Mortality and Potential Years of Life Lost Ontario Range in LHINs Mortality, 2011 Total deaths, 2011 88,967 2,189 – 11,314 % change in total deaths (2007-2011) 2.3% -6.9% - 13.8% All-cause mortality rate per 100,000 population 670.8 413.8 - 929.7 % change in all-cause mortality rate (2007-2011) -1.3% -9.4% - 15.6% % of deaths that were premature (age < 75) 37.2% 33.7% - 44.7% Top 10 leading causes of death, 2011 (rates per 100,000 population) Ischaemic heart disease 97.5 50.7 - 149.3 Dementia and Alzheimer disease 52.9 31.3 - 69.3 Cancer of lung & bronchus 49.1 27.5 - 84.5 Cerebrovascular diseases 37.1 25.0 - 50.5 Chronic lower respiratory diseases 28.6 14.7 - 52.4 Cancer of colon, rectum, anus 24.2 12.8 - 32.8 Diabetes 21.6 11.7 - 36.7 Cancer of lymph, blood & related 19.7 9.7 - 26.1 Falls 16.1 8.6 - 21.9 Influenza and pneumonia 15.7 9.8 - 22.7 Potential years of life lost (PYLL), 2011 Total PYLL, 2011 536,071 16,385 – 63,592 % change in PYLL (2007-2011) -3.4% -8.1% - 16.2% PYLL rate per 100,000 population (age < 75) 4,327.0 2,963.9 – 7,437.7 % change in PYLL rate (2007-2011) -6.5% -10.5% - 18.3% Top 10 leading causes of PYLL, 2011 (rates per 100,000 population, age < 75) Ischaemic heart disease 395.0 200.4 - 655.6 Cancer of lung & bronchus 320.0 180.7 - 626.1 Intentional self-harm 269.4 166.7 - 782.6 Perinatal conditions 241.1 117.1 - 454.1 Accidental poisoning 164.8 67.0 - 589.2 Transport accidents 147.6 29.6 - 420.8 Cancer of colon, rectum, anus 146.1 89.3 - 204.7 Cancer of breast 143.0 100.5 - 234.2 Cancer of lymph, blood & related 137.3 92.6 - 182.3 Cirrhosis and other liver diseases 131.2 57.3 - 265.1 Note: In the 2011 death file from Statistics Canada, 4% of postal codes for Ontario residents were missing; this is compared to a negligible percentage of missing data since they started using postal codes to assign municipality of residence in 2008. Consequently, all the geographic fields that are derived from postal code or municipality (including LHINs) have a higher percentage of missing data in 2011.

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North Simcoe Muskoka LHIN

Births and Maternal Outcomes . In FY 2011/12, there were 4,068 births in North Simcoe Muskoka LHIN hospitals. . 5.0% of women who gave birth in the LHIN were under 20 years of age. 15.9% were aged 35 or older when they gave birth, which was lower than provincial average. . The rate of Caesarean deliveries (31.3%) was the third highest in the province. . 74.6% of hospital births were attended by an obstetrician, which was the third lowest proportion among all LHINs and lower than the provincial average. The proportion of births attended by a family physician (16.7%) was greater than the provincial average and was the third highest in the province. . The rate of pre-term deliveries (6.9%) was lower than the provincial rate. . Both the percentages of newborns classified as “small for gestational age” (8.0%) and those classified as “large for gestational age” (11.5%) were similar to the province percentages (9.4% and 10%, for “small for gestational age” and “large for gestational age”, respectively). . The rate of exclusive breastfeeding in the LHIN was more than 70%, which was higher than the provincial rate. . The 30-day obstetric readmission rate (1.8%) for LHIN residents was similar to the provincial rate (1.7%).

Births and Maternal Outcomes 2011/12 Indicator North Simcoe Muskoka LHIN Ontario Total births in North Simcoe Muskoka LHIN hospitals 4,068 139,386 Distribution of maternal age (%) < 20 5.0 3.2 ≥ 35 15.9 22.0 Rate of Caesarean delivery (%) 31.3 28.4 Distribution of care provider who attended the hospital birth (%) Obstetrician 74.6 84.7 Family physician 16.7 8.6 Midwife 5.8 5.2 Rate of pre-term birth (< 37 weeks) (%) 6.9 8.0 % births small for gestational age 8.0 9.4 % births large for gestational age 11.5 10.0 Rate of exclusive breastfeeding at discharge among term live births (%) † 70.6 63.2 30-day obstetric readmission rate, LHIN of patient (%) 1.8 1.7 † Between 10% and 30% of records and missing information were excluded from calculations in HNHB and Central West LHINs. Individual hospitals in Waterloo Wellington, Toronto Central, Central, Central East, and North East LHIN that did not collect information on breastfeeding at discharge from hospital or had more than 30% of missing records on this variable and were excluded from the denominator used for these calculations.

Maternal smoking, alcohol and drug use during pregnancy among all women who live in Ontario and who had a live birth or stillbirth (LHIN of maternal residence), 2013/14 (BORN) . In 2013 there were 3,982 births in North Simcoe Muskoka LHIN to women who were Ontario residents regardless of birth location (hospital, home, birth centre, other) †. . North Simcoe Muskoka LHIN had the highest proportion (ranked 10th) of women who reported smoking at first prenatal visit (17.2%) among all LHINs (with the exception of the MH LHIN) ††. . The prevalence of smoking at first prenatal visit ≥20, 10-19, and 1-9 cigarettes per day were 1.2 percent, 6.1 percent, and 9.3 percent, respectively. . 82.8% of the women were nonsmokers in their first prenatal visit, which was slightly lower than the provincial average (89.2%) (with the exception of the MH LHIN) ††. . The proportion of women who reported smoking at time of admission was 14.7%, compared to 8.4% for the province and the highest (ranked 4th) among all LHINs. The rate has decreased since the first prenatal visit (decrease of-2.5 percentage points). . The prevalence of smoking at admission for birth ≥20, 10-19, and 1-9 cigarettes per day were 0.9 percent, 5.4 percent, and 8.0 percent, respectively. The prevalence has slightly decreased since the first prenatal visit (decrease of -0.3, -0.7, and -1.3 percentage points, respectively). . 85.3% of the women were nonsmokers at time of admission for birth. The rate has increased since the first prenatal visit (increase of 2.5 percentage points). . The women who reported drinking alcohol and using drugs during pregnancy were 2.5% and 3.6%, compared to 1.6% and 2.0% for the province, respectively.

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North Simcoe Maternal smoking at first prenatal visit Ontario Muskoka LHIN All pregnancies with live birth or stillbirth (LHIN of residence) † 3,982 121,792 Number of women who reported smoking >20 cigarettes/day 46 765 % women who reported smoking >20 cigarettes/day 1.2 0.6% Number of women who reported smoking 10-20 cigarettes/day 244 4,352 % women who reported smoking 10-20 cigarettes/day 6.1 3.6% Number of women who reported smoking <10 cigarettes/day 370 7,288 % women who reported smoking <10 cigarettes/day 9.3 6.0% Number of women who reported unknown amount of cigarettes smoked/day 23 768 % women who reported unknown amount of cigarettes smoked/day 0.6 0.6% Number of nonsmokers 3,299 108,619 % nonsmokers 82.8 89.2% Maternal smoking at time of admission All pregnancies with live birth or stillbirth (LHIN of residence) † 3,977 134,206 Number of women who reported smoking >20 cigarettes/day 35 593 % women who reported smoking >20 cigarettes/day 0.9 0.4% Number of women who reported smoking 10-20 cigarettes/day 214 3,703 % women who reported smoking 10-20 cigarettes/day 5.4 2.8 Number of women who reported smoking <10 cigarettes/day 319 6,407 % women who reported smoking <10 cigarettes/day 8.0 4.8 Number of women who reported unknown amount of cigarettes smoked/day 15 627 % women who reported unknown amount of cigarettes smoked/day 0.4 0.5 Number of nonsmokers 3,394 122,876 % nonsmokers 85.3 91.6 Self-reported consumption of alcoholic beverages during pregnancy All pregnancies with live birth or stillbirth (LHIN of residence) † 3,934 129,793 Number of women who self-reported consumption of alcoholic beverages 98 2,072 % women who self-reported consumption of alcoholic beverages 2.5 1.6 Self-reported drug and substance use during pregnancy All pregnancies with live birth or stillbirth (LHIN of residence) † 3,946 130,158 Number of women who self-reported drug or substance use 143 2,610 % women who self-reported drug or substance use 3.6 2.0 †Records with missing values for any variables required to calculate the denominator were excluded. †† Mississauga Halton LHIN had >30% of records with missing information on maternal smoking at first prenatal visit therefore were excluded from the analysis.

Mortality and Potential Years of Life Lost . 3,471 North Simcoe Muskoka LHIN residents died in 2011. . The all-cause mortality rate for LHIN residents has decreased since 2007 but is higher than the provincial rate (763.8 versus 670.8 per 100,000). . The leading causes of death for LHIN residents in 2011 were ischaemic heart disease, dementia and Alzheimer disease, and cancer of lung and bronchus. The top 10 causes of death accounted for 56.4% of all resident deaths of this LHIN. All but one (influenza and pneumonia) of the top 10 specific-cause mortality rates for LHIN residents were higher than the Ontario rates. The mortality rate for colorectal cancer and dementia and Alzheimer were the third highest for LHIN residents among all LHINs. . 38.5% of resident deaths were premature in this LHIN in 2011. This percentage was similar to that for Ontario residents (37.2%). . In 2011, 19,827 years of potential life were lost by LHIN residents. . The 2011 PYLL rate for LHIN residents was 4,714.7 per 100,000 population aged less than 75 years. The PYLL rate decreased by 9.2% since 2007. In contrast, the PYLL rate for Ontario residents decreased by 6.5% since 2007. . The leading causes of PYLL for residents of this LHIN were cancer of lung and bronchus, ischaemic heart disease, and intentional self-harm. Many of the top 10 cause-specific PYLL rates for North Simcoe Muskoka residents were greater than the Ontario rates. In particular, the PYLL rates for diabetes and chronic lower respiratory diseases for LHIN residents were the second and third highest in the province, respectively.

Mortality and Potential Years of Life Lost, 2011 North Simcoe Ontario Comment Muskoka LHIN Mortality Total deaths, 2011 3,471 88,967 % change in total deaths (2007-2011) -1.3% 2.3% All-cause mortality rate per 100,000 population 763.8 670.8 % change in all-cause mortality rate (2007-2011) -3.9% -1.3% % of deaths that were premature (age < 75) 38.5% 37.2% Top 10 leading causes of death, (rates per 100,000 population) Ischaemic heart disease 117.1 97.5 C7

Dementia and Alzheimer disease 64.0 52.9 3rd highest in province Cancer of lung & bronchus 61.8 49.1 Cerebrovascular diseases 38.7 37.1 Chronic lower respiratory diseases 37.4 28.6 Cancer of colon, rectum, anus 30.8 24.2 3rd highest in province Diabetes 30.6 21.6 Cancer of lymph, blood & related 20.2 19.7 Cancer of breast 15.8 14.7 Influenza and pneumonia 14.3 15.7 Potential years of life lost (PYLL) Total PYLL, 2011 19,827 536,071 % change in PYLL (2007-2011) -7.3% -3.4% PYLL rate per 100,000 population (age < 75) 4,714.7 4,327.0 % change in PYLL rate (2007-2011) -9.2% -6.5% Top 10 leading causes of PYLL, (rates per 100,000 population, age < 75) Cancer of lung & bronchus 469.4 320.0 Ischaemic heart disease 452.8 395.0 Intentional self-harm 352.9 269.4 Transport accidents 198.1 147.6 Perinatal conditions 196.1 241.1 Diabetes 187.9 104.6 2nd highest in province Cancer of colon, rectum, anus 183.6 146.1 Accidental poisoning 161.7 164.8 Cancer of breast 137.0 143.0 Chronic lower respiratory diseases 126.0 78.4 3rd highest in province Note: In the 2011 death file from Statistics Canada, 4% of postal codes for Ontario residents were missing; this is compared to a negligible percentage of missing data since they started using postal codes to assign municipality of residence in 2008. Consequently, all the geographic fields that are derived from postal code or municipality (including LHINs) have a higher percentage of missing data in 2011.

General Health, Risk Factors, and Prevention

Notes: This document and the accompanying workbook contain analyses based on the Canadian Community Health Survey (CCHS). The target population of the CCHS annual survey is Canadians aged 12+. Individuals living on Aboriginal Reserves and on Crown lands, institutional residents, full-time members of the Canadian Forces and residents of certain remote regions are excluded.

ONTARIO

General Health . In 2013, 60% of Ontarians said they had very good or excellent health and 71% reported very good or excellent mental health. The proportion of those reporting very good or excellent mental health has declined over the examined time period for most LHINs. . 23% of Ontarians reported that most days were ’quite a bit’ or ’extremely’ stressful. . 14% of Ontarians reported experiencing moderate or severe pain/discomfort, and 31% reported activity limitations because of long-term physical or mental health problems. . 91% of Ontarians reported having a regular medical doctor, but this ranged from 83% in North West LHIN to 95% in South East LHIN. . Although 31% of people received a flu shot in the year preceding the survey, this percentage has been decreasing over time. In 2005, 42% of people reported getting the flu shot. Risk Factors . 18% of Ontario residents reported daily or occasional smoking in 2013. Smoking rates varied by LHIN from 12% in Central West LHIN to 24% in HNHB LHIN. Smoking rates have been declining over time. . 17% of Ontarians reported heavy drinking. Heavy drinking is defined as having consumed 5 or more drinks on an occasion for males or 4 or more drinks for women, at least once a month during the past year. . 54% of Ontarians were either overweight or obese and 46% were physically inactive. . 61% of Ontario residents did not consume enough fruits and vegetables (i.e., had fewer than 5 servings of fruits or vegetables daily.) . These risk factors contribute to many cancers and chronic conditions including heart disease, stroke, COPD, diabetes, and osteoarthritis.

General health, risk factor prevalence: Ontario (2013) Range across Trend over % of population, age 12+ Ontario LHINs time Very good or excellent self-perceived health 60.0 56.9-61.6 - Very good or excellent self-perceived mental health 70.9 65.4-76.3 unfavourable C8

Days that are ‘quite a bit’ or ‘extremely’ stressful (age 15+) 23.4 18.4-27.1 - With moderate or severe pain/discomfort 13.5 9.2-19.0 - With participation/activity limitations sometimes/often 31.3 23.3-37.5 - Have a regular medical doctor 91.0 82.7-95.2 - Received flu shot in the past year 31.2 24.2-40.8 unfavourable Risk Factors Are daily or occasional smokers 18.0 12.4-24.0 favourable Are heavy drinkers 17.2 12.4-25.2 - Are overweight or obese (age 18+) 53.5 42.8-65.2 unfavourable Are physically inactive 45.6 40.2-50.6 favourable Consume < 5 servings of fruits/vegetables daily 60.8 57.1-65.2 unfavourable

North Simcoe Muskoka LHIN

General Health . 61% of North Simcoe Muskoka residents reported very good or excellent health and 71% reported very good or excellent mental health. These rates are similar to those for Ontario. . 27% of LHIN residents reported that most days were ‘quite a bit’ or ‘extremely’ stressful, which was higher than the provincial average (23%). . 17% of North Simcoe Muskoka LHIN residents reported that they usually experience moderate or severe pain/discomfort and 36% experienced activity limitations because of long-term physical or mental health problems. These rates were elevated relative to those for Ontario. . 94% of North Simcoe Muskoka LHIN residents reported having a regular medical doctor. . 32% of LHIN residents reported that they had received a flu shot in the past year. Risk Factors . Approximately 23% of North Simcoe Muskoka LHIN residents were smokers and 22% were heavy drinkers and these proportions were the 3rd highest among all LHINs. . North Simcoe Muskoka LHIN had the 2nd lowest proportion of residents who were physically inactive (42%) among the 14 LHINs. 54% of North Simcoe LHIN residents were overweight or obese, which was comparable to the provincial average. . 63% of North Simcoe Muskoka LHIN residents reported inadequate consumption of fruits and vegetables.

General health, risk factor prevalence: North Simcoe Muskoka LHIN (2013) North Simcoe LHIN Rank LHIN Trend % of population, age 12+ Ontario Muskoka LHIN (1-14) over time Very good or excellent self-perceived health 61.4 60.0 4 - Very good or excellent self-perceived mental health 71.0 70.9 6 - Days that are ‘quite a bit’ or ‘extremely’ stressful 27.1 23.4 14 unfavourable (age 15+) With moderate or severe pain/discomfort 16.9 13.5 12 - With participation/activity limitations sometimes/often 36.1 31.3 11 - Have a regular medical doctor 93.9 91.0 3 - Received flu shot in the past year 32.4 31.2 8 unfavourable Risk Factors Are daily or occasional smokers 22.8 18.0 12 - Are heavy drinkers 22.2 17.2 12 - Are overweight or obese (age 18+) 54.4 53.5 7 - Are physically inactive 41.6 45.6 2 - Consume < 5 servings of fruits/vegetables daily 62.8 60.8 11 unfavourable ↑ LHIN result is significantly higher than Ontario. ↓ LHIN result is significantly lower than Ontario. Ranks: Low ranks (e.g., 1) is ‘better’ Appendix: Prevalence of risk factors across LHIN areas, 2013, population age 12+ % of the population age 12+ 4. 12. with… 1. ESC 2. SW 3. WW HNHB 5. CW 6. MH 7. TC 8. CEN 9. CE 10. SE 11. CH NSM 13. NE 14. NW ONT Very good or excellent self-perceived 59.8 61.6 61.2 57.1 61.6 59.0 61.6 60.0 57.7 61.2 61.2 61.4 56.9 58.8 60.0 health Very good or excellent self-perceived 73.9 69.3 70.7 70.8 76.3↑ 69.6 67.4 74.9 66.5 72.4 70.3 71.0 72.5 65.4 70.9 mental health Days that are ‘quite a bit’ or ‘extremely’ 18.4↓ 19.4↓ 22.5 22.8 24.8 25.7 26.5 24.3 19.7 25.0 24.9 27.1 20.8 20.7 23.4 stressful (age 15+) C9

With moderate or severe 11.9 14.1 14.5 16.6↑ 9.2↓ 9.5↓ 10.3 9.9↓ 19.0↑ 15.6 13.2 16.9 18.6↑ 14.8 13.5 pain/discomfort With participation/activity limitations 29.9 33.6 35.3 34.9 23.3↓ 24.1↓ 30.7 24.5↓ 36.1 37.5↑ 32.5 36.1 37.4↑ 35.8 31.3 sometimes/often Have a regular medical doctor 89.7 93.1 93.1 94.3↑ 93.3 92.5 85.6↓ 91.9 92.3 95.2↑ 87.2↓ 93.9 84.5↓ 82.7↓ 91.0 Received flu shot in the past year 34.0 36.7↑ 25.2↓ 32.2 26.0↓ 24.2↓ 32.5 28.4 29.1 40.7↑ 35.1 32.4 36.8↑ 40.8↑ 31.2 Risk Factors Are daily or occasional smokers 18.3 17.9 18.9 24.0↑ 12.4↓ 15.6 18.9 15.4 15.9 21.02 17.6 22.8 21.3 23.6↑ 18.0 Are heavy drinkers 19.4 21.5↑ 20.6 16.0 12.4 16.9 24.0↑ 9.3↓ 14.1 18.9 18.1 22.2 21.8↑ 25.2↑ 17.2 Are overweight or obese (age 59.8↑ 59.9↑ 51.7 55.1 56.1 53.0 42.8↓ 50.7 51.4 60.4↑ 51.3 54.4 62.0↑ 65.2↑ 53.5 18+) Are physically inactive 50.6 48.6 42.5 43.8 53.9↑ 45.4 42.3 46.6 48.0 45.7 43.9 41.6 43.1 40.2 45.6 Consume < 5 servings of 63.9 60.3 60.6 62.0 59.4 58.9 57.1 60.8 65.2 58.5 59.3 62.8 62.3 64.3 60.8 fruits/vegetables daily 1 Heavy drinking refers to consuming 5 or more drinks on one occasion (4 for women), at least once a month in the past year. † Estimates with high sampling variability (CV between 16.6 -33.3) - must be used with caution. F - Estimates with CVs greater than 33.3% are too unreliable to be published and have been suppressed due to extreme sampling variability. . Missing data Significance testing: LHINs are compared to Ontario (↑ higher; ↓lower)

Chronic Conditions: Prevalence, mortality, hospital separations and hospital days of stay for selected chronic conditions

Notes: Analysis is based on data from the Canadian Community Health Survey, the Discharge Abstract Database (acute separations and total acute days), and mortality data from Statistics Canada and the Ontario Registrar General. Analysis is provided for: arthritis (arthritis & related conditions-in the mortality/hospital analysis), asthma, cancer, congestive heart failure (CHF)-in the mortality/hospital analysis only, chronic obstructive pulmonary disease (COPD), diabetes, hypertension, heart disease (ischemic heart disease (IHD)-in the mortality/hospital analysis), and stroke.

ONTARIO

. 37% of Ontario residents (aged 12+) had a chronic condition and 15% had multiple conditions. . The selected chronic conditions accounted for approximately 60% of deaths, 22% of acute hospital separations, and 26% of total acute hospital days. . In 2013, the conditions with the highest prevalence rates were high blood pressure, arthritis, asthma, and diabetes. . Cancer, ischaemic heart disease (IHD), stroke, and chronic obstructive pulmonary disease (COPD) had the highest mortality rates in 2010 & 2011. Among the selected conditions, cancer, arthritis, IHD, congestive heart failure (CHF), and COPD had the highest acute care separation rates in 2013/14. Cancer, IHD, CHF, arthritis, and stroke had the highest rates of total acute days. . Although hospitalization trends vary by condition, acute separation rates increased between 2010/11 and 2013/14 for 3 of 8 conditions (for which time trends were available), while total acute inpatient day rates declined for 5 of 8 conditions. The diagnostic criteria for CHF have changed since the 2012 analysis; therefore time trends are not available for this condition. . Although the prevalence of cancer was only 1.9%, these conditions were a leading cause of mortality, acute care separations and hospital days in the province. Cancer accounted for 7% of total acute hospital days in Ontario. . Heart disease, including IHD and CHF, accounted for 7% of all hospital days and 7% of all acute care separations. . Approximately 8% of Ontario residents had asthma and 4% had COPD. These chronic respiratory conditions accounted for approximately 3% of hospital days. . Over time, the prevalence and acute separation rates for asthma declined. Acute separation and mortality rates for COPD have remained relatively stable, while inpatient days have declined. . Although the prevalence of stroke is relatively low, this condition had among the highest rates of mortality and total acute inpatient days. . Many chronic conditions can be prevented or onset can be delayed. Smoking, misuse of alcohol, excess weight, poor diet and physical inactivity are well established modifiable risk factors for many chronic conditions. Over 80% of COPD, for example, is attributable to smoking and 50% of diabetes is attributable to obesity.

Condition Ontario Range across LHINs Trend‡ Prevalence (2013), rate per 100, age 12+ Arthritis (age 14+) 17.3 (11.1 – 24.9) Asthma 7.5 (4.3 – 9.4) Decreasing Cancer 1.9 (1.0 – 3.4) Chronic Obstructive Pulmonary Disease 4.3 (2.6 – 6.0) (COPD) (age 35+) Diabetes 6.6 (3.9 – 9.7) High blood pressure 18.3 (14.8 – 24.2) Increasing C10

Condition Ontario Range across LHINs Trend‡ Heart disease 4.8 (2.4 – 7.3) Suffer from effects of stroke 1.3 (0.9 – 2.3) Have a chronic condition 37.3 (31.9 – 48.6) Have multiple chronic conditions1 15.0 (9.1 – 20.7) † - High sampling variability – estimate must be used with caution 1 - Of the selected conditions on this list Mortality (2010 & 2011), rate per 100,000 Arthritis & related conditions 2.7 (1.7 – 6.5) Decreasing Asthma 0.7 (0.4 – 1.1) Increasing Cancer 200.8 (125.5 – 281.6) Congestive Heart Failure (CHF) 13.2 (8.9 – 18.2) NA COPD 26.8 (12.7 – 50.4) Diabetes 21.6 (12.1 – 36.6) Decreasing Hypertension 7.3 (4.1 – 12.4) Increasing Ischemic Heart Disease (IHD) 99.2 (53.7 – 145.9) Decreasing Stroke 29.6 (19.6 – 41.6) Decreasing Acute Inpatient Hospital Separations (2013/14), rate per 100,000 Arthritis & related conditions 367.4 (255.6 – 590.0) Increasing Asthma 34.5 (25.2 –56.0) Decreasing Cancer 424.7 (354.8 – 627.2) CHF 183.8 (136.8 –278.4) NA COPD 182.4 (92.0 – 393.8) Diabetes 99.3 (66.2 – 228.5) Increasing Hypertension 18.5 (10.1 – 33.5) Increasing IHD 357.2 (251.1 – 734.2) Decreasing Stroke 133.7 (102.6 – 205.2) Total Acute Inpatient Hospital Days (2013/14), rate per 100,000 Arthritis & related conditions 1,541.7 (1,099.4 – 2,694.1) Asthma 98.2 (67.7 – 136.5) Cancer 3,592.2 (2,685.4 – 6,037.8) Decreasing CHF 1,653.6 (1,180.3 – 3,079.2) NA COPD 1,360.3 (649.3 – 3,357.5) Decreasing Diabetes 892.2 (632.7 – 2,124.6) Hypertension 86.5 (44.6 – 198.5) Decreasing IHD 1,863.4 (1,254.9 – 3,616.6) Decreasing Stroke 1,474.8 (1,060.8 – 2,469.0) Decreasing ‡Trends refer to comparison of values shown to analysis provided for the 2012 IHSP. For prevalence, 2013 rates were compared to those from 2009- 2010. For mortality, 2010 & 2011 rates were compared to 2006 & 2007. Acute separations and days from 2013/14 were compared to 2010/11.

North Simcoe Muskoka LHIN

. In 2013, 44% of North Simcoe Muskoka residents (aged 12+) had a chronic condition. This rate was significantly higher than the provincial average and was the second highest rate among all the LHINs. 18% of North Simcoe Muskoka LHIN residents had multiple conditions. The rate of multiple chronic conditions increased for North Simcoe Muskoka LHIN residents compared to 2009-2010. . The proportion of residents with high blood pressure was significantly higher among North Simcoe Muskoka LHIN residents compared to Ontario. North Simcoe Muskoka LHIN residents had the highest prevalence of high blood pressure in the province and this rate has increased over time. . The selected chronic conditions accounted for 62% of deaths, 24% of acute separations, and 26% of total acute days for North Simcoe Muskoka LHIN residents. . Compared with Ontario, North Simcoe Muskoka LHIN residents had higher mortality rates for cancer, COPD, diabetes, IHD and stroke. North Simcoe Muskoka LHIN residents had higher acute separation rates than the province for arthritis, cancer, COPD, diabetes, IHD, and stroke. LHIN residents also had higher total acute day rates than the province for arthritis, COPD, diabetes and IHD. . Although the prevalence of cancer in North Simcoe Muskoka LHIN was only 2%, these conditions were a leading cause of mortality and accounted for 7% of all acute hospital days for LHIN residents. . IHD, CHF, and stroke accounted for 11% of all total acute days and 9% of all acute care separations. . Among all LHINs, North Simcoe Muskoka LHIN had among the lowest rates of acute separations and total acute days for asthma. . Over time, mortality rates for arthritis, diabetes, hypertension, IHD, and stroke declined for North Simcoe Muskoka LHIN residents. Acute separation and total acute day rates decreased for asthma, COPD, hypertension, and IHD between 2010/11 and 2013/14.

Chronic condition prevalence rates per 100 population aged 12+, North Simcoe Muskoka LHIN, 2013 North Simcoe Condition Ontario Comment Trend‡ Muskoka LHIN C11

Prevalence (2013), rate per 100, aged 12+ Arthritis (age 14+) 20.0 17.3 Asthma 7.9† 7.5 Decreasing Cancer 2.0† 1.9 COPD (age 35+) 4.3† 4.3 Decreasing Diabetes 6.1† 6.6 Increasing High blood pressure 24.2↑ 18.3 Highest Increasing Heart disease 5.7† 4.8 Suffer from effects of stroke F 1.3 Have a chronic condition 43.5↑ 37.3 2nd highest Have multiple chronic conditions1 18.3 15.0 Increasing ↑ - LHIN result is significantly higher than Ontario; ↓ - LHIN result is significantly lower than Ontario † - High sampling variability – estimate must be used with caution 1 - Of the selected conditions on this list F - Estimates with CVs greater than 33.3% are too unreliable to be published and have been suppressed due to extreme sampling variability ‡ - 2013 rates were compared to those from 2009-2010.

Mortality (2010 & 2011), acute separation and total acute day (2013/14) rates, North Simcoe Muskoka LHIN Mortality rate per Hosp separation rate per Hosp days rate per NSM LHIN Trends† 100,000 100,000 100,000 NSM Condition Ontario NSM LHIN Ontario NSM LHIN Ontario Mortality Seps Days LHIN Arthritis‡ 2.9 2.7 440.2 367.4 1,848.9 1,541.7 Decreasing Increasing Asthma 1.1 0.7 27.4 34.5 67.7 98.2 Increasing Decreasing Decreasing Cancer 237.0 200.8 470.0 424.7 3,443.9 3,592.2 Decreasing CHF 12.6 13.2 188.8 183.8 1,687.8 1,653.6 NA NA NA COPD 37.7 26.8 248.8 182.4 1,880.2 1,360.3 Decreasing Decreasing Diabetes 27.1 21.6 123.0 99.3 1,014.7 892.2 Decreasing Increasing Hypertension 7.5 7.3 18.0 18.5 79.3 86.5 Decreasing Decreasing Decreasing IHD 118.6 99.2 487.3 357.2 2,460.3 1,863.3 Decreasing Decreasing Decreasing Stroke 32.1 29.6 151.7 133.7 1,415.0 1,474.8 Decreasing Decreasing ‡ includes related conditions †Trends refer to comparison of values shown to analysis provided for the 2012 IHSP. For mortality, 2010 & 2011 rates were compared to 2006 & 2007. Acute separations and days from 2013/14 were compared to 2010/11.

Health Care Utilization Analysis of Acute Care Utilization Notes: Analysis is based on data from the Discharge Abstract Database.

ONTARIO

Acute Care Utilization

LHIN of hospital

. In 2013/14, there were 1,003,073 acute separations, 5,397,903 acute days, and 6,278,673 total days from acute care units in Ontario hospitals. Toronto Central LHIN hospitals accounted for the largest proportion of these separations (15.6%) and days (15.9% total and 16.7% acute). . In 2013/14, the average total length of stay for Ontario hospitals was 6.3 days and the average acute length of stay was 5.4 days. The average total lengths of stay ranged from 5.1 days in Central West LHIN to 7.4 days in North West LHIN hospitals, while the average acute length of stay ranged from 4.6 days in Central West LHIN to 6.1 days in North West LHIN. . Between 2010/11 and 2013/14, acute separations increased by 4.9% and acute days increased by 3.2%, while total days remained stable. The average lengths of stay have remained relatively stable over the past 4 years. . Alternate level of care (ALC) days are those days where a physician (or designated other) has indicated that a patient occupying an acute care hospital bed does not require the intensity of resource/services provided in acute care. This analysis includes only those cases that have been discharged from care during the fiscal year. In 2013/14, there were 54,149 ALC separations and 880,770 ALC days in Ontario hospitals. There was a 1.0% reduction in ALC separations and a 15.8% reduction in ALC days between 2010/11 and 2013/14. C12

. The average ALC length of stay decreased from 19.1 days in 2010/11 to 16.3 days in 2013/14. Average ALC lengths of stay ranged from 8.4 days in Waterloo Wellington LHIN hospitals to 27.7 days in North East LHIN hospitals in 2013/14. . The % ALC days (ALC days as a percentage of total days) decreased from 16.7% in 2010/11 to 14.0% in 2013/14. In 2013/14, Central West LHIN hospitals had the lowest % ALC days, while North East LHIN hospitals had the highest. . Long-term care (LTC) (31.8%), home with support (18.3%), chronic care (15.6%) and rehabilitation (11.1%) were the discharge destinations associated with the greatest proportion of total ALC days for Ontario hospitals. The distribution of ALC days by discharge destination varied by LHIN of hospital, which may be related to patterns of care and the availability of particular services. . The Ontario HBAM inpatient grouper (HIG) (similar to CMG+) aggregates acute care separations with similar resource use and clinical characteristics based on most responsible diagnosis and/or principal intervention. The HIG weight is a relative cost value that reflects the resources consumed during each acute care stay. The average HIG weight for Ontario was 1.49 in 2010/11 (based on 2014/15 HIG weights) and increased to 1.50 in 2013/14. Toronto Central LHIN hospitals (1.85) had the highest average HIG weight in 2013/14, while Central West LHIN hospitals (1.18) had the lowest. . The three HIGs accounting for the largest proportion of acute care days for Ontario hospitals in 2013/14 were: 196-heart failure without coronary angiogram, 138-viral/unspecified pneumonia, and 810-palliative care. The leading HIGs vary by LHIN. Some of this variation is due to the types of specialty care provided within LHIN hospitals. . In 2013/14, the HIGs accounting for the largest proportion of ALC days for Ontario hospitals were: 670-dementia; 811-general symptom/sign, and 026-ischemic event of central nervous system; 671-organic mental disorder; and 809-awaiting placement. These HIGs were also among the leading causes of ALC days for all LHINs; however the order differed.

LHIN of patient

. There were 991,471 acute separations and 6,216,903 total days for Ontario residents in 2013/14. Residents of HNHB, Central East, and Central LHINs had the largest number of acute care separations in the province. . In 2013/14, the acute separation rate for Ontario residents was 73.2 separations/1,000 population but varied substantially by LHIN of patient residence. Rates were lowest for residents of the Mississauga Halton and Central LHINs and highest for residents of the North East and North West LHINs. From 2010/11 to 2013/14, the overall acute separation rate for Ontario residents increased by 2.3%. . The average total length of stay for Ontario residents was 6.3 days while the average acute length of stay was 5.4 days. Residents of North West LHIN had the longest average total (7.5 days) and acute lengths of stay (6.2 days), while residents of Central West LHIN had the shortest (5.2 days and 4.8 days, respectively). . Average ALC lengths of stay ranged from 8.4 days for Waterloo Wellington LHIN residents to 27.0 days for residents of the North East LHIN.

Acute care hospital utilization by LHIN of hospital, 2013/14 Acute Average total Average Average HIG LHIN of hospital separations Total days LOS Acute days acute LOS Weight Erie St. Clair 45,128 289,545 6.4 233,348 5.2 1.44 South West 86,356 545,744 6.3 487,080 5.6 1.55 Waterloo Wellington 45,465 241,364 5.3 212,227 4.7 1.31 HNHB 114,466 767,655 6.7 651,269 5.7 1.58 Central West 47,532 239,986 5.1 218,668 4.6 1.18 Mississauga Halton 66,747 402,210 6.0 354,656 5.3 1.38 Toronto Central 156,258 995,501 6.4 900,961 5.8 1.85 Central 97,115 533,281 5.5 458,830 4.7 1.34 Central East 89,274 543,363 6.1 455,683 5.1 1.37 South East 38,728 242,391 6.3 210,423 5.4 1.58 Champlain 98,426 670,783 6.8 583,114 5.9 1.58 North Simcoe Muskoka 33,180 204,841 6.2 160,990 4.9 1.31 North East 59,163 414,741 7.0 316,699 5.4 1.42 North West 25,235 187,268 7.4 153,955 6.1 1.41 Ontario hospitals 1,003,073 6,278,673 6.3 5,397,903 5.4 1.50

ALC separations and days by LHIN of hospital, 2013/14 % ALC days (of total LHIN of hospital ALC separations ALC days Average ALC LOS days) Erie St. Clair 3,090 56,197 18.2 19.4 South West 3,561 58,664 16.5 10.7 Waterloo Wellington 3,486 29,137 8.4 12.1 HNHB 8,518 116,386 13.7 15.2 Central West 1,800 21,318 11.8 8.9 Mississauga Halton 2,746 47,554 17.3 11.8 Toronto Central 7,594 94,540 12.5 9.5 C13

Central 5,748 74,451 13.0 14.0 Central East 3,838 87,680 22.9 16.1 South East 1,557 31,968 20.5 13.2 Champlain 4,494 87,669 19.5 13.1 North Simcoe Muskoka 2,309 43,851 19.0 21.4 North East 3,540 98,042 27.7 23.6 North West 1,868 33,313 17.8 17.8 Ontario hospitals 54,149 880,770 16.3 14.0

Proportion of ALC days (of total ALC days) by discharge destination by LHIN of hospital, 2013/14 Home LHIN of hospital without Home with Long- Chronic Rehab- Another support support term care care ilitation facility† Deceased Total Erie St. Clair 5.3 12.7 19.8 21.6 10.9 20.9 8.9 100.0 South West 4.1 18.8 45.2 9.1 7.9 3.7 11.2 100.0 Waterloo Wellington 6.2 20.9 22.6 17.9 19.2 5.6 7.7 100.0 HNHB 4.8 23.5 27.6 19.5 9.0 6.0 9.6 100.0 Central West 7.5 21.7 16.6 21.4 23.7 1.4 7.7 100.0 Mississauga Halton 6.4 19.0 30.2 17.6 13.8 1.5 11.5 100.0 Toronto Central 5.2 18.7 22.7 17.9 23.9 3.5 8.1 100.0 Central 4.8 24.9 34.1 11.3 11.4 2.7 10.8 100.0 Central East 5.5 8.6 41.8 23.9 8.4 2.5 9.3 100.0 South East 11.1 10.3 39.2 6.2 9.1 10.0 14.1 100.0 Champlain 10.6 23.0 34.3 9.5 9.3 3.9 9.5 100.0 North Simcoe Muskoka 5.9 19.8 36.3 10.2 5.9 6.2 15.8 100.0 North East 14.2 15.2 29.9 13.1 5.4 6.3 16.0 100.0 North West 7.2 14.7 42.3 16.6 5.6 2.5 11.0 100.0 Ontario hospitals 7.1 18.3 31.8 15.6 11.1 5.4 10.8 100.0 †Includes acute and ambulatory facilities

Acute care days by top 10 HIGs, Ontario hospitals, 2013/14 Ontario HBAM Inpatient Grouper (HIGs) Acute Days % of total (196) Heart Failure without Coronary Angiogram 161,289 3.0 (138) Viral/Unspecified Pneumonia 120,046 2.2 (810) Palliative Care 119,068 2.2 (026) Ischemic Event of Central Nervous System 87,537 1.6 (139b) Chronic Obstructive Pulmonary Disease 83,894 1.6 (321) Unilateral Knee Replacement 78,528 1.5 (487) Lower Urinary Tract Infection 76,410 1.4 (654) Other/Unspecified Sepsis 75,863 1.4 (139a) Chronic Bronchitis 71,748 1.3 (811) General Symptom/Sign 71,218 1.3 All Other CMGs 4,452,302 82.5 Total 5,397,903 100.0

ALC days by top 10 HIGs, Ontario hospitals, 2013/14 Ontario HBAM Inpatient Grouper (HIGs) ALC Days % of total (670) Dementia 86,278 9.8 (811) General Symptom/Sign 48,580 5.5 (026) Ischemic Event of Central Nervous System 38,423 4.4 (671) Organic Mental Disorder 37,648 4.3 (809) Awaiting Placement 28,613 3.2 (727) Fixation/Repair Hip/Femur 26,583 3.0 (810) Palliative Care 23,326 2.6 (196) Heart Failure without Coronary Angiogram 21,808 2.5 (487) Lower Urinary Tract Infection 19,475 2.2 (806) Convalescence 17,291 2.0 All other HIGs 532,745 60.5 Total 880,770 100.0

Acute care hospital utilization by LHIN of patient, 2013/14 C14

Acute Acute separations/ Average Average Average HIG LHIN of patient separations 1,000 population Total days total LOS Acute days Acute LOS weight Erie St. Clair 52,400 82.1 339,818 6.5 282,276 5.4 1.56 South West 79,878 83.1 496,933 6.2 440,117 5.5 1.50 Waterloo Wellington 50,543 66.3 276,216 5.5 246,600 4.9 1.41 HNHB 115,294 81.2 763,910 6.6 646,766 5.6 1.55 Central West 59,659 67.0 312,536 5.2 288,000 4.8 1.36 Mississauga Halton 70,177 58.9 434,483 6.2 383,448 5.5 1.44 Toronto Central 79,974 65.2 511,441 6.4 437,076 5.5 1.56 Central 108,665 59.8 628,580 5.8 552,409 5.1 1.47 Central East 109,082 69.2 666,726 6.1 572,168 5.3 1.50 South East 41,310 83.8 259,514 6.3 227,374 5.5 1.62 Champlain 90,198 69.7 619,095 6.9 531,835 5.9 1.56 North Simcoe Muskoka 38,582 82.7 235,802 6.1 193,171 5.0 1.49 North East 64,281 113.4 445,517 6.9 346,938 5.4 1.48 North West 26,079 110.4 195,441 7.5 162,156 6.2 1.49 Unknown 5,349 30,891 5.8 26,923 5.0 1.51 Out-of-province 11,602 61,770 5.3 60,646 5.2 1.60 Ontario residents† 991,471 73.2 6,216,903 6.3 5,337,257 5.4 1.50 †Excludes out of province residents

ALC separations and days by LHIN of patient, 2013/14 LHIN of patient ALC separations ALC days Average ALC LOS Erie St. Clair 3,154 57,542 18.2 South West 3,505 56,816 16.2 Waterloo Wellington 3,520 29,616 8.4 HNHB 8,558 117,144 13.7 Central West 2,027 24,536 12.1 Mississauga Halton 3,070 51,035 16.6 Toronto Central 5,205 74,365 14.3 Central 6,250 76,171 12.2 Central East 4,590 94,558 20.6 South East 1,596 32,140 20.1 Champlain 4,429 87,260 19.7 North Simcoe Muskoka 2,343 42,631 18.2 North East 3,646 98,579 27.0 North West 1,875 33,285 17.8 Unknown 257 3,968 15.4 Out-of-province 124 1,124 9.1 Ontario residents† 54,025 879,646 16.3 †Excludes out of province residents

North Simcoe Muskoka LHIN

. There were 33,180 acute separations, 160,990 acute days, and 204,841 total days from North Simcoe Muskoka LHIN hospitals in 2013/14. Residents from outside the LHIN accounted for 9.8% of the acute separations from North Simcoe Muskoka LHIN hospitals. . There were 2,309 ALC separations from North Simcoe Muskoka LHIN hospitals in 2013/14 with an average ALC length of stay of 19.0 days. The % ALC days (of total days) was greater in North Simcoe Muskoka LHIN hospitals compared to Ontario hospitals in 2013/14 (21.4% and 14.0%, respectively) . Acute separations and total days increased for North Simcoe Muskoka LHIN hospitals between 2010/11 and 2013/14, while acute days decreased. During the same period, ALC separations declined 1.3% while ALC days increased by 13.1%. . The discharge destinations accounting for the largest proportion of ALC days for North Simcoe Muskoka LHIN hospitals were LTC (36.3%), home with support (19.8%) and death (15.8%). . North Simcoe Muskoka LHIN residents had a higher acute care separation rate than the province in 2013/14 (82.7 and 73.2, respectively). . 22.4% of acute separations by North Simcoe Muskoka LHIN residents were from hospitals outside the LHIN in 2013/14. . The average HIG weight for North Simcoe Muskoka LHIN hospitals (1.31) was the second lowest in the province in 2013/14, while the average HIG weight for North Simcoe Muskoka LHIN residents (1.49) was comparable to that for Ontario residents (1.50). . Across all LHINs, North Simcoe Muskoka LHIN hospitals had the largest proportions of acute days for 487-lower urinary tract infection and 139b-chronic obstructive pulmonary disease. In addition, 477-renal failure, and 727-fixation/repair hip/femur were among the top 10 HIGs for North Simcoe Muskoka LHIN hospitals but were not among the leading HIGs for Ontario.

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Acute care hospital utilization, North Simcoe Muskoka LHIN, 2013/14 North Simcoe LHIN % change Indicator Muskoka LHIN Ontario† 2010/11 - 2013/14 LHIN of hospital Acute separations 33,180 1,003,073 2.4 Total days 204,841 6,278,673 1.4 Average total LOS 6.2 6.3 Acute days 160,990 5,397,903 -1.4 Average acute LOS 4.9 5.4 Average HIG weight 1.31 1.50 % Inflow acute separations 9.8 ALC separations 2,309 54,149 -1.3 ALC days 43,851 880,770 13.1 Average ALC LOS 19.0 16.3 % ALC days (of total days) 21.4 14.0 Proportion of total ALC days by discharge destination: Home without support 5.9 7.1 Home with support 19.8 18.3 Long-term care 36.3 31.8 Chronic care 10.2 15.6 Rehabilitation 5.9 11.1 Another facility‡ 6.2 5.4 Deceased 15.8 10.8 LHIN of patient Acute separations 38,582 991,471 3.6 Acute separations/1,000 population 82.7 73.2 1.2 Total days 235,802 6,216,903 1.1 Average total LOS 6.1 6.3 Acute days 193,171 5,337,257 -0.7 Average acute LOS 5.0 5.4 Average HIG weight 1.49 1.50 % Outflow acute separations 22.4 ALC separations 2,343 54,025 -1.6 ALC days 42,631 879,646 10.3 Average ALC LOS 18.2 16.3 †LHIN of patient results for Ontario exclude out-of-province residents ‡Includes acute and ambulatory facilities

Acute care days by top 10 HIGs, North Simcoe Muskoka LHIN hospitals, 2013/14 North Simcoe Muskoka LHIN Ontario Comment HBAM Inpatient Grouper (HIGs) # % # % (196) Heart Failure without Coronary Angiogram 5,392 3.3 161,289 3.0 (487) Lower Urinary Tract Infection 4,060 2.5 76,410 1.4 Largest % in province (139b) Chronic Obstructive Pulmonary Disease 4,021 2.5 83,894 1.6 Largest % in province (139a) Chronic Bronchitis 3,262 2.0 71,748 1.3 (138) Viral/Unspecified Pneumonia 3,224 2.0 120,046 2.2 (654) Other/Unspecified Sepsis 2,945 1.8 75,863 1.4 (026) Ischemic Event of Central Nervous System 2,761 1.7 87,537 1.6 (477) Renal Failure 2,560 1.6 66,863 1.2 Not in Ontario top 10 (810) Palliative Care 2,470 1.5 119,068 2.2 (727) Fixation/Repair Hip/Femur 2,441 1.5 70,028 1.3 Not in Ontario top 10 All other HIGs 127,854 79.4 4,465,157 82.7 Total 160,990 100.0 5,397,903 100.0

Analysis of Unscheduled Emergency Department Utilization Notes: Analysis is based on data from the National Ambulatory Care Reporting System.

CTAS levels: The Canadian Triage and Acuity Scale (CTAS), developed by the Canadian Association of Emergency Physicians (CAEP), is used by hospital emergency departments to prioritize patient’s care according to the type and severity of their presenting signs and symptoms. The levels are noted below. More information on triage level guidelines is available at: http://caep.ca/resources/ctas C16

I Resuscitation: Conditions that are threats to life or limb (or imminent risk of deterioration) requiring immediate aggressive interventions. II Emergent: Conditions that are a potential threat to life limb or function, requiring rapid medical intervention or delegated acts. III Urgent: Conditions that could potentially progress to a serious problem requiring emergency intervention. These conditions may be associated with significant discomfort or affecting ability to function at work or activities of daily living. IV Less Urgent (Semi urgent): Conditions that are related to patient age, distress, or potential for deterioration or complications that would benefit from intervention or reassurance within 1-2 hours. V Non Urgent: Conditions that may be acute but non-urgent as well as conditions which may be part of a chronic problem with or without evidence of deterioration. The investigation or interventions for some of these illnesses or injuries could be delayed or even referred to other areas of the hospital or health care system.

ONTARIO

. This analysis includes unscheduled emergency department (ED) visits to comprehensive emergency departments and hospital-based urgent care centres as reported to the National Ambulatory Care Reporting System. . There were more than 5.9 million unscheduled ED visits to Ontario hospitals in 2013/14, an increase of 6.1% from 2010/11. Champlain, HNHB, and South West LHIN hospitals had the largest number of ED visits in 2013/14. . The Canadian Triage and Acuity Scale (CTAS) is used by hospital EDs to prioritize patient’s care according to the type and severity of their presenting signs and symptoms. The triage levels consist of a five point scale (level I-resuscitation, level II-emergent, level III-urgent, level IV- less urgent, level V-non urgent) that identify the relative urgency of the patient’s need for treatment by a health care provider. The guidelines were developed by the Canadian Association of Emergency Physicians (CAEP) and were originally published in 1999, with revisions in 2004, 2008, and 2013. The revisions have included the addition of modifiers36 and changes to the list of complaints to assist in the objective assignment of acuity levels. As a result, caution must be used when interpreting changes in CTAS levels over time as acuity levels may be influenced by changes to the CTAS guidelines. . In 2013/14, in Ontario hospitals, 36.7% of visits were in CTAS IV & V (less urgent/non urgent), 44.3% were in CTAS III (urgent), and 18.7% of visits were in CTAS I & II (resuscitation/ emergent). . Between 2010/11 and 2013/14, the number of visits in the lower acuity levels declined while those in higher acuity levels increased in Ontario hospitals. The number of visits in CTAS IV & V decreased by 9.0%, while CTAS III visits increased by 14.1% and CTAS I & II visits increased by 27.3%. . The distribution of ED visits by CTAS level differed by LHIN in 2013/14. 52.0% of ED visits to North East LHIN hospitals were in CTAS IV & V compared to 20.3% of visits in Central West LHIN hospitals. Toronto Central LHIN hospitals had the largest proportion of visits in CTAS III (54.3%), while North East LHIN hospitals had the smallest percentage (32.9%). Central West LHIN hospitals had the largest proportion of visits in CTAS I & II (25.9%), while South East LHIN hospitals had the smallest proportion (13.1%). . ED length of stay (EDLOS) refers to the length of time from the earlier of the time of visit triage or registration to either the time the patient left the ED or visit disposition. The 90th percentile refers to the length of time within which 9 out of 10 patients completed their ED visits. In Ontario hospitals in 2013/14, the 90th percentile EDLOS was 8.0 hours, however this varied by LHIN from 6.1 hours in South West LHIN hospitals to 10.4 hours for Toronto Central LHIN. The 90th percentile EDLOS in Ontario hospitals decreased from 2010/11, when it was 8.2 hours. . The leading causes for the ED visits were assigned based on the chapter of the International Statistical Classification of Diseases and Related Health Problems (ICD 10 CA) main problem diagnosis. The leading ICD-10-CA chapters for ED visits to Ontario hospitals in 2013/14 were 19- Injury, poisoning and certain other consequences of external causes (23.1%); 18-Symptoms, signs and abnormal clinical and laboratory findings (19.7%); and 10-Diseases of the respiratory system (10.0%). . In 2013/14, there were 5,809,892 ED visits by Ontario residents, an increase of 5.8% from 2010/11. HNHB, Central East, and Champlain LHIN residents had the largest number of visits in 2013/14. . The distribution of visits by CTAS level varied by LHIN of patient residence, similar to the pattern observed by LHIN of hospital. Residents of the North East LHIN had the largest proportion in CTAS IV & V (51.3%) while Central West residents had the smallest proportion (23.2%). Toronto Central residents had the largest proportion of visits in CTAS III (53.5%) and Central LHIN residents had the largest proportion in CTAS I & II (25.3%). . The provincial ED visit rate (per 1,000 population) was 429.2 in 2013/14 and rates varied by LHIN of patient residence. Mississauga Halton and Central LHINs had the lowest rates (298.2 and 301.2 respectively) and North West and North East LHINs residents had the highest (858.8 and 766.8, respectively). From 2010/11 to 2013/14, the provincial rate increased by 3.3%. . ED visits best treated in alternative primary care settings include visits in CTAS IV & V for those aged 1-74 years for conditions such as upper respiratory infections (e.g., common cold, sinusitis, tonsillitis, pharyngitis), conjunctivitis, otitis media, and cystitis, which did not result in an inpatient admission. The crude rate of ED visits that could be treated in alternative settings varied greatly by LHIN, ranging from 4.8 for Central West LHIN residents to 52.2 for North East LHIN residents. From 2010/11 to 2013/14 there was a 14.7% reduction in the provincial rate. . Differences in rates may reflect differences in access to other types of primary care services.

36 Modifiers were divided into first and second order types; first order modifiers are those that are applicable to a wide number of different complaints (e.g. vital sign modifiers, pain severity); second order modifiers are specific to particular complaints (e.g. low blood sugar, mental health symptoms). Canadian Association of Emergency Physician (CAEP) Update, retrieved from: http://www.cjem-online.ca/sites/default/files/CJEM_Vol_10,_No_3,_p224.pdf C17

Unscheduled emergency department visit utilization, LHIN of hospital, 2013/14 Visits‡ % of visits by CTAS level 90th percentile LHIN of hospital I & II III IV & V EDLOS (hours) Erie St Clair 300,551 20.5 38.8 40.6 8.1 South West 591,102 13.8 37.8 48.3 6.1 Waterloo Wellington 259,429 17.1 50.0 32.8 7.7 HNHB 650,711 19.2 47.9 32.7 9.1 Central West 244,979 25.9 53.7 20.3 8.9 Mississauga Halton 382,295 21.9 44.0 33.9 8.6 Toronto Central 536,626 24.8 54.3 20.7 10.4 Central 533,138 25.3 46.2 28.5 8.5 Central East 583,227 16.7 46.7 36.5 7.8 South East 293,317 13.1 40.0 46.4 6.6 Champlain 651,322 17.4 44.0 38.4 8.4 North Simcoe Muskoka 253,527 16.2 40.3 43.4 7.1 North East 437,125 13.2 32.9 52.0 6.2 North West 207,882 15.4 40.5 42.7 6.8 Ontario hospitals 5,925,231 18.7 44.3 36.7 8.0 ‡Includes visits with missing/unknown CTAS level

Unscheduled emergency department visits by ICD-10-CA chapter, Ontario hospitals, 2013/14 Ontario Major Ambulatory Cluster (MAC) # % (19) Injury & Poisoning & Other Consequences of External Causes 1,366,440 23.1 (18) Symptoms, Signs & Abnormal Clinical & Lab. Findings 1,164,429 19.7 (10) Diseases of Respiratory System 589,994 10.0 (13) Diseases of Musculoskeletal System & Connective Tissue 373,092 6.3 (21) Factors Influencing Health Status & Contacts with Health Services 345,595 5.8 (11) Diseases of Digestive System 334,234 5.6 (14) Diseases of Genitourinary System 316,059 5.3 (01) Infectious & Parasitic Diseases 242,597 4.1 (12) Diseases of Skin & Subcutaneous Tissue 234,925 4.0 (05) Mental & Behavioural Disorders 224,509 3.8 (09) Diseases of Circulatory System 207,638 3.5 (08) Diseases of Ear & Mastoid Process 140,614 2.4 (06) Diseases of Nervous System 89,554 1.5 (07) Diseases of Eye & Adnexa 89,386 1.5 (15) Pregnancy, Childbirth & the Puerperium 83,848 1.4 (04) Endocrine, Nutritional & Metabolic Diseases 59,290 1.0 (03) Diseases of Blood & Blood-Forming Organs & Disorders Involving Immune Mechanism 26,535 0.4 (02) Neoplasms 26,149 0.4 (16) Conditions Originating In Perinatal Period 8,133 0.1 (17) Congenital Malformations, Deformations & Chromosomal Abnormalities 2,210 0.0 Total 5,925,231 100.0

Unscheduled emergency department visit utilization, LHIN of patient, 2013/14 % of visits by Visits‡ CTAS level ED visits best treated in Rate per alternative primary care LHIN of patient # 1,000 I & II III IV & V settings per 1,000§ Erie St Clair 313,829 491.8 20.1 38.8 41.0 29.3 South West 552,642 574.8 14.2 38.1 47.6 42.5 Waterloo Wellington 277,151 363.5 16.9 49.0 34.0 12.7 HNHB 656,318 462.4 19.1 47.9 32.9 21.7 Central West 285,888 321.0 24.8 52.0 23.2 4.8 Mississauga Halton 355,146 298.2 23.0 45.6 31.2 6.4 Toronto Central 405,865 330.9 22.7 53.5 23.6 6.3 Central 547,103 301.2 25.3 47.4 27.3 5.9 Central East 623,218 395.6 17.7 46.6 35.6 13.9 South East 296,335 600.8 13.3 40.2 46.1 35.2 Champlain 568,884 439.8 18.2 44.9 36.7 20.7 North Simcoe Muskoka 246,066 527.3 16.7 40.8 42.5 30.2 North East 434,776 766.8 13.5 33.4 51.3 52.2 North West 202,965 858.8 15.5 40.6 42.4 45.4 Unknown 43,706 24.6 45.7 28.6 C18

Out-of-province 115,339 14.1 37.9 47.9 Ontario residents† 5,809,892 429.2 18.8 44.4 36.4 18.5 ‡Includes visits with missing/unknown CTAS level †Excludes out of province residents §Crude rate for residents aged 1-74 years

North Simcoe Muskoka LHIN . In 2013/14, there were 253,527 ED visits to North Simcoe Muskoka LHIN hospitals and 12.8% of these visits were by residents of other LHINs. Between 2010/11 and 2013/14, the number of ED visits to North Simcoe Muskoka LHIN hospitals increased 5.8% compared to 6.1% growth for Ontario. . From 2010/11 to 2013/14 in North Simcoe Muskoka LHIN hospitals, the number of visits in the lower acuity levels declined while those in the higher acuity levels increased. Specifically, CTAS IV & V visits decreased by 7.6%, while CTAS III increased by 16.9% and CTAS I & II increased by 25.7%. . CTAS IV & V accounted for the largest proportion of ED visits in North Simcoe Muskoka LHIN hospitals (43.4%), which was higher than the corresponding proportion for Ontario (36.7%). North Simcoe Muskoka LHIN hospitals had a lower proportion of visits in CTAS I-III compared to Ontario hospitals. . North Simcoe Muskoka LHIN hospitals had a shorter 90th percentile EDLOS than the province in 2013/14. . There were 246,066 ED visits by North Simcoe Muskoka LHIN residents in 2013/14 and 10.2% of these visits occurred in other LHINs. Between 2010/11 and 2013/14, ED visits for North Simcoe Muskoka LHIN residents increased by 7.9%, while the ED visit rate increased by 5.4%. . The ED visit rate for North Simcoe Muskoka LHIN residents was higher than the provincial average in 2013/14. . In 2013/14, North Simcoe Muskoka LHIN residents had a larger proportion of CTAS IV & V visits compared to Ontario residents (42.5% versus 36.4%) and a smaller proportion of CTAS I & II visits (16.7% vs. 18.8%). . The rate of ED visits best treated in alternative primary care settings for North Simcoe Muskoka LHIN residents was higher than that for Ontario residents in 2013/14. Between 2010/11 and 2013/14 this rate declined 8.6% for North Simcoe Muskoka LHIN residents. . The leading ICD-10-CA chapters for ED visits in North Simcoe Muskoka LHIN hospitals were injuries and poisonings; symptoms, signs and abnormal clinical findings; respiratory system diseases; diseases of the musculoskeletal system; and diseases of the digestive system. Across all LHINs, North Simcoe Muskoka LHIN hospitals had the largest proportion of visits for diseases of the genitourinary system.

Unscheduled emergency department visit utilization, NSM LHIN, 2013/14 LHIN % change Indicator NSM LHIN Ontario† 2010/11 - 2013/14 LHIN of hospital Visits‡ 253,527 5,925,231 5.8 # visits by CTAS level I & II (resuscitation/emergent) 41,181 1,108,343 25.7 III (urgent) 102,271 2,625,170 16.9 IV & V (less urgent/non urgent) 110,054 2,172,564 -7.6 % visits by CTAS level‡ I & II (resuscitation/emergent) 16.2 18.7 III (urgent) 40.3 44.3 IV & V (less urgent/non urgent) 43.4 36.7 90th percentile EDLOS (hours) 7.1 8.0 % Inflow visits 12.8 LHIN of patient Visits‡ 246,066 5,809,892 7.9 ED visit rate/1,000 population 527.3 429.2 5.4 # visits by CTAS level I & II (resuscitation/emergent) 41,072 1,092,134 26.4 III (urgent) 100,457 2,581,509 19.1 IV & V (less urgent/non urgent) 104,483 2,117,319 -5.9 % visits by CTAS level I & II (resuscitation/emergent) 16.7 18.8 III (urgent) 40.8 44.4 IV & V (less urgent/non urgent) 42.5 36.4 % Outflow visits 10.2 ED visits best treated in alternative primary care settings 30.2 18.5 -8.6 /1,000 population age 1-74, crude †LHIN of patient results for Ontario exclude out-of-province residents ‡Includes visits with missing/unknown CTAS level

Unscheduled emergency department visits by ICD-10-CA chapter, North Simcoe Muskoka LHIN hospitals, 2013/14 NSM LHIN Ontario Comment C19

ICD-10-CA Chapter # % # % (19) Injury & Poisoning & Other Consequences of 61,301 24.2 1,366,440 23.1 External Causes (18) Symptoms, Signs & Abnormal Clinical & Lab. 42,788 16.9 1,164,429 19.7 Findings (10) Diseases of Respiratory System 27,265 10.8 589,994 10.0 (13) Diseases of Musculoskeletal System & 16,599 6.5 373,092 6.3 Connective Tissue (11) Diseases of Digestive System 15,087 6.0 334,234 5.6 (14) Diseases of Genitourinary System 14,590 5.8 316,059 5.3 Largest % in province (21) Factors Influencing Health Status & Contacts with 13,750 5.4 345,595 5.8 Health Services (12) Diseases of Skin & Subcutaneous Tissue 11,578 4.6 234,925 4.0 (01) Infectious & Parasitic Diseases 10,538 4.2 242,597 4.1 (09) Diseases of Circulatory System 9,483 3.7 207,638 3.5 (05) Mental & Behavioural Disorders 8,282 3.3 224,509 3.8 (08) Diseases of Ear & Mastoid Process 6,353 2.5 140,614 2.4 (07) Diseases of Eye & Adnexa 4,239 1.7 89,386 1.5 (06) Diseases of Nervous System 3,858 1.5 89,554 1.5 (15) Pregnancy, Childbirth & the Puerperium 2,893 1.1 83,848 1.4 (04) Endocrine, Nutritional & Metabolic Diseases 2,544 1.0 59,290 1.0 (02) Neoplasms 1,113 0.4 26,149 0.4 (03) Diseases of Blood & Blood-Forming Organs & 935 0.4 26,535 0.4 Disorders Involving Immune Mechanism (16) Conditions Originating in Perinatal Period 271 0.1 8,133 0.1 (17) Congenital Malformations, Deformations & 60 0.0 2,210 0.0 Chromosomal Abnormalities Total 253,527 100.0 5,925,231 100.0

Analysis of Day Surgery and Cardiac Catheterization Utilization

Notes: This document and the accompanying workbook contain analysis on day surgery and cardiac catheterization visits in ambulatory care for 2003/04 to 2013/14. Analysis is based on data from the National Ambulatory Care Reporting System.

ONTARIO

Day Surgery and Cardiac Catheterization Visits . In 2013/14, there were 1,250,987 visits for day surgery and cardiac catheterization to Ontario hospitals, with the largest proportions of these visits occurring in Toronto Central, HNHB, Central East, and Central LHIN hospitals. . Between 2010/11 and 2013/14, there was 1.0% growth in visits for Ontario overall; however there was no stable trend in visits across all LHIN areas. South West, Central, Central West and South East LHINs experienced the greatest growth in visits during the period, while Toronto Central, North West, Erie St. Clair, and Mississauga Halton LHINs had the greatest reduction in visits. . There were 1,241,468 day surgery and cardiac catheterization visits for Ontario residents in 2013/14. Residents of North East, South East, and Erie St. Clair LHINs had the highest day surgery visit rates, while Toronto Central, Central West, and Mississauga Halton LHINs had the lowest. . Although there was a slight increase (0.9%) in the number of visits for Ontario residents between 2010/11 and 2013/14, there was a 1.5% reduction in the visit rate. Residents of Toronto Central, Mississauga Halton, and Central West LHINs showed the greatest reduction in the rates, while residents of the South West, South East, and North East LHINs showed the greatest increase in rates over the period.

Day surgery and ambulatory cardiac catheterization visits by LHIN of hospital, 2013/14 Visits LHIN of hospital # % % Change 2010/11-2013/14 Erie St Clair 68,532 5.5 -5.2 South West 100,326 8.0 9.9 Waterloo Wellington 63,771 5.1 -1.7 HNHB 140,208 11.2 1.7 Central West 51,696 4.1 6.3 Mississauga Halton 81,507 6.5 -4.7 Toronto Central 144,359 11.5 -6.6 C20

Central 134,471 10.7 6.8 Central East 135,140 10.8 -1.0 South East 62,142 5.0 5.9 Champlain 124,497 10.0 4.3 North Simcoe Muskoka 42,135 3.4 0.4 North East 74,908 6.0 3.7 North West 27,295 2.2 -5.7 Ontario Hospitals 1,250,987 100.0 1.0

Day surgery and ambulatory cardiac catheterization visits by LHIN of patient residence, 2013/14 Visits % Change 2010/11-2013/14 Rate/1000 LHIN of patient residence # % population Visits Rate Erie St Clair 75,926 6.1 119.0 -3.8 -3.0 South West 93,448 7.5 97.2 9.7 8.7 Waterloo Wellington 68,185 5.5 89.4 -1.6 -3.6 HNHB 144,874 11.7 102.1 2.8 1.7 Central West 62,187 5.0 69.8 0.8 -6.6 Mississauga Halton 85,636 6.9 71.9 -6.0 -8.3 Toronto Central 79,485 6.4 64.8 -7.0 -13.2 Central 137,285 11.1 75.6 3.1 -0.1 Central East 147,126 11.9 93.4 0.0 0.2 South East 65,748 5.3 133.3 5.8 5.0 Champlain 115,863 9.3 89.6 3.3 -0.6 North Simcoe Muskoka 50,856 4.1 109.0 1.9 -0.5 North East 80,554 6.5 142.1 4.1 4.0 North West 28,015 2.3 118.5 -5.3 -4.3 Unknown 6,280 0.5 -0.7 Out-of-province 9,519 0.8 10.9 Ontario residents† 1,241,468 100.0 91.7 0.9 -1.5 †Excludes out- of-province residents

North Simcoe Muskoka LHIN

Day Surgery and Cardiac Catheterization Visits . In 2013/14, there were 42,135 day surgery and ambulatory cardiac catheterization visits to North Simcoe Muskoka LHIN hospitals. Residents from outside the LHIN accounted for 11.2% of the visits in 2013/14. . Between 2010/11 and 2013/14, visits to North Simcoe Muskoka LHIN hospitals increased by 0.4%. . There were 50,856 day surgery and ambulatory cardiac catheterization visits for North Simcoe Muskoka LHIN residents, and 26.4% of these visits occurred in hospitals outside the LHIN. There was growth in the number of visits, but there was a slight decrease in the visit rate for LHIN residents over the period. . The visit rate for North Simcoe Muskoka LHIN residents was higher than the provincial average.

Day surgery and ambulatory cardiac catheterization visits, North Simcoe Muskoka LHIN and Ontario, 2013/14 Indicator North Simcoe Ontario† LHIN % change Muskoka LHIN 2010/11 - 2013/14 LHIN of hospital Visits 42,135 1,250,987 0.4 % Inflow 11.2 LHIN of patient Visits 50,856 1,241,468 1.9 % Outflow 26.4 Visits per 1000 population 109.0 91.7 -0.5 †LHIN of patient results for Ontario exclude out-of-province residents

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Analysis of Inpatient Rehabilitation Utilization Notes: Analysis is based on data from the National Rehabilitation Reporting System. ONTARIO

Adult Inpatient Rehabilitation . The National Rehabilitation Reporting System (NRS) includes information on utilization of adult inpatient units that provide physical and cognitive rehabilitation services. This analysis summarizes admissions recorded in the NRS. There are two rehabilitation institution types in Ontario. Special rehabilitation units provide specialized services for specific patient populations (traumatic brain injury, traumatic spinal cord injury, burns, etc.). These units provide care for the residents of a broader region of the province and therefore, are not located in all LHINs. General rehabilitation units are located in all LHINs and offer multiple types of care with relatively lower treatment complexity than is provided in special rehabilitation units.37 . There were 31,131 admissions to Ontario rehabilitation units in 2013/14, 87.4% of these admissions were to general and 12.6% to special units. Toronto Central, Central, and Champlain LHIN hospitals had the largest number of total admissions in the fiscal year. . There was a 4.8% increase in inpatient rehabilitation admissions between 2010/11 and 2013/14. Admissions to general units increased by 3.4%, while admissions to special units increased by 15.3%. General admissions increased in 8 of 14 LHINs, and admissions increased in 7 of the 8 LHINs that provide special rehabilitation. Hospitals in Erie St. Clair, Central West, and North East LHINs showed the largest increase in total admissions, while North Simcoe Muskoka, North West, and Toronto Central LHIN hospitals had the largest decrease in admissions, over the period. . Residents of Erie St. Clair, Central East and Champlain LHINs had the highest rehabilitation admission rates, while residents of Waterloo Wellington, North Simcoe Muskoka, and Central West LHINs had the lowest.

Adult inpatient rehabilitation admissions by LHIN of hospital and institution type, 2013/14 General Special Total % Change 2010/11 LHIN of hospital # % # % # % to 2013/14 Erie St. Clair 1,475 5.4 632 16.1 2,107 6.8 57.7 South West 1,759 6.5 302 7.7 2,061 6.6 22.6 Waterloo Wellington 1,007 3.7 0 0.0 1,007 3.2 1.2 HNHB 2,089 7.7 587 15.0 2,676 8.6 1.7 Central West 778 2.9 0 0.0 778 2.5 53.8 Mississauga Halton 2,440 9.0 0 0.0 2,440 7.8 0.2 Toronto Central 4,916 18.1 1,511 38.5 6,427 20.6 -5.3 Central 4,369 16.1 39 1.0 4,408 14.2 4.0 Central East 2,940 10.8 0 0.0 2,940 9.4 -0.3 South East 779 2.9 0 0.0 779 2.5 12.4 Champlain 3,212 11.8 413 10.5 3,625 11.6 -0.8 North Simcoe 473 1.7 0 0.0 473 1.5 Muskoka -19.1 North East 695 2.6 245 6.2 940 3.0 42.6 North West 277 1.0 193 4.9 470 1.5 -16.2 Ontario hospitals 27,209 100.0 3,922 100.0 31,131 100.0 4.8

Adult inpatient rehabilitation admissions and admissions per 100,000 population (age 18+) by LHIN of patient residence, 2013/14 Admissions Admissions/100,000 population age 18+ # % % change 2010/11 Rate % change 2010/11 to LHIN of patient to 2013/14 2013/14 Erie St. Clair 2,181 7.0 53.3 428.7 52.8 South West 1,990 6.4 20.7 258.9 18.6 Waterloo Wellington 1,107 3.6 1.7 184.7 -0.7 HNHB 2,703 8.7 -1.7 236.3 -3.7

37Ontario Ministry of Health and Long-Term Care. Utilization of Adult Inpatient Rehabilitation Services in Ontario Hospitals: 2003/04-2007/08. [Online] Available from: URL http://intra.moh.gov.on.ca/MOHLTC_Intranets/HSIMI/Branches/HealthAnalytics/AnalyticReports.html

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Central West 1,400 4.5 14.2 204.9 4.9 Mississauga Halton 2,722 8.8 4.1 292.2 0.4 Toronto Central 3,348 10.8 1.0 331.6 -6.5 Central 4,160 13.4 -1.7 287.3 -5.5 Central East 4,501 14.5 3.3 353.5 2.5 South East 866 2.8 5.6 213.1 3.6 Champlain 3,485 11.2 0.8 335.0 -3.5 North Simcoe 768 2.5 -10.6 203.9 -13.7 Muskoka North East 1,072 3.5 13.9 231.3 13.1 North West 475 1.5 -15.2 253.3 -15.0 Unknown 215 0.7 -12.2 Out-of-province 138 -20.7 Ontario residents† 30,993 100.0 4.9 285.9 1.5 †Excludes out-of-province residents

North Simcoe Muskoka LHIN

Adult Inpatient Rehabilitation . In 2013/14, there were 473 admissions to inpatient rehabilitation units in North Simcoe Muskoka LHIN hospitals and residents from outside the LHIN accounted for 4.2% of these admissions. . Admissions to North Simcoe Muskoka LHIN hospital rehabilitation units decreased by 19.1% between 2010/11 and 2013/14. . In 2013/14, there were 768 rehabilitation admissions for North Simcoe Muskoka LHIN residents, and 41.0% were treated in hospitals outside the LHIN. Both the number and rate of admissions for LHIN residents decreased between 2010/11 and 2013/14. . In 2013/14, North Simcoe Muskoka LHIN residents had the 2nd lowest inpatient rehabilitation admission rate in the province. This rate was lower than the provincial average.

Adult inpatient rehabilitation admissions, North Simcoe Muskoka LHIN and Ontario, 2013/14 Indicator North Simcoe Ontario† LHIN % change Muskoka LHIN 2010/11-2013/14 LHIN of hospital General admissions 473 27,209 -19.1 Special admissions - 3,922 Total admissions 473 31,131 -19.1 % Inflow 4.2 LHIN of patient Total admissions 768 30,993 -10.6 % Outflow 41.0 Admissions per 100,000 age 18+ 203.9 285.9 -13.7 †LHIN of patient results for Ontario exclude out-of-province residents

Analysis of Mental Health Utilization

Notes: Analysis is based on data from the National Ambulatory Care Reporting System, the Ontario Mental Health Reporting System (which includes activity in designated adult mental health units), and ConnexOntario Health Services Information. ONTARIO

Mental Health and Substance Abuse Emergency Department Visits . In 2013/14, there were 222,025 unscheduled emergency department (ED) visits for Ontario residents where the main problem or reason for the visit was a mental health (MH) or substance abuse (SA) condition. There were 279,283 visits in total or 57,258 additional visits with a MH/SA condition in any of the diagnostic fields. . Between 2010/11 and 2013/14, there was 15.9% growth in visits with a MH/SA main problem diagnosis and 16.4% growth in visits with a MH/SA condition in any diagnostic field. There was 13.1% growth in the main problem visit rate and 13.6% growth in the any problem visit rate during the period. C23

. In 2013/14, visits with a MH/SA main problem diagnosis accounted for 3.8% of all unscheduled ED visits for Ontario residents. MH/SA visits accounted for 18.2% of all visits for those with an unknown LHIN of residence. This group includes individuals who could not be assigned to a LHIN based on the recorded postal code for the visit and will include patients who are homeless. . North West and North East LHIN residents had the highest ED visit rates for MH/SA conditions, while residents of Central and Mississauga Halton LHINs had the lowest rates. . Unscheduled emergency department utilization for mental health and substance abuse conditions by LHIN of patient residence, 2013/14 Mental Health/Substance Abuse Visits Visit Rate/1,000 population Main % of Total Any % of Total Main Any LHIN of patient Problem ED Visits Problem ED Visits Problem Problem Erie St. Clair 11,198 3.6 14,235 4.5 17.5 22.3 South West 16,206 2.9 20,760 3.8 16.9 21.6 Waterloo Wellington 10,667 3.8 14,362 5.2 14.0 18.8 HNHB 23,342 3.6 29,366 4.5 16.4 20.7 Central West 11,257 3.9 13,131 4.6 12.6 14.7 Mississauga Halton 12,364 3.5 15,483 4.4 10.4 13.0 Toronto Central 24,033 5.9 28,413 7.0 19.6 23.2 Central 18,498 3.4 23,255 4.3 10.2 12.8 Central East 23,468 3.8 29,245 4.7 14.9 18.6 South East 9,305 3.1 12,466 4.2 18.9 25.3 Champlain 21,688 3.8 27,634 4.9 16.8 21.4 North Simcoe Muskoka 8,294 3.4 10,764 4.4 17.8 23.1 North East 14,875 3.4 19,983 4.6 26.2 35.2 North West 8,871 4.4 11,415 5.6 37.5 48.3 Unknown LHIN 7,959 18.2 8,771 20.1 Out-of Province 2,484 2.2 3,158 2.7 Ontario Residents† 222,025 3.8 279,283 4.8 16.4 20.6 †Excludes out-of-province residents

Utilization of Adult Designated Mental Health Beds . In 2013/14, there were 56,636 admissions to and 61,372 active cases who received treatment in Ontario adult designated MH units. There were 56,629 discharges from these units with an average length of stay of 28.0 days. Toronto Central LHIN hospitals had the largest number of active cases, admissions, discharges and total days, while South East LHIN had the longest average length of stay for discharges. . Between 2010/11 and 2013/14, the number of active cases, admissions, and discharges increased by approximately 5%. However, there was a 5.6% reduction in the total days for discharged patients. There was no stable trend in the average length of stay in Ontario over the last four years; it ranged from 25.9 days in 2012/13 to 31.2 days in 2010/11. Since patients can have an extended stay in designated MH beds, the discharge of a single long-stay patient can skew the average length of stay values. . The case mix grouping method for OMHRS is the System for the Classification of Inpatient Psychiatry (SCIPP), which aggregates cases into broad diagnostic categories based on assessment information. The SCIPP group identifies the most resource intensive diagnosis among all the patient’s conditions. Mood disorders (30.2%), schizophrenia and psychotic disorders (28.4%), and short stay (25.4%) accounted for the largest proportions of active cases in Ontario adult designated MH units in 2013/14. . The proportion of active cases by SCIPP group varied by LHIN. Some of this variation is due to the locations and types of specialized care provided at the specialty MH hospitals. For example, Waterloo Wellington LHIN hospitals had a much larger proportion of active cases with substance related disorders, which is in part, due to the treatment focus of the Homewood Health Centre. Central West and North West LHINs had the largest proportion of short stay active cases. Central East and Erie St. Clair had the largest proportion of active cases for schizophrenia and psychotic disorders. Waterloo Wellington and South West LHINs had the largest proportion of mood disorder active cases.

Adult designated mental health unit utilization by LHIN of hospital, 2013/14 LHIN of hospital Active cases Admissions Discharges Total Days† Average LOS Erie St. Clair 2,886 2,715 2,706 55,712 20.6 South West 5,155 4,726 4,709 145,357 30.9 Waterloo Wellington 4,794 4,403 4,388 141,996 32.4 HNHB 5,708 5,297 5,269 129,292 24.5 Central West 2,620 2,525 2,526 27,754 11.0 Mississauga Halton 2,942 2,748 2,742 40,413 14.7 Toronto Central 9,368 8,655 8,681 295,870 34.1

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Central 5,127 4,976 4,958 58,841 11.9 Central East 5,948 5,273 5,291 180,121 34.0 South East 2,538 2,204 2,245 126,933 56.5 Champlain 5,820 5,442 5,415 133,900 24.7 North Simcoe Muskoka 3,319 2,963 2,967 105,315 35.5 North East 3,827 3,505 3,519 104,530 29.7 North West 1,320 1,204 1,213 38,465 31.7 Ontario Hospitals 61,372 56,636 56,629 1,584,499 28.0 †Discharged cases only

Proportion of active cases in adult designated mental health units by LHIN of hospital and SCIPP group, 2013/14 SCIPP Group Schizophrenia Substance Short & psychotic Cognitive Mood Personality related All other LHIN of hospital Stay‡ disorders disorders disorders disorders disorders disorders† Erie St. Clair 19.6 33.1 3.9 33.4 1.7 2.6 5.7 South West 23.9 24.7 7.4 33.9 2.0 3.1 4.9 Waterloo Wellington 17.8 15.1 2.8 39.4 2.3 16.5 6.3 HNHB 25.3 27.8 4.6 30.7 3.2 2.8 5.6 Central West 33.9 30.9 1.1 23.4 0.4 1.6 8.7 Mississauga Halton 26.2 31.0 4.9 31.4 1.1 1.8 3.6 Toronto Central 23.0 31.7 3.2 30.4 1.8 6.8 3.1 Central 31.2 30.5 3.7 26.7 2.0 1.7 4.3 Central East 21.7 33.7 5.4 31.3 1.6 1.8 4.4 South East 30.7 27.5 7.9 23.0 3.3 3.0 4.5 Champlain 25.8 30.4 7.6 25.6 2.6 3.8 4.1 North Simcoe Muskoka 29.8 24.4 3.6 29.1 3.3 4.4 5.5 North East 28.2 25.2 3.9 32.9 1.9 2.3 5.6 North West 33.9 27.3 5.4 19.0 3.5 3.2 7.7 Ontario Hospitals 25.4 28.4 4.7 30.2 2.1 4.4 4.9 ‡Includes inpatient stays (for any condition) of less than 72 hours. †Includes eating disorders, other disorders, ungroupable and non-mental health SCIPP groups.

. In 2013/14, there were 523.1 active cases in adult designated MH units per 100,000 Ontario residents aged 15 and older. The admission and discharge rates were comparable at 483.2 and 483.4, respectively. Residents of North East and North Simcoe Muskoka LHINs had the highest active case, admission and discharge rates. . Between 2010/11 and 2013/14, the active case, admission and discharge rates increased by approximately 3%.

Adult designated mental health unit utilization by LHIN of patient, 2013/14 Volumes Rates per 100,000 Population Age 15+ Active Total Average Active LHIN of patient Cases Admissions Discharges Days LOS Cases Admissions Discharges Erie St. Clair 2,997 2,798 2,779 63,086 22.7 561.9 524.6 521.1 South West 4,975 4,582 4,590 136,810 29.8 618.1 569.3 570.3 Waterloo Wellington 3,168 2,926 2,940 82,550 28.1 503.9 465.4 467.6 HNHB 5,924 5,496 5,467 136,244 24.9 495.2 459.4 457.0 Central West 2,674 2,517 2,542 52,917 20.8 371.2 349.4 352.9 Mississauga Halton 3,284 3,074 3,045 56,323 18.5 334.9 313.5 310.6 Toronto Central 6,611 6,177 6,156 184,172 29.9 630.6 589.2 587.2 Central 5,966 5,669 5,672 116,471 20.5 393.4 373.8 374.0 Central East 6,196 5,640 5,643 134,166 23.8 465.6 423.8 424.1 South East 1,973 1,670 1,752 106,071 60.5 466.0 394.5 413.8 Champlain 5,523 5,157 5,118 135,883 26.6 508.1 474.5 470.9 North Simcoe Muskoka 2,876 2,621 2,628 83,430 31.8 729.1 664.5 666.3 North East 3,971 3,650 3,655 98,576 27.0 821.1 754.8 755.8 North West 1,324 1,206 1,211 39,932 33.0 673.7 613.6 616.2 Unknown LHIN 1,882 1,629 1,646 98,093 59.6 C25

Out-of Province 2,028 1,824 1,785 59,775 33.5 Ontario Residents† 59,344 54,812 54,844 1,524,724 27.8 523.1 483.2 483.4 †Excludes out-of-province residents

Wait Time for Community Services . Organizations that receive Ontario MOHLTC/LHIN funding to provide MH/SA services must provide information to ConnexOntario Health Service Information for the Drug & Alcohol Helpline (DAH), Ontario Problem Gambling Helpline (OPGH) and Mental Health Helpline (MHH) registries, including regular reporting of the availability of service. Availability or "wait time" refers to the estimated date of the next available treatment slot, where treatment slot refers to a bed, appointment date, and/or caseload opening. Values shown are the median wait time (in days) for all organizations providing the service, across all reporting periods during the fiscal year. Blank values indicate that the service type is not provided within the LHIN, while those with a wait time of zero had no wait for service. . Support within housing and assertive community treatment (ACT) teams had the longest median wait times among the community MH services, while diversion and court support, early psychosis intervention, and short-term crisis beds had the shortest wait times for Ontario. There was substantial variation in wait time by LHIN and by service type. . The provision of SA treatment services varies by LHIN area, with more specialized services such as community and residential medical/psychiatric treatment and residential supportive treatment services being provided in less than half of all LHINs. Community and residential medical/psychiatric treatment, support within housing, and residential treatment had the longest median wait times among all the SA treatment services. . Community treatment is the only problem gambling service that is provided in all LHINs. The median wait time for Ontario was 5 days, with a range of 0 to 20 days by LHIN.

Median wait time (in days) to next available treatment slot for community mental health services by LHIN of service and service type, 2014/15 Abuse Case Counselling and Diversion and Court LHIN of service Service ACT Team Management Treatment Support Erie St. Clair 0 16 0 10 0 South West 0 0 3 4 0 Waterloo Wellington 0 0 22 28 3 HNHB 60 91 0 28 0 Central West 0 0 180 30 3 Mississauga Halton 120 14 16 0 Toronto Central 0 151 7 42 0 Central 29 1 17 21 0 Central East 7 0 7 9 0 South East 4 62 28 28 0 Champlain 24 181 7 32 0 North Simcoe 60 0 7 14 0 Muskoka North East 3 17 0 20 0 North West 0 26 6 0 0 Ontario 3 32 5 17 0

Median wait time (in days) to next available treatment slot for community mental health services by LHIN of service and service type (continued), 2014/15 Early Psychosis Short-Term Crisis Vocational/ LHIN of service Intervention Support Support within Housing Employment Erie St. Clair 0 0 14 14 South West 0 1 58 65 Waterloo Wellington 4 0 456 0 HNHB 0 0 32 0 Central West 61 0 1095 0 Mississauga Halton 7 0 83 25 Toronto Central 0 0 7 28 Central 4 0 32 0 Central East 0 0 365 South East 4 0 93 29 Champlain 0 0 0 0 C26

North Simcoe Muskoka 0 0 38 North East 0 1 30 0 North West 0 0 182 14 Ontario 0 0 77 9

Median wait time (in days) to next available treatment slot for substance abuse treatment services by LHIN of service and service type, 2014/15 Community Community Medical/ Community Case Day/Evening Psychiatric Community Withdrawal LHIN of service Management Treatment Treatment Treatment Management Erie St. Clair 0 0 0 0 South West 0 5 7 0 Waterloo Wellington 50 0 5 HNHB 54 0 4 1 Central West 0 0 2 Mississauga Halton 18 18 1 Toronto Central 0 1 2 1 Central 0 0 3 2 Central East 6 28 7 1 South East 0 14 Champlain 21 0 90 21 0 North Simcoe Muskoka 14 7 7 North East 5 0 12 0 North West 0 14 Ontario 14 0 65 9 1

Median wait time (in days) to next available treatment slot for substance abuse treatment services by LHIN of service and service type (continued), 2014/15 Residential Medical/ Residential Psychiatric Residential Supportive Level Residential Support within LHIN of service Treatment Supportive Level 1 2 Treatment Housing Erie St. Clair 32 48 South West 34 90 14 Waterloo Wellington 43 345 HNHB 0 42 23 7 Central West 344 Mississauga Halton 64 Toronto Central 32 0 57 0 Central 29 71 Central East 37 280 South East 19 21 Champlain 98 11 11 54 North Simcoe 47 35 29 Muskoka North East 0 0 10 39 North West 10 181 59 40 Ontario 52 7 15 31 39

Median wait time (in days) to next available treatment slot for problem gambling treatment services by LHIN of service and service type, 2014/15 Com. Day/Evening Community LHIN of service Treatment Treatment Public Awareness Residential Treatment Erie St. Clair 13 1 0 22 South West 14 Waterloo Wellington 1 C27

HNHB 0 10 0 Central West 6 Mississauga Halton 0 4 Toronto Central 0 3 0 Central 3 Central East 4 South East 2 0 Champlain 20 North Simcoe Muskoka 10 North East 1 4 North West 57 0 64 Ontario 0 5 0 19

North Simcoe Muskoka LHIN

Mental Health and Substance Abuse Emergency Department Visits . In 2013/14, there were 8,294 unscheduled ED visits for North Simcoe Muskoka residents where the main problem was a MH/SA condition. There were 10,764 visits in total or 2,470 additional visits with a MH/SA condition in any of the diagnostic fields. . Between 2010/11 and 2013/14, the number of visits with a MH/SA main problem diagnosis increased by 35.6% and there was 32.4% growth in visits with a MH/SA condition in any diagnostic field. . The main problem MH/SA visit rate for North Simcoe Muskoka LHIN residents was higher than the provincial average. The main problem visit rate increased by 32.4% over the period, while there was 29.3% growth in the any problem visit rate. . Visits with a MH/SA main problem diagnosis accounted for 3.4% of all ED visits for North Simcoe Muskoka LHIN residents.

Unscheduled emergency department utilization for mental health and substance abuse conditions, North Simcoe Muskoka LHIN and Ontario residents, 2013/14 Indicator North Simcoe Ontario† % change 2010/11- Muskoka LHIN 2013/14 LHIN of patient Main problem visits 8,294 222,025 35.6 % of total ED visits 3.4 3.8 Any problem visits 10,764 279,283 32.4 % of total ED visits 4.4 4.8 Main problem, visits per 1,000 17.8 16.4 32.4 Any problem, visits per 1,000 23.1 20.6 29.3 †LHIN of patient results for Ontario exclude out-of-province residents

Utilization of Adult Designated Mental Health Beds . In 2013/14, there were 2,963 admissions to and 3,319 active cases who received treatment in adult designated MH units in North Simcoe Muskoka LHIN hospitals. There were 2,967 discharges from these units with a total length of stay of 105,315 days. The average length of stay in North Simcoe Muskoka LHIN MH units was 35.5 days compared to 28.0 days for Ontario. Residents from outside the LHIN accounted for 23.0% of the active cases treated in North Simcoe Muskoka LHIN. The activity for North Simcoe Muskoka LHIN hospitals includes forensic cases treated at the Oakridge division of Waypoint Mental Health Centre. . Active cases, admissions, and discharges for North Simcoe Muskoka hospitals increased between 2010/11 to 2013/14, while total days decreased by 1.9%. . Short stay (29.8%), mood disorders (29.1%) and schizophrenia and psychotic disorders (24.4%) accounted for the largest proportions of active cases in North Simcoe Muskoka LHIN hospitals in 2013/14. Compared with the provincial average, North Simcoe Muskoka had larger proportions of active cases for short stay, personality disorders, and slightly more for ‘all other’ disorders. . There were 2,876 active cases, 2,621 admissions and 2,628 discharges for North Simcoe Muskoka LHIN residents from Ontario adult designated MH units. 11.1% of North Simcoe Muskoka LHIN residents’ active cases received treatment in hospitals outside the LHIN. North Simcoe Muskoka LHIN residents had the 2nd highest rates of active cases, admissions, and discharges per 100,000 population in the province. . Active cases, admissions, discharges, and the associated rates increased for North Simcoe Muskoka LHIN residents between 2010/11 and 2013/14, while total days declined.

Adult designated mental health unit utilization, North Simcoe Muskoka LHIN hospitals and residents, 2013/14

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Indicator North Simcoe Ontario† % change 2010/11- Muskoka LHIN 2013/14 LHIN of hospital Active cases 3,319 61,372 8.0 Admissions 2,963 56,636 7.8 Discharges 2,967 56,629 8.5 Total Days (discharged patients only) 105,315 1,584,499 -1.9 Average Length of Stay 35.5 28.0 % Inflow Active Cases 23.0 % of Active Cases by SCIPP Group: Short Stay 29.8 25.4 Schizophrenia & Psychotic Disorders 24.4 28.4 Cognitive Disorders 3.6 4.7 Mood Disorders 29.1 30.2 Personality Disorders 3.3 2.1 Substance Related Disorders 4.4 4.4 All Other Disorders 5.5 4.9 LHIN of patient Active cases 2,876 59,344 10.0 Admissions 2,621 54,812 11.0 Discharges 2,628 54,844 10.3 Total Days 83,430 1,524,724 -7.9 Average Length of Stay 31.8 27.8 % Outflow Active Cases 11.1 Active Cases per 100,000 (age 15+) 729.1 523.1 6.7 Admission per 100,000 (age 15+) 664.5 483.2 7.6 Discharges per 100,000 (age 15+) 666.3 483.4 7.0 †LHIN of patient results for Ontario exclude out-of-province residents

Wait Time for Community Services . In 2014/15, abuse services and support within housing had the longest median wait times among the community MH services provided in North Simcoe Muskoka LHIN. The median wait times for North Simcoe Muskoka abuse and case management programs were greater than the medians for Ontario. . Among the SA services provided in North Simcoe Muskoka LHIN, residential medical/psychiatric and residential treatment had the longest median wait times in 2014/15. The median wait time in North Simcoe Muskoka LHIN for residential treatment was longer than that for the province. . The median wait time for community treatment for problem gambling in North Simcoe Muskoka LHIN was 10 days, which was longer than the provincial median wait time in 2014/15.

Median wait time (in days) to next available treatment slot for community mental health, substance abuse and problem gambling services by service type, North Simcoe Muskoka LHIN service providers, 2013/14- 2014/15 North Simcoe Muskoka LHIN Ontario Service Type 2013/14 2014/15 2013/14 2014/15 Community Mental Health Services Abuse Service 60 60 3 3 Assertive Community Treatment Team 21 0 41 32 Case Management 8 7 4 5 Counselling and Treatment 14 14 16 17 Diversion and Court Support 0 0 0 0 Early Psychosis Intervention 0 0 0 0 Short-Term Crisis Support Beds 0 0 0 0 Support Within Housing 18 38 53 77 Vocational/Employment 3 9 Substance Abuse Services Case Management 0 14 14 14 C29

Centralized/Coordination Access 0 0 Community Day/Evening Treatment 0 0 Community Medical/Psychiatric Treatment 55 65 Community Treatment 8 7 11 9 Community Withdrawal Management 7 7 1 1 Residential Medical/Psychiatric Treatment 47 47 48 52 Residential Supportive Level 1 17 7 Residential Supportive Level 2 30 15 Residential Treatment 28 35 32 31 Support within Housing 69 29 52 39 Problem Gambling Services Community Day/Evening Treatment 0 0 Community Treatment 10 10 7 5 Public Awareness 1 0 Residential Treatment 37 19

Analysis of Complex Continuing Care Utilization

Notes: Analysis of complex continuing care utilization (2001/02-2013/14) is based on data reported to the Continuing Care Reporting System-CCC (CCRS-CCC). ONTARIO

Complex Continuing Care . Complex continuing care (CCC) is the provision of continuing, medically complex, and specialized services in a hospital setting for individuals of any age who have long-term illnesses or disabilities and who require skilled, multidisciplinary, technology based care that is not available in the patient’s home or in LTC homes. Patients often remain in CCC for an extended period of time. . Active cases are those that received one or more day of treatment in a CCC unit during the fiscal year. Discharges are those that occurred in 2013/14 and will include episodes admitted in previous fiscal years. The total days and average length of stay refer only to episodes that were discharged in 2013/14. . There were 29,502 active cases, 23,986 admissions and 24,050 discharges from Ontario hospital CCC units in 2013/14. Toronto Central and Hamilton Niagara Haldimand Brant (HNHB) LHIN hospitals had the largest number of active cases, admissions and discharges in 2013/14. The average length of stay in Ontario CCC units was 78.7 days. There was substantial variation in the length of stay by LHIN with a range from 31.8 days in Central LHIN to 145.5 days in Champlain LHIN hospitals. Since patients may remain in CCC for an extended period, the discharge of a single long-stay patient can have a significant impact on the average length of stay. . Between 2010/11 and 2013/14, there was growth in active cases (2.8%), admissions (5.1%), and discharges (4.9%) and an 8.0% reduction in the total days for Ontario CCC units. However there was no stable trend across LHIN areas. HNHB and North Simcoe Muskoka LHIN hospitals had the greatest growth in active cases, while Central West and North West had the greatest reduction over the period. The average length of stay in Ontario CCC units declined from 89.8 days in 2010/11 to 78.7 days in 2013/14. . North West, HNHB and Toronto Central LHIN residents had the highest CCC active case rates, while residents of Central West, Champlain, and Mississauga Halton LHINs had the lowest. The active case rate for Central West LHIN was substantially lower than the rates for other LHINs, approximately one-third of the provincial rate. . The average length of stay ranged from 54.3 days for HNHB LHIN residents to 147.4 days for Champlain LHIN residents.

Complex continuing care utilization by LHIN of hospital, 2013/14 Average LHIN of hospital Active Cases Admissions Discharges Total Days† CCC LOS† Erie St. Clair 1,548 1,257 1,284 134,561 104.8 South West 1,969 1,618 1,660 117,383 70.7 Waterloo Wellington 1,352 1,119 1,095 73,787 67.4 HNHB 5,477 4,675 4,634 249,653 53.9 Central West 259 213 228 12,815 56.2 Mississauga Halton 1,516 1,244 1,277 113,928 89.2 Toronto Central 7,542 5,926 5,910 603,917 102.2 Central 1,410 1,300 1,299 41,357 31.8 Central East 1,964 1,687 1,693 92,244 54.5 South East 1,424 1,133 1,155 63,435 54.9 Champlain 1,936 1,387 1,390 202,200 145.5 C30

North Simcoe Muskoka 843 725 734 38,866 53.0 North East 1,180 837 847 87,341 103.1 North West 1,082 865 844 61,736 73.2 Ontario hospitals 29,502 23,986 24,050 1,893,223 78.7 †Discharged cases only. Complex continuing care utilization by LHIN of patient, 2013/14 Active Cases/1,000 Average LHIN of patient Active Cases Population Admissions Discharges Total Days† CCC LOS† Erie St. Clair 1,552 243.2 1,258 1,290 137,662 106.7 South West 1,962 204.1 1,613 1,660 116,257 70.0 Waterloo Wellington 1,354 177.6 1,121 1,099 66,819 60.8 HNHB 5,451 384.0 4,652 4,601 249,615 54.3 Central West 678 76.1 567 560 33,206 59.3 Mississauga Halton 1,683 141.3 1,349 1,392 133,981 96.3 Toronto Central 3,848 313.7 3,017 3,034 327,864 108.1 Central 3,076 169.4 2,594 2,579 182,860 70.9 Central East 3,237 205.5 2,779 2,754 160,286 58.2 South East 1,427 289.3 1,138 1,152 64,563 56.0 Champlain 1,815 140.3 1,297 1,302 191,945 147.4 North Simcoe Muskoka 668 143.1 555 571 34,325 60.1 North East 1,205 212.5 858 867 91,085 105.1 North West 1,079 456.6 863 844 59,857 70.9 Unknown 232 175 175 20,040 114.5 Out-of-province 235 150 170 22,858 134.5 Ontario residentsǂ 29,267 216.2 23,836 23,880 1,870,365 78.3 †Discharged cases only ǂExcludes out-of-province residents

North Simcoe Muskoka LHIN

Complex Continuing Care . In 2013/14, there were 843 CCC active cases treated in North Simcoe Muskoka LHIN hospitals and residents from outside the LHIN accounted for 29.2% of these active cases. There were 725 CCC admissions and 734 discharges from North Simcoe Muskoka LHIN hospitals in 2013/14. In 2013/14, North Simcoe Muskoka LHIN had the 2nd shortest average CCC length of stay in the province. . Between 2010/11 and 2013/14, CCC active cases, admissions, discharges, and total length of stay increased for North Simcoe Muskoka LHIN hospitals. . In 2013/14, there were 668 CCC active cases for North Simcoe Muskoka LHIN residents, and 10.6% were treated in hospitals outside the LHIN. There was a reduction in the number and rate of active cases, admissions, discharges and total days for LHIN residents over the period. . North Simcoe Muskoka LHIN residents had the 3rd lowest active case rate in the province and this rate was lower than the provincial average. North Simcoe Muskoka LHIN residents also had a shorter average length of stay than the province in 2013/14.

Utilization of complex continuing care, North Simcoe Muskoka LHIN and Ontario, 2013/14 Indicator North Simcoe Ontario† LHIN % change Muskoka LHIN 2010/11-2013/14 LHIN of hospital Active cases 843 29,502 16.4 % Inflow 29.2 Admissions 725 23,986 22.3 Discharges 734 24,050 22.3 Total days‡ 38,866 1,893,223 2.8 Average LOS‡ 53.0 78.7 LHIN of patient Active cases 668 29,267 -10.6 % Outflow 10.6 Active cases per 100,000 population 143.1 216.2 -12.7 Admissions 555 23,836 -8.0

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Discharges 571 23,880 -7.0 Total days‡ 34,325 1,870,365 -14.6 Average LOS‡ 60.1 78.3 †LHIN of patient results for Ontario exclude out-of-province residents ‡Discharged cases only.

Home Care Utilization

Notes: Analysis is based on data from the Home Care Database.

ONTARIO

Active Home Care Clients . In Ontario, Community Care Access Centres (CCACs) are responsible for the management of a range of health care services, including placements to long-term care homes, case management, and the provision of home care services. Home care services include in-home professional services (e.g. nursing, physiotherapy), in-home personal support and homemaking, and school health services for children. It is important to note that not all CCACs offer/capture the same services in the same manner; therefore some differences between LHINs may be due to data collection or the types of services that they provide. In August 2013, the ministry instituted physiotherapy reform which included an expansion of in-home physiotherapy for up to 60,000 more seniors and people with mobility issues. As part of this initiative, CCACs were asked to clear current physiotherapy waitlists in order to manage the substantial influx of new physiotherapy clients post-August 1, 2013. As a result, this will affect the physiotherapy numbers and rates in 2013/14. . Active home care clients are those that received one or more home care service during the fiscal year. . In 2013/14, there were 624,355 active home care clients in Ontario. HNHB and Central East had the largest number of active clients while North West and North Simcoe Muskoka LHINs had the smallest. . In 2013/14, there were 45.8 active home care clients per 1,000 population for Ontario overall. South East and North East LHINs had the highest rate of active clients, while Mississauga Halton and Central LHINs had the lowest rates in the province. Number of active home care clients and rate per 1,000 population by LHIN, 2013/14 Number of Active Clients Crude Rate of Active Clients per 1,000 Population LHIN # % % change # % change 2010/11- 2010/11-2013/14 2013/14 Erie St Clair 37,043 5.9 6.3 57.6 6.5 South West 54,870 8.8 12.7 56.6 11.1 Waterloo Wellington 36,630 5.9 14.7 47.2 10.7 HNHB 79,188 12.7 13.9 55.1 11.5 Central West 31,011 5.0 14.5 36.2 10.1 Mississauga Halton 40,932 6.6 12.9 33.5 7.2 Toronto Central 48,759 7.8 -40.5 42.4 -40.8 Central 66,414 10.6 20.9 35.5 13.7 Central East 71,099 11.4 16.1 42.9 10.7 South East 30,679 4.9 18.6 62.2 17.8 Champlain 56,893 9.1 16.0 44.3 12.7 North Simcoe Muskoka 22,806 3.7 17.7 48.4 14.0 North East 34,148 5.5 9.0 60.6 9.9 North West 13,883 2.2 16.5 58.0 16.3 Ontario 624,355 100.0 6.9 45.8 3.7

CCAC Services by Type . As noted, services may not be offered by all CCACs. For example, psychology visits occurred in only two LHINs, respiratory visits in four LHINs, and ‘other’ visits in 11 of the 14 LHINs in 2013/14. Since these services are not consistently available in all LHINs, provincial rates for these services will be misleading. Therefore values for psychology, respiratory and ‘other’ are not shown; however these services are included within the ‘All Visits’ totals. . In 2013/14, there were just over 9.9 million home care visits, which represented 729.7 visits per 1,000 population. The number of visits ranged from 256,031 in the North West LHIN to 1,335,574 in the HNHB LHIN, while the visit rates ranged from 452.6 in the Central West LHIN to 1,197.3 per 1,000 population in the North East LHIN.

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. Nursing and case management accounted for the largest number of visits. However not all LHINs report case management services in the same manner; therefore differences between LHINs may be due to differences in data collection. In 2013/14, the nursing visit rate for Ontario was 474.8 visits per 1,000 population. The nursing visit rate ranged from 292.0 in the Central West LHIN to 768.3 in the North West LHIN. . In 2013/14 there were nearly 29 million home care service hours in Ontario, or 2,126.5 service hours per 1,000 population. The service hour rates ranged from 1,420.2 in the Mississauga Halton LHIN to 3,064.8 in the Hamilton Niagara Haldimand Brant LHIN in 2013/14. Personal support work and homemaking accounted for 93.4% of all home care service hours in 2013/14. . Between 2010/11 and 2013/14 there was a 16.2% increase in home care visits and a 29.6% increase in home care service hours for Ontario. The services with the largest increase in visits/hours over the period were physiotherapy (68.9%), personal support work and homemaking (30.6%), nursing shift (17.4%), and occupational therapy (16.9%).

Summary of CCAC Services‡ by Type in Ontario, 2013/14 Visits/Hours Crude Rate/1,000 population % change % change 2010/11- Services by Type # Rate Range in LHINs 2010/11-2013/14 2013/14 Service Visits All Visits† 9,947,405 16.2 729.7 12.6 452.6 - 1,197.3 Nursing Visit 6,472,107 13.5 474.8 10.0 292.0 - 768.3 Physiotherapy 721,032 68.9 52.9 63.7 34.6 - 75.7 Occupational Therapy 553,173 16.9 40.6 13.3 23.6 - 72.6 Social Work 51,182 -1.2 3.8 -4.2 0.8 - 9.8 Nutrition and Dietetic 47,667 5.3 3.5 2.1 1.4 - 7.4 Speech Language Therapy 265,082 13.0 19.4 9.5 9.1 - 49.1 Case Management 1,799,132 10.9 132.0 7.5 61.3 - 392.6 Service Hours All Hours 28,989,316 29.6 2,126.5 25.6 1,420.2 - 3,064.8 Nursing Shift 1,899,307 17.4 139.3 13.9 21.1 - 275.1 Personal Support Work and 27,090,009 30.6 1,987.2 26.7 1,329.4 - 2,926.4 Homemaking ‡Not all CCACs offer the same services or report services in the same manner. For example, case management visits may not be reported consistently across LHINs. †Includes visits for respiratory, psychology, and ‘other’ service types (not shown), which are not consistently reported/available in all LHINs.

North Simcoe Muskoka LHIN

Active Home Care Clients . In 2013/14, there were 22,806 active home care clients in NSM LHIN. . Compared with Ontario, NSM LHIN had a higher rate of active home care clients. . Between 2010/11 and 2013/14, there was a 17.7% increase in active home care clients and a 14.0% increase in the active client rate for NSM LHIN. CCAC Services by Type . In the NSM LHIN, there were 362,676 home care visits and 1,145,839 home care service hours in 2013/14. . Between 2010/11 and 2013/14, there was a 9.9% increase in all home care visits and a 29.9% increase in all service hours in NSM LHIN. During the period, the service types with the largest increase in visits/hours were physiotherapy (37.5%), personal support work and homemaking (37.0%), and occupational therapy (15.0%). There was a reduction in visits/hours, during the period, for social work, nutrition and dietetic, speech language therapy, and nursing shifts. . NSM LHIN had higher rates of home care visits and service hours than the province in 2013/14. . Compared with Ontario, NSM LHIN had higher rates for nursing, nutrition and dietetic, case management, and personal support work and homemaking in 2013/14. Home Care Clients and Services in the North Simcoe Muskoka LHIN, 2013/14 North Simcoe Muskoka LHIN % change 2010/11- Indicator Ontario LHIN 2013/14 Active Clients 22,806 624,355 17.7 Active Clients/1,000 Population 48.4 45.8 14.0 Number of Visits All Visits† 362,676 9,947,405 9.9 Nursing Visit 242,801 6,472,107 11.9 Physiotherapy 21,055 721,032 37.5 C33

Occupational Therapy 17,788 553,173 15.0 Social Work 1,928 51,182 -28.1 Nutrition and Dietetic 2,262 47,667 -16.4 Speech Language Therapy 7,149 265,082 -5.9 Case Management 69,368 1,799,132 0.3 Number of Hours All Hours 1,145,839 28,989,316 29.9 Nursing Shift 53,662 1,899,307 -36.6 Personal Support Work and 1,092,177 27,090,009 37.0 Homemaking Service Visits/1,000 Population All Visits† 769.5 729.7 6.2 Nursing Visit 515.1 474.8 8.2 Physiotherapy 44.7 52.9 33.0 Occupational Therapy 37.7 40.6 11.2 Social Work 4.1 3.8 -30.5 Nutrition and Dietetic 4.8 3.5 -19.2 Speech Language Therapy 15.2 19.4 -9.0 Case Management 147.2 132.0 -3.1 Service Hours/1,000 Population All Hours 2,431.0 2,126.5 25.6 Nursing Shift 113.8 139.3 -38.6 Personal Support Work and 2,317.2 1,987.2 32.7 Homemaking †Includes visits for respiratory, psychology, and ‘other’ service types (not shown), which are not consistently reported/available in all LHINs.

Long-Term Care: Supply, Demand, and Time to Placement

Notes: Analysis is based on data from the Long- Term Care System Reports (Health Data Branch), Client Profile Database (CPro) and the Occupancy Monitoring Database (OCCM). ONTARIO . LTC supply is the number of long-term care (LTC) home beds occupied or available for occupancy (adjusted for bed openings and closings) including long stay, short stay (respite and convalescent care), and interim beds as of March 31, 2014. . The LTC waitlist is the total number of clients on the waiting list for a long stay bed during the fiscal year, excluding those who were already occupying a permanent or interim bed and awaiting a transfer. . LTC demand includes LTC residents plus clients on the wait list. . The Time to Placement (TTP) is the median number of days from application to placement for those clients placed in a long-stay bed in the fiscal year. These values exclude clients who were transferred from another LTC home. . In 2013/14, the LTC Home bed supply rate (per 1,000 population age 75+) ranged from 62 in Mississauga Halton LHIN to 105 in North East LHIN. . The LTC resident rate was 79.7 for Ontario overall and ranged from 60.9 in Mississauga Halton LHIN to 100.0 in North East LHIN. The LTC waitlist rate ranged from 10.3 in Central West to 37.7 in Central East LHIN. The LTC demand rate ranged from 81.2 in Mississauga Halton to 132.8 in North West LHIN. . The LHINs with greater supply of LTC home beds did not necessarily have lower waitlists. For example, Champlain and Erie St. Clair LHINs had similar LTC bed supply rates, but had very different waitlist rates (12.4 for Erie St. Clair and 24.7 for Champlain). . The median TTP ranged from 58 days in North East LHIN to 199 days in Toronto Central LHIN. . The supply of LTC Home beds was not necessarily related to the median TTP. Waterloo Wellington and Central East LHINs had similar supply rates, but the median TTP in Waterloo Wellington was 79 days, whereas in Central East LHIN it was 138 days.

LTC supply, residents, waitlist and demand rates per 1,000 population, age 75+ and median TTP, 2013/14 LTC supply, residents, waitlist and demand

per 1,000 population age 75+ Median LTC beds TTP (days) LHIN LTC Supply LTC Residents LTC demand waitlist Erie St. Clair 87.6 83.9 12.4 96.4 99 South West 97.4 94.6 16.8 111.3 60 Waterloo Wellington 81.4 79.3 19.6 98.9 79 C34

HNHB 88.6 86.3 15.3 101.6 81 Central West 81.3 79.0 10.3 89.3 74 Mississauga Halton 62.3 60.9 20.2 81.2 189 Toronto Central 73.1 71.3 24.2 95.5 199 Central 62.9 60.3 23.9 84.2 157 Central East 82.9 80.2 37.7 118.0 138 South East 92.2 90.0 17.7 107.7 84 Champlain 87.5 84.0 24.7 108.7 111 North Simcoe Muskoka 82.3 78.1 32.4 110.5 152 North East 104.6 100.0 25.0 124.9 58 North West 99.1 95.8 37.0 132.8 169 Ontario 82.6 79.7 22.7 102.4 108

North Simcoe Muskoka LHIN

. The LTC bed supply rate (per 1,000 population, age 75+) in the North Simcoe Muskoka LHIN was similar to the rate for Ontario overall. . While the LTC resident rate was comparable to the Ontario rate, North Simcoe Muskoka LHIN had higher waitlist and LTC demand rates than the province. . The median overall TTP for North Simcoe Muskoka LHIN (152 days) was much longer than the provincial median (108 days). Among all LHINs, North Simcoe Muskoka LHIN had the 3rd highest median TTP for clients from acute care, 55 days longer than the provincial median. . The median overall TTP increased by over 30% between 2011/12 and 2013/14, to 152 days.

LTC supply, residents, waitlist and demand (number and rate per 1,000 population, age 75+) and median TTP, North Simcoe Muskoka LHIN, 2013/14 North Simcoe Muskoka Ontario Comments† LHIN # Rate‡ # Rate‡ LTC Bed Supply Long stay beds, including interim 3,027 77,014 Short stay respite & convalescent care beds 74 1,037 Total beds in operation 3,101 82.3 78,051 82.6 LTC residents 2,942 78.1 75,489 79.7 LTC beds waitlist 1,222 32.4 21,547 22.7 3rd highest LTC demand (residents + waitlist) 4,164 110.5 97,036 102.4 Median time to LTC Placement (in days) Overall 152 108 From Acute Care only 124 69 3rd highest From Community 160 116 ‡Rate per 1,000 population age 75+ †Ranking in the province, compared to other LHINs.

Primary Care Selected indicators from the Health Care Experience Survey, Follow-up with a primary care physician following acute hospital discharge, Primary care enrolment

Notes: Analysis of selected indicators from the Health Care Experience Survey; percentage of patients who saw a primary care physician within seven days of acute discharge from hospital for selected conditions (based on 25 Case Mix Groups (CMGs)), derived from data from the Discharge Abstract Database (DAD), Claims History Database (CHDB), and Corporate Provider Database (CPDB); and primary care enrolment, obtained from the Primary Health Care Status Report, derived from the Client Agency Program Enrolment (CAPE) and CPDB. ONTARIO Access to, and satisfaction with, primary care

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. Timely and appropriate access to primary health care is a key part of the Ministry’s Action Plan for Health Care. Specifically, goals include ease of access and faster access to primary care, with more patients receiving same day or next day appointments. . In 2014, 94.0% of Ontarians aged 16 years and older had a primary care provider (referred to as the attachment rate). The attachment rate ranged from 87.3% in the North West LHIN to 97.3% in the South East LHIN. . As well, 44.3% of Ontarians aged 16 and older were able to see a primary care provider on the same day or next day when they were sick; this ranged from 28.4% in the North West LHIN to 57.0% in Central West LHIN. . Access to after-hours care is another important component of primary care in Ontario. In 2014, 38.1% of Ontarians aged 16 and older were aware that their provider offers an after-hours clinic. In addition, 52.4% had difficulty accessing after-hours care without going to an emergency department; this was lowest for the Mississauga Halton LHIN at 45.3% and highest for the North West LHIN at 73.0%. . The majority of Ontarians aged 16 and older who were attached reported that their primary care provider always or often gives them the opportunity to ask questions (85.3%); similarly, most reported that their provider always or often spends enough time with them (82.5%). Primary care physician follow-up . Physician visits within seven days of discharge from an acute hospital stay can help to integrate patient care, and prevent avoidable hospital readmissions. . In 2013/14, almost 36% of Ontario patients who had an acute hospital discharge (for selected conditions based on 25 Case Mix Groups (CMGs)) saw a primary care physician (GP/FP or pediatrician) within seven days of their discharge. This ranged from 24.6% for North West LHIN patients to 46.3% for Central West LHIN patients. . The percent of Ontario patients who saw a primary care physician within seven days of discharge was 41.2% for congestive heart failure (CHF) discharges and 34.3% for chronic obstructive pulmonary disease (COPD) discharges. The proportion of patients who saw a primary care provider for CHF discharges was consistently higher than the proportion who saw a primary care provider for COPD discharges across all the LHINs. Primary care enrolment . Patient enrolment models (PEMs) are primary care physician payment models that involve comprehensive care-based group practice and patient rostering (i.e., enrolment with a particular primary care provider group). . Over 10.4 million Ontarians were enrolled with a PEM as of May 2015. . Of those enrolled in PEMs, 62% were enrolled with a Family Health Organization (FHO), almost 30% with a Family Health Group (FHG) and 3.8% in Comprehensive Care Models (CCMs). Primary care access and satisfaction, adults (aged 16 and older), by LHIN of residence, January 2014- December 2014 Access to, and satisfaction with, primary care % aware of % with difficulty % whose % same/next % whose provider % patient after-hours accessing after- provider allows day access spends enough attachment clinic offered hours care without opportunity for when sick time with them LHIN of residence by provider going to ED questions Erie St. Clair 96.0% 42.5% 35.5% 61.9% 84.8% 82.2% South West 94.8% 41.3% 42.5% 56.9% 87.6% 81.7% Waterloo Wellington 96.5% 42.6% 50.9% 54.1% 86.7% 83.6% HNHB 95.7% 48.7% 49.6% 48.3% 88.3% 84.5% Central West 93.8% 57.0% 32.2% 46.8% 76.8% 74.5% Mississauga Halton 94.5% 47.6% 36.9% 45.3% 80.9% 80.7% Toronto Central 91.8% 49.3% 34.5% 49.4% 89.3% 85.0% Central 94.2% 48.1% 30.0% 48.6% 84.6% 82.8% Central East 93.7% 39.0% 37.1% 49.5% 83.0% 81.5% South East 97.3% 39.5% 41.9% 59.6% 91.8% 86.9% Champlain 92.5% 44.0% 37.8% 56.4% 87.4% 83.5% North Simcoe 96.5% 29.4% 34.8% 61.1% 87.1% 81.7% Muskoka North East 88.3% 31.9% 34.6% 61.1% 84.0% 85.5% North West 87.3% 28.4% 38.7% 73.0% 82.1% 80.4% Ontario 94.0% 44.3% 38.1% 52.4% 85.3% 82.5%

Percentage of patients who saw a primary care physician within seven days of acute discharge from hospital for selected conditions based on 25 Case Mix Groups, by LHIN of patient, 2013/14 Primary care physician follow-up within 7 days of discharge Total number of % with visits in Discharges for % with visits in Discharges for % with visits in discharges for all 7 days CHF patients 7 days COPD patients 7 days LHIN of patient conditions

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(based on 25 CMGs) Erie St. Clair 2,689 35.0% 308 37.7% 435 34.3% South West 3,580 30.6% 490 34.7% 499 29.6% Waterloo Wellington 2,275 34.8% 287 38.1% 332 33.9% HNHB 6,090 36.7% 807 39.5% 856 37.6% Central West 3,198 46.3% 375 52.4% 299 44.4% Mississauga Halton 3,937 43.0% 495 49.4% 373 41.9% Toronto Central 3,865 38.6% 622 47.3% 443 38.2% Central 5,515 42.4% 787 47.8% 544 43.2% Central East 5,057 37.1% 658 40.3% 705 32.5% South East 2,112 34.9% 278 43.7% 373 34.0% Champlain 3,710 32.0% 511 37.9% 650 30.5% North Simcoe 1,865 33.3% 209 37.1% 302 31.5% Muskoka North East 2,715 27.2% 312 34.1% 547 30.3% North West 1,030 24.6% 110 30.1% 172 25.0% Ontario 47,941 35.9% 6,293 41.2% 6,570 34.3%

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Number of Ontarians enrolled in Patient Enrolment Models (PEMs) by LHIN of Provider and Group Type*, as of May 2015 Patients enrolled, by Primary Care Models Total # LHIN of provider CCM CSA FHG FHN FHO RNPGA Other enrolled # % # % # % # % # % # % # % Erie St. Clair 473,920 21,377 4.5% 12,302 2.6% 128,788 27.2% 10,671 2.3% 300,782 63.5% - 0.0% - 0.0% South West 745,139 25,168 3.4% 13,863 1.9% 102,423 13.7% 43,258 5.8% 560,427 75.2% - 0.0% - 0.0% Waterloo Wellington 585,108 6,501 1.1% 11,030 1.9% 5,228 0.9% - 0.0% 562,349 96.1% - 0.0% - 0.0% HNHB 1,121,586 35,888 3.2% 6,998 0.6% 280,170 25.0% 45,796 4.1% 752,597 67.1% - 0.0% 137 0.0% Central West 684,005 17,556 2.6% - 0.0% 419,973 61.4% - 0.0% 246,476 36.0% - 0.0% - 0.0% Mississauga Halton 920,583 42,014 4.6% - 0.0% 409,941 44.5% - 0.0% 467,451 50.8% - 0.0% 1,177 0.1% Toronto Central 1,009,659 52,258 5.2% - 0.0% 284,932 28.2% - 0.0% 652,658 64.6% - 0.0% 19,811 2.0% Central 1,298,732 72,964 5.6% 7,164 0.6% 666,177 51.3% - 0.0% 552,297 42.5% - 0.0% 130 0.0% Central East 1,321,965 53,335 4.0% 2,295 0.2% 450,868 34.1% - 0.0% 815,467 61.7% - 0.0% - 0.0% South East 400,406 18,182 4.5% 10,222 2.6% 37,828 9.4% 20,101 5.0% 313,935 78.4% - 0.0% 138 0.0% Champlain 973,635 30,791 3.2% 17,126 1.8% 236,045 24.2% - 0.0% 689,673 70.8% - 0.0% - 0.0% N Simcoe Muskoka 344,779 1,906 0.6% - 0.0% 13,471 3.9% 36,784 10.7% 292,618 84.9% - 0.0% - 0.0% North East 408,989 10,012 2.4% 1,626 0.4% 40,987 10.0% 48,807 11.9% 201,479 49.3% 42,483 10.4% 63,595 15.5% North West 166,010 5,811 3.5% - 0.0% 51,595 31.1% 17,218 10.4% 65,069 39.2% 23,546 14.2% 2,771 1.7% Ontario 10,454,516 393,763 3.8% 82,626 0.8% 3,128,426 29.9% 222,635 2.1% 6,473,278 61.9% 66,029 0.6% 87,759 0.8% *see next table for description of group types

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Primary Care Models CCM Comprehensive Care Models are solo-practitioners who enroll patients but are paid primarily on a fee-for- service basis CSA Community Sponsored Agreement Models where physicians are paid largely by salary and part of a FHT. FHG Family Health Group Models where physicians are paid Fee-for-Service plus incentives. FHN Family Health Network FHO Family Health Organization RNPGA Rural and Northern Physician Group Agreement Other Includes groups with alternate payment type agreements for primary care services to a specific patient type such as HIV or palliative, or primary care in a specific location such as Sault Ste Marie or Moose Factory.

North Simcoe Muskoka LHIN

Access to, and satisfaction with, primary care . In 2014, 96.5% of North Simcoe Muskoka adults (aged 16 years and older) had a primary care provider; this was the third highest attachment rate among the LHINs. . Close to 30% of adults in the North Simcoe Muskoka LHIN were able to see a primary care provider on the same day or next day when they were sick. This was the second lowest proportion among the LHINs. . 34.8% of LHIN adults were aware that their provider offers an after-hours clinic. In addition, 61.1% had difficulty accessing after-hours care without going to an emergency department; this was the third highest proportion in the province. . 87.1% of adults in the LHIN who were attached reported that their primary care provider always or often gives them the opportunity to ask questions, and 81.7% reported that their provider always or often spends enough time with them. Primary care physician follow-up . In 2013/14, 33.3% of patients in the North Simcoe Muskoka LHIN who had an acute hospital discharge (for selected conditions based on 25 CMGs) saw a primary care physician within seven days of their discharge. . The percent of LHIN patients who saw a primary care physician was 37.1% for CHF discharges and 31.5% for COPD discharges, both of which were lower than the corresponding proportions for Ontario. Primary care enrolment . Over 344,000 Ontarians were enrolled with a PEM located in the North Simcoe Muskoka LHIN as of May 2015. . Of those enrolled in PEMs located in the LHIN, almost 85% were enrolled in a FHO and 10.7% in a Family Health Network (FHN).

Health Human Resources

Notes: This document and the accompanying workbook contain data extracted from existing published reports (Physician in Ontario Report and Health Professions Database 2011 Stat Book) or data query tool (College of Nurses of Ontario (CNO)). Only members in their respective regulatory college verified as actively practicing in Ontario are included. College members who hold educational certificates (i.e. are registered as students or interns) are excluded. LHIN classification is based on practice location.

Counts and rates in this report refer to health professionals in active practice, defined as follows: Physicians are those licensed to practice and practicing in Ontario for a significant portion of the calendar year. Nurses employed in Ontario in full-time, part-time, and casual positions. Employment information is collected on all of a member's nursing employers. Health Professionals are those who held active registration with their Regulatory College and are able to practice in full or in any one capacity (clinical, research, teaching, sales, health promotion, etc.).

The numbers in this report need to be interpreted with caution. The counts are not full time equivalents (FTEs), therefore a professional who works part-time is counted the same way as one who works full-time. This is especially true for physicians in the older age categories, as older physicians may reduce their medical practice activities.

Nursing employment information is provided by the CNO. There was a change in the data collection method in 2011 to include information from all the members’ employers. Prior to 2011, employment information was only collected from the member's primary nursing employer. Therefore comparison to employment information reported prior to 2011 is not possible.

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Finally, the rates shown are counts of the number of providers practicing in each LHIN divided by the LHIN’s population and do not take into consideration that LHIN residents may receive care from providers in other LHINs.

ONTARIO

Physicians . From 2010 to 2013, the total number of physicians (family physicians and specialists) in Ontario increased from 24,875 in 2010 to 27,125 in 2013, an increase of 9.0%. Over the same time period, the Ontario population grew at a slower rate (2.5%). . The rate of total physicians (per 100,000 population) increased from 188.3 in 2010 to 200.2 in 2013. . There was a moderate increase in the number of family physicians (8.7%) between 2010 (11,628) and 2013 (12,635). Across LHINs, rates of family physicians ranged from 67.7 in Central West LHIN to 135.0 in Toronto Central LHIN in 2013. . There was a 9.4% increase in the number of specialists between 2010 (13,247) and 2013 (14,490). Across LHINs, rates of specialists ranged from 51.3 in Central West LHIN to 299.8 in Toronto Central LHIN in 2013. . The majority of family physicians in Ontario were between the ages of 30 and 64 (84.3%), with just over 13.7% age 65 and over. Nurses . The total number of nurses in Ontario increased from 147,510 in 2011 to 161,022 in 2014, an increase of 9.2%. The rate of nurses increased from 1,112.1 in 2011 to 1,177.2 in 2014. . There was a 4.4% increase in the number of registered nurses (RNs) between 2011 (107,625) and 2014 (112,411). The rate of RNs ranged from 408.5 in Central West LHIN to 1,582.8 in Toronto Central LHIN in 2014. . A large increase in the number of registered practical nurses (RPNs) was observed (21.1%) between 2011 (37,775) and 2014 (45,742). Across LHINs, rates in 2014 ranged from 164.0 in Central West LHIN to 605.8 in North West LHIN. . The number of nurse practitioners (NPs) increased by 36.0% between 2011 (2,110) and 2014 (2,869). Across LHINs, rates in 2014 ranged from 6.3 in Central West LHIN to 61.4 in North West LHIN. Regulated health professionals . Between 2008 and 2011 there was 38% growth in the number of midwives, a 27% increase pharmacists, 22% increase in optometrists, and 17% growth in opticians and occupational therapists.

Physicians, nurses, and regulated health professionals in Ontario # Professionals Rate per 100,000 population Ontario % change Ontario Range across LHINs PHYSICIANS IN ONTARIO, 2013 2010-2013 Family physicians 12,635 8.7% 93.2 67.7 - 135.0 Specialists 14,490 9.4% 106.9 51.3 - 299.8 Total physicians 27,125 9.0% 200.2 119.0 - 434.8 NURSES IN ONTARIO, 2014 2011-2014 Registered Nurses (RNs in general class) 112,411 4.4% 821.8 408.5 - 1,582.8 Registered Practical Nurses (RPNs) 45,742 21.1% 334.4 164.0 - 605.8 Nurse Practitioners (NPs = RNs in extended class) 2,869 36.0% 21.0 6.3 - 61.4 Total Nurses 161,022 9.2% 1,177.2 578.8 - 1,997.0 SELECTED HEALTH PROFESSIONS, 2011 2008-2011 Midwife 555 37.7% 4.2 0.5 - 7.5 Occupational Therapist 4,949 16.5% 37.3 14.6 - 67.9 Optician 2,467 16.6% 18.6 6.3 - 22.2 Optometrist 1,910 21.6% 14.4 9.9 - 24.4 Pharmacist† 12,891 26.8% 97.2 57.9 - 133.4 †In 2011, the number of pharmacists assigned to ‘unknown LHIN’ was substantially higher than in previous years. As such, caution should be taken when interpreting results.

North Simcoe Muskoka LHIN

Physicians . From 2010 to 2013, the total number of physicians in North Simcoe Muskoka LHIN increased by 10.9%, while the population only grew by 2.2%. . The total physician rate (per 100,000 population) in North Simcoe Muskoka increased from 144.6 to 156.7 from 2010 to 2013. . North Simcoe Muskoka LHIN had a lower rate of specialists relative to Ontario, but had a similar rate of family physicians. . The North Simcoe Muskoka LHIN had a relatively lower proportion of family physicians aged 65 and over compared to Ontario. C40

Nurses . From 2011 to 2014, the total number of nurses in North Simcoe Muskoka increased by 10.8%. The largest increases were seen for NPs (50.6%) and RPNs (23.7%). . Compared to the province, North Simcoe Muskoka had higher rates of RPNs and NPs, but lower rates of RNs per 100,000 population in 2014. Regulated health professionals . In 2011, North Simcoe Muskoka had lower rates of opticians, occupational therapists, optometrists, and pharmacists than the province. . Between 2008 and 2011, the number of occupational therapists, optometrists, and pharmacists practicing in North Simcoe Muskoka LHIN increased.

Physicians, nurses, and regulated health professionals: North Simcoe Muskoka LHIN # Professionals Rate per 100,000 population North Simcoe North Simcoe LHIN % change Ontario Muskoka LHIN Muskoka LHIN Family and Specialist Physicians, 2013 2010-2013 Family physicians 424 9.6% 90.9 93.2 Specialists 307 12.9% 65.8 106.9 Total physicians 731 10.9% 156.7 200.2 Family Physicians, 2013, by age group % of total physicians Age <30 7 1.7% 2.0% Age 30-64 374 88.2% 84.3% Age >65 43 10.1% 13.7% Age >75 4 0.9% 1.9% Nurses, 2014 2011-2014 Registered Nurses (RNs) 3,776 4.2% 801.5 821.8 Registered Practical Nurses (RPNs) 1,971 23.7% 418.4 334.4 Nurse Practitioners (NPs) 122 50.6% 25.9 21.0 Total Nurses 5,869 10.8% 1,245.8 1,177.2 Selected professions, 2011 2008-2011 Midwife 17 -10.5% 3.7 4.2 Occupational Therapist 136 19.3% 29.9 37.3 Optician 78 -10.3% 17.2 18.6 Optometrist 53 12.8% 11.7 14.4 Pharmacist 317 13.2% 69.8 97.2 Notes: In 2011, the number of pharmacists assigned to ‘unknown LHIN’ was substantially higher than in previous years. As such, caution should be taken when interpreting results.

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