1. Need for Comprehensive Canadian Strategy Role of the Provincial Governments Obesity in Canada: Prevention to Treatment 1 st Annual CABPS Conference in Conjunction with OBN & CMAS Mississauga, Ontario June 8, 2012 NAMD

2. Overview 2 Role of Provincial Government in General - Scope limited to context of program delivery Case Study: Ontario Bariatric Services Strategy - Treatment focus (will not include prevention role)

3. Other Aspects 3 Share and liaise with other provinces Engage in broader discussion

4. Policy and Delivery Roadmap 4

5. Program Cycle 5 Develop evidence- based policy and program design Allocate resources through provincial priority-setting and budget process Engage experts in setting standards and performance measures Fund and apply appropriate accountability mechanisms Support implementation and make adjustments Monitor performance and accountability

6. 6 Ontario Health Technology Assessment Committee Expert Consultations Framework Evidence-based Framework Bariatric Services Strategy HealthTUGO Literature Other Jurisdictions Key Recommendations Provincial Program Team Approach Centres of Excellence Role for Primary Care Registry Telemedicine

7. Ontario Bariatric Network Clinical Standards Best Practice s Registry Wait Time Management Central Referral Portal Patient Outcomes Tracking Research Regional Assessment & Treatment Centres (RATC) Telemedicine Education & Outreach Centres of Excellence (CofE) Program Design

8. 8 Allocate Resources Out-of-Country and In-Province Surgeries Out-of-Country and In-Province Surgeries 2002 – 2011

9. 9 Behind the numbers DRIVERSSITUATIONIMPACT ↑ Rate of obesity ↓ Risk (laparoscopic approach) ↑ Knowledge & acceptance of bariatric surgery Few Ontario bariatric surgeons Limited knowledge among referring physicians Applications driven by patients (incl. surgery type) Limited Ontario capacity Inconsistent assessment Variable or no long-term follow-up Celebrity publicity Internet Aggressive marketing by US providers Walk-in clinic referrals OOC patients with complications Rapidly increasing expenditures OOC and also in-province due to complications CONTEXT

10. 10 Allocate Resources Bariatric Services Strategy Announcement in July 2008 $75 M as part of Ontario Diabetes Strategy Comprehensive Bariatric Strategy to build capacity in Ontario to:  improve patient outcomes;  increase patient safety; and  reduce the demand for increasing number of referrals for out-of-country (OOC) bariatric procedures. Short-term Reduce the cost/case for OOC bariatric surgeries Establish surgical capacity at two provincial Centres of Excellence Medium- term Help reduce patient volume sent OOC Implement provincial waiting list Establish assessment capacity throughout Ontario Long-term Increase provincial surgical capacity at 6 - 7 Centres of Excellence.

11. 11 Standards & Performance Measures Ontario Bariatric Network in Action Assessment Surgery Selection Pre-op Testing Mental Health Registry Implementation Telemedicine Teleconferences Trouble-shooting Quick sharing of innovations Topic-focused Working Groups

12. 12 High-Level Bariatric Referral Process 1 st Assessment is booked (if patient agreeable) Confirmation Letter: 1 st Assessment Appt sent to Patient & Referring Physician Confirmation Letter: 1 st Assessment Appt sent to Patient & Referring Physician Y Patient Shows First Assessment Occurs Subsequent Assessments Booked SURGERY Date Booked SURGERY Date Booked SURGERY Occurs 9-month Surgery Goal (1-year Max) 9-month Surgery Goal (1-year Max) Confirmation Letter: Surgery Date is sent to Patient & Referring Physician Composition of Team differs between Centres. May include: Dietitian Social Worker Patient Education Psychologist/Psychiatrist Internist/Endocrinologist Composition of Team differs between Centres. May include: Dietitian Social Worker Patient Education Psychologist/Psychiatrist Internist/Endocrinologist Confirmation Letter: Orientation Date is sent to Patient & Referring Physician Orientation Session Occurs Orientation Session Occurs Patient Responds Physician Faxes Referral Form to the Bariatric Registry Referral Data is sent to BCOE/RATC based on LHIN designation BCOE/RATC receives Referral Data Information Orientation Session: within 3-weeks of Referral received at the centre, patient & referring physician receives info about the next Orientation Session Package Received: Patient has 4-weeks to respond to the BCOE/RATC for their Orientation Date. Y 3-month Goal 3 month Goal Y 3-months1 st Assessment to Surgery Date

13. 13 Wait Time Paradox Assumption : Patients who have the most severe obesity-related co-morbidities should have quicker access to surgery. Clinical Reality: Patients who have the most severe obesity-related co-morbidities require several months of assessment and preparation prior to surgery to reduce surgical risk and achieve good outcomes: Diagnostic tests Management & stabilization of co- morbidities

14. 14 Funded Programs Toronto Collaborative Centres of Excellence Ottawa Centre of Excellence Kingston Regional Assessment & Treatment Centre Windsor Regional Assessment & Treatment Centre Sudbury Regional Assessment & Treatment Centre Guelph Centre of Excellence Thunder Bay Regional Assessment & Treatment Centre Hamilton Centre of Excellence Ontario Bariatric Network Registry HSC PRATC CHEO PRATC

15. 15 Implementation 2009 436 surgeries in Ontario 200+ OOC Approvals / month 2012 Ontario Bariatric Network Bariatric Registry 2,500+ surgeries in Ontario Bariatric Centres across province

16. 16 Implementation & Adjustments Examples of Innovations & Best Practices ISSUESOLUTIONBENEFITS “No shows” & cancellations for appointments Group Orientation Sessions Protocol for no shows Standard intro to bariatric program Patients return committed to process Access to step down units for bariatric surgery patients (“bumping”) Enhanced post-op ward monitoring (remote O 2 ) Early alert of complications Fewer pre-op sleep studies required

17. 17 Performance & Accountability Ontario Bariatric Registry Phase II comprehensive clinical data currently being collected Phase I central referral portal, live as of October 8th, 2010 Aim to improve the care of the obese patient and increase the effectiveness of health care dollars

18. 18 Bariatric Registry AGGREGATE PATIENT DATA Anthropometrics Laboratory Comorbiditdy Medication Surgical PROGRAM DATA Type of Surgery Intra – Operative Complications Post – Operative Complications (Surgical) Post – Operative Complications (Medical) Care path timelines Baseline → 6-mos → 1-yr → 2-yr → 3-yr → 5-yr Regular Site & Provincial Report Cards

19. Lessons 19 Forums for both formal and informal discussions at all levels were key to sharing of ramp up lessons and systems response to issues as they arise Communication Mechanisms involving data and health information privacy protection take time Health Information Institutions and clinicians are capable of high levels of collaboration given mandate and supports Collaboration

20. 20 www.ontariobariatricnetwork.ca