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Central East CCAC Response to Patient First Consultation

 EXECUTIVE SUMMARY

 

The Board of Directors of the Central East Community Care Access Centre (CCAC) is pleased to respond to the December 17, 2015 Discussion Paper Patients First – A Proposal to Strengthen Patient-Centred Health Care in Ontario. As an overarching principle, the highest priorities for our Board are the continuity of quality care for those patients and their caregivers that we serve, and the necessary continuity and stability of staffing to ensure this quality of care can be achieved.

Our response identifies four issues that we believe require consideration by the Ministry of Health and Long-Term Care in order to be successful in achieving your goal to strengthen patient-centred care and expand the role of the Local Health Integration Networks (LHINs):

The four issues and our recommended actions are:

1. Sector Funding Inequities

Recommendations:

The Ministry of Health and Long-Term Care:

  1. Must address long-standing regional home care funding inequities;
  2. Is encouraged to signal commitment to the success of home and community care through an increased allocation of home and community care funding as a proportion of the overall health care system; and,

Is encouraged to provide clear definitions of how much and what kind of support Ontarians can expect based on their care needs, and commit to providing the necessary funding. 

2. Leadership through the Transition
Recommendations:
The Ministry of Health and Long-Term Care:

  1. Is advised to create a centralized provincial transition team to lead a coordinated and consistent transition;
  2. Is encouraged to put in place a new skills based organizational board governance structure to support the new LHIN responsibilities; and,
  3. Is encouraged to develop a strategy to establish skills based leadership/management structures that support the new entity’s vision and mandate.

 

3. CCAC Home Care Service Purchasing Model
Recommendation:
The Ministry of Health and Long-Term Care:

  1. Must give priority to putting in place a new and streamlined service provider purchasing and delivery model.
     

4. CCAC Technology, Program and Human Resource Assets 
Recommendation:
The Ministry of Health and Long-Term Care:

  1. Should consider retaining and leveraging one of the CCACs’ current greatest assets in the new home care model – CHRIS
  2. Should consider building on the successful experiences of integrated care coordination, and innovative home and community care programs and services that are already in place, and may serve as a template for province wide application. 

Introduction and Background

 

On December 17, 2015 the Ministry of Health and Long-Term Care released its discussion paper setting out the next phase of its plan to put patients first, address structural issues that create inequities, and truly integrate the health care system so that it provides the care patients need no matter where they live.

 

The December 17th discussion paper notes that “over the past decade, Ontario’s health care system has improved significantly[1],” including expanded services for Ontarians at home and in their communities. It notes that “Ontarians, including care providers and system experts” have identified challenges and gaps in care[2]. While the discussion paper lists five gaps, two are most relevant to home and community care and the focus of this position paper: 

  • Some families find home and community care services inconsistent, hard to navigate, and many family and caregivers are experiencing high levels of stress and,
  • Health services are fragmented in the way that they are planned and delivered, and this fragmentation can affect patient experience, can result in inefficient use of patient and provider time and resources, and can result in poor health outcomes[3].

 

The discussion paper frames its proposal to strengthen patient-centred care and expand the role of the Local Health Integration Networks (LHIN) within four components:

 

  1. More effective integration of services and greater equity
  2. Timely access to primary care, and seamless links between primary care and other services
  3. More consistent and accessible home and community care and,
  4. Stronger links between population and public health and other health services[4].

 

The third of the four components relates to more accessible home and community care and is most relevant to our response and to this position paper.  It suggests “strengthening accountability and integration of home and community care through the direct transfer of responsibility for service management and delivery from the Community Care Access Centres to the LHINs”[5]. Under this proposal: 

  • LHIN boards would govern the delivery of home and community care, and CCAC boards would be dissolved;
  • CCAC staff providing support to patients would be transferred to the LHINs
  • Home care coordinators would be focused on LHIN sub-regions and may be deployed into community settings;
  • Current service provider contracts and arrangements would continue, although over time these contracts would be expected to change to be more coordinated within the LHIN sub-region models;
  • LHINs would be responsible for long-term care placement processes currently undertaken by the CCACs;
  • The MOHLTC’s 10 point plan for home and community care would continue under the LHINs;
  • The function of establishing clinical standards and outcome-based performance targets would be centralized and standardized provincially[6].

 

Central East CCAC

Identified Issues and Recommendations

 

The Central East CCAC, along with all CCACs in the province, has long advocated for many of the changes that this discussion document identifies. The sector has provided commentary on the fundamental issues that contribute to the concerns expressed by patients and their care-givers through papers produced through the Ontario Association of Community Care Access Centres (Health Comes Home series) and some of these issues are addressed in this response. Through this paper we hope to bring into focus our belief that until these fundamental issues are resolved, “the disparate way(s) different health services are planned and managed”[7] will not likely be eliminated by simply structural changes.

 

1. Sector Funding Inequities

 

The growth in the number of older adults is resulting in an increase in the incidence of chronic disease, and creating a shift in the health care system away from a time when the population was younger and the system required a focus on episodic and acute care. The traditional hospital-centred approach to care is increasingly less appropriate as a model for meeting these changing patient needs and the need for a stronger primary, and home and community care model is increasingly being recognized. 

 

It is understood that home care services are less costly than their relative hospital services that people want to receive their care at home and in their communities, and often have better outcomes as a result. If we acknowledge these facts, it is difficult to understand the ongoing lack of sufficient investment in home and community care as a proportion of overall spending that is so critical to modernize home and community care.    

 

Over the past decade, the provincial expenditure in the home and community care sector has hovered between four to five per cent of the province’s overall health spending. In fact, the proportion of health care expenditure on home care in 2014/15 is close to par with 2000/2001[8].

 

 

 

The CCACs have played a key role in supporting the shift to a stronger home and community care system and have evolved their care to support the rise in the number and complexity of Ontarians requiring home and community care. The number of people served since 2003/2004 has doubled, and ninety-four per cent more patients have higher care needs than in 2008/2009. The strength of Ontario’s home care system has helped to maintain lower per capita hospital beds, lower hospitalizations and emergency department visits, as well as reduced or delayed demand for long term care beds as more people are supported longer in their own homes[9].

 

The Office of the Auditor General of Ontario’s September 2015 Community Care Access Centres – Financial Operations and Service Delivery Report[10] highlighted the variance in funding between CCACs. It noted that between 2009/10 and 2013/14 overall, CCAC expenses increased 26% yet it clearly indicates that the Central East CCAC funding only increased 16% in the same period. It also highlighted that the Central East, served the second largest number of patients, at the third lowest spending per patient served. While this seems commendable, the Central East CCAC had little choice. We have undertaken significant quality improvement initiatives and have implemented administrative efficiencies that allow us to provide care to such a large number of patients at such a low spending rate. However we continue to have one of the largest personal support waitlists in the province, and are continually challenged to meet the needs of our community.

 

Recommendation:

To truly put patients first and address structural inequities, the government:

  1. Must address long-standing regional home care funding inequities;
  2. Is encouraged to signal commitment to the success of home and community care through an increased allocation of home and community care funding as a proportion of the overall health care system; and
  3. Is encouraged to provide clear definitions of how much and what kind of support Ontarians can expect based on their care needs, and commit to providing the necessary funding.

 

2. Leadership through the Transition

 

The December 17th discussion paper notes that the health system gaps and challenges arise from the way different health services are planned and managed, and that “local hospital, long term care, community care services, and mental health and addiction services are all planned by the province’s 14 Local Health Integration Networks but that home and community care services are planned by separate entities in different ways.”[11] It further notes that because of the different structure the LHINs are not able to align and integrate all health services in their communities.

 

This is not an accurate reflection. The LHINs currently have Service Accountability Agreements in place with all the hospitals, community support service agencies and long term care homes, and the CCAC in their region to manage the care provided by these agencies as part of the overall regional system, and have the authority to hold them accountable to the performance metrics contained within. CCACs, hospitals, many community support agencies and long term care home are all governed by independent boards of directors, whose Board Chairs and CEOs sign off on the Service Accountability Agreements.

 

The discussion paper fails to provide insight into how the MOHLTC will devolve their decision making powers to the LHIN to ensure that they have the independent authority and power to achieve what has been set out, including how the proposed transition will address the ongoing and continued independence of hospital, Long-Term Care Homes and Community Support Services sector boards of directors. Nor does it address how the evolution to LHIN sub-regions thereby increasing the service planning and delivery regions from the current 14 to approximately 80 will provide more integrated, coordinated and consistent service quality and ensure that those services are evenly distributed across the province.

 

Standardized and high quality care is a key tenet of this transformation agenda, and was also an observation made by the Auditor General of Ontario who noted the need for “certain types of care being standardized so that patients with similar conditions are consistently treated using agreed-upon best practices[12].” 

 

Furthermore, despite the government’s overall philosophy of patients first, it is a challenge to see a patient centred approach in the transition of CCAC patient care functions to an organization focused on planning and funding, and that has no operational patient care experience.  It is important that throughout this transition, quality of care provided to patients remains a top priority.

 

In addition, the discussion paper fails to clearly define the benefits that the government sees in mixing the authority for governance, operations and resource allocation responsibilities within the new LHIN entities. It overlooks the challenges that the leadership will more than likely experience allocating resources across numerous disparate care agencies within their region in addition to funding themselves to provide the service delivery functions within their own organization. The model appears to create an inherent conflict of interest with the LHINs taking on both the operating responsibility and funding for CCAC service delivery operations, while being responsible and accountable for all the other parts of their mandate.

 

As the government continues with their intent to vest the CCAC service delivery functions within the new LHIN entities, it would be advisable for the MOHLTC to establish a provincial oversight transition secretariat to ensure greater potential for consistency during this transformation and to address the issues noted above. The current approach appears centralized from the perspective that the government asks for information from, and provides direction to the LHINs, however the LHINs then appear to be free to move forward in the direction that seems reasonable to them. This local approach to transition CCACs is at a minimum an inefficient approach to the transition given the commonality in the work to be undertaken across the province, and at its maximum introduces considerable risk with every LHIN trying to figure this all out for themselves.

 

In addition the current process fails to make use of and capitalize on the experience and knowledge that the current CCAC leadership can provide. The approach fails to build on the history of staff within the sector who have achieved significant successes over the past many years, such as patient experience ratings over 90%; dramatic growth in patient volumes and complexity without a proportionate increases in health system funding; and introduction of several new MOHLTC program initiatives (i.e. Mental Health & Addiction in Schools, Rapid Response Nursing, Home First, etc.).  Lack of involvement of the CCAC leadership knowledge and expertise introduces unnecessary risk as it fails to actively involve those with the most understanding of how the complex home and community care sector operates.

 

We suggest that the government review and learn from the structure and success of the last government directed reform of the CCAC sector, the provincially coordinated CCAC transition of 2006-2007. The 2006-2007 transition was centrally directed by a provincial oversight team, and coordinated through Transition Managers at each of the 14 CCAC regions working to execute detailed, prescriptive and common province wide project milestones and deliverables.

 

It will also be essential that the government clearly outlines how it intends to develop and put in place a strong credible competency based governance system which will be directly responsible for program operations, performance accountability and outcomes. While there is a stated plan to put in place a system of centralizing clinical standards and outcome-based performance targets provincially to help address the consistency of care across the provinces such as that developed for cancer care in Ontario, the new LHIN governance must be equally constituted with the necessary skill, competency and expertise, and given the authority to make local decisions to meet these accountability and performance needs for their region.

 

Falling out of a strong skills-based governance structure, it is critical that the government develop a plan that ensures the recruitment of leadership teams which bring to the transition agenda the right set of skills and experience to meet the dual accountability for resource planning and allocation, and service delivery and performance results within the new mandate of the reformed LHIN entities.

 

Recommendation:

To achieve a successful transition from the current system to the one proposed and to reduce the structural variations and inequities across the province, the government:

  1. Is advised to create a centralized provincial transition team to lead a coordinated and consistent transition;
  2. Is encouraged to put in place a new skills based organizational board governance structure to support the new LHIN responsibilities; and,
  3. Is encouraged to develop a strategy to establish skills based leadership/management structures that support the new entity’s vision and mandate.

 

3. CCAC Home Care Service Purchasing Model

 

The model under which CCACs operate has continued, primarily unaltered since the late 1990s.  At the time they were designed CCACs were not expected to be direct care providers, but designed to be more neutral brokers commissioning a selected set of home care services and providing case management, based on a fully competitive quality based procurement model. The procurement model at times did result in contract transitions, and many perceived these as too disruptive for patients and destabilizing for home care workers. Therefore, the government placed a moratorium on competition, and in 2012 the policy on home care service provider procurement was formally changed and replaced by long-term performance-based contracts which change only in the event of performance issues. The discontinuation of the competitive procurement processes has meant that CCACs primarily remain with the contracts that they had in place from their predecessor CCACs prior to the January 2007 restructuring, creating significant challenges to introduce changes, increase efficiencies and drive quality care.

 

Within the Central East CCAC this has resulted in provider agencies having multiple and different contracts for services in different yet adjacent parts of the LHIN and hundreds of non-harmonized billing rates. While the Central East CCAC, as other CCACs, has worked to address the complexity these contractual arrangements have created, the operational challenges to monitor, control and ensure quality of care in patients’ homes as set out through the multiple contracts remains an ongoing barrier to optimizing patient care and creates challenges driving consistent reform across a complex system. In addition it has removed the benefits a competitive procurement process based on quality and price, designed to drive improved quality of care and better value for money.

 

Furthermore, the lack of flexibility to fundamentally change the contractual arrangements continues to result in individual patients having to deal with multiple agencies. For example an individual patient could have a personal support service provider, a nursing provider and a therapy provider all from different agencies. If that patient was going to be unavailable on a certain day for care, they would have to call three agencies to rearrange their care. Alternately, should something about their condition change, again they would have to inform three agencies. The existence of multiple home care agencies involved in a single patient’s care also creates inherent structural challenges to coordinated care.

 

Changes need to be made to the home care service purchasing model to facilitate consistent skilled teams of providers from the same agency to support better communication within and across the interdisciplinary team, as well as to create efficiencies such as the ability to improve management of delegated acts from nursing to personal support workers. The existing system may meet the needs of the providers, but fails to prioritize the needs of the patients.

 

Recommendation:

To bring the focus on quality into patients’ homes and achieve the goal of a more integrated system:

  1. Must give priority to putting in place a new and streamlined service purchasing and delivery model.

 

4. CCAC Technology, Program and Human Resource Assets

 

The Patients First Discussion Paper challenges the health care system to more truly integrate so that it provides the care patients need no matter where they live. CCACs have long held this as a strategic goal, and they have 2 significant assets which should be leveraged in moving the integrated care agenda forward – CHRIS and integrated care coordination.

 

The March 2015 Expert Group on Home & Community Care report, Bringing Care Home, suggested the use of a common electronic medical record to improve efficiency and care[13]. CCACs are the only health care sector to have a fully operational, province-wide comprehensive electronic health record that not only supports essential patient related health record functions, but also supports critical patient service delivery tracking and billing, as well as performance management and evaluation.

 

The Client and Health Related Information System (CHRIS) is a powerful electronic solution developed by the CCAC sector to meet a growing demand for integrated electronic patient records which fundamentally changes how we provision and track the care that we provide, and results in numerous benefits to our patients and our health care partners. CHRIS significantly contributes to the stewardship of the government’s approximately $2.3B[14] in CCAC funding, supports seamless transition of patients between regional areas across the province through the integrated province-wide solution; provides for valuable information sharing for many hospitals and CCACs regarding hospitalizations and ED visits; provides an electronic solution that supports e-referral for many programs including within Central East, the Centre for Complex Diabetes Care; Assisted Living Services in Supportive Housing (ALSSH); Long Term Care Home placement processes and Community Support Services referrals, and has recently been approved as an interim solution to support Coordinated Care Plans in five of the Central East LHIN Health Links.

 

Currently CHRIS is fully supported through the Ontario Association for Community Care Access Centres (OACCAC), a decision reached by the CCAC sector to achieve best value for money. The dissolution of the CCACs would threaten this valuable provincial resource and the patient care, rich data and funding stewardship that CHRIS supports.

 

The discussion paper notes that planning in regards to primary care would include “improving access to inter-professional teams for those who need it most, facilitating care plans and supporting an integrated, coordinated patient-centred experience”[15]. It further notes that “home care coordinators would be focused on LHIN sub-regions, and may be deployed into community settings (such as family health teams, community health centres or hospitals)”[16]. It is important to acknowledge that currently CCAC care coordinators are already strongly integrated into hospitals, primary care practices and in many areas, community support service agencies. Within the Central East CCAC we have 97 care coordinators working within our local hospital sites, typically from 8:30am until 8:30 pm, 7 days a week and on-call support available outside of these regular business hours to support the seamless transition of patients back into the community and reduce hospital readmissions and avoidable emergency department visits. In addition we have staff from the region’s Community Support Services agencies physically working within our branches alongside CCAC Patient Services staff to facilitate smooth transitions for patients between the CCAC and Community Support Services agencies. During the coming transition, these successful realities should be leveraged and built upon.

 

The Central East CCAC sees the value in integrating care coordinators in primary care practices, have some experience in that regard and see how that might work within the various collective primary care practices. However, the challenge with the integration of care coordinators into solo primary care practices will be especially difficult from a human resources demand perspective and will need special consideration in an overall vision of integration. The government must respect the value that is gained from the ongoing collaboration amongst care coordinators colleagues who know each other, work for the same organization and within similar cultural and process environments.

 

Achieving collaboration is a challenge at the best of times. Achieving meaningful collaboration in a virtual team where care coordinators are deployed into primary care practices across the region is possible, but requires ongoing attention to ensure consistent and integrated services. It is important that the government consider the impact of disbursement of care coordinators and consider structural elements that would support continued team collaboration and partnerships and remove any barriers.

 

The December 17th discussion paper notes that to make it easier for patients to connect with primary care, “each LHIN sub-region would have a process to match unattached patients to primary care providers”[17]. It is recommended that the MOHLTC and LHINs approach their planning and transition activities for this objective, by examining and leveraging where appropriate the Health Care Connect program currently operating within each CCAC.

 

It is also important not to lose track of the other innovations that the home and community care system has identified and implemented to date amongst and between all partner CCACs. These include such initiatives as Home First, e-Shift; and combined home care delivery teams such as the Central East CCAC Combined Palliative Care Delivery Team. 

 

Recommendation:

To smooth the transition of patient care, build on a solid foundation and support improved integration of care at a grassroots operational level, the government:

  1. Should consider retaining and leveraging one of the CCACs’ current greatest assets in the new home care model – CHRIS
  2. Should consider building on the successful experiences of integrated care coordination, and innovative home and community care programs and services that are already in place, and may serve as a template for province wide application.

In closing, we appreciate the opportunity to provide feedback on the Patients First proposal to strengthen patient-centered health care in Ontario and information that we believe will be helpful to inform the transition plans, and setup the new entities for success. As the MOHLTC moves ahead, we look forward to working with the LHIN and the MOHLTC to bring the new vision to reality and to improve the care to the residents of Ontario.

 



[1] Ministry of Health and Long-Term Care, Patients First: A Proposal to Strengthen Patient-Centred Health Care in Ontario (Discussion Paper), December 2015, pg 2.

[2] Ibid, pg 4.

[3] Ministry of Health and Long-Term Care, Patients First: A Proposal to Strengthen Patient-Centred Health Care in Ontario (Discussion Paper), December 2015, pg 4.

[4] Ibid. pg 5-6.

[5] Ibid. pg 6.

[6] Ibid. pg 18.

[7] Ministry of Health and Long-Term Care, Patients First: A Proposal to Strengthen Patient-Centred Health Care in Ontario (Discussion Paper), December 2015, pg 4.

[8] OACCAC, Right Care, Right Time, Right Price: Investing in Ontario’s Home and Community Sector, January 2016, pg.6.

[9] OACCAC, Right Care, Right Time, Right Price: Investing in Ontario’s Home and Community Sector, January 2016, pg.1.

[10] Office of the Auditor General of Ontario, Community Care Access Centres – Financial Operations and Service Delivery, September 2015, pg.8.

[11] Ministry of Health and Long-Term Care, Patients First: A Proposal to Strengthen Patient-Centred Health Care in Ontario (Discussion Paper), December 2015, pg 4.

[12] Office of the Auditor General of Ontario, Community Care Access Centres – Financial Operations and Service Delivery, September 2015, pg.5.

[13] Ministry of Health and Long Term Care, Bringing Care Home, Report of the Expert Group on Home & Community Care, March 2015, Recommendation 9, pg 18.

[14] OACCAC. 2016. CCAC Fast Facts. [ONLINE] Available at: http://oaccac.com/Quality-And-Transparency/Fast-Facts

[15] Ministry of Health and Long-Term Care, Patients First: A Proposal to Strengthen Patient-Centred Health Care in Ontario (Discussion Paper), December 2015, pg 16.

[16] Ibid. pg 18.

[17] Ministry of Health and Long-Term Care, Patients First: A Proposal to Strengthen Patient-Centred Health Care in Ontario (Discussion Paper), December 2015, pg 16.