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A Healthier Tomorrow

Health System Design Blueprint -


Vision 2022

South West Local Health Integration


Network
Table of contents
Foreword..................................................................................................................................... 1
Note from the South West LHIN Board of Directors .................................................................... 2
Executive summary ..................................................................................................................... 3
Background and introduction....................................................................................................... 8
Why consider health system design now? ............................................................................ 8
Project Scope and Objectives .............................................................................................. 9
Building a Blueprint for the future? ......................................................................................10
An overview of today – Case for change .................................................................................. 11
An understanding of the South West LHIN ..........................................................................11
Overview of health services and implications for the future .................................................14
Profile of our Health Human Resources ..............................................................................24
On the road to transforming the current health care system… .............................................26
A blueprint for the future............................................................................................................ 28
Overview of the Integrated Health System of Care ..............................................................28
Population-based Integrated Health Services ................................................................31
How is the Population-based Integrated Health Services approach delivered?..............32
Centrally Coordinated Resource Capacity .....................................................................34
Operationalize the Integrated Health System of Care ..........................................................41
Call to action ............................................................................................................................. 46
Supporting documents .............................................................................................................. 48

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Foreword
All of us value our health care system. We also value the health service providers and
professionals that care for us in times of need.

However, accessing services or managing more complex needs can often be a challenge.
Based on our conversations with our health service providers and the members of the public,
we have heard clearly that these challenges most often relate to disconnects within the health
care system.

It is for this reason that the South West LHIN Board of Directors initiated the Health System
Design Blueprint process so that the bold and necessary step towards system transformation
through the development of the Health Services Blueprint, a future state vision for our health
system, could be advanced. Informed by your input through various forums of engagement and
building upon initiatives to date, we developed a Blueprint which outlines and sets a vision for
an Integrated Health System of Care.

The Blueprint, centered on individuals/families, describes a system which facilitates equitable


access to services, more appropriate use of our resources, and better management of the
health of our population. It will begin to address existing needs and gaps across the South
West LHIN.

Where we have previously been troubled by scarcity and competition for resources, I am
hopeful that new understandings and flexibility will allow for new initiatives and enhancements.
Health care is changing and how we deliver services and manage our health care system must
also change if we are to continue to meet the needs of our communities.

To ensure the Blueprint can be translated into action, I urge Boards, health service providers,
communities and other partners to seek to understand how the transformation will impact you,
demonstrate a willingness to lead change, and collaborate to develop an improved health care
system.

The Blueprint represents a strong first step towards realizing a better health care system that is
essential to meet the needs and demands of our population. I ask that you join us on the road
to transformation, the collective journey to ensure that our communities receive the care they
deserve now and in the future.

Michael Barrett

Chair
Health System Design Steering Committee

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Note from the South West LHIN
Board of Directors
Development of the Health System Design Blueprint - Vision 2022 is a significant milestone for
the South West LHIN. Building on the commitment and achievements of health services
providers across the LHIN over the last several years, this document represents a shared vision
for the future health and health services delivery for individuals in the South West LHIN.
Moreover, the Blueprint provides the foundation from which all health services providers,
communities, and other system partners can collaboratively and progressively work towards an
Integrated Health System of Care.

The South West LHIN Board of Directors has endorsed the direction set forth within the
Blueprint, and also recognizes that this document represents a launching pad for future change.
The Blueprint, informed by the input of providers and other partners from across the LHIN,
provides a strong vision for the future of our health system and the work required in making that
happen.

If we are to realize meaningful change and transform the Blueprint from words to reality, we
must all collectively work together. As a Board, we are committed to working with other Boards,
providers, and community leaders across the LHIN to enable those tasked with driving change
to realize success in their endeavours.

As we embark on the next phase of our health system transformation journey, I would also like
to take this opportunity to thank the Health System Design Steering Committee, LHIN staff, and
all providers and other partners for their engagement and participation in the development of the
Blueprint. It is because of your efforts that we now sit on the precipice of transforming how
individuals who receive care in the South West LHIN manage their health and how health
services are delivered.

Change is upon us. We look forward to working with you to build an Integrated Health System of
Care that will allow us to collectively enable a healthier tomorrow.

Janet McEwen

Board Chair (A)


South West LHIN

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Executive summary
Since 2006, the South West LHIN (LHIN) has dedicated itself to building a future vision of the
health care system, an Integrated Health System of Care. By bringing local people together,
including both the community and providers, we are committed to creating “A health care
system that helps people stay healthy, delivers good care to them when they get sick and will be
there for their children and grandchildren.”

Guided by the first Integrated Health Service Plan (IHSP), the past three years have resulted in
a foundation upon which we, our providers and communities are poised to continue the next leg
of our health system transformation journey.

For this reason, we began the health services design initiative. After reaching consensus with
health system partners regarding the approach to be used, the South West LHIN‟s Health
System Design Steering Committee came together to develop the Health Services Blueprint.
The intention of the Blueprint is to provide an overall framework and set a direction for future
detailed health services design.

Development of the Blueprint has reinforced the fact that health services are provided by a
talented and dedicated group of service providers across the LHIN. Moreover, it should be
acknowledged that care providers, while dedicated in their pursuit to deliver the highest quality
care, also recognize considerable challenges do exist. As a result, there are many examples of
the development of innovative partnerships and initiatives that have been completed in order to
address system and service delivery related challenges. However, despite these successes,
many challenges still persist.

More specifically, across the sectors, health service professionals and South West LHIN
residents consistently face challenges within the current system:

 Inequitable distribution of health services across the LHIN pose access challenges for
residents, particularly those in rural communities.
 Resource constraints, both health human resources (HHR) and funding, present challenges to
meeting current and anticipated health service demand.
 Current funding and operating models reinforce a provider-focused vs. person-centred
approach to health service delivery.
 Access challenges continue to persist for marginalized populations across the LHIN.
 Lack of integration across sectors and health service providers inhibits the seamless transition
of individuals and families across the continuum of care.
 The health profile of the South West LHIN necessitates the need for more appropriate,
integrated screening and early identification of health risk factors and conditions.
 Lack of integrated platforms across the LHIN inhibits seamless information sharing among
health service providers across sectors and geography.

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In order to address these current and emerging challenges, the Blueprint has developed a
vision for the future health system, an Integrated Health System of Care. Building on the work
of teams that had previously come together and developed through the input and participation of
providers and public engagement forums through the Blueprint development process, the future
system seeks to address today‟s challenges, and adjust for tomorrow‟s needs.

Local Multi- LHIN


Community Community Community
• Services provided close to • Service delivery by • Delivery of low
home geographic clustering volume/highly complex
• Delivery of high volume/low of moderate services to manage
complexity services to volume/complexity specialized populations
broader population services focused on • Support multi-community
• Collaboration across local targeted populations and local providers with
traditional and non- • Seamless referral accessibility to
traditional providers relationships with local specialized services
• Emphasis on an individual‟s and LHIN providers • May serve as a broader
self-health management provincial resource
• Manages referrals and
refers out of LHIN as
necessary

This system emphasizes the message that all health programs and services are part of a single,
unified health system of care. A unified system clearly communicates the roles and
responsibilities of the various health service providers and non-health organizations, and also
delineates the interdependencies between the various stakeholders to enable a shared
approach to service delivery. In acknowledging unique characteristics among community, long-
term care, acute services, and primary care services, the Integrated Health System of Care is to
be implemented through two integrated service delivery approaches:

 Population-based Integrated Health Services which is tailored to the collective needs of a


local population and its health service providers. It enables local communities to support the
health and wellness of its catchment population enabling them to better manage their own
health and maintain independence. The local community services are supported by the multi-
community services and have access to LHIN community services as needed.
‒ Throughout an individual‟s life, he or she may access primary care, home and community
care, complex continuing care, long-term care, rehabilitation, palliative care, chronic disease
prevention and management, mental health and addictions (MH&A), and emergency
services coordinated through this service delivery approach.
 Centrally coordinated resource capacity optimizes the use of targeted resources to
improve access and complement the management of health and wellness at the more local
level.
‒ Throughout an individual‟s life, he or she may access medicine, surgical, and critical care
inpatient and ambulatory services coordinated through this service delivery approach.

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Realization of these future
service delivery approaches The Integrated Health System of Care
provides an opportunity to provides an essential roadmap for all of us
enhance the roles and
responsibilities of providers, who lead and participate in change,
health professionals, individuals, something that is critical to the success of
and other entities (e.g.
ministries) to operationalize an our South West LHIN health system.
optimal, person-centred
approach to care. This system
design represents a significant Tom McHugh, Tillsonburg District
change for communities and Memorial Hospital and Alexandra Hospital
providers, providing the
opportunity to realize several – Ingersoll
benefits.

How is this different from today’s service delivery model?

 Develops collaborative partnerships across health sectors, continuum of care, and beyond broader
health sectors.
 Equitably distributes services across the LHIN to enable care close to home as appropriately
possible.
 Establishes referral processes to enable seamless, connected transfer of individuals across the
continuum of care.
 Enhances collaboration among providers across the LHIN to ensure that the right individual is in the
right place at the right time.
 Expands provider roles across the continuum to optimize care delivery. Enhances capacity of direct
service providers on knowledge, understanding of services and individual health needs.
 Standardizes evidence-based approaches to care provision.
 Increases access through multiple entry points so that “any door is the right door.”
 Involves the individual as part of their care by consistently sharing information throughout the
process to enable decision-making.
 Emphasizes an individual‟s accountability through enhanced reliance on self-health management.
 Requires modifications to existing organizational relationships and structures.

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This system realizes benefits for both providers/health professionals and individuals/families.

What are the benefits?

Individuals and Families:


 Empowerment and accountability of individuals/family members in managing their own care.
 Emphasis on providing care closer to home balanced with access to specialty services.
 Early identification and management of the individual‟s needs in order to enable people to optimize
their level of function and quality of life in their community and home environment.
 Strengthened relationship among individuals/families and health service professionals.
Providers and Health Professionals:
 Further development of physician relationships through traditional and virtual networks of physicians
across LHIN to collaborate and share best practices, education, and ensure quality monitoring.
 Strengthened relationships among health professionals across health sectors.
 Strengthened partnerships with other ministry partners who can influence the health of our
communities (e.g. education, social services).
 Seamless referral and linkage of individuals/families across health and other sectors.
 Enhanced capacity of local communities to increase focus on prevention, screening and early
identification of chronic illnesses and addressing mental health and addictions needs.
 Optimize capacity as a result of precise navigation to appropriate health facilities.
 Improved quality of care through the adoption of standardized care pathways from screening,
assessment through to discharge guidelines.

Acknowledging the realities of today and potential pressures of the future, change is even more
imminent and the success of the future health system is dependent upon our collective
responsibility. The Blueprint builds upon your input and the work accomplished through the
2007-2010 Integrated Health Service Plan (IHSP), the Priority Action Teams, and other
integration initiatives being led by South West LHIN health service providers.

The Blueprint has been developed through a methodical process that has been specifically
designed to engage you - a broad cross section of stakeholders, enable development of the
Blueprint through an iterative process and integrate the insights gained through the “best
available” data/information, and learnings from leading practices within other jurisdictions.

In order to take the Blueprint from words to action, a collective commitment is required on the
part of all provider organizations, direct care providers and communities. Together, working with
our partners within the Ministry of Health and Long-term care, primary care, public health and
other partners, we must keep the needs of our communities front and centre, and build and
align all aspects of our system to work in concert with one another such that we are all
collectively working towards the same objective – a healthier South West LHIN population.

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How are we going to get there?

South West LHIN in Collaboration with its Health System Partners:


 Developing future IHSP releases and accountability agreements aligned to the vision of the Health
Services Blueprint;
 Decision-making and prioritization based on the Blueprint as a key guiding document;
 Incenting health service providers and partners for integration and innovation as able and deemed
appropriate; and
 Facilitating transparent processes with open lines of communication to enable easy collaboration.
Health Service Providers and Health Care Professionals:
 Seeking opportunities to integrate the local health system as they align to the Health Services
Blueprint;
 Transforming governance and leadership relationships to facilitate and oversee change;
 Expressing interest in the success of everyone‟s organization, as well as your own; and
 Demonstrating how you fit into the future vision philosophically and operationally to showcase the
outcomes of your transformational efforts to inspire others to become the change.

In summary, in order to progressively work towards


the realization of the vision set forth in the System change is required to
Blueprint, building on the initial guiding steps
indicated above, we all must work together to allow our health service
undertake and implement a number of providers to do what they do
transformative initiatives. Transformative elements
to realize the future health system have been best – deliver quality care
identified and illustrated through a programmatic within a dynamic, ever-
implementation roadmap which includes health
program-specific initiatives as well as system-wide evolving environment. We
changes. can only make it happen
It is this road map that will provide the necessary together.
framework to guide the LHIN, its providers and
community partners in taking the next steps along
the health system design journey. Michael Barrett,
South West LHIN

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Background and introduction
Why consider health system design now?
Since 2006, the South West LHIN has been dedicated to its vision of “A health care system that
helps people stay healthy, delivers good care to them when they get sick and will be there for
their children and grandchildren.” With today‟s economy and HHR shortage, change is upon us
whether we choose it or not. Thus, through the Blueprint process, we have proactively engaged
you, our health service providers and partners, to help direct us in transformation and control
our changes so that it aligns to our vision. Under the Local Health System Integration Act,
2006, providers now have an accountability to look for opportunities to integrate the local health
system. With that said, it is our responsibility to collectively transform our health system
through integration to enhance access, quality of care, and ultimately, the health of our
population.

What is the Blueprint?

Building on the foundation of the IHSP, the Blueprint has been developed to guide the LHIN and
health service providers in shaping the future design of our health system within the South West
LHIN. The Blueprint will be fundamental in guiding the decisions to be made in transforming the
way in which services are designed to meet the needs, and changing demands, of local
populations.

The Blueprint integrates and advances the work of the Priority Action Teams (PAT) through the
development of service delivery frameworks that will guide health service providers in their
shared quest to improve how people experience and interact within the health care system.
This will improve the overall health of its residents and maximize the value realized through
health care expenditures.

The Blueprint describes the shared vision for the future design of our health system and the
changes needed to make that happen.

Seeking to understand how people experience their health care and the improvements that we
must make to ensure optimum health for South West LHIN residents is at the core of our
responsibilities. This is an enormous undertaking, but one that we have already begun through
the creation and implementation of its first Integrated Health Service Plan (IHSP) 2007 – 2010,
which articulated four strategic priorities:

 Strengthening and improving primary health care


 Preventing and managing chronic illness
 Building linkages across the continuum for all seniors and adults with complex needs
 Accessing the right services, in the right place, at the right time, by the right provider
As an outcome of the IHSP 2007-2010, we launched the development of a Blueprint to guide
the transformation of health services across the South West LHIN for the future.

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Project Scope and Objectives
Guided by the Health System Design project charter, the Blueprint continues the journey of
health care system integration for the LHIN by designing a future health system, which will be
realized through a multi-year staged implementation.

More specifically, in developing the Blueprint, the intent is to create a guiding framework to
enable the LHIN, health service providers and communities to progressively work towards the
South West LHIN health system goals:

 A focus on outcomes that includes improved heath care for the people of the South West
LHIN to enable a Healthier South West LHIN Community.
 A commitment to evidence-based and leading practice literature in delineating service delivery
changes to ensure Quality of Care and Service.
 Acknowledgement of service distribution across the LHIN to enable Equitable Access to
Services.
 Significant engagement and input from a broad range of stakeholders including priority action
teams, providers, volunteers, the community and consumers to ensure Sustainability of the
Local Health System.
 An understanding that while this project focuses on the South West LHIN, we will consider a
number of other province-wide initiatives which will influence the options for integration and
non LHIN-funded organizations which play a critical role in the health care continuum to
enable Integration of Health Care Delivery.
With these goals in mind, the Blueprint development has been guided by the following
objectives:

Blueprint Guiding Objectives:

 Provide response to f irst Integrated Health Service Plan (IHSP) priority to


ensure access to the right services, in the right place, at the right time, by
the right provider
 Develop a f ramework f or how the system should be structured, across
programs and geography, based on a detailed understanding of current
services
 Facilitate health care providers and the LHIN to plan f or change rather than
react to health system trends, challenges and best practices
 Broadly and collectively leverage our resources rather than reacting to
single issues f aced by one organization, sector, or discipline

 Recognizing that health system transformation will not be a “quick fix”, the Blueprint will set a
direction that will guide the work of the LHIN and health service providers (across disciplines
and sectors including hospitals, long-term care, complex continuing care, and home and
community care), in conjunction with the communities they serve, over a multi-year time
frame.

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Building a Blueprint for the future?
The Blueprint guiding objectives provided the foundation to the process that was undertaken for
its development. In designing the approach, the intent was to create and execute a Blueprint
development process that integrated a significant level of stakeholder engagement, iterative
development cycles, was based on the “best available” data/information, and integrated insights
of leading practices. Key activities have been included below.

 The project began with assessing the LHIN‟s current service utilization patterns and projecting
the overall future service needs. Consultations with over 150 key cross-sectoral stakeholders
(e.g. existing taskforces and coalitions, clinical leaders, community leaders) helped develop a
well-rounded profile balanced with data and qualitative findings.
 This current state assessment complemented a cross-jurisdictional review of peer models of
care to provide context into service delivery elements that should be incorporated into the
development of future models of care. This enabled the Health System Design Steering
Committee to understand the service gaps and set the stage for the next phase in developing
a future state health services Blueprint.
 The LHIN held two health system design symposiums over
two days, with 400+ participants, which orchestrated the
planning of future models of care for eight health program
areas. Building on the work of priority action teams where
available and informed by service utilization profiles and
peer models of care research, participants were facilitated
to work through a model of care framework to discuss,
develop, and gain consensus on the components
comprising a future model of care. Models of care were
developed for Mental Health and Addictions, Long Term
Care Services and Complex Continuing Care, Chronic
Disease Prevention and Management, Women‟s Health and Paediatrics, Emergency
Services, Surgical Services, Medicine Services, and Critical Care Services.
 The models of care were then refined and enhanced through the facilitation of 12 refinement
sessions with existing and ad-hoc taskforces and coalitions. This enabled concentrated
clinical input and pivotal cross-sectoral conversations on the integrated approach to delivering
these models of care.
 An order of magnitude analysis was conducted to better understand the implications of the
future models of care on today‟s service delivery models. Base-case future state projections
were adjusted with future health system planning assumptions to better understand the
realities of capacity, HHR, and infrastructure implications in year 2022.
 17 community sessions were held to engage the public on the Blueprint and IHSP.
 The LHIN and Health System Design Steering Committee developed a future health system
with two service delivery approaches for the South West LHIN community based upon
common underpinnings of the models of care.
 This approach helped derive the implementation elements required to operationalize the
health services Blueprint to inform the development of the 2010-2013 IHSP.
Further details regarding the specific methodologies and assumptions applied throughout this
process are provided in Appendix C of the report.

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An overview of today –
Case for change
Across the South West LHIN, health care providers and residents face challenges in both
delivering and accessing services; these concerns are compounded when one considers the
projected future demands that will be placed on a system that is already struggling on a number
of fronts.

 Inequitable distribution of health services across the LHIN pose access challenges for residents,
particularly those in rural communities.
 Resource constraints in terms of both health human resources and funding present challenges to
meeting current and anticipated health service demand.
 Current funding and operating models reinforce a provider-focused vs. person-centred approach to
health service delivery.
 Access challenges continue to persist for marginalized populations across the LHIN.
 Lack of integration across sectors and health service providers inhibits the seamless transition of
individuals and families across the continuum of care.
 The health profile of the South West LHIN necessitates the need for more appropriate, integrated
screening and early identification of health risk factors and conditions.
 Lack of integrated platforms across the LHIN inhibits seamless information sharing among health
service providers across sectors and geography.

These foundational issues are described in further detail throughout this section.

An understanding of the South West LHIN


The South West LHIN health system serves approximately 944,852 residents across 8 counties
spanning 21,865 square kilometres.

For planning purposes, these counties have been segmented into three geographic clusters:

 North: Bruce and 95% of Grey Counties


 Central: Huron and Perth Counties
 South: Middlesex, Oxford, Elgin, and 12% of Haldimand-Norfolk

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While today‟s health system is caring for its current population, emerging challenges may threaten its
sustainability in the future.
 The large geography of the LHIN and the rural nature of some South West LHIN communities
continue to pose challenges for their residents in accessing health services.
 The growing unemployment rate may have an adverse effect on select populations, increasing the
need for mental health and addiction services beyond the current capacity.
 The demands of an aging population significantly impact services and will continue to grow in the
future.
 The high prevalence of chronic disease throughout the South West LHIN may contribute to
increased hospitalizations if managed inappropriately.
If not proactively addressed, the current challenges of the health profile will be exacerbated in the
future, straining our health system further as seen below.

Population density is the highest in the southern cluster with pockets distributed
throughout the rest of the LHIN:

Approximately 70% of the South West LHIN population resides in the southern counties, with
London and Middlesex County having the greatest proportion of visible minority residents and
residents with a non-official language mother tongue.

The population distribution has naturally resulted in a concentration of specialized health


services in the south, which has posed access challenges for northern and central residents.

Socioeconomic indicators may contribute to an increase in health risk factors:1

Overall, the LHIN‟s population reflects a similar educational profile to the provincial
average. Approximately, 45.3% of the LHIN population has completed post-secondary
education, 28.5% did not complete high school, and 8.8% have less than grade 9 education.

The South West LHIN unemployment rate of 5.4% is below the provincial average. However,
the economic downturn experienced over the past year has increased this average and may
have adverse population health implications for some residents within the LHIN. In September
2009, Statistics Canada reported an increase in unemployment for Ontario to 8.4%, an increase
of 2.0% from 2006. Current unemployment data is not available for the South West LHIN as a
whole although London‟s unemployment rate in September 2009 was 11.5%.

LHIN residents are also noted to have a lower average household income compared to
provincial average.

Consultations revealed that these socioeconomic indicators may contribute to an increased


prevalence of mental illness and addictions issues as well as other chronic diseases.

1
Data in this section is from Statistics Canada 2006

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Health profile of the LHIN may contribute to an increased need for health services:

The Canadian Community


Health Survey (CCHS) in Prevalence of Selected Chronic Conditions*
2007 revealed an South West Ontario
Health Indicator
increasing public 2005 2007 2005 2007
awareness of chronic Asthma 7.3% 7.8% 8.0% 8.1%
health conditions, along Arthritis &
18.7% 17.1% 17.1% 16.2%
with a desire to Rheumatism
understand chronic Diabetes 5.2% 5.7% 4.8% 6.1%
disease prevention and High Blood Pressure 17.2% 17.9% 15.2% 16.4%
management strategies. Obesity 18.1% 18.0% 15.1% 16.1%
While the prevalence of Smoker 20.7% 22.7% 20.7% 20.6%
chronic conditions is in
line with the provincial average, we have not seen any substantial improvement over the past
two years. Moreover, there are noted population variations across the South West LHIN with
regards to the prevalence and management of chronic disease.

In addition, recent findings from the Canadian Institute for Health Information report on Primary
Health Care in Canada2 reported that 41% of the Canadian population has one or more chronic
illnesses. As well, historical LHIN data in 07/083 has revealed that 2% of the LHIN population
was dealing with a diagnosis of cancer.

Overall, stakeholders reported an increase in mental health and addictions prevalence across
the LHIN. More specifically, they reported an increase in:

 Use of Mental health service needs within rural populations;


 Complex issues within the adolescent population;
 Addictions, mainly related to the increase in methamphetamine use, within the north and
central geographic clusters; and
 Alzheimer-related cases within the growing senior‟s population cohort.
In addition to health conditions, South West residents reported a need for in-home care through
the CCHS 2007, which reported that:

 2.5% of South West LHIN respondents needed help with personal care. Of the 2.2% who
indicated that they had self-perceived unmet home care needs, 1.6% indicated that they
required personal care support.
 Under the topic of “restriction of activities”, 3.4% of South West LHIN respondents indicated
they needed help for preparing meals. This is comparable to the overall Ontario average.
 Under the topic of “home care”, 2.2% of respondents over the age of 18 indicated that their
home care needs were unmet, while 77.6% of those said their need was for meals.

2
CIHI – Analysis in Brief: Experiences with Primary Health Care in Canada, July 2009
3
2007/08 South West LHIN Oncology Data

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Often, the unattached population rates provide an indication of the at-risk population within our
LHIN. CCHS 2007 and the Primary Care Access Survey4 results revealed that approximately 7-
11% of the population is unattached. Of this, Huron and London/Middlesex counties tended to
have the highest proportion of unattached patients, which exceeded the provincial rate of 7%.

The high prevalence of chronic conditions may lead to increased hospitalizations in the future if
not managed appropriately.

Projected population growth may exacerbate the current health profile straining current
capacity:

South West LHIN Population


South West LHIN Population Projections
While these health needs are evident today,
1200000
service providers will be faced with growing 1150000
pressure to meet future demands for these 1100000 1,054,804
health services. This anticipated service gap 1050000
is reinforced when one considers future 1000000 944,852
demand based on projected population 950000

growth. 900000
2007 2012 2017 2022

By 2022, the population is projected to grow


by 0.7% average annual growth rate to Projected Years
1,054,804 residents as seen in the next
exhibit. Elgin County is projected to have the highest growth rates relative to the other counties
at .98%, with Middlesex and Grey projected at .87% and .80% respectively.

The population distribution relative to the LHIN geography also affirms the fact that the South
West LHIN is largely comprised of rural communities.

As well, the senior‟s cohort of over 65 years is projected to grow from 15% to 21% of the total
population by 2022. The demands of an aging population have already had a significant impact
on the LHIN and will continue to grow over the next 15 years. The largest growth of this age
cohort will occur in the north, where it will grow from 11% to 16% of the total northern
population.

If not addressed, the growth in population will exacerbate the current challenges, further
straining our health system.

Factors such as demographics, population density, health status indicators, and growth
contribute to determining the service needs of the future population profile, which will influence
the type, location, quantity and model of how services are delivered throughout the LHIN.

Overview of health services and implications for the future


To date, South West LHIN health service providers have implemented innovative solutions to
address the evolving needs of its catchment population. While there have been great strides in
enhancing services, emerging demands continue to pose systemic challenges that require a
more coordinated approach.

4
Primary Care Access Survey (PCAS) Results for the South West LHIN and Ontario, July 2007-June 2008

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Profile of South West LHIN Health Service Providers
The South West LHIN population receives services from an array of LHIN and non-LHIN funded
organizations across the community, long-term care, and acute health sectors. Residents rely
on these organizations for a variety of needs including home/social support, episodic, chronic,
and long-term care.
The following LHIN-funded organizations play a critical role in delivering services to its
residents:
 19 public hospitals operating 33 sites and 1 private hospital
 62 community support services
 2 community health centres (plus 3 under development)
 28 mental health agencies (including 1 children‟s mental health)
 10 agencies providing addictions services (including 4 which also provide problem gambling
services)
 75 long-term care homes
 1 Community Care Access Centre (SWCCAC)
In considering the above organizations, a proportion of organizations have been active in
advancing the health services integration agenda. This is reflected in the various governance
structures that exist, shared leadership roles and the number of partnerships/coalitions that are
in place – all with the purpose of driving system integration.
In addition, non-LHIN funded organizations such as family health teams, family health
organizations, family health networks, solo-physician offices, and public health units, play a
critical role in the delivery of primary care services. While these providers are not under the
LHIN‟s mandate, they play a significant role and have thus been captured in the health services
Blueprint process.
For purposes of analysis, this report summarizes LHIN-wide profiles of these health services
through a sector analysis of 2007-2008 utilization.
These summaries are based on current state and future state assessment findings which are
provided in Appendix H.
Community Sector
The community sector plays a pivotal role in managing chronic illnesses, providing services to
those with mental health and addictions needs, and providing support services that enable
individuals and their personal support networks to manage locally. Examples of these services
include, but are not limited to:
 Homemaking, in-home personal support, meal delivery, programs to assist the hearing and
visually impaired, transportation, social and congregate dining; foot care, visiting hospice
services, day services; assisted living/supportive housing
 Crisis intervention services, psycho-geriatrics; supportive housing, mental health case
management, counselling, vocational/employment support programs,
social/recreation/rehabilitation, consumer and family initiatives, peer support, addictions
assessment, group sessions, withdrawal management
 Nursing, occupational therapy, physiotherapy, social work, speech language pathology,
nutrition

15
The following table provides an overview of key observations regarding the state of the
community sector today, implications for the future and the challenges that will need to be
addressed as part of the future state design.

 A number of organizations deliver community and in-home support services such as homemaking,
in-home personal support, meal delivery proportionate to the population distribution across the LHIN.
 Some services are reported to have inconsistency in the capacity levels across the LHIN. For
example:
‒ A lower proportion of day services programs were delivered in the north relative to the population
ratios in the other geographic clusters.
‒ Despite the high volume of transportation assistance provided through LHIN-funded groups,
transportation challenges were raised during consultations across the LHIN, especially by rural
Observations

service providers.
 A review of community-based mental health and addictions services revealed inconsistencies across
the LHIN:
‒ While community crisis intervention, case management services, and psycho-geriatric services
were provided across the LHIN, capacity levels appear to be greater within the southern and
central geographic clusters within the LHIN relative to the north.
‒ Community residential treatment and supportive services were provided by organizations mainly in
the north and south.
‒ Services to support those with concurrent disorders were mainly provided in the south, which
poses challenges in providing these specialized services to residents across the LHIN.
 South West CCAC enabled a variety of interdisciplinary practitioners to deliver care that allowed
clients to remain in their home environment. CCAC facilitated a variety of services, with nursing and
personal care support comprising the largest proportions.

 Reported long waitlists for community support services.


 Increasing complexity of patients discharged to community which impacts the finite resources
dedicated to meeting these needs.
 Community organizations face challenges of managing multiple funding sources and expectations in
Key Challenges

service delivery.
 Stakeholders revealed that a narrowing mandate of the role of community mental health services
has compromised the ability to provide early identification and intervention for those with mild to
moderate mental health problems, a population at-risk for more serious issues.
 Consultations suggest a need for strengthened screening of mental health illnesses and addictions
at the local level.
 Reported transportation challenges hinder access of health services in rural communities.
 Organizations heavily dependent upon volunteers are at risk due to increased need attributed to
aging population.

16
 The aging population will likely be high users of Seeds of Transformation:
home and community care, which will be important Partnerships for integrated delivery of
to helping seniors maintain independent living at
Implications for the future

comprehensive mental health


home. services via multi-agency mental
 Current service gaps across community-based health teams
services will grow in the future requiring an
integrated, coordinated approach to delivery of Mental health crisis intervention
community-based services. teams play a critical role in managing
 Sustainable HHR model to address capacity individuals with emergent mental
challenges. health and addictions needs. While
 Design of services to address current and projected providing the most appropriate care,
service needs for specialized populations (e.g. they also help avoid visits to the ED,
psycho-geriatrics, concurrent disorders, dual which is currently 2.7% of total ED
diagnosis). volumes.

Strengthening the capacity of crisis


Long-term Care Home Sector teams can result in improving the
management of these individuals,
The South West LHIN has 75 long-term care homes while diminishing their use of the EDs.
(LTCH), which provide a range of services for individuals
with varying needs. These include Alzheimer secure units,
ethno-cultural/religious services, short stay,
convalescent, and psycho-geriatric beds. Ratio of Long-term care beds per 1,000
Population 75+ years FY 2007-08
With the pending addition of 608 beds to the southern Sub-LHIN Beds Beds per 1,000 people
portion of the LHIN, it is expected that the relative North 1,325 106
Central 1,331 119
access to these beds across the LHIN will increase the
South 4,163 94 (107 with new beds)
ratio of beds per 1000 population within the south to
be more in line with the north and central geographic areas of LHIN.

In addition to services within LTCHs, residents have also benefitted from an array of health
services provided by community agencies, as indicated in the services provided through the
community sector and non-acute services such as Complex Continuing Care (CCC),
rehabilitation, and transitional care units (TCU), currently located within hospitals.

The following table provides an overview of key observations regarding the state of community
sector today, implications for the future and the challenges that will need to be addressed as
part of the future state design.

17
 The South West LHIN‟s waitlist is 8% of the provincial wait Seeds of Transformation:
list. In July 2009, 1,893 clients were on waitlists, with
Improved management of
average time spent as 146 days. On average, 175
individuals get placed into a home on a monthly basis. population through cross-
sector collaboration and
 The South West LHIN also experienced consistent LTCH service coordination:
admissions, 5.3-5.9%, for individuals between ages 18-65.
This was reported to be mainly due to the lack of appropriate
supportive housing and wrap around services in rural areas.
The South West CCAC‟s
Wait@Home initiative has
Observations

 While additional convalescent care beds are projected to be provided a win-win option to
provided in the LHIN in 2010, survey findings and
patients and providers. It has
consultations raised the concern for more specialized units,
especially around Psycho-geriatrics, Alzheimer, transitional
optimized current acute
care and convalescent care. capacity by letting patients
wait for LTC services in the
 For the 75+ age cohort, the need for long-term care beds are comfort of their own homes. It
projected to increase across the LHIN, with the north having
the highest increase due to the growth rate of this age
facilitates this by providing up
cohort. to 24/7 personal support care
for individuals to wait at home.
In the last four months of
08/09, a shift in 67 patients
was realized.

 Waitlists are abundant and growing across the LHIN. In any given month, 10-12% of acute care
beds in hospitals are occupied by ALC patients. Up to 61% of the ALC patients in these beds are
waiting for long-term care beds.
Key Challenges

 Increase in acuity of population, multiple co-morbidities, result in a need for homes to care for
specialized populations (sub-acute, Complex Continuing Care (CCC), mental health, dialysis,
dementia, etc).
 Consultations reveal that residents often improve within a LTCH and can be discharged, but often
are not due to lack of alternative services.
 Survey findings and consultations speak to an increased need for LTCH or supportive housing to
accommodate the 18-65 years of age population that need 24/7 support.
Implications for the future

 Alternative models to provide long-term care services to address the projected need in services.
 Need for more specialized services including dementia secured units, psycho-geriatrics, and
TCU/convalescent care. Increase in acuity of population, multiple co-morbidities, result in a need
for homes to care for specialized populations (sub-acute, CCC, mental health, dialysis, dementia,
etc).
 Need for supportive housing and wrap around services to address the 18-65 population.

18
Acute and Non-acute Hospital-based Services Sector

Across the South West LHIN community, there are 20


hospital organizations. These range from small rural to
large urban sites. According to The Core Service Role of
Small Hospitals in Ontario 2006, the majority of sites are
considered small hospitals. These hospital organizations
enable access to core hospital services either through
multi-site or single locations. While these small hospitals
are mainly located in the northern and central geographic
areas within the LHIN, a few sites reside in pockets of the
southern geographic area.

All hospitals accounted for 94,118 separations within the South West LHIN. The southern
institutions encompassed approximately 71% of total separations across the LHIN, of which
London Health Sciences Centre (LHSC) and St. Joseph‟s Health Care (St. Joseph‟s) accounted
for 57% and 16%, respectively.

The South West LHIN has four major referral centres as depicted by the map in the next exhibit:

 Grey Bruce Health Services-Owen Sound in the north;


 Huron Perth Healthcare Alliance –
Stratford General Hospital in the
central area; and
 LHSC and St. Joseph‟s in the south.
The map illustrates that GBHS-Owen
Sound appears to capture major market
share, 50% of total separations.

Huron Perth Health Alliance - Stratford


General Hospital captures significant
market share in the central area of the
LHIN with the service patterns extending
beyond LHIN borders, with
approximately 54% of total admissions
being derived from within its natural
catchment area.

Hospitals located in the southern portion


of the LHIN managed the largest
proportion of inpatient separations in the
South West LHIN. LHSC and St.
Joseph‟s have large catchment areas,
which is consistent with their role as
tertiary care providers.

The following summarizes other key


highlights related to acute care-based
services:

19
 The distribution of beds from designated Complex Continuing Care beds and rehabilitation
beds appear to align with the LHIN population density. Of all the CCC patients, 67% of them
were either in the clinically complex or rehabilitation category.
 In evaluating rehabilitation services, the largest number of admissions occurred in the
southern hospitals, 65% at St. Joseph‟s-Parkwood. While all organizations offered
orthopaedic and stroke in-patient rehabilitation services, volume of orthopaedic rehab was the
greatest in central, while stroke rehab was utilized the most in the north.
 The south has the highest volume of ED visits, while north and central experienced a greater
proportion of visits per population. Of the 29 sites that registered ED visits, 21 sites managed
greater than 10,000 visits in fiscal year 2007-08, with LHSC-Victoria as the busiest ED with
over 100,000 visits.
 Although these services are widely distributed across the LHIN, 69% of surgical and 89% of
medical ambulatory visits were captured in the south.
 As well, 79% of total chemotherapy visits were provided at LHSC, of which a portion of these
visits is attributed to northern and central residents.
Overall, the hospitals within the South West LHIN provide the vast majority of acute care
services to its residents. Approximately 6.7% of residents were admitted for acute services
outside of the LHIN, mostly to Hamilton Niagara Haldimand Brant, Toronto Central, and
Waterloo Wellington LHINs.
Beyond servicing the residents of the South West LHIN, hospitals within the LHIN also provide
care for a proportion of residents from outside the LHIN which account for 14% of the 94,118
separations. Of the 14%, Erie St. Clair accounted for 7.2% of the total admissions.
The following table provides an overview of key observations regarding the state of acute and
non-acute hospital-based services sector today, implications for the future and the challenges
that will need to be addressed as part of the future state design.

20
Emergency Services:
 Overall, while the majority of hospitals fall below the provincial average for total time spent in
emergency departments, the LHIN exceeds the provincial average of total visits per population.
In 2007, on a quarterly average, the LHIN had 159 visits per 1,000 residents, while the provincial
average was approximately 100 visits per 1,000 residents. This may be attributed to the largely
rural nature of the LHIN and the fact that the hospital ED is often the primary source of after
hours primary care in many smaller communities.
 The South West LHIN continues to face human resources challenges related to physician ED
coverage and staffing, often putting some sites at risk for closure. The LHIN is the highest
recipient of physician coverage hours through HealthForce Ontario‟s Emergency Department
Coverage Demonstration Project program.
 Across the LHIN, approximately a third of visits are attributed to non-urgent visits, which were
Canadian Emergency Department Triage and Acuity Scale (CTAS) Level 4 and 5.
 Challenges in addressing ED visits attributed to mental health and addictions exist across the
LHIN.
Medicine and Surgical Services:
 Each geographic cluster seems to manage the majority of the medicine-related needs in its
communities.
 However, for surgical services, a significant proportion of northern and central residents receive
care by the southern providers. Approximately 30% and 37% of central residents frequented
southern hospitals for their orthopaedic and trauma needs respectively, while, 16% and 18% of
Current Observations

northern residents frequented southern hospitals for their general surgery and trauma needs.
 Due to relatively lower case volumes in the „smaller‟ sites, stakeholders report
concerns/perceptions with scope of surgical services provided outside of London and the
associated quality of care. Conversely, there are reported concerns regarding the ability to
access services within London hospitals.
 Overall, there is a sentiment that a “rebalancing” is required to further enable and build surgical
services delivery capacity outside of London.
 A proportion of stakeholders state surgical cancellations have increased at their sites as a result
of ALC patients in acute care beds.
 Northern hospitals tend to have the highest proportion of ALC days attributed to surgical
services. This could be reflective of the availability of post-operative services.
Critical Care:
 In the smaller community hospitals, the volume of critically ill patients is low and it is therefore
challenging for the local physicians/nursing staff to attain and maintain a comfort level in dealing
with these critically ill patients.
 Nine hospitals are capable of providing Level 3 mechanical ventilation making it challenging to
provide immediate access to Level 3 beds, which are distributed over a large geographical area.
Challenges with maintaining access to designated ICU beds, arise from staffing
availability/overrun of critical care budgets, beds blocked by patients who no longer need them,
high-acuity patients, and reported variable occupancy rates in critical care units across the
LHINs.
Mental Health and Addictions:
 Across the LHIN, there is a stated gap in services related to children and youth with mental
health needs.
 Currently, the majority of paediatric and adolescent admissions occur at southern providers
which are most likely attributed to the fact that designated paediatric MH&A beds are located at
LHSC and St. Joseph‟s. This current bed distribution results in inequitable access to paediatric
mental health services.

21
 Lack of availability of specialty services in rural areas is particularly challenged by the uneven
distribution of specialists.
Key Challenges

 Shortage of generalists in rural communities due to impeding retirement challenges and the
availability of physicians with broad experience and capacity of previous generations.
 Lack of coordinated process to manage emergent surgical cases (i.e. emergent orthopaedics).
 Inconsistent approach to identifying patients in CCC that would be appropriately served in an
alternate setting, such as LTCH or home with appropriate supports, impedes timely discharges to
other community environments.

Direction for
 Need to optimize current acute capacity in order to offset
the projected increase in demand.
Transformation
 Alternative model to coordinate resource capacity across Sustaining access through
the LHIN to better manage upstream and downstream flow optimization of current capacity:
of patients.
Implications for the future

 Need to strengthen the health resource base outside of Improve patient care and
London to enable care “closer to home” where appropriate optimize current capacity
and create capacity for London-based services to better through the creation of multi-site
deliver upon their local, tertiary and quaternary care maternal networks across the
mandates. LHIN. A network would consist
 Better use of visiting specialists requires adequate local of a larger site managing the
resources to support care. majority of obstetrical cases,
providing support to the local
 All geographic clusters will need to play a role in delivering
oncology systemic therapy (e.g. chemotherapy) that meets sites to ensure that they meet
quality standards and brings care closer to home. the appropriate standards as a
collective body.
 Need for community-based chronic ventilation program to
address needs of growing population and to alleviate ICU
bed pressures.

Primary Care Services

A significant proportion of primary health services are provided through public health units,
community health centres (CHC), family health teams (FHT), family health organizations (FHO),
family health networks (FHN), family health groups (FHG), Comprehensive Care Model (CCM),
Blended Salary Model (BSM) and individual practitioners. While the LHIN funds two existing
Community Health Centres and one Aboriginal Health Access centre, there are also
organizations and practitioners not funded by the LHIN that are pivotal in the delivery of health
services to its residents.

22
The organizations in the next exhibit are the first point of access to the health system and
provide an array of educational and early intervention services including:

 System navigation for many communities;


 Prenatal and sexual health screening services that often serve as the stepping stone into
education and early intervention;
 Health education and promotion services which can help reduce the incidence of chronic
illnesses; and
 Key contact for identification and early intervention for mental health and addictions
challenges and associated risk factors.

Distribution of Primary Care Resources


All other primary care
Public Health
Community Health Centre resources (FHT, FHN,
Units
FHO, FHG, CCM, BSM)
North 1 0 and 1 under development
Central 2 0
South 4 2 plus 2 under development
Total 7 2 plus 3 under development 87

 Reported inconsistency in the availability of primary care


resources in general across the LHIN. Transformation in Action
Key Challenges

 Inconsistent access to primary resources (e.g. those Improved population health


individuals who are on the rosters of existing FHTs have
greater access to other inter-professional care resources as
management:
compared to those who may receive their primary care
through a solo practitioner). Partnerships for Health,
collaborative team-based
 Primary care resources are first point of contact, but not
approach, has experienced
often resourced with tools and skill sets to appropriately
screen for mental illnesses and addictions.
success improving management
of chronic diseases and
optimizing use of current
resources, through working in a
collaborative team-based setting
Implications for the future

that has strong relationships with


 Enhance provision of primary care services through CCAC, physicians, diabetes
alternative service delivery approaches.
centres, mental health and
 Need for development of personal relationships across addiction partners, and
health service providers and primary care to maintain community pharmacies.
connectedness across the continuum of care.
 Need for a stronger emphasis on health promotion and
education at local level.

23
Profile of our Health Human Resources
The delivery of health services is dependent upon regulated and non-regulated health human
resources across the LHIN. Regulated resources include disciplines such as physicians,
nurses, occupational therapists, physiotherapists, speech language therapists, midwives,
chiropodists, pharmacists, audiologists, dietitians, massage therapists, psychologists and
respiratory therapists. Non-regulated resources such as personal support workers,
acupuncturists, naturopaths, chiropractors, social workers, and mental health and addictions
counselors also a play a critical role in delivery of health services.

 Capturing data on health human resources is often a challenging exercise as there is no central
database that exists. Professionals who are regulated are attached to professional bodies so
some information can be gleaned. There are a total of 1,805 physicians registered in the LHIN,
with 79% practicing in the south.
 Approximately 11% and 20% of physicians are registered in counties in the north and central
portions of the LHIN, while 17% and 15% of the LHIN population reside in the north and central
segments of the LHIN.
 There is a relatively even distribution of Family Medicine physicians across the LHIN.
Current Observations

 Specialist practitioners are however primarily concentrated in the South, aligned to the academic
health centres, LHSC and St. Joseph‟s.
Overview of Ontario Distribution &
 Consultations reveal a projected Characteristics of Registered Professionals
shortage of generalists in rural Registered Members South West LHIN %
communities. Chiropodists 480 n/a

 Given that 7% of the population of Midwives 334 7%


Nurse Practitioners 594 5%
Ontario residents live in the South West
Occupational
LHIN, there appears to be alignment Therapists
4,010 10%
between the population and resources, Physiotherapists 6,080 10%
with the exception of Nurse Registered Nurses 89,054 9%
Practitioners.5 Registered Practical
24,482 11%
 One major noted concern is the age Nurses

distribution of regulated professionals


across the South West LHIN. The majority of professionals within the LHIN are over the age of 40
years, with the exception of Occupational Therapists; a profile that is consistent with the overall
trend across Canada.

5
This chart does not include a comprehensive list of regulated and non-regulated resources. The proportion of chiropodists in the
South West LHIN was not available.

24
 In the absence of change to how
services are delivered, it is projected that
the resource base of physicians and Anticipated high
other inter-professional resources would growth based on
base-case population
need to increase relative to population
Implications for the future

projections
growth in order to meet future service

Volume of HHR
demands. With the realities of HHR Gap in resources
addressed through
recruitment, a more moderate increase alternative service
may be possible. The gap in services Moderate delivery models
may need to be offset through alternative growth based
on realities of
service delivery models (i.e. inter- HHR
professional care).
 Current education of physicians may not
match the needs of communities.
 Need for strengthened, personal
relationships between health service 2012 2017 2022

professionals across/within sectors.


 Collaboration with physician partners to illicit change in service delivery.

25
On the road to transforming the current health care system…
Recognizing the realities of today, health service providers have proactively undertaken several
initiatives to progressively improve health service delivery. Stakeholders recognize the
impending challenges and have embarked on initiatives to help improve the health system. In
developing the Blueprint, it is important to leverage and build on the many initiatives that have
either been previously completed or are underway and are already focused on advancing the
system towards the LHIN‟s system level goals. Below is a sampling of various initiatives
identified through consultations and survey findings currently underway within the LHIN. (Note:
in summarizing, these initiatives have been aligned to their primary health system goal focus;
however initiatives may positively influence multiple goals.)

System Level
Sampling of current initiatives
Goal

 Primary care resources (e.g. FHTs, CHCs) are providing coordinated services to
address patient needs, particularly those with several co-morbidities.
Healthier  Alzheimer Society‟s “Remember me” program accommodates services according to
South West client needs.
LHIN
Community  Several organizations have adapted delivery to cultural sensitivities to meet the needs
of populations such as Mennonites, Aboriginals, Amish and other ethnic minorities.
 Partnerships with schools and public health deliver wellness programs.

 South West CCAC‟s Advanced Home Care Team, a quick response team of
community-based primary nurse practitioners who work in partnership with physicians
and the home care team to provide “hospital in the home” care to keep people out of
Equitable the hospital and avoid ED and LTC.
access to  Distribution of Flex Clinics for mobile outreach approach to providing services.
services
 Delivery of crisis services through collaboration of two Grey Bruce Mental Health
organizations.
 Huron Perth Transportation providing central access to services.

 Community Stroke Rehab Teams operate as inter-professional teams that follow the
patient through mobile, in-home, ambulatory care settings, local community sites, LTC
homes, etc.
 Pathways for People with Stroke to Live Fully in the Community to ensure consistency
Quality of of care.
Care and  First Link program educates physicians & other front-line staff on recognizing the early
Service signs of dementia which has allowed for early identification.
 St. Joseph‟s has launched a project which enhances primary care provider skills in
managing depression.
 Grey Bruce connection, an integrated information management system with evidence-
based care program and clinical pathways.

 Inter-professional Education Program at University of Western Ontario to ensure


Sustainability professions are planning for care collaboratively, through a person-centred approach.
of the Local
 thehealthline.ca‟s South West Career Network that supports recruitment for rural
Health
providers.
System
 Rural medical on-call model for Obstetrics in north to address HHR challenges.

26
System Level
Sampling of current initiatives
Goal

 Through Aging at Home strategy, Tillsonburg-based assisted living program facilitates


the movement of people from hospital to community.
 Tillsonburg & Alexandra share Director of Laboratory & Diagnostic Imaging, Manager
of Health Information & Privacy.
 Huron Perth Healthcare Alliance (HPHA) Bed Management System serves as a single
bed management system for all HPHA hospitals.
 MRI Task Team operates as a regional team coordinating MRI scans to improve wait
times.
 Grey Bruce Integrated Health Network, 10 hospitals, utilizes visiting specialties,
Integration of common pharmacy services at Owen Sound and a shared lab system (IHLP).
Health Care
Delivery  Listowel/Wingham connects community and hospital through an Electronic Medical
Record.
 Caregiver Connect serves a web portal accessible to caregivers for educational
services.
 ConnexOntario serves as an integrated information source for mental health,
addictions and problem gambling services.
 thehealthline.ca provides a service inventory and information on service capacity /
availability.
 Mental Health Grey Bruce, legal partnership of three organizations, provides
integrated mental health services through five multi-agency teams.

These initiatives and others


represent a significant and positive While health service providers are doing a
launching pad from which the health
system can transform the manner in
great job in addressing the pressures of
which services are delivered. The today, it’s clear the needs of the residents of
Blueprint provides the framework for
the next steps to be taken in order to
the South West LHIN and the challenges of
progressively enable greater the future mean we cannot continue to
transformational change across the
system.
provide care the way we do today. We
need to fundamentally transform how we
More details on the overview of
today are provided in the supporting
provide care and work together in a far
technical report documents. more collaborative way centered around
the client.

Sandra Coleman – South West CCAC

27
A blueprint for the future
Overview of the Integrated Health System of Care
Grounded in the vision and system level goals of the South West LHIN, the Blueprint strives to
optimize the delivery of health services in the future.

With this foundation in place, the Blueprint has been developed on the basis of common vision
elements and guiding principles that have been determined by service providers and
communities across the LHIN.

It aims to create “A health care system that helps people stay healthy, delivers good
care to them when they get sick and will be there for their children and grandchildren”
by:
 Integrating the delivery of services to provide the right care, at the right time, in the right place;
 Focusing on care that is person and family centered;
 Ensuring efficient and sustainable health human resources; and
 Providing and supporting equitable and timely access to services for individuals and providers.

As well, it works to realize the system level goals through the guiding principles.

Healthier South West


• Empowering the individual and their family to play an active role in
LHIN Community
the management of their care.
through

Equitable Access to • Focus on the philosophy of care „close to home‟ while ensuring
Services through a quality care.

Quality of Care and • Embracing health care innovation; and


Service through • Practicing evidence-based health care.

• Ensuring transparency and accountability in the broader system;


Sustainability of the
• Ensuring sustainability of health human resources in the LHIN; and
Local Health System by
• Delivering efficient and cost-effective services.

Integration of Health • Promoting and instituting collaboration across all disciplines and
Care Delivery by across the entire continuum.

28
Consequently, the end result is a future South West LHIN health system predicated on an
Integrated Health System of Care. This system emphasizes the message that all health
programs and services are part of a single, unified health system of care. It clearly
communicates the roles and responsibilities of the various health service providers and social
services partners, and also delineates the interdependencies among various stakeholders to
enable a shared approach to service delivery. In acknowledging unique characteristics among
community, long-term care, acute services, and primary care services, the Integrated Health
System of Care is to be accessed through two integrated service delivery approaches:

 Population-based Integrated Health Services which is tailored to the collective needs of a


local population and its health service providers. It enables local communities to support the
health and wellness of its catchment population enabling them to better manage their own
health and maintain independence. The local community services are supported by the multi-
community services and has access to LHIN community services as needed.
‒ Throughout an individual‟s life, he or she may access primary care, home and community
care, complex continuing care, long-term care, palliative care, rehabilitation, chronic disease
prevention and management, mental health and addictions services and emergency
services coordinated through this service delivery approach.
 Centrally coordinated resource capacity which optimizes the use of targeted resources to
improve access and complement the management of health and wellness at the more local
level.
‒ Throughout an individual‟s life, he or she may access medicine, surgical, and critical care
inpatient and ambulatory services coordinated through this service delivery approach.
It is important to note that these approaches are not mutually exclusive, but are truly integrated,
recognizing that as an individual at various points in their lifetime interacts with the system, their
needs will vary and the system will be able to respond in a seamless and coordinated manner.

Services should be delivered and accessed in a


manner that enables them to represent the Planning at the system level is one
unique characteristics of managing clusters of
population segments. Underlying each service of the best ways of ensuring
delivery approach are the specific characteristics continued access to high quality
of how care should be delivered and accessed
within the various health service program healthcare into the future.
groupings, such as mental health and addictions,
chronic disease prevention and management and
critical care. Andrew Williams,
Huron Perth Healthcare Alliance
For the purposes of this report, the focus will be
on the two overarching service delivery
approaches that are focused on different
components of the Integrated Health System of
Care. A detailed description of how the future of
specific health services will be delivered is
provided in Appendix A.

29
The system of care relies on coordinated and effective working relationships among providers within local communities, across
multiple communities, and across the entire South West LHIN and beyond. It calls for providers to work with others outside the LHIN
to ensure continuity of services delivered for our residents within and outside of the South West LHIN boundaries. The following
provides further explanation in order to define the terms Local Community, Multi-Community, LHIN community as applied within the
Blueprint:

Local Multi- LHIN


Community Community Community
• Services provided close to • Service delivery by • Delivery of low
home geographic clustering volume/highly complex
• Delivery of high volume/low of moderate services to manage
“Local Community” complexity services to volume/complexity specialized populations
broader population services focused on • Support multi-community “LHIN Community” refers
involves the coordination • Collaboration across local targeted populations and local providers with
traditional and non- • Seamless referral accessibility to to those services where the
of provision of services traditional providers specialized services
relationships with local resources and expertise are
provided „close to home.‟ • Emphasis on an individual‟s and LHIN providers • May serve as a broader
self-health management provincial resource not widely available
These types of services • Manages referrals and
refers out of LHIN as throughout the LHIN. These
include primary care, necessary
programs will be led by one
some secondary care,
identified organization and
home and community
the organization will be
care, inter-professional
mandated to provide
clinics for chronic
appropriate access and care
diseases, and local Service Delivery
Approaches to residents across our LHIN.
hospital services. For
Population-based Travel to a location may be
these services, there will integrated health services: required to access these
be many sites for service • Home and community care, long-term care homes, complex
continuing care, rehabilitation services Centrally coordinated highly specialized services.
access across the LHIN, • Chronic disease prevention and management
• Mental health and addictions
resource capacity: These organizations may
located in communities, •Surgical services
• Emergency services •Critical care services also serve as a provincial
connected through an •Internal medicine services resource for certain services.
inter-professional team.
Local Multi- LHIN
Community Community Community

“Multi-Community” is the coordination and provision of some specialized services that will be provided through
service providers who serve both their local community, but also surrounding communities within a defined
catchment area. Some travel to access services may be required; however services should still be accessible
within the Multi-Community area. Services may be located at two or more sites to serve several clustered
communities. These sites will serve a large proportion of individuals who may require certain types of
subspecialty programs, yet do not need to travel to LHIN Community sites.
30
Population-based Integrated Health Services
The Population-based Integrated Health Services approach exhibits the following
characteristics:

 This approach calls for health service


delivery tailored to the local needs of its A responsive, comprehensive
catchment population and health service health system is one that recognizes
providers. It builds local communities to be
able to support the health and wellness of and responds to the needs of all
its catchment population. This approach populations, including those who
will focus on total health management
including prevention, screening, are marginalized, those with
identification, assessment, treatment, complex needs and those who
follow-up and the necessary support.
experience barriers to care. It is
 There is an emphasis on individual‟s
accountability in the management of one‟s also essential that we provide
own health. person-centred care: care that
 The majority of service coordination and focuses on the whole person within
intervention will be delivered through local
health and social service providers and his/her context, and not just on the
coordinated through local health person’s illness or disease.
resources, integrated health services
collaboratives. These collaboratives will
be achieved through various delivery Sandy Stockman, Grey Bruce
models such as co-located, mobile, and/or
virtual settings depending on the health Community Health Corporation
and social needs of the community and
health service provider base.
 Relies on care coordination and inter-
professional support at the local level,
including primary care, community, and
public health professionals as part of the
broader health care team.
 As individual needs become increasingly
complex, referral to specialist and sub-
specialist care at the Multi-Community
and LHIN levels may be required and
coordinated through the inter-professional team.

31
How is the Population-based Integrated Health Services approach delivered?
The services will be delivered and facilitated through integrated health services collaboratives
(IHSC) through a variety of settings, including virtual, mobile, co-located settings. Depending on
the geographic profile, current primary care resources (e.g. FHTs, FHNs, FHO, CCM, BSM,
FHG, CHCs, and solo-physician offices) can be transformed into collaboratives connected by
technological infrastructure and shared resources. Solo-physician offices will capitalize on this
model through the access to inter-professional resources. These IHSCs will provide
education, screening, assessment, treatment, navigation, and the necessary support
services.

• Long-Term
Integrated health Care Homes
services collaborative • Supportive
housing
Co-located • Home and
setting Community
Care
• Rehabilitation

Mobile Coordinated
setting Community
Strengthened
Care services
Relationships

Virtual
setting Fitness
programs Mental
health
services

Problem
Substance gambling
abuse services
Nutritional
services
clinics

• Linkage to core • Linkage to


hospital services specialist
(medical and services
surgical) (Schedule 1, Physician
etc) Inter-prof essional resource
• Emergency Services

Inter-professional teams (comprised of regulated and non-regulated practitioners) will


manage chronic illnesses (manage multiple conditions as directed by individual vs. disease-
specific), primary mental health and addictions needs and other less emergent cases as
appropriate. They will focus on integrated screening of at-risk populations.

These teams will also provide navigation services including tools for self-navigation, service
coordination, and clinical case management which will involve family/caregivers as part of the
process, which is further described in the Foundational Elements section. This will involve
holistic assessment of the individual’s health and social needs to connect them to the most
appropriate service.

IHSCs will work to provide the appropriate preventive, promotive, and lower acuity services
close to home and in the community setting while referring to Multi-Community and LHIN
Community sites for higher acuity needs.

32
Coordinated community care services will continue to play a critical role in managing chronic
illnesses, mental health and addictions issues, general health and wellness related needs,
rehabilitation services through a coordinated delivery model. This will enable care provision for
mild and complex cases at home as appropriate. These community organizations will
demonstrate a stronger partnership with primary care partners to ensure seamless referral of
individuals based on needs with a stronger emphasis on coordinated capacity.
This model also emphasizes the provision of care closer to home. These services include
long-term care home placement as well as home and community care and palliative services.
As needed, individuals will be connected with specialized housing capacity (e.g. mental health
and addictions specialized housing and LTCH).
There will also be a focus on advanced care planning accounting for health and social
assessments. Local integrated health services collaboratives will play a critical role in
coordination. Dependent on the geographic profile (size and demographics of catchment
population), the coordination services (e.g. SWCCAC) may be housed within an integrated
health services collaborative or attached as a virtual partner.
The population-based integrated health service delivery approach realizes the following
transformative elements which produce benefits to both providers and individuals.

How is this different from today’s service


What are the benefits?
delivery model?

 Development of collaborative partnerships across Providers and Health Professionals:


health sectors, continuum of care, and beyond  Increased focus on preventing chronic
broader health sectors. illnesses and addressing mental health and
 Inter-professional teams to maintain continuity for addictions needs within a local capacity.
individuals as they access services across the health  Appropriate use of complex continuing care
system. and long-term care home capacity.
 Established referral processes to enable seamless,  Availability of standardized tools to aid
connected transfer of individuals across the health care professionals in care delivery.
continuum of care.
 Seamless referral of individuals/families
 Integrated health services collaboratives to screen, across health and other sectors.
assess, and provide early intervention (care
coordination, and liaison to specialist services as Individuals and Families:
needed).  Empowerment of individual/family members
 Expansion of provider roles across the continuum to in managing their own care.
optimize care delivery. Enhanced capacity of direct  Emphasis on providing care closer to home
service providers on knowledge, understanding of to the extent that is reasonable and feasible.
services and individual‟s health needs.
 Early identification and management of
 Standardized, evidence-based approach to care individual‟s needs in order to enable people
provision. to optimize their level of function and quality
 Enhanced reliance on self-management – involving of life in their community and home
individual as part of health care team. environment.
 Alignment of service distribution to population
needs/location across the LHIN.

More details on this service delivery approach are provided in Appendix D.

33
Centrally Coordinated Resource
Capacity We, as hospital partners, need to
The Centrally Coordinated Resource collaborate to better manage our
Capacity service delivery approach resource capacity. This is the only way
does not intend shifting to a single
owner of resources, but exhibits the to ensure seamless flow of our patients
following characteristics: upstream and downstream.
 Approach focuses on optimizing the
use of targeted resources to improve Dr. Nancy Whitmore,
access and complement the
management of health and wellness St. Thomas Elgin General Hospital
at the more local level.
 LHIN-wide coordination of
medicine, surgical and critical care inpatient and ambulatory services to maximize our
resident‟s access to services. Service delivery will be coordinated across local community,
Multi-Community, and LHIN community providers.
 Local providers will play a key role in primary and secondary identification, assessment,
treatment, and follow-up services for their local communities. Providers will also focus on
changing their practices to include the individual and their families as part of the care team to
emphasize the individual‟s accountability in the management of one‟s own health.
 Providers whose role will be to deliver services at the Multi-Community level will provide
specialist services for a larger population.
 South West LHIN-wide providers will be responsible for delivering highly specialized
services for complex population segments.
 It should also be noted that while in some cases tertiary hospitals will be expected to function
as a LHIN-wide resource, it is also expected that they will also continue to function as the local
care resource for the communities in which they currently operate today.
 Development of shared physician on-call system and structure.

How will a Centrally Coordinated Resource Capacity model be delivered?

The service delivery approach emphasizes LHIN-wide management of capacity allowing


individuals to flow through the system equitably, minimizing backlogs and optimizing use of
available resources. It focuses on facilitating an individual‟s access to the right provider based
on complexity of need. This will enable to appropriately react to planned and unexpected
events. This is dependent upon strengthened partnerships across the service delivery levels
which would enable seamless referral relationships across health service providers. In addition
to clinical expertise, expansion of provider roles would include navigation and
information/referral as appropriate.

All health service providers and professionals would comply with standardized, evidence-based
practices developed in collaboration across all levels. Vehicles, such as telemedicine and other
enabling technologies, would be utilized to execute best practices, tools, and quality guidelines
across providers at all levels.

34
The approach ensures equitable access by delivering a network of visiting specialists or
physicians at the multi-community or LHIN level as warranted by demand and critical mass. As
well, vehicles such as telemedicine would be used to provide speciality services as appropriate.

As a result, the service delivery model requires a balanced distribution and alignment of
services to critical mass, which is required to maintain a required level of quality and clinical
practice competency and includes the appropriate alignment to population/community needs.

 Local Community: Sites providing core services as warranted by critical mass and managing
repatriated individuals. These sites are supported by in-house or visiting physicians depending
on the catchment area.
 Multi-Community: A site or network of sites dependent upon the community to provide care for
moderate cases and managing repatriated individuals. The north and central may institute
multi-site network of resources that provide visiting services at a few locations. The south
may have specific Multi-Community sites distributed based on spread of population.
 LHIN Community: Single site providing specialized services for higher acuity needs. Based on
utilization, and concentration of clinical specialists in the south, the expectation is that such a
resource would likely be located in the southern portion of the LHIN.
Critical care services would also require LHIN-wide coordination across small, rural hospitals to
urban sites. The distribution of resources would be dependent upon medical and surgical
capacity as well. This could result in:

 Local Community: Sites managing lower complexity cases, repatriated individuals for Multi-
Community and LHIN-wide sites, and provide support to community-based ventilation
services. These sites provide Level 2 beds that are sustainable and ensure critical mass.
 Multi-Community: Distributed sites supporting the service delivery of moderate cases,
management of repatriated individuals, and ventilation needs to community-based ventilation
services. These sites also have respiratory therapists as needed to provide coverage and
have a smaller inventory of Level 2 and Level 3 beds.
 LHIN Community: Two sites managing complex ventilation needs, higher acuity individuals,
acute dialysis, and respiratory therapy. They will have the bulk of Level 3 beds and a higher
inventory of Level 2 beds.
The Centrally Coordinated Resource Capacity model realizes the following transformative
elements which produce benefits to both providers and individuals.

35
How is this different from today’s
What are the benefits?
service delivery model?

 Collaboration among all sites across the Providers and Health Professionals:
LHIN to ensure that the right individual  Capacity utilization in the LHIN will improve as a result
is in the right place at the right time of a shared and integrated approach to resource
(consistent admission criteria). coordination.
 Development of coordinated physician  Increased physician base within which on-call coverage
on-call system and structure. can be shared; with the coordinated on-call system, all
 Unified point of access with common consults will be directed to an on-call physician.
referral standards / process by  Improved quality of care through the adoption of
specialty. standardized care pathways from screening,
 Consistent use of standardized, assessment through to discharge guidelines.
evidence-based care pathways across  More dedicated time for direct patient care by
the LHIN. leveraging telemedicine capabilities.
 Care close to home balanced with  Virtual linking of physicians across LHIN to share best
access to the right care. practices, education, and quality monitoring.
Individuals and Families:
 Strengthens relationship with individual, families and
providers.
 Improved equity, timeliness and access to care in the
„right‟ place.
 Direct engagement in health care decision-making
processes through an enhanced information sharing
and access.

More details on this service delivery approach are provided in Appendix D.

36
Enablers to realize the Integrated Health System of Care

The success of the Integrated Health System of Care is contingent upon four threads of
enablers, highlighted within the green border in the diagram below, which will transform health
service delivery across all health sectors. Stakeholders in the South West LHIN identified
fundamental, systemic elements which are required to help transform the current system by:

 Multi-level system of navigation framework


 Integrated health human resource strategies
 Enabling information and clinical technologies Local Multi- LHIN
Community Community Community
 Health Systems Blueprint implementation and • Services provided close to • Service delivery by
home
• Delivery of low
geographic clustering volume/highly complex
accountability frameworks • Delivery of high volume/low of moderate
complexity services to
services to manage
volume/complexity specialized populations
broader population services focused on • Support multi-community
• Collaboration across local targeted populations and local providers with
traditional and non- • Seamless referral accessibility to
Planning and implementation of these traditional providers
• Emphasis on an individual‟s
relationships with local specialized services
• May serve as a broader
and LHIN providers
elements, fundamental to system effectiveness, self-health management provincial resource
• Manages referrals and
will require a long, continuous process, with refers out of LHIN as
necessary
cross-sectoral providers and health professional
dedication. While it is a time-consuming
process, benefits can be realized with interim
milestones. These elements are described
below.

Multi-level system of navigation framework: As the underpinning to health care provision


across all health programs, this framework consists of a balanced approach to self-navigation,
service coordination, and clinical case
management as required by the individual. These
services can be provided by direct service Development of
care plan
providers (regulated and non-regulated) or
dedicated, specialized resources such as a care
coordination resource. Referral to
Information System of appropriate
and Navigation service
 Self-navigation: Individuals will play an active role education provider
in managing their own health care, self-
navigation, as they are able. They will be able to Health/non-health
navigate themselves and their family through the needs post
services
integrated system of care. To enable individuals
to take on this role, there will be a requirement for
individuals to have access to:
‒ Health education resources and tools;
‒ Inventory of health services with knowledge and understanding of the service; and
‒ Access to local services for coordination and clinical case management as needed.
 Service coordination will be provided by a collection of resources depending on the setting
of care. This can be delivered by a direct service provider or dedicated resource.

37
 Depending on health need, clinical case management services will be provided by clinical
case managers and/or direct service providers:
‒ Assessment and development of care plans with appropriate health/non-health resources
‒ Referral and contact to the appropriate health/non-health service provider as needed
‒ Management of care needs post services in order to maintain continuity throughout
individual‟s life cycle
‒ Provision of education, support and consultation to the individuals and their families
‒ This person ensures that their client‟s involvement in decisions regarding their care is
maximized and that all parties are in good communication and share common
understandings
Navigation services will vary dependent on the needs of
the individual. For the majority of the population who
need self-care support/management, individuals may
just require readily access to service coordination as Level 3
these individuals may need a more collaborative High
complexity
relationship with a navigator for educational and case
coordination purposes as needed. For those individuals management
who are at higher risk, they may require a moderate
presence of clinical case management and stronger
need for service coordination for individuals with specific
Level 2
diseases or chronic illnesses. Individuals may be High risk disease / care
considered high risk due to medical and/or social management
conditions. These resources would assist the individual
through health and medical needs across health sectors
and social agencies.

For more specialized populations who need high Level 1


Self care support /
complexity case management, there is a need for strong management (70-80%)
presence of clinical case management and service
coordination. This would involve a navigator and case
manager that stays attuned and connected to the
individual as he/she goes through health, medical, and social services.

Integrated health human resource strategies: The Integrated Health System of Care requires
integrated, proactive HHR strategies to better equip LHIN providers with the resources needed
to adequately deliver services. This includes:

 Developing a sustainable workforce planning process based upon data collection and
performance management
 Creating collaborative networks within and beyond the LHIN to leverage best practices and
drive policy changes

38
 Building capacity and optimize the use of current and
future HHR across the system through various Our health system needs
initiatives: to account for the life-
‒ Institute inter-professional team models in settings long journey of
across health sectors to increase collaboration and
provide coordinated care for individuals. individuals. No matter
‒ In collaboration with LHIN providers, develop a
the time or place, health
recruitment and retention strategy for HHR in both care needs to be seamless
rural and urban communities.
to the individual and their
‒ Leverage recruitment programs across LHIN
providers.
family.
‒ Incent organizations to create cultures that encourage
retention and growth. Sue McCutcheon, Grey
‒ Develop and implement training programs to enhance Bruce Health Services
skillsets to include management of specialized
populations.
‒ Set clear expectations of roles and responsibilities of HHR within the future service delivery
models.
‒ Leverage current provincial and South West LHIN initiatives to manage HHR.
Enabling information and clinical technology: The provision of health services can be
enhanced through the use of information and clinical technology related solutions.

 Examples of potential information technology related solutions:


‒ Health care professionals will be equipped with a centrally accessed repository of all
South West LHIN health services (e.g. thehealthline.ca, ConnexOntario) which includes
inventory of services to enhance health education and enable care coordination across
organizations, accessible online or via telephone. This may also enable enhanced
functionality of real-time capacity update and electronic appointment booking.
‒ Leverage existing infrastructure to create a real-time, easily accessible clinical information
repository available to health providers LHIN-wide, across the continuum of care that can
be accessed through various existing applications such as physician office electronic
medical records, hospital-based clinical information systems, other care provider records
systems, and shared clinical portal technologies.
‒ The clinical information repository, connected to a personal health portal, will enable
individuals to access and share health information as needed (e.g. with alternative care
providers). The personal health portal will be equipped with self-assessment, management,
and scheduling tools.
 Examples of Clinical Technology related solutions:
‒ Implementation of clinical technologies to enhance care delivery as needed across LHIN
(e.g. Diagnostic Imaging, Lab)
‒ LHIN-Community or Multi-Community systems to coordinate acute care services
capacity. This could be enabled through the expansion of Criticall system with enhanced
functionality. Enhanced functionality would include communication and reporting of bed

39
capacity status, facilitate communication between physicians and triage, which collectively
would serve as a mechanism to receive physician consult prior to referral of individual, and
facilitate physician consults.
 Care coordination system to enable electronic appointment referrals and bookings for
organizations across sectors (e.g. GPS-type system for ED)
‒ Telemedicine and telehealth services will provide health services. Specialized tele-
consult services will be provided to enable treatment and referral as needed. This will play
a major role in the rural areas of the LHIN and will help defer referral to LHIN-wide site for
higher acuity needs.
Health systems Blueprint implementation and accountability frameworks: The South West
LHIN will need to establish an implementation and accountability framework in order to
effectively enact and monitor the Blueprint. This would require establishment of a framework
which enables:

 Clear expectations of governance and leadership relationships which will facilitate and
oversee change;
 Stewardship through coordination of key stakeholders and driving the agenda forward;
 Improved efficiency and clarity of decision-making;
 Clarity of roles and responsibilities;
 Clear conflict resolution pathways;
 Adoption of established standards (e.g. project management, performance management, etc);
and
 Improved cross-sector, stakeholder coordination and communication.
This framework would be operationalized through agreed upon policies and procedures around
mandate, process and information needs, and system monitoring and evaluation.

40
Operationalize the Integrated Health System of Care
Recognizing that transformation takes time, the Blueprint project‟s planning horizon has taken
into consideration the projected population and service demands out to the year 2022. In
developing the road map, it is also important to acknowledge that some providers and parts of
the system are more experienced in undertaking systems integration initiatives relative to
others. The implementation roadmap recognizes this difference. For example, where there are
existing working groups or entities that have already started to not only think about future
change, but are acting on their plans (e.g. chronic disease prevention and management and
mental health and addictions), these groups will
be able to more quickly mobilize and take action
on the Blueprint. Conversely, where such groups Change in health care is not
do not exist, time will be required to establish
these groups and build their readiness to take on new; we must continue to be
the challenge of implementing the Blueprint‟s bold in our actions.
vision.

In order to take action and initiate the journey Sandy Whittall, London Health
towards the direction outlined in the Blueprint, the
South West LHIN and health service providers Sciences Centre and St. Joseph's
need to progressively take on a series of Health Care
implementation elements. Together, these
elements serve as a roadmap to realize the
Integrated Health System of Care. The
implementation roadmap has been created based
upon the characteristics of the future health system, which includes the current actions as
documented in recently published IHSP 2010-2013.

As seen in the next exhibit, the implementation roadmap will be realized through a multi-year
journey phased over a few IHSP cycles. The upcoming cycle, IHSP 2010-2013, includes actions
which serve as natural starting points to continue health system transformation.

IHSP IHSP IHSP IHSP


2010-2013 2013-2016 2016-2019 2019-2022

Integrated Health System of Care

During these IHSP cycles, the LHIN and health service providers will work to align IHSP actions
to further the Integrated Health System of Care and ensure progress is made in efforts of
transformation. On a periodic basis, the LHIN and health service providers will revisit the
detailed workplan and refresh it to account for environmental considerations (e.g. political
interventions, changing priorities) to be fluid in planning and implementation.

Therefore, as appropriate, the IHSP actions will align to one of the following three threads which
provide a framework for implementation planning.

41
Accelerate 2010-2013
IHSP strategic directions

Initiate implementation
elements

Launch enablers

During the 2010-2013 timeframe, the LHIN and health service providers will focus on
accelerating the IHSP strategic directions while initiating planning for the remaining threads,
initiate implementation elements and launch enablers. Progress on these threads will be
furthered through upcoming IHSPs and accountability agreements as deemed appropriate.

These threads, which create a framework for implementation planning, include key processes
that will be involved in operationalizing the Integrated Health System of Care.

Accelerate implementation of the 2010-2013 IHSP strategic directions and actions:

The IHSP strategic directions and actions have been developed and aligned to the health
services Blueprint project. The identified actions are in progress or ready to be launched, have
dedicated resources, and have engagement of health service providers.

As well, the LHIN and Health Service Providers should continue to support the current initiatives
and pursuits which have dedicated stakeholders and align to the Blueprint. This process would
encompass performance measurement strategies so as to collect and measure performance
indicators throughout implementation.

A summary of these initiatives is provided below.

Actions Related to Enhancing Capacity and Integration of Primary, Specialized


and Community-based Care, with a Focus on the Following Populations:

Seniors and Adults with People Living with Mental People Living with or at Risk of
Complex Needs Health and Addictions Chronic Disease(s)
Challenges

 Through Aging at Home (Year  Increase supportive housing  Implement Chronic Disease
3): for people with problematic Prevention and Management
‒ Develop and implement an substance use and strategies with an initial focus on
integrated model of care for concurrent disorders the Ontario Diabetes Strategy
high-risk seniors  Implement a screening tool and extend to other chronic
to screen universally for illnesses where relevant
‒ Develop and implement a
coordinated system of care concurrent disorders  Leverage success of the
for seniors with behavioural  Implement a training Partnerships for Health project
issues program to help people to and extend to other chronic
develop personal wellness illnesses where relevant
‒ Enhance services and
supports for Aboriginal plans  Implement enabling technologies
seniors  Improve access to with an initial focus on the
community mental health provincial Diabetes Registry and
‒ Enhance capacity and include other enabling
coordination of transportation and developmental services
for persons with a dual technologies where relevant
services
 Explore the applicability of the

42
‒ Create additional diagnosis Diabetes Registry to manage
convalescent care beds in  Work with partners to data for other chronic diseases
long-term care homes facilitate the movement of  Continue with, and expand,
 Define the role of and access specialty hospital services implementation of self-
to complex continuing care (Tiers 2 and 3 divestment) management strategy
beds and rehabilitation  Work with partners to  Implement peritoneal dialysis in
services enhance the availability of long-term care homes to align
 Monitor results of all Aging at and access to children‟s with Ontario Renal Network
Home initiatives mental health beds

 Continue to work with Aboriginal and Francophone communities to improve availability of and access to
services

Actions related to Enhancing Access and Sustainability of Hospital-based Treatment and Care
Related to:

Emergency Services Medicine, Surgical and Critical Care Services

Based on the recommendations of the Emergency Engage key local, multi-community and LHIN
Department Human Resources Study, engage key community stakeholders to develop an action plan
local and multi-community stakeholders to initiate a for creating and implementing Centrally
process to develop and implement strategies Coordinated Resource Capacity for medicine,
tailored to their communities‟ emergency services surgical and critical care services, with a focus on:
needs, with a focus on:  A LHIN-wide resource capacity management
 Emergency services recruitment and retention system
capability  A centralized coordinated referral system,
 Emergency services coverage with current evidence based care pathways and order sets,
resource pool tools and quality guidelines
 Emergency services health care personnel
capacity

The success of these actions will serve as a catalyst for further operationalizing future
implementation elements.

Initiate implementation elements: • Long-Term


Integrated health Care Homes
services collaborative • Supportive
housing
Other implementation elements, outside of those Co-located
setting
• Home and
Community

included in the IHSP 2010-2013, will be initiated in a Care


• Rehabilitation

timely manner dependent on the status of supporting Mobile


setting Strengthened
Coordinated
Community
Care services
Relationships
reference groups. The reference groups responsible for
initiating implementation elements following those Virtual
setting Fitness
programs Mental

identified in the IHSP 2010-2013 would also be in a health


services

position to integrate key lessons learned from the initial Substance


Problem
gambling
services
abuse
IHSP opportunities. services
Nutritional
clinics

• Linkage to core • Linkage to


hospital services specialist
(medical and services
surgical) (Schedule 1, Physician
etc) Inter-prof essional resource
• Emergency Services

43
Key implementation elements may include:

 The development of Integrated Health Service Collaboratives (IHSC): transforming current


primary care settings (e.g. FHT, FHN, CHC, solo-physician offices) into a co-located, mobile,
or virtual IHSC which works with its health partners to provide education, screening,
assessment, treatment, navigation, and the necessary support services; and
 The development of a resource capacity plan to better coordinate surgical bed capacity across
the LHIN to accommodate local, multi-community, and LHIN service delivery.
The success of each of these elements is dependent upon the dedication of a reference group
of key cross-sectoral stakeholders able to provide the expertise and guidance in fully
operationalizing the element. In some cases, these groups may exist, or such groups may need
to be created. This reference group would receive the appropriate support by the LHIN to
facilitate the process, resources, and project management expertise as necessary.

 Development of work plan: These groups, with support of the LHIN, would be charged with
developing the process/structure for implementation including a detailed work plan. This
group would be tasked with determining the launch dates for the element.
 Understand the environmental scan: As a key initial step, the expectation would be that the
group understands the approach and quantitative/qualitative findings from the environmental
scan as a source to provide directional insight into moving the element forward.
 Identify champions and launch pilots: Once plans are in place, these groups should support
the identification of initial “pilot” or launch sites which would serve as early adopters or
champions for specific elements. With coordinated support from the LHIN, these pilot sites
will be provided the resources to plan and enact change, measure it, and continue to refine
the initiative.
‒ In serving as a pilot, the site will provide the necessary „lessons learned‟ as the initiative is
rolled out to other sites. Implementation success would be dependent on the support of
partnerships with Health Service Providers, social organizations, and broader non-LHIN
partners as appropriate.
 Implement across the LHIN: Once the initial pilots are completed, the next phase of the
implementation process will be the roll out of a given initiative across the LHIN as
appropriate. To do this, reference groups would lead the development of a detailed
implementation plan which involves a phased approach to roll out the element.
‒ This process would encompass performance measurement strategies so as to collect and
measure performance indicators.

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Launch enablers to realize Integrated Health System of Care:

The four threads of enablers impact the entire health system and will require a longer journey to
complete implementation. As a result, it is critical that these elements be kicked-off with the
development of a cross-sectoral reference group which will clearly outline a phased approach to
implementation. This reference group would receive the appropriate support by the LHIN to
facilitate the process, resources, and project management expertise as necessary.

 Development of work plan: These groups, with support of the LHIN, would be charged with
developing the process/structure for implementation including a detailed work plan. This
would include the development of interim milestones which would translate into small
successes to be rolled out across the LHIN.
 Understand the environmental scan: As a key initial step, the expectation would be that the
group understands the approach and quantitative/qualitative findings from the environmental
scan as a source to provide directional insight into moving the element forward.
 Phased implementation of the enabler: As defined by the detailed work plan, reference
groups would lead the development of a detailed implementation plan which involves a
phased approach to roll out the enabler.
Implementation success would be dependent on the support of partnerships with Health Service
Providers, social organizations, and broader non-LHIN partners as appropriate.

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Call to action
The Health Services Blueprint has set a transformational agenda for the South West LHIN to
create “A health care system that helps people stay healthy, delivers good care to them when
they get sick and will be there for their children and grandchildren.”

Informed through considerable stakeholder engagement, it builds upon the successes to date,
to outline a more coordinated, collaborative path towards system transformation.

In order to take the Blueprint from words to action, a collective commitment is required on the
part of all provider organizations, direct service providers and communities. Working with our
partners within the Ministry of Health and Long-term care, primary care, public health and
others, we must keep the needs of our communities front and centre, and build and align all
aspects of our system to work in concert with one another such that we are all collectively
working towards the same objective – a healthier South West LHIN population.

How are we going to get there?

Action is required. Without this, the Blueprint is destined to be simply „yet another plan‟. That
said, we must take to heart our collective accountability per the Local Health System Integration
Act, 2006, to look for opportunities to integrate the local health system. In doing so, we must
collectively focus and take action immediately if we are to capitalize on the positive energy and
system-wide anticipation that has been generated through the Blueprint development process.

The time is now to take the critical initial steps towards change.

Recognizing this, we must be prepared to move forward through our impending and future
initiatives. To kick-start the venture, the Health System Design Steering Committee will
immediately undertake the following key initial action steps:

 Identification of leadership to guide and lead change efforts, both at the system-wide
level and within targeted implementation initiatives.
 Framework for implementation planning to be completed by March 31, 2010. This
framework will guide the development of detailed implementation plans. As part of this
process, we will work with stakeholders within the context of the IHSP 2010-2013 priorities, to
identify those opportunities that are innovative, align to the blueprint, and can serve as
“success stories” and in doing so be an example of positive change. While we will collaborate
with health service providers to proactively identify these groups, we urge you to engage in
seeking out opportunities as well.
These “actions” are critical to continuing to build a culture and environment of partnership and
change within our communities and build an understanding that transformation is real and can
happen if there is a collective will.

In addition to the above immediate next steps, we, the LHIN, in collaboration with its health
system partners, will continue to provide overall direction to our health system design process.
More specifically, we will work to take action on the following:

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 Development of future IHSPs aligned to the vision of the Health Services Blueprint;
 Creation of incentives for health service providers and partners as able and deemed
appropriate;
 Maintaining a transparent process with open lines of communication to enable easy
collaboration; and
 Modification of future new accountability agreements to include elements of the health
services blueprint. As appropriate, these agreements will reflect transformative elements
which will prompt health service providers to enact change. These agreements will reflect the
partnerships involved across providers in making change through joint accountability
statements.
Change is never easy. However, acknowledging the resource limitations of today and potential
pressures of the future, change is even more imminent and the success of the future health
system is dependent upon effective partnerships with our health service providers. Through a
shared commitment, we can improve the health of our community, so, please join us in
developing a better tomorrow.

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Supporting documents
 Appendix A: Programmatic Chapter Summaries:
‒ Appendix A.1: Mental Health and Addictions
‒ Appendix A.2: Chronic Disease Prevention and Management
‒ Appendix A.3: Long Term Care Services and Complex Continuing Care
‒ Appendix A.4: Medicine Services
‒ Appendix A.5: Surgical Services
‒ Appendix A.6: Critical Care Services
‒ Appendix A.7: Emergency Services
‒ Appendix A.8: Women‟s Health and Paediatrics
 Appendix B: South West LHIN Vision, Mission, Values, and System Level Goals
 Appendix C: Approach and Methodology
 Appendix D: Service Delivery Approaches
 Appendix E: Implementation Elements
 Appendix F: Glossary of Terms
 Appendix G: Steering Committee Membership
 Appendix H: Technical Report including current state report, future state report, and order of
magnitude analysis
 Appendix I: Peer Models of Care Report

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