Update to the Mental Health and Addiction Network

December 3, 2008James Meloche, CE LHIN

ObjectivesReview and Updates of Current Strategy• Review our Accomplishments, Challenges and Opportunities against

our Strategy– Identified Priorities for new investment– Performance Objectives– Hospital Report Card Results

• Introduction and Update to the Hospital Clinical Services Plan (CSP)

Improving Upon Our Strategy• Introducing the Triple Aim• 1% Challenge: An opportunity for system redesign

Purpose of the Mental Health and Addictions Network• To be a resource for needs identification and health planning

regarding care for mental health & addictions consumers and family members in the Central East LHIN area;

• To provide advice to the Central East LHIN on the strategic priorities, goals and objectives/strategies needed to improve the system of care for mental health & addictions consumers and family members

• To be a Central East forum for communication, collaboration, knowledge exchange and innovation amongst stakeholders towards mental health & addictions.

• As outlined in Appendix A, the Network Steering Committee will act as both a catalyst and conduit to enable the Network to achieve itsgoals/purpose.

Our Current Strategy

The Integrated Health Services Plan

Mental Health and Addictions•Early Youth Intervention

•Disordered Eating •Addictions Project

•WRAP •Caregiver Support

Mental Health and Addictions$1,699,567 (07/08 - 09/10)

Priorities for New InvestmentAs part of the 2009-10 Annual Service Plan Submission, the CE LHIN prioritized investments, pending funding:

– Increase to Community/Outpatient Addiction Services– Mental Health Crisis Beds / Mobile Services– Supportive Housing– Behavioural Support Programs– Inpatient and Outpatient Mental Health and Addiction Services

(including Youth) – Lakeridge Health– Toronto Harbour Lights Redevelopment– Rural ACT

System Goals related to MHA• Rate of ED visits that could be managed elsewhere• Hospitalization rate for ambulatory care sensitive conditions• Percentage of ALC Days• % discharge with LOS at 3 days or less (LOS<3days)• OHIP care within 30 days post discharge • ED visit within 30 days post discharge (not admitted)• 30-day readmission rate

• The LHIN will monitor the following System Measurement and Change indicators (OHA Report):

– Inter-organizational Networking– Notification of Hospitalization (Note: CE LHIN Timely Discharge Information

System)– Discharge Plans with Client Involvement– Discharge Plans with Family Involvement – Discharge Plans with Provider Involvement

MH Hospital Report 2007 - Overview • Hospital Report focuses on performance indicators of inpatient mental

health care• First time that mental health and addictions indicators are reported at

the hospital-corporation level• Twenty-three indicators are reported covering four Balance Scorecard

(BSC) quadrants• Reporting results for the 14 LHINs by hospital peer group and

functional centre• Indicators as a whole show a complex picture of both progress and

continuing challenges

Balanced Scorecard: Results Summary• The Balanced Scorecard (BSC) describes performance across four

dimensions/quadrants: Overall 2006-07assessment by BSC quadrant:– System Integration and Change (SIC)

• Significant increase in values, due to greater awareness, use of client and staff feedback, involving patients in discharge planning, and delivery of care based on best practices

– Clinical Utilization and Outcomes (CUO)• Discharge planning and access to follow-up care continue to need improvement,

with 1 in 5 requiring re-admission or urgent care within 30 days, follow-up within 30 days with OHIP physician remains slightly over 50 days

– Patient Perception of Care (POC)• Ratings of staff responsiveness relatively high• Clients less positive about their involvement in treatment/discharge decisions• Low client ratings for outcomes

Snapshot of MHA Inpatient Activity

Physician Supply/100K Population

GP/FPs (#)* Psychiatrists (#)

Community MH Service Funding per

Capita

Ontario 95.8 17.3 $39

CE LHIN 79.4 8.0 $22

*General practitioners and family physicians

Balance Score Card – Clinical Utilization and OutcomesRelationship Across LHINs of:• OHIP GP/Psychiatrist Supply versus Percent MH&A Discharges with

OHIP 30-day Follow Up– While 3rd lowest in per 100K population MD supply (range from 70-218;

CE LHIN 87), percentage of OHIP follow-up, marginally below the top hospitals at 60%

• Per Capita CMH Service Funding versus 30-day Post- Discharge ED Visit of Re-admission– While 2nd lowest in per in per capita CMH service funding (range from

12-104; CE LHIN 22), percentage of post-discharge ED visit or re-admission, right in the middle of a small band of differentiation of 15-25%

System Integration and Change• System Measurement and Change included 5 numeric indicators:

– Inter-organizational Networking (ION)– Notification of Hospitalization (NH)– Discharge Plans with Client Involvement (DP-CI)– Discharge Plans with Family Involvement (DP-FI)– Discharge Plans with Provider Involvement (DP-PI)

System Integration and Change

0

20

40

60

80

100

PRHC RMH LHC RVHS TSH WMHC Prov Avg

ION

NH

DP-CI

DP-FI

DP-PI

* DK or “do not know” was an option for hospitals to select as reported by RVHS and TSH

Clinical Utilization and Outcomes (CUO)• The CUO quadrant indicators measure client and system level

outcomes that are expected to result from better performing systems of care.

– Hospitalization for psychotic diagnoses– % discharge with LOS at 3 days or less (LOS<3days)– % ALC days – OHIP care within 30 days post discharge – ED visit within 30 days post discharge (not admitted)– 30-day readmission rate (RR)– Repeat inpatients

Clinical Utilization and Outcomes

0

10

20

30

40

50

60

70

PRHC RMH LHC RVHS TSH Prov Avg

Hosp.psychoticdiagnosis% LOS < 3days

% ALC

OHIP Care -30 days

ED Visits -not admit

30-day re-adm rate

Repeat Inp.

The Hospital Clinical Services Plan (CSP)

CSP – Our Shared Vision

‘One Acute Care Network’

Improved and equitable patient access to an integrated hospital system

that provides the highest quality of care across the Central East LHIN

CSP Project Partners• All nine community hospital corporations

– Campbellford Memorial Hospital– Haliburton Highlands Health Services– Lakeridge Health Corporation– Northumberland Hills Hospital– Peterborough Regional Health Centre– Ross Memorial Hospital– Rouge Valley Health System– The Scarborough Hospital– Whitby Mental Health Centre

• Central East Community Care Access Centre

Guide initial steps in Creating a ‘One Acute Care Network’

Foundational Themes• Adopt a “systems” focus that respects local access and local governance• Uses evidence to determine “appropriateness” of local access versus

regional & provincial access• Promote innovation and with a relentless focus on quality• Advance the concept of mutuality of support between CE LHIN

providers• Promote the sustainability of the public health system.

4 Project Goals

1. Hospital Service Planning and Scenario Modeling

2. Identify Integration Opportunities and New Models of Service

3. Supporting Physician Integration

4. Change Management Strategies

First Areas of Focus• Quality Improvement within Clinical Services

• Cardiac• Maternal Child Youth• Mental Health and Addiction• Thoracic• Vascular

Who Is Participating?A Complex Undertaking

• The CSP is a complex undertaking that is being led by a SteeringCommittee comprising the diversity of the CE LHIN, including:– Clinical leadership– Hospital and CCAC Executive Leaders– Nursing– CE LHIN

• Steering Committee work supported by– Medical Leadership Group– Clinical Advisory Groups– Communications, HHR, Nursing, Decision-Support and e-Health working

groups

Advisory Group Role• Each group is responsible for developing models and/or frameworks

that advance the goals of the Clinical Service Planning project, with Deloitte as group facilitators

• Over 150 hospital leaders participating in this role– Front line clinical managers – Physicians– Senior executive administrators– Senior staff

The Mental Health and Addictions Advisory Group• After reviewing a preliminary list of issues and challenges, the

Advisory Group is focusing on developing LHIN wide responses for the following:– Managing Psychiatric Emergencies– Child and Adolescent Mental Health Issues– Availability and access to expertise in Mental Health and Addiction issues– The role of Whitby Mental Health Centre– Geriatric Psychiatry– The impact on Addictions in Mental Health and Concurrent Disorders

I

CSP Timeline/Next Steps• November 2008 – January 2009

• Ongoing communication on how the process in going with hospital boards, union leadership, front line staff, management groups, planning partner teams, community stakeholders

• January – February 2009• Advisory groups complete content recommendations and forward to the Steering

Committee

• February 2009 • Report from the Clinical Service Planning Project Steering Committee presented

to CE LHIN Board• Release of report will begin a process of consultation on how best to implement

these recommendations

Improving Upon our Strategy

Opportunities• Government Mental Health and Addictions Commitments

– 2007 Budget Commitment of $80M over 3 years– Minister’s goal of establishing a 10 year Strategy with the assistance of a

provincial advisory group– Focus on innovation and integrating mental health and addictions

• 2009-12 Central East LHIN Integrated Health Services Plan

Who are the IHI?The Institute for Healthcare Improvement (IHI) is an independent not-for-

profit organization helping to lead the improvement of health care throughout the world. Founded in 1991 and based in Cambridge,

Massachusetts, IHI works to accelerate improvement by building the will for change, cultivating promising concepts for improving patient care, and

helping health care systems put those ideas into action. (IHI Website)

Introduce Triple Aim: goals• The Institute for Healthcare Improvement (IHI) believes that new

designs can and must be developed to accomplish three critical objectives, or the “Triple Aim”:

– Improve the health of the population;– Enhance the patient experience of care (including quality, access, and

reliability); and– Reduce, or at least control, the per capita cost of care.

• The goals must be pursued simultaneoulsy

Triple Aim: Three Dimensions of Value for a Defined Population

PopulationHealth

Experienceof Care

Per CapitaCost

Design of a Triple Aim EnterpriseDefine “Quality” from

the perspective of an individual member of a defined population

The “Triple Aim”

Health care  Public healthSocial services

Per capitacost reduction

Integration

System-LevelMetrics

$E

PH

Definition ofprimary care

1

Patients andfamilies

Population healthmanagement

Potential Triple Aim Outcome Measures

Dimension Measure

1. Health adjusted life expectancy (HALE)(life expectancy and self-rated health status)

2. Composite Health Risk Appraisal score

3. Hospital and ED utilization for ambulatory care sensitive conditions

4. Disease burden

1. Cost per member of the population per month

Per Capita Cost2. Hospital and ED utilization costs

1.Standard question focused on a patient’s overall experiencePatient Experience of Care

2. Key question(s) from current patient survey

Population Health

What’s Our Big Dot for MHA?

What do we want to achievefor our population?

-Health- Care Experience

- Cost

Current Triple Aim Sites• Hospital-Based Systems

Cape Fear Valley (NC)Bellin Health (WI)*Cincinnati Children’s Hospital Medical Center (OH)*Genesys Health (MI) (Ascension)*ThedaCare (WI)

• Health PlansBlue Cross Blue Shield of Michigan (MI)CareOregon (OR)*Eastern Carolina Community Plan (NC)New York-Presbyterian System SelectHealth, LLC (NY)*UPMC Health Plan (PA)Independent Health (NY)Wellmark (IA)

• Integrated Health SystemsGroup Health (WA)*HealthPartners (MN)*Kaiser Permanente, Colorado Region (CO)Kaiser Permanente, Mid-Atlantic Region (MD)Martin’s Point Health Care (ME)Presbyterian Healthcare (NM)Southcentral Foundation and Alaska Native Medical Center (AK)Veterans Health System:

• VISN 10—Cincinnati VAMC (OH)• VISN 20—Portland VAMC (OR)• VISN 23—Nebraska, Western Iowa VAMC (NE)

• Public Health DepartmentKing County Department of Public Health (WA)

• State InitiativeVermont Blueprint for Health (VT)*

• Safety NetColorado Access (CO)Contra Costa Health Services (CA)*North Colorado Health Alliance (CO)*Primary Care Coalition Montgomery County (MD)*Queens Health Network (NY)*

• Employers/BusinessesGeneral Mills (MN)QuadGraphics/QuadMed (WI)*

• InternationalBlackburn With Darwen Primary Care Trust (England)Bolton Primary Care Trust (England)*Central East Local Health Integration Network (Canada)East Lancashire Teaching Primary Care Trust (England)Eastern and Coastal Kent Primary Care Trust (England)Forth Valley (Scotland)Herefordshire Primary Care Trust (England)IMPACT BC (Canada)Jönköping (Sweden)*Tayside (Scotland)

• Social ServicesCommon Ground (NY)

* Sites that participated in the first phase of Triple Aim Prototyping.

1% Challenge

The 1% ChallengeMeeting our Strategic Directions

• The Central East LHIN and its health service providers will reallocate 1% of the 2007-08 Operation of Hospitals budget to community programs by fiscal year 2009-2010.

• This means that by no later than December 2010, a minimum of $10.3 million dollars of 2007-08 hospital expenditures will have been reinvested/transferred to a CE LHIN funded community healthservice provider.

Why?• Generate local investments to rapidly expand capacity of community

services in order to support the overall transformation of the local health system as found in the CE LHIN Integrated Health Service Plan;

• Better align the provision of health services between hospital and community providers, with a focus on appropriateness of access and quality of care;

• Improve shared accountability for performance between hospital and community based providers by pooling resources for joint outcomes; and

• Enhance the sustainability of health services and expenditures with the CE LHIN.

What this Means….

• 1% of the Hospitals Budget represents $10.3 Million

• Annual Expenditures on other CE LHIN Programs

– CHCs: $7.9M– Assisted Living: $9.7M– Community Support Services: $25M

$0

$200

$400

$600

$800

$1,000

$1,200

Hospitals 1% Challenge Community

Hospitals LTCH CCACCommunity MH&A CSS Assisted Living in SHCHC

1%

How?• Rather than adopting a prescriptive approach, CE LHIN funded health

service providers will be responsible for identifying the local re-investment opportunities that best suit the needs of their communities.

• This is consistent with the Local Health System Integration Act that requires health service providers to identify “voluntary integration opportunities.”

Exploring OpportunitiesHospitals may consider:

– What current services do they currently provide that are better suited for community delivery? Can those services be delivered at a lower cost, allowing savings to be directed back to core hospital services?

– What services are not being provided in the community that are providing an adverse impact on quality of care and hospital operations? Will investments in community result in better hospital performance (i.e., cost avoidance, better care)?

– What accountabilities must be in place to ensure the expected outcome of the investment?

This is not about sending a cheque to the community. Its about changing theway care is better provided, making it more efficient & more effective.

The Process

Networks/Task Groups match &

prioritize opportunities. Recommend

supporting Grants

Networks/Task Groups match &

prioritize opportunities. Recommend

supporting Grants

Hospitals prepare Hospital Priority for Community Reinvestment (HPCR)

Hospitals prepare Hospital Priority for Community Reinvestment (HPCR)

Community prepare Health System Reinvestment Pre-

Proposal (HSRP)

Community prepare Health System Reinvestment Pre-

Proposal (HSRP)

CE LHIN Administers Grants

CE LHIN Administers Grants

Hospital and Community Partner Prepare Project Charter for Voluntary Integration

Hospital and Community Partner Prepare Project Charter for Voluntary Integration

Hospital and Community Partner prepare Project Charter

for Voluntary Integration

Hospital and Community Partner prepare Project Charter

for Voluntary IntegrationCE LHIN Board

receives Voluntary Integration Opportunity

CE LHIN Board receives Voluntary

Integration Opportunity

1% Challenge Website Serves as Portal to

exchange ideas

1% Challenge Website Serves as Portal to

exchange ideas

Hospitals and community providers may come forward directly with reinvestment opportunities

Budget for Incentives

Wave One Wave Two Total

Seamless Care for Seniors Network $15,000 $30,000 $45,000

Chronic Disease Prevention and Management Network $20,000 $35,000 $55,000

Mental Health and Addictions Network $20,000 $35,000 $55,000

Wait Times Network $20,000 $30,000 $50,000

Primary Care Working Group $15,000 $30,000 $45,000

TOTALS $250,000

Timelines June 08Wave 1

Launched

June 08Wave 1

Launched

Oct 2008Wave 1

Opportunities submitted to priority-

specific CE LHIN Networks or Task

Groups

Oct 2008Wave 1

Opportunities submitted to priority-

specific CE LHIN Networks or Task

Groups

Nov 2008Networks /

Task Groups Prioritize

Opportunities

Nov 2008Networks /

Task Groups Prioritize

Opportunities

Dec 08Wave 1

Report to CE LHIN Board

Dec 08Wave 1

Report to CE LHIN Board

Mar 09Project

Charters for Voluntary

Integration to CE LHIN

Board

Mar 09Project

Charters for Voluntary

Integration to CE LHIN

Board

Mar 09Milestone:

40 % of 1%

Challenge Achieved

Mar 09Milestone:

40 % of 1%

Challenge Achieved

May 09Wave 2

Launched

May 09Wave 2

Launched

Sept 09Wave 2

Opportunities submitted to priority-

specific CE LHIN Networks or Task

Groups

Sept 09Wave 2

Opportunities submitted to priority-

specific CE LHIN Networks or Task

Groups

Oct 2009Networks /

Task Groups Prioritize

Opportunities

Oct 2009Networks /

Task Groups Prioritize

Opportunities

Nov 09Wave 1 Report

to CE LHIN Board

Nov 09Wave 1 Report

to CE LHIN Board

Feb 10Project

Charters for Voluntary

Integration to CE LHIN

Board

Feb 10Project

Charters for Voluntary

Integration to CE LHIN

Board

Feb 10Milestone:

100 % of 1% Challenge Achieved

Feb 10Milestone:

100 % of 1% Challenge Achieved

Dec 10Reallocations/Agreements Complete

Dec 10Reallocations/Agreements Complete

Wave 1 MilestoneWave2Legend

2008

-09

2009

-10

2010

-11

Concluding Thoughts…• Health, not just health care.

• The opportunity for change continues to exist…• …but is our system ready for it? (culture, information and financial

systems, people)• Enhance our focus on the circle of care, including family and caregivers• Balancing the needs of acute care and the broader health of the

population – including determinants of health - will require new partnerships

• Resources must be found within the “health system” – meaning – Shifting resources (e.g., 1%)– Back Office and service delivery integration

Thank You.