Working Group DE Report, and the Working Group DE Report Resulting from the Fraser Health Authority Review

Memorandum

Ministry of Health Office of the Deputy Minister

June 2014

To: Honourable Terry Lake Minister of Health

Re: Fraser Health Authority Review

I am pleased to transmit for your consideration a summary of Working Group DE Report, and the Working Group DE Report resulting from the Fraser Health Authority Review.

The review committee was guided by the Fraser Health Authority Special Directions Regulation which, in addition to a variety of other requirements, instructed the committee to consider the relationship of Fraser Health and neighbouring health authorities in the lower mainland. Specifically, the regulation states: (d) whether there is duplication or redundancy in the delivery of health programs and services between the board and neighbouring regional health boards; (e) whether the health needs of the region's population would be met more effectively or efficiently by changing the area of British Columbia that constitutes the region; In executing the mandate set out in clause (d), the Working Group focused its analysis on duplication and redundancy in select high intensity services (trauma, stroke and cardiac) and on academic health science activities. In its evaluation of regional considerations as described in clause (e), the Working Group sought to explore and understand the health needs and current utilization patterns of patients originating in Fraser Health.

The analysis has resulted in ten recommendations which range from system-level strategic direction to site-specific actions. The recommendations highlight a number of meaningful opportunities for Fraser Health to work collaboratively with Vancouver Coastal and the Provincial Health Services Authority to improve sector planning, and service and program delivery activities. With respect to the issue of boundary changes, the Working Group recommended any potential boundary adjustments be considered in a larger context of service design and structures, and further noted that any contemplation of boundary changes should be initiated by the Ministry, and involve consultation with the appropriate partners.

I look forward to speaking to you about the report, should you have any questions or concerns.

Steve Brown Deputy Minister

Enclosures

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Summary – Working Group DE Report 1 of 32

Working Group DE Report

Summary

Prepared by: Health Sector Planning and

Innovation Division,

Ministry of Health

Source: Working Group DE Draft

Report

Date: June 2014

Summary – Working Group DE Report 2 of 32

CONTENTS

EXECUTIVE SUMMARY…………………………………………….……………………..…….4

EXAMINING REGIONAL DUPLICATION IN THE DELIVERY OF HEALTH SERVICES…...……….....6

HIGH INTENSITY SERVICES……………………………………………...……………..6

TRAUMA CARE: ACCESS AND QUALITY………………………………………….7

STROKE CARE: ACCESS AND QUALITY…………………………………………..7

CARDIAC CARE: ACCESS AND QUALITY……………………...………………….9

ACADEMIC HEALTH SCIENCE NETWORK………………………………….…………..11

CURRENT SITUATION………………………………………………………….11

PROPOSED B.C. ACADEMIC HEALTH SCIENCE CENTRE AND NETWORK MODEL……………………………………………….…………….11

BENEFITS………………………………………………………….….………14

UNDERSTANDING REGIONAL HEALTH NEEDS AND UTILIZATION – FRASER HEALTH AND THE LOWER MAINLAND…………………………….…….…..……….16

LOWER MAINLAND CONSIDERATIONS…………………………….….….….….……..16

PATIENT FLOW – THE STATISTICS……………………………………….….…..……18

CHANGE IN ACUTE CARE PATIENT FLOW BY CLINICAL CATEGORY……..…...….……19

CHANGE IN ACUTE CARE BASED PATIENT FLOW BY SURGICAL AND MEDICAL COMPONENTS……………………………………………………..………20

PATIENT FLOW – ANALYSIS BY LOCATION OF MEDICAL PRACTITIONER……….…....23

FOCUS ON PATIENT FLOW FROM BURNABY AND DELTA TO VCH AND PHSA……...…24

CONCLUSION……………………………………………………………………..……..…..29

APPENDIX A: RECOMMENDATIONS………………………………………………..…..…….31

Summary – Working Group DE Report 3 of 32

EXECUTIVE SUMMARY

In October 2013, the Minister of Health directed that a strategic and operational review of the Fraser Health Authority be undertaken. The review was supported by a committee tasked with examining the health authority’s operational practices to identify priority action areas to address service and fiscal challenges.

The review committee was guided by the Fraser Health Authority Special Directions Regulation which, in addition to a variety of other requirements, instructed the committee to consider the relationship of Fraser Health (FH), Vancouver Coastal Health (VCH) and the Provincial Health Services Authority (PHSA) in the lower mainland. Specifically, they were to ascertain, as the regulation states:

(d) whether there is duplication or redundancy in the delivery of health programs and services between the board and neighbouring regional health boards (e) whether the health needs of the region's population would be met more effectively or efficiently by changing the area of British Columbia that constitutes the region These requirements under the regulation were undertaken by Working Group DE (a sub- committee of the Review Committee), so named to reflect the clauses as above.

The report of Working Group DE was provided to the Fraser Health Authority Board for consideration. The findings of the Working Group culminated in recommendations that exceed the mandate of the Fraser Health Authority Board, and as such, the Board has forwarded the material to the Ministry of Health. This document summarizes the report as received by the Ministry.

In executing the mandate set out in clause D, the Working Group focused its analysis on duplication and redundancy in select high intensity services (trauma, stroke and cardiac) and on academic health science activities. In its evaluation of regional considerations as described in clause E, the Working Group sought to explore and understand the health needs and current utilization patterns of patients originating in Fraser Health. The analysis resulted in ten recommendations which range from system-level strategic direction to site-specific actions (see Appendix A).

Examining clause D, the review found that, while joint VCH-FH clinical planning is underway, more could be done to exploit existing service platforms to improve quality of care, access to care, and service capacity system-wide. The Working Group noted that the movement of FH patients to Vancouver Coastal for these critical services is not always triaged according to urgency, resulting in delays to treatment for time sensitive conditions. In all three service areas, the Working Group recommended enhancements to joint planning and service delivery activities.

Summary – Working Group DE Report 4 of 32

With regard to research activities, the Working Group proposed the creation of a province-wide academic health science centre and network model, which focused on VCH, PHSA and Providence Health Care and linked to other partners, such as Fraser Health. The Working Group recommended Fraser Health enter into a formal agreement with the academic institutions in Vancouver to ensure future research investments achieve the maximum value.

Examining clause E, the Working Group looked at the movement of the general patient population across a number of daycare and inpatient services, then focused specifically on patient flows out of two Fraser Health local health areas into Vancouver Coastal.

Among the general patient population, the Working Group found that, while patients originating in Fraser Health are increasingly being treated in their home health authority, significant numbers of patients continue to seek care or are referred for care outside their home health authority. These patterns result from patient choices and historical relationships, from provider referral preferences, and from Fraser Health’s proximity to one-of-a-kind provincial and tertiary services offered in Vancouver Coastal and in Provincial Health Services Authority facilities.

The Working Group found that some of these services could be safely and appropriately provided in Fraser Health, and could be repatriated. The Working Group recommended joint planning and modeling activities to appropriately address patient population growth over time, and noted that the Ministry of Health’s participation is critical to ensuring appropriate care is given to fiscal considerations, including physician service funding. The Working Group also recommended modeling the desirable distribution of medical resources by specialty.

Having looked generally at the patient flow relationship between FH and VCH, the Working Group focused on two specific local health areas (LHAs) – Delta and Burnaby – as patients from those LHAs made more extensive use of Vancouver Coastal facilities than those from other areas of Fraser Health. The Working Group also noted a flow of patients from Vancouver into Burnaby. The Working Group found that a modest improvement in regional self-sufficiency would occur if Burnaby LHA was repositioned within Vancouver Coastal, but the same improvement would not necessarily result from the inclusion of Delta LHA in Vancouver Coastal. The review noted that the lower mainland health authority composition could be reimagined along service delivery lines, which would afford the opportunity to concentrate tertiary and specialty services, while allowing alternative structuring for secondary and community services. The Working Group recommended further exploration of those options under the leadership of the Ministry of Health, in consultation with others.

Summary – Working Group DE Report 5 of 32

EXAMINING REGIONAL DUPLICATION IN THE DELIVERY OF HEALTH SERVICES

(d) whether there is duplication or redundancy in the delivery of health programs and services between the board and neighbouring regional health boards

HIGH INTENSITY SERVICES In light of the time constraints, the review committee focused its considerations on potential for duplication, overlap or misalignment in high intensity clinical services.

In the latter part of 2013, VCH and FH identified a number of areas for which examination and recommendations for action are required:

o Joint physician workforce resource co-planning with priority focus on psychiatry, thoracic surgery, stroke neurology, pathology, radiology and otorhinolaryngology, specifically: o Appropriate recruiting and siting of these individuals. o Thoughtful deployment of specialist services across boundaries. o Clinical alignment/standardization in the lower mainland with the priorities being stroke and oncological surgery and then cardiac services and cataracts. o Co-planning on emergency department growth, demand, analysis, and response o Patient transfer and flow working with the British Columbia Ambulance Services (BCAS) and Patient Transport Network alignment

Clinical improvement is a continuous process for all health care providers. Provincially, there are multiple mature service platforms that can be used more effectively to ensure a population health and continuum-focused approach to improvement and optimum performance. These include Cardiac Services BC, Stroke Services BC, BC Renal Program, Perinatal Services BC, Child Health BC and others.

To reinforce the opportunity for the lower mainland organizations to formalize efforts to continuously improve clinical and operational performance three examples – trauma, stroke and cardiac – are described. Within each area, greater collaborative planning and decision-making processes between FH, VCH, and Providence Health Care (PHC) would support improved clinical outcomes and improved system-wide capacity optimization. In keeping with the inter- health authority learning potential arising from the FH review, there are opportunities to improve the processes of care for the population that the lower mainland health authorities serve through formalized agreements between FH, VCH, PHSA and PHC and emergency health services.

Summary – Working Group DE Report 6 of 32

Trauma Care: Access and Quality A provincial trauma planning committee exists with representation from the health authorities, BCAS and the Ministry of Health. The two major sites for serious adult trauma services in the lower mainland are the Royal Columbian Hospital (RCH) and the Vancouver General Hospital (VGH). The main site for serious pediatric trauma services is BC Children’s Hospital (BCCH). The VGH and BCCH sites are accredited by the Trauma Association of Canada. The RCH site is not.

Sites for major trauma require the support of many different services including a robust intensive care unit, general surgery, orthopedic, and thoracic surgery services, as well as a number of medical subspecialties. Moreover, major trauma patients typically require long lengths of stay. There are two highly sub-specialized trauma services, the adult spinal cord unit and the adult burns unit, at VGH. At this time, there would appear to be no recommendations from the provincial planning committees to make changes to this model.

VCH plastic surgery trauma service has been the recipient of major cases from the FH including fractured jaws, severed digits, limbs and other complicated plastics cases which have been refused service by FH surgeons. This has, in part, required VCH to create special contracts with these surgeons.

Stroke Care: Access and Quality Historically, British Columbia had among the worst stroke outcomes in the country. For that reason, provincial funds were made available in 2011/12 to begin the planning for improved stroke services through Stroke Services BC.

A mature stroke program requires rapid access clinics for transient ischemic attacks (secondary prevention), professional support for acute thrombolytic therapy in the emergency department, acute stroke care wards/units, and acute as well as long term integrated rehabilitation units. Optimum stroke care requires health authorities to designate specific stroke roles for their hospitals. The hospitals with higher levels of expertise to manage hyper-acute, and acute inpatient care of stroke (CT scanning and 60 minute door to needle time for thrombolysis 24/7, dedicated stroke unit beds) need to work closely with BC Emergency Health Services and the Patient Transfer Network to ensure patients experiencing stroke symptoms are transported to the nearest appropriate site within the recommended time.

FH has not been able to fully operationalize three designated stroke sites (Royal Columbian (RCH), Surrey Memorial (SMH) and Abbotsford Regional hospitals). At RCH, thrombolytics – the medical protocol to treat stroke – has been adopted, but capacity issues in the RCH emergency department make this site reluctant to accept more patient volume.

At Surrey Memorial, the emergency department and neurology have not embraced or implemented the use of thrombolytics. Abbotsford Regional has made some efforts to operationalize as a designated site, with modest results.

Summary – Working Group DE Report 7 of 32

Consequently, some community hospitals within FH (including Surrey Memorial) contact Vancouver General Hospital – rather than one of the intended dedicated sites within FH – when they receive a stroke patient who may be eligible for thrombolysis. The patient is then transported to the VGH site. This is poor patient care as it results in time delays to a treatment that is time sensitive. Additionally, this approach impacts pre-hospital emergency and patient transport resources, and compounds volumes at VGH. A further issue arises after the patient completes their acute care in that there is a need to repatriate the patient back to FH for ongoing acute/rehabilitation.

Advances in non-invasive interventional neuro-radiological treatments require skills development and maintenance that is based on a critical mass of experience. This needs to be coordinated in a logical fashion within the province.

In-patient rehabilitation and/or specialized slow stream rehabilitation may benefit from consolidation of resources from FH and VCH. Creation of an improved, more specialized centre of care to achieve better patient outcomes would likely be feasible with the critical mass that could arise from both health authorities planning and implementing together. Across FH and VCH there are disparate stroke inpatient rehabilitation resources with differing criteria for acceptance. This difference results in more patients being discharged to long-term care (evidenced in the 2010 National Stroke Audit). Joint planning to consolidate inpatient stroke rehabilitation could allow for economies of scale, improved patient outcomes and improved acute and residential bed utilization.

Using nationally accepted data and intentional resource redistribution, VCH has over three years been able to significantly improve stroke outcomes (death rates, appropriate discharge sites, thrombolytic treatments), albeit still not at best levels for Canada.

The number of neurologists providing stroke services is concentrated in the western end of the lower mainland (VCH), and thus innovative methods to provide these services are needed for the less well served FH population. A common provincial picture archival communication system and the use of other telehealth services can assist.

A common lower mainland strategy for stroke care excellence is one of the goals of the VCH-FH senior clinical planning committee. Cross-site credentialing, dedicated contracts for stroke neurologists, adherence to the best evidence informed criteria for acute medical and invasive care, and for acute and chronic rehabilitation are needed.

Summary – Working Group DE Report 8 of 32

Cardiac Care: Access and Quality Within the lower mainland there is sufficient catheterization laboratory, and heart surgery physical capacity; however it does not align with regional service demand (from the perspective of being self-sufficient within the region).

FH serves approximately 75 per cent of the angioplasty demand and 60 per cent of heart surgery needs of patients originating within FH. The remaining demand is provided by VCH at Vancouver General and St. Paul’s hospitals. The flow of patients to the VCH sites is not by design, and not always triaged according to urgency. Consequently, there are significant wait time issues with an increasing number of patients exceeding the recommended wait time.

A recent review of cardiac services cited the need for a lower mainland triage process. Triage coordinators and regional staff as well as Cardiac Services BC have struggled with wait time management issues especially for diagnostic catheterization and heart surgery over the years. Ministry direction, support and timely expectations will serve to fast track some action on this front, to be followed by a collaborative planning process as a five to seven year sustainable plan is required given timeframes for proposed capital redevelopment plans.

Procedure utilization and appropriateness are issues that may affect wait times. The lower mainland review noted that the B.C. rate for coronary revascularization per acute myocardial infarction was 21 per cent higher than the Canadian rate, adjusted for age and sex. This suggested more room for medical rather than revascularization intervention. This was particularly true for FH. In addition there was a higher rate of utilization at RCH of diagnostic catheterization and revascularization after controlling for demographic, clinical and patient characteristics. Moreover, outcomes and efficiency did not compare well with Ontario.

While VCH has academics (post graduate training and research) as one of its cardiac care priorities, FH is almost solely focused on clinical services. RCH has, over the last several years, developed the full continuum of tertiary cardiac services, providing an environment for RCH to take on more teaching and academic responsibilities. By 2030, the population of the lower mainland is projected to be approximately 3.5 million people with almost two thirds of the population living within the boundaries of FH. That population should have access to the best practices afforded by association with an academic program.

System-wide cooperation is a key consideration for an effective cardiac system. A coordinated approach is required to balance workloads across sites and to respond to patient needs in a timely and safe manner. A key message from this review is that the current system tends to be reactive rather than proactive and that a clearly articulated vision and strategic plan for cardiac services is required.

The population growth in the Fraser Valley, the declining referrals to downtown hospitals, and the major capital redevelopment plans currently on the table for Royal Columbian Hospital and

Summary – Working Group DE Report 9 of 32

St. Paul’s Hospital suggest the timing is right for implementation of key decisions regarding the future roles and program focus of cardiac sites throughout B.C.

Overall, the Working Group has concluded that Cardiac Service BC has been unable to establish an inclusive relationship with the health authorities in the lower mainland that makes all involved think in terms of a single, collective population.

Summary – Working Group DE Report 10 of 32

ACADEMIC HEALTH SCIENCE NETWORK Historically, the PHSA, PHC, and VCH have individually operated as academic health science centres (AHSCs) for British Columbia. In partnership with their primary academic partner, the University of British Columbia (UBC), as well as other academic partners, these three health authorities have delivered on the tripartite AHSC mission of care, education and research. They have provided the province’s most highly specialized acute care, provided clinical training for physicians, nurses and other health providers, and conducted 80 per cent of the health research that takes place within the province.

Collaboration exists on many levels, from formal affiliation agreements that articulate research and education arrangements between the health authorities and university partners, to the vital collaboration amongst researchers affiliated with different entities that drive innovative and breakthrough discoveries.

Traditional roles and traditional relationships have served British Columbians well for many years. However, health authorities and academia face new challenges and pressures. While they are all individually responding to those challenges and pressures, the absence of strategic linkages between these organizations, including at the governance level, is limiting their ability to successfully support the needs of British Columbia today and into the future.

A bold new vision – one that integrates the shared AHSC functions of PHSA, PHC, VCH and UBC at its hub and strategically connects FH and other players through a provincial academic health science network (AHSN) – is needed to drive improvements in patient outcomes and efficiencies within the B.C. health system. B.C. is uniquely positioned, within Canada and internationally, to establish this model and achieve the benefits it can deliver.

Current Situation Currently, PHSA, PHC and VCH are responsible for the hospitals and agencies that provide the lion’s share of health authority AHSC functions – specialist care, clinical training/education, and research - for the province. UBC operates the sole medical school in the province through a distributed model that delivers medical education through partners located in the interior and northern regions, Victoria, and the lower mainland.

Health authorities have varied health research interests and levels of activities. The distributed teaching model, unique population health challenges and features, and development of specialty services provide greater opportunities to coordinate, align and leverage existing research clusters to achieve regional and system wide benefits.

Summary – Working Group DE Report 11 of 32

The current profile of research clusters includes: o Vancouver based academic health science centres – this includes larger tertiary centres in Vancouver where the majority of biomedical and clinical research occurs. o Simon Fraser University and Fraser Health Authority o Northern Health Authority and the University of Northern British Columbia o Interior Health Authority and UBC Okanagan o Vancouver Island Health Authority and the University of Victoria o Community, public health and social service agencies and multiple advanced education organizations interested in advancing interdisciplinary science and population and system science

The impact of technology also requires a broader engagement of engineering, computer science, biology and other areas of expertise to advance a province-wide research and innovation agenda. PHSA, PHC and VCH all have individual academic liaison committees that support communication between the senior leadership level of the health authorities with the vice provost/dean of medicine level of UBC. However, there is no mechanism that enables joint forward planning and issues resolution at a senior level between UBC and the three health authorities that drive the bulk of academic health.

Nor is there a mechanism to bring government to the same table. Funding for AHSCs is complicated and derives from several sources, including global health authority budgets, university salaries, alternate physician funding plans, external grants/awards, and philanthropy. Pressures on government funding sources, and the unpredictability of external grant/award and philanthropy sources, makes it difficult to achieve the predictable and stable funding needed to fulfill the tripartite mission. Because of the interdependence of that mission– and the multiple roles played by key individuals such as subspecialist physicians – instability in one area of funding such as research can significantly destabilize delivery of patient care. This poses significant and real challenges for recruitment and retention, challenges which are further exacerbated by competitive health research investments in other countries.

While UBC, PHSA, PHC and VCH are the major academic health players in B.C., Simon Fraser University, University of Victoria, University of Northern British Columbia and others have growing roles in supporting academic health. Fraser Health, Interior Health, Island Health and Northern Health have growing roles providing clinical training because of the distributed medical school model, and an emerging role in health research. Differing policies and operations, and the lack of linkages between these various players, result in inefficiencies, and potential duplication of resources.

The ability of the Province to ensure availability of health human resources and avoid shortages of qualified health professionals is hampered by the lack of linkages between: health authorities identifying need; universities and colleges planning and delivering education programs to train those disciplines; and health authorities providing clinical training.

Summary – Working Group DE Report 12 of 32

Health research infrastructure and funding has increased in B.C. over recent years, in particular as a result of the funding programs of the Michael Smith Foundation for Health Research, and Genome British Columbia; however, health research funders at all levels need to better understand the tangible outcomes resulting from their investment in health research. This requires a heightened emphasis on translational research.

Funding from industry for late stage science and commercialization requires a significant critical mass, efficient governance and management and a clear strategic focus. Many other jurisdictions have embraced health and life science research as an area of significant economic growth, diversification and sustainable job creation.

Proposed B.C. Academic Health Science Centre and Network Model The proposed new model would establish a single B.C. AHSC comprising the province’s major academic health cluster - PHSA, PHC, VCH and applicable UBC components – at its hub. Linked to this hub and driving the integrated mission and improvements to all reaches of the province would be an associated B.C. academic health science network representing health authority dyads – the spokes: B.C. academic institutions, and government, including the ministries of Health; Advanced Education; and Jobs, Tourism and Skills Training.

The B.C. AHSC structure would more strongly integrate care, research, and education, and would form an essential underpinning for the AHSN by providing the planning, coordination and services to support improvements for patients and the public throughout the entire province. Single secretariats to support the three core mandates of care, research and education would be established to improve administrative efficiency and reduce duplication. Governance structures at the centre and network levels would be established to improve planning and alignment with provincial priorities. Such a network must be focussed on clear, achievable deliverables to be successful, and be designed to support other contributors like Michael Smith Foundation for Health Research, British Columbia Clinical Research Infrastructure Network and the Personalized Medicine initiative to name a few.

Summary – Working Group DE Report 13 of 32

Benefits The benefits of the proposed structure include: o A governance structure that ensures all of the players that are part of the system of academically-based care, education and research are brought to a single table where they can plan, prioritize, and resolve issues. o Stronger links between care, research and education – so that clinical needs are addressed through research and education. o A clear, shared health research agenda that builds on B.C.’s internationally established strengths, drives innovation, and aligns with the province’s need for improved outcomes and sustainability. o An enhanced focus on translational research, with research results more quickly translated into changes in patient practices and outcomes. o Less competition within the province, enabling B.C. to compete more successfully outside the province, drawing in more external grants and industry involvement. o Improved performance of health research as an economic driver through increased commercialization and outside investment revenue, and through the positive contribution to B.C.’s economy by a growing knowledge-based workforce. o Improved administrative efficiency and effectiveness. o Strengthened recruitment and retention at all levels – from nursing to highly specialized physicians upon whom entire clinical care programs depend. o Recognized national and international leadership through establishment of the first model that builds on the foundation of strength provided by the province’s traditional major academic health players, while achieving integration and driving improvements throughout the entire province.

Because of its health authority structure, and single, distributed medical school program, B.C. is uniquely positioned to lead the country in the establishment of a new model for academic health science.

The established AHSCs within PHSA, PHC and VCH, together with the leading education and research partner, UBC, provide a core foundation uniquely and centrally located within the province’s urban centre of Vancouver. Internationally renowned research enterprises already exist within these facilities. Rich databases, unique within Canada, capture province-wide patient data in areas such as cancer, renal disease, cardiac disease, transplantation, medical genetics, infectious diseases, and perinatal services.

The regional health authority structure provides a framework upon which a network can be built that integrates care/education/research in collaboration with other partners throughout the province, and that supports faster translation of research to improve patient outcomes and system sustainability.

Summary – Working Group DE Report 14 of 32

By capitalizing on these unique B.C. assets, the B.C. AHSC and AHSN will improve patient and population health outcomes, contribute to sustainability, and act as an economic engine for the province.

Summary – Working Group DE Report 15 of 32

UNDERSTANDING REGIONAL HEALTH NEEDS AND UTILIZATION – FRASER HEALTH AND THE LOWER MAINLAND

(e) whether the health needs of the region's population would be met more effectively or efficiently by changing the area of British Columbia that constitutes the region;

LOWER MAINLAND CONSIDERATIONS The service profile of Fraser Health (FH) includes the tiers of services outlined in Figure 1. FH is geographically adjacent to the academic health centres and other facilities of the western lower mainland, which provide services to their respective local communities as well as a range of medical specialties for the entire province. An analysis of the flow of patients from FH into Vancouver, and consideration of the role FH plays now and in the future within the lower mainland system of care, reveals opportunities to consider adjustments to boundaries, differentiation of facility roles and formalized collaborative initiatives for service planning, and clinical service improvements. Lower mainland system collaboration would ensure the development of a single plan for achieving the new Ministry of Health (MoH) health priorities.

For over a decade Fraser Health has been engaged in an ongoing intensification of service self- sufficiency at all levels from primary to tertiary and beyond. This effort requires building a range of capacity in specialty services, and academics in order to achieve the underlying strategic priority. The risk is that this could result in the unnecessary duplication of the most specialized and difficult to resource services. When viewed from the perspective of a network of services available across the lower mainland, opportunities exist to regard service self-sufficiency from a system-wide as well as a geographic perspective.

The most specialized services and academic activity (teaching and research) in the province are concentrated in Vancouver at PHSA, PHC and VCH. Along with UBC, these partners have committed to establishing an academic health science centre which can function as a hub for an academic health science network for the province. The AHSN can be used as a platform for building service and academic capacity, and achieving the strategic priorities for British Columbia as inaugurated and updated by MoH. A balance between geographic considerations and broader opportunities to integrate key system improvements that achieve optimum patient outcomes is required, as is the best use of very scarce and specialized human inputs, and the best available value for money. This shift in strategic focus drives a different approach to service planning, investment, decision making and accountability.

Summary – Working Group DE Report 16 of 32

Figure 1

Current health authority boundaries in the lower mainland represent historical factors which are not always the most relevant from a population and patient perspective. Factors which drive potential patients to seek a location for care include:

o Proximity to where they live and/or where they work o Historical relationships with providers, especially family physicians o Location of specialty services o Reputation of providers and sites o Family care giver support o Other factors such as waiting times

While these factors often result in the movement of patients between health authorities, in FH, the tide of growth is eastward within the Fraser Valley with a particular concentration of growth in Fraser South. The challenge is to ensure that excellence in care accompanies that growth.

Constructive growth in the care environment requires that health infrastructure, including facilities, people, processes, and structures, match population growth. As well, infrastructure decisions must be tempered by the fact that for complicated programs and procedures, critical masses of practitioners and patient volumes are always needed.

Summary – Working Group DE Report 17 of 32

Thus, careful intentional inter-regional planning is required to ensure that care services are developed in a logical needs-based fashion. In this instance “needs” refers not only to the population need for care but also the parallel need for professional specialties to maintain high skill levels, a fundamental aspect of quality care.

PATIENT FLOW – THE STATISTICS The degree to which Fraser Health appropriately provides care for its residents within its own boundaries warrants investigation. For the year 2012/13, Table 1 examines the percentage of inpatient-medical, inpatient-surgical or day-surgical care services provided within Fraser Health to Fraser Health residents, compared with the percentage of inpatient-medical, inpatient-surgical or day-surgical care services provided within Vancouver Coastal Health to Fraser Health residents.

Much of the care Vancouver Coastal Health provides for Fraser Health residents is related to patterns of physician referral, proximity of Vancouver Coastal Health services for many Fraser Health residents, and one-of-a-kind provincial and tertiary services offered only in Vancouver Coastal Health. Nonetheless, some of these services can be provided in Fraser Health now and could be repatriated. This would require a careful review by the two health authorities and MoH on issues of resourcing and the resource distribution necessary to provide these services in Fraser Health.

Table 1

% Bed Days in Fraser Health Facilities that are % Bed Day in Vancouver Coastal Health Fraser Health Patients Facilities that are Fraser Health Patients

Inpatient Medical 94.2% Inpatient Medical 11.3%

Inpatient Surgical 92.8% Inpatient Surgical 24.9%

Day Surgical 93.6% Day Surgical 26.2%

The PHSA is also an important destination for FH patients, with 33.4% of PHSA bed days that are FH residents

Summary – Working Group DE Report 18 of 32

CHANGE IN ACUTE CARE PATIENT FLOW BY CLINICAL CATEGORY Building from the previous presentation, Table 2 displays the percentage increase in acute care workload for Fraser residents handled in Fraser Hospitals since 2005/06, examining the growth by major clinical category (MCC). Table 2

Summary – Working Group DE Report 19 of 32

Examination of Table 2 identifies an encouraging underlying trend; Fraser Health handled approximately 92 per cent of the growth in weighted caseload volume from 2005/06 to 2012/13. Major clinical areas where the FH local response rate exceeded the average local growth level in terms of weighted caseload include diseases of the respiratory, digestive, pancreatic, kidney, urinary, male reproductive, blood and lymphatic systems, mental diseases/disorders and burns. Circulatory disorders grew by 24.8 per cent in FH since 2005/06 (weighted inpatient and outpatient caseload combined) versus an average FH weighted caseload growth rate of 28.5 per cent.

Clinical areas with above average growth in Vancouver Coastal weighted caseloads used by Fraser Health residents include: diseases and disorder of the eye, ear, nose and throat, circulatory, hepatobiliary, pancreatic, blood, lymphatic, burns and trauma. Blood disorders, hepatobiliary/pancreatic and burns cases originating in FH grew at above average rates of caseload- weighted workload growth in both FH and VCH facilities. The circulatory system weighted caseload growth rate was split with 85 per cent in FH and 15 per cent VCH, very close to the 92-to-8 per cent split for overall weighted caseload growth absorption.

CHANGE IN ACUTE CARE BASED PATIENT FLOW BY SURGICAL AND MEDICAL COMPONENTS However, concentration on major clinical categories masks the underlying differentiation between surgical and medical growth rates. Further analysis of the clinical categories in Table 2, disaggregated into medical and surgical components, demonstrates that surgical weighted caseloads originating from FH grew by almost exactly the same amount in each HA, 14.4 per cent in FH, 14.3 per cent in VCH from 2005/06 to 2012/13.

This ratio is entirely different for medical caseloads, with FH workload growth for FH residents at 38.7 per cent over the same 8 year time period compared to 7.7 per cent growth in VCH (for FH residents). Unique among the identified major clinical categories, all of the FH weighted caseload growth in mental health diseases and disorders was handled in Fraser Health facilities.

Table 3 provides specific details of FH caseloads handled in VCH facilities over the three year 2010/11 to 2012/13 time period. Viewed in this way from the Vancouver perspective, it is clear the resources devoted to FH residents are increasing even while FH absorbs increasing percentages of local volumes. The reason is the much higher rate of population growth in FH. Responding to the acute care pressure associated with population growth in the lower mainland is a shared responsibility which cannot be addressed by either VCHA or FH acting alone.

Evidence from the 3 year span ending March 31, 2013, suggests that the VCH workload for FH residents has “stuck” at approximately 30,000 cases, 35,000 weighted cases, and 100,000 patient days. Weighted inpatient surgical workloads are climbing, modestly year over year, as part of the mix. In the absence of directed efforts, renewed growth pressure within VCH originating from FH residents should be expected.

Summary – Working Group DE Report 20 of 32

In general, FH self-sufficiency is relatively low – around 60 per cent – for paediatric medical and surgical services. Specifically, self-sufficiency rates for neonatology level 3, and child psychiatry were around 59 per cent and 30 per cent respectively.

FH’s relatively low self-sufficiency rates for paediatrics services are particularly important as FH is the home region for much of the projected growth in child and youth populations. On the other hand, the close proximity of a world class Children’s Hospital, which falls under the purview of the PHSA, will always represent an attractive alternative venue for service development and care. Patient needs, family needs, availability of specialized resources, ease of access, care networking and partnership development are all important considerations as the balance between PHSA and FH is addressed over time. Progress over the full age spectrum, broaching both the location of content and care obliges the participation of all three HAs involved in lower mainland care delivery.

Table 3: Fraser Health Workload in VCHA Facilities, 3 Year Trend

Summary – Working Group DE Report 21 of 32

Table 4 provides the weighted caseload distribution of FH patients, indicating where patients who live in FH are receiving care (by percentage of total FH population). The table shows that a growing percentage of FH patients are receiving care within their home HA, and that as the retention rate increases, the proportion of transfers out to PHSA is down about a third in terms of weighted workload from the peak in 2003/04. However, given the growth in FH population, the decreasing FH outflow percentage does not necessarily correspond to a declining proportion of workload in receiving hospitals; while a higher percentage of the population are receiving care at home, the total number of cases being transferred to PHSA and VCH is higher.

Table 4: Weighted Caseload Distribution of FH Patients

Table 5 reports weighted caseload treated in PHSA hospitals by place of patient residence. The actual volume of weighted cases originating in FH is down from 2003/04 as the rate of treatment within FH increased, but the overall percentage of PHSA workload originating in FH increased modestly from 36.3 per cent to 37.0 per cent. Specifically, the percentage of BC Children’s workload provided to FH residents increased from 38.3 per cent in 2003/04 to 41.4 per cent in 2012/13. Although the FH self-sufficiency rate is lower for child and youth populations, with implications for both FH and PHSA, there is available evidence of notable progress in the repatriation of maternity care. The percentage of workload at BC Women’s Hospital dedicated to FH residents decreased from 33.43 per cent in 2003/04 to 31.7 per cent in 2012/13, reflecting a concerted effort to repatriate less complex deliveries.

Summary – Working Group DE Report 22 of 32

Table 5: Weighted Caseload in PHSA Hospitals by Place of Patient Residence

PATIENT FLOW – ANALYSIS BY LOCATION OF MEDICAL PRACTITIONER This section provides an analysis of patient mobility extended to medical practitioners in the fee for service (FFS) sector. Encounters by place of residence and location of provider were tracked over time. In this location of provider analysis, providers associated with PHSA facilities are included in the VCH regional contingent. It should be noted that not all medical clinical activity is captured in the fee for service payment system, and the examination is limited to visits without weighting for intensity or fee differentiation. Provider billing location is not necessarily equitable with the service delivery site. Laboratory medicine is particularly problematic in this regard. Nonetheless, general trends are evident:

o The 2012/13 percentage split for GP services has the split of Fraser Health visits distributed between FH and VCH with an 85.9 per cent capture by FH. This is very similar to the split for hospital cases, although there would be a very small likelihood of an overriding cause and effect relationship between the location of primary care resources and secondary service delivery. o The 2012/13 percentage split for non-laboratory specialist services has the split of Fraser Health visits distributed between FH and VCH with a 78.2 per cent capture by FH, which is lower than the rate of inpatient services capture. o The 2005/06 to 2012/13 growth rate in FFS encounters for GP services delivered in Fraser Health for FH residents was 9.3 per cent. The observed growth rate in FFS encounters for GP services delivered in VCH for FH residents was 2.1 per cent. These numbers are lower than both the population growth and hospital workload growth in evidence over the same time interval.

Summary – Working Group DE Report 23 of 32

o The 2005/06 to 2012/13 growth rate in FFS encounters for non-laboratory specialist service delivered in Fraser Health for FH residents was 55.2 per cent, far higher than population, or hospital activity growth rates. Based on FFS encounters, the growth rate for non-laboratory specialist services delivered in VCH for FH residents was 8.1 per cent. This number is lower than the population growth or hospital workload growth.

The broad brush picture emerging is one of:

o A substantial build-up of specialist capacity within Fraser Health over and above the rate of population growth; o A FH specialist capacity increase that is obviously important for the patients of all health authorities in the lower mainland as service delivery patterns change with time; o A specialist capacity increase that has been necessary for FH to handle the 90 per cent retention of incremental acute hospital care volumes that has been achieved but which has not been sufficient to enable repatriation of hospitalized acute clinical care beyond the observed modest repatriation of admitted mental health patients over the past 8 years.

The chain of events from symptom development to presentation in a medical office to diagnosis to intervention decision to intervention location is complex, and further study is required to unpack the variables at play within each specialty and sub-specialty.

FOCUS ON PATIENT FLOW FROM BURNABY AND DELTA TO VCH AND PHSA Residents of the Burnaby LHA and a portion of the Delta LHA make more extensive use of VCH facilities than other local areas within Fraser Health. The issue in the Delta LHA surfaces in the western part of the community (Ladner, Tsawwassen) where patients move northward as part of a regularized and acknowledged pattern of care.

In 2012/13, 10,110 cases from Burnaby were treated in VCH. Map 1 below displays the pattern of external patient movement, once the 44 per cent of the weighted caseload treated in Burnaby General is factored out of the pattern (assumption: the Burnaby General share of the overall Burnaby LHA pattern of use is, in the short term, independent of health authority placement).

Summary – Working Group DE Report 24 of 32

Map 1

The most significant findings portrayed in Map 1:

o Of the weighted inpatient cases leaving Burnaby, 9.8 per cent went to St. Paul’s Hospital, 25.6 per cent to Vancouver General Hospital, 7.5 per cent to other VHC facilities, 3.1 per cent to BC Women’s, and 5.4 per cent to BC Children’s. This means a total of slightly more than 50 per cent of those seeking care outside of Burnaby left FH for facilities in other lower mainland health authorities. o Of the weighted inpatient cases leaving Burnaby but staying within the Fraser Health Authority, 32.7 per cent went to the Royal Columbian, 3.4 per cent to Eagle Ridge, 2.8 per cent to Surrey Memorial and 5.7 per cent to Queens Park. This means approximately 44 per cent of the weighted caseload leaving Burnaby stayed within Fraser Health. o The small residual percentage (6 per cent) sought treatment outside the lower mainland.

Summary – Working Group DE Report 25 of 32

Table 6 focuses on use of the Vancouver General Hospital by Burnaby residents.

Table 6

Noteworthy in the growth pattern is the substantial ramp up in the use of VGH in 2010/11. Just as Burnaby residents are crossing to VGH in greater numbers, there is a large movement to Burnaby from Vancouver for care. On average in 2012/13, Vancouver Coastal residents used 111 beds in FH, while FH used 275 beds in VCH.

If Burnaby had been repositioned into VCH in 2012/13 with no change in referral patterns, 7204 cases would have been left for the scaled down FH, 22.0 per cent of all cases, 21.8 per cent of medical cases, and 26.8 per cent of surgical cases. Regional self-sufficiency in terms of weighted caseload deployment would improve modestly if Burnaby was repositioned within Vancouver Coastal.

Map 2 displays out migration from Delta. It can be seen that the trends associated with the Burnaby LHA do not apply to the Delta LHA. Regional self-sufficiency would not increase with a theoretical relocation of the Delta LHA into VCHA. Unlike the Burnaby LHA utilization profile, Delta LHA use of Surrey and the Royal Columbian easily “trumps” VGH and SPH use once residents leave the local LHA for care. Cutting the LHA into two parts is not considered viable as the LHA construct has underlying community focused validity.

Summary – Working Group DE Report 26 of 32

Map 2

The pyramidal structure featured in Figure1 discloses that functional elements and facility roles are at least as important as service referral patterns when boundary changes are contemplated as a means of enhancing service effectiveness. For example, the lower mainland health authorities could be reconstructed along service delivery lines, better distinguishing between levels in the care hierarchy, concentrating tertiary services and bundling secondary and community services in different ways. A full examination of programs and alternative service delivery structures is an important precursor before any micro-tuning of boundaries is advanced to the decision stage.

Any boundary changes being contemplated must align with health system strategy and be supported by evidence that such changes support:

 enhanced health services delivery with effective health promotion and prevention;  integrated and targeted primary and community care; and  provision of high quality hospital services responsive to local demographics and population needs.

Summary – Working Group DE Report 27 of 32

Proposed changes must support improved quality health care services for local residents, and must reflect actual and projected referral patterns. Changes brought forward must advance in a fashion where a quality of care benefit is made available without material exposure to incremental costs.

Given the cross flow of patients in both direction between the Burnaby LHA and Vancouver, and the analysis of trends presented earlier, there is considerably more merit in a possible reassignment of the Burnaby LHA than for the Delta LHA.

Summary – Working Group DE Report 28 of 32

CONCLUSION

The Fraser Health Review Committee Working Group DE was tasked with examining whether there is duplication or redundancy in the delivery of health programs and service between Fraser Health and its neighboring health authorities (clause D of the regulation). The Working Group also considered the needs of the population of Fraser Health to determine whether they could be more effectively met by changing the health authority’s regional composition (clause E of the regulation).

(d) whether there is duplication or redundancy in the delivery of health programs and services between the board and neighbouring regional health boards Given the limitations of time, the Working Group’s review of services and programs was limited to three select, high intensity services: cardiac care, trauma care, and stroke. The group also contemplated Fraser Health’s academic science activities through this lens.

The review found that, while joint VCH-FH clinical planning is underway, more could be done to exploit existing, mature service platforms to improve quality of care, access to care and service capacity system-wide. The Working Group noted that the movement of FH patients to Vancouver Coastal for these critical services is not always triaged according to urgency, and that delays to treatment for time sensitive conditions results. In all three service areas, the Working Group recommends enhancements to joint planning and service delivery activities.

With regard to research activities, the Working Group proposed the creation of a province-wide academic health science centre and network model, which focused on VCH, PHSA and Providence Health Care and linked to other partners such as Fraser Health. The Working Group recommended Fraser Health enter into a formal agreement with the academic institutions in Vancouver to ensure future research investments achieve the maximum value.

(e) whether the health needs of the region's population would be met more effectively or efficiently by changing the area of British Columbia that constitutes the region Examining clause E, the Working Group looked at the movement of the general patient population across a number of daycare and inpatient services, then focused specifically on patient flows out of two Fraser Health local health areas into Vancouver Coastal.

Summary – Working Group DE Report 29 of 32

These patterns result from patient choices and historical relationships, from provider referral activities, and from Fraser Health’s proximity to one-of-a-kind provincial and tertiary services offered in Vancouver Coastal and in Provincial Health Services Authority facilities.

The Working Group found that some of these services could be safely and appropriately provided in Fraser Health, and could be repatriated. The Working Group recommended joint planning and modeling activities to appropriately address patient population growth over time, and notes that the Ministry of Health’s participation is critical to ensure appropriate care is given to fiscal considerations, including physician service funding. The Working Group also recommended modeling the desirable distribution of medical resources by specialty.

Having looked generally at the patient flow relationship between FH and Vancouver Coastal, the Working Group focused on two specific local health areas (LHAs) – Delta and Burnaby – as patients from those LHAs made more extensive use of Vancouver Coastal facilities than those from other areas of Fraser Health. The Working Group also noted a flow of patients from Vancouver into Burnaby.

The Working Group found that a modest improvement in regional self-sufficiency would occur if Burnaby LHA was repositioned within Vancouver Coastal but, the same improvement would not necessarily result from the inclusion of Delta LHA in Vancouver Coastal. The review noted that the lower mainland health authority composition could be reimagined along service delivery lines, which would afford the opportunity to concentrate tertiary and specialty services, while allowing alternative structuring for secondary and community services. The Working Group recommended further exploration of these options under the leadership of the Ministry of Health, in consultation with others.

In summary, the Working Group found that benefits to patient care and service functioning were likely to result from enhanced collaboration, coordination and joint planning across all lower mainland health authorities, and made a number of specific recommendations related to this finding. The group found changes to boundaries among the lower mainland health authorities warranted further exploration.

The full list of recommendations follows in Appendix A.

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APPENDIX A: RECOMMENDATIONS

Number Recommendation

1 The FH Board, the PHSA Board, and the VCH Board should commit to joint planning activities to model and structure the desirable evolution of patient population growth rates over time. Ministry of Health buy-in and participation will be necessary to anchor this planning process within the parameters of fiscal reality, and to incorporate full consideration of implications for the physician services funding system.

2 The FH Board, the PHSA Board, and the VCH Board should commit to joint planning activities to model the desirable distribution of medical resources by specialty, as needed to facilitate the modelled distribution of clinical and patient service activities.

3 The matter of possible changes in health authority boundaries should be considered in a larger context including service design and service structures. Any move to reposition LHAs should be initiated by the Ministry of Health, and advanced in consultation with appropriate parties.

4 The FH Board should commit to working with the VCH Board to ensure that service planning and improvement activities are conducted through the province- wide service platforms and councils focused on standardization and performance improvement based upon best evidence informed practice. They may wish to pass joint Board enabling resolutions to ensure this takes place.

5 FH Board should ensure that RCH complete the requirements to be accredited by the Trauma Association of Canada.

6 FH should continue work with VCH and the PHSA-based provincial trauma coordinating office to determine which patients are appropriate to transfer to a tertiary facility for trauma.

7 FH and VCH should continue with lower mainland strategies to ensure that the outcomes for stroke care, (primary and secondary prevention, acute stroke management and acute and chronic rehabilitation) are the best that evidence informed practice can achieve. This will require joint planning for physician resources, common credentialing, and cooperation with BC Emergency Health Services and the Patient Transport Network.

Summary – Working Group DE Report 31 of 32

8 FH Board needs to work with VCH Board to ensure that capital resources [particularly major capital redevelopment under consideration for Royal Columbian Hospital and St. Paul’s Hospital) are presently best utilized in the lower mainland and that future capital planning reflects population needs given the academic and research context upon which they are based. Both boards need to ensure that both health authorities and Cardiac Services BC provide a coordinated triage function for the lower mainland that enables the best outcomes utilizing the most effective and efficient methodologies

9 The FH Board should review research spending to ensure it is aligned with roles and unique population characteristics and is contributing to improved patient outcomes and value generation.

10 FH should enter into a memorandum of understanding with the Academic Institutions in Vancouver to establish an AHSN to ensure that all future investments in research are optimized.

Summary – Working Group DE Report 32 of 32