Mid East Toronto Health Link Let’s Make Healthy Change Happen New MoHLTC Health Link Indicators Mid-East Toronto HSP Training Session Fall/Winter 2018-19

Context In April 2018, the Ministry of Health and Long Term Care released a series of new indicators for Health Link. There are 2 modified indicators and 3 new indicators which apply to HSPs. The goal of the new indicators is to standardize the approach to tracking quality and value of the Health Link approach. HSP data collection on the new indicators needs to begin January 1 2019 and cover the Q4 FY 2018/19 period. A manual data tracking spreadsheet was developed provincially for all HSPs. HSPs will need to begin with manual data collection on all 5 indicators using this spreadsheet. At this point, you can submit either the manual data collection sheet, or the summary table (last slide) with the calculations. It is likely that all 5 indicators will be possible to track centrally at TC LHIN via the eCCP (CHRIS + HPG). That said, all staff should collect data manually for Q4 FY 2018/19, even if they are being on-boarded to eCCP (CHRIS + HPG). Our hope is that in FY 2019/20, staff will be actively using eCCP (CHRIS + HPG) and manual data collection will no longer be necessary. Organizations that are not being on-boarded to the eCCP will need to report data manually ongoing. In January 2019, it was announced that a Provincial Health Link Patient Registry will be compiled of all patients/clients with a (Coordinated Care Plan) CCP. TCLHIN is looking at how they will approach this from a consent and data management perspective - manual data collected via the indicators (or eCCT) could be used for the registry - you will be informed in advance of the details related to consent processes.

Health Quality Ontario Coordinated Care Management Process Manual Data Collection Points – Corresponding Columns on Excel Spreadsheet Column A, B, C, F Column J, Column G, H Column K Column I, L, M, N Column D, E

Indicator 1: New CCPs Developed Number of individuals living with multiple chronic conditions and/or complex needs with a new CCP developed through the Health Links approach to care. Definition: New CCP developed in the given quarter Created with client and/or caregiver and 2+ healthcare professionals Follows provincial CCP template (paper or electronic) Contains an action plan for 1+ health issues (physical, functional, mental, social, etc.) Available to individual and/or caregiver and team members This indicator (and all subsequent indicators) are reported on based on the client’s sub-region of residence.

Determining Client Sub-Region of Residence (Column F) Mid-East Toronto sub-region is highlighted in green, and East Toronto in purple. You can use the following links to determine sub-region of residence as well: http://map.toronto.ca/maps/map.jsp?app=TorontoMaps_v2 http://www.torontocentrallhin.on.ca/forhsps/subregions.aspx For homeless clients/those without a fixed address, please use the sub-region in which the agency or site leading the client’s CCP is located.

Indicator 1: New CCPs Developed - Calculation Numerator: Use “Date of newly developed CCP” (Column I ) to count the number of CCPs created during the quarter, per client sub-region of residence. Denominator : 1

Indicator 2: Primary Care Attachment through Health Link Percentage of individuals with a CCP who are newly attached to a primary care provider through the Health Links approach. This indicator refers to the number of clients who are newly rostered with a primary care provider as a result of the Health Link work. This indicator does not refer to whether the client regularly see their primary care provider nor does it refer to the quality of their relationship with their PCP, but rather, simply if they are registered with a Primary Care Provider. The number of clients who were unattached to a PCP at the time of being identified/referred to Health Link is collected first. Then the date of attachment is recorded for these clients. This indicator relates to all clients with a CCP developed, not just those with a CCP developed in the given quarter. It is a “rolling” indicator, updated on an ongoing basis.

Indicator 2: Primary Care Attachment through Health Link - Calculation Numerator: Total number of individuals with a CCP who are newly attached to a primary care provider, by sub-region of residence. 1) Identify all individuals who have had a CCP initiated. Refer to "Date of Initial Face-to-Face Visit/Assessment with the Individual which is the proxy for date of newly initiated CCP (Column G) 2) Using "Date of Individual's attachment to a PCP", (for those who were unattached at date of identification/referral), count the total number of dates in this column. (Column K) This measure is cumulative.

Indicator 2: Primary Care Attachment through Health Link - Calculation Denominator: Total number of individuals with a CCP who are unattached to a PCP at the time of identification /referral for the Health Link approach to care, whose care coordination status is active, by sub-region of residence. Use "Date of Initial Face-to-Face Visit with the Individual” (= date of newly initiated CCP) (Column G) to identify all individuals who have had a CCP initiated. Use the status of the individual's attachment to PCP at time of identification/referral (Column J). Count the total number of individuals listed as “unattached” in this column. Use the “Care Coordination Status” (Column D) column to count the number of individuals that are now “inactive” and subtract this number from step 2. “Inactive” means that they have been “discharged” from caseloads for any of the reasons that are listed in the drop-down. This measure is cumulative.

Indicator 3: Timely Access to PCP, Self-Report Percentage of individuals with a coordinated care plan (CCP) and attached to a primary care provider (PCP) who self-report timely access to PCP. This indicator measures all individuals with a CCP who are attached to a PCP who self-report timely access to their PCP. Question: “Would you say the length of time between making the PCP appointment and the actual visit was about right, somewhat too long, or much too long?” Note: This question cannot be rephrased. Although, if the client requires clarification as to the meaning of the question, this can be offered. There is a drop-down in the spreadsheet with specific answer options listed: about right, somewhat too long, or much too long, other, don’t know, or no answer. Clients should be asked this question at the care conference where the CCP is developed. Ideally, the client is asked this question by the provider each time their goals change. There is a drop-down in the spreadsheet to indicate the last date the question was asked.

Indicator 3: Timely Access to PCP, Self-Report - Calculation Numerator: The number of individuals with a CCP and attached to a PCP, who within the reporting period, responded “about right” to the PCP Access question, by sub-region of residence. Use "Date of Newly Developed CCP” (Column I) to identify all individuals who have had a CCP created. Refine this list by determining all those who are attached to a Primary Care Provider in "Status of Individual's Attachment to a Primary Care Provider at the Time of Identification/Referral" (Column J). For those who were unattached, see “Date of Individual’s Attachment to Primary Care if they were Unattached at Date of Referral/Identification” (Column K). For individuals who were attached to primary care according to the data in either Column J or Column K, use “Date PCP Access Question Asked” (Column L), identify the individuals who answered the PCP Access question this quarter. Then count the number of individuals who gave the answer “About Right” as Answer of PCP Access Question (Column M). Denominator: Total number of individuals who answered a “PCP Access” question this quarter (Column L), per sub-region of residence. All “no answer” responses are excluded.

Indicator 4: Wait Time from Identification to Initiation Percentage of individuals living with multiple chronic conditions and/or complex needs who waited 7 days or less from Health Links referral/identification to initiation of the coordinated care plan (CCP). Date of initiation is recorded as the point of a face-to-face visit with the CCP lead where the provincial CCP template is used. It is necessary to report both the date of identification/referral and the date of the newly initiated CCP/first face-to face visit to be able to calculate this. The spreadsheet will automatically calculate the number of days between these two dates. If your spreadsheet does not automatically calculate the number of days between identification/referral and the newly initiated CCP, please calculate the number of days on your own.

Indicator 4: Wait Time from Identification to Initiation – Calculation Numerator:  For each individual with a newly initiated CCP within the reporting period per sub- region of residence, determine the number of days between the date of referral/identification and the date of initiation. The numerator is the number of individuals for whom the date difference is 7 days or less. Use the date of the initial Face-to-Face visit (Column G) to identify individuals who had a newly initiated CCP during the quarter. Use the number of days in “Wait time” (Column H), to count the number of individuals who waited 7 days or less . Denominator: Use the date of initial Face-to-Face visit (Column G) to count the number of individuals who had a CCP initiated in the reporting period

Indicator 9 – Patient Confidence Score Percentage of individuals with a coordinated care plan (CCP) who have a recorded patient confidence score. Question : “How confident do you feel that your care goals will be reached?” The client is asked to give “a score” between 0 (not very confident) and 10 (very confident). The question should not be adapted. If you are concerned that the client may perceive a conflict of interest, you can say: “This will not put you at risk for any reductions or changes in service as a result of your answer, it is intended to help us serve you better”. Only the date of the first confidence score should be recorded in the spreadsheet. This question should be asked in the Care Conference where the CCP is developed. Ideally, the question is asked whenever the clients goals or approach to their goals changes. When the client states that their confidence score is less than 7, the provider should ask the client: “What would it take to increase your score?” The response to this question is intended to influence the work you will do for the client.

Indicator 9: Patient Confidence Score - Calculation Numerator: The number of people with a CCP developed within the reporting period who have a recorded patient confidence score, by sub-region of residence. Use “Date of the newly developed CCP” (Column I) to identify all of the individuals who have a newly developed CCP in the reporting quarter. Use "Date of First Confidence Score” (Column N) to count the number of individuals identified in Step 1 who were asked their confidence score in the given quarter. Denominator: Use "Date of newly developed CCP” (Column I) to identify the number of individuals who have a newly developed CCP in the reporting quarter.

Important Information on Other Columns Individual’s Care Coordination Status (Column D) and Date of Care Coordination Status Change (Column E): There is no specific “Discharged/Inactive” option in the dropdown in Column D. Health Link clients that have been discharged from caseloads should be noted according to the options that are provided on the dropdown. In some cases, clients who Move or who Decline service for example, may not always be discharged from caseloads and may still be marked as “Active”. Column E indicates the date of any change in Care Coordination status. Be sure to review and update Column E each quarter before calculating your indicators. Identifying/Referring Organization (Column C): This is required for the sub-region to be able to report out on a separate indicator: Percentage of HSPs in the sub-region identifying clients for Health Link.

Reporting on the Indicators HSP staff should track data in the provincial spreadsheet. Managers/Directors should summarize the data using the table below - they can submit both an aggregate Excel spreadsheet for their organization and the summary table to the Sub-region, or if they prefer, just the summary table. If HSPs choose to submit the summary table only, they should also provide the names of the organizations who are listed in Identifying/Referring Organization (Column C). A separate Summary Table needs to be done for each sub-region of residence your has collected client data on for the indicators. Organization Name: Sub-Region Reporting On: Contact Person: Indicator Name Q4 2018/19 Q1 2019/20 Individuals with a CCP Developed Numerator   Denominator PCP Attached through Health Link PCP Access is Timely Wait Time 7 days or less Confidence Score Question