Mississauga Halton CCAC

2015/16 Annual Report to the Community

Constant Caring in a Year of Change

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On behalf of the Mississauga Halton CCAC Board of Directors, we are proud to

volunteer our skills and leadership to represent the health needs of people across our region. We invite you to read a summary of our role on page 30 of The Faces of Care.

Welcome to our 2015/16 Annual Report to our Community. It was an extraordinary year for several reasons.

1. We launched a new Strategic-Plan 2015-2020 that makes “people the point of care” and focuses on: • Making Meaningful experiences and

outcome for people• Modernizing the health system• Mobilizing professionals and technology to

make health care work for people

2. We oversaw the responsible use of funds and achieved a balanced budget despite an increase of 13 per cent of patients with complex care needs; and we earned the confidence of 95 per cent of patients who would recommend our organization to family and friends.

3. We received and responded to the proposal to change health care at home, entitled, Patients First: A Proposal to Strengthen Patient-

centred Health Care in Ontario, released by the Ministry of Health and Long-Term Care on December 17, 2015. That proposal calls for the elimination of the CCAC Boards of Directors.

On behalf of patients and caregivers in this region, we are building on our history of collaboration with our LHIN Board colleagues that began in 2013. Since January 2016, we’ve re-focused our attention on the Patients First discussion paper. If the ministry’s proposal is implemented, we will use our governance expertise to ensure stability in the system during the transition for patients and for our teams of dedicated staff.

As we continue our leadership in 2016/17, we remain focused on governing this outstanding organization, while educating decision-makers to better understand what is required to care for patients in our community today and for the forecasted exponential growth of patients in the future. As experienced governors of the Mississauga Halton CCAC, we are using our vital insight to protect patients through this significant proposed change.

Dieter Pagani, Chair, Mississauga Halton CCAC Board of Directors

Board of Directors’ Message

Roshan Sapra Rhonda Lawson Laurie Cabanas Rhonda Chou Kareen Hall-Clarke

Ray Gilbert Steve Heck Frank Kelly Sona Khanna Ebere Morgan Erika DomijanCommunity Member

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We govern in interesting times

Don Taylor

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We learn our strength when we are challenged with change. I experienced

and thrived through changes in health care throughout my career, from my beginnings as a nurse to executive positions in acute care and to my role as CEO of the Mississauga Halton CCAC for the past six years.

It is with tremendous pride that we look on fiscal year 2015/16 as a year that we enhanced our ability to “make people the point of care.” With our unwavering focus, we cared for a total of 48,000 patients, serving 1,369 more people in our region than in the previous year. We were not distracted by proposed changes to the CCAC sector. Indeed, we realized an increase of 27 per cent positive employee engagement, as all teams continued to focus on caring for patients.

The past year also saw our CCAC achieve enhanced care coordination and effective collaboration. I am proud to highlight just four of our accomplishments.

1. Our Care Coordination Program of Workis the most significant change we’ve ever undertaken to enhance the care and support that patients and caregivers experience; I invite you to read the overview and watch the video featured on page 5.

2. Insights is a game-changer for helping ourcare coordinators keep a crucial line of sight to each of their patients. Insights is much more than a simple dashboard; it is an evidence-based, real-time, customized summary of each patient, helping us to better manage the many aspects of each patient who is in our care.

3. In partnership with the Primary Care Networkand our LHIN, we developed a primary careprovider data base. The first of its kind inOntario, the data base is an accurate, singlesource of primary care providers workingacross our region, including up-to-datephysician profiles. This tool also enables directcommunication to physicians’ offices toshare important patient information inreal time.

4. Another innovation, DocSearch, is a medicalspecialist electronic compendium that helpsprimary care providers know which specialistsare in their region and available for referrals to see their patients.

Thriving in ambiguity also means contributing our expertise and experience to inform important proposed changes in our health system. We produced an organizational overview to help leaders making changes to our health system understand that “it takes a team to care for patients.” We are pleased to share The Faces of Care with you.

As we celebrate the care we provided to patients and families in 2015/16, we continue in 2016/17 with the next phase of our Care Coordination Program of Work – care coordinator and contracted service provider neighbourhood realignment, which will provide greater consistency and closer collaboration with patients and families. We will also expand our vital partnerships with health care organizations throughout our region in pursuit of our goal of an integrated, sustainable system of care implemented for people in this region and beyond.

Sincerely,

Caroline Brereton, CEO, Mississauga Halton CCAC

Focus on care our constant in a year of change

CEO’s Message

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Through our innovative Strategic Plan 2015-2020 initiative, the Care Coordination Program of Work, we completed an extensive, evidence-based professional practice re-design of our care coordination approach to better meet the needs of all patients in the Mississauga Halton region, including those enrolled in Health Link. Our new rigorous, enhanced care coordination ensures that patients receive consistent care that integrates their services where they live, in their own neighbourhoods.

While every patient is unique, our new approach to care coordination removes variability; it’s consistent for all patients. Regardless of where patients live in our region, they will receive the same care coordination approach, the same quality of care and compassion.

Patient-centred Design

Share Care Council: We engaged our patient and family advisory forum to understand how care coordinators can provide more consistent experiences for patients and carers. They recommended the following.

“Support me in my journey from illness to wellness (or illness to palliative) by becoming my care coordinator who oversees all of my care – my trusted advisor, advocate and coach.”

“The health care system is difficult to navigate; do more to make sure my care plan meets my needs. I need a life plan that tells me what will happen next.”

Community Capacity Plan: This unprecedented study helps determine the care needs of older adults now and in the future.

Community Capacity Plan key findings:

• Care coordination reduces health risk, but is most effective when one person/entity is responsible for coordinating care across multiple providers

• Health and social programs in Mississauga Halton region, including care coordination, need to be targeted at specific patient populations that take into account a patient’s socio-economic and cultural status, diagnosis and place of residence

Client and Caregiver Experience Evaluation (CCEE): A quarterly third-party, independent survey of patients and carers revealed that consistency in care experiences matters most.

Achievements1. Care Coordination Enhancement

A Care Coordination Framework was implemented for all care coordinators, including eight core competencies and new care practices for care planning and care conferencing. The framework focuses on teaching, evolving and coaching care coordinators to consistently deliver care with skill and confidence.

Care Coordination Program of Work: “Making People the Point of Care”

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The skills, knowledge and behaviours associated with each core competency defines our expectations of how care coordinators will interact with patients and families to support optimal care experiences, every time.

Training does not stop at our doors. Care coordinators practice this compassionate approach with patients in their homes and they are supported by professionals who conduct a thorough quality practice validation and provide real-time feedback on their patient-centred approach.

Already, several care coordinators are demonstrating mastery of multiple skills, including writing care plans in a way that are meaningful to patients and families. Owen, a 78-year old patient says, “My care coordinator took the time to explain things to me. She was extremely knowledgeable and very helpful. She linked me to services I did not know were there, and she took time to answer my questions. It was like she really cared.”

2. More help for Patients and Families

Patients and carers told us they need a written life plan. Our new patient package, My Story, is a customized resource binder of important information that patients use to track their care at home. The foundation of My Story is a one-page care plan, focused on patients’ personalized life goals. Care coordinators co-develop this care plan with patients and families and ensure all those in the circle of care understand and follow the plan. It also includes a section dedicated to managing medications and equipment, information on the roles of different community providers, tips for falls prevention and our Patient and Caregiver Bill of Rights.

We developed a complementary carer support guide, A Helping Hand While Caring for Your Loved One, with local resources to support carers, including adult day programs, tips to reduce stress and avoid burnout, advance care planning tools, videos and disease- specific resources.

Neighbourhood RealignmentWe know that to deliver the care that patients and carers need and want, we must establish strong, connected teams that wrap care around patients.

To realize this goal, we realigned our care coordination teams to neighbourhoods where patients live. With extensive collaboration and careful planning, starting July through to December 2016, we are realigning our contracted service providers to respond to patients’ demand for consistent nursing, rehabilitation and personal support services from people who “know them and their unique needs.”

We’ve designed and implemented a consistent, interdisciplinary team approach to help achieve what’s most important to patients.

Click here on Care Coordination Program of Work to learn how our new neighbourhood care coordination approach benefits all patients and families in the Mississauga Halton region.

Learn how one of our expert care coordinators, Natoya Hylton, applied our new care coordination approach to help her patient, Betty, recover at home.

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Patient-Centred Care in

2015/16

95.6%of all patients received nursing care through home visits

or clinics, within five days after their assessment.*

91.7%of our patients with complex care needs received their first personal support worker (PSW) visit within five days after their assessment.*

Cared for

48,000patients, including 13%

more patients with complex care needs than in 2014/15.

of all our patients

discharged from hospital did not visit the emergency department within the first 30 days.**

96.2%of all our patients discharged from

hospital were not readmitted within the first 30 days (excluding planned admissions).**

84%

of patients said they would

recommend the Mississauga Halton CCAC to their family and friends.***

95%

5 Days

Notes:

* Internal data, based on Ministry of Health and Long-term

Care indicators, average for April 1, 2015 to March 31, 2016 (Q1 - Q4

2015/16).

** Available hospital statistics, average for July 1, 2014 to June 30, 2015 (Q2 - Q4 2014/15 & Q1 2015/16).

*** Based on independently conducted Client & Caregiver Experience Evaluation, average from April 1 to December 31, 2015 (Q1 - Q3 2015/16).

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Notes: Financial results are based on audited financial statement.

Overall Totals 2015-16 2014-15 % Change

Average number of patients served per month 16,421 15,898 3.3%

Total number of patients served 48,000 46,631 2.9%

Programs

Number of Palliative patients 2,053 2,010 2.1%

Number of visits to care for Palliative patients 345,211 330,640 4.4%

Number of patients on Stay at Home, Wait at Home - LTC, and Wait at Home Enhanced programs 987 925 6.7%

Fast Facts 2015-16 2014-15 % Change

Percentage of patients and caregivers who would recommend our services to family and friends 95.36% 96.10% -0.7%

Financial results ($ in ‘000s) 2015-16 2014-15 % Change

Revenues $166,677 $159,468 4.5%

Operating expenses

Administration 7,442 7,164 3.9%

IS, Plant, and Other 7,085 6,852 3.4%

Patient Care 151,759 145,842 4.1%

Total Operating expenses $166,286 $159,859 4.0%

Net Surplus / (Deficit) $391 $(391)

Fiscal Year 2015-16 Results

Fiscal Year 2015-16 Results

7.1%12.0%

7.7%

12.4%23.4%

37.4%

Visits by Age in 2015/16

52.1%28.5%

8.9%10.5%

Contracted Servicesin 2015/16

Personal Support/Respite

Nursing

Medical Supplies and Equipment

Rehabilatation Services

4.5% 4.3%

91.3%

Operating Expenses in 2015/16

Administration

IS, Plant, and Other

Patient Care

0-18

19-54

55-64

65-74

75-84

85+

VisionOutstanding Care – every person, every day.

MissionTo deliver a seamless experience through the health system for people in our diverse communities, providing equitable access, individualized care coordination and quality health care.

Etobicoke Office

401 The West MallSuite 1001Etobicoke, Ontario M9C 5J5

8:30 a.m. to 4:30 p.m.

Milton Office

611 Holly AvenueUnit 203Milton, Ontario L9T OK4Mississauga Office8:30 a.m. to 4:30 p.m.

Mississauga Office

2655 North Sheridan WaySuite 140Mississauga, Ontario L5K 2P88:30 a.m. to 4:30 p.m.

Our Access Care Team is available from 8:30 a.m. to 9:00 p.m.

We have offices and staff located in the following hospitals. No referral is required to contact them.

Trillium Health Partners (THP)Mississauga Hospital, Queensway Health Centre, Credit Valley Hospital

Halton Healthcare (HH) Oakville Trafalgar Memorial Hospital Georgetown Hospital, Milton District Hospital

310-2222 (CCAC) no area code required

www.healthcareathome.ca/mh

www.mississaugahaltonhealthline.ca