Integration Conversation Advancing the Integration Conversation Toronto Central LHIN Board Presentation April 27th, 2016 Integration Review Project Co-Leads: Anne Babcock Marnie Weber

- Toronto Central LHIN resident “I don’t care how you organize my health care or about the rules – I just want care when I need it, where I can get to it, and to feel confident that it is going to make me better.” - Toronto Central LHIN resident

Integration is a Means to Create Real Change Health Service Providers and the Toronto Central LHIN have a shared accountability to deliver health care services that result in the best experiences and outcomes for clients and patients, as well as value for money Informed by the Toronto Central LHIN Strategic Plan 2015-2018 and Patients First, the objectives of the Integration Review Project were to explore: How to leverage continued success and build the momentum of voluntary integrations How and when the Toronto Central LHIN should use facilitated integrations successfully Identify specific opportunities in Toronto Central LHIN where integration could be used as a means to improve system performance, as well as outcomes and experiences of clients and patients

Diverse Inputs were Used to Inform the Integration Review Project The Review Team engaged over 200 people, received 146 surveys, analyzed local data, and researched leading integration practices

Integration Is More Than Just Mergers Additional Considerations for Integration Degree of Integration Linkage (ad hoc) Coordination Structured Collaboration Program/Service Transfer Full Integration Limited or informal connections, network One time / ad hoc working arrangement Ongoing formal partnership/coordination agreements within a system Program/service level No structural changes Ongoing formal collaboration agreements within a system Standardization along care pathway, shared services Brands remain separate Formal transfer, merge or amalgamation of program services May include back office services/functions as well as clinical Creation of single system of care Based on Kodner’s model

Health Service Providers Clients, Patients and HSPs See the Opportunities that Integration Brings Apprehension surrounding integration exists, but there is also an urgency to move forward in doing what is best for clients, patients and their families Clients and Patients Health Service Providers Want an improved experience and smooth transitions in care Want better access to information and education See barriers to care: language, wait times, affordability, cultural sensitivity Feel pressures of family and caregiver burnout Want care and services to address their full range of needs, including housing, transportation, and financial assistance, not just their medical needs Desire active LHIN support for integration, when and how it makes sense Want to create improvement in services from a client/patient perspective Want to be engaged and involved in planning processes that affect them Want to remain viable and sustainable Want control over their future

Recommendations for Toronto Central LHIN Create a Culture of Integration and Change Changing the way we think and talk about integration Drive Effective System Performance Working with each other to deliver a health care system that is responsive to local needs, creating better outcomes and experiences Build Capacity and Success for Health Service Providers Supporting HSPs to use integration to improve viability and sustainability of programs and services of the LHIN Sustain and Build on the Successes of Voluntary Integrations Sharing knowledge, information and tools to promote voluntary integrations

What We Heard: Integration Should be Discussed Openly Integration can elicit anxiety and fear due to uncertainty: Program and organizational impact Staff layoffs Maintaining a unique identity Relinquishing control A shift is needed in how we talk about integration, through: Thoughtful and consultative processes Well-founded rationale and evidence Defining success Open communication “What is the hidden agenda here? We need to be transparent when we talk about our intentions with integration.” (Interviewee in Toronto Central LHIN) Clients, patients and HSPs want the LHIN to talk openly about integration

Create a Culture of Integration and Change Recommendation #1 Create a shared understanding across the Toronto Central LHIN that integration means a spectrum of activities – not only organizational mergers – to create desired change within and across sectors including: Partnerships; Collaborations; Transfers; Consolidations of programs, services, and back office administrative functions. When integration can be openly discussed, voluntary integration opportunities will develop

Drive Performance: What We Heard Clients and providers identified areas for improvement across the LHIN Health professionals do not always communicate well, and care and access to care is not always well coordinated Clients/patients do not always get the information they need Services do not always address the unique needs of neighbourhoods and populations “I feel like I’m the one who has to keep track of my medical records, because no one else manages them for me or knows everything about my situation.” (Toronto Central LHIN resident) “I want to be able to spend the time to talk to my doctor about my health. It is hard to figure out what my lab results mean and I don’t know how to ask the right questions.” (Toronto Central LHIN resident) Clients, patients and HSPs are not confident that the local health care system is well coordinated around their needs

Drive Performance: What the Data Says Intensive Case Management: 4 months 3% 12% 15% 21% Supportive Housing: 4 years COPD HTN Cancer CHF Chronic Disease ED Visits ED Visit Rates Long Waits An increasing number of Emergency Department visits for Chronic Conditions: 3%-21% increase over 5 years Rates of low urgency ED visits (CTAS 4/5) range between Sub-LHINs: 61.9 – 111.7 per 1,000 population Long waits for Mental Health and Addictions care: Median 4 months for Intensive Case Management; 4 years for supportive housing at 90th percentile

Drive Effective System Performance Recommendation #2 The Toronto Central LHIN should establish Sub-LHIN Region Integration Tables to create better client/patient outcomes and experiences, tasked with: System planning; Identifying, prioritizing, and coordinating integrations; and, Focusing on: Community mental health and addictions; Home and community care; and, Primary care services and programs. Bringing cross-sector HSPs together to focus on common problems will create momentum for improvement in Sub-LHINs

Drive Effective System Performance Recommendation #3 The Toronto Central LHIN should drive system change that will have a measureable positive impact on the health of the population in Toronto Central LHIN and beyond, by: Identifying and encouraging voluntary integrations; and, If needed, facilitating and supporting integrations. Taking an active role in driving improvements will increase the speed of positive change

Collaborate to Support Health Service Providers: What We Heard Providers struggling to meet performance goals are often seeking ways to improve Integration discussions are occurring internally and with potential partners HSPs sometimes want supports from the LHIN, in different forms Some HSPs want the LHIN to be more active in making changes happen “One of our enablers was bringing the Boards of various HSPs together to have a dialogue around opportunities. Boards of different HSPs don’t meet together naturally, and it was helpful to sit together face-to-face and talk about the patient journey” (Other Ontario LHIN Perspective) HSPs want to make changes and report that they are doing them independently, but want some LHIN support in some situations

Collaborate to Support Health Service Providers: What the Data Says Some HSPs struggle to remain viable and sustainable, needing some additional support to build capacity 10 (14%) had negative margins for the last two fiscal years 10 (15%) had negative margins for the last two fiscal years

Collaborate to Support Health Service Providers: What the Data Says Administrative costs vary significantly across HSPs

Build Capacity and Success for Health Service Providers Recommendation #4 To build the viability and effectiveness of health service providers, the Toronto Central LHIN should: Actively work with those HSPs which are struggling to meet performance targets; and, Identify and act upon strategic options that may include a range of integration solutions. Leveraging good data will help identify and evaluate integration opportunities

Build Capacity and Success for Health Service Providers Recommendation #5 The Toronto Central LHIN should facilitate inter-HSP conversations at the HSP governance level, to: Talk about the benefits and realities of integration; and, To create Toronto Central LHIN-wide momentum for Voluntary Integration strategies. Board Directors will be able to identify and push strategic opportunities

What We Heard: Share Integration Resources Leaders are looking for a range of supports from the LHIN throughout the integration process Integration expertise Process expertise Project management Legal counsel Communications IT/IM Financial support for: Exploration Assessing Feasibility Planning & Implementation “The amount of work can be huge, and HSPs sometimes find that this is larger than what they originally scoped.” (Other Ontario LHIN Perspective) HSPs want different levels and types of LHIN support depending on the unique situation

Sustain and Build on the Successes of Voluntary Integrations Recommendation #6 The Toronto Central LHIN should create and maintain an integration knowledge centre, to: Share the successes and challenges of integration; and, Support those exploring, assessing, planning and implementing integrations in Toronto Central LHIN. Access to integration resources will ensure that HSPs can apply learnings to their own situations, to improve success rates

Sustain and Build on the Successes of Voluntary Integrations Recommendation #7 The Toronto Central LHIN should widely launch the Integration Toolkit to enable Health Service Providers to explore, assess and plan for Voluntary Integrations. Providing evidence-informed tools will support HSPs to explore and undertake strategic integrations

What Will be the Impact? Successful implementation of the recommendations is expected to have the following impacts: Clients, Patients, Families Health Service Providers Toronto Central LHIN Improved access to appropriate care More focus on local needs Improved outcomes and experiences Expectations of a common experience Better health information sharing Programs and services matched to need Leaders and Board members consider integration a tool to create better services More voluntary integrations Increased availability of support for HSPs to explore and pursue integration HSP businesses and operations stability Performance-related issues addressed Improvement on key system indicators More voluntary integrations Shift to shared group accountability for system improvement More effective and focused use of health care dollars Momentum to implement integrations Clarity around role of LHIN in initiating/ supporting integrations

Recommendations Strengthen the Toronto Central LHIN 1. How to leverage continued success and build the momentum of voluntary integrations 2. How and when the Toronto Central LHIN should use facilitated integrations successfully 3. Specific opportunities across Toronto Central LHIN where integration could be used as a means to improve system performance Recommendation #1: Shared Understanding of Integration  Recommendation #2: Sub-LHIN Region Integration Tables Recommendation #3: Integrations to Impact Health of Population Recommendation #4: HSP Viability and Effectiveness Recommendation #5: Governance-to-Governance Recommendation #6: Integration Knowledge Centre Recommendation #7: Launch Integration Toolkit

Advancing the Integration Conversation Appendix Advancing the Integration Conversation

Reference Documents: Table of Contents APPENDIX 1: INTEGRATION PATHWAY IN THE TORONTO CENTRAL LHIN Exploration Feasibility Planning and Implementation APPENDIX 2: INTEGRATION TOOLKIT FOR TORONTO CENTRAL LHIN HEALTH SERVICE PROVIDERS Who Should Use the Integration Framework and Toolkit Tool 1: Strategic Options Assessment Tool 2: High-Potential Partnership Identification Tool 3: Due Diligence to Assess Feasibility Integration Implementation Considerations APPENDIX 3: IMPLEMENTATION PLAN DETAILS FOR RECOMMENDATIONS APPENDIX 4: DETAILED SUMMARIES OF RESEARCH Defining Integration in the Toronto Central LHIN Summary of Engagement Findings: Clients, Patients, and Providers Summary of Data Analysis Activities Wait Times for Mental Health Services Care Best Managed Elsewhere Total Margin Percentage of Budget Spent on Administration Cost per unit of Service and Individuals Served per FTE APPENDIX 5: BIBLIOGRAPHY

Integration Pathway for Toronto Central LHIN

Integration Toolkit Strategic Options Assessment Tool High-Potential Partner Identification Tool Due Diligence Tool

Implementation Timeline 2016 2017 Q1 Q2 Q3 Q4 Q1 Q2 1. Create a shared understanding of the benefits of integration 2. Establish Sub-LHIN Integration Tables to encourage system-level integration discussions 3. Drive system change by identifying, facilitating and supporting integrations that will enhance the health of the population 4. Build viability and effectiveness with HSPs not reaching targets by exploring strategic options such as integrations 5. Facilitate conversations at the governance level to explore and initiate voluntary integrations 6. Create an integration knowledge centre 7. Launch the Integration Toolkit broadly Legend Create a Culture of Integration & Change Drive Effective System Performance Build Capacity and Successes for HSPs Sustain and Build on the Success of Voluntary Integrations