Strengthening Integrated Heath Care in the Toronto Central Local Health Integration Network North Toronto May 31, 2016 Welcome Moderator and today’s Presenters • Tess Romain • Susan Fitzpatrick • Bill Manson • Vania Sakelaris • Alvin Cheng 2 Thank you all for coming • Anne Johnston Health • Sunnybrook Health Station Sciences Centre • Baycrest • Toronto Central CCAC • COTA • Toronto Intergenerational • Hospice Toronto Partnerships in Community • Madison Community (TIGP) Services • Toronto North Support • Mood Disorders Association Services of Ontario • The Bob Rumball Centre for • Regional Geriatric Program the Deaf of Toronto • Warden Woods • Renascent • Yorkminster Park Meals on • St. Matthew's Bracondale Wheels House 3 A special thanks to … • Toronto Central LHIN Citizens’ Panel – Audrey King • Toronto Central CCAC – Gayle Seddon • Primary Care Transition Steering Committee – Dr. Jocelyn Charles and Dr. Yoel Abels 4 Purpose of this first cross-sector session 11. Share the vision of how we will move forward through a population-health approach 22. Clarify our approach to planning 3. Discuss how locally integrated care relates to regional 3 and provincial systems of care 44. Provide an update on primary care 55. Looking forward – what’s next 5 Future sessions (summer / fall) 11. Discuss the role and contribution of hospitals within a new collaborative approach 22. Share collaborative work in home care, community support services, and community mental health and addiction services 33. Discuss vision for integrated Community-based care 44. Discuss how to formalize patient / client, family, caregiver, and community involvement 6 Everything begins with our Patients, Clients, and Community members Please welcome Audrey King 7 Today’s agenda 11. Vision and approach for achieving 20 minutes local, integrated, and population-based health care 22. Vision for a regional approach to care 15 minutes 32. Update on Primary care 15 minutes 43. Get to know our local patients / clients 30 minutes and families • Population data 54. Table talk and feedback on next steps 20 minutes 8 Key messages to keep in mind • We have much to celebrate • We all share a responsibility for the health of our communities • All of our efforts must build toward a systems approach to care – no longer sector-based • This meeting today is the start of a collaborative, continuous process • We don’t have all of the solutions right now • We are working together, and together we will define a vision and prioritize work to achieve that vision 9 What has brought us here today Research, Analysis, and Strategic Plan Community Engagements Expert Reports 10 What we have heard from patients, clients, families, and caregivers … Want to be at home and healthy “I don’t care how you organize my health - ACCESS – care or about the rules – I just want care when Searching is stressful I need it, where I can get to it, and to feel - NAVIGATION / confident that it is going COORDINATION - to make me better.” - Toronto Central LHIN Act as one team resident - COMMUNICATION - 11 TC LHIN Strategic Plan A vision for local planning Susan Fitzpatrick, CEO 12 Our Shared Goals Community Our Strategic Goals Outcomes Vision Wellness Prevention& A Healthier Toronto We are a healthy and active Transform the community system to achieve better Positive Patient We have timely health Experiences access to care that includes us outcomes for & Access and meets our Equity people now needs and in the future Innovation & We receive the System right care and all of our health care Sustainability & Quality providers act as a Value team 13 Current patient experience Health Link Primary Care / Family - Access - Physician / Walk-In Hospital / Acute Availability of core services may vary across Toronto Home Care Families and communities CaregiversHussein Family - Navigation / Coordination - CSS and CMHA Service Home Care Agencies Assessment Largely patient- and family- directed LTC Home - Communication - Multiple care plans 14 Current system of sectors 1.2 M Citizens navigating sectors of care 22 Home Care Agencies Specialists 1200+ Family 58 Diagnostics Practice / 17 54 CSS 17 CHCs CMHA 36 LTCHs Independent Hospitals Agencies General 1 CCAC Agencies Health Physicians Facilities Limited shared accountability across providers or sectors Accountable to MOHLTC Individual accountability agreements Varying models Individual volume-based funding Varied access to inter- professional, team-based care 15 Note: Numbers based on unique HSPs. Note that an HSP may have a number of agencies across sectors What we have heard from providers … • Build on successes • Pursue a population health approach • Integrate community service delivery • Partner to strengthen intersection with social determinants • Create consistency in core services across communities • Support providers to respond to community specific needs, including cultural competency • Map primary care capacity 16 Achieving a system for citizens "Every system is perfectly designed to get the results it gets" Current incentives What we want to incent Focus on individual patients Holistic care for an entire community needs (preventative and responsive) Individual providers funded based Teams funded based on community on volumes of care need and their outcomes achieved Individual provider accountability Shared, team accountability for for outputs outcomes Sector care planning One patient care plan Sector I&IT Shared I&IT Organized pilot projects Front line innovation PROVIDER CITIZEN 17 Desired patient experience “One team” approach to care Emergency Care and Scheduled Procedures Family and Primary Care Caregivers Local care Information Sharing Information team and care plan, rooted in primary and community care Care Coordination / Navigation 18 How we will work together to achieve the vision of “one team”? • A new process • Sector tables → Cross collaborative tables • An enhanced way of organizing how we work together • We serve the same communities → a single team in the eyes of the patient • A means to develop local, integrated, and population- based care • Plan and take action together 19 The motivation for this approach ... Together, we will: • Understand the needs of E.g. the whole population and Identify local communities care models • Meet the needs of sub- populations (e.g. E.g. Address Francophone, Indigenous, health marginalized) inequities • Tackle health inequities E.g. Work • “Get upstream” upstream (maintain and (prevent) prevent) 20 Taking a Population Health Approach with a focus on Equity • A cross-cutting theme in the implementation of our strategic plan • Planning to date has generally been focused on meeting the needs of those actively receiving health care, but our mandate is to deliver excellent care to all (reinforced by Ontario’s Excellent Care for All Act). 21 Population Health: What does this mean to our partners? Focusing on sub-populations, understanding their unique needs and challenges and working with communities to find sustainable solutions: • This will require collaboration and shared accountability between the LHIN and HSPs, public health, and other partners to implement targeted solutions that will improve the health status of unique ‘sub-populations’ • Successful implementation will require: • Greater integration with primary, hospital, home, and community- based care, • Enhanced performance measurement through more valuable data, • Engaging marginalized populations, and • Strategic partnerships with health and non-health entities. • The LHIN will focus on strengthening local planning partnerships to advance a population-based approach while maintaining regional and provincial systems 22 Purpose of a new approach to collaboration Establish local Create strength in collaboratives of diversity diverse providers, patients / clients, and Share accountability families that share a for change common vision for local, integrated, and Outline the steps we will population-based health take together to make care in the TC LHIN that vision a reality 23 Moving to “One Team” Patients / Clients, Families, and Caregivers Establish patient Deepen and caregiver understanding of involvement the community’s health needs Align home & Build a strong community care community-based as one integrated primary care system network Long-Term Care Primary Care Practices Homes FHT Define a model of Housing with FHN CHC Supports care coordination Care Supportive Community Coordination/ FHG Share information and navigation Mental Health and FHO Primary Care Navigation Addictions Network across all Services Inter- Solo Home and professional partners Health Link Practitioner Community Other teams partnership Support Services Clinics Post-Acute (complex care) Short-Stay Emergency Community Department Care Coordinate access to Build partnerships to specialized and advance social Hospital(s) regionally-based care determinants of health 24 when needed What can the future look like for patients and clients … • Play an active role • Their outcomes and feedback drive continuous quality improvement - Access - • Have equitable and reliable access to care in their community - Coordination / Navigation - • Single point access to choice of primary care • Access to navigation and care coordination that meets their needs - Communication- • Providers work as one team and information follows the patient 25 What can the future look like for providers … • Co-design local solutions with patients / clients - Access - • Access to inter-professional team supports including local Health