Ontario Health Team Readiness Assessment: In-Person Visit

Eastern York Region and North Durham Ontario Health Team

October 28, 2019

Before we begin

• What is most important to you about what we cover today?

• What would you like to learn from us today to feel confident in our application, process and plans?

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Emerging Vision for Our Ontario Health Team(created by patients,

caregivers and providers across our network)

• Clients and caregivers will experience our OHT as one tight, shared system, not as 30 different organizations.

• Every point of contact will be safe, humane and person-centred, embedded in trusting relationships between clients and providers and among providers.

• We will create infrastructure for a seamless system, including standardized assessments, integrated access points (any point, full system), a portal for accessing and understanding all services available, and a shared patient record.

• Our performance indicators will drive towards key outcomes that demonstrate an improved patient experience, effective and efficient use of full system resources, improved health for our population and a thriving and engaged health workforce.

Intentions for our Ontario Health Team

• Transform how we provide care to our patients and caregivers making it seamless and integrated.

• Nurture collaborations among all partners, ensuring patients, providers and primary care physicians have an equal voice.

• Improve access, ensuring 24/7 coordination and navigation of services.

Our Chosen TargetsTwo populations with critical and challenging needs

• Mental Health and Addictions― People affected by mental illness and addiction continue to face tremendous barriers to care

― While there are strong programs and treatment in our region, access remains a huge challenge (waitlists, navigation challenges, resources that match needs)

• Dementia― People affected by dementia (patients, caregivers and providers) are under an incredible

amount of stress

― Needs continue to grow as the population ages, and services and supports have not kept up

― There are deep needs around education, navigation, programming, long term care, respite and more

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Emerging Principles for High Level Care Pathways (Mental Health and Addictions Example)

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• Any door access• Meaningful assessment• Tell your story once • Every point of contact is safe, humane, culturally appropriate and

person-centred• Everyone gets evidence informed care• Support patients’ journey of recovery and in achieving their best

quality of life

• Streams of care and support that draw fully on system resources• Immediate support provided even if there are waits for programs

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Next Step in Our Process – Deep Co-Design

Engagement strategies: Primary Care (Part 1) • Designated Primary Care OHT Lead Physician

―Face-to-face engagements ―Auto-fax ―Email blast through collaboration with Ontario

Medical Association―Over 105 physicians from FHO, FHG, FHT (~50% of

physicians in the catchment)

• Primary Care Physician Town Hall―60 community primary care physicians ―Representative from OntarioMD―Representative from Ontario Medical Association

• Engagement with ethnic physician groups• Markham Stouffville Hospital physician

collaborations 8

Engagement strategies: Primary Care (Part 2)• Involvement in co-design sessions • Recruitment of a Primary Care OHT Lead Physician • Primary Physician visioning session to develop shared vision and

common goals including governance participation • Utilizing preferred communication channels to continue updating

physicians • Expansion of enrollment of physicians • Physician Advisory Committee

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Engagement strategies: Patients, families and caregivers

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• Patients and caregivers are the focal point of all discussions at OHT working groups ―Patients, caregivers and clients part of current

working groups, co-design sessions and steering committee

• Hosted a community engagement session ―More than 40 patients, families and

caregivers attended―Learnt about OHT, various work and

opportunity for involvement

Engagement strategies: Patients, families and caregivers

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• Utilizing the OHT partners including primary care providers, patient and caregiver advocates to spread the word ―Over 50 patients, caregivers and clients are signed up for co-design sessions

• Building a client/patient facing website to support information sharing, and feedback collection

• First OHT to work with The Ontario Caregiver Organization to develop a webinar to coach caregivers interested in system change on how to be on an advisory group/steering committee

Engagement strategies: Communities• Community engagement survey

―In addition to English, translated to French, Traditional Chinese and Tamil

―Survey was disseminated via primary care physicians, OHT partners, outpatient clinics, faith-based organizations, and newcomers centers

―Over 1,800 completed survey―Opportunities for improvement, barriers to access, and

priorities ―Survey results are used as a foundation for OHT work

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Engagement strategies: Communities• Quarterly informative webinar open to community organizations, service

providers, healthcare professionals and the community at large

• Engagement guide for use by all of our OHT partners, outlining strategies to engage the community in discussions and garner their involvement in the development process

• Ongoing media updates through social media, local radio stations and partner websites

• Co-design sessions are open to community members, allowing everyone to have a say in model of care development

• Collaborating with Entité 4 on Francophone community engagement and increasing access to French Language Services

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Implementation plan: Plan for providing 24-hours/7-days-a-week service coordination and navigation

1- Utilizing the currently existing infrastructures―Centralized Mental Health and Addictions Access Point: Streamlined Access―Dementia: First Link ―Hospital Mental Health and Addictions Navigator (1-800 info line)

2- Transforming the Home and Community Care by providing “neighbourhood care” model

―Integrated Psychiatry Outreach Program (IPOP)―Traditional and non-traditional support

3- Centralized website with the inventory of services and opportunity to register online for appropriate programs, workshops and seminars

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Implementation plan: Plan for providing expanded virtual care offerings and options for patients to digitally access their health information

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Patient Portal Trending 6-9% monthly usage

Virtual Encounters74% of partners use digital tools

Telehealth Services3+ telehealth programs offered

Primary Care110+ primary care provider network

Implementation plan: Our shared decision-making framework• Environmental scan of Decision Making Frameworks was done

• Our OHT has chosen to use Gibson Mitton Decision Making Framework ―Health Equity Impact Assessment (HEIA)―IDEA: Ethical Decision Making Framework

• Incorporates economic and ethical values

• Adopts principles from international economics and ethics approaches (A4R and Program Budgeting and Marginal Analysis)

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Implementation plan: structures

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• Confirm Steering Committee & Working Groups Membership• 80% completion of co-design engagement sessions• Engage primary care providers (PCP) membership confirmed • Development of a central OHT website and communication plan

30 Days

60 Days• Joint OHT agreement signed by partners • Review of co-design findings, recommendations and next steps • Establish working groups directives• Commence Population Health data analysis

90 Days

• Evaluate current-state intake and assessment Mental Health, Addictions & Dementia• Review home and community model and best practices • Initiate development of clinical pathway for Year 1 target population • Launch PCP & caregiver awareness marketing campaign• Initiate the Privacy Impact Analysis and evaluate interim digital health strategy• Harmonize data collection and sharing

6 Months

• Mid-year review• Standard Care Coordination Toolkit• Establish 24/7 navigator role• Complete redesign intake pathways: Streamline Access & First

Link Capacity• Development of a standardized assessment form • Initiate discussion on community PCP clinic for unattached

complex Year 1• RFP launch for homecare providers (only if decided and meeting

Ministry guidelines) • Track Quadruple Aim metrics

Implementation plan: Our readiness to implement the plan

Successes we foresee achieving in Year 1 as a result of implementing our plan• Improvement in frequent ED visits (4+ per year) for mental health and addictions

―Current performance: 4.9% (Ontario: 9.0%)―Clear direction and better access to formal and informal supports ―Investing in navigator in ED

• Avoidable ED visits ―Current performance: 2.4% (Ontario: 4.6%)―Utilizing Streamlined Access, First Link, a centralized 1-800 information line, 24/7

care coordination―Enhanced support for primary care providers

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Successes we foresee achieving in Year 1 as a result of implementing our plan• 30-day inpatient readmission rate

―Current performance for 30-day crude readmission rate: 14.4% (Ontario: 16.3%)―Warm hand offs from inpatient to community coordinators or primary care ―Wrap around services

• Caregiver distress ―Current HQO data: Ontario rate is at 50% ―Collection of the OHT specific data ―Launch of the Caregiver Awareness Campaign

• Patient Reported Experience Measures, Provider Reported Experience Measures, and Patient Reported Outcome Measures

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Supports and enablers needed from the ministry and other partners to achieve our plans

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Policy and Guideline Review

• PHIPA• Billing codes• Change management

and leadership

Enable Data Flow and Utilization

• ConnectingOntario• Provincial assets (HPG/CHRIS)• Population Health Planning

Support

Redistribute Assets

• LHIN assets • Start up investment

for Primary Care Engagement, and Patients and Caregivers

Support Standardization

• Standardized assessment forms

• Provincial digital strategy

• Standardized communication plan

Demonstrations

Shine Patient Portal Overview

Patient Portal – Patient Connect Target Audience

Chronic or complex health issues

Experienced healthcare consumers

Access to other patient portals

High expectations

Value

On-demand access

Ease of access

Adoption

6% uptake and growing

Strong communications plan

Patient Connect Scope Inclusions

Chemistry, Hematology and Microbiology results (6 hours delay)

Home medications and medications ordered on discharge

Visit history and demographic informationHealth Information Management reports

Diagnostic Imaging reports (14 days delay)

Some PDOC reports* (14 days delay)

Upcoming appointments

Exclusions

Mental Health Reports

HIV, STD, Pregnancy, Genetic Results & Drug Screening

Pathology & Blood Bank Results

Scanned Images

PDOC Progress Notes

Remote out-patient monitoring

Virtual Monitoring Services (ViMos)

Navigation

Access to clinical support

Frequent healthcare utilization

Early detection and treatment

Care co-ordination Education

The Value:

The Program:

Positive results for patients and the organization

ViMos Key Takeaways

Opportunities to scale across programs and the community

Enabling better connectivity with primary care

Mental Health and Addictions System Navigator• From April 2019 till today more than 500

clients have been served

―In-patient support:o Discharge planning, educate and assist

patients to make linkages with community and outpatient resources

―Outpatient support: o Point person for community people o Welcome calls for outpatient referrals o Support primary care physicians and other

mental health care providerso Patient advocate

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