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Mississauga Halton LHINCSS and MH&A Sector Meeting

December 10, 2009

Agenda

AgendaWelcome•Getting to Know Each Other – Ice Breaker

Angela Jacobs 20 min

CSS/MH&A Agency Profile•Links2Care

Sandra MelhuishExecutive Director of Links2Care

20 min

Mississauga Halton LHIN Strategic Priorities•A @ H Year 3•ED/ALC•Results of Previous Planning:

oMH&AoPalliative Care

•Integration OpportunitiesoTable Discussions

Monita O’Connor Cindy Hawkswell – ED/ALC Lead

Angela JacobsRoberta Lee

Monita / All

10 min15 min

10 min10 min

30 min

Break 10 min

Shared Services West Sue Turcotte / John Simpson 15 min

Transformation of Community Sector•ASSIST Approach

Ray Applebaum 15 min

Finance Update Paulette Zulianello 15 min

Questions/CommentsNext Meeting: TBD

Angela Jacobs 5 min

Ice Breaker Angela Jacobs

Winning the Lottery!•

One lucky HSP at your table will be allocated $1 million from an anonymous donor.

•

Take turns introducing yourself, your HSP and what services your HSP provide.

•

Explain to everyone at your table, why your HSP deserves to get this additional funding and how you would use this new money.

•

Select one “winner”

per table to report to the larger group what they would do with the $1 million.

Links2Care Sandra Melhuish

Executive Director

• Multi-service community organization delivering a wide variety of programs and services to children, youth, adults and seniors

• Serve over 7,000 clients in Halton/Mississauga• $6 million operating budget with funding from MH LHIN,

MOHLTC, MCYS, Employment Ontario, United Ways, Town of Oakville, Town of Halton Hills, Town of Milton, Region of Halton, Ontario Trillium Foundation, Alcoa Foundation, individual and corporate donations…

• Eleven site locations in Georgetown (head office) Oakville, Mississauga and Acton; approximately 125 staff and 250 volunteers

WHO WE ARE

Seniors and Adults with DisabilitiesMeals on Wheels, Congregate Dining, Wheels to Meals Friendly Visiting, Home Maintenance & Repair, HomeHelp, Reassurance & Assistance, Letter Carrier Alert Client Intervention, Assisted Living, CompanionRespite.

AdultsAssistance and Advocacy, Needs Coordination, Transitional Housing, Holiday Hampers, EmploymentResource Centre.

YouthOff the Wall Youth Centre (Acton), Open Door Youth Centre (Georgetown), Parent and Youth Support andHealthy Snack Program.

ChildrenOntario Early Years in Acton and Georgetown providing support and information on parenting,child development and other early years services in the community. Programs for parents/caregivers with theirchildren include: Adult and Child Together (Drop-In),- Family Together (Drop-In), Mother Goose, ToddlerShimmy and Shake, Networking Together, Young Parents Dinner Club

Family Resource Programs also includes Preschool Shimmy and Shake, books, videos, tapes and kits areavailable at the Resource Library.

Calling New Parents and DEIPP Clinics also take place at some locations.

Links2Kids in Georgetown providing daycare and before and after school programs.

WHAT WE DO

Mississauga/HaltonRegion

GeorgetownHead Office

Ontario EarlyYearsActon

AssistedLivingActon

Acton Employment

Centre

Acton Office

OakvilleOffice

Ontario EarlyYears

Georgetown

Links2KidsDaycare

Open DoorGeorgetown

Off the WallActon

MississaugaOffice

Programs for Seniors And Adults with Disabilities

“If youth knew; if age could” ~Henri Estienne

The Home Help Program providesassistance with bathing, laundry,vacuuming, cleaning, shopping andsmall meal preparation.

Home Help

Home Maintenance and Repair

Using a brokerage model, assistance is provided for work needed inside and outside of the home. Jobs could include yard maintenance, snow shoveling, painting or seasonal housecleaning.

Client Intervention and Assistance

This program provides support forseniors who may be at risk due to acritical change in their life situation.Referrals may also be made to otheragencies in an effort to create asustainable plan.

Visiting-Social & Safety

Friendly Visiting provides a regular visit to seniors in theirown home. Seniors can experience and build a one-on-onerelationship with a volunteer visitor.

Letter Carrier’s Alert is a routine check done by Halton Hillsletter carriers if a registrant’s mail is not attended to.

Telephone Assurance is provided by volunteers whocall seniors regularly for a safety check and social contact.

Meals Programs

Our Meal Programs offer a variety of meal options to seniors and adults with disabilities who are unable to manage food preparation. Provided in Georgetown and Acton.

Meals On WheelsHot lunchtime meal or sandwich meal is available. Frozen meals for the weekend can be ordered and delivered with thelunch meal.

Meals On IceA large variety of entrees, soups and desserts are available. Meals will be delivered or can be picked at the office.

Meals Programs

Wheels to MealsLuncheons are held twice a month at a local restaurant, church or community hall. Transportation is provided through volunteers.

Congregate DiningMeals are provided in designated senior’s buildings in Georgetown and Acton.

Social &Congregate Dining

Respite Care

Companion respite relief allows thecaregiver some personal time withpeace of mind that their loved one isbeing well cared for.

Assisted Living

The Assisted Living Program provides essential supportservices to eligible seniors living at 17 ElizabethDrive in Acton to allow independence, safety and dignity.

Lead/banker for Ministry of Health andLong-Term Care’s PSW Training Funds in:

• Mississauga/Halton• Central West• Waterloo/Wellington

Provide administration, monitoring and evaluation of funds

PSW TRAINING FUNDS

The Centre provides:

• Computer workstations, internet access, fax, phone and employment search resources to “job ready” clientele.

• Information on local job opportunities in Acton and the surrounding area, researched and posted daily.

• Monthly themed workshops and information sessions on employment related topics.

ACTON EMPLOYMENT RESOURCE CENTRE

Support for families experiencing difficulties, especially those whohave no other place to go, or are unable to access serviceswithout assistance.

We help fill out forms, advocate for clients, and make referralsto appropriate community services.

The Community Support Program provides a “wraparound”service for clients. When a client presents with one issue, we takea holistic view and assist or refer as required.

GENERAL ASSISTANCE AND ADVOCACY

INCOME TAXTrained volunteers complete income tax returns for people withlow incomes. Over 160 individuals per year receive free incometax services.

NEEDS COORDINATIONDonors with items to donate are connected with people who are inneed of the items. Appliances, furniture and kitchen ware areexamples of items that are requested and matched to individualsand families in need.

COMMUNITY SUPPORT

Five transitional housing units are available in Halton Hills forfamilies who are homeless or at risk of becoming homeless.Families are temporarily housed in our furnished units while theysearch for permanent housing.

During their stay, the services of the Community SupportCoordinator are available to provide support, assistance andhelp with finding permanent housing. This program is funded bythe Region of Halton.

TRANSITIONAL HOUSING

Open Door has been meeting the needs of Georgetown youth since 1985.

Open Door is a Drop-in program where youth, ages12 to 19, can visit during their school lunch hour or spare time. Approximately 100 – 130 youth attend the centre daily.

Off The Wall was an Acton community initiative, which opened in June 2000.

Off The Wall is a Youth Resource Centre offering age appropriate programs for youth aged 12–19 three evening a week.

Common Issues Programming Benefits

Relationships Crime Prevention Confidence BuildingDrugs & Alcohol Use Relationship Building Healthy RelationshipsSuicide Assessment Drug & Alcohol Education LeadershipVerbal & Physical Abuse Fundraising ResponsibilityBullying Body Education Reduce Crime RateLearning Disabilities Conflict Resolution Improved Self EsteemOut of Control Behavior Diet & Nutrition Body AwarenessSocialization Sports Activities & Workshops Finance AwarenessResponsibility Leadership Development Respectful BehaviorDecision Making Arts & Crafts Decision Making SkillsProblem Solving “Hang Out” Community Involvement

YOUTH

“A Place For Parents and their Children”

Community Programs and Services:

•Parent and Tiny-Tot (Drop-In)•Adult and Child Together(Drop-in)•Mother-Goose•Toddler-Shimmy and Shake•Networking Together•Dad’s Connect

•Caregiver’s Connect•Young Parent’s Dinner Club•T.E.A.M. Lunch and Learn•Stay and Play•Writing to Rulers•Muffins to Magnets

Community Services and Programs:

• Resource Lending Library• Toy Lending Library• Preschool Music Makers Programs• Summer Fun Mini Camp

Georgetown Parent-Child Centre Family Resource and Toy Lending Library

Licenced daycare services at the centre located in Georgetown and before and

after school programming at two schools in Georgetown

Early Learning and Childcare Centre

Thank you

Mississauga Halton LHIN Strategic Priorities

Monita O’ConnorDirector Performance Improvement and Integration

34

Ontario Health System

•

Growing pressure to contain costs

•

Health care spending increased faster than GDP in Canada (1996 -

2006 ≈

10 % ↑

annually)

48% of Total Provincial

Budget

36

More Health Care is Not Always Better

The largest factor contributing to major health care expenditure is…

“Contrary to popular belief, population growth and agingare not the biggest contributors to the rise in Canada’shealth care spending”

[“Value For Money: Making

Canadian Health Care Stronger.”

Health Council ofCanada, February 2009]

Canada’s Total Health Care Spending1997 –

79 Billion2009 –

172 Billion

* * 70% publicly funded

37

“More health care is not always better for individuals or for populations”

38

Challenges In Health Care Delivery Patient First

“Insanity is doing the same thing over and overand expecting different results”

–

Albert Einstein

The Saskatchewan “Patient First”

Report noted “We will not see a permanent change in thepatient experience if we keep running the system the same way we always have.”

(1)

Integration Integration Integration

(1)

Patient First, Report of the Saskatchewan Patient First Review, October 2009 Prepared by KPMG, October 2009 for Saskatchewan Ministry of Health

39

Focus on Patient First – Need For More Effective Patient (and Family) Centred Care

•

Our “collective”

patient whose needs are met by the appropriate providers at appropriate times in an integrated manner i.e. interests of clients/patients are ahead of specific organizational interests

•

Ensuring appropriate patient/client needs (not provider preference) drives care

Right Time

Right Person

Right Place

40

•

Canada’s Health Care is too political-too many conflicted interests---Frank McKenna, V. Chair, TD Bank

•

Organizational and financial interests, will tend to override system integration especially when fiscal restraint is required

Aging at Home Summary of Investments by Programs Cash Flow 2008/09 & 2009/10

10.53%9.90%

5.04%

2.21%

4.33%

5.98%

1.93%

36.50%

23.57%

SDL $6.952M

ADPs $2.004M

RGP $1.884M

Palliatve Care $0.960M

Mental Health $0.422M

ABI (Behavioural) $0.824M

Enhanced Home Serivces$1.138MTransportation $0.367M

Transitional Beds $4.487M

Aging at Home 2010-2011 (Year 3)

Key Ministry Expectations

Demonstrate the following:

1.

Quantify expected outcomes to reduce time spent in ER

2.

Quantify optimizing inpatient hospital capacity

3.

Describe supporting evidence

4.

Cross-LHIN collaboration

5.

Reduce reliance on LTC beds

Priorities Description

1.

2.

3.

LHIN examples include Safe at Home; Wait at Home, Home at Last etc

4. Outreach Teams

5. Other TBD

Targeted support to provide enhanced nursing assessment and treatment services in any home setting (e.g. home, LTC home, Supportive Housing)

Targeted outreach service towards high risk seniors who comprise high ER volume or high volume of ALC patients (e.g. psycho-geriatrics, interdisciplinary teams)

Ministry A@H 2010-11 Priorities

Enhanced Home Care (Building community based services)

Initiatives that enhance the range of home care services for seniors to avoid unnecessary ER visits, ER and hospital admissions, and support timely discharge of seniors

Initiatives permitted: intensive community-based case management, in-home primary care, enhanced community support services, enhanced mental health and crisis services, etc.

Additional Temporary Care Bed Capacity

Initiatives targeted to increase capacity across the post-acute spectrum of care including rehab, Complex Continuing Care, Convalescent Care, Interim LTC and other innovative settings to enable appropriate discharge from acute care and transition back to

Admission Avoidance/Timely Discharge Initiatives (Hospital process enhancements)

Initiatives targeted to seniors to avoid unnecessary ER admissions and support timely discharge form ER hospital

Initiatives permitted: enhanced case management functions in the ER and hospital, Flow Coordinators, GEM nurses in the ER and hospital, psycho geriatric nurses in ER and hospital

MH LHIN Request for Proposals for 2010-2011•

Focus on four priority areas:

•

ER and Admission Avoidance/Timely Discharge Initiatives•

Enhanced Community Support Initiatives•

Outreach programs•

Specifically:

•

Supports for Daily Living•

Volunteer Visiting Hospice•

Continence care for seniors living at home/community•

Admission avoidance / Timely Discharge Initiatives•

Outreach Programs•

Chronic Disease Prevention and Management

Mississauga Halton LHIN ED/ALC

Cindy HawkswellMH LHIN ED/ALC Lead

Average ALC Patient Count vs. Total ALC LOS Days (CIHI)

9,87310,234

15,146

5,877

220 225

206 202

227

187

133122

112

93

117 121

143152 155

141 136

121

73

55

77 7364

38

5361

0

50

100

150

200

250

Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09

Avg

ALC

Daily

Cen

sus

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

End

of Q

uarte

r ALC

LO

S D

ays

(CIH

I)

CIHI ALC Days (Quarter) Total ALC Pts Total ALC - LTC Pts

(11.11%) (11.24%)

(15.62%)

(7.61%)

Your Input From Our September Sector Meeting

Prior Café Question:•

What still needs to be done in the community to facilitate improved access and flow of clients to services they need?

•

Responses:•

Themes:•

IT/e-Health

•

Access•

Capacity

•

Common Tools –

Assessments, Intake•

Communication/Education

•

Other

Results of Previous Planning Work - Mental Health and Addiction

Palliative Care

Mental Health and Addictions Investment

Strengthening Community Supports for Concurrent Disorders

Mixed News : ER Use

•

Many LHINs showed a decrease in early return rates

52

Change in Early Return to ER after Previous Visit by LHIN from baseline to 2007

-8.00

-6.00

-4.00

-2.00

0.00

2.00

10 14 5 7 2 9 11 12 8 4 3 13 1 6

LHIN

Act

ual P

erce

nt

Cha

nge

Reduce ED Visits MH&A Task Team•

Established and Lead by Vivian Demian –

Program Leader for

Mental Health, HHC

•

Membership –

Hospital and Community MH&A HSPs

•

Reviewed and analysed data related to repeat ED visits

•

Tracked referral patterns by hospital/ by diagnosis

•

Identified opportunities to decrease of the number of patients attending ED as first step to receiving treatment

•

Addressed SIGMHA on the need to priorize referrals from ED

Findings:•

3 year trend of increasing new and early return ER visits across all hospital sites

•

In past 2 years, 23.5% repeat visit within 30 days

•

In 2008/09, there were 6,570 ED visits

•

791 returned within 30 days (12%)

•

27.3% of visits related to substance abuse

•

23% related to both Depression and Anxiety

•

31.6% related to young people (17-30)

•

71% discharged home/29% admitted

Working Group identified 10 Strategies to Decrease ED visits

•

Drop in Centre as alternative to ED visits •

Partnership with Urgent Care Clinics

•

Train Staff to respond to Walk-ins •

Intensive Case management for people with Concurrent Disorders

•

Bridging Program from ED to community services•

Home based Withdrawal Management Program

•

Shared Care model to nursing homes•

Day Treatment program

•

Peer Supports in the ER to provide follow up•

Expand COAST to North Halton

Futu

re

Stat

e

Strengthening Community Supports for Concurrent Disorders

One program –

Three services

1.

Community Crisis Support

2.

Community Chemical Withdrawal Management

3.

Enhanced Concurrent Case Management

•

All programs need to align to reduce ED utilization and Hospital LOS

•

Respond to urgent referrals

1. Community Crisis Support•

Addiction Crisis Worker, aligned with each ED

•

Accept priority referrals from ED and Inpatient Units for people with addictions and concurrent disorders

•

Short term support and link to community programs

•

Client seen within 1-2 days in office or own home to assess, monitor and counsel

•

Early intervention with improved clinical outcomes

2. Community Chemical Withdrawal Management

•

Expand current Community Withdrawal management services to be available LHIN wide

•

Assess, monitor and provide medical supervision during withdrawal process

•

In-home service

•

Program enhancement:

•

Case management to provide bridging to community programs

3. Concurrent Case Management•

Enhance current capacity

•

Target geographic areas with long wait times

•

Accept urgent referrals from EDs and Inpatient Units

•

Priorize clients with addiction or concurrent disorders

•

Strengthen linkages with existing community programs

Program Requirements:•

One LHIN wide program focus to strengthen community supports for Concurrent Disorders and transform current system:•

3 services work together to create complete, seamless and timely support for clients with addictions or concurrent disorders

•

Quick and easy handoffs between services•

Standardized referral form

•

Common assessment tools •

Strong Linkages to existing community supports and services

•

Flexibility to meet service needs•

Pilot new processes and protocols to ensure service integration

•

Collaboration and partnership but one program Lead

Linkages with Existing System•

Crisis services:

•

COAST Teams, Mobile Crisis of Peel

•

Safe Beds

•

Emergency Department, Crisis Teams

•

Priority referrals

•

Simplified referral and intake processes

•

Addiction and Mental Health Services;

•

ACT, Intensive Case Management

•

primary care

Recommendations :•

17 new FTE positions

•

Staffing:

•

3 FTE crisis supports

•

Establishment of new Chemical Withdrawal Management – 2 Addiction Counsellors, 2 RNs

•

4 Concurrent Case Managers aligned with CWM teams

•

6 additional Concurrent Case Managers for intensive case management throughout the LHIN

OutcomesIncreasing community capacity to support people with addictions or

concurrent disorders

•

80% reduction in early return ED visits

•

Overall 10% reduction in ED visits

•

Reduced Length of Stay in ED

•

Reduced Average Length Of Stay in hospital

•

Seamless service for those most in need

•

Case complexity

•

Compliance with common practices –

improved access

•

Compliance with MOHLTC standards

Mississauga Halton LHIN Palliative Care Initiative

Roberta LeeSenior Lead, Health System Development

The MH LHIN Palliative Care Initiative

Developed: A palliative care model in the community setting that meets the needs of patients and their families

•

which is accessible, well coordinated, comprehensive, and patient–centred and

•

will avoid unnecessary use of acute hospital setting (ER visits and admissions)

Mississauga Halton LHIN

Summary Palliative Care Model

10/5/2009

Mississauga Halton LHIN Palliative Care Patient Flow Chart – Appendix A

Patient Points of Entry

Hospital*

including E.R.Out-Patient

*

Clinics

Primary *

Health Care Office

Out of Region *

Centre

Patient/FamilySelf-Referrals

Advance Practice NurseOR

Medical Doctor

Diagnosis / Prognosis

CCAC Referral / Central

Registry

YES NO

CCAC SERVICE ENGAGEDPalliative Case Manager

NO CCAC SERVICESby Patient’s choice

(If Hospital Patient)DISCHARGE?

YES NO

LTC RESIDENTIAL HOSPICE

COMPLEX CONTINUING

CARECORRECTIONAL

INSTITUTION ACUTE BED

Home is:o Retirement Homeo Long-Term Careo Own homeo Residential Hospiceo Complex Continuing

Careo Correctional Centre

Patient Points of Entry

Home

* any health professional “flags” patient

based on criteria. Criteria is anyone

suspected to be within their last year of life

Identify and build the Primary Palliative Care Team (PPCT)(including the identified lead across the sectors)

PatientDiscussion

Diagnosis / Prognosis

Remain withFamily Physician

Care Coordinator

10/5/2009Mississauga Halton LHIN PALLIATIVE CARE MODEL

Primary Palliative Care Team

Physician (Family MD, Palliative Care MD, Specialist MD)Nurse (Community nurse, Advanced Practice Nurse)

Palliative Care Coordinator – (care coordinator / identified lead) Pharmacist

Primary Support Team

Personal Support Worker, Spiritual Care, Volunteers, Social Worker, Physical Therapist Occupational Therapist, Dietician,

Grief & Bereavement Counselor, Respiratory Therapist

CARE LEVEL 1

PATIENT & FAMILYare the centre of our focus and will move through

the three levels of care as needed

Primary Palliative Care Servicescan be provided in any setting including Long Term Care and Retirement Homes, own home, Residential Hospice, Complex Continuing Care, Correctional Centre, Outpatient Clinic and Community Hospice.

Palliative Care Resource Team

Palliative Care Physician (Secondary or tertiary level) Palliative Care Nurse (Advanced Practice Nurse / Palliative Care Consultants)

Psycho-social – Spiritual care providerPharmacist

CARE LEVEL 2

Palliative Care Serviceso Community Hospice: Volunteer visiting & Adult Day Programso Outpatient Clinics providing Palliative Care:

Nephrology Cardiology Respirology Transplant Liver Oncology Neurology

o Grief & Bereavement Serviceso Palliative Care Clinico Residential Hospiceo Pain and Symptom Management Serviceso Respite Serviceso Spiritual Careo Psych-social Serviceso Community Hospice Services

Tertiary Palliative Care Team

Palliative Care Physician (tertiary level)Physician (Medical/ Radiation/ Surgical Oncologists, other

Medical Specialists, Anesthetists)Advanced Practice Nurse in palliative Care/Oncology/Medical Specialty

Psycho-social care provider with expertise in advanced illnessPharmacist

CARE LEVEL 3

Tertiary Level Services such as:

o Radiation Therapyo Chemotherapyo Interventional Radiologyo Acute Palliative Care Unito Anesthesiologyo Surgery

Direct Care will be provided based on the Square of Care, Ferris F. D. et al, “A model to Guide Hospice Palliative Care”, 2002.

Roles and Responsibilities of Team Members and Levels of Care . Please see Appendix B

MH LHIN Palliative Care Patient Flow Chart

Please see Appendix A

Final- September 4, 2009

Recommendations for the ModelBuild Community Capacity-

Community Palliative APNs to be integral part of the team and liaise between hospital and community to reduce need for hospitalization and ER visits

Front line nurses and physicians education and mentorship:

Education on advance care planning, CME sessions, nursing and PSW palliative care education and mentorship.

Shared care approach with family physicians/palliative care physicians

Care Coordinator- identified coordinator to ensure healthcare coordination/system navigation, i.e. in LTC, CCAC in community

Early identification and central access/referral.

Consistent, common pathway through the system

24/7 availability of team

Recommendations for the Model - continued

Enablers for the Initiative:

Providers sharing of patient database through e-portal

Training for Advanced Care Planning

Development and distribution of a Palliative Care Resource Guide

Comprehensive communication strategy

Evaluation and performance metrics

Key Measures of the Palliative Care Initiative

a) To reduce the need for palliative care ER visits, hospital admissions, and shorten the length of stay in hospital by 1/3rd

(30 beds)

b)

To reduce the number of deaths of palliative patients occurring in hospital

The equivalent of 90 hospital beds were occupied by palliative patients in MH LHIN*

(* Source: 07/08 DAD, at 90% occupancy)

Regional Approach to Palliative Care:

Identified hospital and CCAC leads

Identify physician champion

Advanced Practice Nurses to liaise between hospital and community to reduce need for hospitalization and ER visits

Enhanced direct care palliative services through the CCAC.

Next Steps•

Confirm co-leads and physician champion

•

Develop a Palliative Care Steering Committee

•

Hire Palliative Advance Practice Nurses

•

Hire (short-term) project coordinator to roll out initiative

•

Enhance palliative care CCAC services for the additional visits for patients’end-of life needs

•

Roll out palliative initiative: education and marketing to providers and consumers.

•

Develop, print, and distribute Palliative Care Resource Guide give to patients, caregivers, physicians, and providers.

Questions?

Integration OpportunitiesMonita O’Connor

Discussion Using “World Café”

World Café•

Select a scribe for your table.

•

For the next 15 minutes, discuss the question on the next slide (also typed on the piece of paper being handed out).

•

Make notes during this time period.•

At the end of 15 minutes (time will be called) everyone EXCEPT the scribe moves to other tables. Mix it up!

•

The scribe reads out the notes they took and the discussion will continue.

•

Scribe to take more notes on the discussion. •

The paper will be handed in to the LHIN for consolidation.

•

Move back to your original table.

Café Question:

•

Given the current economic constraints that we expect to see over the next couple of years, what do you see as being the best integration opportunities to sustain or improve the system?

Break! 10 Minutes

Shared Services West Sue Turcotte

Director, Finance and Risk Management MH LHINJohn Simpson -

SSW

Transformation of Community Sector ASSIST Approach

Ray Applebaum

ASSIST Update Presentation - October 20, 2009

86

Purpose of Presentation• To provide an update on project activities since the

Value Stream Analysis session held in February 2009• To provide an outline of the initial thinking on

performance measurement• To obtain feedback/direction on the proposed directions

of the project, as it proceeds to test phase preparations


87

Outline of PresentationProject Overview

Update on High Level Project Plan for 2009-10• Where are we now?• Achievements to Date and Progress Towards Deliverables• Recommended Direction – 3 Model Elements• Target Areas For Test Phase (under consideration)• Early Thinking – Performance Measurement of Test Phase

Next Steps – Fall and Winter 2009-10


88

Project Overview All-Inclusive Seamless Services for Independence of Seniors for Today and Tomorrow (ASSIST)

• The ASSIST concept is a cornerstone priority of the MH LHIN IHSP• The ASSIST Access, Information, Referral and Intake Project is

designed to address the need for a more decipherable, systematic, co-ordinated and collaboratively orchestrated referral system that supports a flow of clients across service continuum and early identification of at risk seniors in the community

• Or said differently, this project is designed to provide the “sheet music” that will guide all parties to carry out and improve the delivery of information, referral and intake practices in a consistent, streamlined and collaborative manner.

• These improvements will provide a more supportive system for client navigation and access by facilitating increased knowledge, skills, and inter-organizational communications across the intake staff.

• These improvements are the essential building blocks for the automation of referrals across the health service providers.


89

Project Overview

What these improvements will mean for Health Service System:• Improved service access, navigation and continuity of services for

seniors and caregivers • Strengthened system knowledge, relationships and integration of

intake practices among the staff of agencies/providers• Enhanced and more effective information and referral practices

among staff across organizations• Leveraged deployment of existing providers in the MH LHIN• Enhanced seniors’ health, wellness and independence through

leveraging an improved community support service capacity within an integrated and co-ordinated health system delivery model

• Optimization of health care resources and flow of clients across the continuum


90

Project Overview What these improvements will mean for Health Service Providers:• Consistent language in describing services across providers • Clear paths and directions for routine/directing referrals• A culture shift among health care providers - towards collaborative

customer service, and ensuring no clients are dropped between providers during referral process

• Capacity to identify clients “at risk” and may require case management or specialized expertise (via common intake tool) during intake process

• Readiness for automating referrals via the Community Services Portal


91

Jul 1, 2009 Oct 1, 2009 Jan 1, 2010

Access, Information, Referral and Intake Component of ASSIST Model Project Outline

June - October 2009Meeting with Value Stream Analysis participants – sign up for Task Teams Task Teams (via concentrated meetings) develop and agree to a common referral form /dataset, common risk screening tool, and common user friendly service definitions, referral protocols, validated reference and education resourcesStakeholder Consultation regarding resource requirementsPerformance measurement plan development including client satisfaction

February – March 2010Begin Operational Test Phase(s) of Model Review high-level “next steps for initiativeReview and decide upon ongoing leadership/ governance modelMeasure performance

Participating Health Service Organizations confirmed (via Expression of Interest)Common intake/referral formCommon risk screening toolCommon user friendly service definitionsCommon phone answering/transfer protocolsConfirmed the ASSIST Coordinator rolePerformance measurement plan

Agency referral and services search toolReferral and risk tool database in Community Portal Community Portal tested for transfer of Referral Form and Risk ToolAgencies trainedImplementation plan

Letter of agreement for Participation in Test PhaseOngoing leadership/governance model established

KEY

AC

TIVI

TIES

DEL

IVER

AB

LES

November – January 2010Data collection and validation from 53 agencies re: services available in agencies (as per common definitions)Catchment mapping as per service definitionsTechnical development of agency and service advanced referral search tool Technical development of referral and risk database (within Community Portal)Test use of Intake Referral Form and Risk Tool – using Community Portal and selected agenciesOperational Phase(s) design, training and preparations

Ongoing: Project Management, Internal Stakeholder Communications and Change Management

OU

TCO

MES Improved service access, navigation, and continuity of services for seniors and caregivers

Strengthened system knowledge, relationships and integration of intake practices among the staff of agencies/providersEnhanced and more effective information and referral practices among staff across organizationsEnhance seniors' health, wellness, and independence through leveraging an improved community support service capacity within an integrated and coordinated health system delivery modelOptimization of health care resources and flow of clients across the continuum

Note: Where possible, this project will leverage existing initiatives / work underway, and will align with provincial and LHIN strategies.Technology Elements Subject to Approvals

Nov Feb


92

Design Phase: June - Oct. 2009

92

Steering

Committee

Kick‐off

Steering

Committee

Kick‐off

Internal Stakeholder Communications, Change ManagementInternal Stakeholder Communications, Change Management

Project ManagementProject Management

Steering Committee oversightSteering Committee oversight

Steering

Committee

Approvals

Steering

Committee

Approvals

July ‘09 Aug ‘09 August – October ‘09 Oct ‘09

Common Process and Protocols Task TeamCommon Process and Protocols Task Team

Common Intake and Screening Tool Task TeamCommon Intake and Screening Tool Task Team

Common User Friendly Service Definitions Task

Team

Common User Friendly Service Definitions Task

Team

Task Teams

Orientation

Task Teams

Orientation

Project Team development and supportProject Team development and support

Review of existing

models, processes

and tools

Approve project

team workplan

and

deliverables, scope

and high level

process

Approves process

and protocols, intake

and screening tool

and user friendly

service definitions

Reviews, provide inputs to and recommends detailed

intake and referral model and processes

Reviews, provides input to and recommends tool

Reviews, refines and identifies new definitions and

recommends a final set of definitions

Design and develop revised model, process, tools and definitionsProvide support to the establishment and operations of Steering Committee and task teams

Develop measurement plan (e.g. program logic model, indicators)


93

Achievements to Date Project Planning and Design

• Completed the 4-day (Feb 2009) Value Stream Analysis Session (lean quality improvement methodology) to create the vision for the ASSIST Access, Information, Referral and Intake Project

• Project Charter and High Level Plan completed and approved (July 2009)

• Task Team Initiation (June 2009) and completion of deliverables (October 7, 2009)

Project Oversight and Management• Steering Committee established (Chair, Ray Applebaum, and

Vice-Chair Nancy Kula) and had 2 meetings held to date, with 3 more planned for the fall

• Project Team in place (Sue Lantz, Jennifer Boucher and Brenda Elliott to support work completion)


94

Achievements to Date

Task Teams with representatives from over 24 Health Service Provider organizations have developed and agreed to:

Common Intake and Risk Screening ToolCommon Service DefinitionsCommon Risk Screening and Warm Transfer/Hand off process for referrals

These products are scheduled for review and approval by the ASSIST Steering Committee on October 23An ASSIST Project Space (folders, etc) set up on MH LHIN websitefor all Task Team and Steering Committee members to ensure transparent access to all project materials (read only basis)


95

Foundation Inter-organizational Referral Model

AgencyHospital

Discharge Planner/ SW/Clinic StaffCCAC Case Manager

GEM Nurse

Community senior/caregiver has a need and contacts an agency for help/service

All agencies will screen for need beyond what is asked, as appropriate. (Protocol & Form)

If the agency does not provide the service the senior needs, the agency will take the responsibility to make the right referral and ensure the senior is linked. (Protocol)

There is no wrong door for a senior calling – the first agency called, is the starting place.

CCAC Contact Centre

Specialized agency(ies)

If an agency doesn’t know how to match the senior’s need to the right service(s) the agency can call for information to the following:• CCAC Contact Centre or • 1 or 2 pre-defined specialized agencies that serve specialized, complex target groups of seniors e.g. mental health and addictions, Alzheimer Society (Protocol)

CCAC

Resource HubAreas of Specialization

Recommended Direction


96

Foundation Inter-organizational Referral Model

The Foundational model is the basic inter-agency referral model where each organization is responsible for providing access and referrals to other service provider organizations using common tools and processes, protocols and roles developed by ASSIST Project

Every door leads to service” therefore the foundation model is the minimum process to implement for the test phaseLeverages model implemented in Central LHIN (DWTC) and piloted in Toronto Central LHIN (CNAP) aiming for full implementation this fiscal year (2009/10)

Foundation model includes the ability to escalate client (based on complexity of needs/risk) to appropriate agency for case management based on risk screening aspect of Intake Tool – for example:

CSS agency for case managementCCAC for case managementRecommendation to client to seek medical referral for SGS services (protocol)


97

Enhanced Model FeaturesCCAC Resource Hub

• CCAC Contact Centre serves as a resource for staff within “spoke” (participating) organizations, which leverages their current expertise and Information role and mandate

• “Spoke” organizations use the CCAC Contact Centre staff as a resource when determining referral options for client

Areas of Specialization • Provider organizations that serve specialized, complex sub-

populations designated as providers of support to other agencies when determining referral options for client

• And/OR, or Provider organizations that offer co-ordinated intake on behalf of the LHIN funded agencies for a particular type of service (e.g. SDL or SGS)


98

Recommended Direction: Case for Implementation

CCAC Resource Hub:• Strength of this approach is that the process for seeking support for

guiding referrals is defined• New staff can use this formal process to gain knowledge over time by

consulting with I&R experts in the CCAC contact centre (via 310-CCAC)• Support provided by CCAC contact centre staff to agency staff is designed to

increase effectiveness of I&R provided to the client• Infrastructure is in place in the CCAC Contact Centre already – trained

staff, current resources, LHIN wide, cross-LHIN to other CCACs• Enhances ability of small, less resourced organizations to participate in

ASSIST by providing staff with additional supports by the CCAC contact centre staff


99

Recommended Direction: Case for Implementation

Areas of Specialization:• Enhances ability of small, less resourced organizations to participate in

ASSIST by providing staff with additional supports of a hub organization• Strength of this model is that the process is defined and clear – and,

new staff can use this formal process to gain knowledge about referrals to specific types of services (e.g. SDL) or client populations (e.g. mental health)

• Collaborative model designed to strengthen relationships and collaboration and build capacity within the system

• Support provided by specialized organization to spoke agency designed to increase effectiveness of I&R provided to the client


100

Test Phase Design: Recommended ScopeInteragency referrals

Referrals between a mix of 10-15 community agencies, mental health and addiction agencies, hospice, etc.

CCAC staff to community referralsGSN referrals to communityCCAC contact centre staff accept referrals to CCAC from providers that are participating in ASSIST test phase

Hospital to community referralsReferrals from one SGS provider to the community providersReferrals from a community mental health outreach team to community providersReferrals from one or two specific hospital clinics or units, e.g. falls clinic, diabetes clinic, or a rehab unit


101

Test Phase Target Areas - Analytical Framework Used

Description Description of the target area including the current state and the proposed change being considered for ASSIST test phase implementation

Overall Impact Overall impact of the proposed change being considered. Derived from analysis of the target area criteria.

Target Area Criteria: Impacts

Analysis of the target area against each of the target area criteria : Provides adequate referral volumes in order to truly test the implementation of the

modelReflects LHIN priorities: reduce ALC use and ED wait times in hospitals and support

clients in the communityAbility to demonstrate improvements in the system within the test phase period


102

Initial Thinking – Performance Measurement of Test Phase

Domain Draft Indicator Data SourceQuality Increased number of accurate referrals (or

reduced duplicative or inaccurate referrals) that can be acted upon

Common Referral and Intake Form (e.g. did staff consult each other prior

to routing referral)

Efficiency Reduced Lead time (between date of client contact or referral request and referral confirmation )

Common Referral and Intake Form (e.g. dates of service request, date of referral confirmation by recipient agency)

Client Satisfaction

Increased clarity among seniors/caregivers about what will happen next and who will help them next

Common Referral and Intake Form (e.g. questions at end of conversation with client and data capture on the form)

Staff Competency

Increased knowledge/understanding of the types and locations of various health services for seniors/caregivers

Customized Survey (based on G. Browne and David Ryan methodology pre-and post test phase)

System Co- ordination and Integration

Increased inter-agency collaboration, relationships and integration of referral and intake practices

Customized Survey (based on G. Browne and David Ryan methodology pre-and post test phase)


103

Enablers of Test Phase Implementation and Measurement

• Commitment of organizations participating in test phase • Tools such as the Agency Referral Search Tool• Utilizing the Community Service Portal features as a

resource (e.g. instant messaging, collaborative workspace, presence, secure e-mail, etc.)

• Staff Training and Change Management Structure/Roles • Availability of Project Team advice and trouble shooting• Measurement Resources/Expertise


104

Next Steps Steering Committee - Decisions

• October 23: Review and Approval of Intake Tool, Common Service Definitions, and Detailed Process/Protocols, Proposed Test Phase Design and Preparation Plan, and Measurement Plan

• November 26: Final Review and Approval of Test Phase Details (including tools, training plans, letter of agreement, measurement data collection, etc)


105

Next Steps Test Phase Preparations

• November, December and January will focus on the preparations for Test Phase (note: High Level Workplan for these preparations being reviewed by Steering Committee – October 23, 2009)

• Test Phase scheduled for 8-week period beginning February 1, 2010 through to March 2010

MH LHIN Finance Update Paulette Zulianello

Senior Lead, Funding and Allocation

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Reporting- Re-cap

2008/09 ARR’s all received

2009/10 Q2 – CAT tool reporting – one outstanding

Great job!!!

2009/10 Q2 Supplementary Reporting for Initiatives-three outstanding

Key due Dates

Q3 MIS – due Jan 29, 2010

Q3 CAT Tool reporting – due Feb 5, 2010

Q3 Supplementary Reporting for Initiatives- due Feb 5th as well

2009/10 – Year End Forecast Form – due Dec. 15 (purpose is for LHIN in-year recovery)

MIS Data Quality

Feb 9, 2010

Location tbd

Feedback on last year

Suggestions for this year agenda items?

QUESTIONS?

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