Health System Design: Blueprint Initiative Phase 2

1 Health System Design: Blueprint Initiative Phase 2Health System Design: Blueprint Initiative Phase 21

Health System Design:

Blueprint Initiative Phase 2Models of Care updated with Programmatic Refinement Session Updates

September 30, 2009

A Healthier Tomorrow

2 Health System Design: Blueprint Initiative Phase 2

The model of care framework was used to design the future state of

programs

Enablers

South West LHIN Vision “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.”

Program Vision

Program Principles

Building Blocks

Po

ints

of

Access /

En

try

Ed

ucati

on

& I

nfo

rmati

on

Req

uir

em

en

ts &

Flo

w

Earl

y I

den

tifi

cati

on

,

Assessm

en

t &

In

terv

en

tio

n

Sp

ecia

lized

Need

s

Co

mp

lem

en

tary

Need

s

Care

Co

ord

inati

on

Healt

h R

esearc

h


ProvincialLHIN-wideSub-LHINLocal

Life Span Lens

The building blocks were further refined when evaluated against the

three “lenses”

Continuum of Care Lens

Service Delivery Lens

“We need to create a simple

path for people to navigate

through the health care system

throughout their life.”

Symposium Participant


Models of Care


Chronic Disease

Prevention &

Management

(includes cancer care)


The model of care has been developed upon the guiding vision

elements and principles

Vision

Elements

• Empower / Involve Individuals

• Broad Partner Spectrum

• Quality of Life and Health Status

• Collaboration

• “A Person‟s Perspective” – healthy people managing their disease who know where to get the help they need to manage their disease

• Delivering value

• Shared committment to screening and early identification

Principles

• Person-Centred: The holistic health needs of the individual and the caregiver/support network through their life journey should be the focus for our integrated system of care, including LHIN-funded and non-LHIN funded services. Integrated system of care should include LHIN-funded and non-LHIN funded services which involves and empowers the individual

• Interdisciplinary: A shared model of care will be provided by an interdisciplinary team. Promote and facilitate interdisciplinary teamwork in the area of chronic disease through strengthened communication. Ensuring access to the most appropriate health care providers available (i.e. NP, SW, etc.) Chronic disease prevention and management teams are responsive to the needs of the local communities.

• Self-Management: The person and family members/caregivers afflicted with a chronic disease manages his/her condition(s) in partnership with an interdisciplinary team. Level of self-management is customized upon the individual‟s capacity.

• Accessible: The model aims to provide comprehensive, integrated, and coordinated CDPM services throughout the LHIN regardless of personal barriers to care (i.e. without a physician, social determinants of health, geographic limitation)

• Evidence-based: Increase individual, as well as health care provider knowledge of and adherence to current evidence-based clinical practice guidelines and standards of care for CDPM.

• Provides Equitable and Consistent Quality of Care: People with a chronic disease in our LHIN should received consistent quality of care services based on evidence

• Cultural Safety: Service will be delivered with cultural and linguistic competency, sensitivity, and compassion to other circumstances that affect individuals and families. “Call to Caring”

• Outcome Oriented: Services are focused to be delivered holistically and drive person-experience outcomes. Measure and report chronic disease performance measure at the individual patient, health professional, and LHIN-level

• Knowledge Transfer: Spread and share innovations in delivery of disease-specific care with health providers across the LHINs, individuals/families, and globally.

• Sustainability and Accountability: Leverage existing resources (using scarce resources wisely), infrastructure, and knowledge.

• Scalable: This model is a foundation that can be leveraged to multiple chronic diseases based on infrastructure and modifiable risk factors.


Providers

• Increased focus on

preventing chronic

illnesses within a

local capacity

• Availability of

standardized tools

to aid health care

professionals in

care delivery

• Improved

satisfaction of

providers

• Strengthened relationship between health

care providers across the continuum of care

and service delivery model

• Inter-professional teams that are linked to

individual practitioners at a local level. They

will serve as a vehicle to care delivery

• Enhanced reliance on self-management

across the continuum – involving individual

as part of health care team

• Standardized, consistent approach to care

provision

• Health care providers to evaluate, identify,

and manage entire suite of chronic illnesses

• Focus on marginalized population (cultural,

etc)

Model of care focuses on keeping care close to home through

sufficient local capacity, effective partnerships across health/non-

health organizations, and self-management

How is this model different from

today’s service delivery model?

What are the benefits of the

Model of Care?

Individuals/ Families

• Empowerment of

individual/family

members in

managing their own

care

• Emphasis on

providing care

closer to home

• Improved person

satisfaction

• Improved clinical

outcomes


Overview of Chronic Disease Prevention & Management Model

Pri

ma

ry C

are

–L

oc

al D

eli

ve

ry

En

han

ced

Care

–

Su

b-L

HIN

De

live

ry

Sp

ec

iali

st

Ca

re –

LH

IN-w

ide d

eli

ve

ry

• Individuals/ families will access

services through local resources or

self referral

• Local resources comprised of various

disciplines will be able to cross-refer

individuals/families to inter-

professional health programs as

needed

GPS

GPS

GPS

GPS

• Sub-LHIN organizations provide

enhanced care, managing

specialized needs

• The integrated care plan will evolve

as health needs are evaluated

• If individual requires complex,

specialized care, he/she will be

referred to sub-LHIN and LHIN

centres

• HHR will educate person and

conduct an integrated, holistic

assessment providing primary care

and targeted enhanced care

services

• If further specialization is required,

will refer to sub-LHIN organizations

Self-Management

GPSGuided Practical Solutions

1

1 2 3

3

2

4

4

Interdisciplinary

health programs

http://www.archi.net.au/e-library/build/moc/acp/implementing









How will the model of care work?How will people access this

program:

• Individuals will be able to access

chronic disease services through

places “close to home.”

• Local resources such as

schools, community centres,

youth centres, cultural group,

outreach within workplaces

etc. will be able to

appropriately refer people to

primary care and targeted

enhanced care services as

needed

• Urgent and emergent cases

will enter through the ED,

hospital depts, and receive a

holistic assessment and be

triaged to appropriate service

provider. ED will have broader

accountability in access /

referral

• Individuals/families will also be

able to self-refer themselves

by using educational resources

– interactive web-based tools

and information lines with a

repository of health services

and evidence-based

information

• Local resources will also

conduct outreach activities at

places close to home and

workplaces - providing

prevention and promotion

services

How will people be referred throughout course of health journey?

• Referral pathways will be broadened to enable non-traditional resources to refer individuals to local

health services

• At point of entry through any “door”, the individual/families will partake in a continuum of navigation from self-

managed navigation, to front-line provider supported navigation, to more complex cases that need a special

advocate/navigator

• This navigation preference will be based on clinical need or individual choice

• All health care professionals will be accountable to appropriately referring individuals/families to care

provider and communicating with the primary care physician

• Navigation resources will provide service coordination and/or clinical case management services. They will

assess the individual “holistically” and triage them to the appropriate care provider. At this time, the

navigation resources will provide the individual/family with “Guided Practical Solutions” as a care plan

moving forward. (i.e. Aboriginal healthcare navigator)

• Recognizing that not all people need the same help, those in more need will be provided special advocates

to aid them through their life journey

• Strong relationships between local, sub-LHIN, and LHIN providers will enable individuals/families to move

seamlessly through the system

• Local providers will manage less complex cases, while referring more specialized services to sub-LHIN or

LHIN-wide centres

• Specialized needs of co-morbidities may result in referrals to LHIN wide centres

• Other health wellness needs may result in referrals to alternative providers (massage therapy,

acupuncture, meal programs, exercise, spiritual) or consultations with health coaches

• Complementary needs: food/security, housing, financial planning, childcare, stress/coping mechanisms

• Caregiver health needs, respite and support services will also be integrated into care plan as needed

• A LHIN-wide transportation program will enable individuals/families to be transported to services across

the LHIN in a timely fashion


How will the model of care work? (cont’d)

How will the system stay connected to the individuals/families?

•As needed, navigation resources or HHR will step up to provide service coordination

and/or clinical case management services. Clinical resources will be equipped with

the right skill sets and tools to provide clinical case management.

•Throughout the time in the system, HHR will be kept up to date on the individual's

GPS and health status. As it evolves through the journey of the individual,

navigators/ advocates will be informed.

• Health information will be shared across sectors through an EHR/personal

health record

•HHR will stay be attuned to the individuals needs as they go through life stages and

health statuses. Advanced care planning to proactively prepare for long term care

services that may be needed (i.e. end-of-life care)

•Certain individuals will be provided health coaches to provide mentorship in staying

healthy

•Individuals will also be able to access lay coaches for support (people from the

community who are equipped with information and prepped to support

individuals/families)

How will individuals be assessed and treated?

•Local resources will function more as inter-professional

teams. This will enable them to provide integrated

assessments on the individual across entire suite of

chronic diseases

•Based upon health care needs of the individual, different

disciplines will be able to cross-refer to other providers

as appropriate

•Throughout health assessments/treatments, the health

care professional will emphasize self-management and

accountability as a necessary step to taking control of

one‟s own health

• Tactics such as motivational interviewing will

provide a „positive‟ assessment of the individual‟s

health


How will information be communicated?

•Information flow will follow the individual through their health journey.

This will occur through a real-time, easily accessible electronic

health record (EHR) available to health providers across the

continuum of care and geographic location

•The EHR will be connected to a personal health portal which will

enable individuals to access and share health information as needed

(i.e. with alternative care providers) – keep track of their GPS

•Health information will consist of standard guidelines which are

evidence-based and span the continuum of care and life span

•Health care professionals will be equipped with tools such as

“information sheets” and inventory of services to enable care

coordination across organizations


How will funding be coordinated across sectors?

•Funding will follow the individual – be directed to providers who

bear burden of delivering care

•Collaboration across ministries so that funding is seamless to

the individual/family

•LHIN will manage priorities and implementation to control

funding across sectors

•Change in fee structures to accommodate CDPM approach

•Flexible funding model to enable individuals to manage their

own care delivery

•Innovative healthcare solutions: Platform to discuss successes

and failures in field and also provide funding for healthcare

innovations


The Chronic Disease Prevention & Management model focuses on having

services increase in complexity/specialty as individuals go from local to

LHIN-wide/provincial providersService

ComponentsLocal Sub-LHIN LHIN-wide

Prevention &

Promotion

• Independent and guided self health management

• Health promotion

• Primary and Secondary Prevention

• Healthy lifestyle behaviour

• Health education

• Outreach services

• Nutritional services

• Prevention and promotion services through non-health resources

(schools, daycares, employers, cultural and religious groups)

• Online health information portals

(thehealthline.ca,

ConnexOntario)

Screening

Services• Self-navigation tools

• Service coordination and clinical case management for

specialized/complex cases

Assessment &

Diagnostic

Services• Early identification, assessment, treatment, and follow-up and

management of chronic illnesses (foot care, diabetes, asthma, etc)

• Annual health check-ups

• Pharmacy services

• Clinical case management and service coordination services (tools,

health information, referrals, etc)

• Core-hospital based services including:

• Inpatient and ambulatory core hospital services

• Follow-up on inpatient / ambulatory care for individuals who receive

services in other hospitals(i.e. large community, tertiary centres)

• Systemic therapy (chemotherapy)

• Alternative medicine (acupuncture, naturopathy, reflexology,

massage therapy)

• Early identification, assessment, treatment,

and follow-up of chronic illnesses

• Service coordination and clinical case

management for specialized/complex cases

(eligibility placements, care plans, coping

techniques, decision-making guidance etc)

• Core hospital-based and specialty services

including:

• Radiation and systemic therapy

• Surgical services (general breast,

colorectal)

• Diagnostic assessments for oncology

services

• Pain and symptom management services

(i.e. chronic pain)

• Follow-up inpatient / ambulatory care for

individuals who receive services in other

hospitals (i.e. tertiary)

• Tertiary care services

including:

• Specialized surgical

services (i.e. thoracic,

gynaecological, etc)

• Specialized radiation and

systemic therapy

• Education, research, and

clinical trials

• Specialized clinical case

management (personal

coaching, care plans,

coping techniques, etc)

• Complex multi-disease

management

• Telehealth, telemedicine,

and telehomecare

Treatment

Services

Pre/post treatment

care, supportive

care

• Healing services

• Home-based Rehabilitation services

• In-home community support services

• Bereavement support

• Caregiver/Family support

• Supportive services for chronic illnesses (stroke, dialysis, etc)

• Peer support services

• Recreational and Social programs for people with disabilities

• Clinical case management and service coordination services

• Home-based palliative services

• Respite care for caregivers/families

• Progressive community living programs

• Inpatient rehabilitation services

• Supportive housing services (general and

specialized (i.e. concurrent disorders,

addictions)

• Long term care services (general and

specialized (i.e. dementia-secured services,

dialysis)

• Transitional residential services

• Enhanced caregiver support

• Specialized support centres (Cardiac Rehab,

epilepsy, Liver disease)

• Residential hospice services

• Day services

• Tertiary acute palliative

care

Cura

tive

Rehabilitative &

Support

ive

Pre

ventive a

nd

Pro

motive

Primary and secondary prevention

Public health services

Integrated screening services


Implications of Chronic Disease Prevention & Management model of

care

• Enabling “true self-

management”, will require

individuals to have easy

access to evidence-based

health information and

inventory of health services

• Developing effective

working relationships with

health care professionals

and navigators/advocates

• Seamless referral system and development of integrated care plans, Guided

Practical Solutions, will require stronger relationships among stakeholders

across health and social agencies

• Accountability for all providers in taking necessary education/communication

steps to refer individuals/families to appropriate provider

• Development of relationships with health/non-health providers outside of

traditional care settings – leveraging the “Partnerships for Health” initiative

• Shift to local resources will require increased capacity of front-line resources

within community with regards to:

• Knowledge and understanding of all health services across the

continuum

• Understanding of person‟s health care history and social considerations

• Consistent interpretation and application of privacy laws to enable information

sharing across health sectors, social agencies, alternative care providers, and

ministries (regulated and non-regulated health professionals)

• Changes in funding model will require enhanced collaboration between

ministries and empowerment of LHIN to manage health priorities

• Changes in hospital budgeting to accommodate the future state of healthcare

delivery

• Accountability agreements across health care providers to ensure

collaboration and shared flow of funds towards healthcare initiatives

Health Care Professionals Individuals/Families


Mental Health &

Addictions




Vision

Elements

• Person-directed

• Equitable and timely access

• Empowerment and support (all providers, individuals, families, caregivers)

• Culturally sensitive and appropriate

• Inclusion and acknowledgement of other bodies of knowledge and experience

• Holistic

• Continuous research and innovation to drive practice and standards of care

• Ability to respond to people‟s needs throughout one‟s life span

• Social inclusion of individuals with mental health and addictions issues

• Eradication of discrimination towards individuals with mental health and addictions issues

Principles

• Shared care philosophy

• Partnerships with Primary Care

• Recovery-oriented

• Empowerment through education (provider, individual, family)

• Keep it simple

• Keep it local

• Person/family focus – people are assets

• Population oriented

• Evidence based practice

• Innovation and integration

• Sustainability

• Partnerships

• Flexible/responsive

• Comprehensiveness


• Increase timely access through multiple entry

points “any door is the right door”

• Expand focus to prevention and early

identification in alignment with provincial mandate

• Equips the system with resources to provide

increased support for those individuals with mild

to moderate mental health and addictions

challenges

• Development of collaborative partnerships across

health sectors and continuum of care

• Implementation of “Most Responsible Provider”

for individuals with complex needs (include

navigation and clinical case management)

• Promote and expand capabilities of current

platforms to provide a “health information bank”

for individuals/families/ caregivers and local

health resources (i.e. ConnexOntario)

• Standardized, consistent approach to care

provision

Through shared care and collaborative partnerships across health

and non-health entities, the model of care facilitates coordinated

access for individuals / families affected by any degree of mental

illness or addictionHow is this model different from


Providers

• Involved care

management of

individuals with

complex needs

• Seamless referral

of individuals /

families across

health and other

sectors


Model of Care?


• Empowerment of

individual/family

members in

managing their own

care – Individual is

part of health team

• Emphasis on

providing care

closer to home

• Early identification

and management of

individual‟s needs in

order to enable

people to optimize

their level of

function and quality

of life in their

community and

home environment


Overview of Mental Health & Addictions Model

Lo

cal S

erv

ices

Su

b-L

HIN

se

rvic

es

LH

IN-w

ide

serv

ices

• If individual requires further

specialization, he/she will be

referred to sub-LHIN

organizations

• Sub-LHIN organizations provide

enhanced and targeted care,

managing specialized needs

• As individual moves through the

system, communication will occur

across providers

• If individual requires complex,

specialized care, he/she will be

referred to tertiary centre

• HHR will refer individual/family with

mental health and addictions for

appropriate health care attention

• Mental health and addictions and primary

care HHR will educate person and

conduct an integrated, holistic

assessment

• For those with complex needs, they will

be assigned a “Most Responsible

Provider” to navigate person through

transition of life/health stages

Health Information

Knowledge

1

1

3

2

4

4

Community

programs

Most Responsible

Provider

3• Individuals/ families will access mental health

and addictions services through local

resources or self referral

• Community resources will be equipped with a

health information bank that will provide

resources with an understanding of health

care/social services

• Urgent/emergent cases will filter through the

ED and crisis intervention services and be

navigated to the appropriate service provider

2





How will the model of care work?How will people access this

program:

• Individuals will be able to

enact consumer choice and

access mental health and

addictions service through


• Individuals/families will be

able to access health

information to make

informed decisions

through online health

information and community

resources which are real-

time and evidence-based

• Local resources such as

primary care networks,

schools, community

centres, health clubs, youth

centres, etc. will be able to

access an information bank

(building on

ConnexOntario). All local

resources are not expected

to be equally

knowledgeable, but well

informed to refer

individuals to appropriate

place

• Urgent/emergent cases

will come through the ED

and crisis intervention

services and be

appropriately referred

How will people be referred throughout course of health journey?

• Community and medical resources will develop partnerships to enable seamless referrals and maintain continuity

• At point of entry through any “door”, navigators will assess the individual “holistically” and triage them to the

appropriate care /service provider(s). Could be more than one service required (i.e. health related, social service)

• Recognizing that not all people need the same help, those with complex needs will be provided a “Most

Responsible Provider” to aid them through their life journey

• Services will have a broadened scope, enabling providers to care for the person, not the disease

• Mental health and addictions providers will follow a stepped care model which match the needs of people with the

most appropriate services and based on increased complexity of intervention. These services will provided in

collaboration across local, sub-LHIN, and LHIN providers to enable individuals to stay close to home.

• Local providers:

• Focus on health wellness, prevention/promotion to shift focus to early identification and provision of local support

services (community-based)

• Build local capacity to support those with mild to moderate mental health and addictions challenges

• Utilize telemedicine to connect individuals with specialized providers

• Specialized Services:

• For cases where needs are more complex and require specialized knowledge/skills (e.g. Acquired Brain Injury,

eating disorders, dual diagnosis, concurrent disorders, psycho-geriatrics, abuse, etc)

• Other health wellness needs may result in referrals to alternative providers (i.e. massage therapy, acupuncture,

meal programs, exercise, spiritual)

• May be delivered locally to keep individuals at home

• Complementary needs: Financial planning, childcare, stress/coping mechanisms, EMS, social agencies, EAP,

Public Health, Justice system

• Caregivers health needs, respite and support services



How will the system stay connected to the

individuals/families?

• Throughout the time in the system, HHR will be able to

keep atop of the individual‟s health status through

access to:

• EHR/personal health record shared across sectors

• Individuals/families will be equipped with care

coordination (navigation and clinical case

management) services to best match their needs.

• Individuals with complex needs will be connected with a

“Most Responsible Provider” to provide close contact

throughout the health care system

• These resources will help transition individuals

through life and health stages by staying attuned with

their health needs and building a relationship with

their families throughout their journey. (i.e.

knowledge transfer)

• System will provide enhanced peer support models to

support clients and families dealing with mental illnesses

and addictions as needed


• Local resources (i.e. Primary care, pastoral, teachers, etc) will play a key role in

referring individuals to mental health and addictions providers „help get

individuals/families where they need to be‟

• HHR will holistically assess and create treatment plans that place a strong

emphasis on accountability

• Health care professionals will assess individual for not only mental health and

addictions, but other chronic illnesses and complementary needs

• They will provide screening, early identification, assessment, treatment, and

follow-up services

• The converse will also be true – providers caring for individuals whose primary

reason for care is that of a physical condition, will also be better educated and

cognizant of key signs/symptoms related to potential mental health and

addictions related issues

• Throughout health assessments/treatments, the health care professional will

emphasize self-management as a necessary step to taking control of one‟s

own health

• Resources will be equipped with simple, straightforward tools which will be

reliant on local requirements such as case mix, urban vs. rural, etc

• HHR will conduct outreach activities for early intervention of specialized needs



• Information flow will follow the individual through their health journey. This will occur through a real-time, easily accessible electronic

health record (EHR) available to health providers across the continuum of care and geographic location

• The EHR will be connected to a personal health portal which will enable individuals to access and share health information as needed (i.e.

with alternative health providers)

• Will include integrated clinical practice guidelines/protocols and supported with electronic clinical decision support capabilities

• Will span the continuum of care and life span

• Health care professionals will be equipped with an information bank, (i.e. ConnexOntario) which includes inventory of services to enable

care coordination across organizations

• Include curriculum for health care providers, public, education system to raise awareness of condition and services

• Development of protocols for service coordination of information sharing, communication, and collection of standards


How will funding be coordinated

across sectors?

• Funding will follow the individual.

Collaboration across ministries so

that funding is seamless to the

individual/family

• Flexible funding model to enable

individuals to manage their own care

delivery

• Modification of physician fee

schedules

• Innovation fund


Implications of Mental Health and Addictions model of care

• Enabling “true self-management”, will require

individuals to have easy access to evidence-

based health information and inventory of

health services

• Developing effective working relationships

with health care professionals and

navigators/advocates

• Shift to local resources will require increased capacity of front-line resources

within community with regards to:


continuum

• Understanding of person‟s health care history and social considerations

• Care and management of individuals with mild to moderate conditions

and their families

• Defined roles and responsibilities of HHR providing mental health and addictions

services through a stepped care model. Identification of who is responsible for

care, what is the focus, and what they do (www.nice.org.uk)

• Health care professionals need more education, resources, understanding

(attitudinal change), and skill development to appropriately provide services

through the transition period from youth to adults to seniors.

• Develop trust and accountability with partners beyond traditional boundaries (i.e.

health and non-health)

• Increased need for infrastructure (i.e. transportation, e-health) to enable

collaboration across health sectors

• Consistent interpretation and application of privacy laws to enable information

sharing across health sectors, social agencies, alternative care providers, and

ministries



• Increase in service capacity to effectively manage mental health and addictions

services (supportive housing, peer support groups, psychiatrists, problem

gambling, etc)

Providers Individuals/Families


The Mental Health and Addictions model focuses on having services

increase in complexity/speciality as individuals/families go from local to

LHIN-wide providersService

ComponentsLocal Sub-LHIN LHIN-wide

Prevention &

Promotion





• Outreach services (i.e. mobile)


• Online health

information portals

(ConnexOntario)

• Antistigma/discriminatio

n reduction

Screening

Services

• Universal, standardized screening for all mental health and

addictions illnesses

• Self-navigation tools

• Specialized screening services for mental health

and addictions

Assessment &

Diagnostic

Services

• Early identification, assessment, treatment, follow-up and

management of mental health and addictions services

• Life skills training

• Psychotherapy

• Clinical case management and service coordination services (tools,

health information, referrals, etc)


• Acute mental health and addictions services, eating disorders

• Follow-up on inpatient / ambulatory care for individuals who

receive services in other hospitals(i.e. large community, tertiary

centres)


• Alternative medicine (acupuncture, naturopathy, reflexology,

massage therapy)

• Early identification, assessment, treatment, follow-up

and management of mental health and addictions

services

• Primary health care services (concurrent disorders,

dual diagnosis, psychogeriatrics)

• Service coordination and clinical case management

for specialized/complex cases (eligibility placements,

care plans, coping techniques, decision-making

guidance etc)

• Crisis intervention services


including:

• Psychogeriatrics, acute mental health and

addictions services, eating disorders, schedule 1

inpatient beds including additional beds for

paediatric services


individuals who receive services in other hospitals

(i.e. tertiary)

• Psychiatric assessment and intervention

• Tertiary care /

psychiatric hospitals

services including:

• Paediatric mental

health and

addictions services,

forensic psychiatry,

24/7 residential

addictions treatment

programs, ABI

• Education, research,

and clinical trials

• Specialized clinical

case management

(personal coaching,

care plans, coping

techniques, intensive

case management ,etc)

• Telehealth,

telemedicine, and

telehomecare

Treatment

Services

Pre/post

treatment care,

supportive care

• Consumer / family initiatives

• Social rehabilitation and recreation services

• Caregiver education





• Service coordination services


• Community withdrawal management


• Supportive housing services (concurrent disorders,

addiction, etc)

• Long term care services (i.e. dementia-secured

units)




• Day program services

Cura

tive

Rehabilitative &

Support

ive

Pre

ventive a

nd

Pro

motive Primary and secondary prevention


• Community mental health and addictions services:

• Mental health and addictions counselling services

• Primary health care services for mental health and

addictions

• Mental health and addictions case management

• Crisis intervention services

• Problem gambling

• Community substance withdrawal management services


Women’s Health &

Paediatric Services

Women‟s Health & Paediatrics

model of care refers to the delivery of

services to child-bearing women and

children. Other women health needs

will be addressed in other models.




Vision

Elements

Population served: Women; Infants; children and youth

Elements:

• Family/client centered care

• Accessible/ease of navigation

• „Wholistic‟

• Provide evidence informed quality of care

• Maintain transparency and accountability

• Strength/capacity based (individual)

• Culturally appropriate/competent

• Integrated care delivery

Principles

• Collaborative across the LHIN and ministries and agencies outside of health

• Sharing resources

• Engages clients and promotes ability and self-management/fostering resiliency

• Timely access

• Fosters a safe environment

• Considers the individual in context of family and community

• Supports life transitions

• Developmentally appropriate

• Continuous coordinated care

• Create and maintain efficiency and effectiveness


• Increased access points which are

integrated and community-based

• Integrated and evolving care plan that

follows the person/family through the

health journey

• Availability of relevant and integrated

health information across health sectors,

ministries, and social agencies and

readily available to individual/family

Model of care emphasizes individual/family focused care enabled by

relationship-based navigation across health / non-health

organizations



Providers

• Strengthens

relationship with

social agencies in

managing care of

individual

• Shift in focus to

providing holistic

care to individual

and family

• Enhance and

improve work/life

for providers


Model of Care?

Individuals/

Families

• Emphasizes care

closer to home

• Empowerment of

individuals through

self-management


Overview of Women’s Health & Paediatrics model of care

Access through

multiple doors

(e.g. primary care)

close to home

“no wrong door”

Referred to basket of

community services

close to home

Care coordinator discusses

concerns and refers to

appropriate health provider

Based upon need, age and

gender profile, person is

actively linked to most

appropriate provider

Strength-based

assessment

provided to

individual

Services provided to

individual/families

Information flow follows individual;

Funding follows individual

Person/family is directed to local

services for additional care

needs and concerns

Care

plan

Care

plan

Care

plan

Care

planCare

plan

Services

Basket

The following figure reflects an individuals‟ ongoing interaction within the model over the course of their

lifespan. Further details explaining each element are available in subsequent slides.


















How will the model of care work?How will women and children access this program:

• Services will be accessed through:

• Close to home, common places accessed by women, children, and their

families (daycare, school, community programs, service clubs, church, non-

traditional healers, libraries, family physician)

• Urgent/emergent entry points (ED, hospital, etc) which will also be equipped

with resources to navigate person for appropriate medical attention

• Utilize various online portals for communication and outreach to individuals/

families

• At point of access, individuals will be referred to a repository of community

services

• At community services, a health care navigator will assess health needs and direct

individual/family to appropriate health provider. Throughout lifespan of individual, this

health care navigator will build upon existing relationships in referring individual to

appropriate care setting, thus becoming a relationship-based health care

navigator.

• For specialized populations, individuals can access a health system advocate from

within system who is involved throughout the person‟s journey

• Users will also have the ability to self-schedule to provide greater ease of access

Where will women and children be referred

throughout course of health journey?

•Shift in focusing referrals based on active linking

to promote relationship-centered practice

•Based upon a „wholistic‟ assessment, individual

and family will be triaged to the right resource –

may be a single or multiple health provider(s)

across sectors and specialties.

• Specialized needs and services – domains

of medical, mental health, rehabilitation, and

social services. Practice a hub/spoke model

with immediate local resources provided

through spokes and LHIN-wide collaborative

as the hub. Various spokes needed in each

specialty domain

• Services will also be accessible within

communities through mobile specialty

services

• Support services – housing, women‟s

shelters, faith communities, schools,

aboriginal health programs, non-traditional /

traditional healers

• Services for caregivers- health needs,

respite, support services, etc




• Development of care plans across health sectors and

social agencies which engages the family with the individual

that includes strength-based strategies

• Care plans will evolve as they progress through the health

system

• Broader screening of “stigma issues” and evidence-based

diagnoses to promote early intervention before

behavior/disengagement

• Health research will be integrated into front-line practice.

How will the system stay connected to the individual?

•Relationship-based health care navigator will become

main point of contact for individual/family across their journey

in the health care system

•Individual/family will be able to communicate/share personal

health information as needed to ensure continuity of care

•Navigator will support individual through transition periods

across life/health stages both chronologically and

developmentally (i.e. end-of-life care)

•Proactive planning for transition



• Provincially driven electronic health record containing evidence-based/informed information that is accessible to health providers and

social agencies across the continuum of care

• Electronic health record will be linked to validated portal (personal health record) to support health literacy and evidence-based self-

management

• Information includes quality of care (wait times)


How will funding be coordinated across sectors?

•Funding should follow the individual and their care needs.

•Cross-ministry funding strategies which are seamless to the individual

• Collaboration across multiple ministries (Ministry of Education,

Ministry of Child Youth Services, Ministry of Health Long Term

Care, Ministry of Community and Social Services)

•Focused health research design targeted towards female and

paediatric populations. Specific sub-population needs include pre-natal

and female geriatrics.


The Women’s Health and Paediatric Model places an emphasis on local

health care which will support the centralized model

Service Components Local Sub-LHIN LHIN-wide

Prevention & Promotion






• Nutritional and dietary services (healthy child)

• Smoking cessation

• Prenatal health

• Healthy mom and healthy baby services

• Birth control services

• Immunizations• Online health information portals

Screening Services• Infant hearing screening


Assessment &

Diagnostic Services • Prenatal and post-partum and new born services

• Midwifery services

• Annual health check-up


• Clinical case management and service coordination

services (tools, health information, referrals, etc)


• Inpatient and ambulatory core hospital services including

obstetrics, eating disorders, paediatric services, mental

health

• Follow-up on inpatient / ambulatory care for individuals

who receive services in other hospitals(i.e. large

community, tertiary centres)

• Psychology

• Asthma services


management for specialized/complex

cases (eligibility placements, care

plans, coping techniques, decision-

making guidance etc)

• Core hospital-based and specialty

services including:

• Obstetrics and gynaecology services

• Neonatal Level 1 and 2, Obstetrics

level 1 and 2, Level 2 paediatrics

• Follow-up inpatient / ambulatory care

for individuals who receive services

in other hospitals (i.e. tertiary)

• Pschiatric services (paediatric mental

health)

• Tertiary care

• Services may include: Paediatric

surgical and medical sub-speciality

services (oncology, neurology,

etc), Neonatal Level 3, High-risk

pregnancy and obstetrics model,

Adult eating disorder clinics, Rare

genetics model, Cystic fibrosis

services, Cleft lip/palate

specialized services, Paediatric

trauma acute services

• Education, research, and clinical

trials

• Specialized clinical case management

(personal coaching, care plans, coping

techniques, intensive case

management, etc)

• Telehealth, telemedicine, and

telehomecare

Treatment Services

Pre/post treatment care,

supportive care

• Breast-feeding support services


• Home-based Rehabilitation services (OT, PT, SLP)

• Recreation therapy




• Transition services



• Supportive housing services for child

and youth with specialized needs



• Respite services

• Alternative medicine services

• Abuse services

• Post partum services

Cura

tive

Rehabilitative &

Support

ive

Pre

ventive a

nd

Pro

motive





Implications of Women’s Health & Paediatric services model of care


individuals to have easy access to evidence-

based health information and inventory of health

services

• Develop effective working relationships with

navigators and proactively coordinate

information across health and social agencies

(i.e. communication of child behavior within

schools to primary care physician for „wholistic‟

assessment)

• Referrals by “active linking” and development of

integrated care plans will require stronger relationships

among stakeholders across health and social agencies

• Shift to local resources will require increased capacity of

front-line resources within community with regards to:

• Knowledge and understanding of all health

services across the continuum

• Understanding of person‟s health care history and

social considerations

• Develop trust and accountability with relationships

beyond traditional boundaries (i.e. health and non-health

ministries)

• Consistent interpretation and application of privacy laws

to enable information sharing across health sectors,

social agencies, non-traditional providers, and ministries

• Changes in funding model will require enhanced

collaboration between ministries of education, child youth

services, and health and long term care



Long Term Care

Services & Complex

Continuing Care




Vision

Elements

• Person-centered

• Sustainable

• Quality

• Accessible

• Timely

• Proactive

• Preventative

• Community-based services

Principles

• Connected for Life

• Diverse

• Promotes Independence

• Collaborative

• Simple

• Equity for All

• Sustainable

• Shared Accountability

• Engaging

• Evidence/best practice

• Maintain home “whereever home is”

• Ethical

• Relationships

• Sensitivity to language differences


• Focus on maintaining independence for

individuals within their homes

• Community hubs, centered around

individual/caregivers for support, will

facilitate access to all long term care

services (i.e. LTCH, CCC beds)

• Personal care teams to maintain continuity

for individuals as they access services

across the health system

Model of care uses community hubs to manage and facilitate local

access to all long term care and complex continuing care services



Providers

• Appropriate use

of complex

continuing care

and long term

care capacity

• Early

identification and

intervention of

health needs


Model of Care?


• Case management is provided

in settings that optimize care

delivery

• Empowerment of

individual/family members in

managing their own care –

Individual is part of health

team

• Care provided closer to home

allows individuals to have

increased access to personal

support network

• Individuals are connected to

health system through their

journey – “connected for life”


Overview of Long Term Care Services and Complex Continuing Care

Model

• Individuals and caregivers will be

able to access information on long

term care and complex continuing

care services through any “door”

including community resources,

primary care, or emergency services

• Individuals and caregivers will be

referred to the individual to

community hub

1 Individual/caregivers will be connected with

a Knowledge Broker and Personal Care

Team (PCT) who will holistically assess

individual‟s need and create a care plan that

will rely on community support services or

referral options

2

If further specialization is

required, the individual

and PCT will discuss

other options including

long term care homes,

complex continuing care

beds, Transitional beds,

Supportive housing, etc

3

As much as possible,

care will be provided at

or close to home. If

individual is transferred

to a facility,

arrangements to move

back home will occur as

appropriate

4


How will the model of care work?

How will people access this program:

• Individuals will be able to access health services through


• Regardless of entry point, organizations will refer people to

single source of information – Knowledge broker in

community hub.

• Individuals/families will be able to access health information

to make informed decisions through online/hotline which is

real-time and evidence-based

• Local resources such as day programs, senior centres,

health clubs, etc. will be able to access health information

and refer to community hub

• Urgent/emergent cases will come through the emergency

department and be appropriately referred

• Primary care networks – individuals may be referred to the

community hub for additional services through family doctor

• Local resources will be equipped with accessibility tools to

educate and refer all individuals (i.e. physical disabilities and

cultural competency)

• A broadened scope for referrals will enable referrals from

health and other social providers

• Individuals/community hubs will be able to rely on a central

dispatch transportation program to coordinate transport

across the model

• Community hub-type services will be accessible to where

people congregate (work, senior centres, etc)


How will the model of care work? (cont’d)How will people be referred throughout course of health journey?

• Community hubs will be equipped with a variety of resources to enable appropriate care or referral:

• Knowledge broker – provide health information/education as needed on options of services

(health, social, complementary needs, etc)

• Personal Care Team (PCT) – Support team built around the care needs of the individual – assign

person to help access care through their life journey

• Primary Care services

• Community resources – adequate supply of these types of services (day programs, education,

etc.)

• Within communication hub, health care professional will assess the individual “holistically” and

triage them to the most appropriate PCT. The PCT will empower individual/caregiver with “options”

and coordinate all the health services needed, which may be at home or referral to a facility

• Services will have a broadened scope, enabling providers to care for the whole person. PCTs will

ensure a seamless transition

• Local providers:

• Focus on health wellness, prevention/promotion to shift focus to early identification


• Utilize tele-medicine to connect individuals with specialized providers

• Other health wellness needs may result in referrals to alternative providers (i.e. massage

therapy, acupuncture, meal programs, exercise, spiritual)

• Specialized Services:

• Needs may include: Acquired Brain Injury, complex needs, co-morbidities, mental

health/elderly, <18 years of age, palliative care, etc. These types of cases will receive

specialized navigation to guide them to receive the appropriate resource

• Based on health assessment requiring extended support, individual will be referred to Long

Term Care Home, Supportive Housing, Transitional, CCC, acute services, or in-home

community support services. As much as possible, individuals would remain in their

community with the right supports as long as possible.

• Long Term Care Homes would be targeted for individuals unable to remain in the

community or have specialized needs (e.g. behavioural issues, acquired brain injury,

dialysis, mental health, dementia)

• Under 18 – youth will be referred to targeted supportive housing programs

• Group homes for targeted illnesses delivered in collaboration with the ministry of health

• Complementary needs: food/security, housing, financial planning, stress/coping mechanisms

• Caregivers health needs, respite and support services




• PCT will use standardized assessment tools for specific populations. In

collaboration with individual/caregiver, PCT will provide a comprehensive

treatment plan (via personal health record, hardcopy report, etc)

• Assessment will be comprehensive evaluating risk factors and health

triggers (age, social condition, ER visits, etc)

• Client will be monitored where they aggregate to conduct not only a

medical, but a social assessment (seniors centres, adult day

programs)

• This assessment will be attached to the individual as he or she moves

through the system

• Complex Continuing Care, Long Term Care Homes, Supportive Housing,

Transitional services – based on acuity level and need, individuals will be

assessed and referred to appropriate setting. - right care, right time, right

place

• Shared accountability across providers – the treatment plan will be

shared by all health professionals (physician, nurse, pharmacist, allied

health)

• These organizations will also be responsible to coordinate with the PCT

on appropriate discharge planning into community or home

• Specialist services will also be available through telemedicine services

within a local capacity

How will the system stay connected to the individuals/families?

• Periodically, every individual discharged within this program will

be visited by a PCT member to discuss health status and

maintain continuity

• This PCT member will stay attuned to the individual‟s needs as

they cross health / life stages (i.e. end-of-life care)

• Assessment tool will be a part of individuals personal health

record and revisited by PCT periodically

• Community hub will be the key coordinator and resource to

maintain continuity and flow across services

• Share the care – information caregiver support and other lay

people will be integrated into the health care planning



• Information flow will follow the individual through their health journey. This will occur through a real-time, easily accessible electronic

health record (EHR) available to health providers across the continuum of care and geographic location

• The EHR will be connected to a personal health portal which will enable individuals to access and share health information as needed (i.e.

with alternative care providers)

• Will include integrated clinical practice guidelines/protocols and supported with electronic clinical decision support capabilities

• Will span the continuum of care and life span

• Health care professionals will be equipped with a repository of services to enable care coordination across organizations

• Include curriculum for health care providers, public, education system to raise awareness of condition and services

• Other social providers will be able to access repository of services to educate its clients

• Health tools will be pushed out to employers to enable them to refer individuals as needed (i.e. healthline)


How will funding be coordinated

across sectors?

• Funding will follow the individual.

Collaboration across ministries so

that funding is seamless to the

individual/family (housing, education,

health and long term care)


The Long Term Care Services and Complex Continuing Care model emphasizes

service delivery at a “local” level, only referring complex cases to LHIN-wide providers


Prevention &

Promotion







• Falls prevention

• Online health information

portals

Screening Services • Self-navigation tools

Assessment &

Diagnostic Services • Early identification, assessment, treatment, follow-up and

management






• Inpatient and ambulatory core hospital services




• Local geriatric services

• Mobile primary health care services

• Alternative medicine (acupuncture, naturopathy,

reflexology, massage therapy)

• Early identification, assessment, treatment, and

follow-up and management






including:

• Complex continuing care, psycho-geriatrics,

geriatric services

• In addition, they may provide follow-up

inpatient ambulatory care for individuals who

receive services in other hospitals (i.e. tertiary

hospital)




• Tertiary care services

including:

• psycho-geriatrics

• Education, research,

and clinical trials

• Telehealth, telemedicine,

and telehomecare



coaching, care plans,

coping techniques,

intensive case

management ,etc)

Treatment Services

Pre/post treatment

care, supportive care

• Healing services(aboriginal health)

• Assisted living services

• Home-based Rehabilitation services; community rehab

groups; outpatient

• Community support services (meals delivery, home-

making, day services, assisted living services etc)




• Recreational and social programs for people with

disabilities



• Progressive community living services


• Community-based chronic ventilation services

• Slow stream rehab services

• Inpatient rehabilitation services (general rehab

units or by cluster – stroke, cardiac, etc)

• Specialized Long Term Care homes

(behavioural, ABI, dementia, dialysis, mental

health, etc)




• Day services

• Transportation Services

• Specialized supportive housing (e.g. ABI, chronic

vent patients, youth with disabilities

• Highly specialized

inpatient rehabilitation

beds (ABI, etc)

• Highly specialized

outpatient rehab

services (ABI, spinal

cord, etc)

• Tertiary acute palliative

care

Cura

tive

Rehabilitative &

Support

ive

Pre

ventive a

nd

Pro

motive





Implications of Long Term Care Services and Complex Continuing

Care model of care

• Enabling “true self-

management”, will require

individuals to have easy access

to evidence-based health

information and inventory of

health services

• Expand focus of long term care

services provided beyond

traditional long term care homes

• Need to define the use of LTCH/CCC beds in order to appropriately use

capacity

• Need to reconsider capacity of transitional and CCC beds across north,

central, and south regions to ensure an appropriate distribution in rural

areas

• Distribution of community hubs across the LHIN will require the physical

relocation of health and social provider resources

• Shift to local resources will require increased capacity of front-line

resources within community with regards to:


continuum

• Understanding of person‟s health care history and social

considerations

• Increased need for infrastructure (transportation, e-health, etc) to enable

collaboration across health sectors

• Consistent interpretation and application of privacy laws to enable

information sharing across health sectors, social agencies, alternative

care providers, and ministries



• Providers will be mandated to evaluate individuals holistically, assessing

all healthcare and social needs as deemed appropriate



Emergency Services




Vision

Elements

• 24/7 available emergency services within overall system with timely, accessible

levels of care using the right provider, providing the right care

• Individual and family centered care

• Culturally competent care

Principles

• Available and appropriate time to care

• Ensuring individual/families and staff safety

• Evidence-based care: LHIN-wide ED medical directives supported LHIN-wide,

clinical pathway, pre-printed orders

• Collaborative, inter-professional team working to their full scope of practice

• Access to adequate back-up support from other programs

• Access to timely diagnostics


• GPS-type care coordination system to

enable emergency services to book

follow-up appointments across health

sectors

• Expansion of provider roles across

the continuum to optimize care

delivery

• Integrated collaboration across health

sectors to enable seamless referrals

Model of care focuses on expanding access to emergency services

beyond emergency departments



Providers

• Enables the right

practitioners to

provide the right

care in the right

place

• Strengthened

relationship

between partners

across health

sectors


Model of Care?


• Care is coordinated

for individual and

family before leaving

the provider


Overview of Emergency Services Model

• Individuals/ families will access

emergency services through any door

– “right ride to the right place”

• Once care is provided within the

provider setting, the individual will be

discharged to community resources for

any follow-up care – “right follow-up”

• Once the individual enters the

system, they will be holistically

evaluated and treated and/or referred

to the appropriate care – “right care

by right provider”

1 3

Triage

Assessment /

Reassurance

Treatment

Care Coordination

Education / Self

Care: Referral

to primary care

Consults with

specialists

Inpatient Care –

Facility Transfers

GPS – Booking of all

follow-up appointments

Culturally sensitive care

for homeless and other

specialized populations

2

telehealth

Health

Information

Community Support

ServicesUrgent

Care

Centre

Emergency

Department

Primary

Care

(FHT/FHN/C

HC/GP/NP

Clinic)

“Right ride to the

right place”

EMS

1

2

3

Release

Assess and

transport (if

necessary)
















• Individuals will be able to access

emergency services through any door –

„any door is the right door‟

• While the Emergency Department is

accessible to all, alternative entry points

will enable other resources to treat

appropriate cases. These entry points will

include:

• Primary care (with extended hours)

• Stand-alone NP clinics and/or

integration of NP/Physician Assistants

along service provider continuum

(including EDs)

• Urgent Care Centres (urban)

• Advanced “Telehealth” services to

effectively advise residents to

appropriate services and reduce visits

to ED

• Enhanced crisis/mobile teams -

Appropriate triaging can also occur prior

to the individual reaching the ED

through enhanced crisis team roles.

• Expanded EMS capabilities will also

allow them to divert potential ED visits

as appropriate (transport to primary

care, etc)

• EMS hospital bypass protocols for

certain conditions and diagnosis

segments

How will people be referred through their interaction with emergency services and

their transition to other services as required?

• Within emergency services, care coordination resources will use the following tools to

appropriately refer individual to best care option (i.e. inpatient, specialist consult,

community resources, home, family doctor)

• Enhanced use of Ontario Telemedicine Network to access clinical expertise

• Access to consultation, diagnostics and inpatient services

• A care coordination resource/electronic system will conduct a timely assessment (i.e.

CCAC) and develop a plan that relies on health providers across sectors through “GPS

Care Coordination.” Through this system, providers will schedule all diagnostics and

consultant appointments electronically prior to the person leaving the ED

• Coordination of all services (LHIN-funded, non-LHIN funded)




• Emergency services will be equipped with LHIN-wide access to specialized skill sets as needed by its local population (i.e.

psycho-geriatrics, mental health and addictions, complex developmental behaviours, etc). These specialized resources will be

accessed through community resources, such as crisis intervention teams, or urban clinical expertise via telemedicine.

• Communities with low volumes – resources will maintain competency to manage specialized cases


• Health service providers will be accountable to one another through „Memorandums of Understanding‟ to clarify roles and responsibilities

of EDs and their partners within the community and within the acute care system

• Information flow will follow the individual through their health journey. This will occur through a real-time, easily accessible EHR

available to health providers across the continuum of care and geographic location

• The EHR will be connected to a personal health portal which will enable individuals to access and share health information as needed

(i.e. with alternative care providers)

• Health information will be consistent, standardized guidelines which are evidence-based and span the continuum of care and life span


The Emergency Services model focuses on having services available as

needed by its population

Service ComponentsLocal Sub-LHIN LHIN-wide

Prevention & Promotion

• Primary care services (Early identification,

assessment, treatment, and follow-up of chronic

illnesses)

• Local hospital services to provide core hospital-

based services

• In addition, may provide follow-up inpatient /

ambulatory care for individuals who receive

services in other hospitals ( i.e. tertiary, large

community hospital)



• ED/Urgent Care Centres / Reduced hours of

operation

• EMS

• Enhanced crisis intervention

• Diagnostic services



• Large community hospital

to provide core and

specialty services

• Emergency

Departments

• In addition, may

provide follow-up

inpatient / ambulatory

care for individuals

who receive services

in other hospitals ( i.e.

tertiary)

• Service coordination and

clinical case management

for specialized/complex

cases (eligibility

placements, care plans,

coping techniques,

decision-making guidance

etc)

• Diagnostic services,

interventional radiology (i.e.

MRI, CT)

• Tertiary Hospital will operate as a

hub for the LHIN

• Emergency Departments –

Trauma Centres

• Tele-medicine and telehealth

services



coaching, care plans, coping

techniques, intensive case

management ,etc)

Screening Services

Assessment & Diagnostic

Services

Treatment Services


supportive care

Cura

tive

Rehabilitative &

Support

ive

Pre

ventive a

nd

Pro

motive


Implications of Emergency Services model of care

• Expand focus on accessing emergency

services beyond the emergency

department. Increase reliance on non-

ED resources for health needs (i.e.

PCP, urgent care, NP clinic, etc)

• Future service model is driven by ensuring quality service delivery

via all access points in the system, not as a cost-containment

strategy. This is particularly important when planning for access to

emergency services within HHR limitations

• Further research to be conducted to determine appropriate time to

care in rural and urban areas – what is considered acceptable travel

time in South West LHIN in relation to these areas. Implication: Both

sessions understand rationalization of resources is a consequence

of this definition

• Clarification of policy on “Hospital” designation, if ED operates on

reduced hours

• Seamless referral system will require stronger relationships and

accountability among stakeholders across health and social

agencies

• Need to evaluate the impact of reduced hour EDs on nearby

services, as well as to other areas of the hospital (i.e. inpatient

units)

• Increased workload to EMS and RNs for escorting patients during

transfers

• Changes in physician workload and reimbursement systems

• Consistent interpretation and application of privacy laws to enable

information sharing across health sectors, social agencies,

alternative care providers, and ministries



Enablers for Emergency Services model of care

• LHIN-wide HHR strategy for recruitment and retention for physicians and RNs providing

emergency services, in particular, targeted towards rural and remote communities

• Appropriate physician remuneration models to reflect the work and hours required in

delivering care 24/7

• Effective back-up/specialist clinician support practitioners in managing acute and/or

complex cases

• A LHIN wide bed management system to facilitate admissions from ED.

• LHIN wide non-ambulance patient transportation delivery model and algorithm. Cost of

non-ambulance patient transportation needs to be recognized in the funding for institutions.

• MOHLTC legislative adjustments to enable expanded role of EMS


Medicine

Medicine model of care refers to the

delivery of internal medicine services

and medical sub-specialties (e.g.

cardiology, nephrology,

endocrinology, etc)




Vision

Elements

• Access will be timely, person-focused, and evidence based

• Efficient use of care resources

• Individual‟s care experience is built on consistency, quality, and excellence

• Evidence based quality of care

• Integrated seamless model

Principles

• Transparent and accountable system

• Standardized communication and language

• Designed and tailored care at each point along an individuals care continuum

• Resources flow with the individual‟s care needs

• Enhance local capacity


• A centralized system navigator in the

form of a coordinated primary care

network across the LHIN

• Care close to home balanced with

Centres of Excellence

• Information sharing portal for

individuals, providers, and families

• An „advanced‟ telemedicine service

will serve as a true option for

individuals/families and providers

• Standardized, consistent approach to

care provision

Model of care uses a centralized system navigator in the form of an

expanded primary care network to assess and triage individuals /

families based on level of complexity/intensity


today’s service delivery model?What are the benefits of the

Model of Care?

Providers

• Capacity utilization

in the LHIN will

improve as a result

of precise

navigation to

appropriate health

facilities

• More dedicated

time for quality

care as a result of

advanced

telemedicine

support and easily

accessed online

education and self

management tools


Model of Care?


• Individuals and

families will have a

trusted point of first

contact for all

medical situations

• Individuals and

families will have

access to health

education and self-

management tools

through several

mediums


Overview of the Medicine model of care

PRIMARY CARE NETWORK

COMMON REFERRAL PROCESS FOR ALL SERVICES

SELF MANAGEMENT

EDUCATIONAL INFORMATION

ADVANCED TELEHEALTH

Complex / specialized

Moderate

Intensity

Lower

Intensity

CLOSE TO HOME SUB-LHIN LHIN WIDE

LowerIntensity

Complex / Specialized

ModerateIntensity

CENTRES OF EXCELLENCE

NON TERTIARY SUB-LHIN CENTRES

CASE MANAGEMENT

STANDARDIZED TRANSPORTATION SERVICES

•The individual‟s first point of contact occurs at the primary care level

with a primary care network

•The individual has access to health education, self management tools,

and an „advanced‟ telemedicine service that will always be present as a

navigator and source of pertinent information

1

•Either through the primary care professional or through

self-referral, the individual will be assessed by intensity

and complexity and will be guided to the appropriate

service provider. Tele-consult services will be available

for easier access to specialized support.

•Standardized referral structure/processes with the use

of telemedicine will enable broadened referral capacity

•Standardized transportation services and access to

continuing health education will be available to the

individual and their family

2

•Based on the assessment, the individual

will be assessed as Low Intensity,

Moderate Intensity, or Complex /

Specialized; this assessment will guide

their path along the continuum. LHIN-wide

management of capacity will enable

individuals to flow through the system with

equal urgency. Tele-consult services will

enable timely access to specialized

medical support.

•If the individual is considered as Complex /

Specialized, they will likely be transported

to a Centre of Excellence and will be

supported under a case management

model

3

1

2

3

* Further details explaining each element are available in subsequent slides.










How will people access this program?

•Individuals and their families will be supported by an integrated

primary care network consisting of traditional providers such as

physicians and nurses but also consisting of allied health and

alternative care providers. They will have the ability to refer

individuals.

•Individuals and health care providers will have access to tele-consult

services to ensure timely access to specialized support

•Individuals will also have online health information and self

management tools to enable and promote responsible health

management and choices

•Individuals and their families will have 24 hour telephone access to

an advanced version of telemedicine, whereby they can choose to

receive basic consultation or be navigated to the appropriate resource

•Primary care networks will offer extended hours in each community in

order to offer flexible choices and access

•Centralized transportation dispatch system across the LHIN will

streamline access as needed

How will individuals be referred in this continuum?

•Upon their interaction with a primary care practitioner, they will

then be assessed for social, clinical, and geographic factors and

by level of complexity / intensity. Tele-consult services will be

used as required.

•Members of the primary care team (i.e. OT, PT, physician) will

triage the individual to the appropriate health provider upon

completion of the assessment. Both health providers and

individuals/families will be able to use a standardized referral

structure to seamlessly access specialty services



How will individuals be identified

and assessed?

• Online educational materials and self

management tools will help to enable

and promote responsibility of the

individual to self manage illness or

condition

• Individuals will be assessed by a team

of practitioners within a broader

primary care network

How will individuals and providers

access education and information?

•For the individual and their family, there will be

single point of access to education and

information available anywhere; examples

include, telemedicine, online self management

tools, information and education at community

centres and schools

•Online health information portal accessible

anywhere for individuals and families and

providers that can be easily understood

•Tele-consult services available for specialized

medical advice

•Electronic health record (EHR) available to both

individuals and providers. This information will

be communicated back to the primary care

network via the EHR

•Standardized tools, resources, and knowledge

exchanges for providers



What role will Medicine play in complementary care?

• Individuals and their families will be taken care of in a culturally

sensitive environment

• The primary health team will bring holistic approaches to health as

well as tailored care (i.e. aboriginal care, seniors care)

• There will be access to complementary services through online

support and telehealth (i.e. meals on wheels)

How will Medicine care for specialized needs?

• Individuals will have unique specialty services available to them in

key areas of the LHIN

• Individuals will receive case management support for highly

complex / specialized cases at tertiary hospitals and Centres of

Excellence located across the LHIN



How will Medicine support health research?

• Meaningful data will be collected at each

point of interaction within a common data

warehouse (i.e. person-provider, person-

website, provider-provider). This will be used

to prioritize funds for LHIN-initiated research

• Partnerships among traditional and

alternative care practitioners and academic

health centres will be strengthened

How will care be coordinated?

•For less complex individuals, case management support will be provided by the primary care

physician; for specialized / complex individuals, the CCAC will work together with primary care

networks to support more complex case management

•Standardized processes and operations will be instituted throughout the LHIN to support

screening, assessment, and discharge at all hospitals and facilities across the LHIN


The Medicine model focuses on using the expertise of primary care practitioners to

appropriately assess and navigate individuals to the appropriate service facility


Prevention &

Promotion




• Health education and advocacy


• Nutritional services and dietary services

• Smoking cessation services


Screening Services • Self-navigation tools

Assessment &

Diagnostic Services• Early identification, assessment, treatment, follow-

up and management of chronic illnesses



• Clinical case management and service

coordination services (tools, health information,

referrals, etc)


• Inpatient and ambulatory, high volume/low acuity

general medicine and internal medicine services

• Follow-up on inpatient / ambulatory care for


hospitals(i.e. large community, tertiary centres)

• Diagnostic assessments

• Shared care services with specialists and

primary care

• Emergency services



• Early identification, assessment, treatment, follow-up

and management of chronic illnesses

• Service coordination and clinical case management for

specialized/complex cases (eligibility placements, care

plans, coping techniques, decision-making guidance

etc)

• Core hospital-based and specialty services including:

• Inpatient and ambulatory, moderate volume/acuity,

internal medicine physician (PCI, oncology, etc)

• Follow-up inpatient / ambulatory care for individuals

who receive services in other hospitals (i.e. tertiary)

• Diagnostic assessments – interventional radiology

(i.e. MR, CT)

• Pain and symptom management services (i.e.

chronic pain)

• Systemic and radiation therapy

• Tertiary /Quaternary care services

(low volume/high acuity):

• Sub-specialized inpatient and

ambulatory internal medicine

services (i.e. specialized thyroid

and parathyroid services, sub-

specialized respiratory services,

rheumotology)

• Specialized radiation and

systemic therapy


trials


management (personal coaching,

care plans, coping techniques,

intensive case management ,etc)

• Complex multi-disease

management

• Telehealth, telemedicine, and

telehomecare

Treatment Services

Pre/post treatment

care, supportive

care







• Recreational and social programs for people with

disabilities



• Supportive services to manage chronic illnesses

(Dialysis, stroke, diabetes, chiropody, weight

management)


• Chronic ventilation services


• Inpatient rehabilitation services (general rehab units or

by cluster – stroke, cardiac, etc)

• Supportive housing services

• Long term care services




• Day services

• Palliative care services (end stage COPD)

• Highly specialized inpatient

rehabilitation beds (ABI, etc)

• Highly specialized outpatient

rehab services (ABI, spinal cord,

etc)

• Tertiary acute palliative care

Cura

tive

Rehabilitative &

Support

ive

Pre

ventive a

nd

Pro

motive

Integrated Screening (aneurysm, carotid disease, etc)



Patient, family, and caregiver education and information services


Implications of the Medicine model of care

• Enabling “true self-management”, will

require individuals to have easy access

to evidence-based health information

and inventory of health services

• The primary care networks and primary health teams that will be

supporting individuals and their families throughout the LHIN will

require greater attention in terms of health human resources

recruitment and distribution.

• A clear delineation of each providers role, at all levels, within the

system.

• A commitment to building a world class, advanced Telemedicine

service will require a coordinated commitment by leaders in health

care to develop and institute 1) an inventory of available services at

each facility across the LHIN, 2) a common set of screening,

assessment, and discharge guidelines, and 3) a real time view of

capacity utilization across the LHIN.

• Implementing a case management approach for Complex /

Specialized individuals will require a common set of clinical

standards across the LHIN and all agencies and organizations; it

will also require increased coordination between hospitals /

organizations and physician offices in order to best translate

inpatient information into outpatient practice.

• A coordinated effort across the health care providers to collect and

contribute to an electronic health record database.

• Leverage purchasing power in coordinating a centralized

transportation system



Critical Care


• Collaboration among all critical care units

across the LHIN to ensure that the right patient

is in the right place at the right time (consistent

admission criteria)

• Being respectful of family and patient by

consistently sharing information throughout the

process to enable decision making

• Development of the Electronic Health Record

will enable the seamless transition of care to

other services within the hospital, to their local

community or local hospital

• Development of regional critical care physician

on-call system and structure

Model of care focuses on LHIN-wide management of critical care

resources to enable appropriate use, ensure critical mass, and

maintain individual/family focused care

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

What are the benefits of the Model of Care?

Providers

• Maximizes utilization of

resources across the

entire LHIN

• With the regional on-call

system, all consults will

be directed to the on-call

physician. This

minimizes stress as

providers will no longer

have to provide both

patient care and on-call

consults concurrently

• Access to quicker advice

from critical care

physician



• Strengthens relationship

with patient, families and

providers

• Minimizes stress to patient

and families during

transition points in care


Overview of Critical Care model of care

1

Patient / Family

Focus

• Care of critical care

patients will focus

on the needs of

patients and their

families.

Consistent

communication of

information

throughout the care

journey across

transition points is

needed to minimize

stress and optimize

recovery

Communication

• Communication between

the local, sub-LHIN and

LHIN wide referral centres

will be required to

optimize the utilization of

beds throughout the LHIN

• CritiCall will serve as

triage system to facilitate

communication to

consultant

Critical Mass

• Critical mass ensures

patients receive safe

and effective treatment.

2

4

Appropriateness

• Critical care beds will operate as

LHIN-wide beds to ensure the right

patient is in the right bed at the right

time.

• CritiCall will serve as an efficient

critical care triage system to ensure

patients are in the appropriate

bed by having real-time

access to information on the availability

of level 2 & 3

beds throughout the LHIN

• A referral will be made only

if the sending physician

consults with a critical

care physician.

Consultation to be

facilitated by CritiCall.

CritiCall

Sub-LHIN Hospital

Level 2 & 3

LHIN-Wide Referral

Hospital

Level 3

CritiC

all

Cri

tiC

all

CritiCall

Long Term Care Services / Complex

Continuing Care

Local Hospital Level 23

* Further details explaining

each element are available in

subsequent slides.






How will the Critical Care model of care work?

Where will patients be referred throughout course of Critical

Care journey?

• Clear and consistent definition of Level 2 & Level 3 beds is required to

ensure that there is clarity and accountability managing the utilization of

beds across the LHIN

• Development of guidelines / protocols for “Resuscitation – Stabilization and

Transfer of the Critically Ill Patient” to promote a common understanding to

the appropriateness of referrals across the LHIN

• Development of hospital patient transfer criteria. These criteria will be

determined by each hospital‟s limitations to provide patient‟s needs. Local,

sub-LHIN and LHIN-wide referral hospitals will develop consistent

guidelines for assessments and transfers.

• Development of transfer partnerships between community hospitals and

LHIN-wide referral centre. These partnerships will be both within and

external to LHIN and will be focused on patient need.

• Development of Hospital Repatriation Policy – once the patient‟s care can

now be met by the local hospital, arrangements will be made to transfer

patients.

• Promotion of communication and support between local and LHIN-wide

referral centre using telemedicine, LHIN-wide teleconferences on topics

relevant to each hospital‟s needs or related to recent patient transfers.

How will Critical Care accommodate for specialized

needs?

• Patients requiring acute dialysis, burn, trauma, neurological

and cardiac surgical services will require referral to the

LHIN-wide Referral Hospital

• For Chronic Vent patients, services will require early and

proactive coordinated funding and services within and

external to the critical care setting (i.e. CCAC, LTC, respite

services etc.)

How will patients / families / providers access this program:

• Providers (i.e. EMS and physicians) will contact CritiCall to understand real

time critical care bed availability in the LHIN. CritiCall will determine the

most appropriate critical care bed for the patient based on the level of

acuity of illness, urgency and geography.

• A referral will be made only if the sending physician consults with a critical

care physician. These consultation to be facilitated by CritiCall.


How will the Critical Care model of care work?(cont’d)

How will local, sub-LHIN and LHIN-wide referral centres support each other to optimize quality patient care?

• Critical Care Information System will provide up to date information on the utilization and level of acuity of patients

currently occupying critical care beds across the LHIN. As such, this information with CritiCall will support providers in

determining the appropriate occupancy of the patients and initiate transfers as needed to optimize capacity and

resource utilization of their beds

• Support from LHIN-wide referral centres to local sites for information, assessment and treatment via telemedicine and

transfers as required.

• To increase consistency, expertise and quality of critical care, LHIN-wide educational programs using protocols / care

bundles / benchmarks directed at enhancing patient care will be implemented



How will the system stay connected to the individual?

• Understand and document as early as possible the goals

of care by patient / families to optimize level and setting

of care provided. As care progresses, these goals will

require ongoing assessment and updates

• To minimize stress on patients and families, care

planning by involving patients/families through the care

journey and providing education to enable decision

making. This communication and information will also

ease transitions from critical care to different levels of

care (i.e. general medical units, different hospitals, LTC,

palliative care etc.) for patients/families

• Involvement and communication with other providers as

needed (i.e. End of Life, Palliative Care, CCAC,

respiratory services, LTC services)


• Development of information to educate patients on the appropriateness of care in the various facilities. This will raise the awareness and

confidence in patients / families that the most appropriate care is being provided in the right setting

• Implementation of the Electronic Health Record (EHR) that supports broad provider access to accurate patient histories and current

interventions, will enable all providers to make care decisions in a timely manner. The EHR will also result in more seamless transitions of

care from hospital to in-patient unit (i.e. surgical, medical, etc.), between hospitals and hospital to community / home

• CritiCall will serve as triage system to facilitate communication among providers and critical care consultants


The Critical Care model places an emphasis on right patient, right

place and right time

Service Components

Local

(Lower Complexity, Higher

Volume)

Sub-LHIN

(Higher Acuity, sub-LHIN Referral

Centre)

LHIN-wide

(Specialized Services, LHIN-Wide Referral

Services)

Prevention & Promotion Public Health (i.e. health & safety promotion programs, health education etc.)

Screening Services EMS, Emergency Services, integrated screening services; primary care services

Assessment & Diagnostic

ServicesDiagnostic services; interventional radiology; emergency services; outreach teams

Treatment Services

• Level 2 Critical Care Beds

• Step down or high intensity

treatment for surgical and

medicine services

• Level 2 & 3 Critical Care Beds

• Step down or high intensity

treatment for surgical and

medicine services

• Level 3 Critical Care Beds

• Trauma

• Burn

• Cardiac Surgery

• Neurological Services

• Acute dialysis

• Organ transplantation

• Level 3 LHIN-wide Referral centre will

provide telemedicine consults to local

hospitals and determine if transfer is

required


supportive care

• Community-based chronic

ventilation services

• Home-based Rehabilitation

services


(general rehab units or by cluster –

stroke, cardiac, etc)

• Supportive housing services (i.e.

vented patients)

• Long term care services (i.e.

vented beds)


Tertiary acute palliative care

Cura

tive

Rehabilitative &

Support

ive

Pre

ventive

and P

rom

otive


Implications of Critical Care services model of care

• A focus on patient / family preferences to determine

the appropriate use of critical care resources. The

community will be educated on the level of care

available at the local, sub-LHIN and LHIN-wide level

• A shift to LHIN-wide ownership of critical care beds

requiring collaboration, shared accountability and

transparency to ensure patients are in the right place

at the right time. This will require the development of

LHIN-wide definitions for beds, protocols for

stabilization & transport, and repatriation policies

• In making this shift, there will be a need to

balance the management of scarce resources

centrally while still enabling local access, i.e.

centrally managed pool for critical care beds.

Providers across the LHIN would need to have

visibility into these resources to not only

enable key processes such as scheduling and

monitoring availability, but manage locally to

provide access.

• Develop the Electronic Health Record to support

seamless transitions between hospitals, within

hospitals and from hospital to community



Surgical Services




Vision

Elements

• Maintain transparency and accountability

• Require patient/consumer accountability through empowerment and choice

• Deliver effective transitioning through the care continuum

• Provide equitable, appropriate access to care

• Enable the flow of the right information

• Provide evidence based, standardized care; „the right care, the right time‟

Principles

• Increase the patient‟s/consumer's ability to play an active role in the management

of their care

• Maximize the use of technology

• Ensure the efficient use of health human resources to increase the sustainability of

health human resources in the LHIN

• Equitable access regardless of geography

• Ensure that service capacity reflects population requirements

• Maximize utilization of the current system capacity

• Maintain an individual centered, high quality approach to care delivery

• Ensure critical volumes are maintained when distributing services in the LHIN


• Single, unified point of access with

common referral standards / process

by specialty

• Consistent use of standardized care

pathway‟s across the LHIN

• Utilization of tertiary and non-tertiary

Centres of Excellence across the

LHIN to ensure that care is provided

closer to home when possible

Model of care emphasizes a centralized and coordinated point of

access to all surgical services across the LHIN

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


Providers

• Improved capacity

utilization and

patient flow across

the LHIN

• Improved quality of

care through the

adoption of

standardized care

pathways from

screening,

assessment

through to

discharge

guidelines



•Improved equity,

timeliness and access

to care in the „right‟

place

•Increased choice for

individuals when it

comes to their care

delivery


Overview of the Surgical Services model of care

BED CAPACITY AND AVAILABLE SERVICES DASHBOARD

ELECTRONIC HEALTH RECORD REPOSITORY

PATIENT / CAREGIVER INFORMATION AND EDUCATION

Capacity +

Patient C

hoic

e

PATIENT AND FAMILY

24 h

our

Local A

ssessm

ent

Navig

ation to P

ost-

Op C

are

•Information is collected at each

interaction point in the

continuum and entered into an

EHR repository

•Transportation infrastructure

and support is in place

throughout the continuum

4

4

The patient and their family‟s

first point of contact will be

local and available on a 24-

hour basis. This coordinated

centralized process will serve

to navigate the patient to the

right provider at the right

location.

1

1

CENTRES OF EXCELLENCE

LO

CA

LSub-LH

INLH

INPR

OV

INC

E

HIGHLY SPECIALIZED SURGICAL SERVICES

CORE, CRITICAL MASS SERVICES

HIGH VOLUME CORE SERVICES

The patient will be given the

information that is required to inform

them of the wait times and availability

of the required services across the

LHIN. The patient can balance factors

like wait times and location to make a

decision that works for them.

2

2

The patient will experience a

coordinated approach for

rehabilitation and supportive

service options, including health

promotion and prevention to

ensure smooth transition between

hospital and home/other HSP.

3

3








•Referrals for surgical services within the LHIN will be managed centrally

through one centralized coordinated referral service; physicians can refer

directly to a surgeon but patients will be given the option to take first

available appointment or wait for a specific physician.

•Standardized care pathways will enable assessment, preoperative care and

some postoperative care to be delivered by HSP closer to the patients home.

•Supportive transportation infrastructure will ensure that patients and their

families have equal access to services across the LHIN

How will patients be referred in this continuum?

•Standardized practice guidelines, coupled with capacity

considerations and patient choice will determine where the

patient will receive preoperative, surgical and postoperative

care. The patient will be appropriately triaged to the right

surgical service provider for further surgical consult.

•CCACs, HSPs and other community organization like the

cancer society and the Alzheimer's society will navigate

preoperative and postoperative planning and support for

patients along the continuum

•Standard assessment, screening, and discharge guidelines will

connect patients to rehab, prevention, and supportive care when

required



How will patients be identified and

assessed?

• A standardized tool will assist to

assess early intervention needs based

on social, clinical, and geographical

factors that dictate early intervention

and subsequent referrals to the

appropriate surgical site

• Standardized assessment tools (i.e.

checklists / questionnaires) will be

utilized during surgical consults

• Feedback will be provided to referring

physicians/ and or other provider to

track patients who are currently not

meeting preoperative conditions

How will patients and providers access education and

information?

• All key information points from preoperative consideration, to

procedure overviews and post-operative care, including health

promotion and prevention information will be shared in a repository

of information to be access by providers and their patients

• Online portal for patients and families in terms the patient can easily

understand

• Utilizing Cerner Surginet on a LHIN-wide platform to allow

clinicians to appropriately share information



What role will Surgical Services play in complementary care?

• Implement pre and postoperative guidelines as it relates to

complementary needs; including proactively engaging allied health

professionals (i.e. nutritional services) to support the elderly

population that require surgical intervention

• Ensure that there is consistent funding for and availability of

complementary care services based on population needs

How will Surgical Services care for specialized needs?

• Collaboration and coordination of case management resources

within the LHIN, the CCACs and other community support

organizations to better coordinate pre and postoperative care and

rehabilitation

• Health care professionals will work with patient support networks

where applicable to the patient‟s case



How will Surgical Services support health

research?

• At each interaction point along the surgical

services continuum (pre and post operative),

information will flow into a central database

and an electronic health record database in

order to support utilization analysis and

health outcomes research

How will care be coordinated?

• Use of a real-time system dashboard will guide decision making on navigation and coordination-

much like “Criticall‟ for urgent surgical serves

• Cerner Surginet will be used as a LHIN-wide platform to coordinate information flow

• Centres of Excellence will work to ensure predictability of services offered and appropriate

capacity utilization

• Standard care maps will help to identify which services should and can be delivered at the local,

sub LHIN, LHIN, and provincial level

• Transportation infrastructure will be in place to support patients and families to access all

available facilities for their care


The Surgical Services model focuses on using tertiary and non-tertiary sites

to ensure timely, individualized, and appropriate care


Prevention &

Promotion

• Independent and guided

self health management



Screening Services


• Outreach teams to encourage screening

(urologist teams, pre-cancer screening)

Assessment &

Diagnostic Services• Primary care services - Early identification, assessment,

treatment, and follow-up and management


• Clinical case management services

• Decision-making support


• Inpatient and ambulatory, high volume/low acuity, surgical

services (i.e. General surgery, primary ortho surgery,

cataracts)




• Pain and symptom management services

• Shared care services with specialists and primary care

• Emergency services

• Early identification, assessment, treatment,

and follow-up and management






including:

• Inpatient and ambulatory, moderate

volume/acuity, surgical services (i.e.

endoscopy, joint repairs, urology, vascular

surgery)




• Specialized diagnostic modalities not

available at the local level – interventional

radiology (i.e. MRI, CT)

• Tertiary and quaternary care (low

volume/high acuity) including:

• Burns, neurosurgery, thoracic

surgery, plastic, tertiary GI

services, organ transplantation, etc


trials

• Telehealth and telemedicine services


management (personal coaching,

care plans, coping techniques,

intensive case management ,etc)

Treatment Services

Pre/post treatment

care, supportive

care






• Recreational and social programs for people with disabilities




• Pre- and postoperative care

• Audiology services

• Inpatient rehabilitation services (general

rehab units or by cluster – stroke, cardiac,

etc)

• Supportive housing services

• Long term care services


• Highly specialized inpatient

rehabilitation beds (ABI,

neurosurgery, etc)

• Highly specialized outpatient rehab

services (ABI, spinal cord, etc)

• Tertiary acute palliative care

Cura

tive

Rehabilitative &

Support

ive

Pre

ventive a

nd

Pro

motive

Integrated Screening (colonoscopy, breast cancer,

etc)


Primary and Secondary Prevention (eye health education

Patient and family /caregiver information and education


Implications of Surgical Services model of care

• Increased surgical services capacity either at the

local or sub-LHIN level, reducing reliance on potential

need to travel and access London-based services

where appropriate


individuals to have easy access to evidence-based

health information and inventory of health services

(i.e. online portal)

• A „Centres of Excellence‟ model for both tertiary and

non-tertiary services will require increased navigation

resources at each step in the care continuum and a

coordinated look at LHIN capacity

• Increased commitment to aligning rehabilitation and

support aspects of an individual‟s care will require the

development of practice guidelines specific to

surgical patients

• A single point of first access delivered locally to

individuals and their families will require 1) standard

guidelines for assessment and referral, and 2)

investment and development of a real time system

dashboard that tracks bed capacity and services

utilization.

• There will be a need to balance the management of

scarce resources centrally while still enabling local

access, i.e. centrally managed pool for surgical

services (beds and OR blocks). Providers across the

LHIN will need to have visibility into these resources

to enable key processes such as scheduling and

monitoring availability, but would be managed locally

to provide access.


Documents

Health System Design: Blueprint Initiative Phase 2