Community Health Services Integration Strategy

Central East LHIN Board of DirectorsFebruary 2012

Goals

To achieve Central East LHIN Board approval to move forward on an integration strategy and process for Community Support Service providers and Community Health Centreswithin the Central East LHIN.

2

Strategic Aim for Community Health Services Integration

Design and implement a cluster-based service delivery model for CSS and CHC agencies by 2015 through integration of front-

line services, back office functions, leadership and/or governance to:

improve client access to high-quality services,

create readiness for future health system transformation and,

make the best use of the public’s investment.

3

Outline

• Definitions and Background

– Service Delivery Context. Strategic Context.

• Sector Engagement on Integration

• Strategic Aim for Community Health Sector Integration

• Who will be involved?

• Community Engagement and Communications

4

SERVICE DELIVERY CONTEXTCommunity Health Services Integration Strategy

5

Community Support Services (CSS)Community Support Services help clients maintain their safety and independence while living at home. Services are delivered either in home or in different locations around a clients community.

How many

• 40 (12 Durham, 8 Scarborough, 20 Northeast)

CE LHIN Budget

• $ 51,386,095.00

Types of Services

• Security Checks and Reassurance• Transportation

• Meal services (Wheels-to-Meals, Diners Club or Congregate Dining )

• Caregiver Supports: Relief/Respite, Support Groups and Counseling

• Volunteer Hospice (Palliative Care)

• Foot Care • Home Help Home Maintenance

• Social and recreational services

• Home maintenance and repair

• Supportive Housing /Assisted Living

• Personal Support Workers

6

Community Health Centres (CHCs)Non-profit organizations that provide primary health and health promotion programs for individuals, families and communities. CHCs work with individuals, families and communities to strengthen their capacity to take more responsibility for their health and wellbeing.

How many?

• 7 (3 Durham, 2 Scarborough, 2 Northeast)

CE LHIN Budget

• $23,030,006.00

Types of services

• Primary Care Physicians and Nurse Practitioners

• Nurses, Dieticians, Diabetes Educators, Chiropodists

• Social Workers, Health Promoters

• Education and advice on helping families access the resources they need from other community agencies

• Health promotion initiatives within schools, in housing developments, and in the workplace.

• Link families with support and self-help groups that offer peer education, support in coping, or are working to address conditions that affect health

7

Hospitals Providing CSS ProgramsHospitals providing CSS programs help clients maintain their safety and independence while living at home. Services are delivered in hospital locations around a clients community.

How many?

• 4 (2 Durham, 2 Northeast)– Lakeridge Health– Ontario Shores Mental Health – Haliburton Highlands Health

– Peterborough RHC

CE LHIN Budget• 1,306,769.00

Types of services

• Mental Health and Addiction Services• Assisted Living for At Risk Seniors

• Palliative Care

8

Expected Growth in Home Care Sector

• 26% increase in demand for home care services, majority of which provided through the Community Care Access Centre (CCAC).

• To provide care within expected resources, requires more deliberate shifting of service provision to the CSS sector.

9

Expense Simulation: Central East - Provincial per Senior Funding

• Applying the Provincial benchmarks, CE LHIN’s expenses are forecast to increase faster than under current state:

– CSS: 42%

– Assisted Living: 111%

10

Expense Simulation: Central East - Higher Performing LHIN per Senior Funding

• Applying the higher performing LHIN benchmarks, CE LHIN’s expenses are forecast to increase faster than under current state:

– CSS: 54%

– Assisted Living: 213%

11

The Time for Action is Now!

Example: Assisted Living Services

• Based on 10 year projected growth, there is a $27 Million gap in Central East LHIN compared to Higher performing LHINs investment in Assisted Living.

• Using an optimistic scenario of 3% annualized funding increases for Assisted Living Services in the Central East LHIN (and 0% increases in the higher performing LHIN), it would take 19 years to close this gap.

• With each annual increase, a range of 10-20% of new funding is directed to support administrative, non-direct services expenses. Consolidation of services and creating administrative efficiencies now will enable greater proportions of new funding to be directed to client services.

12

STRATEGIC CONTEXTCommunity Health Services Integration Strategy

13

Strategic Context

Demographics• Aging population with increasing

prevalence of chronic disease and mental illness

• Informed, customer-driven approach to health care experience.

Public Policy Directions• Shift of healthcare delivery

system

– to improve patient outcomes and access to care, & support health promotion and wellness

– Meet the healthcare needs of communities within available and sustainable resources

• Excellent Care for All Act

• Minister’s Action Plan

14

Why Integration?

While defined as the mandate of LHINs and responsibility of Health Service Providers in legislation, the imperative for integration is:

• NOT simply driven by the top-down, by LHINs

• IS being demanded by health care consumers and their funders globally

– Better Experience

– Better Value-for-Money (including donors, government funders)

– Responsive, SMART systems that are tailored to individual clients

15

Reality Check

The current delivery system is neither organized nor

prepared to meet the current and future needs of

patients, caregivers and communities.

Value System

Delivery System

16

Principle #1: Value Creation for Clients

• Integration process will be guided and motivated by a continuous focus at how to best meet client and caregiver needs.

• The outcome will be to re-engineer the delivery system to support the values of patients and communities.

17

Every Door Is the Right Door(CMHA Northeast Integration…)

18

Principle #2: Return on Investment

• In addition to providing value to clients, integration must be focused on increasing value to shareholders of the health care system… the public.

– The biggest threat to our healthcare system is our own failure to adapt to the changing environment

19

Integration Example Resulting in Increased Value For Money

2010 Facilitated integration of two hospice service providers with an existing Community Support Services Agency resulted in:

– 2011/12 administrative operating costs reduced by approx 50% from 2010/11 pre-integration projections. Savings were redirected to client services.

– 2011/12 cost of hospice service is within 6% of projected CE LHIN allocation - conservative estimate of fundraising easily addresses difference and provides opportunities to enhance program services. This reduces risk to service delivery resulting from over-reliance on fund raising.

20

Principle #3: Leverage the Local

• Community services are best supported by local governance that understand their communities, and by local management that can take advantage of local volunteers and fundraising opportunities.

• Clients, Patients and Caregivers should have maximal close-to-home access to community services.

– This does not preclude opportunities for broader regional approaches that support health care delivery and coordination (e.g., back office supports).

21

Integration Continuum: Scale of Possibilities

Linkage Focused IntegrationHigh on communication and low on structure

Network Focused IntegrationHigh on communication and moderate-to-high in terms of structure for coordination among equals

Full Integration

Collaboration

Cooperation

Coordination

Delegation

System Governance Model

Transfer of Responsibility

Merger / Consolidation

22

Minister’s Action Plan for Health Care (January 2012)

Quotes:

• “Today’s fiscal reality requires that we act now to make Ontario’s health care system sustainable”

• “We need to create a system that improved quality for patients as it delivers increased value for taxpayers.”

• “Evidence helps answer the question of how finite health care dollars should be allocated to best serve patients.”

• “Care providers should be rewarded for ensuring better patient outcomes.”

23

SECTOR ENGAGEMENT ON INTEGRATIONCommunity Health Services Integration Strategy

24

Integration Activities

• Exploring integration opportunities is a legislated requirement of all health service providers.

• Central East has promoted integration through forums, education, tools and resources.

• Required integration activities as part of selected CSS & CHC Multi-Service Accountability Agreements.

– Limited success and outcomes

• Funded programs and services that have demonstrated the value of integration for clients, health care providers and the health care system.

– Home First. Home at Last.

– Common Assessments Tools and Records

25

CSS Stakeholder Engagement (Nov 2011)

• 30 CSS providers from across the Central East LHIN participated in a Strategic Planning event.

• Success and lessons learned shared by CSS, CCAC and LHIN through integration activities

• Table top discussions with peers regarding current and proposed new integration was focus of the day.

• The day ended with statements of commitment to action to carry positive momentum and messages about integration forward.

26

CSS Stakeholder Event – Current and Future State

Current State

• CSS organizations described their current role as supportive, compassionate, community-based environments of care focused on providing responsive, client-centered supports.

Future State

• The preferred future state of CSS organizations included an accessible, seamless, proactive environment offering consistent yet flexible, cost-effective services for clients within their own community.

27

CSS Stakeholder Event – Outcomes

• HSP statements of commitment to carry positive momentum and messages about integration forward.

• Confirmed the strategic importance of CSS within the Central East health care system and importance of identifying and exploring opportunities to maximize the value and capacities of the CSS sector.

28

Other Recent Engagements

On February 15th the Central East LHIN team convened a face to face and web-based information session with CHC and CSS providers.

The purpose was to be transparent with HSPs on the intent to bring the Community Health Integration Strategy and implementation plan forward as a recommendation to the Central East LHIN Board on February 22nd.

29

Initial CSS and CHC Take Away Messages

• CHC and CSS sector welcomed transparency and the clarification of community health aim.

• Aim resonated – there is readiness, timing is understood.

• Frustration expressed by CHCs in not knowing this aim was coming from the Central East LHIN – given all efforts to date on identifying CHC sector integrations.

• This will be an iterative learning process for the Central East LHIN and HSPs.

• Integration solutions will not necessarily look the same in each cluster.

• The process will better prepare all to be pro-active in identifying and addressing system issues.

Continued…

30

Initial CSS and CHC Take Away Messages

• This aim is an opportunity – it has taken time to be recognized as the next step – it is not an indication of the failure of parties to deliver.

• Some interest expressed by Group 2/3 HSPs to participate as part of Group 1 – no declaration of the desire to opt out.

• Is the CSS and CHC focus too narrow? Should we include all social services? This will be an evolutionary process which may lead to greater integration of health and social services.

• Aim has potential to create a stronger more unified voice for volunteers and with other partners (e.g. municipalities).

• Should HSPs proceed with integration opportunities underway?

• Regular engagement of governance is essential.

31

STRATEGIC AIMCommunity Health Services Integration Strategy

32

Strategic Aim for Cluster Based Integration (CSS/CHC)

Design and implement a cluster-based service delivery model for CSS and CHC agencies by 2015 through integration of front-line services, back

office functions, leadership and/or governance to:

improve client access to high-quality services,

create readiness for future health system transformation and,

make the best use of the public’s investment.

33

Strategic Aim for Cluster Based Integration (CSS/CHC)

Design and implement a cluster-based service delivery model for CSS and CHC agencies by 2015 through integration of front-line services, back

office functions, leadership and/or governance to:

improve client access to high-quality services,

create readiness for future health system transformation and,

make the best use of the public’s investment.

34

PROCESS

OUTCOMES

Outcome: Improve client access to high-quality servicesWhat is it? Current State Future State What do we hope to

achieve ?

People should have seamless and equitable access to a continuum of community health services across the Central East

Incomplete access to basket of services based on distribution of resources and capacities of health service providers.

Difficult to navigate

Non standardized user-fees

Equitable access to a consistent standard of service as close to home as possible

Support independence

Enable caregivers

Better health outcomes for individuals and communities

Improved client and caregiver experience

Clients should be supported by informed, proactive care teams

Fragmentation of care delivery and health care information

Proactive identification of need with direct access to service and information

Empowered and engaged care teams meeting the needs of their clients

35

Uneven Access to Health Care Services

Not all LHIN-funded services are available across the region. For example:

– No Central East LHIN funded ADP* in Northumberland.

– Limited Adult Day Programs in Peterborough.

– Limited Foot care services and respite

Adult Day Services

Respite Caregiver Supports

FootCare Services

ElderlyPersons Centres

Durham 4 2 1 2 1

NE 3* 2 4 1 2

Scar 5 2 3 0 4

Based on 2010-11 OHRS/MIS Central East HSP submissions

36

Outcome: Readiness for future health system transformation

What is it? Current State Future State What do we hope to achieve ?

The community health care sector should possess the capacity to meet the future demands of clients, donors and funders.

Service model evolvedwithout explicit focus on sustainability and growth

Declining and stretched volunteer capacity and philanthropy

Financial and performance requirements challenge boards and staff

Challenge to implement new technology solutions

Growth in knowledge base and expertise (staff & board) to support quality improvement and expected service enhancements

Coordinated fundraising to maximize commitments

Increased volunteer capacity

A vibrant and robust community healthsector able to meet the growing challenges of clients, communities and funders

37

Outcome: Make the best use of the public’s investmentWhat is it? Current State Future State What do we hope to

achieve ?

The Community health sector should continually seek ways to improve value-for-money (efficiency/effectiveness) for the public’s investment

High needs and complex clients strain system to deliver effectively and efficiently

Duplication and/or gaps in services.

Poor information technology infrastructure to support improvements in client services

Significant administrative resources and energy directed to sustain small organizations

Concentration of services into fewer, multi-service organizations organized in to sub-regions (clusters) of the LHIN.

Strengthen management and governance functions that can respond to community needs .

Capitalize on information technology to improve quality of client services

Savings created through efficiencies redirected into front-line services

Client complexity is expected and responded to effectively through integrated services supported by information technology.

38

Duplication of Services Creates Opportunity for Efficiencies

Transportation Meals Delivery

Congregate Dining

Durham 2 1 4

NE 3 4 3

Scar 6 5 7

Integration of some services will eliminate duplication of support systems and streamline access for clients.

Based on 2010-11 OHRS/MIS Central East HSP submissions

39

Savings / Efficiency Opportunities

• Using the savings achieved through this integration strategy, investments can be made to close gaps in service delivery, such as CSS and CHC services for Seniors both 65+ and 75+

• All Estimates: Based on previous CE LHIN integrations, 2 to 3% of savings have been captured and reinvested in front-line services. Actual savings are anticipated to be higher given the number of health service providers involved.

Savings Opportunity

2% 3%

CSS $911 K $1.4 M

CHC $500 K $700 K

Combined CSS & CHC $1.4 M $2.0 M

2012 CE LHIN Population 65+

230,000 230,000

2012 CE LHIN Population 75+

106,000 106,000

Savings per senior 65+$6 $9

Savings per senior 75+$13 $19

40

Reinvestment Opportunities

• Using the savings achieved through this integration strategy, investments can be made to close gaps in service delivery, such as Assisted Living Services and Adult Day Programs.

Reinvestment Opportunity

Savings 2% 3%

AssistedLiving Services (ALS)

51 117

Adult Day Programs (ADP)

301 693

Additional annualized clients served through reinvestment of savings for ALS or ADP.

41

Integration Decreases Risk and Improves Sustainability• In addition to creating new financial opportunities, the Integration strategy

will also reduce risks current facing the community health services sector:– Governance: Sustaining governance succession of small organizations

and enabling stronger system stewardship.

– Management and Back Office: Sub-optimal operational supports to management (HR planning, IT investment) limited sectors ability to identify, monitor and achieve improved performance.

– Fundraising and Volunteering: Over-reliance on fund-raising and volunteerism puts at risk key services. Significant infrastructure required to support both.

– Human Resources Planning: Challenges in recruitment and retention of the skill mix required to delivering services.

– Client Services: Challenges related to any of the above create directchallenges to clients services. This has been the consistent example of all of the LHIN integrations to date.

42

Summary of Benefits

• Improve client access to high-quality services

– Access to consistent and integrated basket of services will improve client and caregiver experience and outcomes.

• Create readiness for future health system transformation

– Create critical mass in governance, management, delivery and IT capacity to enable future growth in community care.

• Make the best use of the public’s investment

– Create opportunities through efficiencies to re-invest in direct client services and reduce latent risk within the sector that jeopardizes quality and access to client services.

43

HOW WILL THE AIM BE ACHIEVED?Community Health Services Integration Strategy

44

Approach: Proven Strategies and Lessons Learned

• LHIN will invite HSPs from each Cluster to the integration table and this will occur in a phased approach in across LHIN clusters and HSPs.

• Utilize Integration Toolkit and lessons learned from completed/in progress integrations will be applied.

• Leverage HSP readiness opportunities (e.g. pending retirements, performance and service pressures and expectations).

• FORM (Leadership and Governance) will follow the future state FUNCTIONs (delivery front-line direct client services and supporting back-office functions).

• Status Quo is NOT an option - explore full range of service integration options.

45

Timeline for Initiation Integration Engagement

• Durham Cluster Start: April 2012 Finish: March 2014

• Scarborough Cluster Start: Nov 2012 Finish: Nov 2014

• Northeast Cluster Start: June 2013 Finish: March 2015

8 months: Estimated time to identify facilitate and identify a preferred integration option

3 months: Estimated time to have preferred option approved by health service provider and LHIN board.

12 months: Estimated time to from approval to final implementation of the preferred integration option.

46

Proposed Timeline

March/April 2012• Durham GAC

Meeting• Initiate Durham

Cluster• Northeast,

Scarborough Cluster GAC Meetings

Nov 2012• Initiate

Scarborough Cluster

• Present Durham Options

March 2013• Approvals of

Durham Solution

June 2013• Initiate NE

Cluster• Present

Scarborough Options

Nov/Dec 2013• Approvals of

Scarborough Options

• Present NE Options

March 2014• Approval of NE

Option• Durham Option

Implemented

Nov/Dec 2014• Scarb Solution

Implemented

March 2015• NE Option

Implemented

47

WHAT ORGANIZATIONS ARE INVOLVED?Community Health Services Integration Strategy

48

Phases of Integration Activity

Integration planning is beginning with the first grouping of health service providers for whom integration is most likely to achieve greatest return on investment. Organizations may request to participate in earlier phases.

• Group 1: Single or multi-service HSPs who provide service within a clearly defined region within the Central East (includes LHIN services provide through municipalities).

• Group 2: HSPs with broader affiliations (e.g. Cross-LHIN, Provincial or National Agencies).

• Group 3: HSP serves multiple Central East LHIN Clusters, or a specific client population (Acquired Brain Injury, Services for the disabled).

**A separate strategy will be developed for Groups 2 and 3

49

Group 1 Integration Engagement Cluster # of CSS HSP # of CHCs

*one HSP is both a CHC and CSS

provider

Total LHIN$ % of LHIN Pop(n)

DURHAM 7 3 $20.7M 39%

SCARBOROUGH 4 2* $14.9M 41%

NORTHEAST 12 (+1 HHHHospital)

2* $14.7M 20%

TOTAL 24 7 $50.3M 100%

50

Group 1: HSPs in Durham ClusterHealth Service Provider LHIN Funding Other Funding

Brock Community Health Centre $2,961,362 $92,833

The Youth Centre (Barbara Black Youth Community Health Centre) $3,711,415 $139,882

Oshawa Community Health Centre $3,214,925 $1,213,293

Community Care Durham $6,957,307 $530,630

Faith Place $445,369 None

Sunrise Seniors Place $785,075 None

The Regional Municipality of Durham, Sr. Services (Fairview Lodge) $663,078 $ 74,409

Hospice Durham $418,246 $253,250

Oshawa Senior Citizens Centre $757,243 $106,432

VON for Canada - Ontario Branch, Durham Region Site $840,926 $11,164

51

Group 1: HSPs in Scarborough ClusterHealth Service Provider LHIN Funding Other Funding

Scarborough Centre for Healthy Communities (SCHC) –CHC & CSS $6,622,485 $106,432

TAIBU Community Health Centre $2,973,764 $233,811

Transcare Community Support Service $2,343,191 $3,049,098

Centre for Information and Community Services of Ontario $102,071 $9,520

St. Paul L’ Amoreaux Centre $2,909,648 $67,956

52

Group 1: HSPs in Northeast ClusterHealth Service Provider LHIN Funding Other Funding

Campbellford Memorial Multicare Lodge $381,659 None

Community Care City of Kawartha Lakes – CKL CHC $4,831,068 $498,881

Community Care Northumberland $1,089,830 $667,352

Port Hope Community Health Centre $2,942,059 $91,603

Community Care Peterborough $993,163 $460,362

Activity Haven Senior Centre (Peterborough) Inc. $104,237 $17,976

Community Counseling & Resource Ctr- Family Counseling Service Volunteers & Information $205,875

$4,474

Hospice Peterborough $336,044 $221,126

Lovesick Lake Native Women's Association $73,838 None

St. John's Retirement Home Inc. $1,200,184 $69,000

Victorian Order of Nurses for Canada, Ontario – Peterborough $1,256,397 $67,043

Supportive Initiatives for Residents in the County of Haliburton* $144,831 $42,166

Haliburton Highlands Health Services* $659,595 $69

Community Care Haliburton County* $560,843 $87,037

*The LHIN is interested exploring unique integration options in Haliburton Highlands such as the establishment of a vertically integrated health system.

53

COMMUNITY ENGAGEMENTCommunity Health Services Integration Strategy

54

Community Engagement Plan

Governance

• Utilize Governance Advisory Committees to provide strategy “check in” and feedback.

• Engagement of government stakeholders (provincial and municipal).

• Create mechanisms to keep cluster based providers directly informed and involved during planning phase. Support governance through approvals phase.

Management

• Create cluster-based facilitation/planning venues of staff and senior management.

• Make ‘materials’ (evidence) readily available to all (transparency), including staff and volunteers.

55

Community Engagement Plan

General Public

• As with current practice, provide opportunities for stakeholder consultation during the planning phase, and consultation on the draft integration model before decision making.

• Provide various mechanisms for input by full range of stakeholders (clients, caregivers, staff, agency partners, funders).

• Make ‘materials’ (evidence) readily available to all (transparency).

56

Communications Plan

Supports Integration and Community Engagement Plan :

• key contacts and spokespersons for clarification

• key messages – on-going/updated

• Milestones for decision-making

• Government Relations – for LHIN, then cluster specific

• Emphasize reason/objectives for and importance of integration and engagement

57

Key Dates• February 15: All health service provider Webinar

• February 22: Central East LHIN Board meeting

• March 8: All health service provider open session

• March 29: Durham Cluster Governance Advisory Committee meeting

• April 4: Northeast Cluster Governance Advisory Committee

• April 5: Scarborough Cluster Governance Advisory Committee

• April : Initiate Durham Cluster Integration Process

• May 29: Joint Governance Advisory Committee meeting

• May 30: Annual Symposium

• June: First Update to the CE LHIN Board (with subsequent updates to follow at a minimum of every second month)

58

Proposed Board MotionBe it resolved that…

It is the aim of the Central East LHIN and specified health service providers to design and implement a cluster-based service delivery model for CSS and CHC agencies by 2015 through integration of front-line services, back office functions, leadership and/or governance to improve client access to high-quality services, create readiness for future health system transformation, and make the best use of the public’s investment.

Further, the Central East LHIN Board directs staff to embark on a facilitated integration strategy that will achieve the above aim, and that Management report back regularly on the progress and barriers.The Central East LHIN shall inform health services providers of their requirement to participate in facilitated Community Health Services Integration Strategy as outlined.

59