strategic health system plan - hnhb lhin...2 pwc presentation objectives 1. to present to the...

Strategic Health System Plan

Board of Directors Meeting October 30, 2012

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Presentation Objectives

1. To present to the Hamilton Niagara Haldimand Brant LHIN Board the draft Strategic Health System Plan for their receipt and direction

2. To engage in discussion on the concepts of the Strategic Health System Plan - ACTION project

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Developing the Strategic Health System Plan

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Background

• HNHB LHIN is pursuing an integrated health system that supports a person centred care delivery model aligned with The Triple Aim Framework

• The LHIN is developing a 5-year Strategic Health System Plan with an overall objective to achieve, a local health system where individuals will experience care that is coordinated, of the highest quality and results in better outcomes for the population

• Process included: current state assessment, engagement of stakeholders, review of international leading practices and design of future state

• The Plan will include: – identification of integration opportunities – an implementation plan – a community engagement strategy – an evaluation framework – the identification of risks and mitigation strategies

• The plan will inform the next iteration of the LHIN’s Integrated Health Service Plan (IHSP)

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Hamilton Niagara Haldimand Brant LHIN

Our Vision • A health care system that helps keep people healthy, gets them good

care when they are sick, and will be there for our children and grandchildren

Our Mission • To ensure availability of and access to linked services in order to improve

the health of the population and the continuity of health care Our Values • Respect * Integrity * Accountability • We work from the approach of being a catalyst for change; with a

viewpoint based on the individual, and their caregivers, who need to access local health services. To achieve this we are committed to: – Transparency * Collaboration * Innovation * Real conversation

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Minister of Health’s Action Plan: Released January 2012

Vision for Health Care in Ontario To make Ontario the healthiest place in North America to grow up

and grow old • Key directions from the Minister of Health’s Action Plan include:

– Support to become healthier – Faster access and stronger link to family health care – The right care, at the right time, in the right place

• This vision and the directions provided input to the plan from the outset and were a key component of governance deliberations and community consultation

How will HNHB action these directions to the benefit of HNHB residents?

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Bernice

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How are things working for her?

What can we learn from Bernice’s current experience?

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Bernice’s Current Experience • Meet Bernice. • Bernice lives at home • The CCAC visits her every week. • Her children visit frequently. • Bernice falls and gashes her arm. • An ambulance takes her to hospital. • They treat her arm and discharge

her home – no follow-up is planned, and her GP isn’t notified.

• The CCAC is surprised on their visit to see her wound.

• Twelve months later Bernice falls again and breaks her hip.

• She travels by ambulance to the hospital again.

• She waits three days in the ER. • Finally, she is transferred to the

community hospital for surgery. • She spends six months recovering in

hospital and acquires MRSA. • Bernice has to sell her house, and is

discharged to LTC.

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Current State: What did we find?

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Environmental Scan: Summary of Key Findings #1

• HNHB LHIN has lower population growth but the largest number of seniors – this has implications for funding and programming

• HNHB residents are not as healthy as other Ontarians on many measures - most disturbing of these is the higher mortality rate and higher numbers of potential life years lost

• There are high degrees of variation across sub-LHIN areas and within sub-LHIN areas as demonstrated by the “Code Red” series

• There is a higher prevalence of poor life style choices as shown by higher daily or occasional smoking, heavy drinking, and obesity (in adults) in the HNHB LHIN

• Have higher rates of chronic conditions including arthritis, high blood pressure and asthma compared to Ontario rates

We need to and can do a better job at “keeping people healthy.”

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Environmental Scan: Summary of Key Findings #2

• The residents of the LHIN receive most of their care from HNHB providers and thus providers have the ability to impact population health

• Utilization data suggests that there is room for improvement in inpatient care and mental health services

• The top 1% population offers a unique opportunity to bend the cost curve and promote financial sustainability

• Funding out of hospital to a less costly level of care should be a priority • The health human resources retirement profile suggests that HNHB

outlook will be challenging and will be worse than the provincial average Care delivery systems will need to focus on right provider, right

care, right time and right place in order to meet the health care needs of LHIN residents.

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Environmental Scan: Summary of Findings #3

• HNHB providers are challenged to meet provincially set performance standards which are largely a measure of access to services

• There is variation in sub-LHIN performance that is being masked by the LHIN “average”

• Age standardized data shows utilization rates above the provincial average. This variation should be investigated to determine its impact on population health, quality and cost

• There has been some success in performance efforts linked to provincial priorities (e.g. ER/ALC); this should continue and be leveraged with other provincial priorities e.g. the primary care strategy and the seniors strategy There are many findings suggesting opportunities to address LHIN

level performance exist and if addressed would improve the health of the population and public confidence in the health care system.

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Community Engagement

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What has our Community Told Us?

• Through a diverse number and means of engaging with our community we heard a number of common themes emerge. Our community has told us that they want us to transform the system into a system that: – Focuses on the person – Focuses on health promotion and disease prevention – Shifts services as appropriate out of hospital and into community – Provides specialized community-based care for highest risk

populations using a “health coordinator”, “care navigator” or “pivot person”

– Improves value for money – address inefficiencies , want to access general care at the least expensive provider level, decrease administrative costs

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What has our Community Told us About the Minister’s Action Plan?

Keeps people healthy

• Focus on the person with specific strategies around health promotion related to childhood obesity, smoking cessation and cancer screening

• Respectful communication, appropriate education and information

Faster access to family health care

• Improve primary care access

– increasing the use of house calls, integrating Family Health Teams and other organizations into the LHIN leadership model, and driving a focus on quality / best practice

• Improve access to home/community-based care

Right care, right time, right place

• Shift services and care out of the hospital and into the community

• Consider a care navigator – or pivot person

• Decrease administrative costs and review administrators salaries

• Make funding contingent on outcomes

• Address inefficiencies in the system

• Use the most appropriate provider

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What Have Providers Said About the Minister’s Action Plan?

Keeps people healthy

• Focus on prevention and promotion: better outcomes and sustainability • Integrate prevention and promotion with other parts of the system • Focus on priority populations and people who are high users of the

system (hot spots) Faster access to family health care

• Primary care needs to be the foundation for transformation Right care, right time, right place

• A common philosophy of care and vision • Funding allocations based on right care, right time, right place • Metrics that are person centric, system-based and favour system

performance and outcomes rather than provider performance • LHIN should provide leadership and direction in health system

transformation

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Leading Practices

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Leading Practices: Summary of Key Findings

• Leading practices research identified that all leading health systems: – Focus on prevention, promotion, and self-management – Develop strategies for priority populations – Have a strong primary care foundation, with broad access to

specialty and community services – Focus on patient-centric delivery – Implement a standardized system-wide approach to quality

management and improvement – Have governance models that engage clinicians and the public

in decision-making, enabling informed service provision that meets community needs in a timely way

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• Enhancing Access to Primary Care – focused on advancing strategies to ensure people have timely access to a primary care provider and creating enabling structures and processes to align primary care more effectively within the overall continuum

• Enhancing Coordination & Transitions of Care for Targeted Populations – e.g Seniors Strategy: focus on seniors have individualized plans of care that allow them to receive the care they need, when and where they need it; and the transitions post-acute are smooth and coordinated

• Implementing Evidence Based Practice to Drive Safety - focused on high priority safety issues that require consistent, coordinated responses to ensure that patents are safe and that adverse events are minimized/eliminated

• Holding the Gains – focused on ensuring that new initiatives will not cause previous gains to be eroded (e.g., ER/ALC, ER Wait Times, and access to care, coordination amongst providers, enhanced focus on accountability)

LHIN’s Provincial Priorities

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Overall Summary of Key Drivers • The LHIN needs to concentrate its efforts on transformation of the

health system -- to improve the patient experience, patient outcomes and the overall health of the population.

o Suggested by a combination of poor population health measures in a variety of areas, the resource utilization profile and HNHB LHIN performance results.

• Learnings and research from leading practices demonstrate what

can be done to improve the patient care experience, quality and outcomes at a lower cost.

• To build “a health care system that helps keep people healthy”, ensures the availability of services and improves the health of the population transformation efforts will need to learn from the past and from what others have accomplished.

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Transformation of the Health Care System

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Health System Planning Framework

Integration and Accountability

Access Quality Transitions

The Patient Experience

Value for Money

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Health System Transformation

Principles for HNHB LHIN Strategic Planning

Improve the patient experience

Ensure alignment with a common vision and philosophy of care

Improve quality

Promote integration

Enable enhanced sustainability

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The Strategic Directions

The three Strategic Directions are: 1. Dramatically improving the patient experience by

embedding a culture of quality throughout the system 2. Dramatically improving the patient experience by

integrating service delivery 3. Dramatically improving the patient experience by evolving

the role of the LHIN to become health system commissioners

HNHB LHIN: Dramatically improving the patient experience through Quality, Integration, and Value

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Strategic Direction #1:

Dramatically improving the patient

experience by embedding a

Culture of Quality throughout the

system

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Creating a Quality System

• Common LHIN-wide philosophy and approach to quality

• Reduce variation, increase standardization

• Drive quality, drive outcomes, drive value for money

• LHIN to provide leadership to:

– Achieve better outcomes for their communities: lives saved, quality of life improved and disability decreased

– Ensure a better experience for the people it serves.

– Reduce disparities in quality measures across different groups in HNHB’s communities

• LHIN will work with provincial partners both at the Ministry of Health and Long Term Care and at Health Quality Ontario to achieve these goals

“Everything is Quality and Quality is Everything”

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Dramatically improving the patient

experience by Integrating Service

Delivery

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Possibility #1: Status Quo

200 LHIN Providers

Leadership per Provider Organization Total # of Senior Leaders LHIN-Wide HNHB LHIN

X Average of 3 senior leaders /org = 600 Senior Leaders + 7 Senior Leaders

X Average of 10 Board Members /org = 2,000 Board Members + 6 Board Members

Community Support Services

• 68 Community Support Services Providers

Long Term Care

• 86 Long Term Care Homes

Hospitals • 10 Hospital

Corporations • 23 sites plus 1

pending

CCAC

• 1 CCAC

Mental Health & Addictions Agencies

• 35 Mental Health & Addictions Providers

HNHB LHIN

Ministry of Health and Long - Term Care

Academic Partners

Municipalities M

Other Ministries

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Possibility # 1: Status Quo (Cont’d)

Pros • ‘Easiest’ option – no structural/ governance changes • Current model is broadly understood Cons • Impossible to achieve a common vision and philosophy of care across 600 Senior

Leaders and 2000 Board members who all have an organizational focus • Highly fragmented – can’t manage what you don’t know • Does not promote the patient experience • Provider focused • Not population focused • ‘System’ isn’t really a system (silo based) • Reinforces provider silos • Does not consider the importance of primary care • No consistency of vision/ philosophy of care across providers • Will not enable the degree of change advocated by stakeholders • Has not achieved the desired results

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Possibility # 2: Horizontal Integration

Community Support Services

Organization • 1 Board • 1 Leadership Team

Long Term Care Consortium

• 1 Board • 1 Leadership

Team

Hospital Organization


Team

CCAC Organization


Team

Mental Health & Addictions

Organization • 1 Board • 1 Leadership Team

HNHB LHIN

Ministry of Health and Long - Term Care

Academic Partners

Municipalities M

Other Ministries

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Possibility #2: Horizontal Integration (Cont’d)

Pros • Fewer providers and Boards • Greater standardization within sectors • High degree of integration within sectors Cons • Does not support the patient journey as this continues to be provider focused • Transitions are not improved • Not patient or population focused • Does not support the best practice which identifies primary care as key to

transformation • ‘Hospital as dominant player’ is further entrenched • Does not promote a local perspective • Restructuring to maximize the worst in everything (stronger, bigger silos) • Not a solution-oriented option • Develop a consortium of LTC would be very challenging

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Possibilities #3 & 4: Transforming the System

COMMUNITY CARE NETWORKS:

PRIMARY CARE AND COMMUNITY BASED

SERVICES

INTEGRATED SERVICE

DELIVERY ZONES

HNHB LHIN



SERVICES



SERVICES

LHIN-WIDE CLINICAL PROGRAMS

Wrapping Services Around the Person & Priority Populations

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Possibility # 3: Vertical Integration with One Hospital System

1. High Risk Seniors 2. Chronic Disease 3. Mental Health & Addictions 4. Palliative/End of Life Care 5. Children & Youth

Other Ministries

HNHB LHIN

-

-

Quality Guidance Council

- -

East Integrated Service Delivery Zone

• Public Health • Primary Care

Services • Community-Based

Services • Post-Acute Services

Central Integrated Service Delivery Zone




South Integrated Service Delivery Zone




Ministry of Health and Long Term Care Other Ministries

Priority Populations

Academic Partners

Municipalities M

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Possibility #3: Vertical Integration with One Hospital System (Cont’d)

Pros

• Simpler structure than the status quo

• Easier to monitor for accountability

• Better likelihood of future sustainability

• Promotes within sector integration

• Greater potential to focus on the local populations and priorities

• Reduces duplication of the case management function within divisions

• Less fragmented within the two divisions – hospitals and community

• Enhanced ability to hold zones accountable for targets and population outcomes

• Greater standardization

• Will require commissioning to move to the LHIN from the CCAC

Cons

• Does not maximize improvements in patient transition

• Requires significant change management capacity

• Providers must buy-in to vision (resistance is anticipated due to consolidation)

• Requires a long term solution for LTC at the zone level

• ‘Hospital as dominant player’ is further entrenched

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Possibility #4: Vertical Integration with Zone Level Hospital Integration

Municipalities

Other Ministries

HNHB LHIN

Em

be

dd

ing

Qu

alit

y

LHIN-wide Clinical Programs (i.e., Priority Populations, Specialty)

Integrated Support Services System Co

mm

issi

on

ing:

O

utc

om

es,

Qu

alit

y &

Val

ue

- -

East Integrated Service Delivery Zone

• Existing hospital and community services

• Strengthen primary care, Public Health, EMS relationships

Central Integrated Service Delivery Zone



South Integrated Service Delivery Zone



Ministry of Health and Long Term Care Other Ministries

Academic Partners

Municipalities M

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Possibility # 4: Vertical Integration with Zone Level Hospital Integration (Cont’d) Pros • Through quality and integration enhances the patient experience • Affords the greatest opportunity for the adoption of the common vision and philosophy of care • Positions the LHIN for future sustainability • Promotes within and across sector integration • Focuses on the local populations and priorities • Reduces duplication of the case management function across the continuum • Promotes care coordination / navigation as a function not only a role • Supports the ‘no wrong door’ concept • Less fragmentation • Enhanced ability to hold zones accountable for targets and population outcomes • Greater standardization • Truly integrated ‘health system’ across all levels Cons • Requires significant change management capacity • Providers must buy-in to vision (resistance is anticipated due to consolidation) • Will require commissioning to move to the LHIN from the CCAC • Requires a long term solution for LTC at the zone level

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LHIN-wide Clinical Programs

Two types of LHIN-wide Clinical Programs:

1. Population-focused programs, including:

– High-risk seniors

– Mental health and addictions

– Multiple Chronic diseases

Proposed priority areas of

focus

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LHIN-wide Clinical Programs

2. Specialty-based programs: Highly specialized, high-cost, critical mass considerations (for equipment, technology and HHR), which may include: – Stroke – Palliative/End of Life Care – Diagnostic services- Imaging, Laboratories – Cardiac – Oncology – Renal – Respiratory medicine – High-risk obstetrics – Forensics – Paediatrics

Proposed priority areas of

focus

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Discussion of the Possibilities

Consider… • Possibility #1 – no change • Possibility #2 – Strengthens the individual sectors, but

limited integration across the continuum of care • Possibility #3 – One hospital system, integration

across community providers, but limited integration across the continuum

• Possibility #4 – Three care delivery systems with maximum integration across the continuum at the local and zone levels

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Integrated Support Services System

• An integrated support services system is a feature of high performing health systems – Cost effective, allows for improved consistency and decision-making

• An Integrated Support Services System will enable the successful adoption of a system wide quality culture, and should include: – Information management / information technology – Decision support – Human resources – Finance, payroll – Procurement

• Integration with quality agenda is key

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Dramatically Improve the Patient

Experience by evolving the role

of the LHIN to become Health

System Commissioners

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What is Commissioning?

Commissioning is:

…the process of ensuring that the health and care services provided effectively meet the needs of the population*

*http://webarchive.nationalarchives.gov.uk/+/dh.gov.uk/en/managingyourorganisation/commissioning/index.htm

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What is Commissioning in the HNHB LHIN?

• Commissioning is a complex process with responsibilities ranging from:

– Assessing population needs

– Prioritizing health outcomes

– Procuring products and services and

– Holding health service providers accountable.

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What will Commissioning Require of the HNHB LHIN?

• Commissioning will require the HNHB LHIN Board and staff to: – Understand the population – Work with providers to understand the current state and

to identify gaps – Make health system decisions based on evidence and

performance (or in the absence of evidence – based on a locally agreed upon process)

– Make decisions that are in the best interest of the person to be served

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The LHIN as Health System Commissioners

Current State Future State

Focus on providers Focus on populations and accountability for health outcomes

Setting the vision and determining the values for the system

Current plus, expectation for alignment with the vision, values and philosophy of care across the system

Strategic Planning – Integrated Health Service Plan (IHSP)

Current plus, requiring providers to align with system goals and plans

Funding providers Commissioning services and procedures based on population needs

Tactical management of multitudinous, unwieldy, silo-based providers

Strategic management of continuum of care managed to achieve quality outcomes at best price

Silo-focused accountability System-focused accountability

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Feedback from Consultations Regarding the Possibilities

• Robust discussion and good feedback to improve the directions

• Strong preference for Possibility #4 was repeatedly voiced

• Need to take Action as many are concerned this is just another planning exercise

• Build capacity, utilize leading practices to ensure an evidence-based approach to transformation

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HNHB LHIN will focus efforts on…

Dramatically improving the patient experience

through Quality, Integration, and Value

through the...

Proposed Strategic Directions and Goals

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SD #1: Embedding a culture of quality

throughout the system

Goal #1: Develop a common vision for and commitment to quality.

Goal #2: Launch the Quality Guidance Council to identify areas for focus and incorporate common quality metrics into accountability agreements.

Goal #3: Build the capacity of boards, leaders, physicians and frontline staff in quality.

Goal #4: Leverage academic expertise to support the adoption of evidence-based practice and evaluate the achievement of expected outcomes.

Goal #5: Establish processes for sustaining quality at the network, zone and LHIN-wide program levels, using a balanced scorecard approach.

Goal #6: Leverage the benefits of the Integrated Support Services, one system wide Decision Support service, to enable LHIN-wide quality improvement.

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SD #2: Integrating service delivery

Goal #1: Develop a common commitment to, and vision for an integrated service delivery system.

Goal #2: Identify Community Care Networks and Integrated Service Delivery Zones across the LHIN.

Goal #3: Continue to evolve strong LHIN-wide Clinical Programs for priority populations and specialty programs that adopt evidence-based practice and quality improvement to deliver the best value for money.

Goal #4: Create one Integrated Support Services System for all providers across the LHIN.

Goal #5: Develop strong partnerships at the network and zone levels with public health, EMS, social services and other providers as appropriate.

Goal #6: Develop a phased implementation for integrating service delivery at the network and zone level, including mechanisms to support accountability and an evolution towards integrated management and governance.

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SD #3: Becoming health system

commissioners

Goal #1: Determine the actions required to become a leader in health system commissioning in Ontario and Canada.

Goal #2: Ensure that the LHIN is aligned with the provincial work on Quality-Based Procedures.

Goal #3: Develop and implement a communications plan related to Quality-Based Procedures and Commissioning.

Goal #4: Establish the collaborative structures and partnerships required to drive quality and value within HNHB.

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Key Performance Indicators

Embedding a Culture of Quality Throughout the System

Patients state: “I receive the care I

need when I need it.”

Reduction in variation

Improved care transitions

Staff ability to impact system

Culture of quality

Integrating Service Delivery

Common Vision & Philosophy of Care

Increased use and access to community

services

Reduced costs/wait

times

Reduced governance and management

Becoming Health System Commissioners

Governance & management capacity

developed

Mechanisms &measures for meaningful provider and community

engagement

Residents state: “We have confidence in our health care

system.”

Measuring our Health System Improvements

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High Level Implementation Plan Phase 2: Full

ImplementationYears 2-3

Phase 1: Early Implementation

Years 1-2

· Develop common vision and philosophy of care for HNHB LHIN

· Establish goals to support vision and philosophy statement

· Articulate and communicate the LHIN’s expectations in relation to each strategic direction

· Establish governance structures for each strategic direction

· Communicate and socialize Plan with stakeholders

· Education, training, and capacity building to support implementation

· Determine role and expectations for academic partners

· Determine and engage external LHIN partners (e.g., Public Health, EMS, academic, HQO)

· Education, training, and capacity building to support implementation

· Establish initial Community Care Networks

· Identify and implement quick wins

· Establish operational framework for the Zones

· Conduct baseline needs assessment for Integrated Support Services System

· Build capacity for commissioning role within HNHB LHIN

· Incorporate strategic direction metrics into accountability agreements

· Establish framework and begin implementation for LHIN-wide Clinical Programs

· Establish mechanisms to monitor and track quality improvement efforts across the LHIN

· Establish infrastructure to support quality efforts

· Implement balanced scorecard in relation to strategic directions

· Continue implementation of Community Care Networks

· Full implementation of LHIN-wide Clinical Programs for priority populations and specialty programs

· Design and implement governance and operational framework for Integrated Shared Services

· Develop service agreements for Integrated Shared Services System

· Implement management and governance changes to support mature Zone structure

· Full implementation of commissioning model

· Monitor and tracking of progress of strategic directions’ goals and initiatives

· Conduct evaluation of Health System Plan outcomes

Phase 0: Implementation

Start-Up – Q3 & Q4

Phase 3: Monitoring & Evaluation

Years 4-5

· Implement mechanisms to

support mature Zone

structure

· Full implementation of

commissioning model

· Monitor and tracking of

progress of strategic

directions’ goals and

initiatives

· Conduct evaluation of

Health System Plan

outcomes

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Bernice

Will things be better for Bernice?

What will Bernice’s future look like

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Bernice’s New Experience • Meet Bernice. • She lives at home. • The CCAC visits her every week. • Her children visit frequently. • Bernice falls and gashes her arm. • EMS treats her at home, contacts

her GP and makes a geriatric assessment referral.

• Her children take Bernice to her appointment, and learn how they can improve her functional ability.

• Bernice is enrolled in a bi-weekly falls prevention clinic.

• At the clinic, she meets new friends and starts going to Bingo.

• Bernice lives at home for the next three years.

• Leaving Bingo one day, she slips on ice and breaks her hip.

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Bernice’s New Experience

• She goes to Haldimand War Memorial Hospital.

• Hospital staff call Brantford General and Bernice receives her surgery there 36 hours later.

• She is transferred back to Haldimand War Memorial for recovery.

• A week later, she is discharged to a transitional care program for a month.

• Bernice then goes home with ongoing support to maintain her functional level.

• Bernice and her family are happy.

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Cost of Bernice’s care

Pre- transformation: $488,527 (over 5 years using 2012 dollars)

Post- transformation: $130,047 ( over 5 years using 2012 dollars,

no future value of money factored )

Difference: $358,480 (over 5 years)

Difference: $71,696 per year

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Next Steps

• Post the draft strategic plan on website for community feedback

• Present to MPP offices (constituency assistants) and follow up with MPP’s as requested

• Present to municipal officials (webinar)

• Final Health system strategic plan to LHIN board December 12

Thank You.

strategic health system plan - hnhb lhin...2 pwc presentation objectives 1. to present to the...

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