` Overview of the Toronto Central LHIN Sub-Region Quality Improvement Approach: Mid-East Version 1.0 – July 2017 1 Table of Contents Background: Toronto Central LHIN sub-region planning approach 3 Starting point: Quality improvement 4 Planning exercises 4 Sub-region profiles: 4 Neighbourhood level profiles: 7 Prioritizing where to start: 9 Detailed analysis 12 Capturing human experience: No data without stories, and no stories without data 15 Summary of process taken: 16 Snapshot of sub-region initial opportunity areas: 16 Next Steps: Supporting Collaborative Quality Improvement Planning (C-QIPs) 17 Future Vision 19 2 Background: Toronto Central LHIN sub-region planning approach The Toronto Central LHIN has established 5 sub-region planning areas to serve as the focal point for population based planning, service alignment and integration, partnership building, and quality improvement. We recognize and celebrate the diversity of our Toronto communities and we acknowledge that the path to improving health will be different for the diverse communities and population groups throughout the City. By honing in on five smaller, more manageable geographies, we can look at communities on a neighbourhood by neighbourhood basis, and plan care more appropriately. In May and June of 2016, we held an inaugural cross-sector meeting within each sub-region planning area. The purpose of these meetings was to bring all types of providers together, with our common element being the communities and people that we serve. This group of local providers within a sub-region planning area is our Local Collaborative. Why are Local Collaboratives important? No one organization or individual has the full set of resources, expertise, and capacity to ensure the best possible outcomes – physical, mental, and social – for all individuals. It is incumbent on all service providers to work together in and across sectors to support the holistic wellbeing of communities. 3 Starting point: Quality improvement Sub-region Local Collaboratives are the foundation for: • Local population-based planning (meeting local need); • Local service alignment and integration (improving access and communication); • Locally based partnership building (influencing social determinants of health); and, • Local quality improvement (beginning with a health equity perspective). Taking a health equity perspective to quality improvement meant beginning by identifying neighbourhoods or groups of people that are not receiving care that they need in order to be as healthy as the broader population around them. From our Strategic Plan: Health Equity is a state of health system design in which the provision of health and health care services is proportionate to nee Planning exercises To achieve this, the 5 sub-region Local Collaboratives worked through a series of population- based planning exercises throughout the fiscal year (2016/17). Sub-region profiles: As a starting point, the LHIN developed comprehensive sub-region profiles that included population demographics, health outcomes, and rates of health care utilization down to a neighbourhood level (see Mid-East example on our website: About the Mid-East). These profiles were introduced to the Local Collaboratives as a resource for local planning, and formed the basis of the population-based planning exercises throughout the year. 4 SAMPLE OF MID-EAST SUB-REGION SNAPSHOT: Data Source [4] Mid-East sub-region overview: Six of nine neighbourhoods have rates of low income (after tax) higher than the Toronto Central LHIN average (20%). Socio-demographics are changing due to gentrification. Highest proportion of seniors living alone (43.2%) in Toronto Central LHIN, highest in Church-Yonge Corridor (54.5%) and Moss Park (53.3%) neighborhoods. Most heavily represented visible minorities are East Asian, South Asian and Blacks. The most common languages spoken other than English include Chinese (including Cantonese and Mandarin), Tamil, and African languages (e.g. Bantu languages and Amharic). Regent Park and North St. James Town have particularly high levels of marginalization. Second highest number of homeless shelters in the LHIN (21) (most in Moss Park, and Church-Yonge Corridor) with the highest number of beds (2,030 beds). Health status: Second lowest rate of total hospital births women aged 15-49: 31.2/1000 (2012/13-14/15). Lowest number of deaths (770) and second lowest crude death rate (537.0/100,000 population) among sub-regions in 2011. Particularly high rates for all chronic diseases among the Sub-Regions for adults 20+ years and older. Primary care and other health service providers: 213 primary care physicians, 56% in Community Health Centres and Family Health Teams (highest proportion in all sub-regions). Neighbourhoods with the lowest levels of continuity of primary care include Waterfront Communities-The Island (26.9%), Moss Park (25.4%), and Church-Yonge Corridor (24.9%). Main hospital is St. Michael’s. Highest concentration of Community Mental Health and Addiction agencies (24), high number of Community Support Services (15) and 4 Long-term Care Homes [1]. High number of health/community providers serving the Indigenous population. Health service utilization: 25.7% (14,437) of total visits to Emergency Department (56,259) were of low urgency 2015/2016. 11,781 hospital separations in 2015/16. 14.6% of the total number of hospital inpatient days were designated as Alternate Level of Care. 5 SAMPLE OF DETAILED SUB-REGION PROFILE CONTENT: 6 Neighbourhood level profiles: In the first planning exercise (“A Walk around the Neighbourhoods”), analytics were presented at a neighbourhood level. A number of neighbourhoods were selected based on high utilization (ED, ALC, etc) and variance in health status (such as chronic disease) (see Mid-East example on our website: About our Neighbourhoods). In the Mid-East, the following neighbourhood profiles were reviewed: Regent Park, Moss Park, Church-Yonge Corridor, and North St. James Town. As part of this exercise, participants rotated across each individual neighborhood profile, reviewing a detailed demographic and health service profile for each neighborhood. Participants were asked: how the data aligned with their experiences, what additional questions it raised, and the potential impacts on future planning. 7 SAMPLE OF A NEIGHBOURHOOD PROFILE: 8 Prioritizing where to start: Feedback from this session was used to further analyze opportunities within the sub-region. The LHIN reviewed the detailed sub-region analysis to identify areas of greatest disparity and variance in health outcomes and refined the list of initial opportunity areas in partnership with a sub-region working group. The following list of opportunities was identified in the Mid-East: This list was reviewed with the Mid-East Local Collaborative in a final exercise where Local Collaborative participants prioritized which opportunities may be the most appropriate starting points for initial quality improvement efforts. A sample is provided below. The full list of opportunities can be found on our website (Mid-East Areas of Opportunity). 9 As part of this exercise, participants were divided into small groups to evaluate the opportunities based on criteria considering the potential impact of focusing on the issue and the expected effort required to create improvements. The specific criteria were: Impact Effort 1. This is a “wicked” problem 1. Will require partnerships among multiple 2. There is a measureable gap in HSPs (>3) performance that needs to be addressed 2. Will require partnerships with non-LHIN 3. Impact can likely to be measured in the funded service providers short-term (first year) 3. There are few existing efforts in place 4. By addressing this opportunity area there already that we can build on is high potential to improve health 4. Interventions would likely require no, or outcomes (longer-term) limited, new resources 5. By addressing this opportunity area there 5. There are proven or evidence-based is high potential to improve patient solutions that we already know of that we experiences can put in place For each of the opportunity areas the criteria were rated on a scale of 1 to 5 based on level of agreement with the statement, with 1 indicating strong agreement, 3 indicating neutral and 5 indicating strong agreement. Once all the opportunities had been evaluated by each group, the scores were totaled to assign ranks to each one (high score to low). The scores were then mapped onto the graph below: 10 Prioritization feedback was reviewed by the Mid-East working group and it was recommended that Moss Park be selected as the initial opportunity area for quality improvement: • Poor economic conditions with high percentage of residents living below the low income measure, after tax (38.6%) • High number of residents who self-identify Indigenous • Anishnawbe Health Toronto on Queen St. East • 8 shelters (2 Family, 4 Men and 2 Women): Total 1,397 beds, including largest shelter (men) in Toronto – Seaton House on George Street (562 beds) • High number of 'high urgency' and ‘low urgency’ ED visits in adults 20+yrs (high: 7,936, low: 2,174) (both higher among males) • High hospitalization for mental health conditions, 20+ (642 hospitalizations) • High count of ACSC hospitalizations, 2012/13-2013/14 (20-74 yrs: 246) • High number of ALC inpatient days, 2011-2012 (all ages: 22,058) It was acknowledged that each of the opportunities needs to be addressed, and each require relatively high effort with the potential