advancing primary health care integration in the toronto

Advancing the Integration of Primary Health Care in the Toronto Central LHIN (Report) A Strategy for Primary Health Care

1

Advancing Primary Health Care Integration in the Toronto Central LHIN

A Strategy for Primary Health Care

Report

January 2013


2

Acknowledgements

A study of this magnitude cannot be successful without the input of time, energy and knowledge of many individuals.

Corpus Sanchez International would like to extend special thanks to the project sponsors – the Toronto Central LHIN, the Toronto Central CCAC and St. Michael’s Hospital – and specifically the lead individuals from each organization:

Ms. Stacey Daub, CEO of the Toronto Central CCAC;

Ms. Camille Orridge, CEO of the Toronto Central LHIN; and

Dr. Doug Sinclair, Executive VP and Chief Medical Officer at St. Michael’s Hospital.

Your foresight in recognizing the importance of this project, and your guidance to the team cannot be overstated.

We want to acknowledge the efforts of several staff at the Toronto Central LHIN including: Ms. Vania Sakelaris, Senior Director; Ms. Ashnoor Rahim, Project Manager Primary Care; and Ms. Jasmine Paloheimo, Administrative Assistant Primary Care. Your individual and collective interactions with the CSI team and your unwavering support have been invaluable.

We also extend our appreciation to the Toronto Central LHIN’s Primary Care Advisors: Drs. Yoel Abells, Phil Ellison and Tara Kiran. This work would not have been possible without your support and guidance.

We thank the participants of the Current State Working Group and the Design Working Group who helped to frame and prioritize the current state issues and provided the foundation for the proposed future primary care model. Your commitment to Primary Care in Toronto is applauded.

We want to acknowledge the people who helped gather the data used to inform the review Ms. Rachel Solomon, Senior Director; Ms. Shirley Bryant, Epidemiologist; and Ms. Cynthia Damba, Epidemiologist, and other staff at the TC LHIN who have dedicated significant time and energy in interpreting the current state and conducting future planning analysis included in this report. We also thank Dr. Rick Glazier for his valuable input and support. We recognize that this is only the “tip of the iceberg” in terms of understanding the starting point. Your ongoing assistance will be invaluable.

Finally, our appreciation goes to the over 250 individuals who participated in interview sessions, committee meetings, focus groups, and the Think Tank Session who shared their insights, and ultimately gave this review an invaluable degree of robustness and depth.

To all those who participated, we hope you recognize the value of your contribution to the ultimate goal of providing improved primary care services to the people who rely on all of the providers and agencies within the Toronto Central LHIN to meet their needs.


3

Table of Contents

EXECUTIVE SUMMARY 4

INTRODUCTION 8 Setting Context 8 Understanding the Mandate 9

A CLEAR NEED FOR ADVANCING PRIMARY CARE 11 Drivers for Changing Our Health Care System 11

UNDERSTANDING THE LOCAL CONTEXT 14 Confirming the Case for Change 14 Understanding the Uniqueness of the Toronto Central LHIN 15

CONFIRMING KEY AREAS OF FOCUS 21 Focus 1: Innovation in Care Delivery 22 Focus 2: System Leadership and Clear Vision 23 Focus 3: Building Enablers and Supports for Success 25

VISION FOR PRIMARY HEALTH CARE IN THE TORONTO CENTRAL LHIN 26

THE PRIMARY HEALTH CARE MODEL 27 Building the Network Concept 27 Confirming the Benefits of the Network Concept 28 Identifying the Networks 29 Defining Core Services for the Each Network 31 Evaluating the Impact of Networks 32

BUILDING A PLAN TO MOVE FORWARD 33 Six Imperatives to Achieve the Vision 33 Imperatives and Supporting Recommendations 34 Philosophy for Moving Forward 38 Commitment from the Toronto Central LHIN 39

APPENDIX 40 Current State Design Working Group 40 Design Working Group 41 Think Tank Participants 42 Learnings from the International and National Landscape 45 Identifying How to Measure Success 49 Proposed Network Maps 53 Framework for Evaluating Impact of Primary Care Networks (Draft) 58 References 61


4

Executive Summary Setting Context

Health systems in countries around the world are struggling with the issue of system sustainability. While all health care systems have their own unique characteristics, a common under-pinning of all reform efforts is that they are grounded in a vision of a strong primary care system that ensures effective care at a local level, while enabling access to higher levels of care through coordinated access.

In Ontario, primary care evolution has been under consideration for decades, with multiple models being proposed over the years as part of successive governments’ ongoing desire to strengthen primary health care. All of this work has been grounded in the realization that primary care is a, if not the, fundamental building block of an effective care delivery system. Drawing on this rich history and willingness to explore innovative models, Ontario’s Action Plan for Health Care reaffirms the importance of primary health care and seeks to improve access to family health care, ensuring patients and families get the right care, at the right time, and in the right place.

The Toronto Central LHIN (TC LHIN), along with its many providers, also acknowledges the need for a comprehensive, system-wide strategy to establish sustainable primary care delivery models capable of meeting the growing, diverse, and changing needs within the LHIN. In keeping with the LHIN’s strategic aim to transform the system to achieve better health outcomes for people now and in the future, the overarching goal is to ensure that the right primary care resources are in place and incorporated into an integrated continuum of care that meets the needs of individuals requiring services now and in the future, and creates a care system focused on the health of a population. The TC LHIN understands also that primary health care is just one element of an overall solution to better serve populations, and that efforts around Seniors Health and other important efforts like the Ministry’s Health Links initiative must effectively work together.

Building on Ontario’s Action Plan for Health Care and the TC LHIN’s Strategic Plan, the Toronto Central Local Health Integration Network (TC LHIN), in partnership with the Toronto Central Community Care Access Centre (TC CCAC) and St. Michael’s Hospital initiated a comprehensive review of the Primary Care System in Toronto. To support the overall project goals, over 250 stakeholders were engaged in focused discussions to better understand key issues and identify system-wide opportunities to advance primary care within the LHIN. Stakeholders included, but were not limited to, patients and families, point of care providers and navigators, primary health care provider organizations, community-based providers, family medicine department leaders, system level informants, and institutional providers.

The report summarizes two important phases of work. Phase 1 focused on building an understanding of the primary care landscape in the Toronto Central LHIN with a focus on primary care physicians, and Phase 2 transitioned into building a Primary Health Care Strategy for communities within the Toronto Central LHIN.


5

Confirming the Need and Opportunity for Change

In Phase I, a clear understanding of the key issues impacting primary care were defined, confirming that there are clear needs and drivers for changing our systems of health care. These include an understanding that quality can – and must – be better for individuals requiring care; the growing burden of chronic illness that is emerging within the LHIN’s aging and constantly changing population represents a major challenge for many providers; a recognition that our health care system is not a system at all but rather a series of silos; and the continued awareness of the need to manage the costs to ensure the ongoing sustainability of the health care system.

Fortunately, as the Toronto Central LHIN providers move forward, it is starting from a position of strength. Toronto Central LHIN is home to some of the very best primary care providers, CCAC, community providers, hospitals, teaching institutions, and broader social service agencies. And as a collective, is capable of providing the very best in health care. Providers in the LHIN have already initiated some important foundational work in primary care that will be leveraged to ensure early and ongoing success. Phase 1 confirmed that Toronto Central LHIN stakeholders and partners are in full agreement that change needs to happen.

Establishing the Vision to Move Forward

In Phase II, the focus transitioned into establishing a strategy for primary health care for the Toronto Central LHIN to guide its efforts over the coming three to five years. It was identified early on that to advance primary care in the TC LHIN, the system must be viewed as part of the broader primary health care continuum which includes the many providers who work together to contribute to the health of the population. To achieve these goals, a vision for Advancing the Integration of Primary Health Care was established:

The Providers of the Toronto Central LHIN will provide personalized, seamless, timely, comprehensive, and high quality primary care to its population through collaboration across the system to advance improved patient outcomes and improved patient experience in the context of a sustainable health care system.

This vision for primary health care in the Toronto Central LHIN will ensure:

Every resident will have a primary care practitioner who provides them with accessible, high quality care regardless of which practice model they are a part of;

Every primary care physician will have equal and equitable access to interprofessional teams in the community to support their most complex patients and regardless of practice type;

A collaborative, interdisciplinary team supports all comprehensive family doctors and their patients; Individuals requiring services and their families play an active role in directing plans of care; Primary care services are integrated across a broader system of health care (e.g., acute care, long

term care, rehabilitation, end of life care), and other community health and social services including public health and schools;

Primary care services are delivered in accordance with patient and community need with a view to reducing health inequities;

Best practices, innovations and information systems are leveraged and spread; and Patient outcomes and experience are measured at the practice and system level to support

continuous quality improvement.


6

Designing the Network Concept To deliver on the vision, a proposed Primary Health Care Model is established on the premise that transforming primary health care cannot, and must not, be solely focused on primary care providers in isolation of the broader care system. A broader, network approach must be leveraged that brings together providers to jointly tackle the key challenges facing primary health care.

The idea of Networks is simple: Providers supporting providers to deliver the best possible care for people and communities to ensure access to the core health care services in the communities and neighbourhoods where they live their lives. This Network Concept will seamlessly bring together primary care, the CCAC, community based services, hospital and specialized care, teaching and education, and linkages with social and support services together. This will be achieved through the creation of smaller sub-LHIN boundaries that create Networks that will build on local capacity to meet the health care needs of the population. The result – the Networks come together to deliver better value for money, ensure higher quality of care, improve access, support deeper engagement of individuals requiring services and family, and develop a truly patient-centred focus.

To be successful, Networks must be grounded in the local needs of populations within a community; be built on voluntary partnerships; be guided by local leadership; will focus on delivery comprehensive core services to a population regardless of the existing family practice/general practitioner funding model; must enable access to specialized services; be guided by a patient-centred approach to planning that will focus on the complex, high need and high cost populations initially; and leverage existing successes and partnerships which have been built on an inter-sectoral and interprofessional team approach, and through an increasing degree of trust across providers.

Pursuing the Network model will result in a number of benefits for individuals requiring services.

Individuals requiring services will have improved experiences and will be at the center of the transformation.

Individuals requiring services will have consistent access to required services reflecting the local needs of the population.

Individuals requiring services will have equitable access to the same range of services and supports regardless of who their physician is, and who their physician knows and has access to.

Individuals requiring services will be supported by interprofessional providers who will support their transition and navigation to help access the care and services they need.

Individuals requiring services will have more options to receive their care when they need it, including after-hours.

The Network model will also result in a number of benefits for providers. These include: Providers will benefit from enhanced levels of flexibility to deliver services in ways that best meet

the needs of their communities. Providers will have enhanced access to services and navigational support including access to primary

care, community, hospital and social services within and beyond their Network. Providers will enhance their client’s experience through timely and smooth access to the services

clients’ need, when they need it through enhanced core coordination. Referral patterns will be established to support the transition of individuals requiring services. Providers will access care standards, information from across the system, and improved tools to

support delivery of the best care for their individuals requiring services. Providers will have more support in caring for patients with complex care needs. Support for

primary care providers will leverage existing capacity and experience currently available.


7

Building a Plan to Move Forward With

The TC LHIN has proposed the creation of nine (9) networks. Each network will have commonality in terms of access to core services and expected outcomes, but will have a degree of customization based on the needs of the local community. Specialized services will be available to all networks through a formal referral process. Each network will be supported by robust information management practices to identify and track improvements for defined efforts to improve the patient experience, quality of care received, and timely access to services.

To realize our vision for personalized, seamless, timely, comprehensive, and high quality primary care that are focused on collaborative approach that advances improved patient outcomes and patient experience, the Toronto Central LHIN will take a phased approach to implementation. However the work must begin and be completed in a timely fashion as residents of the LHIN cannot wait.

While it would be impractical to get all of the Networks up and running at the same time, our goal will be to get all nine networks operational over the next three years. We will utilize implementation waves, where subsequent Networks will learn from and build on the experience of networks that were established before them to ensure future deployments will get easier. Every area of the LHIN and every provider will be part of this. The first focus will start with Primary Care Providers and the CCAC as a foundation. This is about ensuring primary care is available where clients live their lives.

While we know the next few years will require ongoing dedication and support to achieve the vision for primary health care, we believe the Toronto Central LHIN as a collective of its providers and partners is up for the challenge. Our providers have an abundance of talent, capacity and knowledge to make this happen. We also understand the importance, and have the will and the courage to make difficult changes for our clients and communities. With a planned and structured approach, we are more than capable of delivering on what the Minister is calling on us to do.

Together, we can create the kind of system and experience that people tell us they want and that we know they should be able to count on.


8

Introduction

Setting Context Health systems in countries around the world are struggling with the issue of system sustainability. While all systems have their own unique characteristics, a common under-pinning of all reform efforts is that they are grounded in a vision of a strong primary care system that ensures effective care at a local level, while enabling access to higher level care needs through integrated and coordinated care delivery.

In Ontario, primary care evolution has been under consideration for decades, with multiple models being proposed over the years as part of successive governments’ ongoing desire to strengthen primary health care. All of this work has been grounded in the realization that primary care is, if not the, fundamental building block of an effective care delivery system. Drawing on this rich history and willingness to explore innovative models, Ontario’s Action Plan for Health Care seeks to improve access to family health care, ensuring patients and families get the right care, at the right time, and in the right place. Key efforts to enhance primary health care include:

Strengthening and promoting the role and philosophy of family-centred health care throughout the primary health care system;

Integrating family health care at the local level ensuring individuals requiring services and families have access to the multiple providers they may require across the continuum and throughout the patient journey;

Ensuring that more Individuals receive timely access to care in the most appropriate setting, enabling access to same-day or next-day appointments when needed, appointments available after hours (i.e. evenings/weekends) if required, and being able to access care at home when other options present a barrier to access due to mobility issues and/or other concerns; and

Harnessing technological advances to enable individuals requiring services to receive care more quickly and to support information exchange between providers to facilitate care coordination.

In addition, the recent report from the Commission on the Reform of Ontario’s Public Services included a significant focus on health care and the importance of primary care as a foundational element that will drive sustainability. Key recommendations that will influence primary care design include:

Make primary care a focal point in a new, integrated health model with the system centred on the patient and population needs, not on institutions and practitioners;

Initiatives should recognize changes in demographics and lifestyles by putting more emphasis on chronic care, as well as prevention, health promotion and keeping people out of hospitals;

Regions and communities must progress towards greater adoption of patient enrolment models, followed by the integration of physicians into a rostered health system with a supporting payment model that best matches the goals of the system; and

Advance opportunities to build care teams to manage the care of populations, and encourage more interdisciplinary integration, particularly in the care of those with the most complex needs, through quality improvement and improving information management.

Both reports drive towards a transformed model of primary care – one truly centred on the individual.

“. . . there is almost universal agreement that primary health care offers tremendous benefits to Canadians and to the health care system . . . no other initiative holds as much potential for improving health and sustaining our health care system”.

Romanow Commission on the Future of Healthcare in Canada 2002


9

Understanding the Mandate The Toronto Central LHIN, along with its many providers, has acknowledged the need for a comprehensive, system-wide strategy to establish sustainable primary care delivery models capable of meeting the growing, diverse, and changing needs within the LHIN. The goal is to ensure the right primary care resources are in place and integrated into the continuum of care for individuals requiring services now and in the future. Design of future strategies will be guided by a goal of ensuring every patient gets the care they need.

The work to advance primary care within the Toronto Central LHIN is perfectly aligned with the LHIN’s strategic aim to transform the system to achieve better health outcomes for people now and in the future. Advancing primary care will meet all five of the LHIN’s Strategic Priorities in their 2012 – 2014 Strategic Plan – to address the needs of the highly complex patients with greatest needs, requiring the most resources; prevent and delay serious illness and injury among those who at greatest risk of declining health; improve the patient experience; deliver value and sustainability through efficient use of resources; and ultimately sustain the gains made in the system.

Building on Ontario’s Action Plan for Health Care and the TC LHIN’s Strategic Plan, the Toronto Central Local Health Integration Network (TC LHIN), in partnership with the Toronto Central Community Care Access Centre (TC CCAC) and St. Michael’s Hospital initiated a comprehensive review of the Primary Care System in Toronto in May 2012 with two areas of focus:

Phase I focused on understanding the primary care landscape within the boundaries of the Toronto Central LHIN, with a particular emphasis on primary care physicians. This focus was deliberate in Phase 1 as access to physicians, and access to additional services when required through integration with larger team-based models is a key need within the TC LHIN. On a go-forward basis, strategies will be expanded to include other health care providers and reflect the broader primary health care mandate. The intent of Phase 1 was to articulate a clear understanding of the current state of primary care within the LHIN to provide a foundation for future strategies and planning. Phase I was completed between May to September 2012 and resulted in a Summary of the Current State report; and

Phase II transitioned the work of Phase I into a strategy for primary health care for the Toronto Central LHIN to guide efforts over the coming three to five years within the LHIN. To support the overall project goals, the TC LHIN, working closely with its formal Project Partners (the Toronto Central CCAC and St. Michael’s Primary Care) and its Primary Care Advisors (PCAs), have engaged over 250 stakeholders in focused discussions to better understand key issues and identify system-wide opportunities to advance primary care within the LHIN. Stakeholders included, but were not limited to, patients and families, point of care providers and navigators, primary health care provider organizations, community-based providers, family medicine department leaders, system level informants, and institutional providers. Phase 2 was initiated and completed between October to December 2012, with implementation planning starting in January 2013.


10

This Final Primary Care Strategy outlines the findings from Phase 2. Specifically this includes:

A Clear Need for Advancing Primary Care provides a summary of the drivers for advancing primary care in the Toronto Central LHIN;

Understanding the Local Context provides a summary of some of the key challenges within the Toronto Central LHIN that will drive change;

Confirming Key Areas of Focus identifies three areas for development – a focus on innovation in care delivery, system leadership and a clear vision, and enablers and supports for success;

A Vision for Primary Care in the Toronto Central LHIN defines the purpose and describes the proposed three to five year end-points for what primary care will look like in Toronto;

The Primary Health Care Model describes the proposed model for primary care in the LHIN including the network concept, the benefits, initial proposed network boundaries, core services in each network, and a plan for how networks will be evaluated; and

Building a Plan to Move Forward outlines the strategy the TC LHIN will collectively use to move forward including a summary of the key imperatives and supporting recommendations, a roadmap and proposed structure, and supporting enablers and risk mitigation approaches.


11

A Clear Need for Advancing Primary Care

Drivers for Changing Our Health Care System There are clear drivers for changing our systems of health care. While we have often focused on acute care, current thinking has shifted some of the emphasis towards better integrating primary care and community-based solutions. We increasingly recognize the evidence that primary care is the foundation of a high performing health care system, and know that the goals of the acute care sector, particularly in managing those with chronic diseases, cannot be met without better linkages to primary care.

Robust evidence shows that patient care delivered with a primary care orientation is associated with more effective, equitable, and efficient health services. Countries more oriented to primary care have residents with better health at lower costs. Health is better in United States regions that have more primary care physicians, whereas several aspects of health are worse in areas with the greatest supply of specialists. People report better health when their regular source of care performs primary care functions well. In addition to features promoting effectiveness and efficiency, there are fewer disparities in health across population subgroups in primary care–oriented health systems.12

The following provides some supporting arguments for change.

Quality Can – and Must – be Better. Health Quality Ontario (HQO) defines quality using nine (9) dimensions: seven (7) of which apply to organizations and two (2) that reflect system level /policy issues (see table to the right). Engagement with stakeholders identified a clear need and opportunity for improvement in many of these dimensions. Quality must guide all future planning and is key to the evaluation of success.

1 Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005;83:457-502 2 Starfield B, Shi L, Grover A, Macinko J. The effects of specialist supply on populations' health: assessing the evidence. Health Aff (Millwood)2005;W5-97

“Indeed, if we didn’t change anything, kept the age-specific costs what they are today and applied them to the 2030 population, our health costs would increase by $24 billion – 50 per cent more than today from changing demographics alone.”

Ontario’s Action Plan for Health Care, Ontario Ministry of Health and Long-Term Care

Health Quality Ontario’s Dimensions of Quality

Patient Centred: Health care providers should offer services in a way that is sensitive to an individual’s needs and preferences.

Accessible: People should be able to get the right care at the right time in the right setting by the right health care provider.

Equitable: People should get the same quality of care regardless of who they are and where they live.

Effective: People should receive care that works and is based on the best available scientific information.

Efficient: The health system should continually look for ways to reduce waste, including waste of supplies, equipment, time, ideas and information.

Integrated: All parts of the health system should be organized, connected and work with one another to provide high-quality care.

Safe: People should not be harmed by an accident or mistakes when they receive care.

Appropriately Resourced: The health system should have enough qualified providers, funding, information, equipment, supplies and facilities to look after people’s health needs.

Focused on the Population: The health system should work to prevent sickness and improve the health of the people of Ontario.


12

Our Aging Population. The demographics of the TC LHIN population clearly identifies a growing challenge that will not be adequately supported by our current system – people are living longer and baby boomers are reaching the age where they will need more health care. The growing burden of chronic diseases such as diabetes, asthma, chronic obstructive pulmonary disease, hypertension and depression; as well as health human resource shortages across provider groups, and shifting patient expectations all point to a less sustainable system unless major change occurs.

Our Health Care System is Not Really a System. In the TC LHIN, there are a series of disjointed services operating in many silos. These silos need to be brought together to ensure continuity of a patient`s journey, establishing critical mass and coordination to ensure systems work together and benefit from each other, and advance opportunities for prevention and health promotion. A greater focus must also be placed on the determinants of health as only 25 per cent of the population’s health outcomes can be attributed to the health care system. Yet amazingly, upwards of 75% of the factors that have the biggest impact on health outcomes (e.g. education and income), barely registers in the health care debate. Ontario needs to do better at integrating the many silos that impact health status, and we need to start by ensuring efficient and effective access to primary health services.

The Cost of Our Health System is Creating Sustainability Challenges. Canada has one of the most expensive health care systems in the world. Among 34 countries in the Organization for Economic Co-operation and Development (OECD), Canada had the sixth most expensive system in 2009 and was not far behind the second most expensive one. Despite its high cost, our system does not produce superior results on a value-for-money basis relative to other countries. Ontario has responded to this need with a clear focus on better patient care through better value from its health care dollars. Clear action to change the course of spending is required to create a sustainable system all Ontarians want and need.

Complex Cases are Driving costs. A 2011 study indicates that about one per cent of Ontario’s population accounts for 34 per cent of health care costs, and 10 per cent of the population accounts for 79 per cent (with the majority of the costs being incurred by hospitals). The people in the one per cent group are frequently being admitted and readmitted into hospitals, even though there is increased ability to care for some of the more complex individuals requiring services in the community. The future system must re-think where care is provided and support the individuals with the most complex needs differently. If we don’t, care will continue to be fragmented for these individuals and costs will become unmanageable as the numbers of people with complex needs increase over time.

Mental Health and Addiction Needs will Also Drive Costs. The economic costs of mental health and addiction have been estimated at $39 billion annually, three-quarters of those from productivity losses. Ripple effects are felt in the justice, educational and social services sectors. New solutions must be found as the numbers of people identified with, and requiring support for, mental health and addictions issues will undoubtedly increase. The focus must support enhanced levels of prevention and promotion, timely access to care, and helping people to manage their own health.

While primary care will not resolve all of these issues, it is a critical foundational building block for Ontario’s future health care system - a building block that requires attention now.

Given this unique moment in time, the Toronto Central LHIN initiated work to develop a comprehensive model and approach to implementing a new primary care model that will bring together providers and system leaders to achieve one goal: To create an effective, accessible primary care system that will improve the health outcomes of individuals requiring services, keep health care costs down, and help people to lead healthy, productive lives.


13

Fortunately, the Toronto Central LHIN stakeholders and partners are in full agreement that change needs to happen:

There is growing consensus, at all levels of leadership and in all sectors, of the role that primary care must play as an enabler of effective system reform.

There is increased recognition of the need for interprofessional teams working together, at their full scope, to meet the primary care needs of individuals requiring services and families.

Lots of good work is underway, much of which is focused on partnerships between providers designed to meet the needs of people with complex care needs. For example, work by the TC CCAC to support integrated care for complex populations provides an effective foundation for advancing primary care in the community through a focus on building critical supports to primary care providers. Early signs are that the efforts are yielding positive benefits and having a positive impact for individuals requiring services and families.

There is strong academic support from the University of Toronto’s key faculties including Medicine and Nursing, Ryerson University, and George Brown College.

There are many cross-sectoral collaborations underway that support greater levels of horizontal integration (i.e., integration between same sector providers/entities such as between two or more primary care physicians, community based health and social service agencies) and vertical integration (i.e., integration between different sector providers/entities across the continuum, such as between community based providers and hospitals).

A growing number of family practitioners are implementing Electronic Health Records (EHRs) although the diversity of electronic systems limits intra-operability between provider entities. There is early work to connect providers together by advancing timely information flow and communication that must be supported and should be a key area of early investment.

In addition to the above, there is a clear understanding that any efforts at renewal/reform must be grounded in a fundamental commitment to advancing quality across the multiple dimensions defined by Health Quality Ontario (HQO). This framework will guide all design efforts and support the formal evaluation of the changes within the primary care system in the TC LHIN.

Accordingly, this strategy focuses on:

Improving the Patient Experience by meeting people’s needs as they define them;

Enhancing Access to services when and where they are needed;

Ensuring Equity of access regardless of where in the LHIN the person lives or population subgroups they may represent;

Supporting providers to deliver services that are Effective and reflective of best practices;

Building an Efficient system that we can afford now and in the future;

Promoting interprofessional teamwork to enable Integration of care as required; and

Monitoring all services to ensure that they are Safe and appropriate for individuals


14

Understanding the Local Context

Confirming the Case for Change Approximately 250 system leaders and stakeholders participated in the consultation process, providing their thoughts and views on primary care in the Toronto Central LHIN, all of which ultimately informed a current state scan. The following quotations highlight challenges within the local landscape.

“The current primary care ‘system’ in Ontario has developed with no coherent comprehensive plan, and is fragmented and provider driven”. At a provincial level, primary care must not focus just on illness, but must include greater emphasis on levels of enabling wellness, health promotion, supporting disease prevention, reducing the burden of illness when it occurs, and building capacity of individuals requiring services, families and providers to manage identified health care needs.

“Health care continues to be organized in a fragmented manner, with many silos and many organizations pursuing their own agendas. The end result is outdated models that fail to put the patient first”. Within the LHIN, there is a general lack of integration between and amongst primary care providers, community-based providers of services, acute care hospitals, and non-acute institutional providers such as complex continuing care, rehab hospitals and long-term care providers. Integrated solutions must be part of any future strategy to improve primary care.

“What we need is a clear vision for primary care – one that helps to bring us together”. “A huge part of the sector is misunderstood, and poorly engaged”. “Need to really understand that there is more to it [primary care] than just community health centres and family health teams”. There are many primary care physicians who with the right supports could be more integrated and supported to provide care to complex populations.

“Primary care must go beyond nurses and doctors”. Stakeholders consistently emphasize the need for an interprofessional team-based approach to care, one grounded in the fundamental relationship that exists between a patient and their family physician, yet can be augmented when needed to draw on the skills and expertise of a larger team of providers. This is seen as a fundamental need – and gap – for many individuals requiring services and their families in the Toronto Central LHIN today.

“Cannot be a ‘one-size fits all’ solution – no single bullet”. No single solution will work in a city as diverse as Toronto. Solutions will need to be community-based, building alignment within neighbourhoods as this is where people live and function. Just as communities differ from neighbourhood to neighbourhood, so will the solutions. A cookie cutter approach will fail.

“Much work has been completed to date, but the work is not done yet”. A number of initiatives are underway and these need to be celebrated, expanded and leveraged as they provide the foundation that will enable additional change to be implemented. The goal must be to leverage all of the prior work to drive innovation and create a system that individuals requiring services and families in the TC LHIN deserve and need.

“We serve residents from across the GTA and this is not likely to change”. The TC LHIN provides a number of services to residents of the adjacent LHINs and primary care is no exception. While difficult to quantify with data, it is clear that a number of people – people who work in the city but live elsewhere or people who used to live in the city and moved – continue to access a primary care provider within the TC LHIN. This is simply Toronto’s reality and must be built into any future plans for primary care.


15

Understanding the Uniqueness of the Toronto Central LHIN

Significant Variability in Incomes Across the LHIN

The Toronto Central LHIN has significant variation of income levels.

The LHIN is Supported by a Number of Different Primary Care Physician Models

The Toronto Central LHIN is home to approximately 1,800 primary care physicians and other primary care providers, all of whom function in a variety of practice models including family health teams, family health groups, family health networks, community health centres, and solo practice environments. These models serve diverse urban and inner city populations and neighbourhoods.

Income Distribution (by Census Dissemination Area) and Hospital Locations Provided by Hospital Care for All May 2012, CRICH, ICES, Hospital Collaborative on Marginalized and Vulnerable Populations,

M4XM4XM4XM4XM4XM4XM4XM4XM4X

Toronto Central LHIN

Legend

Family Physician Locations (based on HAB database)Family Physician Locations (based on CPSO)

M4X - St. Jamestown

Model Number of Organizations

Signed Physicians

CHC 18 77 CCM 1 46 FHG 24 241 FHO 35 507 FHT 11 203

Other 6 38 Total 95 1,112

Location of Primary Care Physicians within TC LHIN TC LHIN includes a number of models with ~ 1,112 (61%) associated with a PEM, CHC or FHT. Approximately ~ 700 (39%) are not in one of these models

Prepared by the Toronto Central Local Health Integration Network


16

The LHIN has the Highest Proportion of Non-PEM Physicians in Ontario

The Toronto Central LHIN has the second highest rate of physicians not practicing in a Patient Enrolment Model (PEM). Patient Enrolment Models include Family Health Teams (FHTs), Family Health Networks (FHNs), Family Health Organizations (FHOs), Family Health Groups (FHGs), Comprehensive Care Model (CCM), and Rural-Northern Physician Group Agreement.

LHIN PEM Physicians

All Physicians

% of PEM Physicians

Erie St. Clair 297 483 61% South West 534 945 57% Waterloo Wellington 379 664 57% Hamilton Niagara Haldimand Brant 727 1225 59% Central West 393 606 65%

Mississauga Halton 607 1008 60% Toronto Central 869 1820 48% Central 993 1585 63% Central East 794 1187 67% South East 335 601 56% Champlain 836 1585 53% North Simcoe Muskoka 242 429 56% North East 346 615 56% North West 149 347 43% Total 7501 13100 57%

The LHIN has the Lowest Rate of Enrolment in a PEM in Ontario

TC LHIN has the lowest rate of enrolment in a Patient Enrolment Model in the province.

Ontario

Physician Enrolment Model Distribution Across Ontario LHINs Source:

PEM Physicians Data: Corporate Provider Database (CPDB), Generic Alternative Payment Program (GAPP) - November 2011

All Physicians Data: Corporate Providers Database (CPDB), Prepared by Health Analytics Branch - January 2012

Percentage of Patient Enrollment in a PEM in Ontario Source:

Registered Persons Database, Ontario MOHLTC.

Client Agency Program Enrolment, Ontario MOHLTC Health Analytics Branch, 2011


17

All existing sub-LHINs within the TC LHIN are below the provincial average of physician enrolment.

TC LHIN has the 2nd Lowest Percentage of Individuals Referred Using Health Care Connect

While there is a relatively high concentration of primary care providers in the TC LHIN, many of the individuals with the greatest and most complex health care needs do not have regular and consistent access to primary care providers and therefore access the primary care system through other routes, resulting in fragmentation and uncoordinated care. In the TC LHIN, only 42% of individuals who contacted Ontario’s Health Care Connects program to get access to a primary care physician were successfully matched to a provider. This is the second lowest rate in the province.

LHIN Total Eligible Patients

Registered

High Needs Patients

Registered

High Needs Patients Referred

Total Patients Referred

% of Patients Referred

Central 10,718 1,418 1,372 8,488 79.19% Central East 25,253 2,143 1,545 19,501 77.22% Central West 9,203 537 502 8,605 93.50% Champlain 29,103 2,687 2,110 17,647 60.64% Erie St. Clair 12,796 1,380 1,262 11,705 91.47% HNHB 9,388 1,210 1,173 8,840 94.16% Mississauga Halton 5,454 335 323 4,710 86.36% North East 42,283 4,592 2,562 28,585 67.60% North Simcoe Muskoka 16,867 1,765 1,473 13,760 81.58% North West 7,614 968 258 3,020 39.66% South East 17,964 1,602 1,394 16,009 89.12% South West 22,822 1,923 1,468 18,025 78.98% Toronto Central 11,485 761 576 4,857 42.29% Waterloo Wellington 12,103 1,038 642 7,253 59.93% Unassigned 1,007 91 68 766 76.07% Total 234,060 22,450 16,728 171,771 73.39%

Source: Health Care Connect Report, October 2012

Percentage of Patient Enrollment in the TC LHIN Source: Registered Persons Database, Ontario MOHLTC.

Client Agency Program Enrolment, Ontario MOHLTC Health Analytics Branch, 2011


18

A number of additional factors further complicate the access issue.

The TC LHIN has a high proportion of older seniors (85 years of age and older). This age group is growing the fastest out of all age groups – projected increase of 48.5% between 2005 and 2015. Age is a predictor of increased illness and use of health care services. A higher proportion of residents in older age cohorts will have greater demands on the local health care system.

The TC LHIN has a higher proportion of the immigrant population (TCLHIN: 43.1%, Ontario: 30.9%) and physician diversity does not currently match the population diversity.

TC LHIN has a high rate of diabetes – 9.8% of residents 20 years and older. Diabetes is the leading cause of heart disease, stroke and end-stage kidney disease.

More than one in three of TC LHIN residents have at least one chronic condition such as – diabetes, certain cancers, depression, arthritis, asthma, hypertension, chronic obstructive pulmonary disease.

TC LHIN has a high concentration of infectious diseases compared to the province (66% of Ontario’s syphilis cases, 44% of Ontario’s AIDS cases, and 24% of Ontario’s TB cases).

The TC LHIN has 170 unique health service providers offering a total of 208 unique programs. This includes: 17 hospitals, 37 long term care homes, 17 community health centres, 1 community care access centre, 67 community support services programs, and 69 community mental health and addictions programs. The TC LHIN also has the highest proportion of teaching hospitals whose tertiary role and academic goals may not always align with a primary care approach to population needs based health care planning and delivery.

The TC LHIN has a relatively low proportion of Family Health Team physicians per capita resulting in relatively poorer access to interprofessional primary care.

TC LHIN has the Highest Percentage of Adults Without a Family Doctor within the GTA

8% of adults within the TC LHIN do not have a family doctor, almost 2% greater than the Provincial average.

Source: MOHLTC Quality Monitor – 2012.

Percentage of Adults without a Family Doctor in GTA LHINs 2009/10 Source:

Percentage of Adults without a Family Doctor, Quality Monitor – 2009/10.


19

TC LHIN is Responsible for Providing Care Beyond the Residents of the LHIN

Like all other LHINs, the Toronto Central LHIN provides acute and primary care services to individuals beyond its geographic boundaries. Inflow into the TC LHIN for Primary Care Services. The following table highlights the percent inflow

into the Toronto Central LHIN for GP/FP Services – FY 2010/11 regardless of where they live. Including TC LHIN residents, 1,593,414 patients received care in TC LHIN. Of that total, 723,556 were TC LHIN residents (45%), and 869,858 patients or 55% inflow were from other LHINs. The majority of non-TC LHIN patients are from the GTA LHINs (Central 20%, Central East 12.4%, Central West 6.4% and Mississauga Halton 8.8%). Inflow to TC LHIN physician offices is similar to the LHINs inpatient hospital utilization pattern.

Source: Intellihealth Medical Services FY 2010

Outflow from the TC LHIN for Primary Care Services. The following table highlights the percent

outflow of Toronto Central LHIN residents who received care regardless of which LHIN the physician worked in. The total number of TC LHIN residents that received care from a primary care physician regardless of which LHIN the physician worked in is 1,171,399. The total number of TC LHIN residents receiving care in TC LHIN was 723,556, reflecting 61.8% of patients. The difference (1,171,399 minus 723,556 = 447,843) is the outflow. TCLHIN residents receiving care outside of TCLHIN or 38.2%.

Source: Intellihealth Medical Services FY 2010

0%

5%

10%

15%

20%

25%

% Total Unique Patients

% Total Visits

0%2%4%6%8%

10%12%14%16%18%

% Total Unique Patients

% Total Visits


20

However, the TC LHIN is a bit different in that it has the highest concentration of health services in Canada delivered across 174 agencies many of which have highly specialized mandates; it provides specialized services that bring individuals from across Ontario and sometimes Canada to receive these care and potentially follow-on care and support; and it draws a number of residents from other LHINs to the Toronto Central region daily for work and school. While it is very difficult to accurately estimate the impact of this daily movement, it is believed to draw on additional primary care services and resources that may not be accounted within existing resource allocations or demand statistics.


21

Confirming Key Areas of Focus The result of the consultations and discussions by a Current State Working Group of experts from across the system identified three key foci for development as part of the environmental scan.

A Focus On Innovation in Care

Delivery

A Focus On System

Leadership & A Clear Vision

A Focus On Building

Enablers & Supports for

Success

The future health care system must be grounded in a robust primary care model to enable greater access, enhance navigation and support improved flow, and nurture interprofessional care teams.

The future primary care system must be guided by strong system leadership that supports greater alignment and accountability, and brings partners and stakeholders together under a shared vision that reduces silos.

The future primary care system must be supported by the necessary enablers to enhance communication amongst system providers, and support the adoption of new technologies.


22

Focus 1: Innovation in Care Delivery The future primary care system must be supported by an innovative care model that enhances the patient and family experience, enables access, and leverages interprofessional care teams.

Patient / Family Experience Research into best practices in care delivery, regardless of the jurisdiction or system of care, increasingly acknowledge the importance of the patient and family experience as a core element affecting their perceptions of quality. Some of the Issues identified in the literature and raised by stakeholders during the course of this planning include:

The health care system has not been effective at either supporting people to be partners in their own care or at involving individuals and communities in decisions about the health system or how services are arranged and delivered.

Patient/provider communication is viewed as central to engaging individuals requiring services as partners in their own health care. At the same time, it is also seen as a major source of frustration and, at times, can even create a barrier to effective interaction.

Individuals requiring services want health professionals to take the time to talk to them – in language they can understand. Some of the early work from the Health Quality Council of Alberta focused on this very issue, leading to a successful campaign entitled “It’s Okay to Ask” that supported individuals requiring services to be better organized for their patient appointment.

Providers are increasingly recognizing the vital role played by caregivers and family and want to include them in communication processes with the patient. They are an essential part of the individual’s support team and know the patient better than the provider does.

Individuals requiring services want to be able to have influence over the course of their care. When necessary, individuals requiring services and families must be persistent in challenging the system when satisfactory answers and explanations are not forthcoming.

Individuals requiring services need to be involved in discussions of their treatment and to be informed of what alternatives may be available when deciding on a course of therapy.

Enabling Access The majority of physicians in the TC LHIN operate outside of the Patient Enrolment Models that have emerged. These physicians express needs, and frustration, related to accessing support such as allied health resources and medical specialties when one of their patients has needs that exceed their ability to respond. This is the reality of the system that we have today where access to an interprofessional team of resources is available and readily accessible through certain models (e.g. CHC and FHT) and more difficult to access in other models. This is not the fault of primary care providers, but rather a challenge that has emerged as a result of other primary care reform efforts. In the future, primary care providers must have the necessary supports and tools to provide care and gain access to additional services they require to meet the needs of their patient regardless of their remuneration model. Consultations indicated that primary care providers are working very hard to meet the needs of their patient; however with growing volumes and complexity of care, these supports are required to help primary care providers navigate the system. In addition, many requests for streamlined processes were made ranging from consistency in referral forms and a “one number to call” model to virtual teams that would be available within each community/network to provide access to professionals as required.


23

The engagement conducted confirmed the following:

− Need to focus on reducing the number of unattached patients and enhance their access to primary care. Options include creating neighbourhood networks, and development of strategies to define solutions for populations of individuals requiring services that extend beyond a geographic context (e.g. a focus on advancing services and navigational supports for the mental health and addictions populations).

− Need to develop an understanding of the challenges faced by primary care physicians, regardless of practice model, and work collaboratively with them to address these challenges, and better integrate care for those needing their services into a system that meets the community need.

Working as an Interprofessional Team Reports from primary care physicians highlight the challenge of how best to coordinate care and how to manage individuals with chronic disease. International literature points to significant differences in incentives, practice information, capacity, access and the use of teams. Policies related to payment practices and other initiatives may be national in scope or they may be dependent on local, market-driven actions, influencing the process of primary care reform.

There has been an evolution of the care delivery model within some organizations leading to a greater focus on an interprofessional team of providers, advancement of new provider models that divert pressures in the system, utilization of providers at full scopes to enhance the breadth of services that can be provided, and strategies to organize differently (e.g., Multispecialty Physician Networks, Hospital-Primary Care Alliance). While two of the primary care models (CHCs, FHTs) have been specifically designed to enable teams of professionals to be co-located to meet the needs of individuals requiring services, many people report that care is not truly organized under a team construct. Professionals are co-located and often interact with the patient as individual, rather than following a true team approach. As a result:

− New models and processes of care delivery need to be designed to leverage the benefits of interprofessional care teams working to full scopes of practice to the benefit the most complex populations.

− Need to simplify the process and develop tools for understanding the myriad of resources available, and facilitate access to the right service for the more complex individuals requiring services.

Many believe that these “innovative” models must become common practices in our system.

Focus 2: System Leadership and Clear Vision The future primary care system must be guided by clear system leadership that supports greater alignment and accountability bringing partners and stakeholders together under a shared vision that reduces silos.

Advancing Leadership Structures The system needs leadership in primary care. Players are looking for someone to step up and define the priorities, ensure alignment, and hold people accountable for actions.

Drummond’s call for a system focused on community-based solutions that enable more effective management of chronic illness and complex needs is echoed by many, with suggestions that existing models and structures must be leveraged more effectively. Specific mention was made of the FHTs, CHCs, CCAC and CCC Hospitals as providing unique “Made in Ontario” options for new models, yet people acknowledge that each of the provider groups/organizations are not well-understood by others. This lack of understanding is seen as a barrier to moving forward.


24

On a positive note, it is very encouraging to see multiple system players (e.g. CCAC, Hospitals, FHTs, CHCs, independent Primary Care providers and others) working collaboratively to explore innovative models. For example, the Toronto Central CCAC has advanced a number of important initiatives including the Integrated Care for Complex Populations (ICCP) Project that has changed the way that individuals with complex needs access care and receive services. This work, which was funded by the TC LHIN, brings together a number of partners (e.g. Physicians, Hospitals, Community Support Services, EMS) to rethink how care is coordinated for people with complex needs. This is part of the foundational work that the LHIN’s primary care strategy will build on.

Hospitals are also supporting and pursuing initiatives related to primary care and these efforts are applauded by many who see the hospital system as a critical piece of a complex puzzle. At the same time, some of the reactions from stakeholders have been mixed as people have expressed concerns about the ability of acute organizations to truly understand the needs and potential solutions that exist in a community context, particularly given the many specialized and academic hospitals in the TC LHIN.

These cooperative models are helping to build a shared understanding of issues and opportunities as well as the individual and collective strengths that already exist in the system. At the same time, there is concern that the lack of clear consensus on system leadership/governance models to support primary care will result in fragmented leadership processes, and weaken the overall potential for improvement in the TC LHIN.

While the TC LHIN is viewed as the logical leader for some of the primary care efforts, many feel that credible leadership can only be provided from within the Primary Care system itself (e.g., MDs, FHTs, CHCs). This is a key need that must be addressed as part of implementation planning.

Evidence collected highlighted the need to build strategies leveraging existing structures, and to do so in an integrated fashion.

− Need to establish innovative governance and accountability structures and processes in primary care that incorporates collaborative decision-making and input from the local community.

− Need to develop guiding frameworks or models to advance the system. Explore frameworks such as Medical Home, or the Institute of Healthcare Improvement’s Triple AIM framework, as guidance for the TC LHIN.

− Need to understand, and build on, the many efforts currently underway in order to better build on primary care delivery activities (data, inventory of efforts).

Opportunity for a Shared Vision to Reduce Silos There is a general lack of a shared vision leading to fragmentation of systems involved in care. A number of innovative initiatives in primary care are being pursued and these are applauded throughout the system. However, there is an opportunity and need to link these initiatives together. It is recognized that some initiatives are largely taking shape at the organizational level, in response to issues identified by the organizations themselves, without benefit of a larger system vision that provides context, defines priorities and establishes measures for performance improvement.

− Need clarity on each party’s role/accountability and how they contribute to a vision of primary care grounded in a patient experience and quality health.

− Neighbourhood-based solutions that support the community must be sought. A focus must be on continuing to build meaningful relationships that connect solutions together seamlessly.

− Need for a compelling vision that enables a system level perspective to support and guide innovation at the organizational level, while clarifying the overarching goals and priorities.


25

Focus 3: Building Enablers and Supports for Success The future primary care system must be supported by necessary enablers and supports. This future primary care system must be grounded in enhanced communication amongst system providers, and support the adoption of new technologies. Enhance Understanding and Build Alignment Across Providers To be successful, providers across sectors must understand the intent of the primary care plan, have an opportunity to provide input and advice, and truly understand the benefits of the plan and how it affects them.

− Develop a communication/engagement strategy to build a shared and collective understanding and endorsement of the Primary Care strategy by leaders across the system.

Invest Building and Adoption of New Technologies Concern was expressed regarding the communication processes amongst providers, including specialist consultation feedback, Emergency Department discharge summaries, and hospital inpatient discharge summaries. Most were described as ineffective and not timely, although some exceptions were noted. Primary care providers are looking for more interactive options that allow for timely access to information to support decision making, and an ability to connect with and engage the specialist and other providers in a dialogue that supports capacity building in primary care.

A greater focus on building improved mechanisms and processes to share information between organizations is currently being pursued at various levels of the system (e.g., by individual/group primary care providers, by hospitals, by provincial and national agencies like eHealth, Canada Health Infoway, and the Canadian Institute for Health Information (CIHI). There is a need to ensure these efforts align and converge to build the necessary system infrastructure to enhance care delivery and ultimately seek to improve health.

To achieve this, open dialogue and effective planning must occur between parties to ensure the technology solutions address the needs of providers and individuals requiring services, and will ultimately be adopted. The need for connecting information systems and processes, and ensuring timely access to relevant information is viewed as a key priority and enabler to truly integrating primary care. Without this level of connectivity, advancement of primary care will not proceed at the pace that is required. Strategies to support greater adoption must be a focus of planning efforts.

− Make necessary investments in supporting technologies (e.g., EHRs, EMRs) and the linking of these technologies to ensure effective transmission of information to support timely decision-making across the broader health care system. Invest in tools and processes to enhance communication of information to support clinical decision-making across the sectors. A strong focus must be placed on ensuring providers have the information they need, when they need it.

− Enhance data sharing processes and information exchange by developing more integrated information sources, exploring resource centre model (e.g. central place for access to information) to enable info flow to individuals requiring services, families and providers to improve navigation, and creating accountability for a two-way information exchange.

− Build performance and system measures that show who is performing well related to supporting and enabling access as well as those that have room for improvement


26

Vision for Primary Health Care in the Toronto Central LHIN To advance primary care in the TC LHIN, the system must be viewed as part of the broader primary health care continuum which includes the many providers who work together to contribute to the health of the population. Primary health care plays a central role in building a health system that is sustainable, accessible, provides quality care, and is relevant to individuals requiring services.

This approach supports Ontario’s Action Plan – right care at the right time in the right place requires that individuals requiring services and providers work together more closely than they have in the past.

Primary health care in the Toronto Central LHIN will ensure:

Every resident will have a primary care practitioner who provides them with accessible, high quality care regardless of which practice model they are a part of.

Every primary care physician will have equal and equitable access to interprofessional teams in the community to support their most complex patients and their caregivers regardless of practice type.

A collaborative, interdisciplinary team supports all comprehensive family doctors and their patients. Work of the Ontario College of Family Practice referred to the development of “hubs of care” that establish a single entry to point to an umbrella of services to ensure effective use of resources while ensuring equitable access.

Individuals requiring services and families play an active role in designing and directing plans of care.

Primary care services are integrated across a broader system of health care (e.g., acute care, long term care, rehabilitation, end of life care), and other community health and social services including public health and schools.

Primary care services are delivered in accordance with patient and community need with a view to reducing health inequities.

Best practices, innovations and information systems are leveraged and spread.

Patient outcomes and experience are measured at the practice and system level to support continuous quality improvement.

Advancing the Integration of Primary Health Care The Providers of the Toronto Central LHIN will provide personalized, seamless, timely, comprehensive, and high quality primary care to its population through collaboration across the system to advance improved patient outcomes and improved patient experience in the context of a sustainable health care system.


27

The Primary Health Care Model

Building the Network Concept The proposed Primary Health Care Model is established on the premise that transforming primary health care cannot, and must not, be solely focused on primary care providers in isolation of the broader care system. A broader, network approach must be leveraged that brings together providers to jointly tackle the key challenges facing primary health care.

This Network Concept will seamlessly bring together primary care, the CCAC, community based services, hospital and specialized care, teaching and education, and linkages with social and support services together.

The first focus will start with Primary Care Providers and the CCAC as a foundation. This is about ensuring primary care is available where individuals requiring services live their lives. This initial focus will leverage existing capacity and the experience of CCAC staff in every geography and neighbourhood as regional providers, existing shared accountability for the most complex populations, existing efforts to advance care and connect providers for the most complex clients, and current knowledge of the system to support navigation and education. A number of existing programs and services can be utilized to advance this first focus quickly.

A second focus will be Community Based Services to ensure services that extend beyond primary care including key community based services, addictions and mental health, and public health are available when they are needed. Mental health and addictions will be an early and key focus to address needs and opportunities within the TC LHIN.

A third focus must be Hospitals - acute (tertiary, quaternary), specialty acute (Addiction and Mental Health, Cancer, Women, Children, Rehab/CCC), together with long-term care are critical for seamless transitions to and from primary care when a higher level of care is required.

A fourth focus of the Network model centers on Teaching and Education which create opportunities for educating and training our future providers of care. The Network will support education opportunities within primary care, hospitals, and community based services.

A final focus of the Network model centers on Social and Support Services which connect residents with critical key support services that enhance the well-being of individuals, families, and communities.


28

While all five elements are important, a phased-plan must be employed to move forward, one that starts with Primary Care and CCAC for the complex populations:

Consultations have indicated that it is both an area of need and a current area of interest;

There are many efforts and successes to build upon and leverage (e.g., LHIN funded initiatives with the CCAC to support complex populations has established existing capacity and knowledge that can be utilized – Integrated Care for Complex Populations - ICCP); and

It provides a critical foundation – a blueprint to build on and extend to include other areas of focus

Confirming the Benefits of the Network Concept Pursuing the Network model will result in a number of benefits for individuals requiring services. These include:

Individuals requiring services will have an improved experience as they will be at the center of the transformation.

Individuals requiring services will have access to services that have been informed by the local needs of the population.

Individuals requiring services will have equitable access to the same range of services and supports regardless of who their physician is, and who their physician has access to.

Individuals requiring services will be supported by interprofessional providers who will support their transition and navigation to help access the care and services they need.

Individuals requiring services will have more options to receive their care when they need it, including after-hours.

The Network model will also result in a number of benefits for providers. These include:

Providers will benefit from enhanced levels of flexibility to deliver services in ways that best meet the needs of their communities.

Providers will have enhanced access to services and navigational support including access to primary care, community, hospital and social services within and beyond their Network.

Providers will enhance their client’s experience through timely and smooth access to the services clients’ need, when they need it through enhanced core coordination.

Referral patterns will be established to support the transition of individuals requiring services.

Providers will access care standards, information from across the system, and improved tools to support delivery of the best care for their individuals requiring services.

Providers will have more support in caring for patients with complex care needs. Support for primary care providers will leverage existing capacity and experience currently available.


29

Identifying the Networks To achieve the vision, the primary health care conceptual model supports the development of smaller sub-LHIN boundaries that create Networks that will build on local capacity to meet the health care needs of the population. The result – the Networks come together to deliver better value for money, ensure higher quality of care, improve access, support deeper engagement of individuals requiring services and family, and develop a truly patient-centred focus. The conceptual model will have the following attributes:

Grounded in Local Needs. The Networks will be defined by geography (i.e. minimum 50K population) to serve the needs of the local population but will not use or force a “one size fits all” approach. Early efforts will include a focus on the complex, high-use and high need populations.

Built on Voluntary Partnerships. Networks will be based on voluntary participation and will bring together primary care providers, community-based services, CCAC, specialists, hospitals, long-term care homes, public health, and educational facilities.

Guided by Local Leadership. Each Network will be governed by local leadership to guide operations and strategies to meet the needs of the population served. Each Network will be accountable to the LHIN to meet a set of defined expectations.

Built on Existing Successes. The Networks will not be a new layer or additional silo, but will build on existing infrastructure and relationships that have already been locally developed and defined. Where required, Networks will receive required supports (e.g., technology infrastructure and applications, redesign support, change management support). The Toronto Central CCAC will be a foundation for the Networks building on its strength and successes of establishing neighbourhood level solutions that address local and complex needs of individuals requiring services.

Delivering Comprehensive Core Services. All Networks will deliver a core set of services regardless of the existing family practice/general practitioner funding model (Family Health Team, Community Health Centre, Physician Enrollment Model, and Non-Physician Enrollment Model). The CCAC will be an important enabler of this goal.

Enabling Access to Specialized Services. Each Network will also offer a set of specialized services based typically on existing capacity. These specialized services will be available to the “home” Network but also to other Networks through established referral processes.

Enabling Measurement of Impact. Each Network will be supported by robust information management practices to identify and track improvements for defined efforts to improve the patient experience, quality of care, and timely access to services.

Person Centred Focus. All Networks will be guided by a patient-centred approach to planning, and will focus on the complex, high need and high cost populations initially. The goal is to empower this group so they can make informed choices, thereby promoting independence and improving how they interact with providers. Overtime, developed solutions will broaden the focus to extend beyond the complex population.

Built on Collaboration. Each Network will reflect a foundation of integration which has been developed through the strength of the current partnerships, and which has been built on an inter-sectoral and interprofessional team approach, and through an increasing degree of trust across providers.


30

To achieve the vision, the primary health care conceptual model supports the development of sub-LHIN boundaries that create Networks that will build on local capacity to meet the health care needs of the population. The Networks will cover the entire TC LHIN. The following is a sample of potential boundaries. Further work to define boundaries will be undertaken.

Proposed Boundaries for the Toronto Central LHIN Primary Care Networks

Prepared by the Toronto Central Local Health Integration Network.


31

Defining Core Services for the Each Network To support planning, consultations with Think Tank participants were utilized to identify a starting list of core services that should be available in each network. These should be considered the list of services that all residents of the LHIN will have access to within their own network. Please note, this does not obstruct residents from seeking services in other networks, however ensures core services are available for all residents close to home.

The following reflects core services in descending order of importance as identified by Think Tank Participants.

Physician single point of access to the Health Link services/program.

Integrated/coordinated care plans for the top 1 and 5%.

Access to afterhours and weekend care.

Family practice providers have access to specialist advice.

Access to an interprofessional care team either directly at the provider office or indirectly through the Network.

Mental health and addiction services (e.g., withdrawal management, counseling and support, clinical psychology).

Chronic disease management programs (e.g., diabetes, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), pain management, tele-homecare).

Palliative care (e.g., pain management, hospice care).

Access to interpretive services.

Serve each client in the Network if they should choose to receive services. Over time, every client who chooses to get services within their Network should receive services within their Network.

Every client in the 1% and 5% is assigned and known to the primary care provider(s) and the CCAC and who have shared responsibility for navigating and coordinating their care.

Health promotion, disease prevention and lifestyle programs (e.g., exercise, nutrition, medication, rehab, flu clinics, smoking cessation, memory clinics, cardiac care, weight clinics).

Prenatal and maternity services.

Child wellness programs (e.g., social worker for individuals, families, groups)

Community Support Services (e.g., friendly visiting, meals on wheels, transportation, home maintenance).

Enhanced programs for seniors.

Behavioural support programs to support individuals requiring services and families where they live.

Geriatric assessments available across the continuum.

Adult day programs and enhanced adult day programs.


32

Evaluating the Impact of Networks To help ensure networks are effectively developed, deployed and maintained, an evaluation framework grounded in HQO’s Quality Framework has been developed to clearly define how the LHIN will evaluate successes upfront. See Appendix for a Draft Framework for Evaluating Impact of Primary Care Networks.

HQO Dimension Anticipated Benefits Potential Indicators

Patient-Centred

Individuals wishing to be connected to a primary care provider in the TC LHIN will be able to do so.

Services will be responsive to individual's culture and choice of language and will provide information and resources to support their management of their own care.

Providers will be able to provide the services their clients/patients require, or know how to refer them to the services they need even if offered by another provider (e.g., to connect complex patients to care coordination/services).

Fewer patients will require services through Emergency Rooms, this reducing congestion.

Patient and provider experience surveys.

Fewer unattached patients identified through Health Care Connects.

Reduced number of CTAS 4 and 5 patients.

Accessible Services will be coordinated to provide ease of access Individuals requiring care and their families will be able to

access their primary care provider within 24-48 hours of requesting an appointment; have access during evenings and weekends; and will have facilitated and coordinated access across providers without unnecessary delay.

Teams of resources will be available to support smooth and timely access to other providers when primary care providers require support in transitioning patients.

Continuity of care with primary provider and their organizations.

Number of services accessed through centralized intake processes.

Equitable Consistent sets of core services will be available within an individual’s local neighbourhood.

Utilization patterns for primary care services, or referrals for specialty services, will not differ significantly between communities based on factors such as income, ethnicity, etc.

Inventory of services to ensure no gaps in a community.

Utilization metrics will demonstrate equity.

Effective Individuals requiring care and their families will have access to information regarding best practices and care standards that they can expect from all levels of providers.

Providers will be able to refer their patients/clients to the select the intervention that is most likely to produce the optimal results for their patient/client in a timely fashion.

Best practice measures at a population level.

Efficient Cost of transportation and other related costs associated with access will be affordable for individuals requiring care.

Participation in system led initiatives will not result in inappropriate costs being incurred by providers.

Population based utilization measures.

Cost/resource utilization scorecards.

Integrated Providers across the system are organized, connected, and work together to provide high quality care to meet the primary health care requirements of needs of patients.

Interprofessional teams delivering integrated care

Safe People will not be harmed by an accident or mistake when they receive care.

Monitor all services to ensure they are safe and appropriate (e.g., medication use, post-discharge from acute care).


33

Building a Plan to Move Forward To this point, there has been clear agreement that change related to primary care must occur now, and that this change must include broader system stakeholders working together to advance the integration of primary health care. The result will be personalized, seamless, timely, comprehensive, and high quality primary care to residents through collaborative efforts across the system to advance improved patient outcomes and improved patient experience in the context of a sustainable health care system.

The driver for this change will be creation of networks that will seamlessly bring together primary care, community based services, hospital and specialized care, teaching and education, and linkages with social and support services together.

Six Imperatives to Achieve the Vision To support implementation of the model, the design process acknowledged the need to provide the necessary supports to help realize the model. The following six imperatives have been established to ensure the vision is achieved by ensuring clear understanding of the message and intent, ensuring everyone works together, strengthening capacity, developing innovative ways of working together, building buy-in and support, and ultimately acknowledging the benefits and impact of the model.


34

Imperatives and Supporting Recommendations To assist in moving forward, each imperative has key recommendations that will provide the necessary foundation and supports to implement the network model. While there may be a tendency to “pick and choose” recommendations, each recommendation is critical to assist in moving forward and should be supported.

Imperative Key Recommendations

Engagement & Communication The “Getting the Message Out” imperative focuses on ensuring stakeholders from residents, to providers, to system agencies and leaders understand the plan and opportunities to build alignment are supported.

Support Continuous Community Engagement/Involvement in all planning, implementation and evaluation steps moving forward.

Develop Communication Strategies and Tools to get the vision out and build commitment to ensure stakeholders are informed and involved in the dialogue. Activities will include early engagement with key system stakeholders (e.g., OMA), and enhanced levels of integration with system providers to support better integration across sectors (e.g., public health and EMS, social service sector to enhance care coordination and transitions for less complex populations). TC LHIN web services and social media can support provider groups to share information, communicate, and collaborate within their community and across the LHIN.

Build Tools/Mechanisms to Receive Input and Advice from the field in a timely manner, and ensure mechanisms to review and act on feedback are in place. Activities may include development of mechanisms to engage providers in a dialogue to ensure timely feedback and guidance is received to support continuous improvement of the model and ensure learnings inform future deployments.

Governance & Shared Leadership The “Ensuring Everyone Works Together” imperative focuses on establishing and supporting critical accountability structures to ensure the plan is supported and delivered.

Establish a Representative Network Council (e.g., Primary Care Leads, Network Leads, Cancer Care Ontario, Ontario Medical Association, CCAC, etc.) to guide the work of Networks. A Network Council will work together to provide advice to the LHIN, to ensure continuity and provide important support and oversight to ensure success of the Networks through a diverse and representative membership including all sectors. Education to support council members will be developed.

Define Reporting and Accountability Relationship to the LHIN and to each other will be established to ensure clarity of accountability and understanding for how the impact of primary care in Networks will be measured.

Define Proposed Structure of Networks to ensure an appropriate level of consistency in structures, efficiencies, appropriate representation, and accountability.


35


Capacity Building The “Strengthening the Capacity and Ability of Partners” imperative focuses on building the necessary capacity of providers and agencies, and leveraging areas of strength to build future capacity.

Understand Strengths and Needs of System to understand populations and their needs to further develop the Network model to ensure the design is based on the needs of the local population and not grounded in providers and their current service offering.

Build a Targeted Plan for Capacity Development to increase services in areas that providers cannot currently access and/or do not provide and are deemed as core. Ensure Networks enable providers with enhanced access to services and coordination to decrease their workload. In addition, support and education for leadership and providers within the Network will be provided, and key resources to enhance capacity within each Network will be identified and supported.

Identify Strategies to Invest in Capacity Building in other sectors beyond acute care and CCAC. Need to make investments to support the creation of the Networks (e.g., seed money to support coordination, education).

Identify the Core Partners who will help lead the change. While CCAC, FHTs and CHCs have been identified, an early focus must also extend to bringing hospitals (teaching, community and CCC hospitals) into the process and build a strategy for how they can constructively support the model. Will need to develop partnership agreements to ensure clarity of roles and accountability. For example, use resources from organizations like HQO and bestPATH to teach Networks how to work together as teams.

Incentive Models The “Creating Tools to Ensure Buy-In and Support” imperative focuses on establishing incentives to ensure stakeholders buy-in and support the network model (e.g., adherence to defined protocols, interdisciplinary team model, seamless handoffs).

Identify and Implement Incentive Structures (monetary, non-monetary) for physicians and non-physicians (e.g., align compensation models).

Developing Reporting Systems that are transparent (e.g., dashboard that has an aggregate and then a detailed account within and across all areas) to ensure a professional sense of responsibility.


36


Critical Supporting Processes, Tools and Infrastructure The “Developing Innovative Ways of Working” imperative focuses on ensuring key supporting processes, tools and infrastructure is available to support the network model as part of a broader system of care.

Establishing Pathways and Protocols to ensure common approaches and clarity for how the system works (e.g., one number to call for primary care navigation and access).

Building Interprofessional Teams functioning at full scopes of practice. While every primary care service organization will not include a full interprofessional team, mechanisms will be put in place to ensure access to additional services when it is required to ensure appropriate, seamless care. Activities may including promoting full-scope of practice for all providers and promote the use of team-based models to deliver care, and building models that enable all providers to access teams regardless of the physician remuneration model.

Navigation and Care Coordinator Roles must be established to ensure timely access and transitions across the system and the sectors. Activities may include enabling and supporting Network-to-Network communication and coordination to avoid silos and promote efficiency; aligning with emerging models designed to support seniors’ health care services; and improving access to and collaboration around mental health and addictions services in the LHIN.

Patient Engagement and Wellness Programs must be developed to help keep residents healthy and informed and involved in their own plans of care.

Integrated Information Systems that ensure patient information from across the health sector is shared and is accessible where it is needed, when it is needed, by the appropriate providers (e.g., Connecting GTA to provide point of care access to patient information securely). Activities may include leveraging support from eHealth to integrate the exchange of information enabling providers to share info; support strategies and critical investments to focus on technology including e-chart/integrated record or other information system solutions to support information continuity to enhance care; and improving communication between hospital and primary care leveraging electronic information systems (e.g. Hospital Report Manager to transmit patient reports to EMRs, Standardized Discharges Summaries).

Identify Key Supporting Processes to Change will include focused efforts to change traditional models of working and transitioning individuals requiring services across the system in favour of new, innovative practices that leverage available capacity, ensure high quality outcomes, and create a positive experience for individuals requiring services and providers. A number of processes will undergo redesign/Lean efforts. Activities may include establishing pathways across providers and tools to facilitate and automated handoffs (e.g., referral process between Networks); or establishing shared communication hub/clearing house/central registry to help providers navigate the system of resources effectively (e.g. a compendium of services that is continuously updated and available in an easy-to-use format). Opportunity to build on the work of the TC CCAC.


37


Building Evidence for Further Expansion The “Acknowledging Benefits and Impact” imperative focuses on establishing the necessary supporting structures, framework and capacity to continual monitor the implementation of the evolving primary health care model with the Network, assess and report on impact, and identify opportunities for improvement.

Nurture a Culture of Accountability supporting an ongoing desire and need to transparently track and review performance. Activities may include developing mechanisms to ensure information is provided back to providers and to the Network to help them understand how they are doing; establishing performance measurement/data related efforts to ensure meaningful and useful information is collected and used; and performance measurement and reporting capacity established within primary care to enable 2-way information flow from Networks to LHIN.

Enhance Decision Support Capacity to ensure effective measurement and monitoring of Networks and more broadly access and care outcomes must be enhanced. Focus will be on developing reporting and evaluation tools, and initiation and monitoring of quality metrics (e.g., TC LHIN Decision Support Unit to offer decision support services, Integrated Decision Support to provide access to a cross-sector integrated data set and suite of data query tools).


38

Philosophy for Moving Forward Implementing the proposed Primary Health Care Network Model within the Toronto Central LHIN will start at the Network level and capitalize on local leadership, capacity, and motivation. This approach will ensure each Network focuses on the needs of the population, builds on the capacity of the providers, while all work is guided by the Network Model and is supported by the attributes and recommendations. The Toronto Central LHIN will work with local providers to identify demonstration sites, and provide support to each site to enable implementation and delivery of services that will be guided by each local Network. While work will initially focus on primary care providers and the CCAC within each network, the scope will quickly expand to include community providers, hospitals, teaching institutions, and the broader social service agencies, all of which will be undertaken with a person-focused approach to care. The following highlights the proposed phases of implementation.

While work will initially focus on selected demonstration sites, the goal is to have Networks rollout across the LHIN using a multi-wave, multi-phase approach that continually builds leadership and capacity and translates learnings and tools throughout the process. The following diagram highlights the suggested multi-wave approach. It is expected that Networks will be deployed across the entire TC LHIN within three years.


39

Commitment from the Toronto Central LHIN The idea of Networks is simple: Providers supporting providers to deliver the best possible care for people and communities to ensure access to the core health care services in the communities and neighbourhoods where they live their lives. This future system of care must be founded on a highly accessible and responsive primary health care system.

As the Toronto Central LHIN providers move forward, we are starting from a position of strength. Toronto Central LHIN has some of the very best primary care providers, CCAC, community providers, hospitals, teaching institutions, and broader social service agencies. And as a collective, is capable of providing the very best in health care. Providers in the LHIN have already initiated some important foundational work in primary care that will be leveraged to ensure early and ongoing success.

The TC LHIN is also fortunate to have support from the Ministry of Health and Long-Term Care. The direction of the TC LHIN to advance primary health care using its network model is strongly endorsed by the Ministry as evident in the development of Health Links. Like Health Links, the TC LHIN strategy for primary health care will improve the quality care for all; achieve better outcomes for patients; advance system transformation through integration; and put the local health care system on a more sustainable footing. Building on the work undertaken over the last eight months to build a primary health care model, the TC LHIN will leverage the new Health Links mandate to achieve the common goals of faster care and less time waiting for services; improved transitions through the system; supported by a team of health care providers at all levels of the health care system; and more responsive care that addresses an individual’s specific needs. The timing could not be better.

The TC LHIN has proposed the creation of nine (9) networks. Each network will have commonality in terms of access to core services and expected outcomes, but will have a degree of customization based on the needs of the local community. Specialized services will be available to all networks through a formal referral process. Each network will be supported by robust information management practices to identify and track improvements for defined efforts to improve the patient experience, quality of care received, and timely access to services.

To realize our vision for personalized, seamless, timely, comprehensive, and high quality primary care that are focused on collaborative approach that advances improved patient outcomes and patient experience, the Toronto Central LHIN will take a phased approach to implementation. However the work must begin and be completed in a timely fashion as residents of the LHIN cannot wait.

While it would be impractical to get all of the Networks up and running at the same time, our goal will be to get all nine networks operational over the next three years. We will utilize implementation waves, where subsequent networks will learn from and build on the experience of networks that were established before them to ensure future deployments will get easier. Every area of the LHIN and every provider will be part of this. The first focus will start with Primary Care Providers and the CCAC as a foundation. This is about ensuring primary care is available where clients live their lives.

While we know the next few years will require ongoing dedication and support to achieve the vision for primary health care, we believe the Toronto Central LHIN as a collective of its providers and partners is up for the challenge. Our providers have an abundance of talent, capacity and knowledge to make this happen. We also understand the importance, and have the will and the courage to make difficult changes for our clients and communities. With a planned and structured approach, we are more than capable of delivering on what the Minister is calling on us to do.

Together, we can create the kind of system and experience that people tell us they want and that we know they should be able to count on.


40

Appendix

Current State Design Working Group Name Organization

Co-Chairs Stacey Daub Toronto Central CCAC Dr. Phil Ellison Toronto Central LHIN

Membership Dr. Yoel Abells Toronto Central LHIN Dr. Javed Alloo East GTA Family Health Group Cheryl Chapman Health Quality Ontario Dr. Jocelyn Charles Sunnybrook Health Sciences Centre Chris Gilles Ontario Medical Association, District 11 Dr. Rick Glazier Institute for Clinical Evaluative Sciences Jodeme Goldhar Toronto Central CCAC Dr. Tara Kiran Toronto Central LHIN Stephanie McLaren South Riverdale Community Health Centre Brenda McNeill Anne Johnston Health Station Kavita Mehta South East Family Health Team Carla Ribeiro Parkdale Community Health Centre Dr. David Tannenbaum Mount Sinai Hospital Clarys Tirel Mount Sinai Hospital

Consultations Dr. Sandy Buchman Cancer Care Ontario Dr. Pauline Pariser Taddle Creek Family Health Team Dr. Lynn Wilson Department of Family and Community Medicine,

University of Toronto


41

Design Working Group Name Organization

Co-Chairs Stacey Daub Toronto Central CCAC Dr. Phil Ellison Toronto Central LHIN

Membership Dr. Yoel Abells Toronto Central LHIN Dr. Reva Adler Bridgepoint Health Dr. Javed Alloo East GTA Family Health Group Jason Altenberg South Riverdale Community Health Centre Sheila Braidek Regent Park Community Health Centre Kathy Bugeja Ontario Medical Association, District 11 Dr. Sandy Buchman Cancer Care Ontario Cheryl Chapman Health Quality Ontario Dr. Jocelyn Charles Sunnybrook Health Sciences Centre Kim Chow Bridgepoint Family Health Team Erika Coleman 416 Community Support for Women Mira Dodig Flemingdon Health Centre Dr. Geordie Fallis Toronto East General Hospital Dr. Sid Feldman Baycrest Geriatric Health Care System Dr. Lee Ford-Jones The Hospital for Sick Children Dr. Rick Glazier Institute for Clinical Evaluative Sciences Jodeme Goldhar Toronto Central CCAC Linda Jackson Baycrest Geriatric Health Care System Dr. Tara Kiran Toronto Central LHIN Dr. Leo Levin Toronto Central CCAC Seonag Macrae Woodgreen Community Services Dr. Danielle Martin Canadian Doctors for Medicare Brenda McNeill Anne Johnston Health Station Dr. Heather McPherson Women’s College Hospital Dr. Nicole Nitti Access Alliance Community Health Centre Trish O’Brien Department of Family and Community Medicine,

University of Toronto Dr. Pauline Pariser Scope Project, UHN. Taddle Creek Vania Sakelaris Toronto Central LHIN Dr. Chandrakant Shah Anishnawbe Community Health Centre Dr. Douglas Sinclair St. Michael’s Hospital Rachel Solomon Toronto Central LHIN Dr. Vicky Stergiopoulos St. Michael’s Hospital Dr. David Tannenbaum Mount Sinai Hospital Clarys Tirel Mount Sinai Hospital Dr. Jonathan Tolkin Community Physician Norm Umali Toronto Central CCAC Dr. Peter Voore Centre for Addiction and Mental Health Dr. Lynn Wilson Department of Family and Community Medicine,

University of Toronto Dr. Barbara Yaffe Toronto Public Health

Consultation Dr. Jose Silveira St. Joseph's Health Centre Toronto


42

Think Tank Participants Name Organization

Speakers Honourable Deborah Matthews Minister of Health and Long-Term Care Wayson Choy Guest Speaker Lisa Priest Guest Speaker

Co-Chairs Stacey Daub Toronto Central Community Care Access Centre Dr. Phil Ellison Primary Care Advisor, Toronto Central LHIN

Participants Dr. Yoel Abells Primary Care Advisor, Toronto Central LHIN Dr. Reva Adler Bridgepoint Health Dr. Javed Alloo Community Physician Jason Altenberg South Riverdale Community Health Centre Anne Babcock Woodgreen Community Services Dr. Philip Berger St. Michael's Hospital Dr. Bob Bernstein Bridgepoint Health Patrick Boily Reflet Salvéo Nancy Bradley Jean Tweed Treatment Centre Sheila Braidek Regent Park Community Health Centre Catherine Brown MOHLTC, Health System Accountability and Performance

Division Maggie Bruneau Providence Healthcare Claire Bryden Bellwoods Centre for Community Living Kathy Bugeja Ontario Medical Association, District 11 Janet Chappell Ryerson University Dr. Jocelyn Charles Sunnybrook Health Sciences Centre Kim Chow Bridgepoint Family Health Team Erika Coleman 416 Community Support for Women Mae Couzens-Duffy Private Citizen Mary Jane Cripps Reconnect Mental Health Services Rob Devitt Toronto East General Hospital Mira Dodig Flemingdon Health Centre JoAnne Doyle United Way Toronto Dr. James Edney City of Toronto Long-Term Care Homes and Services,

Castleview Wychwood Towers Dr. Larry Erlick Scarborough Hospital Dr. Geordie Fallis Toronto East General Hospital Melissa Farrell MOHLTC, Primary Health Care Branch Angela Ferrante Toronto Central LHIN Russ Ford Lakeshore Area Multi-Service Project (LAMP) Community

Health Centre Dr. Lee Ford-Jones Hospital for Sick Children John Fraser Toronto Central LHIN Dr. Jeremy Friedman Hospital for Sick Children Carie Gall Mississauga Halton LHIN Kathleen Gallagher-Ross Toronto Central LHIN Dr. Rick Glazier Institute for Clinical Evaluative Sciences Jodeme Goldhar Toronto Central Community Care Access Centre Gerry Hille Private Citizen


43

Name Organization Janine Hopkins Toronto Central LHIN Linda Jackson Baycrest Centre for Geriatric Care Michelle Joseph Central Toronto Community Health Centre Dr. David Kaplan Primary Care Lead, Central LHIN Dr. Michael Kates Primary Care Lead, Mississauga Halton LHIN Krista Keilty Hospital for Sick Children Dr. Tara Kiran Primary Care Advisor, Toronto Central LHIN Maura Lawless 519 Church Street Community Centre Ester Lipnicki St. Joseph’s Health Centre Nancy Lum-Wilson Central LHIN Terry McCullum LOFT Community Services Brenda McNeill Anne Johnston Health Station Dr. Heather McPherson Women’s College Hospital Rabah Mezouari Private Citizen Dr. Sioban Nelson University of Toronto Wendy Nelson Consultant Dr. Nicole Nitti Access Alliance Community Health Centre Diana Noel Liberty Village Family Health Team Genevieve Obarski The Change Foundation Trish O’Brien University of Toronto Jim O’Neill St. Michael’s Hospital Camille Orridge Toronto Central LHIN Dr. Pauline Pariser Taddle Creek Family Health Team Dr. Paul Philbrook Credit Valley Hospital Lynne Raskin South Riverdale Community Health Centre Hélène Nicole Richard Private Citizen Hélène Roussel Reflet Salvéo Dr. David Ryan Regional Geriatric Program of Toronto Vania Sakelaris Toronto Central LHIN Dr. Chandrakant Shah Anishnawbe Community Health Centre Lorie Shekter - Wolfson George Brown College Dr. Douglas Sinclair St. Michael’s Hospital Juanita Smith Ontario Council of Agencies Serving Immigrants Rachel Solomon Toronto Central LHIN Dr. Vicky Stergiopoulos St. Michael's Hospital Dr. David Tannenbaum Mount Sinai Hospital Clarys Tirel Mount Sinai Family Health Team Dr. Johnathan Tolkin Community Pediatrician Agnes Tong Central West LHIN John Toogood Bridgepoint Health Norm Umali Toronto Central Community Care Access Centre Dr. Sarita Verma University of Toronto Mark Vimr St. Joseph’s Health Centre Dr. Peter Voore Centre for Addiction and Mental Health Dr. Barbara Yaffe Toronto Public Health, Communicable Disease Control

Consultations Aysha Bandali Baycrest Centre for Geriatric Care Dr. Ty Turner St. Joseph's Hospital


44

Name Organization

Regrets Dr. Richard Almond North West LHIN Helen Angus MOHLTC, Associate Deputy Minister’s Office Dr. Rob Annis South West LHIN Michael Barrett South West LHIN Donna Cripps Hamilton Niagara Haldimand Brant LHIN Paul Davis Hospital for Sick Children Dr. Robert Drury Central East LHIN Dr. Sholom Glouberman Patients’ Association of Canada Deborah Hammons Central East LHIN Dr. Jonathan Kerr South East LHIN Laura Kokocinski North West LHIN Bruce Lauckner Waterloo Wellington LHIN Chantale LeClerc Champlain LHIN Dr. Martin Lees Erie St. Clair LHIN Dr. Jaques Lemelin Champlain LHIN Dr. Sabrina Lim Reinders Waterloo Wellington LHIN Dr. Ross Male Hamilton Niagara Haldimand Brant LHIN Dr. Danielle Martin Canadian Doctors for Medicare Kathryn McCulloch MOHLTC, LHIN Liaison Branch, Health System

Accountability and Performance Division Dr. Harry O’Halloran North Simcoe Muskoka LHIN Louise Paquette North East LHIN Saäd Rafi Deputy Minister, MOHLTC Dr. Joshua Tepper Sunnybrook Health Sciences Centre Jill Tettmann North Simcoe Muskoka LHIN


45

Learnings from the International and National Landscape

To support moving forward, it is important that any changes are informed by primary health care work occurring on the international stage, as well as work happening across Canada and within the Toronto Central LHIN.

The Global Picture: Innovative and Evolving Models in Primary Health Care A 2011 survey by the World Health Organization (WHO) on Primary Health Care Reform concludes that much remains to be done in reforming primary care. Following the 1978 declaration of Alma Ata on primary health care, many countries implemented “selective” primary care focused on the provision of medical care and services, as well as treatment of specific conditions rather than offering comprehensive primary care which includes the social determinants of equity, social development and social justice. Most of the twelve countries in the survey have achieved at least some level of universal coverage, but it is mainly limited to primary care physicians, excluding allied primary health care providers.

Primary care is characterized by being the first contact access for each health care need; ongoing person-focused (not disease-focused) care; comprehensive care for most health needs; and coordinated care by other providers as needed with growing acceptance that primary care is provided in the context of family and community. To support advancing primary care, countries have explored various models and approaches. The following provides a summary of key global efforts.

Australia: In 2010, the Australian government introduced its first comprehensive national policy statement for primary health care, the National Primary Health Care Strategy. It is based on key building blocks such as regional integration through formation of “Medical Locals”, jointly with GPs and Local Hospital Networks; information and technology; skilled workforce, infrastructure to ensure the right physical facilities and right equipment as well as enhancements to the Rural and Remote Infrastructure Program; sustainable financing and system performance arrangements; and public release of performance information.

Netherlands: Reform of the Dutch system began in 2006 so it is now possible to see the consequences of this regulated market orientation to care. Every citizen is registered with a general practitioner who provides care for 95% of health problems with specialist consultation through referral in order to be covered by insurance. Public insurers have been privatized or have merged with private insurers. All Dutch citizens are required to purchase a basic package of health services with an annual deductible of approximately 150 Euros. Insurers cannot refuse applicants. Physician fees include capitation plus a partial fee-for-service payment and extra allowances for certain patient populations or for participating in health care innovation. Health care providers must utilize evidence-based guidelines and performance indicators when negotiating with insurers. While the importance of indicators is recognized, the associated methodology is not yet fully developed.

New Zealand: A 2009 Economic Survey in New Zealand concluded that the country has not yet achieved the goals laid out in its 2001 Primary Health Care Strategy which was intended to close

``Primary care clinicians in most countries provide the foundation for health care systems and serve as the linchpin that improves access, connects care and provides continuity for patients and families.”

A Survey of Primary Care Physicians in Eleven Countries, 2009: Perspectives on Care, Costs and Experiences. The Commonwealth Fund


46

existing gaps in health outcomes through improved access to care, particularly for Maori and Pacific Island minorities. The newly-created Primary Health Organizations (PHOs) have had only limited success in introducing this new model of care. Private funding is not utilized except to bypass wait times, and the country struggles with significant HR shortages due to an aging physician and nurse workforce as well as a high rate of emigration.

United Kingdom: Prime Minister David Cameron introduced the 2012 Health and Social Services Bill to the UK in 2011, proposing sweeping changes to the National Health Service. He has announced that more than 150 NHS organizations including all Primary Care Trusts (PCTs) and 10 Strategic Health Authorities are to be scrapped. The bulk of the health budget will be turned over to General Practitioners with a newly-created NHS board to provide oversight. The bill is controversial and there has been vocal concern that this reform is too much too soon. Many PCT staff are leaving even before the creation of the new GP practices and the consortia.

United States: Since 2002, the concept of a patient-centred ``medical home`` has been gaining ground, with support from seven national family medicine organizations. The medical home is provided by a team-based delivery model led by a physician, and is intended to provide comprehensive, coordinated care using information technology, appropriately trained staff and payment models that support the coordination component of care. Most recently, the landmark Patient Protection and Affordable Care Act introduced by the Obama administration to address inequities in access to care is encountering personal, political and judicial challenges. If fully implemented, this legislation will have a profound impact on equitable access to health care in the US, extending coverage to dependent children under the age of 26, expansion of Medicaid eligibility, creation of health insurance exchanges for individuals and small businesses and a requirement that all legal US residents obtain health insurance.

The Cross-Canada Snapshot The federal government allocated $576 million between 2000-2006 to fund primary health care initiatives through the Primary Health Care Transition Fund (PHCTF), funding projects in all 13 jurisdictions provided they met five objectives: (1) increase in the proportion of the population with access to primary health care organizations (2) emphasis on health promotion and disease/injury prevention (3) increased 24/7 access to essential services (4) creation of multidisciplinary teams and (5) facilitating coordination with other health services such as hospitals and specialists. In addition, the PHCTF led pan-Canadian initiatives to address common barriers, using a federal/provincial/territorial approach.

Canadian provinces and territories are approaching primary care reform in ways that best suit their geography, demographics and other salient factors. Individual primary care practices across the country are also developing innovative ways to improve primary care, and those innovations can be replicated by others. It is impossible to capture the richness and diversity of those approaches in this paper.

British Columbia has experimented through numerous evolutions of primary care, with the most recent initiatives focusing on reversing a trend for family physicians to withdraw from full service practices because of the perceived demands and complexity of such a practice in today’s health care system. Alarmed by the trend away from full-service family practice, leaders in BC established the Practice Support Program (PSP) to improve provider satisfaction and promote a return to full service practices. Several elements of the PSP are available, including educational modules such as: advanced access booking, patient self-management, group medical visits, chronic disease management, quality improvement, and mental health screening and interventions. Initial evaluations were positive, although it is acknowledged that additional research is required.


47

Some family physicians in Alberta have signed service agreements with other specialists which define the scope of practice for those family physicians and also facilitate collaboration and communication. Alberta has also created local Primary Care Networks (PCNs) to improve access to and delivery of primary care. PCNs are led by family doctors who deliver and coordinate health services, resulting in better collaboration, more timely referrals and more comprehensive care. A network can be one clinic with many family doctors and other health professionals (nurse practitioners, RNs, LPNs, dieticians, pharmacists, social workers and mental health workers), or many family doctors and other health professionals in several clinics in a geographic area. Every PCN is unique, developed by local family doctors and their health region. The local approach allows, and encourages, the network to focus on the needs of individuals requiring services and to develop local approaches to meet their particular needs.

Twenty-one pilot projects in Saskatchewan led to the creation of primary health care teams in much of the province. One Saskatchewan urology group practice has developed a form to provide referring family physicians with a standard list of necessary tests, facilitating the referral for everyone involved.

Manitoba has introduced The Right Door, The First Time, a pilot project to bridge generalist and specialist care, reducing the wait time between referral by a family physician and the appointment with a specialist.

Ontario has been particularly systematic in its approach to primary care reform, creating three innovative primary care models since 2002. First came Family Health Networks (FHNs) comprised of groups of family physicians working with a nurse staffed telephone advisory service in order to provide primary care on a 24/7 basis. A year later, a second model of physician practice was introduced, Family Health Groups (FHGs), defined as at least three physicians working in a group practice. In 2004, a third model, Family Health Teams (FHTs) appeared. This model of primary care consists of interdisciplinary teams consisting of physicians, nurses and other health care providers working in collaboration. The introduction of 25 nurse-practitioner led clinics is another innovative approach, with a target date to be fully operational by the end of 2012. The clinics utilize a collaborative practice approach including Registered Nurses, Registered Practical Nurses, collaborating family physicians and other health care professionals.

Quebec has embarked on the creation of local service networks to merge CLSCs with residential and long term care centres as well as with general and specialized hospital centres, in an effort to better coordinate the delivery of primary, secondary and tertiary primary care.

New Brunswick introduced a pilot project in 2004 to increase access for “orphan” patients through adding the services of nurses and nurse practitioners in doctors’ offices.

Nova Scotia has adopted alternative payment methods for physicians, introduced computerized information systems and successfully run projects to demonstrate the value of having nurse practitioners collaborate with family physicians in the provision of primary care.

Prince Edward Island has embedded primary care as one of its cornerstone priorities for the province’s single health authority - Health PEI – leveraging a model of Primary Care Networks to support care delivery. Five Primary Care Networks are being established across the province and each serves a defined geographic area that includes multiple health centres and medical clinics. A team of health care professionals including family physicians, nurse practitioners, nurses, licensed practical nurses, diabetes nurses and dieticians, and clerical staff provide the core health services, while other providers such as community dieticians, social work and mental health therapists may also be available within each network. All five networks have similar population sizes and access to resources to ensure that all Islanders have equal access to primary health care, and are within 30


48

kilometers of a primary-care site. The networks focus on diagnosis and treatment, health promotion, illness prevention, and chronic disease management. Each network can also develop services locally to meet the specific needs of individuals requiring services. For example, the networks have been hiring and training staff and offering special programs on COPD (chronic obstructive pulmonary disease) care, PAP testing, diabetes management, and hypertension (high blood pressure).

Newfoundland announced a provincial PHC framework in 2003-2004, known as Moving forward together: mobilizing primary health care. While fiscal constraints have limited advancement, a number of primary care systems already exist. The province has long had a tradition of paying salaries to physicians, rather than fee-for-service.

The above “snapshot” is intended to showcase some of the efforts underway, and is not presented as an all-inclusive picture of primary care initiatives in Canada. The key message is that many good things are being tried and that there are lots of initiatives to build on. That said, there is still work to do. The Canadian Policy Research Networks (CPRN) issued an update in 2008 on primary care reform in Canada, citing several factors that are impeding progress:

Lack of financial incentives for physicians to change practice patterns;

Anticipated shortage of physicians and other health professionals in the near future;

Lack of adequate financial support for implementation of electronic records;

Lack of agreement on the appropriate roles of physicians and other health professionals.

None of these factors are insurmountable, and efforts are already underway to address those factors and bring about change.


49

Identifying How to Measure Success To support planning, Think Tank participants provided advice for how success should be measured. The following tables provide a summary for how success should be measured at the one-year and three-year mark, from a number of provider positions including physicians in a Physician Enrollment Model (PEM), Community Health Centres (CHC), Community Care Access Centre (CCAC), Community Care Providers, Acute Care Hospitals, Specialty Hospitals, and Academia.

Responses from Physicians in a PEM

In One Year, how will we know we have moved in the right direction? What will we measure?

In Three Years, how will we know we have achieved success? What will we measure?

Individuals requiring services

Providers System Individuals requiring services

Providers System

Timely access as appropriate Telephone access

made easy Email and text

access There is a system

within Networks to connect high needs individuals requiring services to a provider Measure number

of individuals requiring services in TC LHIN registered with a provider

Smooth access to consultants, mental health assessments, timely receipt of consults and reports Efficient use of

provider time and enhanced access to supports Timely access to

discharge summaries Easy access to

consults Providers have

access to a core group of services

Better FHO compliance regarding access Increased EMR and

system access Network

boundaries and provider members are defined and established Reduction of ED

visits Alter hours of

accessibility

Systematic satisfaction surveys Same or next day

access Redirect CTAS 4

and 5 patients from emergency to PC Networks urgent care centres Increased access /

utilization of social media technology Enhanced self-

efficiency

Quick smooth access to patient info via EMR Providers have

comprehensive data on individuals requiring services, and receive reports on outcomes and provider performance Access to an

interdisciplinary team Better

relationships with providers in Network Care pathways for

complex individuals requiring services

QI embedded throughout the system of 1% care Total system IT

access Reduction in

readmissions Reduction of

individuals requiring services dying in acute care beds Fewer unattached

patients – particularly vulnerable individuals requiring services

Responses from CHCs





Providers System

Communicate with primary care physicians over email Individuals

requiring services book their own appointment online Individuals

requiring services know where they can get help to access the services they need

One phone number to call to make community referrals Know who else is

in the Network

Reduction of emergency visits Technology

improvements

Individuals requiring services have access to their own EMR online Succession

planning for retiring doctors to ensure that there are no orphaned patients Individuals

requiring services have direct access to allied health

GP’s have access to all patient info Direct

prescriptions to pharmacies (online) Primary care

provider Primary care

providers responsible for delivering coordinated care Can utilize

interdisciplinary team

e-prescribing capabilities Networks provide

preventative care High risk

populations have access to preventative care


50

Responses from CCAC



Clients Providers System Clients Providers System

As a senior, has someone spent time with me to review my medications (doctor, pharmacist)? Do I have a

coordinated care plan that is centred on my goals and that the different providers in my care understand and have contributed to? As a client with

complex needs, do I have a dedicated Care Coordinator who offers continuity of care regardless of where I am in my journey and who works hand in hand with my primary care physician As a client with

complex care needs, do I have a single point of access to the health and social service system? As a caregiver, is

there a care plan in place that supports me and ensures my ability to maintain my informal caregiver role?

As a family doctor, how much time is spent on getting inventory of medications for elderly patients – has time decreased? As a family

doctor, do I have a direct contact at the CCAC (and a virtual clinical team if required) that I can work with to support by complex clients living at home and in the community As a family

doctor, do I have a single point of access to the heath and social service system? CCAC Physician

Outreach Coordinators established a meaningful relationship with

Identification of all patients with ambulatory care sensitive conditions

As a client with complex needs, do I have a family physician?

-

Standardized medication lists flowing from community pharmacists to primary care Networks GP’s not spending

more than 3 minutes getting medication lists Notification

system working for every complex client who has called EMS or been transferred to Acute care CCAC Physician

Outreach Coordinator established a meaningful relationship with all primary care physicians

Reduced re-admission levels (deemed preventable) within 30 days Med checks for all

over 65 years with 5+ meds Integrated

interdisciplinary/ inter-organizational care plans for all populations with complex needs


51

Responses from Community Providers





Providers System

Access to family physician services After hours and

on weekends Improved

connection between GP’s and other service providers (e.g. MH&A, Seniors, etc…) Patient

information is available to all those caring for a person

Use technology more effectively Allow individuals

requiring services to connect to providers via email, ask questions and book appointment online

Close or limit walk-in clinics and enforce FHT offer extended

and weekend hours Offer some

information and/or intervention in groups Use nurse

practitioners more broadly Increase

community-based multi-disciplinary teams that go to the patient

Increased medical services provided to seniors in their homes Senior have

access to services in their home Shorter nursing

home wait lists Shorter waiting

periods for doctor appointments and other health care providers

Providers go to the patient 24 hour medical

support (GPs/nurses) to reduce ED visits

Monitor compliance through contractual agreement Complete access

to a health record electronically Individuals

requiring services can book their own appointments electronically Individuals

requiring services can access their own medical records electronically Increased home

care access

Responses from Acute Care Hospitals





Providers System

Know what options exist Reduced wait

times to see a specialist Educated public

on the different options (e.g. NP) Quality of Life

Measurement Seamless access

to specialty services

More patient navigator positions Creation of

virtual health care professional lounge Less provider

frustration Less time spent

on non-clinical time Receive timely

responses from specialists for appointment. Avoid sending individuals requiring services to emergency

Clear accountability-ties for each organizational provider (transitions of care) Redefine role of

acute care Build more wait

time targets and publish them online Fewer individuals

requiring services in emergency Fewer ALC

All unattached individuals requiring services connected with a FHT/ primary care provider Electronic access

to personal health info Confidence of

individuals requiring services & family to be responsible for care Patient

preference is central Individuals

requiring services are in the Network but can select provider based on skill, region, etc.

Common e-chart Measurement of

e-access Measurement

around full scope of practice Comparative

performance data that lets providers know how the team is performing

Lower readmissions (frequent users) Individuals

requiring services have choices and specialists are working with FP’s Online

appointments Government

records wait times x% of population

have documented advanced life directives


52

Responses from Specialty Hospitals





Providers System

Fewer unattached patients Fewer visits

(access to more time per provider) Access to holistic

services Access to care

and prevention in a client’s neighbourhood quickly Determine mode

of engagement with patient

Providers spending more time with individuals requiring services and less time on non-direct care times Increased

number of Nurse Practitioners Providers have

good information about individuals requiring services Providers know

resources in their neighbor-hood resources Identify what

supports are needed for each Network

Child and family voice is integrated Fewer walk-in

clinics – docs now part of FHTs or neighbor-hood Increase in uptake

of unattached patients

Higher rates of chronic illness self-management The 1-5% can get

primary care from provider with specialized knowledge Specialized

services are available to children and families closer to home Vulnerable

individuals requiring services are prioritized Individuals

requiring services have access to their own doctor and patient questions are answered

Access to an inter-professional team that can help take care of all of the patient’s needs Family docs are

supported by teams Providers can

identify neighbor-hood resources

Matching time to demand (e.g. Hours of accessibility) We will have an

integrated eHealth strategy No walk-in clinics Weekend and

after-hour care available locally Begin to be able

to measure integration Cost reduction in

high user groups

Responses from Academia





Providers System

Language translators available Cultural check-list

available in all services The Network and

its components have been announced Individuals

requiring services have knowledge of the Network Access to same-

day care

Providers have access to medical records and given time to absorb it % of providers/

stakeholders have signed on to Networks Incentives are

being developed for providers Providers benefit

from stronger integration and expanded community of colleagues and resources Technology will

allow providers to follow individuals requiring services in and between other health professionals

Integrate family/ guardian responsibilities Improved access Students are

admitted based on their commitment to care Reduction in ED

use Outreach

programs for communities (i.e. chronic disease conditions)

Central language services through departments Transitions

between homecare, to doctors, to hospitals are seamless Coordinated,

client-centred – not multiple appointments Data will move

across system and be accessible to individuals requiring services Team-based care

will be norm, not just focused on physician access

Indexed medical records (date, name of pills, doctor) available universally Individuals

requiring services are getting better care Referrals happen

early and quickly Primary care no

longer means access to physicians or clinic hours, but access to a range of health focused and social services Utilizing a wider

array of practitioners that better match client / patient needs

Family/ guardians report on duty Improved quality

in determinants of health Improved

outcomes in individuals requiring services Sustained funding

in place Parking is free for

all individuals requiring services


53

Proposed Network Maps Based on an analysis completed by the Toronto Central LHIN, the following maps reflect proposed network distribution across the Toronto Central LHIN. All maps are viewed as initial drafts and will be revised as networks complete population analysis and providers work together to develop service coverage strategies.

Proposed Boundaries for the Toronto Central LHIN Primary Care Networks with Populations



54

Proposed Boundaries for the Toronto Central LHIN Primary Care Networks with All Provider Locations



55

Proposed Boundaries for the Toronto Central LHIN Primary Care Networks with CHCs and FHTs



56

Proposed Boundaries for the Toronto Central LHIN Primary Care Networks with Hospitals



57

Proposed Boundaries for the Toronto Central LHIN Primary Care Networks with Primary Care Physician Locations



58

Framework for Evaluating Impact of Primary Care Networks (Draft)

HQO Dimension

Anticipated Impact/Benefits To …

Process Indicators Outcome Indicators (For All Dimensions)

Individuals Requiring Care

and Their Families

Providers System

Patient-Centred

Anyone wishing to be connected to a Primary care Provider in the TC LHIN will be able to do so.

Providers will be able to provide the services their clients/patients require, or know how to refer them to the services they need even if they are offered by another provider. Health Service

Providers with clients who are not attached primary care will have a timely way to do so.

Reduced avoidable ED visits for patients with conditions best managed elsewhere. Reduced

unnecessary hospital admissions, readmissions and ALC.

Fewer unattached patients identified through Health Care Connect. Reduced numbers of

CTAS 4 and 5 patients visiting ED.

Health outcomes: Rate of Ambulatory

Care Sensitive Conditions admissions.

Repeat ED visits

within 30 days. Readmissions within

30 days. Rate of inpatient

admission for complications of selected chronic diseases.

Reduced alternative

level of care (ALC) in hospital.

Patient experience &

Equity: Overall Patient

Satisfaction with quality of primary care services received.

Decrease in

disparities in health outcome and patient experience indicators, by key socio-demographic characteristics (e.g. age, sex, income, language).

Financial: Reduced cost for 5%

highest users of the health care system.

Services will be responsive to individuals' culture and choice of language.

Providers will be able to connect more complex patients to care coordination and related services thru relationships with community care and specialized services (e.g. Diagnostics and Specialty Physicians). Providers will

have access to language services and where possible culturally relevant programs to care for their clients.

Improved appropriate management of patients with complex high care needs.

Proportion of primary care providers conducting patient experience & provider surveys using standardized tools. Streamlined

processes for primary care referring to community care and specialty hospital services.

There will be increased support for individuals and their families to manage their conditions through better information and access to resources.

Providers will have tools and resources to give to clients and their families so that patients can self manage their conditions when at home.

Improved outcomes for patients with chronic diseases. Enhanced

experience with the health care system for patients with the greatest health care needs.

% of primary care patients who have a regular doctor or place of care who helps to coordinate care received from other doctors. % of patients who

received whose providers allowed them to ask questions, explain choices.


59

Accessible Individuals requiring care and their families will be able to access their primary care provider within 24-48 hours of requesting an appointment. Primary care providers will be accessible during evenings and weekends.

Resources will be available to support smooth and timely access to other providers when primary care providers require assistance in meeting the needs of their patients and clients. Services will be

coordinated to provide extended hours of coverage without placing an unnecessary burden on individual providers. Health service

providers discharging patients or caring for patients in the community can ensure that their clients will be able to access their primary care resources if needed.

Continuity of care with primary provider and other organizations. Decreased time

from referral to service initiation/delivery Increased access

to timely and appropriate access to primary care.

% of patients who could see a doctor or a nurse on the same or next day the last time they were sick. % of patients who

stated it was easy to get medical care in the evening/on weekend/holiday/ without going to ED.

Equitable Consistent sets of core services will be available within each community and be tailored to meet the needs of the community.

Provider will be able to refer patients to required services.

Decrease in inequity in services and health outcomes for patients.

Inventory of services by neighbourhood will confirm that there are no gaps in any community.

Utilization patterns for primary care services, or referrals for specialty services, will not differ significantly between communities based on factors such as income, ethnicity, etc.

Providers are supported in providing care to a diverse community in a culturally competent way.

Selected appropriate process indicators broken down by socio-demographic variables (e.g. age, sex, income, etc.) where feasible.


60

Effective Individuals requiring care and their families will have access to information regarding best practices and care standards that they can expect from all levels of providers. Care will be

focused on the whole person as opposed to intermittent episodes/ symptoms.

Providers will be able to refer their patients/clients and work with partners in other sectors to the select interventions that are most likely to produce the optimal results for their patient/client who may have multiple chronic conditions.

Increased patients receiving best practice care pathways which will improve outcomes and health.

Best practice measures at a population level: Regular testing that is

appropriate for diabetes patients (HbA1C, eye exams, and cholesterol). Period health exam

rate, stratified by those with chronic conditions (diabetes, mental disorders). Influenza vaccination

rates stratified by high risk groups (pregnant, children, seniors, selected chronic conditions). % of patients on right

drugs after hospitalization for diabetes, CHF, AMI.

Efficient Cost of transportation and other related costs associated with access will be affordable for individuals requiring care.

Access to technology e.g. EHRs and EMRs will support effective sharing of information and timely decision-making eliminating redundant processes for providers.

The LHIN will be able to demonstrate improved efficiency in the use of resources, reducing or eliminating waste and optimizing spending to enable care.

Population based utilization measures e.g. Cost per weighted case. Cost / resource

utilization scorecards.

Integrated Patients and their families experience seamless hand-offs between providers through the continuum of care.

Providers have increased ability to access full spectrum of services for their clients. Providers receive

the information they need from other members of the care continuum in order to effectively care for their patients.

Providers across the system are organized, connected, and work together to provide high quality care to meet the primary health care requirements and needs of patients. Providers share

resources to maximize value of health resources.

% of patients who report their regular doctor is informed about care received in the acute sector. % of patients with

visits to the primary care provider within 7 days of discharge. % of patients

discharged from hospital for mental health conditions that had a physician visit 30 days later.

Safe People will not be harmed by an accident or mistake when they receive care.

Increased providers following best practice pathways for their patients. Providers spend

less time treating avoidable conditions.

Fewer resources consumed on avoidable/ preventable interventions.

Full medication reconciliation completed upon hospital discharge to another setting. % of hospital

discharge summaries done using electronic discharge summary using standardized template.


61

References Cathy Fooks Implementing Primary Care Reform in Canada: Barriers and Facilitators Health Network,

Canadian Policy Research Networks Inc presented at Implementation of Primary Care Reform School of Policy Studies January 2004

Boris Kralj, PhD, Jasmin Kantarevic, PhD. Primary Care in Ontario: reforms, investments and achievements Ontario Medical Review February 2012 pp 18-24

J. Andre Knottinerus MD PhD and Gabriel H M ten Velden MD PhD Dutch Doctors and Their Patients New England Journal of Medicine 2007 357 pp 2424-2426 December 13, 2007

Nancy Kuehl Transformed Launches Project to Prove Innovative Model of Care American Academy of Family Physicians

Brian Yoshio Laing; Lisa Ward, MD MScPH MS; Thomas Yeh; Ellen Chen MD; Thomas Bodenheimer MD Introducing the “Teamlet”: Initiating a Primary Care Innovation at San Francisco General Hospital The Permanente Journal Spring 2008 vol 12 no. 2

Anne Medlock, Elaine McKee, Jenna Feinstein, Stephanie H. Bell and C. Shawn Tracy Applying an innovative model of interprofessional team practice: The IMPACT model in action

Cathy Schoen, Robin Osborn, Phuong Trang Huynh, Michelle Doty, Jordan Peugh and Kinga Zapert On The Front Lines of Care: Primary Care Doctors’ Office Systems, Experiences and Views in Seven Countries Health Affairs web exclusive w 555-571

Cathy Schoen, Robin Osborn, Michelle M. Doty, David Squires, Jordon Peugh and Sandra Applebaum A Survey of Primary Care Physicians in Eleven Countries, 2009: Perspectives on Care, Costs and Experiences Health Affairs web exclusive w 1171-1183

Anthony Shih MD, MPH, Julia A Berenson MSc, Melinda Abrams MS Preventive Health Services Under the Affordable Care Act: Role of Delivery System Reform posted 04/12/2012

Barbara Starfield, Leiyu Shi and James Macinko Contribution of Primary Care to Health Systems and Health Issues in Health Policy November 2011 The Commonwealth Fund

Sharon Willcox, Geraint Lewis and Jako Burgers Strengthening Primary Care: Recent Reforms and Achievements in Australia, England and the Netherlands Issues in Health Policy November 2011 The Commonwealth Fund

A Vision for Canada: Family Practice: The Patient’s Medical Home College of Family Physicians of Canada 2007

An Update on Primary Care Reform in Canada Canadian Policy Research Networks Health Policy Monitor (11)2008

Building a 21st Century Primary Health Care System: Australia’s First National Primary Health Care Strategy Australian Government

Building on Values: The Future of Health Care in Canada: The Romanow Commission Government of Canada 2004

Economic Survey of New Zealand 2009: Health care reform: challenges for the next phase 2009

Experiences from the forefront of EMR use: 20 Canadian physician studies Canada Health Infoway and Canadian Medical Association

Government takes first steps towards NHS reform 2011 The Independent

Pan-Canadian Primary Health Care Indicators: The Agreed-Upon PHC Indicators CIHI pp 9-31

Family Physicians must remain focal point of primary care CMA Leadership Series

Primary Care in Canada – a national overview CMA Leadership Series


62

Primary care reform – Change in search of evidence? CMA Leadership Series

The Wait Starts Here: The Primary Care Wait Time Partnership Final Report December 2009 The College of Family Physicians of Canada and the Canadian Medical Association

Toward Patient-Centred Care: Digitizing Health Care Delivery Canadian Medical Association (CMA)

Halman L et al. Changing values and beliefs in 85 countries. Trends from the values surveys from 1981 to 2004. Leiden and Boston MA, Brill, 2008 (European Values Studies, No. 11).

Moran M. Governing the health care state: a comparative study of the United Kingdom, The United States and Germany. Manchester and New York NY, Manchester University Press, 1999.

Lübker M. Globalization and perceptions of social inequality. Geneva, International Labour Offi ce, Policy Integration Department, 2004 (World Commission on the Social Dimension of Globalization, Working Paper No. 32).

Starfield, B. Refocusing the System. N Engl J Med 2008; 359:2087-2091, November 13, 2008

Macinko J, Montenegro H, Nebot C. Renewing primary health care in the Americas: a position paper of the Pan American Health Organization/World Health Organization (PAHO/WHO). Washington, DC: Pan American Health Organization, 2007.

World health report 2008 — primary health care: now more than ever. Geneva: World Health Organization, 2008.

advancing primary health care integration in the toronto

Documents