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NSM CCAC Response to Patients First

About the North Simcoe Muskoka CCAC

The North Simcoe Muskoka Community Care Access Centre (NSM CCAC) assesses for and provides home care services such as care coordination, information and referral, nursing, telehomecare, personal support, physiotherapy, occupational therapy, respiratory therapy, speech and language therapy, dietician services and social work across the NSM region. In 2014-15, NSM CCAC brought more care into homes across our communities than ever before. Nearly 25,000 people received the care they needed by the CCAC care team, including 14,500 seniors 65 years of age and older. Our dedicated team of health professionals also serve as the single point of access to supportive care settings, like convalescent care, assisted living and long-term care.

Through direct engagement with patients and caregivers, NSM CCAC redesigned our service delivery model to be better integrated with other health care providers and community partners in the LHIN sub-geographic regions including but not limited to hospitals and primary care providers. Every acute care hospital in the region is staffed with CCAC Care Coordinators who work alongside hospital staff to identify and assess patients who require home care and other services. We coordinate the timely provision of those services to support bringing patients safely home or to be navigated and transitioned to other appropriate care destinations as soon as possible. Primary care practitioners in the NSM region are connected to CCAC Care Coordinators to improve care coordination, clinical outcomes and the overall experience for each patient receiving CCAC care. Please refer to Appendix A for more details about the NSM CCAC.

Objectives of This Response

We are pleased that the Ministry of Health and Long-Term Care (the Ministry) is seeking stakeholder input on the ideas presented in the December 2015 Patients First: A Proposal to Strengthen Patient-Centred Health Care in Ontario. The vision presented in the 'Patients First' proposal to make the Ontario health system more integrated and accessible is well aligned with the CCAC's mission of improving patient health outcomes, experience and the local health system in NSM. CCAC staff, management and Board members were asked to provide their best advice on how the proposed changes can support an evidence-based, high performing, patient-and caregiver -focused local health care system. 
 
At NSM CCAC we take this responsibility to inform, advise, and guide the Ministry very seriously. Our consultation process has resulted in the identification of 22 critical success factors to support a seamless experience for our patients, timely, equitable access to services, provide for the best possible health outcomes and improve the overall health system in the NSM region. Please refer to Appendix B for the consolidated list of critical success factors, Appendix C on how we will know home care has improved and Appendix D for the details of our consultation process.
 

Our advice and guidance is based on extensive knowledge of and experience in the home care sector and some elements of community care; however, we caution that the CCAC's primary focus is home care and as such, our response cannot represent the broader 'community care' sector.  It is with great pleasure that the NSM CCAC's provides this response back to the Ministry for their consideration and planning, and we look forward to further discussions to continue to inform the path forward.

Patient-and Caregiver-Focused Care

The fourteen CCACs across the province have made significant gains in providing patient-and caregiver-focused care. In particular, our deep understanding of the needs of unique patient populations has enabled us to design evidenced-based, patient-focused care pathways and care plans that deliver high quality, individualized care across the province. Our patient-and caregiver-focused approach is the foundation of our mission to deliver a seamless experience through the health system for people in our diverse communities, providing equitable access, individualized care coordination and quality health care. As we reflected on the Ministry's 'Patients First' proposal, NSM CCAC identified a number of critical success factors that must be in place to ensure that the patient-and caregiver-focused care that our population deserves is realized.

We were pleased to see that in their 'Patients First' proposal, the Ministry has re-stated their commitment to the 2015 Home and Community Care Roadmap. The roadmap provides the foundational elements to support the envisioned transformation. In particular, we strongly encourage the Ministry to stay dedicated to the Roadmap's Statement of Values with a focus on patient-and caregiver-centred care. There are a number of very critical elements of the Roadmap that must continue to be developed without interruption, including but not limited to, the Level of Care Framework and increased funding for home and community care.

NSM CCAC is strongly committed to continual improvement, providing continuity of care and a consistent patient experience in our LHIN sub-geographic regions. To do so, it is imperative that our collective knowledge of and experience with our local patient populations is utilized to inform any changes to the way care is coordinated and delivered. In particular, we encourage the Ministry to learn about, maintain and build upon our most successful individualized, patient-and caregiver-focused care delivery programs, methods and systems.

Clear Vision and Strategy for the Future

NSM CCAC acknowledges and confirms agreement with the specific desired health system improvements the Ministry has articulated in the 'Patients First' proposal. Our vision of the best possible health care system is one that is:

  1. Accessible when and where patients need care;
  2. Accountable to deliver evidence-based, high quality health outcomes;
  3. Effectively and responsibly managing resources to deliver those health outcomes;
  4. Integrated and coordinated in care across providers in all sectors;
  5. Responsive to providing simple and timely health system navigation; and
  6. Reliable in delivering consistent, patient-and caregiver-focused approach to care.

We were very pleased to see these six outcomes of a high quality health system reflected in parts throughout the Ministry's 'Patients First' proposal. However, we struggled with truly understanding how these outcomes can be achieved solely with the health system changes proposed in each of the four main sections of the Ministry's proposal.

It is critical that a vision articulated in the form of specific health system outcomes be supported by a very clear mission, strategy and set of values that can logically bridge the gap between the proposed path forward and those desired outcomes. To facilitate this degree of clarity, NSM CCAC advises that the Ministry draw on the experience and resources in home care and other key health care sectors to co-design a clear vision, mission, strategy and set of values that can logically and confidently lead the way forward

Governance and Management

A clear vision and mission of the future state is a critical first step to describing the desired health system transformation. To enable the realization of that vision and mission, the Ministry must ensure that the appropriate governance and management are established to guide and implement the desired future state. The structural changes contemplated in the Ministry's 'Patients First' proposal introduce some very significant governance and management considerations.

The governors of the proposed new Local Health Integration Network (LHIN) structure will be challenged with the task of effectively governing an entity responsible for both the planning and funding of many health care providers in the region, while simultaneously governing the operational components of a home care delivery organization that directly supports over 25,000 patients each year. This introduces the following significant challenges for the governors:

  • Maneuvering both real and perceived conflicts of interest in making decisions about the allocation of funding and resources between sectors across the NSM health care system, while also directly governing the funding and delivery of the home care services.
  • Having the experience, knowledge and competencies to apply risk management and ethical decision-making to help governors manage the additional liabilities associated with governing direct care provision. 
  • Ensuring that governors allocate appropriate time and focus on the governance of the system-wide health care planning and funding functions, while continuously monitoring and advising on the home care delivery services opportunities and challenges.

Patients, their caregivers and families need to be confident that the governors of the new entity have the skills, knowledge and experience to most effectively govern both the planning and delivery of health care services. As such, the form and composition of the board of governors must follow the functions of the new entity. The international leading practice approach to establishing effective board composition includes open recruitment for specific competencies and experience that align to the mission and functions of the organization, while also providing ongoing development support to all board members.

Similarly, the senior management of the proposed new LHIN entity will also be challenged to balance directing the health system planning and funding functions while also managing the operational components of the home care operations in a constantly evolving environment. In addition to a clear vision, mission and strategy, it will be critical that all leadership in the new entity understand and appreciate the cultures of home care providers and thoughtfully establish and embed meaningful values that will guide providers to continually meet the needs of home care patients, their caregivers and families. The future senior management of this new entity will require very specific types of operational health service provider expertise to manage the safe, high quality and effective delivery of clinical care for highly variable and often complex patient populations along with a values-driven leadership style. We recommend that the Ministry provide resources to each LHIN to enable them to conduct an independent talent management review to ensure the most qualified individuals are recruited to senior roles in the new organization.  

Critical Success Factors for Integrated Care

NSM CCAC appreciates that the Ministry has identified integrated care as one of the key objectives in the 'Patients First' proposal. To provide integrated care and create a seamless experience for patients as they receive care from multiple providers across different sectors, it is critical that all members of that patient's care team have a common understanding of the patient's goals and a shared care plan to guide the realization of those goals. To support this common understanding in an effective and efficient way, all members of the care team must be able to view and contribute to a patient's common health care record and effectively communicate through shared information systems.

Not only do shared information systems save clinician effort and time gathering and entering information about each patient, they also provide a better experience for the patient and their caregivers, reducing the number of times they are required to reiterate their health information and care goals to different providers. Further, a shared, common care record and communication system, such as the home care sectors' Client Health and Related Information System and Health Provider Gateway (CHRIS and HPG) can help to identify and reduce the duplication of services provided to the same patient by different providers, creating further efficiencies for the health system as a whole.

While having shared patient information can help the members of the care team have a common understanding of the patient, NSM CCAC emphasizes that integrated care also requires that all care team members understand their respective roles and responsibilities and trust each other to effectively execute those responsibilities. Across the sectors, there must be clearly documented expectations for each team member's functions, responsibilities, and accountabilities to optimize an integrated, multi-disciplinary care team's efficiency. This degree of clarity builds trust and often makes it possible for the care team to take advantage of a logical division of labor and reduce duplication and waste, thereby accomplishing more than the sum of its parts. The care teams' ability to ensure that roles, responsibilities and accountabilities are understood in a way that always puts the needs of the patient and caregivers first are currently limited by an out-dated home care sub-contracting model and the lack of shared health information and communication systems across the sectors.

Finally, one of the key tools to support consistent, high quality integrated patient care is commonly adopted, evidence-based leading-practice clinical pathways. NSM CCAC urges the Ministry to prioritize the further development and wide-spread adoption of leading practice home care clinical pathways. Adherence to these pathways must be supported by shared system-level outcome monitoring and performance management tracking indicators to understand how well we are doing in meeting our health system's objectives for our patients. Timely and consistent performance reporting must be used to enable provider organizations to be responsive to the evolving patient, caregiver and system needs and drive continuous improvement. We encourage the Ministry to pursue work on an integrated scorecard for home and community following the guidance provided in the 2015 Report of the Expert Group on Home and Community Care and the Roadmap to Strengthen Home and Community Care.

We will know that our health system is well integrated in 3-5 years if:

  • There is increased consistency in the delivery of patient care, the achievement of outcomes and improved patient experience;
  • Clear roles and responsibilities of all care team members have increased efficiency and reduced duplication and waste; and
  • Patients and their caregivers have the information and support to make informed decisions about their care.

 

Access to Care Where and When Patients Need It

Patients, their caregivers, families and their care teams need more support and options to access the appropriate care they need whenever those needs arise, particularly during evenings and on weekends. We support the Ministry's objective to expand access to more primary and urgent care options during evening and weekend hours and are committed to continuing to support care teams during those hours. To encourage more flexible access to care across all sectors, the Ministry must address the funding inequities across the home care sector. In addition, the Ministry must address the inequity of 'rewarding' some parts of the health care system for expanding their hours, while other parts of the system struggle with funding pressures and outdated contracting arrangements that limit their ability to appropriately compensate front-line workers for evening and weekend work. Furthermore, where patients are being supported by services during the evenings and weekends, care providers need the means to effectively communicate, update and coordinate the patient's care during those hours as well.

Throughout the NSM LHIN, CCAC Care Coordinators and primary care professionals have invested significant time and energy to further integrate home and primary care services for patients. Today, all primary care practitioners in NSM are connected to a CCAC Care Coordinator. These connections enable CCAC Care Coordinators to build trusted relationships, provide much needed knowledge of a patient's day-to-day functioning in their home environment, and regularly collaborate with primary care to plan and enable access to the best possible care for shared patients. NSM CCAC supports having primary care professionals as part of all integrated care teams for patients who need them and we encourage the Ministry to continue building on the Provincial CCAC Primary Care Integration Strategy.

To help patients, their caregivers and their providers better understand and access available care options, system navigators need enhanced information and referral (I&R) tools to help them identify the services that are available to them. These enhanced tools should build on the existing 'thehealthline.ca' tool and provide more detailed and specific information about program and service eligibility and capacity. To improve access to care, reduce wasted effort and duplication of work, all providers across the sectors should be regularly contributing to, updating and ensuring the accuracy of our vital system navigation tools.

We will know that our health system is more accessible in 3-5 years if:

  • Patients can access care when and where they need it;
  • Equitable funding enables patient access to the appropriate care provider on evenings and weekends;
  • Patients trust that providers share appropriate information to improve their care; and
  • Patients receive relevant, accurate health services information from all providers.

 

Operational Design Considerations

NSM CCAC advises the Ministry that the future-state vision, mission and detailed strategy for the upcoming system transformation should be designed using a structured logic model approach that clearly identifies the critical success factors to deliver the desired outcomes. It will be critical to bring the appropriate home care expertise to the planning table to help identify which proposed operational changes will logically result in the desired outcomes. As our stakeholders reviewed the significant structural changes proposed by the Ministry in the 'Patients First' discussion paper, a number of immediate operational design considerations have been identified. 

In shifting the focus of planning to LHIN sub-regions, it will be important to not reverse the gains patients have made in terms of having access to the specialized skills and experience that population-specific care coordinators and home care providers have developed to coordinate and deliver individualized care that meets the unique needs of patients in specific patient populations. This is particularly relevant to both geographic clusters of populations such as indigenous and francophone populations in specific LHIN sub-regions in NSM, as well as palliative patients, complex seniors and children's populations that are spread across the LHIN. Furthermore, it will be imperative to have a strong centralized home care quality and standards body to ensure that greater autonomy in the LHIN sub-regions does not adversely affect the significant practice consistency and quality improvements that have been made over the past few years, but continues to enable further advancements across the province. 

To accelerate improvements in the consistency and quality of home care, NSM CCAC strongly advises that the Ministry prioritize modernizing and streamlining the home and community care contracting model and harmonize the rates. The current contracting model has been one of the greatest structural barriers to instituting integrated patient care, improving access to care in rural areas and ensuring transparency and accountability for quality outcomes for home care patients across the province. In addition, managing the complex administration of the different service care provider contracts and over 14,000 different service provider rates across the province requires a tremendous amount of administrative effort. A modern contracting model and/or enabling more direct care delivery will improve accountability for the quality of care, enable more responsive performance management and ultimately deliver better patient outcomes. 

Further, NSM CCAC stresses that valuable local innovations, such as the Shared Services Back-Office model for community support service organizations and community health centres should not be lost in the design process. We advise that the Ministry learn about our local innovations and consider applying the practices and processes developed for our successful shared service model to broader shared services functions across the LHIN and province.

In summary, the final operational design should consider how specific patient populations, partner organizations, and other stakeholders are affected by each of the changes to minimize unintended negative consequences for the overall system.

We will know that home care operations have improved in 3-5 years if:

  • Patients receive individualized, population-specific care that meets their needs;
  • Quality standards continue to be improved and implemented across the sector; and
  • The home care contracting and direct service delivery model drives value for money, greater accountability, higher quality care and better patient outcomes.

 

Transition Considerations

The NSM CCAC acknowledges and supports the need to review relevant legislation in advance of implementing the proposed changes. In considering legislative changes, we advise that the Ministry focus on the areas that will have the most direct impact on the patient and caregiver experience. We advise the Ministry to strike a careful balance between the need for regulatory standards and providing flexibility for the LHIN and other organizations to design systems and processes to meet the desired future-state outcomes.

Careful planning and sequencing of transition activities will be required to ensure that the appropriate systems, processes and staff are in place and can continue to support quality, timely patient care throughout the transition and beyond. We advise that the Ministry establish dedicated resources with the experience and capacity to successfully direct the transition process. The NSM CCAC recommends that a centralized provincial transition support team with deep home care expertise be established to conduct the planning and sequencing, develop transition tools and plans, and align communications across the province. This dedicated team should be supported by a Steering Committee composed of local stakeholders who will be dedicated to managing the transition process in each LHIN. Furthermore, it will be critical to ensure that the patient and caregiver safety and experience is not compromised during the transition process and that every possible step is taken to maintain care and service stability, mitigate patient and staff uncertainty and resultant anxiety, and retain people with the competencies and experience that the system will continue to require in the future state.

As the plan for moving home care operations into the LHIN is developed, NSM CCAC stresses the importance of taking a considered and evidence informed approach to the transition. We advise that the Ministry and LHINs not be tempted to make sweeping overnight changes to structures and systems or establish unrealistic timelines. Research has shown that the most successful health system transformations are conducted over many years following a very clear and committed strategy and plan that is driven by the desired patient and caregiver outcomes. We also recommend that the Ministry take the time to learn from previous successful local and international restructuring models.

It will be important to consider where existing structures and processes are working well and fit with the mission, strategy and values of the future-state and then co-creating the necessary further improvements needed to achieve the future-state vision. This methodical approach will minimize disruptive changes that could end up being reversed or re-directed again in the near future. Finally, lasting transformative change requires deep organizational culture shifts to align values and practices with the vision and strategy of the future state. The Ministry must allow for the time and effort required to have all health service organizations in the region understand and work towards achieving the common, shared culture required for true system integration.

Conclusion

In conclusion, the NSM CCAC has dedicated significant time and effort to do a review of the Ministry's 'Patients First' proposal and have formulated our advice based on identifying the most critical success factors to support the desired patient and health system outcomes articulated in the proposal. In the design of the future-state system, the Ministry should support health care providers from all sectors with the tools, systems and processes they need to provide consistently accessible, effective, integrated care throughout the patient's care journey. We also emphasize the need for the patient and caregiver voice in all of these considerations. As patients and caregivers have not had direct relationships and interactions with the LHIN, we agree that the LHIN name should change to reflect the mission and functions of the new entity and signal the continued evolution of our health system.

During the transformation process, we stress that the Ministry prioritize ensuring that there are sufficient resources and capacity to seamlessly provide quality care to Ontario patients and their families throughout the transition process. It is our hope that this thoughtful and comprehensive response to the 'Patients First' proposal will inform the Ministry's planning process and we look forward to further discussions to inform the path forward.

APPENDIX A: North Simcoe Muskoka CCAC at a Glance

In 2014-15, the NSM CCAC brought more care into homes across our communities than ever before. Nearly 25,000 people got the care they needed by the CCAC care team, and of these people, 14,500 were seniors 65 years of age and older.  CCAC care experienced in the home touched 2,400 people on an average day.  These were people of all ages, across the region, who recieved care coordination, nursing, personal support, physiotherapy, occupational therapy, respiratory therapy, speech and language therapy and social work from our dedicated team of health professionals.

Seniors & Personal Support

  • 14,500 seniors (65+) received care.
  • 1,120,000 personal support hours provided care for patients and support to caregivers.
  • 85 per cent (952,000 hours) of personal support hours supported seniors to remain at home.

Quality Care

  • Home care was provided to over 3,600 patients with complex needs; a 10 per cent increase in the number of complex patients served by the CCAC than the previous year.
  • 1,770 patients received quality palliative care.

Long-Term Care

  • 4,450 individuals were assisted with placement services (e.g., respite, convalescent care, long-term care etc.).
  • Of those, 1,400 individuals were supported in their transition into a long-term care home.

Children Services

  • Care to over 1,800 children and youth was provided in their school setting.
  • We partner with 227 schools to coordinate care for children to enable them to attend school.
  • 36,730 hours/visits of nursing care and 10,500 therapy visits assisted students to optimize their abilities at school.

 Information and Referral

  • CCAC information and referral specialists handled over 29,300 calls, connecting people to community support services.
  • Since 2009, 33,900 patients have been connected to a primary care provider, and 67 per cent of those patients were within 10 km from their home.

Hospital Referrals Received

  • Hospital referrals to home care have increased by 33 per cent, while patients waiting for long-term care from hospital has decreased by 63 percent.
  • 9,890 hospital referrals from hospital to the NSM CCAC supported patients going home in 2014-15.

APPENDIX B: Summary of the Critical Success Factors

Patient-and Caregiver-Focused Care

1.   Stay dedicated to the work in the Home and Community Care Roadmap.

2.   Build upon the most successful individualized, patient-and caregiver-focused care delivery programs, methods and systems.

Clear Vision and Strategy for the Future

3.   Draw on the experience of resources in home care and other key health care sectors to co-design a clear vision, mission, strategy and set of values that can logically and confidently lead the way forward.

Governance and Management

4.   Follow international leading practice approach to establishing effective board composition and provide ongoing development support to all board members.

5.   Conduct an independent talent management review to ensure the most qualified individuals are recruited to senior roles in the new organization.

Critical Success Factors for Integrated Care

6.   Enable all members of a care team to view and contribute to a patient's common health care record and effectively communicate through shared information systems.

7.   Ensure clearly documented expectations for care team member's functions, responsibilities, and accountabilities to optimize an integrated, multi-disciplinary care team's efficiency.

8.   Prioritize the further development and wide-spread adoption of leading practice home care clinical pathways and timely performance management reporting.

Access to Care Where and When Patients Need It

9.     Address funding inequities both across regions and across providers.

10.   Build on the Provincial CCAC Primary Care Integration Strategy.

11.   Leverage the existing 'thehealthline.ca' tool and provide more detailed and specific information about program and service eligibility and capacity.

Operational Design Considerations

12.   Bring home care expertise to the planning table to identify which proposed operational changes will logically result in the desired outcomes.

13.   Ensure continued access to the population-specific care that meets the unique needs of patients in specific patient populations.

14.   Establish strong centralized home care quality and standards body to continue to improve practice consistency and quality improvements.

15.   Prioritize modernizing and streamlining the home and community care contracting model and harmonize the rates.

16.   Consider the local innovations practices developed for our shared service model to inform similar models across the LHIN and province.

Transition Considerations

17.   Strike a careful balance between the need for regulatory standards and providing flexibility for the LHIN and other organizations to design systems and processes to meet the desired future-state outcomes.

18.   Establish dedicated resources with the experience and capacity to successfully direct the transition process.

19.   Ensure that patient and caregiver safety and experience is not compromised during the transition process.

20.   Conducted the transformation over time following a very clear and committed strategy and plan that is driven by the desired patient and caregiver outcomes.

21.   Allow for the time required to have all health service organizations in the region work towards the shared culture required for true system integration.

22.   We also emphasize the need for the patient and caregiver voice in all of these considerations.

APPENDIX C: What Does Success Look Like?

We will know that home care operations have improved in 3-5 years if:

  1. Patients can access care when and where they need it.
  2. Patients receive individualized, population-specific care that meets their needs.
  3. Patients and their caregivers have the information and support to make informed decisions about their care.
  4. Patients trust that providers share appropriate information to improve their care.
  5. Patients receive relevant, accurate health services information from all providers.
  6. Quality standards continue to be improved and implemented across the sector.
  7. Clear roles and responsibilities of all care team members have increased efficiency and reduced duplication and waste.
  8. The home care contracting and direct service delivery model drives value for money, greater accountability, higher quality care and better patient outcomes.
  9. Equitable funding enables patient access to the appropriate care provider on evenings and weekends.
  10. There is increased consistency in the delivery of patient care, the achievement of outcomes and improved patient experience.

APPENDIX D: Our Consultation Process

It was very important to NSM CCAC that we engage, consult and involve all our staff, management and Board members in the development of the response to the Ministry's 'Patients First' proposal. Our consultation process included engaging these stakeholders directly through multiple methods over three phases.

Phase 1 involved conducting an online survey for staff and management to identify the critical success factors that support the desired futures state described in the Ministry's 'Patients First' proposal. A total of 192 staff and management responded to the survey.

Phase 2 involved facilitating seven in-person focus groups, each 2-hours in length, for staff, management and the Board members to elaborate on the feedback and themes that emerged from the survey. Participation in the focus groups was entirely voluntary and scheduled to accommodate various staff shifts.  Overall, a total of 79 participants attended the scheduled focus groups.

Phase 3 involved distributing the draft NSM CCAC response to all staff, management and Board members for review and comment. More than 50 staff, management and Board Members provide their feedback on every section of the response providing more than 60 direct comments which informed the final response paper.

In total, over 250 NSM CCAC stakeholders reviewed and provided direct feedback on the Ministry's 'Patients First' proposal identifying the critical success factors to ensure changes outlined in the 'Patients First' proposal can be successfully implemented to improve patient care and health system outcomes.

 

Click here to access a pdf of the NSM CCAC Response paper.