champlain lhin inpatient mental health & addictions

Champlain LHIN Inpatient Mental

Health & Addictions Capacity Plan

Final Report

21 August 2017

C H AM P L AI N L H I N I N P AT I E N T M E N T AL H E AL T H C AP AC I T Y P L AN

FINAL REPORT

Prepared by OPTIMUS | SBR © 2017 All rights reserved P a g e | 2

TABLE OF CONTENTS

EXECUTIVE SUMMARY.....................................................................................................4

ACKNOWLEDGEMENTS ....................................................................................................6

1. CONTEXT ...............................................................................................................8 1.1 Project Overview ............................................................................................................ 8

1.2 Project Scope.................................................................................................................. 8

1.3 Project Approach & Methodology ................................................................................. 9

2. CHAMPLAIN INPATIENT CAPACITY PLAN CURRENT STATE SUMMARY AND FINDINGS ............................................................................................................. 10

2.1 Inpatient MH&A Programs and Services ...................................................................... 10

2.2 Inpatient MH&A Bed Capacity: .................................................................................... 11

2.3 Related MH&A Programs and Services ........................................................................ 11

2.4 Overarching Current State Themes .............................................................................. 13

3. INPATIENT MH&A SYSTEM GUIDING PRINCIPLES .................................................. 19

4. CURRENT AND PROJECTED CAPACITY EVALUATION .............................................. 20 4.1 Future Projections ........................................................................................................ 22

4.2 Acute Capacity.............................................................................................................. 24

4.3 Specialized Capacity ..................................................................................................... 24

5. CHAMPLAIN INPATIENT CAPACITY PLAN RECOMMENDATIONS ............................. 26

6. IMPLEMENTATION CONSIDERATIONS ................................................................... 28

7. IMPLEMENTATION PLAN: HOW TO EXECUTE......................................................... 29 7.1 Recommendations Inform Steps of a Regional MH&A Capacity Program .................. 29

7.2 Alignment of Regional MH&A Capacity Program to Recommendations ..................... 30

7.3 Work Stream 1: Regional Program Set-Up and Initiation ............................................ 32

7.3.1 Step 1.1 Establish Regional Governance Structure ......................................... 32

7.3.2 Step 1.2 Establish Program Operating Principles and

Mechanisms .................................................................................................... 33

7.3.3 Step 1.3 Transform Levels of System Collaboration,

Cooperation and Communication ................................................................... 34

7.3.4 Step 1.4 Detailed Action Planning and Change Management ........................ 34

7.4 Work Stream 2: System Framing.................................................................................. 35


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7.4.1 Step 2.1 Define Regional Model and Levels of Care that are

both Person-centered and Recovery-oriented ............................................... 35

7.4.2 Step 2.2 Adopt a Regional Population Health and Equity

Framework ...................................................................................................... 36

7.4.3 Step 2.3 Develop a Decision-Making Framework to Guide

Regional Program Implementation ................................................................. 36

7.5 Work Stream 3: Operational Capacity Building ........................................................... 36

7.5.1 Step 3.1 Develop Regional Standards ............................................................. 37

7.5.2 Step 3.2 Develop and Implement a Regional HHR Plan .................................. 38

7.5.3 Step 3.3 Design and Implement System Coordinated Intake ......................... 38

7.5.4 Step 3.4 Leverage Technology to Support Safe, Effective and

Efficient Service Delivery ................................................................................. 39

7.5.5 Step 3.5 Ensure Capacity for High-needs Specialized

Populations and Address Urgent Acute MH&A Capacity

Challenges ....................................................................................................... 39

7.6 Work Stream 4: Broader System Alignment ................................................................ 40

7.6.1 Step 4.1 Enhance Awareness, Understanding, and

Relationships Across the MH&A Continuum .................................................. 41

7.6.2 Step 4.2 Outpatient and Community Engagement and Capacity

Building ........................................................................................................... 41

7.6.3 Step 4.3 Primary Care Engagement ................................................................ 42

7.7 Work Stream 5: Evaluation .......................................................................................... 42

7.7.1 Step 5.1 Evaluation Setup and Planning ......................................................... 43

7.7.2 Step 5.2 Conduct Ongoing Monitoring and Evaluation .................................. 43

8. PROGRAM IMPLEMENTATION IS COMPLEX .......................................................... 45 8.1 Attitudes ....................................................................................................................... 45

8.2 Conditions .................................................................................................................... 46

8.3 Resources ..................................................................................................................... 47

9. APPENDIX ............................................................................................................ 48 9.1 Detailed Implementation Plan Steps ........................................................................... 48

9.2 Regional Program Governance Structure .................................................................... 65

9.3 Change Management Framework to Support Culture Transformation ...................... 66

9.4 Levels of Care/Utilization Management Tool (Example - LOCUS)................................ 67


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Executive Summary

In response to the objectives outlined in the Champlain LHIN’s Integrated Health Services Plan

2016-19, and in recognition of the need to continue to improve access to inpatient mental health

and addictions (MH&A) services, the Champlain LHIN convened a Steering Committee to develop

an Inpatient MH&A Capacity Plan. The Steering Committee was led by Co-Chairs, George Weber,

CEO of The Royal Ottawa Healthcare Group, and Bernard Leduc, CEO of Hôpital Montfort and

membership included:

Representation from each hospital with inpatient MH&A beds

Representations from small, rural, and community hospitals that refer into the inpatient

MH&A system;

Representation from the University of Ottawa Department of Psychiatry;

Representation from the Réseau des services de santé en français; and,

Representation from the Champlain Mental Health Inter-hospital Committee.

The focus of this Steering Committee was to develop a Capacity Plan for inpatient mental health

and addiction services being provided across the Champlain LHIN by schedule 1, schedule 2/3,

and specialty facilities. The specific goals of the project were to increase efficiency, effectiveness

(e.g. patient and family experience), and flow across identified hospitals and inpatient programs

with limited additional financial investment.

The Champlain LHIN Inpatient Mental Health Capacity Plan project resulted in thirteen (13)

recommendations. This document outlines an overview of the Capacity Plan Assessment,

recommendations and implementation plan. The implementation plan has been presented as a

set of integrated implementation activities and titled the Regional Inpatient MH&A Capacity

Program (Regional Program) Implementation. Built on change management principles, and

through consultation with MH&A system experts and users, providers and partners of

Champlain’s MH&A services, the Regional Program is also aligned with the Champlain LHIN goals

of Integration, Access and Sustainability. The Regional Program Implementation includes five (5)

work streams to be completed over a three-year timeframe:

Many of the steps and sub-steps within each work stream will be implemented simultaneously

and complement each other – successes in one area will contribute to successes in others.

Furthermore, many elements of the implementation will begin immediately, whereas other

elements will not begin until later in Year 1 or even Year 2 given their dependencies on other

activities within this Program.


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The following graphic provides the sequencing for implementation of the Regional Program.

High-Level Program Implementation Plan


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Acknowledgements

This report has been prepared on behalf of the Champlain Inpatient MH&A Service Capacity Plan

Steering Committee. The committee is acknowledged for its dedication and thoughtful direction

of the process. The Steering Committee members are listed below.

Steering Committee Membership:

George Weber, The Royal Ottawa Health Care Group, Co-Chair

Bernard Leduc, Hôpital Montfort, Co-Chair

Raj Bhatla, Chair Champlain Inter-Hospital Committee

Barbara Casey, Children's Hospital of Eastern Ontario

Jacinthe Desaulniers, Réseau des services de santé en français de l’Est de l’Ontario

Jeanette Despatie, Cornwall Community Hospital, Interim CEO Brockville General Hospital

Heather Garnett, The Ottawa Hospital

Kathy Gillis, Chair Department of Psychiatry

Marc LeBoutillier, Hawkesbury & District General Hospital

Pierre Noel, Pembroke Regional Hospital

Tom Schonberg, Queensway Carleton Hospital

Frank Vassallo, Kemptville District Hospital, Champlain Alliance of Small Hospitals

Kevin Barclay, Champlain LHIN, Senior Health System Integration Specialist

The OPTIMUS | SBR Project Team:

Terri Lohnes

Andrea Spencer

Rachel Steger

David Lynch

Glenna Raymond

Janice Dusek

Jacquie Dale

Guy Théroux

Nathan Duyck

Lindsay Martin

The following individuals, organizations, and groups are acknowledged for their participation in

the stakeholder consultation process.

ACTT/FACTT-DD

Addiction and Mental Health Network Champlain

C H AM P L AI N L H I N I N P A T I E N T M E N T AL H E AL T H C AP AC I T Y P L AN

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Champlain Crisis Teams

Champlain Inter-Hospital Committee

Champlain Primary Care Working Group

CMHA Ottawa and other Community MH&A Providers

Indigenous Health Circle Forum

Member hospitals of the Champlain Association of Small Hospitals

Montfort Renaissance

Ottawa Police

Ottawa Paramedic Service

Parents' Lifelines of Eastern Ontario

People with lived experience

Psychiatric Survivors of Ottawa

Salus Ottawa

THRIVE

The contributions from the participating organization’s administrative, clinical, and decision

support teams at each hospital and the Champlain LHIN are also appreciated, in particular to:

Andrew Bonner, The Ottawa Hospital

Mitsi Cardinal, The Royal Ottawa Health Care Group

Sonia Dicaire, Hôpital Montfort

Barb Fisher, Children's Hospital of Eastern Ontario

Robyn Griff, The Royal Ottawa Health Care Group

David Hesidence, The Royal Ottawa Health Care Group

Henna Hussain, The Royal Ottawa Health Care Group

Heather Mallon, The Royal Ottawa Health Care Group

El Mostafa Bouattane, Hôpital Montfort

Coralee Purdy, Queensway Carleton Hospital

Brian Schnarch, Champlain LHIN

Gamil Shahein, Pembroke Regional Hospital

Rhiannon St. Pierre, Cornwall Community Hospital

Ellen Whittingham, Queensway Carleton Hospital


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1. Context

1.1 Project Overview

In response to the objectives outlined in the Champlain LHIN’s Integrated Health Services Plan

2016-19, and in recognition of the need to continue to improve access to inpatient mental health

and addiction services, the Champlain LHIN convened a Steering Committee to develop an

Inpatient MH&A Capacity Plan. The Steering Committee was led by Co-Chairs, George Weber, CEO

of The Royal Ottawa Healthcare Group, and Bernard Leduc, CEO of Hôpital Montfort and

membership included:

Representation from each hospital with inpatient MH&A beds

Representations from small, rural, and community hospitals that refer into the inpatient

MH&A system;

Representation from the University of Ottawa Department of Psychiatry;

Representation from the Réseau des services de santé en français; and,

Representation from the Champlain Mental Health Inter-hospital Committee.

The focus of this Steering Committee was to develop a Capacity Plan for inpatient mental health

and addiction services being provided across the Champlain LHIN by schedule 1, schedule 2/3,

and specialty facilities. The specific goals of the project were to increase efficiency, effectiveness

(e.g. patient and family experience), and flow across identified hospitals and inpatient programs

with limited additional financial investment.

Success for the Capacity Planning project was defined as:

A deeper understanding of the capacity of the current inpatient mental health and

addictions system to meet demand, both now and into the future.

A clear path forward for how the Champlain LHIN can better integrate mental health and

addictions services for better outcomes and value, informed by local needs, including

other LHIN-wide initiatives and the needs of priority populations.

Ownership by key staff, medical leadership, hospital leadership, and the LHIN for the

recommendations to improve the capacity of the local inpatient mental health and

addictions system.

1.2 Project Scope

The scope of the Capacity Plan project was designated inpatient mental health and addictions

services in Champlain LHIN provided by schedule 1, schedule 2/3, and specialty facilities.

However, the Inpatient MH&A Capacity Plan must be situated within the larger MH&A system

and recognize the entire MH&A continuum of care, especially how other parts of the system


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impact the use of and need for inpatient services. Given the limits in scope, the capacity of

outpatient and community-based services delivered were not measured but were considered as

they relate to inpatient system inflows and outflows.

1.3 Project Approach & Methodology

The Capacity Planning Project consisted of:

A Current State Assessment of Inpatient MH&A care in Champlain; including extensive

consultations, secondary data analysis, and a jurisdictional scan and best practices review;

Recommended future state changes to increase efficiency, effectiveness, and flow across

the identified hospitals and inpatient programs to meet the mental health and addictions

needs of the Champlain population with limited additional financial investment; and,

Implementation plan and considerations to support the implementation of an integrated

Regional Inpatient MH&A Program.

Champlain LHIN convened the Steering Committee to develop the Inpatient MH&A Capacity Plan.

The Co-Chairs of the Steering Committee, George Weber and Bernard Leduc engaged a third-party

consultant (OPTIMUS | SBR) to support the work in February 2017.

The Steering Committee and OPTIMUS | SBR completed the Capacity State Assessment,

recommendations development and implementation planning between February and July 2017.

The approach included the following steps:


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2. Champlain Inpatient Capacity Plan Current State Summary and Findings

2.1 Inpatient MH&A Programs and Services

Inpatient MH&A services in Champlain LHIN are delivered by seven (7) hospitals across eight (8)

sites. There is a mix of general acute adult MH&A beds, pediatric MH beds, as well as specialty

programs focused on certain patient populations and diagnoses (both adult and pediatric).

Each hospital with inpatient MH&A services offers various inpatient mental health and addiction

programs. The region has a number of programs including:

General Acute Psychiatry: Psychiatric intensive care/observation, stabilization,

psychiatric assessment, diagnosis, treatment and discharge planning for those with acute

mental illness (including crisis).

Crisis: Provides short-term specialized diagnostic clarification, assessment, treatment,

and stabilization of persons experiencing an acute mental health crisis episode.

Mood: Inpatient assessment and treatment for patients with recurrent, chronic

treatment resistant and co-morbid mood disorders.

Forensics: Provides specialized assessment, treatment, and rehabilitation for adults with

severe psychiatric illness who have come into conflict with the criminal justice system.

Geriatric: Provides care for patients over the age of 65 (or younger patients living with

Alzheimer’s or Frontotemporal Dementia) with severe multiple and/or complex

psychiatric illnesses.

Schizophrenia: Specialized treatment and care to individuals with diagnoses of treatment

resistant schizophrenic related illness with comorbidities or psychosis.

Children and Youth: Serving children and youth who are experiencing an acute mental

health crisis.

Recovery: Serves those with severe mental illness (SMI) in developing recovery goals and

skills to meet them using the Illness Management and Recovery (IMR) Model, an

evidence-based psychiatric rehabilitation practice (© 2011 by Dartmouth and Hazelden

Foundation).

Eating Disorder: Inpatient eating disorder programs for pediatric and adult populations.

Substance Use: Medical detoxification (alcohol) and/or stabilization on opioid agonist

therapy for patients with severe substance use disorder who cannot be stabilized as an

outpatient.


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Concurrent Disorder: Provides integrated and specialized stabilization, assessment,

diagnostic clarification, and treatment services to clients with co-morbid severe, complex,

active and symptomatic substance use and mental health disorders.

2.2 Inpatient MH&A Bed Capacity:

There are 423 inpatient MH&A funded beds in operation in the Champlain region, including

pediatric and specialty beds. Overall, the greatest capacity exists at the Royal (210) followed by

The Ottawa Hospital (87) and Montfort (46). Of the beds used for general acute care specifically,

the greatest capacity of funded beds is at The Ottawa Hospital (81), followed by Montfort (38),

and Queensway Carleton (24). There are also a number of specialized program-specific beds

located at The Royal, CHEO, The Ottawa Hospital and Montfort. Table 1 Champlain LHIN Inpatient Mental Health and Addictions Beds by Type and Facility1

Source: Reported by Individual Hospitals

2.3 Related MH&A Programs and Services

Other MH&A services and functions beyond inpatient services are not in-scope for this project

but impact the need for and utilization of inpatient MH&A services. These services and functions

are delivered by many organizations across Champlain region with the largest provision of services

by The Royal. These services include:

Outpatient programs and services

Day hospital programs

1 Note: Please note that the 6 eating disorder beds at the Ottawa Hospital are not fully funded. The 12 bed concurrent disorder unit at The Royal only operates 5 days a week with patients going home on weekends and are hospital-based residential beds. These beds are funded from the Community MH&A stream (the same envelope as other residential addictions beds offered by addictions treatment centres in the LHIN), not from Global funding. Additionally, bed totals do not include unfunded MH&A beds that may be periodically used to address urgent bed pressures or funded beds for which there is physical space but are not operational. The Royal’s 210 beds mentioned in the IP Capacity report encompass only approximately half of the inpatient services the Royal offers. Additional beds are used to provide services at The Royal Ottawa Place LTC facility (64 beds). The Royal operates a unique partnership with the Provincial Ministry of Community Safety and Correctional Services through the St. Lawrence Valley Correctional and Treatment Centre (Secure Treatment Unit) which includes 100 Schedule 1 beds and a 59 bed Forensic Treatment Unit at Brockville Mental Health Center. The Royal also operates 183 beds in Homes for Special Care across the region.


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Case management services

Community-based MH&A services

Community/Supportive housing

Consultations and telepsychiatry services

Psychiatry emergency services

Long-term care programs and services

Research and education,

Regional leadership, planning and capacity building

Services/capacity reserved for other jurisdictions (federal, other LHINs, other provinces)2

Additionally, within Champlain, three organizations have specialized mandates with respect to

certain patient populations or regional leadership for MH&A

Regional MH&A Leadership: The Royal is the primary provider of specialized levels of

MH&A care within Eastern Ontario and provides a wide range of intensive level services.

The Royal operates the largest Community Mental Health program in the LHIN including

seven community treatment teams. It also offers, through many of its programs,

outreach, consultation and clinical capacity building services through partnerships. The

Royal operates the Pathways to Better Care Program which provides administrative

capacity building and system transformation services across the LHIN. The Royal offers a

diverse set of education and training activities which are accessed by many professionals,

individuals with lived experience and the public. The Royal acts as an expert resource for

the region/province and the LHIN and is often tasked with developing innovative solutions

to tackle complex emerging MH&A issues within the community.3

Francophone MH&A Services: Montfort is Ontario’s Francophone Academic Hospital and

has a provincial mandate to improve access to health care in Ontario, with a specific focus

on francophone communities. This includes participating in planning and supporting

French language health services, helping the Government of Ontario to meet its

obligations under the French Language Service Act, serving as a Centre of Excellence and

hub for French language health care professional education, and demonstrating research

and academic programming consistent with an AHSC.

Child and Youth Mental Health: CHEO is the largest provider of child and youth mental

health services in Eastern Ontario, and houses several provincial and regional programs,

including the Provincial Centre of Excellence for Child and Youth Mental Health which

works with agencies to strengthen mental health services and build an accessible system

2 Other jurisdictions include: Provincial Ministry of Community Safety and Correctional Services, forensic inpatient beds located in

South East LHIN at the Brockville Mental Health Centre, Veterans Canada, Canadian Forces, RCMP, and Nunavut and Yukon. 3 The development of the FACT team, the Regional Complex Schizophrenic Project (Co-Lead in partnership with TOH and other

schedule 1 Hospitals in the Ottawa region), the development of a new community CBT program and lastly, bringing CAPA to the youth system are a few examples of The Royals regional leadership.


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of care for children, youth and their families and caregivers; and The Young Minds

Partnership strategy (in partnership with The Royal).

These broader MH&A services and regional/provincial leadership mandates will be important

considerations in future state planning and implementation as they can have impact on the need

for and delivery of inpatient MH&A services and may be important resources to build upon and

leverage as part of system-wide MH&A improvements.

2.4 Overarching Current State Themes

The Current State summary below outlines the overall capacity of the inpatient MH&A system. It

also outlines how the current capacity is being used, and the resulting experience and outcomes

for patients, families, and providers. Throughout the Current State assessment, a number of key

themes emerged which are categorized in the graphic below. Observations in these areas have a

number of implications for how the inpatient MH&A system operates and have significant impact

on patient experience, providers, and overall value to the system. Figure 1 Current State Themes and Opportunities

Leadership, Governance & Culture

Equity & Access Flow Service Delivery

Health Human Resources


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Leadership, Governance & Culture: Leadership, governance, and culture includes the structure

of the system, accountability structures and mechanisms, focus and direction of leadership, and

the behaviours and attitudes exhibited by system stakeholders. The key observations in this

category have broad and significant implications on the entire system, including many of the other

key theme areas identified above. As a result, addressing the key findings and observations in this

area will also have broad impact on the entire system including equity and access, flow, service

delivery and health human resources.

Observations No regional governing or oversight body that

holds the MH&A system accountable for delivering coordinated and effective services across the continuum of care.

Variability in the level of trust between inpatient care providers and community care providers.

Forums exist for collaboration and relationship building among the inpatient system; however, there are limited formal partnerships or oversight.

Lack of clarity of roles and responsibilities across hospitals and the continuum of care, especially clear definitions of which providers should be providing what levels/types of care (specialty vs acute vs primary).

Organizational silos, both within and between sites, due in part to funding, capacity challenges and differences in operating mechanisms and system.

Successful implementation of Regional Programs

in other disease areas as well as specific initiatives

in MH&A.

Implications Regional variation in the capacity and use of

Health Human Resources and inpatient MH&A service delivery.

Limited awareness and communication across the continuum of care (inpatient, outpatient, community, and primary care) lead to challenges managing patient flow as well as the provision of coordination of person-centered care across the continuum.

Political dynamics and territorial behaviours (clubs of patients) by organizations impact patient access and flow and impede trust and communication between different system providers and result in sub-optimal use of inpatient resources.

Leadership focus on the advancement of individual sites and programs and the specific part of the care pathway they provide rather than a holistic view of the patient.

Perceptions that there is an imbalance of influence and equity in system planning discussions with a focus and emphasis on the Urban-Ottawa region with less influence and understanding of the needs and barriers of smaller and more rural communities.


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Equity & Access: Equity and Access includes whether people in Champlain are able to receive

high-quality, appropriate and timely inpatient MH&A service and care that is fair and appropriate

to them and their needs, no matter where they live, what they have, or who they are.

Observations Patients and those with lived experience

indicated that the MH&A services they received varied depending on where care was accessed across the Champlain region.

Perceptions by patients, families and providers that the only/easiest way to get MH&A support is through a MH crisis and entering the system through the ED. The ED is the primary entry point into the inpatient MH&A system, in 2016/17 there were approximately 5560 ED visits that resulted in direct admission to a site with inpatient MH&A beds representing 79% of the region’s MH&A admissions.

Populations with limited/no service options due to program inclusion/exclusion criteria: o Neuropsychiatric disorders o Acquired brain injury o Autism without intellectual disability o Concurrent disorders o Dementia o Involvement in criminal justice system o Other medical comorbidities o Lack of housing support

Populations with limited access to appropriate in-patient service programs/environments: o Dual diagnosis o Neuropsychiatric disorders o Medically complex geriatric psychiatry

Socioeconomic, demographic and cultural factors impact access to care options o Financial barriers for therapy o Transportation barriers for acute and

specialized services o Gaps in culturally appropriate care for

Indigenous populations o Variable access to French language services

and care milieu

Implications

Challenges for specialized clinical populations to access appropriate care environments can contribute to ALC, suboptimal outcomes, poor experiences, and unsafe work environments.

Francophone – Montfort is the only facility that offers full Francophone service and milieu. Most Francophone patients access services at Montfort; however, a large number access care at other hospitals with varying levels of French language services and lack of a francophone milieu.

Indigenous – Providers identified that there are opportunities to enhance the relationships between Indigenous communities and hospitals to ensure effective transitions for Indigenous patients as well as the provision of culturally appropriate care. Challenges with transitions between inpatient and outpatient/community are compounded by lack of culturally-appropriate programs and supports.

Rural Communities – Most specialized inpatient programs and some acute programs must be accessed far from home. This is compounded by lack of community programs and supports to treat patients in the community resulting in increased used of inpatient resources.

Pediatrics and Youth – Capacity gaps were identified for specialized treatment programs for pediatric populations (e.g., addictions) as the only treatment program is for eating disorders. Transitional aged youth were also identified as a high needs population who require support as they transition to the adult system. The strategic partnership between CHEO and The Royal is currently making progress to support better transitions, but there are further opportunities to ensure effective supports and transitions.

Specialized clinical populations have access challenges and cause ALC rates due to capacity gaps and/or eligibility.


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Flow: Patient flow includes entry into the system, as well as movement within the system and

finally discharge and transition out of the system. These all represent significant pain points and

can impact outcomes, patient experience and system efficiency.

Observations Patient, providers and the data suggest that the

ED is the primary entry point into the inpatient MH&A system because access through other entry points is too challenging.

Inpatient units are facing different levels of flow and capacity challenges across the region, although there are high levels of variability within sites, especially during surges. Unit occupancy levels range from 71% at Pembroke to 108% at Ottawa General. When ED holds and off-service are included, occupancy ranges from 72% at Pembroke to 114% at Ottawa General.

Patients are not effectively transferred throughout the system to use available capacity and ensure patients are accessing the right level of service. ALC rates are better than the provincial average, however there is a lot of variability between sites with quarterly rates ranging from close to 0% up to a maximum of 24.4% since 2012. Additionally, providers qualitatively identified that patients often wait in designated MH&A beds for a different level of care (acute waiting for specialty).

Capacity of outpatient and community-based services and supports for MH&A patients are limited resulting in increased demand for inpatient services: o Lack of integration and coordination of

services between many inpatient and community programs

o Long wait times for community programs and transitional supports

o Lack of community supports for some specialized populations

Many hospitals have lower length of stay than peers but are challenged to connect patients to the appropriate supports in the community.

Significant capacity is used by ALC patients waiting for supportive housing and long-term care, although there is significant variability between sites.

Implications Patients are not entering the inpatient system

through the most efficient and patient-centered path (coordinated direct referral) and are often entering in crisis.

Hospitals are not managing capacity and flow at a system level and are developing local workarounds and quality improvement initiatives to address capacity pressures that are not scaled broadly.

Patients are experiencing long wait-times to access community/specialty programs resulting in longer stays in inpatient setting and poor transitions between inpatient and the community because patients often are not able to access resources.

Hospitals are faced with ALC challenges in inpatient units which act as a barrier to patient flow and prevent patients from accessing the most appropriate level of care based on their needs.


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Service Delivery: Service delivery includes how much service is delivered across the system, why

that service is being accessed and how it is delivered.

Observations Lack of common standards across the system:

o Standards of care o Admission and discharge criteria o Models of care o Defined care pathways o Standard scope of services o Common admission, assessment and

discharge tools o Health Human Resource resourcing

Providers and those with lived experience lack awareness / knowledge of the various components of the MH&A system.

Service focus on stabilization with a lack of access to treatment, beyond pharmacological therapy, was raised as a concern by both patients and providers.

Circle of care and information sharing often excludes families and community providers. Interpretation and application of existing privacy legislation often creates challenges with respect to privacy and disclosure.

Patients and families feel there are opportunities to improve level of compassion and empathy while reducing stigma while accessing services.

Outcome measures at the patient level are not well integrated into clinical services.

There are differences in philosophies of care between inpatient and community settings and there are still challenges with communication and coordination of services even when the programs are part of the same larger organization.

There is significant variability in different quality outcomes, cost per inpatient day and the use of tools such as restraints across hospitals.

Implications Patients experience differences in baseline care

at different sites across Champlain.

There are likely opportunities for standardization to improve effectiveness and quality.

Information is not transferred effectively between different providers treating the same patient at different points in the continuum.

The services being delivered are not aligned with recovery focused philosophy and do not meet expectations of patients receiving the services or the providers delivering them.

There are poor transitions between care settings.


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Health Human Resources: Health Human Resources include all types of people engaged in actions

whose primary intent is to enhance health (e.g., psychiatry, nursing, allied health, peer supports).

Observations .

Champlain LHIN appears to be well resourced with Psychiatrists, as compared to the provincial average; however, there are still a number of challenges with psychiatry capacity, including:

o Regional distribution of psychiatrists with higher concentrations in urban-centers and challenges recruiting and retaining psychiatrists in rural areas

o Age distribution, with a large proportion close to retirement

o Gaps in specialty-psychiatry (e.g., geriatric psychiatry)

o Limited community-based access (e.g., limited referrals to community-based psychiatry, roster size, etc.).

There is no consistency (or standard) for a staffing model across Champlain.

Many MH&A care providers identified that they are not working to full scope of practice due to health human resource capacity constraints. For example, mental health nurses and social workers do not have capacity to complete Cognitive Behaviour Therapy (CBT) and Dialectical Behavior Therapy (DBT) and there was a lack of Psychologist resources at many of the sites.

Family and peer support programs have been especially valuable and well received, where they are available.

Implications

Patients use inpatient MH&A system to gain access to psychiatry resources.

Rural bed capacity is constrained by psychiatry coverage limiting admissions and patient flow.

Health human resources are not being optimally used to support patient care.

Patients and families often do not have access to peers supports which can impact outcomes as well as the quality and experience of transitions.


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3. Inpatient MH&A System Guiding Principles

The following 11 principles were developed by the Steering Committee and guided the

development of recommendations and implementation planning. The principles articulate the

features of the desired future state inpatient MH&A system in Champlain. The guiding principles

were developed based on of the ideal and overarching goals of mental health and addictions care

delivery, and informed by work done by the Mental Health Commission of Canada as well as the

Champlain’s MH Strategy and IHSP. Going forward, the spirit of these principles needs to be

embraced by leadership and staff across the inpatient MH&A system, and guide decision-making

and the implementation of recommendations.

Champlain Inpatient MH&A Guiding Principles


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4. Current and Projected Capacity Evaluation

A full needs assessment of inpatient MH&A was not in scope for this review; therefore,

operational ratios and current use (inpatient days) have been used as proxies for demand. The

graph below shows the total number of MH&A beds in adult acute and specialty hospitals within

each LHIN. In the same graph, provincial average and the number of beds in each Champlain sub-

region is compared. Overall, Champlain is close to Ontario’s average beds per 1000 population

(0.30 vs 0.32); however, that difference manifests itself as the region being short 34 beds relative

to the provincial average. It is important to note that Champlain also has a large specialty MH&A

hospital and a pediatric hospital that treat patients beyond LHIN boundaries and so actual bed

deficits (relative to provincial averages) may be larger. Additionally, the beds are unevenly

distributed across the LHIN with Western Champlain, Western Ottawa and Eastern Champlain all

with lower capacity than the provincial average. The lowest ratios are in Western Ottawa and

Eastern Champlain; although, Eastern Champlain borders a higher bedded sub-region (Eastern

Ottawa) which has specialized capacity to address the sub-region’s high need for francophone

services.


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Figure 2 Acute and Specialty Hospital Hundred MH&A Beds per 1000 Population4

Source: OMHRS; Hospital self-reported data

4 Does not include pediatric beds as these are not reported in OMHRS

0.09

0.32

0.09

0.30 0.26 0.26

0.09

0.49

0.75

0.45

0.69

0.42

0.58 0.56

0.322854

0.10 0.08

0.72

0.22

0.08

-

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

Nu

mb

er o

f Fu

nd

ed M

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A B

eds

per

10

00

po

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on

Acute and Specialty Funded MH&A Beds per 1000 population


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4.1 Future Projections

A projection of the future demand for inpatient MH&A beds based on the current Ontario average

per capita bed capacity and projected population growth shows that 482 beds will be required in

2026 and 529 beds will be required in 2036.5 This assumes no changes to current service models

or demand. An alternative methodology, projecting future capacity requirements using

population growth projections, current inpatient days per capita and an occupancy rate of 0.95

results in an expected demand for 448 adult beds (acute and specialty) and 30 pediatric beds in

2026, and 492 adult beds and 32 pediatric beds in 2036. These gaps would require significant

investment to address the gap of 58 adult beds over the next 10 years.

Through the Current State Assessment, a number of opportunities were identified to improve

service delivery and/or help patients access the most appropriate level of MH&A care. These

include reducing ALC rates by assessing and addressing gaps in community capacity and supports,

improving patient flow and integration of the inpatient system through the implementation of

regional standards and coordinated intake, and diversion of M&A emergency department visits

through enhanced community supports and services. By reducing current ALC rates (adult

regional rate = 8.2% and pediatric rate = 3%) there would be a reduced need for investment over

the next 10 years. Addressing the current ALC challenges would result in reduced investment

needs to support population growth over the coming decade, with the deficit decreasing to 15

adult beds. Length of stay is also a potential opportunity to improve the use of current system

capacity; however, most hospitals within Champlain have similar average lengths of stay relative

to peer organizations resulting limited opportunities for improvement.

Additionally, as highlighted in the Current State Summary there are a number of challenges with

patient transitions into and out of the inpatient system, as well as capacity and access challenges

for outpatient, community, and primary care to support patients with MH&A problems in the

community, resulting in increased use of inpatient resources. It is recognized that an increasing

prevalence of MH&A in the population compounds this challenge; however, given that the scope

of the project is set within the context of “limited new financial investment”, future investments

would be better used to address gaps in the flow of patients into and out of the inpatient system

by addressing gaps in capacity and support in outpatient, community and primary care settings.

Compensating for the lack of an integrated and accessible outpatient and community MH&A

system by making significant investments in inpatient capacity does not align to the future state

guiding principles or with the interests of patients. Prior to making any investments to address

future capacity gaps, these broader system issues should be addressed, likely reducing the need

for additional inpatient capacity to support population growth over the next decade.

5 The Ontario average number of beds per population from the previous page was multiplied by the forecasted population to calculate

the above forecast.


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Figure 3 Champlain LHIN Forecasted Required Beds

Sources: Ministry of Finance; OHFS

2016 2026 2036

Forecasted Required Beds; Adult 400 448 492

Forecasted Required Beds;Child/Pediatric

26 30 32

Forecasted Required Beds,excluding ALC; Adult

367 411 451

Forecasted Required Beds,excluding ALC; Child/Pediatric

26 29 31

-

50

100

150

200

250

300

350

400

450

500

Nu

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Champlain LHIN Forecasted Required Beds, by Year


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4.2 Acute Capacity

The scope of the project assumed limited to no additional funding, if there were additional

resources available to address current capacity challenges and build capacity for future, there is

opportunity to add additional acute capacity to Champlain LHIN. Currently, Western Champlain

transfers all involuntary and high acuity patients to hospitals in Western and Central Ottawa

leading to capacity pressures. The Ottawa Hospital consistently operates in a surge situation, with

occupancy levels frequently above 100%. Additional capacity (with the appropriate psychiatry

coverage), would allow other sites to help patients access care closer to home and reduce some

of the urgent flow and capacity challenges faced by The Ottawa Hospital due to surge, transfers

and CritiCall assignments. In the near-term, a regionally coordinated approach is required to

support the Ottawa Hospital’s urgent flow and capacity challenges and support equitable access

to acute MH&A services, including crisis services.

4.3 Specialized Capacity

There were many specialized populations that were identified qualitatively as needing more

MH&A capacity in the current system, however, dual diagnosis, neuropsychiatric disorders,

medically complex psychogeriatric patients, and concurrent disorders were the most frequently

identified. These patient populations require a specialized treatment environment, with different

health human resource models. These populations were also identified as being some of the

largest patient groups contributing to ALC rates, although data of ALC diagnosis was not

consistently tracked among hospitals to validate.

Data on dual diagnosis population size and hospitalizations is not consistently tracked across the

region making it a challenge to estimate demand for inpatient services. It is also valuable to note

that The Royal is the only Specialty MH&A Hospital in Ontario without a specialized dual diagnosis

unit. A recent provincial report on dual diagnosis recommended a rate of 1 bed per 100,000

population. Based on this recommended ratio, Champlain would require an additional 13

specialty dual diagnosis beds.6 These additional beds should be made with corresponding

investments in the community to avoid inpatient capacity being immediately blocked by ALC

patients. The Royal also has a Regional Dual Diagnosis Consultation Team and a Dual Diagnosis

Flexible Assertive Community Team (FACT-DD) which could be expanded to provide further

support to community hospitals and developmental sector homes. Improving capacity for these

specialized services would improve the ALC challenges and flow of dual diagnosis patients in

hospital environments and help dual diagnosis patients access care in the most appropriate care

setting.

6 Note that the diagnosis of Dual Diagnosis is not consistently reported across the region and so whether the capacity of 13 is sufficient

to address current demand is unknown. Additionally, Dual Diagnosis was qualitatively identified as a large contributor to ALC populations within inpatient MH&A programs; however, the diagnosis of ALC populations is also not currently captured.


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Geriatrics and neuropsychiatry were also identified as other areas of need, especially since many

of the rural hospitals have large portions of seniors and comorbidities, such as Alzheimer's

disease, which often exclude patients from many MH&A programs. The Royal has an outreach

service to long-term care by a geriatric psychiatrist and outreach nurse team. Prior to adding

specialized geriatric and neuropsychiatry inpatient capacity, this program should be expanded to

include acute and community hospitals and include a neuropsychiatrist. There is also a need to

ensure that medically complex psychogeriatric and neuropsychiatry patients have access to the

appropriate levels of care to meet their medical and mental health needs. How this capacity is

developed will depend on future decisions including which hospitals should provide which levels

of care. Capacity to support medically complex psychogeriatric patients could also be addressed

by building/reallocating specialized capacity in acute hospitals which have the capacity to address

medical comorbidities or to enhance the capacity to address medical comorbidities in specialty

MH&A hospitals.


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5. Champlain Inpatient Capacity Plan Recommendations

The Capacity Plan Project identified the following recommendations, which were informed by

engagement with people with lived experience, MH&A providers and system partners, secondary

data analysis, and a jurisdictional and best practices scan. The recommendations are also aligned

with recent national and provincial strategies and reports including the Auditor General of

Ontario’s 2016 reviews of Children’s and Specialty Mental Health.


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Recommendations to the LHIN

Leadership, Governance & Culture

Recommendation 1: Develop a governance, accountability, and authority model for inpatient

MH&A for Champlain LHIN that supports enhanced collaboration across the system, increases

accountability for system performance, allows for more effective allocation of resources along the

MH&A continuum, and ultimately allows for the provision of effective and efficient care to patients

and their families.

Recommendation 2: Drive transformational culture across the MH&A system to promote an

integrated and collaborative system team.

Recommendation 3: Implement a recovery-oriented practice as well as a client- and family-centered

model of care by facilitating active participation of patients, families, and peers as part of

collaborative teams and endorsing and integrating recovery-oriented principles into service design

and delivery.

Equity & Access

Recommendation 4: Develop/Adopt a Population Health and Equity Framework to support planning

and decision making.

Recommendation 5: Build/Reallocate capacity for high-needs specialized populations (e.g., dual

diagnosis, neuropsychiatric disorders, etc.) and address urgent acute MH&A capacity challenges.

Flow

Recommendation 6: Design and implement system-wide coordinated intake, triage, and referral

processes to support patients to get access to the appropriate level of care.

Recommendation 7: Establish concrete communication and information sharing protocols for

service delivery across the MH&A continuum.

Recommendation 8: Increase awareness of, and provide education on, both inpatient and

community programs and referral services.

Recommendation 9: Evaluate capacity and gaps of outpatient and community MH&A services and

invest to optimize capacity across the continuum.

Service Delivery

Recommendation 10: Develop/Adopt regional standards for inpatient MH&A services to ensure

consistent person-centered, high-quality experience for all patients.

Recommendation 11: Increase the use of technology in the provision of care by expanding use of

OTN/virtual care and increasing patient access to information.

Health Human Resources

Recommendation 12: Develop a regional Health Human Resources strategy that supports

recruitment, retention and sharing of HHR (including peer supports) and enables MH&A care

providers to work to full scope of practice.

Recommendation 13: Build capacity and better support Primary Care Providers to support patients

with MH&A in the community through education and improving access to consultation and referral

supports


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6. Implementation Considerations

The implementation plan was developed through a consultative process that leveraged the

strengths, weaknesses and gaps identified through the Inpatient Capacity Plan Project, in which

over 200 stakeholders were engaged between February and July 2017. The findings from engaging

stakeholders through multiple interviews and working sessions were used to design the Regional

Program, which is a comprehensive program of implementation activities that work together to

achieve the desired deliverables and outcomes as articulated in the thirteen (13)

recommendations of the Champlain Inpatient Capacity Planning Project. The following graphic

provides an overview of the plan to implement the Regional Program (further details on each step

are provided in later sections):

The implementation of the steps is a complex undertaking, therefore additional considerations

and context have been provided to supplement the activities. The following framework was

applied to categorize various implementation considerations relevant to each step:

Dimension Definition Attitudes The political economy for change: the vision of a different future

and the motivations and commitment to achieve it Conditions The laws, structures, systems, etc. necessary to mandate,

support and manage the change Resources The human, physical and financial resources needed to support

or facilitate the change

There are a number of dimensions to the implementation of a Regional Program for Inpatient

MH&A. As partners work with the LHIN to implement the program there needs to be a strong

commitment to maintaining high standards for quality and safety, with patients at the centre.


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7. Implementation Plan: How to Execute

7.1 Recommendations Inform Steps of a Regional MH&A Capacity Program

The recommendations were designed to achieve a set of objectives through a process of parallel

implementation, where success on one recommendation will result in success in others.

Accordingly, there are significant interdependencies between the different recommendations,

therefore the approach to implementing all seven must be to consider them as a package,

through the design of a Regional Program.

The Regional Program is made up of five (5) major steps that support the execution of all thirteen

(13) recommendations, including:

1. Set-Up & Initiative;

2. System Framing;

3. Operational Capacity Building;

4. Broader System Alignment; and,

5. Evaluation.

The figure below identifies the sub-steps within each of the major steps, which are described in

further detail in the remainder of this section.


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7.2 Alignment of Regional MH&A Capacity Program to Recommendations

The five (5) steps of the Regional Program are fully aligned with each of the thirteen (13)

recommendations, and the approach is expected to achieve all outcomes. The figure below notes

which recommendations are specifically fulfilled by each step in the Regional Program.


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Recommendation – Program Alignment


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7.3 Work Stream 1: Regional Program Set-Up and Initiation

While discussion and collaboration will need to be fostered at all levels and across all inpatient

MH&A service providers, it is very important that the Regional Program be planned, monitored,

and promoted at a system level to ensure consistent high-quality and consistent performance,

effective flow of patients, and efficient use of resources across the region. This will require

establishment and set-up of a regional governance structure that has decision making and

enforcement authority, as well as accountability for system-level decision making. The creation

of a true regional-wide program will require strong leadership, communication, and engagement

to shift the behaviors and attitudes within the region.

Work Stream #1 – Detailed Implementation

7.3.1 Step 1.1 Establish Regional Governance Structure

The first step will be to set-up a regional governance structure for inpatient MH&A (proposed

structure in Appendix 9.2). Multiple levels of governance will need to be included (executive,

operational and delivery) with different perspectives, skills, competencies, and decision authority

at each layer (with authentic involvement of people with lived experience). The governance

structure will require strategic leadership provided by the Executive Committee chair, with day to

day leadership from a Regional Administrative Lead and a Regional Medical Lead. The governance

structure will also require corporate infrastructure that should be provided by the establishment

of a Regional Program Office that is hosted at a member hospital. Staff and supervision of each

hospital’s MH&A programs would remain with the site however would be required to follow the

leadership and direction of the Regional Program.


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Throughout the planning and implementation of this governance structure, there will be a need

to consider and clarify how the different system governance, oversight, and accountability

structures (Regional Program Governance, Hospital Governance, LHIN oversight, Ministry

accountabilities) align to ensure clear accountabilities, division of responsibilities, and avoid dual

governance. A Regional Program, based on collaborative governance, should establish agreed

upon principals, standards and processes for patient care and flow as well as outcome and system

performance measurement. There needs to be clear escalation protocols in place to ensure that

members are held accountable and responsible for adhering to the agreed upon principles. Other

oversight and reporting roles (e.g., to the LHIN) should be clarified and re-enforced with improved

accountability agreements and enhanced performance reporting.

Additionally, the host organization for the Regional Program Office (and Regional Administrative

Lead), Regional Medical Lead, and Executive Committee Chair will need to be selected. Factors

that should be considered as part of this decision include: balance of influence among Regional

Program leadership positions between specialty and acute MH&A provers; existing corporate

infrastructure for regional capacity development that could be leveraged; clinical and research

leadership in MH&A services; and organizational relationships to psychiatry, primary care, and

community providers.

7.3.2 Step 1.2 Establish Program Operating Principles and Mechanisms

The governance structure will require operating principles and mechanisms to function. This will

include development of a specific Terms of Reference document, specific to the Regional Program

to drive productive conversations and collaboration, shared system-level accountability, and

authority. This should include roles and responsibilities, decision and enforcement authority, data

sharing, reporting, and communication protocols for each level of the governance structure:

The Executive Committee should be responsible for setting strategy and priorities;

funding/resource allocation advice to the LHIN; integrated performance accountability;

partner engagement; escalation point for the Operations Committee, and consideration

of how MH&A programs interact with non-mental health components of health service

providers.

The Operations Committee should be responsible for operational policy and procedure

development; regional standards development, implementation and enforcement;

service coordination and collaboration; performance analysis and review; oversight and

direction to the Regional Program working groups; escalation point for the Regional

Program partners. The Regional Administrative Lead and Regional Medical Lead should

act as the co-leads of the Operations Committee and have the authority to mandate a

required response from Regional Program members to support effective patient flow

(according to agreed-upon principles and decision criteria).


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Regional Program staff should be responsible for providing administrative support,

business analytics, project management and communication support to the Regional

Program Executive and Operations Committees’ working groups, and to support initiative

implementation; knowledge sharing and best practices dissemination; and centralized

management of Regional Program resources and tools.

Within each member organization’s inpatient MH&A program(s), staffing levels and

oversight responsibility should remain with the hospital (including staff and clinicians)

following the leadership and direction of the Regional Program.

7.3.3 Step 1.3 Transform Levels of System Collaboration, Cooperation and Communication

Changing the culture of the inpatient MH&A system will support the Regional Program

implementation by enhancing attitudes, behaviours, and relationships. Culture revitalization and

behavior change is difficult and takes time to set up, build momentum, and make sustainable, but

is critical to support meaningful change. Establishment of a People and Culture working group will

be critical to ensure focus and time.

Future state design and action planning should be done collaboratively with significant

engagement of partners and people with lived experience. A desired future state should include

definitions of the common values and principles that the Regional Program would like to guide

behaviours, beliefs, mind-sets, and interactions. Some examples include:

Culture of transparency;

Data driven decision making;

Willingness to work as one system;

Regional vs HSP responsibility for patients; and,

Authentic engagement of people with lived experience.

An implementation plan should be developed in alignment with best practices in organizational

culture change/revitalization and patient safety evidence and literature, should be SMART

(simple, measureable, attainable, realistic and time-bound) and should include a mix of formal

and informal interventions.

7.3.4 Step 1.4 Detailed Action Planning and Change Management

Finally, once the program has been established, regional objectives and focus areas should be

established based on the Current State Assessment. Detailed action planning needs to occur to

design specific initiatives and assign accountabilities. A robust change, communication, and

engagement plan will be essential to support implementation activities.


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Additional implementation detail and considerations are provided in the Detailed Implementation

Plan.

7.4 Work Stream 2: System Framing

To support consistent high-quality service delivery, positive patient experiences, and positive

outcomes, providers across the region need to approach service delivery using common

approaches and principles. Additionally, given that the proposed roles and responsibilities of the

Regional Program includes decision and enforcement authority, a foundational step will be the

establishment of a decision framework. This framework should incorporate the future state

design principles, support delivery of regional models of care, and incorporate other important

criteria such as health equity. The framework will support decision makers to incorporate and

weigh the right factors when making decisions, ensuring that decisions are made in a common

and agreed upon fashion.


7.4.1 Step 2.1 Define Regional Model and Levels of Care that are both Person-centered and Recovery-oriented

Defining a common regional model of care will ensure that people working within or supporting

inpatient MH&A are drawing on a common framework and methodology to guide their attitudes,

actions, and decisions and will support the development of a positive culture. Person-centered

and recovery oriented models are inclusive, participatory, and actively engage patients, families,

and providers. Therefore, these perspectives should be engaged in the development of

Champlain’s regional model, by using a collaborative co-design approach. There has been

significant work completed to date by the Mental Health Commission of Canada in the

development of recovery-oriented practice guidelines that can be leveraged or adopted as part

of the regional model. Additionally, organizations like Cancer Care Ontario are leading the

implementation of person-centered care in other disease areas, which may provide models that

can be adapted to a MH&A context.


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Regional levels of care can be defined using LOCUS or similar tools (see section 9.4) which support

MH&A utilization management and matching patient need to the right level of care. The Regional

Program will need to clarify which levels should be provided by each Regional Program member,

and the decisions should support effective patient flow, efficient resource utilization, improved

outcomes, and enhanced experience. Both the model of care and the level of care will need to be

flexible and responsive to changes in patient populations and needs as well as system capacity

and resource constraints/pressures, but should always be recovery oriented and centered on the

needs of patients and families.

7.4.2 Step 2.2 Adopt a Regional Population Health and Equity Framework

In addition to common measures of effectiveness and efficiency, the Regional Program needs to

support improved outcomes for the population of the region as well as broader social, economic,

cultural, and linguistic dimensions that will impact patient outcomes and experience. Adoption of

a Regional Population Health and Equity Framework will help ensure that these factors drive

policy and clinical decision making across the region. Like models of care, there has been

significant work completed to date in Ontario and internationally which the Regional Program can

leverage. Once a model has been developed or selected, these factors should be incorporated

into indicators and reporting to ensure sustainability and ongoing focus.

7.4.3 Step 2.3 Develop a Decision-Making Framework to Guide Regional Program Implementation

A final step will be developing a decision making framework for the region that supports

consistent and principle-based decision making across the region. This framework needs to be

owned and supported by the Executive Committee, LHIN, and member hospitals and should be

collaboratively developed with people with lived experience. The framework should align with

and/or support the regional model of care, principles of health equity, value, as well as LHIN and

provincial strategies. Additionally, the framework will need to be flexible since various decision

types exist that will require different approaches and authorities – some will be strategic,

operational, tactical, with different groups or individuals with the authority to make them.


Plan.

7.5 Work Stream 3: Operational Capacity Building

Improved operational capacity in Champlain will allow for increased rates of coordinated

admissions, improved patient outcomes and experience, enhanced access to the most

appropriate care settings, and improved flow and transition through the MH&A system. The

development, endorsement, and broad implementation of regional standards and protocols,


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specifically in the areas of program definition and admission criteria, standards of care,

assessment tools, staffing models, surge and transfers, and data reporting are key to achieving

these outcomes.

Ultimately, increased standardization will improve the use of system resources, allow for better

management of occupancy and surge, and lay clear care pathways to support collaborative care

delivery and planning.


7.5.1 Step 3.1 Develop Regional Standards

The first step in developing regional standards for MH&A services requires Champlain LHIN to

assemble a Regional Standards working group which includes sector specific experts, community

partners, and people with lived experience to provide oversight on standards assessment and

selection. Following the assembly of the group, they will need to create an action plan for regional

standards development, endorsement and implementation including the prioritization of focus

areas. The working group will need to identify existing provincial, national, and international

standards and consult with clinical and administrative subject matter experts, community

organizations, academic partners, and policy makers in order to endorse and/or develop the

regional standards. Provincial standards and leading international standards should be considered

for endorsement and implementation prior to development of custom standards to ensure

effective comparisons across the province and to leading jurisdictions. Sources/Examples of

standards include: HQO, Ontario Case Management, ACTT, and Mental Health Commission of

Canada.


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Regional standards need to be developed where there is a lack of clarity around program

definitions and admission criteria; common tools to admit, assess and discharge patients;

service/pathways that are delivered inconsistently across multiple sites; where there are

significant variations in patient outcomes; and, where role and responsibility clarity is required

across professions and specialty care providers.

Regional standards identified as priorities will support the implementation of other components

of program implementation and are quick wins to improve operations and enhance flow. It is

anticipated that there may be a number of attitudinal and cultural barriers that need to be

overcome to implement consistent standards across the Champlain region.

7.5.2 Step 3.2 Develop and Implement a Regional HHR Plan

To develop a regional health human resources strategy, Champlain LHIN will need to first

assemble a People and Culture working group which should include different sector provider

groups such as psychiatry, allied health, nursing, administrative leadership, LHIN representation,

educational institutions, and people with lived experience. In order to address immediate and

pending resourcing gaps, the working group will need to develop a competency framework, based

on regional standards developed in Step 3.1, to define the skills, competencies, and capacity

required across the Regional Program. In the short-term, the Regional Program should address

the urgent psychiatry coverage gaps across the region (especially in rural areas) by sharing

resources and regional recruitment.

A regional HHR action plan needs to address gaps and achieve HHR standards that include shared-

care models and leverages the use of innovative technologies, identifies clear roles and

responsibilities and scope of practice for providers, allows for interdisciplinary collaboration and

team-based models of care, considers ideal patient to HHR ratios, labour relations and

accountability, as well as regional recruitment of both Anglophone and Francophone care

providers, management and retention strategies.

7.5.3 Step 3.3 Design and Implement System Coordinated Intake

Development of system-wide coordinated intake, triage, and referral processes will require the

Regional Program to leverage newly developed regional standards such as common program

definitions, assessment tools, and referral protocols. The program will need to define the scope

of services to be included in the coordinated intake model and it should be implemented using a

phased approach, beginning with inpatient and then moving to outpatient and community.

A coordinated system requires the establishment of a model and business requirements for intake

and triage processes including the design and implementation of a regional inpatient MH&A Bed

Board that can be shared across intake sites. Coordinated intake would also be supported by the


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implementation of Level of Care Utilization System (LOCUS or similar) across the region and the

development of processes and systems (including communication pathways) for a coordinated

intake and referral system.

These steps will allow for standard referral, assessment, and treatment of patients across the

region ultimately resulting in consistent care being received by patients regardless of where they

enter the system, including getting to the right levels of care.

7.5.4 Step 3.4 Leverage Technology to Support Safe, Effective and Efficient Service Delivery

To increase the use of technology, OTN, and virtual care, the Regional Program needs to establish

a System Capacity and Flow working group to develop an opportunities matrix to compare

available technologies, select technologies based on identified need and identified opportunities

to improve provision of safe, effective and efficient care, and implement based on best practices

in change management.

Technology solutions chosen to be piloted and implemented need to be simple and user friendly

in order to encourage widespread adoption and use. Technologies also need to be accessible to

patients, both in urban and rural communities as well as to both Anglophone and Francophone

patients. Ultimately, implementation of additional technological solutions should support all

recommendations explained above and help to move care delivery from inpatient settings to the

community, better leverage available HHR, support transfers and transition of care, and support

enhanced self-care and management.

7.5.5 Step 3.5 Ensure Capacity for High-needs Specialized Populations and Address Urgent Acute MH&A Capacity Challenges

Champlain region has close to the Ontario average bed per capita, although there is an

opportunity to build and better utilize bed capacity in both acute and specialty settings. Additional

capacity (with the appropriate psychiatry coverage), would allow other sites to help patients

access care closer to home and reduce some of the urgent flow and capacity challenges faced by

The Ottawa Hospital due to surge, transfers and CritiCall assignments. In the near-term, a

regionally coordinated approach is required to support the Ottawa Hospital’s urgent flow and

capacity challenges and support equitable access to acute MH&A services, including crisis

services.

There were many specialized populations that were identified qualitatively as needing more

MH&A capacity in the current system, however, dual diagnosis, neuropsychiatric disorders,

medically complex psychogeriatric patients, and concurrent disorders were the most frequently

identified. These patient populations require a specialized treatment environment, with different


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health human resource models, and contribute to ALC rates across the region. Capacity for these

groups can be created by adding a 13-bed inpatient dual diagnosis unit, increasing capacity of

community outreach and consultation teams, and defining levels of care to ensure that medically

complex MH&A patients have access to the appropriate levels of care to meet their medical and

mental health needs.

There is also a need to ensure access for other specialized populations in Champlain, including

those with eating disorders, concurrent disorders, geriatric populations, children and youth

(including both young children and transitional aged youth), indigenous individuals, and

youth/adults that are/have been involved in the criminal justice system (including forensics).

Access for these populations should be addressed through the development of appropriate

models of care, clear definitions of the level of care required for certain populations, and ensuring

that program exclusion criteria are not resulting in inequitable access for certain populations.

On an ongoing basis, reallocation or addition of bed capacity will require Champlain LHIN to use

regional standards established earlier in work stream 3 to identify where imbalances in equity

exist. Over the next decade, based on current use of inpatient resources there will be a deficit of

beds if no action is taken. However, there are a number of challenges with ALC, patient transitions

into and out of the inpatient system, and capacity and access challenges for outpatient,

community, and primary care to support patients with MH&A problems in the community. Prior

to making any investments to address future bed gaps, these broader system issues need to be

addressed which may decrease or eliminate the need for future investments to support

population growth over the next decade.


Plan.

7.6 Work Stream 4: Broader System Alignment

Broader system alignment and the education of a broad range of stakeholders is key to ensuring

that all perspectives across the continuum of care are considered and that both providers and

patients understand what MH&A services are available in Champlain, and how they may be

accessed. Work stream 4 consists of three components which will ultimately ensure that patients

enter the system and transition through the system in the most appropriate manner improving

patient outcomes and overall experience.

Implementation of a range of MH&A community support services will help to avoid

hospitalization, and improve care for patients ensuring that acute and specialized resources are

being used by higher acuity patients. Increased communication and support across the continuum

of care, specifically with primary care physicians, will improve management of patient flow as well

as the provision of coordinated client- and family-centered care.


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7.6.1 Step 4.1 Enhance Awareness, Understanding, and Relationships Across the MH&A Continuum

To develop awareness and education of inpatient and community programs, a key first step is for

the Regional Program to leverage the inventory of inpatient MH&A services completed as part of

this project and complete an inventory for outpatient and community programs. This will provide

a clear understanding of what services are currently available, what the purpose of each program

is, how patients enter the program, as well as program eligibility. However, most of the impact

will come from increasing relationships and connections along the MH&A continuum. Following

the completion of the inventories, Champlain LHIN needs to assess training and education that is

currently provided and determine what additional training and education is required to improve

the appropriate use of inpatient and community programs or what new technologies or

methodologies could be used to enhance effectiveness. During this phase, it is important to

complete engagement and use co-design principles with a broad group of stakeholders including

care providers and individuals with lived experience to support the design of training and

education resources. When building awareness, Champlain LHIN will need to leverage all potential

channels and tools, including coaching and experiential learning.

7.6.2 Step 4.2 Outpatient and Community Engagement and Capacity Building

To assess and enhance outpatient and community capacity, Champlain LHIN needs to complete

an assessment of all current outpatient and community programming including program

descriptions, admission and discharge criteria, typical patient demographics, level of acuity

served, and program availability. This assessment will allow Champlain LHIN to identify gaps in


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community and outpatient services and determine the most appropriate areas for investment

and allocation of resources in order to ensure that patients are receiving the appropriate level of

care in the most appropriate location. Reliable data is key to accurately assessing current capacity.

After the assessment is complete, outpatient and community services should be integrated into

the Regional Program to support a MH&A system that spans and is accountable across the entire

continuum. Work in this area will need to align with current and upcoming provincial priorities

and strategies related to MH&A, including establishing a Provincial Core Basket of Services. This

work is already part of the Pathways to Better Care program work plan which can be actioned

once the MOH publishes its final Core Basket of Services.

7.6.3 Step 4.3 Primary Care Engagement

To support increasing capacity of, and support for, primary care providers, the Regional Program

and Champlain LHIN need to consult with a broad range of providers to assess where current gaps

in support and provision of care exist, including: training and education, consultations and

coaching on referrals, patient medication reconciliation, access to specialized resources. Clarity

on available inpatient, outpatient and community programs will assist the Regional Program and

Champlain LHIN to determine where gaps exist and how to best address them.

There are a number of systematic barriers to implementation that will need to be addressed

including current physician education and training systems, discomfort working to full scope of

practice, and lack of accountability and oversight levers, clarity of accountability and liability for

patients when working within multi-disciplinary teams. It will also be important to leverage

existing relationships with education partners in the region (University of Ottawa), Community

Health Centers and Family Health Teams to implement identified education and training and

support for primary care providers.


Plan.

7.7 Work Stream 5: Evaluation

Ongoing evaluation will be a key component of the Regional Program to ensure that the program

is having the desired impact and to support continuous improvement at a system, hospital, and

program level. Integrating evaluation into program design and implementation activities from the

outset will facilitate this, and will enable the LHIN and Executive Committee to monitor both

progress on program implementation as well as on system-level outcomes. Results of evaluation

activities will be monitored and communicated at regular intervals and improvements made

towards ongoing implementation management.


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7.7.1 Step 5.1 Evaluation Setup and Planning

To support monitoring and evaluation efforts throughout the implementation, the Reporting and

Performance Working Group will first focus on setting up an evaluation plan that includes both

developmental and formative evaluation approaches. A key first step will be to select and validate

a logic model. Validation includes reviewing the listed activities, output, outcomes and impact,

and ensuring their alignment with the Regional Mental Health Strategy, Champlain LHIN’s IHSP,

and broad direction from the Ministry of Health and Long-Term Care, including overall goals and

priorities. This also includes ensuring that the most appropriate indicators and measures for

activities, outputs, outcomes and impact are included in the logic model. Based on the

strengthened model, the Working Group will then determine the specific Regional Program

components that should be monitored and evaluated directly, such as the reporting and

communication strategy, regional referral, assessment and triage tools, as well as regional

clinician to patient ratios.

To support the overall evaluation, outcome data collection methods will be built into ongoing care

provider activities. In addition, data collection tools and approaches will be designed to monitor

each of the distinct work stream activities. A central regional data repository will be built to

support ongoing tracking, data management, and reporting, as well as develop a reporting

template that will support updates to the Executive and Operation Committees and reporting to

the LHIN on integration activities, outputs, outcomes and impact.

7.7.2 Step 5.2 Conduct Ongoing Monitoring and Evaluation

Following evaluation planning, the LHIN will be able to conduct a variety of monitoring and

evaluation activities throughout the implementation process. This will include adding reporting

and results check-ins to meeting agendas, to ensure results are monitored and support ongoing

implementation management and improvement. Based on the planned evaluation activities, the

Regional Program will conduct formative and developmental evaluations of work stream

activities, tools, and outputs.

Near the end of Year 2, the Regional Program will begin annual outcome-focused evaluations of

work stream outputs and outcomes. These evaluations will focus on determining the extent to


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which implemented improvements have had an effect on access to appropriate service, quality of

service received, patient experience, and support for care providers. Based on the evaluation

plan, available results can support monthly reporting to Operations Committee, as well as

quarterly reporting to the Executive Committee and LHIN.


Plan.


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8. Program Implementation is Complex

To support the effective implementation of the Regional Program, a number of important

considerations have been identified; general themes are described below within the categories

of Attitudes, Conditions and Resources. Additional detail is available in the detail Implementation

Details reference document, where specific considerations for each of the implementation steps

are described.

8.1 Attitudes

For some providers in inpatient, outpatient, and community settings in Champlain LHIN,

implementation of a region wide MH&A program is an idea that elicits feelings of anxiety and

uncertainty. These concerns are mainly rooted in uncertainty about how change is going to impact

programs and organizations, delivery of services, distribution of staff and resources, and the

possibility of relinquishing control or not having a say in how services/programs are provided.

However, many service providers are excited about the possibilities that a regional MH&A system

can provide across the Champlain LHIN, and how care providers might work in innovative ways

together to build a more coordinated and efficient system that provides superior care and is well

informed by the voices of patients and their families, as well as by resources delivering the

services.

In building a Regional Program, some of the considerations for shifting negative attitudes and

leveraging positive attitudes include:

Establishing a larger vision for what a regional MH&A system looks like and fostering an

underlying understanding that true transformation is required in alignment with guiding

principles

Developing a culture of accountability for achieving system and patient objectives and an

expectation of continuous improvement

Creating an understanding that no one organization in Champlain region has the capacity

to serve all patients and ensure the best possible outcomes, and therefore each one has

an obligation to patients and to other organizations, including outpatient and community,

to work collaboratively to pursue a coordinated MH&A system

Communications and change management practices will need to address any concerns directly

through open and transparent messaging:

Establishing ownership and engagement of Regional Program members can be facilitated

through providing regular and meaningful opportunities for consultation, engagement

and consensus building, including leveraging of co-design when possible, and aligning

accountability agreements.


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Ensure alignment with broader change management and communication efforts

Build momentum and excitement as culture revitalization takes time to set up and make

sustainable

Identify change champions to own the overall change effort, guide change, ensure

engagement and communicate

Communicate processes for decision-making and evaluation consistently using change

management principles

8.2 Conditions

Promoting a culture of collaboration and coordination will require that the LHIN carefully attend

to and manage aspects of the environment that are within its control and use best practice change

management strategies to build and maintain implementation momentum. As such, the following

conditions will need to be created:

Defined membership and roles and responsibilities at each governance level including the

Executive Committee, Operations Committee, Regional Program Working Groups, MH&A

Hospital Programs, and Regional Program Staff.

Clarity on the governance and accountability relationships between member

organizations, their individual governance structures and the Regional Program structure.

Simple and focused Governance Terms of Reference developed via co-design by those

who are expected to follow them.

Reasonable and regular meeting schedules where there is sufficient face time to continue

momentum, but not so frequently that the content of the meetings has not evolved and

progress can occur.

The Regional Program working group should include people with lived experience;

representation from all Regional Program partners and should be a mix of

clinical/administrative at different levels within organizations; the LHIN; representatives

from the broader MH&A continuum that inpatient providers need to collaborate with to

support patient flow and transitions.

Specific initiatives should be SMART (Simple, Measureable, Attainable, Realistic and Time-

bound) and aligned to best practices in change management.

Various decision approaches and authorities are required to categorize, prioritize, and act

on decisions – some will be strategic, operational, and tactical.

Assessment tools need to be simple, standardized, and adaptable in order to be used in

all areas of MH&A services, including both acute and specialty.

When building awareness of available MH&A programs and services, all potential

channels should be considered. These could include the hospital and community website,

Communication and messaging should always be focused on Regional Program

Governance as a means to drive better outcomes, experiences and value for patients


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periodic LHIN, CHC, or FHT communications, and word of mouth through selected

champions.

8.3 Resources

Implementing the Regional Program will require support from a number of different sources

throughout the implementation plan. Some resources will be required on an ongoing basis to

launch, promote, and sustain implementation, while others will be needed only for specific

activities over a limited period of time.

Access to program level, population health (and occasional Personal Health Information)

data will be required to support evidence-based decision making, system level reporting

and flow management. It is expected that monitoring and evaluation will require support

from a number of different Champlain LHIN resources.

Communications support will be required to ensure appropriate messaging is consistent

and balanced.

Specific initiatives may require funding and some sites may not have the resources to

implement activities requiring investments in people, processes and infrastructure.

Leverage existing relationships with education partners in the region as well as resources

at Community Health Centers and Family Health Teams.

The proposed Regional Administrative Lead and Regional Medical Lead should be funded

positions with protected time to provide leadership to the operational implementation of

the Regional Program.

Regional Program corporate infrastructure and resources includes program staff

(administrative support, business analytics, project management) and budget to support

committees, working groups and initiative implementation.

Adding new or redistributing existing MH&A inpatient capacity will require funding and

investments.


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9. Appendix

9.1 Detailed Implementation Plan Steps

Work Stream # 1 – Regional Program Set-Up & Initiation

Step 1.1 Establish Regional Governance Structure 1.2 Establish Program Operating Principles and Mechanisms

Implementation 1. Establish a regional inpatient MH&A governance structure (see Appendix 9.2) within the LHIN to

drive collaboration and accountability across all inpatient MH&A programs that includes an Executive Committee, Operations Committee, working groups, and delivery entities.

2. Select a host organization for the Regional Inpatient MH&A Program (Regional Program) and update applicable accountability agreements with partner hospitals.

3. Define a competency matrix that outlines required perspectives, knowledge, experience, and behavioural competencies for each level of governance.

4. Recruit committee membership based on required competency matrix and ensuring participation of broad Regional Program partners (specialty and acute) and priority population perspectives (example pediatric, francophone) and select a chair or co-chairs for the Executive Committee.

5. Recruit/appoint a Regional Administrative Lead and a Regional Medical Lead for the program and build the Regional Program corporate infrastructure and resources within a host organization (Regional Program Office).

1. Establish business and operating principles for each level of governance of the Regional Program.

2. Establish roles and responsibilities for each level of the governance structure. 3. Clarify and codify decision-making and enforcement authority and processes for each level

of the governance structure, including mechanisms (e.g., escalation protocols) to hold partners accountable for following the leadership and direction of the Regional Program and an appeals process for decisions.

4. Create data sharing agreements for Regional Program partners to facilitate information sharing between providers and with Regional Program leadership and staff.

5. Establish reporting and communication protocols including meeting schedules, meeting roles, communication objectives, reporting measures, metrics, and reporting templates.

Considerations

Attitudes Some providers and hospitals may be apprehensive about a Regional Program guiding resource allocation and having the authority to direct operational program and delivery decisions. Regional Program ownership and engagement by providers and partner organizations can be facilitated through providing regular and meaningful opportunities for consultation, engagement and consensus

building, including leveraging of co-design when possible, and aligning accountability agreements. Communication and messaging should always be focused on regional governance as a means to drive better outcomes, experiences and value for patients. The spirit of the Regional Program Guiding

Principles developed in conjunction with the Champlain Inpatient MH&A Service Capacity Plan Steering Committee, need to be embraced by leadership and communicated across inpatient, outpatient and community mental health.

Ensure alignment with broader change management and communication efforts.

Conditions Membership at each governance level should include:

The Executive Committee should include: Representation of people with lived experience (both patients and families) to bring

relevant perspectives and ensure person centered decision making; Regional Program member CEOs (or delegates with decision making authority) to

support strategy development and decision making Regional Administrative Lead and Regional Medical Lead (psychiatrist) to support

program leadership and effective communication between the executive committee and the operations committee.

The Operations Committee should include:

Terms of Reference should be simple, focused and co-designed by those who are expected to follow them.

Roles of responsibilities at each governance level should include: Executive Committee: setting strategy and priorities; funding/resource allocation

advice; integrated performance accountability; partner engagement; escalation point for the Operations Committee, and consideration of how MH&A programs interact with non-mental health components of health service providers

Operations Committee: operational policy and procedure development; regional standards development, implementation and enforcement; service coordination and collaboration; performance analysis and review; oversight and direction to the


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Regional Administrative Lead and Regional Medical Lead to support communication with the Executive Committee and committee leadership

Other members should include administrative leadership (manager or director level resources) from Regional Program member’s MH&A programs.

The working groups should include: Subject matter experts Regional Program staff System stakeholders as appropriate. People with lived experience should be included in all working groups or included as a

separate advisory working group. The MH&A Hospital Programs should include:

Inpatient MH&A program leadership from each of the Regional Program members The Regional Program Staff should include:

Staff members who work at the Regional Program Office within the host organization infrastructure but are accountable to the Regional Program through the Regional Administrative Lead and Regional Medical Lead.

Within each member organization’s inpatient MH&A program(s), staffing levels and oversight responsibility should remain with the hospital with the programs (including staff and clinicians) following the leadership and direction of the Regional Program.

Throughout planning and implementation, there will be a need to consider and clarify how the different system governance, oversight and accountability structures (Regional Program Governance, Hospital Governance, LHIN oversight, Ministry accountabilities) align to ensure clear accountabilities, division of responsibilities and avoid dual governance. A Regional Program, based on collaborative governance, should establish agreed upon principals, standards and processes for patient care and flow as well as outcome and system performance measurement. There needs to be clear escalation protocols in place to ensure that members are held accountable and responsible for adhering to the agreed upon principles. Reporting roles (e.g., to the LHIN) should be clarified and re-enforced with improved accountability agreements and enhanced performance reporting.

Consider making Regional Program authority and member participation and operational alignment mandatory via SAAs

The host organization for the Regional Program Office (and Regional Administrative Lead), Regional Medical Lead and Executive Committee Chair will need to be selected. Factors that should be considered as part of this decision include:

Balance of influence among Regional Program leadership positions between specialty and acute MH&A provers.

Existing corporate infrastructure for regional capacity development that could be leveraged

Clinical and research leadership in MH&A services Organizational relationships to psychiatry, primary care, and community providers

There are a number of existing regional planning tables and committees that will need to be incorporated or connected to the Regional Program:

The Inter-Hospital Committee could become the Regional Operations Committee by becoming more formalized and reviewing and revising membership (as appropriate)

Pathways to Better Care program could be expanded to become the Regional Program Office by adding additional resources, capabilities and adjusting the program’s mandate and governance model.

Regional Program working groups; escalation point for the Regional Program partners

Regional Program working groups: engagement and information gathering; subject matter expertise; knowledge sharing and best practices dissemination

Member MH&A inpatient programs: inpatient MH&A program management and delivery; patient experience and outcomes; knowledge sharing and best practices dissemination; management and oversight of staff.

Regional Program staff: provide administrative support, business analytics, project management and communication support to the Regional Program Executive and Operations Committees, working groups and to support initiative implementation; knowledge sharing and best practices dissemination; centralized management of bed board reflecting all inpatient beds

Regional Administrative Lead and Regional Medical Lead should act as the co-leads of the Operations Committee to support effective patient flow (according to agreed-upon principles and decision criteria).

Ensure that perspectives and representation of non-inpatient MH&A services (community MH&A, outpatient, and referring partner hospitals) are incorporated.

Keep meeting schedules reasonable, where there is sufficient face time to continue momentum, but not so frequently that the content of the meetings has not evolved and progress can occur (likely quarterly or three times per year for Executive Committee and monthly for Operations Committee)

Reporting should be transparent across the Regional Program and aligned with expected outcomes and measures of success


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Provider and lived experience forums such as the Addictions and Mental Health Network of Champlain, Mental Health Community Support Services Table, and the Champlain Addictions Coordinating Body should be connected to the Regional Program in an advisory capacity.

LHIN Patient and Family Advisory Committees within each sub-region should be connected in an advisory capacity.

Children and youth inpatient MH&A services are offered by two providers (CHEO and The Royal) which already operate as a regional partnership. Additionally, the funders and system partners differ in pediatric and adult MH&A systems. During the establishment of the Regional Program, further consideration should be given to whether the Regional Program should include both the pediatric and adult mental health systems. Irrespective of the decision, there needs to be connections and co-ordination to support transitional aged youth as they move from the pediatric to the adult system.

Note, as work is completed to address the capacity of outpatient MH&A and community MH&A services the governance structure should evolve and expand to include the MH&A continuum as a regional MH&A system.

Resources The proposed Regional Administrative Lead and Regional Medical Lead should be funded positions with protected time to provide leadership to the operational implementation of the Regional Program. The set-up of the Regional Program Office (with the corporate infrastructure and resources) including program staff (project management, communications, administrative support, business analytics) and

budget to support committees, working groups and initiative implementation. Access to program level, population health (and occasional Personal Health Information) data will be required to support evidence-based decision making, system level reporting and flow management.


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Work Stream # 1 – Regional Program Set-Up & Initiation

Step 1.3 Transform Levels of System Collaboration, Cooperation and Communication 1.4 Detailed Action Planning and Change Management

Implementation 1. Leverage the Regional People and Culture working group to complete the regional culture

development work, beginning with a Current State Assessment of culture, collaboration, communication and collaboration.

2. Design desired future state vision and priorities for culture across the Regional Program and partner organization including defining the values, behaviours and attitudes that the Regional Program wants to demonstrate. The future state should build on positive aspects of the current state.

3. Conduct a gap analysis between the current and future state. 4. Action planning and implementation to re-enforce areas of strength and address high priority

gaps with specific initiatives, and assign accountabilities to working group members, Regional Program members, and the Regional Program Office.

5. Evaluate the and monitor cultural evolution and impact on patients and family experience, staff and provider experience and clinical outcomes and system utilization.

1. Confirm Regional Program objectives and focus areas based on the Current State Assessment. 2. Conduct detailed action planning to address focus areas with specific initiatives and assign

accountabilities to working groups, Regional Program Office, and Regional Program members. 3. Develop and implement a robust change, communications and engagement plan to support

Regional Program implementation and change. Build communications capacity into the Regional Program Office Conduct stakeholder analysis to focus on values and incentives for each

stakeholder segment, and assess impact and influence Develop key messages for each stakeholder segment, leveraging the output of the

stakeholder analysis tool Develop a formal communications plan and schedule

4. Implement the change, communications and engagement plan, including acknowledging and celebrating continued success, through communications and meetings/forums, for all aspects of the implementation.

5. Evaluate effectiveness of communications plan on an ongoing basis and incorporate feedback.

Considerations

Attitudes Culture revitalization takes time to set up, build momentum and become sustainable Culture is often viewed as being important but not urgent; although it is a foundational enabler of

a high performing system Some of the considerations for shifting attitudes include:

Grounding all messages to improve outcomes, experiences and value. Successfully developing a shared understanding of roles and responsibilities across

the spectrum of inpatient MH&A services and across the MH&A continuum more broadly.

Fostering an underlying understanding that true transformation of culture and behaviours is required.

Change champions including demonstrating the desired behaviours by Regional Program leadership and member executives

Creating an understanding that no one provider or organization has the capacity, skills, and knowledge to serve all patients and ensure the best possible outcomes, and therefore each one has an obligation to patients and to other organizations in the system to work collaboratively.

Ensure broad stakeholder participation in all aspects of change management. Identify change champions to own the overall change effort, guide change, ensure

engagement and communicate Identify change leads to enable implementation of change, develop trust, coach

staff and identify risks (e.g. align with project structure) Change leads should include a combination of:

LHIN leadership and staff who engage with Regional Program partners Senior administrative and clinical leaders who can act as champions and support

communication activities People in the front lines who are able to positively influence peers

Conditions The Regional People and Culture team should include representation from all Regional Program

partners and should be a mix of clinical/administrative personnel at different levels within member organizations; the LHIN; representatives from the broader MH&A continuum.

The Current State Assessment should include engagement with people with lived experience (patients and families), defining the culture(s) across the region, identifying the strengths and opportunities for improvement and just include best practice scan in culture transformation. Multiple dimensions of communication, collaboration, cooperation need to be considered:

Between providers and patients Within inpatient MH&A programs and hospitals

Specific initiatives should be SMART (simple, measureable, attainable, realistic and time-bound) and aligned to best practices in change management.

A detailed communications strategy should include: Strategies for each stakeholder segment based on values, motivations, incentives,

and power/influence Identify overall key messages related to program implementation and culture

revitalization, such as: Rational and benefits, How it is done,


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Between inpatient MH&A programs and hospitals Between inpatient MH&A programs and broader system partners (outpatient and

community providers, emergency department, first responders) A desired future state should include definition of the common values and principles that the

Regional Program would like to guide behaviours, beliefs, mind-sets, and interactions. Some examples include:

Culture or transparency Data driven decision making Willingness to work as one system Regional vs HSP responsibility for patients Authentic engagement of people with lived experience

An implementation plan should be developed in alignment with best practices in organizational culture change/revitalization evidence and literature (Pronovost et al. 2006, Gary Yukl, 2013, Jon Katzenbach, 2012) Specific initiatives should be SMART (simple, measureable, attainable, realistic and time-bound) and should include a mix of formal and informal interventions.

Peer to peer learning and collaboration should be supported by leveraging peer networks to advance conversations and actions will support better success

The application of a change management framework that is focused on “people” dynamics will be useful to implement this step (example framework included in section 9.3).

Define the vision collaboratively, engaging various stakeholder segments Identification of change champions and leaders who are able to model the future

state, promote awareness of the change, and support adoption Deliver innovative actions and initiatives and celebrate quick wins Manage it like a project with accountabilities, milestones and deliverables Evaluate and plan for sustainability to make the future culture the new “norm”

Measurement of monitoring of cultural evolution should include: Development of key performance indicators Establishment and measurement of critical behaviours Establishment of milestones over the implementation Staff, provider, patient, family and partner survey results

Urgency and importance Available tools and resources

Communication vehicles and frequency/timing for executing specific communication activities

Specific roles and responsibilities related to communications Tactics that support two-way communication to gather feedback, input and

information from stakeholder groups. Includes metrics on effectiveness

As implementation progresses, a consistent process of “lessons learned” should be developed and undertaken so that there is continuous improvement in processes and outcomes

Resources Regional Program staff can support ongoing project management but working group will require participation from Regional Program members. Communications support will be required to ensure appropriate messaging is consistent and balanced Specific initiatives may require funding


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Work Stream # 2 – System Framing

2.1 Define Regional Model and Levels of Care that are both Client- and Family-Centered and Recovery-

Oriented

2.2 Adopt a Regional Population Health and Equity Framework

Implementation 1. Establish Regional Standards working group that includes clinical and administrative

perspectives as well as people with lived experience. 2. Conduct a literature and best practices review of models of care for MH&A as well as other

disease groups that are recovery-focused and/or client- and family-centered. For example, the Mental Health Commission of Canada Recovery Guidelines has a chapter on attitudes and values which discusses diversity and client- and family-centered care. The review should also include an assessment of how different levels of care are organized across types of different service providers (specialized tertiary, acute, community).

3. Leverage the Current State Assessment report and literature and best practices scan as inputs to inform the development of principles for a regional Model of Care and regional approach to Levels of Care through co-design with providers, patients and families.

4. Create an action plan to support the implementation of the regional model across Champlain inpatient MH&A programs including ongoing engagement, education, training and coaching for providers and partners.

5. Measure and monitor implementation progress through the use of evidence-based tools and indicators.

1. The Regional Standards working group should conduct a literature and best practices review of population health and equity frameworks that could be leveraged for this work.

2. The working group should develop/recommend a framework for regional endorsement and implementation.

3. Reporting and Performance working group should establish/agree on common measures, indicators and reporting schedule for MH&A population health and health equity.

4. Monitor and evaluate the impact of the framework application on population health and health equity indicators.

Considerations

Attitudes Providers have long histories of delivering service in unique ways, some of which are aligned with

leading practices in person-centred care and/or recovery orientation, some of which are not; there are varying levels of awareness and alignment.

Common definitions of these models are recent, and have not been fully adopted across the province, although many organizations have interpreted and applied an organization-specific approach.

Some partner agencies in the community may operate under different philosophies of care intentionally, which may cause challenges in an integrated system.

Partners understand the value of population health and equity based planning, which aligns well with current LHIN direction on planning at the sub-regional level

Planning at this level requires new ways of using data and resources, which is uncomfortable for some individuals.

Conditions The Mental Health Commission of Canada’s Recovery-Oriented Practice Guidelines should be

incorporated into design and be endorsed by the Regional Program. Regional Levels of Care can be defined using LOCUS or similar tools (see section 9.4) which support

MH&A utilization management and matching patient need to the right level of care. Defining Regional Levels of Care will need to include clarifying which levels should be provided by each Regional Program member and should support effective patient flow, resource utilization and improved outcomes and enhanced experience.

The Model and Levels of Care will need to be flexible and responsive to changes in patient populations and needs as well as system capacity and resource constraints/pressures, but should always be recovery oriented and centred on the needs of patients and families.

Consider including a requirement for adoption of guidelines in the Terms of Reference for the Regional Program.

Examples of evidence-based tools include:

Existing tools can be leveraged: Health Equity Impact Assessment (HEIA) tool Health Equity Framework published by HQO LHIN tools Partner organizations’ tools

Participation of community partners to achieve a population health approach


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Recovery Attitudes Questionnaire (RAQ-16) Recovery Knowledge Inventory Opening Minds Scale for Health Care Providers (OMS-HC)

Patient Reported Experience Measures (PREMs) and Patient Reported Outcome Measures (PROMs) should be incorporated in the monitoring approach

Resources Participation in working groups Implementation support Support for internal experts and/or possible third-party service provider to support

development/facilitation of specific operational principles

Participation in working groups Implementation support


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Work Stream # 2 – System Framing

2.3 Develop a Decision-Making Framework to guide Regional Program Implementation

Implementation 1. The executive committee should agree upon a decision making framework and process to guide the Operations

Committee, working groups, Regional Administrative and Medical Leads, Regional Program staff, and individual inpatient MH&A programs on how to balance and make tradeoffs.

2. Engage providers, partners and people with lived experience for input and to support ownership and commitment 3. Pilot the decision framework and process 4. Implement the decision making framework and process across all levels of governance and integrate with reporting

and accountability mechanisms.

Considerations

Attitudes The LHIN has been operating in a model where each organization has its own governance and decision-making processes

and authorities; this new integrated program will require openness to negotiation to move forward on the transformation at all levels.

The Regional Program may make decisions that are difficult or sensitive for individual programs (i.e., shifting resources, shifting programs, etc.), a principle-based framework will support implementation and enforcement of difficult decisions.

Conditions Various decision types exist that will require different approaches and authorities, some will be strategic, operational, or

tactical. It will be useful to list and categorize various decisions that need to be made, to include in the framework with guidelines on how to proceed for each type; for example, some decisions are simple and low risk, can be made by a program level manager. Others are strategic and require shifting of resources, will require Executive Committee approvals.

The framework should include/align with/support: Triple Aim: population health, experience, cost Regional model of care Health equity Patient and family-centred care Recovery-oriented practice Value for money LHIN IHSP and mental Health Strategy Provincial direction and MH&A strategies

Resources Participation in committee LHIN involvement in assigning authorities


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Work Stream # 3 - Operational Capacity Building

3.1 Develop Regional Standards 3.2 Develop and Implement a Regional Health Human Resources Plan

Implementation 1. Assemble Regional Standards working group including sector specific experts, community

partners, and patients to provide oversight on standard assessment, development and selection.

2. Create an action plan for standards development, endorsement and implementation including prioritization of focus areas (* indicates priority):

a. Clear definitions and admission criteria for different levels of care and services* b. Common admission, assessment and discharge tools* c. Standards of care* d. Defined care pathways that span the continuum and include transitions e. Common inpatient evaluation framework f. Staffing models* g. Patient experience measures h. Documentation protocol and shared care maps i. Definition and interpretation of circle of care j. Data reporting*

3. For each standard conduct a review of existing regional/provincial/international standards; consult with clinical and administrative subject matter experts, community organizations, academic partners and policy makers; and endorse or develop a standard for the Regional Program

4. Pilot test prioritized standards in the field 5. Support implementation including dissemination of standards via professional practice

groups and leveraging best practices in implementation science and change management.

1. Assemble a People and Culture working group including different provider groups (psychiatry, allied health, nursing), administrative leadership, LHIN representation, and educational institutions.

2. Address urgent psychiatry coverage gaps across the region by sharing resources and regional recruitment.

3. Develop competency framework (based on HHR standards developed in step 3.1 based on existing regional practices and regional best practices, as well as consultation with clinician and administrative experts) to define the skills, competencies and capacity required across the Regional Program and assess gaps. The Mental Health Commission of Canada Recovery Guidelines offer details on required competencies including knowledge, skills, and attitudes.

4. Develop a regional action plan to address gaps and achieve HHR standards that includes shared-care models and leverages technology.

5. Implement through a phased approach that includes pilot testing at selected sites. 6. Measure success and impact and implement continuous improvement.

Considerations

Attitudes There may be a number of attitudinal and cultural barriers that need to be overcome to

implement consistent standards across the region: Awareness and knowledge of what needs to change and why Motivation for change may be lacking if there is no burning platform or incentives Misalignment with professional or personal beliefs in terms the potential value,

evidence-base, professional autonomy Strong clinical and administrative leadership alignment will be essential to facilitate ownership

Current professional education and training systems as delivered may re-enforce the status quo. There may be disinterest or resistance from provider groups to expand/share/lose responsibilities. There may be disinterest and resistance from providers to work across organizations to provide

regional coverage. Engage the education sector (including medical schools) and discipline specific associations in

addressing HHR aspects in order to receive a neutral and unbiased opinion.

Conditions Regional standards identified as priorities will support the implementation of other

components of program implementation and are quick wins to improve operations and enhance flow.

Provincial standards and leading international standards should be considered for endorsement and implementation prior to development of custom standards to ensure effective comparisons across the province and to leading jurisdictions. Examples of standards include:

HQO Ontario Case Management ACTT Mental Health Commission of Canada

The Regional HHR plan must include: Clear roles and responsibilities and scope of practice for providers Interdisciplinary collaboration and team-based models of care Patient to HHR ratios Labour relations and accountability considerations Allocation model across inpatient sites Regional recruitment of both English and Francophone care providers, management and

retention strategies (health and nursing) Address institutional/corporate barriers (e.g., medico liability) to support clinicians to work

to full scope of practice


FINAL REPORT


Standards should: Support standard delivery of care across the continuum Enhance the recovery model Enhance the importance of provider-patient relationship in terms of preferred

language (English versus Francophone) Support the reduction of stigma Reflect the work of the Mental Health Commission of Canada

Implementation of standards should include: Addressing barriers to change Developing a plan to address barriers through education, outreach, processes and

systems, feedback mechanisms and reporting systems, opinion leaders and champions, education, coaching

Defining a common standard for a circle of care will be impacted by the current interpretation of existing privacy legislation. The regional standard should align with the current legislation and providers should be informed on the implications for conversations and information sharing with a client’s circle of care.

Supporting technology and information sharing, including the use of online resources Proposed Regional Administrative and Medical Lead to be responsible for enforcement Labour relations/union environments must be considered and assessed before any changes to job

requirements or classifications are suggested

Resources Participation in the Regional Standards Working Group Some sites may not have the resources to implement standards and may require investments in

people, processes and infrastructure

Physician and staff reimbursement models are different across the region. Decreasing medico liability may require hospitals to assume more risk.


FINAL REPORT



3.3 Design and Implement System Coordinated Intake 3.4 Leverage Technology to Support Safe, Effective and Efficient Service Delivery

Implementation 1. Prerequisite is regional standards for: level of care and service definitions, admission

criteria and assessment tools. 2. Establish a fair and equitable Mental Health CritiCall assignment schedule/model that

shares coverage among all schedule 1 hospitals and supports patients to access care as close to home as possible and in their preferred language.

3. Define scope of services to be included in the coordinated intake model using a phased approach beginning with inpatient and then moving to outpatient and community.

4. Establish model and business requirements for intake and triage processes. 5. Establish a Regional Inpatient MH&A Bed Board that can be shared across intake sites. 6. Implement a Level of Care Utilization System (LOCUS or similar) across the region, using a

tiered approach. 7. Develop processes and systems (including communication pathways) for coordinated

intake and referral system. 8. Support implementation, leveraging best practices in change management including

education and support. 9. Monitor and evaluate impact on occupancy, ALC and patient and incorporate lessons

learned.

1. Develop an opportunities matrix to compare available technologies a. Psychiatrist participation in LHIN eConsult system b. Expanded use of OTN consultation and education c. Leverage Internet-based Cognitive Behaviour Therapy a. Secure patient portal allowing for patients to access visit history, lab results, clinical

reports, and allergies. Patients can also request medication renewals and send notices to their clinicians.

2. With System Capacity and Flow working group, using the Regional Program decision making framework, select technologies based on identified need and identified opportunities to improve provision of care

3. Pilot test selected programs and services 4. Support implementation with training and change management 5. Monitor outcomes and efficiencies

Considerations

Attitudes Concern from professions needing to retrain on processes and procedures, including

assessment tools and frameworks. Implementation will require roles and responsibilities clarity and strong communication and

working relationships between organizations. Culture revitalization and philosophy of helpfulness will support patient flow based on criteria.

Professionals uncomfortable with the use of technology will require adjustment and additional training.

Not all patients are open to or comfortable with receiving treatment via technological alternatives.

Conditions Assessment tools need to be simple, standardized and adaptable in order to be used in all areas

of MH&A services, both acute and specialty. The following model for implementation:

Recommend a decentralized, no-wrong door model Common Level of Care Utilization System (LOCUS or similar) to help determine the

most appropriate place for patients to access care based on their needs Consistent referral form and criteria regardless of referral or entry point Vacancy information, “bed board” in Champlain region as well as assessment of

CritiCall assignments Oversight of process and monitoring of outcomes, including regular reporting of

system performance

Technology needs to be simple and user friendly Technology needs to be accessible to patients, both in urban and rural communities Technology should:

Move care delivery from inpatient setting to the community Leverage available HHR, especially specialty care providers Support transfers and transitions of care Support self-care and management as well as group care

Enhanced awareness, understanding and relationships across the MH&A continuum can be enhanced through common electronic records, or enhance used of Integrated Assessment Records.

Resources System Capacity and Flow working group participation. Updating the CritiCall agreement will require adequate psychiatry coverage at all Schedule 1

hospitals. Focused project management and implementation support for the intake model

implementation including a Level of Care Utilization System (LOCUS or similar) and a Regional Bed Board.

Shared IT and communication platform would be a significant enabler.

Need to include first responders, including paramedics and police, to ensure information sharing across the continuum.

System Capacity and Flow working group to provide guidance and oversight. Investments will be required upfront during the acquisition and implementation of technology

solutions.


FINAL REPORT



3.5 Ensure Capacity for High-needs Specialized Populations and Address Urgent Acute MH&A Capacity Challenges

Implementation 1. Based on the established decision making framework and the Regional Model and Levels of Care, assess

the opportunity to add additional acute inpatient MH&A beds to Champlain, the establishment of a specialized dual diagnosis unit, and opportunities to ensure appropriate care environments for medically complex psychogeriatric and neuropsychiatric patients, and the opportunity to expand the Royal’s CDU to a 7-day a week inpatient program for concurrent disorders.

2. Ensure that regional standards development include mapping the gaps created by inclusion and exclusion criteria and minimize gaps for specialized populations (e.g., addictions and concurrent disorders).

3. Build the business case for expansion of The Royal’s Geriatric Outreach Program. Regional Dual Diagnosis Consultation Team and FACT-DD to support acute and community hospitals, and housing providers with the care of psychogeriatric and dual diagnosis patients.

4. Reassess capacity needs in 3-years, after the implementation of the Regional Program.

Considerations

Attitudes Resistance to adding beds as there is the concern that they would be immediately filled, and that ALC will

immediately be a challenge due to lack of community/supportive housing supports. Debate among inpatient hospitals as to what location is most suitable for additional bed capacity and which

hospitals should be providing what levels of care.

Conditions Data to determine current use as well as need for inpatient dual diagnosis capacity and medically complex

geriatric patients (including current ALC populations) needs to confirmed. There are a number of challenges with patient transitions into and out of the inpatient system as well as

capacity and access challenges for outpatient, community, and primary care to support patients with MH&A problems in the community resulting in increased use of inpatient resources. Prior to making any investments to address future gaps, these broader system issues should be addressed.

Development of regional standards, specifically around standard program definitions and admission/discharge criteria will be needed to determine which specialty populations require different capacity.

The development and implementation of a regional HHR strategy is key as the persistence of HHR constraints will not allow for increased capacity in inpatient units and the community for specialized populations including those with dual diagnosis, geriatrics, or neuropsychiatric disorders.

Resources Addressing these gaps would require significant investment based on the expected adult bed deficit over the

next 10 years, unless service models change.


FINAL REPORT


Work Stream #4 –Broader System Alignment

4.1 Enhance Awareness, Understanding, and Relationships Across the MH&A Continuum 4.2 Outpatient and Community Engagement and Capacity Building

Implementation 1. Update and/or complete inventories for inpatient, outpatient and community programs

and services including Healthline, DATIS, Bed Board, ConnexOntario, and CritiCall. 2. Assess training and education required to improve the appropriate referral to and use of

inpatient, outpatient and community programs. Include engagement and co-design with patients and families, care providers, and individuals with lived experience in the design of training and education materials to ensure perspectives across the continuum of care are considered.

3. Optimize use of telemedicine/technology for training, education and service knowledge sharing.

4. Increase opportunities for training, relationship building, and support avenues for service knowledge sharing across the MH&A continuum.

5. Implement training and education with referring partners in the inpatient, outpatient and community setting (as needed) to build awareness of program availability, program purpose, admission criteria, as well as available capacity including current wait time.

6. Evaluate effectiveness on ongoing basis.

1. Engage with community to complete a Current State Assessment of all outpatient and community MH&A programs including:

Program descriptions and standards Admission and discharge criteria Patient demographics Volumes and level of acuity served Program availability and wait times Barriers to patient flow and integration with inpatient services

2. Identify gaps in current outpatient and community programming and identify opportunities better collaborate along the MH&A continuum to improve patient outcomes, experience and efficient use of system resources.

3. Develop decision making framework to guide investment in outpatient and community programming and allocation of resources in order to ensure that patients are receiving the appropriate level of care in the most appropriate location.

4. Implement new programs and services through a phased approach including pilot testing. 5. Plan for eventual integration of outpatient and community programming with inpatient MH&A

services including referral and assessment tools.

Considerations

Attitudes Ensure broad stakeholder participation in all aspects of implementation training and education

to ensure system wide understanding of inpatient and community programming. Resistance to changing / extending service offerings in the community and outpatient sites.

Conditions Need to ensure that inventories are up to date and accessible to providers when making

referral / discharge decisions. Leverage work completed to date by lead agencies mapping of MCYS Children and Youth

services and Pathways to Better Care program community capacity building efforts. Peer to peer leaning as well as existing partnerships with education institutions should be

leveraged to advance learning and awareness. When building awareness, all potential channels should be considered. These could include the

hospital and community website, periodic LHIN, CHC, or FHT communications, and word of mouth through selected champions.

Enhanced awareness, understanding and relationships across the MH&A continuum can be enhanced through common electronic records, or enhance used of Integrated Assessment Records.

The Regional Program Office/Pathways to Better Care program should complete an assessment of outpatient and community capacity assessment. Note that developing community and outpatient MH&A capacity is currently within the work plan of the Pathways to Better Care program and there may be an opportunity to leverage and build on the work underway. Resourcing this project should consider internal expert resources, engagement of community providers in project oversight and the need to partner with a third party vendor in order to complete the assessment of available outpatient and community services and the patient groups currently using these services and programs

Need to have reliable data available in order to identify capacity of system and current use of programs and services. Data collection and quality should be monitored as key risks.

Work will need to align with Provincial Core Basket of Services as part of the Mental Health and Addictions Strategy.

Resources All inpatient sites and community providers may not have capacity to complete program

inventories and assignment of a Lead may be required to complete individual inventories. New training and education materials / programs may require investment. Engagement and co-design with broad group of stakeholders is required.

Introduction of new programs will require investment in people, processes and infrastructure. Oversight will need to be established including partners from outpatient and community providers to

provide guidance on the assessment. Additional resources may need to be provided to the Regional Program Office/Pathways to Better Care

program, other working group or internal resource or a third-party vendor to complete the assessment.


FINAL REPORT


Work Stream #4 –Broader System Alignment

4.3 Primary Care Engagement

Implementation 1. Consult with primary care providers to assess where current gaps in support and provision

of care exist including: Training and education Consultations and coaching Access to specialized resources to support MH&A delivery in primary care

settings Reconciliation of patient medications Interdisciplinary and team based models of care Sharing and transfer of patient information Common definitions of programs and an understanding of inpatient,

outpatient and community program availability 2. Develop framework to assess and rank gaps and identify initiatives to target and reduce

gaps, levering existing evidence-based tool kits and specialty outreach programs from across the region, province and leading jurisdictions (examples include The Royal’s Regional Dual Diagnosis Consultation Team, The Royal’s Geriatric Outreach Team, British Columbia’s Bounce Back Program and Antidepressant Skills Workbook, CAMH’s Partners Project).

3. Implement initiatives with a phased approach including pilot tests. 4. Monitor impact on an ongoing basis and implement continuous improvement.

Considerations

Attitudes Some primary care providers have identified discomfort and concern in regards to treating

MH&A patients as they lack required specialty knowledge. Important to consider if other barriers, beyond specialty knowledge, is impacting connections to primary care

Current education and training systems may re-enforce silos and current referral patterns from primary care to specialty services and psychiatry instead of community MH&A program and supports. Changing these behaviours and flow patterns will require significant educational and culture revitalization efforts.

There may be disinterest or resistance from primary care providers to expand responsibilities with respect to patients with MH&A challenges.

Conditions Engage primary care providers as well as other service providers in the community and

outpatient setting in order to gain broad understanding of gaps in support. Need to consider the current political environment and barriers to engaging with primary care

providers for planning and education purposes. Recruit and leverage physician champions can support peer to peer ownership and coaching.

Resources Leverage existing relationships with education partners in the region, including: University of

Ottawa and Carleton University Departments of Nursing, Psychology, Social Work, and the Department of Psychiatry and Department of Family Medicine at University of Ottawa.

Leverage existing resources at Community Health Centers and Family Health Teams.


FINAL REPORT


Work Stream # 5 –Evaluation

5.1 Evaluation Setup and Planning 5. 2 Conduct Ongoing Monitoring and Evaluation

Implementation 1. The Reporting and Performance working group and the Regional Program Office should develop

and validate a Regional Program logic model that includes deliverables over the next 1, 3, and 5 year periods.

2. The specific work stream activities to be included in the monitoring and evaluation phase should be confirmed throughout implementation.

3. Based on the logic model the working group should establish specific work stream outputs that should be monitored and evaluated throughout implementation. For example, likely outputs would include coordinated intake, assessment and triage tools, regional HHR to patient ratios, training and education materials on available MH&A programs and services for care providers including primary care providers, as well as measures on new technologies.

4. The evaluation should also include measurement and focus on outcomes data collection. Specific indicators to be included in the template (and to be analyzed at the output and outcome level). Indicators should reflect system level performance (e.g., regional readmission rate, clinical outcomes) and should reflect Champlain LHIN’s MLAA indicators related to MH&A and Quality Improvement Plans.

5. Design and develop data collection tools and systems to support monitoring and evaluation of the work stream activities and outputs. These can include surveys of output users / care providers, as well as interview guides for different stakeholders such as senior and executive level staff in the inpatient, outpatient and community settings. It should also include mechanisms to capture informal feedback on activities, outputs, and tools that are core to the Inpatient MH&A Capacity Plan.

6. Develop a data repository to track all evaluative data related to the evaluation of work stream activities, outputs, outcomes and impact. This repository could track a combination of findings and feedback for distinct activities and outputs. The repository would also support reporting to the Operations and Executive Committees.

7. Based on the logic model and data repository, prepare a structure for interim and regular reporting. This structure could include the charts and analysis that will be conducted, as well as how results against activities, outputs, outcomes and impact will be presented and discussed.

1. Performance reporting should be a regular agenda item for the Operations Committee and the Executive Committee.

2. Conduct first formative evaluation of work stream activities, tools and outputs. 3. Conduct first outcome evaluation of work streams. Data would be collected from the

repository, as well as other potential data inputs such as interviews with care providers and supplemental performance data provided by specific sites, the Champlain LHIN, MOHLTC, or CIHI. This could include patient outcome data, service utilization data, and financial/organizational performance information.

4. Conduct second formative evaluation of work stream activities, tools and outputs. 5. Conduct second outcome evaluation of work streams. Data would be collected from the

repository, as well as other potential data inputs such as interviews with care providers and supplemental performance data provided by specific sites or the Champlain LHIN. This could include patient outcome data, service utilization data, and financial/organizational performance information.

6. Report to the Operations Committee on progress against activities, outputs and outcomes on a quarterly basis, the Executive Committee should also be informed of outcomes regularly. It is also important to regularly report back to the health service providers to ensure engagement and ongoing support for the regional initiative.

Considerations

Attitudes There may be resistance to a transparent regional performance scorecard (e.g. wait time reporting), if there is duplication with already existing performance monitoring and Quality Improvement Plan

requirements. There needs to be sensitivity to align not duplicate efforts. Data collection can be an onerous process, with most care providers already supporting multiple data and reporting requirements. To support ownership, along with robust data collection, existing data

sources should be leveraged wherever possible. The need for monitoring and evaluation should be integrated into the overall communications strategy to support ownership and justify the importance of program-related evaluative efforts. Whenever possible, data and results should be shared with the Regional Program working groups, care providers themselves and other external stakeholders (e.g., the public) to support trust-building and

transparency. Indicators and measures should support comparisons across Ontario and with leading jurisdictions wherever possible.

Conditions It is not expected that the Champlain LHIN track all of the measurements and metrics detailed below. There is however a need for the Regional Program (Executive Committee) to select those metrics that

are relevant as activities and outputs are implemented. The logic model and evaluation plan should be approved by both the Executive Committee and the LHIN (as the regional oversight body).

Activity Indicators


FINAL REPORT


Key Questions To what extent is the Regional Program being implemented as expected? Are the work stream implementation strategies/tools /activities effective? Could they be improved?

Sample Measures: % Activities started on time Volume of delays % Milestones achieved vs. expected/planned Overall % project completion % of activities implemented in all inpatient sites Volume or Frequency of Plan updates/changes

Output Indicators Key Questions

Was there a clear evaluation outcome identified at the outset of every work stream? How many outputs have occurred?

Sample Measures: # of tools to support referral, assessment and triage developed

Outcome Indicators (Measurement of the Outcome of the Work stream) Key Questions

To what extent has each work stream resulted in improved quality of service, patient experience, and patient outcomes? Sample Measures

Regional and site-specific readmission rates Regional and site-specific repeat ED rates Wait times experienced ALC rates and rate of patients waiting for a different level of MH&A bed Patients able to be treated in most appropriate location based on acuity Patient experience Clinical outcomes Care efficiency/costs LOS/Peer LOS

Impact Evaluation Indicators Key Questions

To what extent has the inpatient MH&A capacity work contributed to the goals of the regional mental health and addictions strategy, positive patient experience, and system sustainability?

Sample Measures: Change in wait times Change in measures of acuity Change in percentages of patients transferred Percent reduction in readmission to hospital through ED’s

Patient Reported Experience Measures (PREMs) and Patient Reported Outcome Measures (PROMs) should be incorporated in the evaluation and monitoring approach wherever possible.

Resources Monitoring and Evaluation will require support from a number of different Champlain LHIN and Regional Program resources:

Reporting and performance working group will support the development, oversight, planning of the evaluative work; Regional Program staff should conduct the evaluations. Site specific decision support teams will need to support supplementary data collection as well as key elements of the outcome evaluation, particularly as it relates to care provider performance

and outcomes, as well as system-level changes. Communications support will be required to support integrating evaluation into the overall Communications Strategy, as well as supporting communications needs for specific evaluation

elements (i.e. introductory emails or letters for survey or interview invitations)


FINAL REPORT


For larger, more robust evaluation efforts in the long-term, the Champlain LHIN should consider hiring a third-party evaluator to not only support the volume of effort required, but to ensure that the evaluation is conducted in an independent and impartial fashion.


FINAL REPORT


9.2 Regional Program Governance Structure


FINAL REPORT


9.3 Change Management Framework to Support Culture Transformation

Vision for

Change

Leadership

for the Future

Innovative

Delivery

Empowered

Teams

Sustaining

Success

Meaningful

Engagement

Organizational change grounded in a compelling and common vision: quality, person-centred and integrated service

Implementing change and transition activities in an innovative & integrated approach

Shared values, sense of purpose and clear benefits that motivate and

inspire change

Coalition and group of change agents that mobilize stakeholders to

enable change

Involvement key stakeholders and

staff to work in collaboration and

gain buy-in

Change embedded in business processes and organizational culture, becoming the “new normal”

Change Management Framework

OPTIMUS | SBR


FINAL REPORT


9.4 Levels of Care/Utilization Management Tool (Example - LOCUS)

champlain lhin inpatient mental health & addictions

Documents