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Central East Local Health Integration Network

Integrated HealtH ServIce Plan

Engaged Communities. Healthy Communities.

november 2006

Fernand Ackey • Robert Adams • Margaret Aerola • June Agnew • Ana Aguat • Michael Aikins • Mary Aisen • Darlene Albright • Lisa Allanson • Jewel Allington • Jamie Allison • Carol Anderson • Mary Lynn Anderson • Doreen Anderson Roy • Virginia Anzlin • Beth Archibald • Pascal Arseneau • Colleen Ashmore • Tariq Asmi • Dianne Atkins • Amy Au • Annick Aubert • Jocelyne Auger • Doohita Aukle • Clene Azhar • Touria Aziz • Susanne Babic • Parvine Bahramian • Libby Bailey • Trish Baird • Julie Baker • Carol Baldasti • Patricia Baldwin • Mrs. P Balendra • Kim Ballantyne • Gilles Barbeau • Roberto Bardetti • Valmay Barkey • Mike Barkwell • Sally Barrie • Andre Barros • Daniel Barry • Jean-Denis Barry • Diane Baskey • Sandy Bassett • Cherie Bates • Lise Marie Baudry • Mary Bazeley • Paula Bebee • Barbara Beck • Jane Becking • Charles Beer • Denys Begin • Danielle Belair • Albert Belanger • M. 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Forward

welcome to your Central East LHIN (Local Health Integration Network) and its first Integrated Health Service Plan (IHSP).

This plan represents the first stage in the trans-formation of ontario’s health care system, from centralized to local health care system planning and funding. It is an initial blueprint for change, a three-year plan towards building a better health care system. our ultimate goal is to realize our vision of Engaged Communities. Healthy Communities.

This transformation of health care began with the creation of 14 LHINs across the province through the Local Health Integration Act (2006). Under this legislation, the LHINs were given a mandate to locally plan, co-ordinate, integrate and fund health care services provided by hospitals, long-term care homes, community care access centres, commu-nity support services, community mental health and addiction services and community health centres.

Two things are certain when it comes to people and their health care system. First, people are deeply attached to the system of public health care in ontario. Secondly, they want it to work better for themselves and their loved ones. during our ongoing process of community engagement, community residents often told us of their high satisfaction with the current health care system. we also heard very clearly people’s frustration about the inability to access a well-co-ordinated system of care.

People told us they sometimes experienced inter-mittent care separated by long and costly delays, and anxiety about “where do I go next?” we also heard from health professionals and residents alike about the inability to provide comprehensive “whole person” health care services to people and their families, commonly due to rigid funding and bureaucratic boundaries and a lack of information of what services are available to people.

Foster LoucksChair, Central East LHIN Board of directors

Marilyn Emery CEo, Central East LHIN

Your health care system is made up of tens of thou-sands of dedicated health care professionals, other health care providers and support workers, plus an army of volunteer caregivers who all work to make it a world-class system. But everyone agrees we can do better. To do so requires both a plan and a commitment to deliver on that plan.

Key to the development of a successful plan for the Central East LHIN is community engagement. all too often, health care initiatives have been planned in isolation, and then brought to the public for late reaction. we started our process of commu-nity engagement with two simple premises. First, that local health care system planning and priority setting should begin with the people who use the system. For that reason, we sought out you and your community’s voice before developing any plans.

The second premise was based on the belief that if LHIN initiatives were to be successful, co-operation and shared responsibility throughout our health care community would be required.

we have listened. The core and foundation of this Integrated Health Service Plan was created by the community through grassroots initiatives. Stakeholders, including health care providers and community residents, have been involved as never before in the development of this Plan to identify local needs, local priorities and local actions to make our system more truly people-centred. while we have already begun moving forward, we will continue to listen to your concerns, needs and ideas for improvements.

This Plan has really been a collective community effort. Hundreds of volunteers, community resi-dents and health care providers alike, have provided invaluable contributions to this Plan. The directions contained within this Plan are a testament to their knowledge, commitment and dedication to their patients, clients, residents, colleagues, neighbours, families and friends.

on behalf of our board members and staff, thank you to everyone for helping to create this shared and forward-looking Plan for lasting change. optimism abounds.


For additional copies of this report or for more information, please contact us at 1-866-804-5446 or [email protected]

Central East Local Health Integration NetworkIntegrated Health Service Plan

TaBLE oF CoNTENTS

Forward

Introduction. Health Care is Changing 5A Vision for the Central East Local Health Integration Network 6

What’s in a Plan? The Purpose of the Integrated Health Service Plan 7

It Begins With You!Effective Community Engagement Creates Effective Plans 8Local Planning and Engagement Collaboratives 9LHIN-wide Priority Networks & Task Groups 11Sharing and Validating the Draft Integrated Health Service Plan 12

Environmental Scan. Who We Are and Where We Live 14

A Plan for Change. Priorities for Change 18Enabling Change to Happen: System Enablers 18 E-Health 19 Shared non-clinical services 19 Moving People Through the System 19 Safe Environments of Quality Care 19 Health and Human Resources 20Performance Dimensions 20

Priority for Change: Mental Health and Addictions 22The Impact of Mental Health and Addictions 23What We Know 25What You Told Us 26What We Have Done 27What We Will Do 28

Priority For Change: Seamless Care for Seniors 29Why Seamless Care for Seniors? 30 Impact on the Individual 30 Impact on the Caregiver 31 Impact on Your Community and Health System 31What we know 32 Our Ageing Community 32 Diversity and Ageing 32 Income and Ageing 32 Growth in Dementia 33 Alternate Level of Care 33What You Told Us 35What We Have Done 35What We Will Do 36

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Priority for Change: Chronic Disease Prevention and Management 37Why Chronic Disease Prevention and Management is a Priority 38 Impact on People 38 Impact on Your Community and Health System 38 Chronic Disease Related Risk Factors 38 Social Determinants 38 Hospitalizations for Chronic Conditions 39 Prevalence of Chronic Conditions in Central East 39 Focus on Diabetes and Chronic Kidney Disease 40What We Know 41What You Told Us 43What We Have Done 44What We Will Do 44

Priority for Change: Wait Times and Critical Care 46What We Know 47 Surgical and Diagnostic Wait Times 47 Critical Care 47 Emergency Departments 48How Are We Doing? 49 Surgical and Diagnostic Wait Times 49 Emergency Departments 49 Central East LHIN Critical Care Resources 50What We Have Done 52What We Will Do 53

Integration Begins With Primary Care 54What We Have Done 54

Cultural CompetenceUnderstanding Health within Our Multicultural Fabric 55What We Know 55What You Told Us 57What We Will Do 57

Improving Services for the Central East Francophone Community 58What We Know 58What You Told Us 58 Access, Integration and Innovation 59 Accountability 59 Health Human Resources 59 A Forum to deal with French Language Health Services 59What We Will Do 60

First Nations and Aboriginal HealthPartnerships to Create Better Understanding and Health 61What We Know 61Moving Forward 62

Conclusion: Optimism Abounds 63

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Integrated Health Service Plan 5

INTrodUCTIoN

Health Care is Changing!

recently, the Government brought forward five strategic directions that will form the basis for the development of a 10-year Provincial Health System Strategic Plan. while that plan will be further defined through a province-wide process of citizen engagement, the initial directions are:

Renewed community engagement and partnerships in and about the health care system

Improve the health status of ontarians

ontarians will have equitable access to the care and services they need no matter where they live or their socio/ cultural/economic status

Improve the quality of health out-comes, and

Establish a framework for sustainability of the health system that achieves the best results for consumers and the community.

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The Mandate of a local health integration network is to plan, fund and integrate the local health system to achieve the purpose of the Local Health System Integration Act, 2006.

The advent of LHINs offers the potential to create a true system of coordinated health care. It is also ontario’s acknowl-edgement of what other Canadian prov-inces and international jurisdictions have come to know: To gain full value of the public’s investment, all the parts of current health care system must be inte-grated into a full continuum of care. By eliminating delays between care provided in people’s homes, doctors’ offices, hospi-tals, day programs, and long-term care homes, and of the system – delays which are costly for the people receiving care and ultimately the tax payers – LHINs can help create a new system of health care that focuses on the continuum of care for the “whole person.” By coordinating the path of care, the health system will not only make better use of its resources, but it will provide people with the right care, in the right place at the right time.

The mandate of the Local Health Integration Network is in keeping with the ontario Government’s vision and strategic priori-ties for the provincial health care system. That vision is for a health care system that helps people stay healthy, delivers good care to them when they get sick and will be there for their children and grandchildren.

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6 Central East Local Health Integration Network

a VISIoN For THE CENTraL EaST LoCaL HEaLTH INTEGraTIoN NETworK

To assist in meeting its mandate and achieving local and provincial strategic priorities, the Central East LHIN has devel-oped a vision and supporting values that reflects the nature of our communities and their aspirations.

our vision is “Engaged Communities. Healthy Communities.” and is orientated towards establishing a health system that is responsive to the needs of people and their community for today and tomorrow, as well as improves health care access and navigation for clients and caregivers. This will be achieved, in part, by: promoting shared responsibilities and innovation; recognizing the importance of equity, quality and safety; and making decisions based on performance-based evidence.

The Central East LHIN Board will be guided by the following values in making decisions and upholding its relationships with the community:

Accountability. we will be required or expected to justify actions or decisions. Public funds will be used responsibly.

Responsiveness. we will listen, we will be accessible, and we will respond in a timely manner. we will build sustainable relationships.

Respect. we will show respect to all.

Integrity. we will consistently adhere to principled behaviour and a high standard of ethics.

Innovation. we will be prepared to test new waters; we will be open to a new idea, method, or device.

Equity. we will recognize the diversity of communities and respond reasonably and fairly.

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Engaged Communities Healthy Communities

Values: Accountability. Responsiveness. Respect. Integrity. Innovation. Equity.

People are supported and proactively engaged in

• managing their own health and wellness

• providing direction and solutions for their health care system and their LHIN

• coordinating the delivery of timely health care services

• Supportive and sustainable environments that address the social determinants of health and cultural competency

• Timely and equitable access to care

• The health of the population has improved



wHaT’S IN a PLaN?

The purpose of the Integrated Health Service Plan

sary use of limited and more expensive health care services “downstream.” To achieve these goals, the LHIN will estab-lish working partnerships with physicians, public health units, government-funded children and community programs, munic-ipal programs (such as transportation and social services), the education sector, the private sector and other organizations like the United way.

Most importantly, the strength of LHIN health planning begins with critical contri-butions to the initial design of the system and its priorities. The most notable of those inputs are effective mechanisms of citizen engagement and a comprehensive use of data, both of which provide in-depth knowledge on the local population and its health care needs.

Patient CentredIntegration & Service

Coordination

CommunityEngagement

Funding & Allocation

Local HealthSystemPlanning

Accountability& Performance

Monitoring

Phase One:

System Design

Phase Two:

System Im

plementation

and Monitoring

Planning can be broken into two distinct but related phases: the design and devel-opment phase; and the implementation and monitoring phase.

This initial Integrated Health Service Plan is focused on system design with a focus on key health care priorities for change. The Plan is intended to set the course for health care improvements in the Central East LHIN for the next three years. Each year the Plan will be revised according to advancements, lessons learned, and emerging trends in our community. The Plan does not directly address the second phase of implementation and monitoring. That phase will be accomplished in LHIN work plans, and accountability agreements between the Central East LHIN and health service providers (hospitals, long-term care homes, community care access centres, community support services, community mental health and addiction services, and community health centres).

This Plan also provides “upstream” strat-egies – such as disease prevention and management, housing, cultural compe-tency – which will reduce unneces-

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IT BEGINS wITH YoU!

Effective Community Engagement Creates Effective Plans

access, your frustrations and confusion about how to get the information and services you need, and your ideas and aspirations for improvements to the health care system.

wanting to do more than express their concerns, many people expressed a will-ingness to get involved and have since plunged into the hard work of developing this Plan for change.

as a first step, the Central East LHIN met with more than 4,000 citizens through a series of informal and formal community consultations to discuss their ideas for the future of their health care system. Some of these sessions were large public forums and day-long workshops. The LHIN also conducted dozens of engagement oppor-tunities, small and large, with members of our health care community: from physicians to front-line workers, from youth to seniors, from members of our Francophone community to Tamil mothers and from members of our First Nations communities to new immigrants.

as health care service providers and resi-dents of the Central East LHIN, you are a vital part of the health care system and the changes taking place in health services cannot be a success without you.

From the beginning, the goal has not been just to effectively listen to people’s concerns and ideas, but also to empower them in creating solutions that lead to better health and a better health care system. But such a goal cannot be achieved by accident. That is why the first major deliverable of the Central East LHIN was the Framework for Community Engagement and Local Health Planning (available at www.centraleastlhin.on.ca/pdfs/framework.pdf). The “Framework” details the Central East LHIN’s commit-ment and plan for organized, effective and sustainable community involvement.

as a result of meeting the objectives set out in the Framework, people from across the Central East LHIN are actively and inti-mately involved in the planning process. You have told us about the barriers to

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Starting with the premise that “local works better,” the Central East LHIN has divided the region into nine geographic planning and engagement zones, based on several characteristics including size and distribu-tion of the population, travel distances, municipal boundaries and commonly understood patterns of service use by citizens. These zones include Haliburton Highlands, Kawartha Lakes, Peterborough City and County, Northumberland-Havelock, durham East, durham west, durham North/Central, Scarborough agincourt-rouge and Scarborough Cliffs-Scarborough Centre.

“This is the first time ever that planning for health care in this province has been developed at the local level. People I’ve talked to believe it can be done at the local level.”

Stephen Kylie Central East LHIN Board Member

during the public meetings, the LHIN found consensus among the communities across the region on common challenges, common values and common hopes for their public health care system. There was also strong agreement on system priorities and opportunities to achieve real, lasting change. These concerns were heard and this Plan is the initial response.

Local Planning and Engagement Collaboratives

The Central East LHIN is far from being a single uniform community: we are a commu-nity of communities, ranging from the multi-culturally diverse urban cities, ageing rural communities, and isolated remote dwellings. It was no surprise when residents made it clear that change would sometimes require different approaches from one community to the next. There was no support for a “one-size-fits-all” solution.


Community Planning & Engagement Zone(Lower Tier Municipalities – Boundaries)

Population2001 Census

1 Haliburton Highlands Algonquin Highlands, Dysart et al, County of Haliburton,Highlands East, Minden Hills

15,085

2 Kawartha LakesCity of Kawartha Lakes

69,179

3 Peterborough City & CountyGalway-Cavendish-Harvey, North Kawartha, Smith-Ennismore-Lakefield,Douro-Dummer, Cavan-Millbrook-North Monaghan, Otonabee-SouthMonaghan, City of Peterborough, Asphodel-Norwood

121,377

4 Northumberland-Havelock Alnwick/Haldimand, Cobourg, Cramahe, Hamilton,Havelock-Belmont-Methuen, Port Hope, Trent Hills

81,976

5 Durham - EastOshawa, Clarington

208,885

6 Durham - West Whitby, Ajax, Pickering

248,305

7 Durham - North/Central Scugog, Uxbridge, Brock

49,660

8 Scarborough Agincourt – RougeBoundary (Clockwise)from Steeles Avenue and Victoria Park, travel east along Steeles - south along Rouge River to Lake Ontario - west along the lake to Morningside Avenue - north to highway 401 - west along highway 401 to Victoria Park - north to Steeles Avenue.

272,165

9 Scarborough Cliffs – Scarborough CentreBoundary (Clockwise) from Victoria Park and highway 401, travel east on highway 401 to Morningside Avenue - south to Lake Ontario - west along the lake to Victoria Park - north along Victoria Park to highway 401.

321,100


The division of the LHIN into zones and the division of the province into LHINs will have no effect on consumer access to needed health services. The delineation of zones is simply to support local plan-ning and community engage-ment. It is fully expected that consumers and health service providers will move freely among these zones and among LHINs to access the services they need.

Each zone has a local volunteer health Planning and Engagement Collaborative which can be described as a local advisory team made up of a diverse cross section of people in your community. They include doctors, pharmacists, nurses and other health professionals as well as represen-tatives from hospitals, community health centres, community support agencies and mental health and addiction services. These advisory teams also include consumers of health care services and members of the community with an interest in improving the health care system.

More than a hundred volunteers are now participating on these advisory teams, bringing a variety of perspectives to the planning discussions. There is an advi-sory team in your community. You can bring them your ideas for local health care system planning. They will work with you and the LHIN to build understanding and knowledge around local population needs and health care challenges in your community.

LHIN-wide Priority Networks & Task Groups

Through community engagement and consultation, three LHIN-wide Health Interest Networks have been established for three of our priorities for change. Task Groups are also being established for our other key initiatives.

Each of these networks and task groups will be composed of local experts, including citizens, to advise the LHIN directly on its priority initiatives and activities. These individuals are a key resource to the LHIN region as they will assume a good deal of

IHSP Community Contribution

Community volunteers and health care leaders contributed about 8,037 hours or 1,108 working days of direct input into the development of this Plan.

FACTS AND FIGURES #1


responsibility in not only representing the needs of their priority populations, but they will bring their collective skills and experience to propel our plans to action, and finally, to achievement. These “expert tables,” each at various stages of devel-opment, will be mentioned further within their respective priorities for change.

Members of the nine Collaboratives or advisory teams, the three Health Interest Networks and other task groups - including health providers, caregivers and citizen activists – are working to create a preferred future for your health care system.

These are people you know in the commu-nity, your neighbours and friends. They, like you, want a health care system that provides the right service to the right person at the right time and they want you to join them in building this plan.

Sharing and Validating the draft Integrated Health Service Plan

on September 29th, 2006, the Central East LHIN board approved a draft of this Integrated Health Service Plan to be shared with community residents for comment prior to its final adoption. To successfully get feedback from the general public, the Central East LHIN conducted 8 awareness events in high-traffic, high-exposure areas (such as shopping malls) across the region.

What You SaidResults from IHSP Feedback Survey

92% indicated that the sessions and Plan gave them a better understanding of LHINs

87% said the Plan, if achieved, would make a difference for them and their community. 82% said the Plan would make a difference for their public health system

96% supported the LHIN priorities Seamless Care for Seniors, Chronic Disease Prevention and Management, Mental Health and Addictions. Support for other LHIN initiatives was also strong: Wait Times & Critical Care (87%), and e-Health (84%).


at each event, Central East LHIN board members, staff and, most importantly, volunteers from your community were on hand to distribute materials, listen to residents, and answer questions related to your health system, LHINs and the Integrated Health Service Plan. Hundreds of conversations were held, and 2500 copies of an “IHSP Quick Facts” were distributed to community residents, along with a feedback form that provided an opportunity for residents to comment.


Figure 1 depicts the journey taken to complete and share this Plan. The LHIN will continue to seek your help and provide more opportunities for input as the Plan evolves and further priorities are established. Transforming the system is a journey we all share. we want to hear from you about your hopes and ideas for the future.

Phase 1 COMMUNITY ENGAGEMENT

Phase 2 COMMUNITY PLANNING

Phase 3 DRAFT IHSP FOR PUBLIC COMMENT

YOUR PLAN

4,000 + Participants 2,000 Pages of Community Input

Environmental Scan to validate findings

9 Local Collaboratives + 3 LHIN-wide Networks250 + people contributing 8,100 hours of direct input

Environmental Scan - evidence to support IHSP directions

Presence in 8 public spaces across the Central East.2500 copies of the IHSP Quick Facts distributed.

FIGURE 1: ROAD TO THE IHSP


ENVIroNMENTaL SCaN

Who We Are, and Where We Live

a General overview

The Central East region is both large and diverse, with a total population of about 1.5 million people living within an area of 16,673 square kilometres. This population is spread across a mix of urban, rural and remote communities, from Scarborough to Northumberland and north to the Haliburton Highlands.

demonstrating the diversity within the Central East LHIN, the average popu-lation density of the LHIN is 89 people per square kilometre. Taken alone, this average masks the range of population density among the nine zones, ranging from 3.75 people in Haliburton to 3,545 in Scarborough.

another example of this diversity is found in the age profile of our communities. It is well known that age is perhaps the most important contributing factor of one’s health status and accessibility to health services. age is also a key factor in considering the supply and availability of health human resources. The percentage of people 65 years and older living in the Central East LHIN and all of ontario

To achieve the forward-looking objec-tives of this Plan, there must be a firm understanding of “where we are” today. This understanding requires knowledge of the characteristics and health profile of the people and communities being served, as well as the range of health services provided.

The “data” of our first environmental scan came directly from our engagement of local residents. They told us their experi-ences – good and bad – in interacting with the health system. we heard about chal-lenges in delivering better and coordinated care. and we heard about opportunities that will make a difference. an extensive summary of those findings can be found at www.centraleastlhin.on.ca/researchan-dreports/researchandreports.html.

Throughout this Plan, examples of “what you told us” will be provided. In addition to this qualitative evidence, this Plan also provides information on “what we know” – that is quantitative evidence and related policy directions supporting a plan for action. This data provides comparisons between the Central East LHIN, other LHINs and the province as a whole. More importantly, the data reveals the signifi-cant differences and similarities between the communities of this LHIN.

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is exactly the same - 12.9%. Between the nine planning zones, the percentage of that population differs from a high of 23.4% in the Haliburton Highlands, to a low of 7.6% in durham west (ajax-Pickering-whitby). The stark differences between the current (2001) and estimated future (2016) age profiles across the Central East LHIN are dramati-cally illustrated through a comparison of the population pyramids from durham west and Haliburton Highlands (right).

a theme that runs throughout the envi-ronmental scan is ‘similar but different’. The Community Profile (Facts and Figures #3) on the following page emphasizes this theme in your LHIN. There are clearly many similarities as one compares the Central East LHIN column to ontario. But taken alone, LHIN-level averages can hide significant differences between our neighbourhoods. Planning your health care services effec-tively means understanding these differ-ences. The environmental scan provides the evidence we need to support our plan-ning and activities.

85 - 89

6% 4% 2% 0% 2% 4% 6%

0 - 45 - 9

10 - 1415 - 1920 - 2425 - 2930 - 3435 - 3940 - 4445 - 4950 - 5455 - 5960 - 6465 - 6970 - 7475 - 7980 - 84

90+

% OF TOTAL PLANNING ZONE POPULATION

% Male 2001

% Male 2016 % Female 2016

% Female 2001

Haliburton Highlands Planning ZonePOPULATION PYRAMID 2001 VS. 2016

85 - 89

6% 4% 2% 0% 2% 4% 6%

0 - 45 - 9

10 - 1415 - 1920 - 2425 - 2930 - 3435 - 3940 - 4445 - 4950 - 5455 - 5960 - 6465 - 6970 - 7475 - 7980 - 84

90+

% OF TOTAL PLANNING ZONE POPULATION

% Male 2001

% Male 2016 % Female 2016

% Female 2001

Durham West Planning Zone POPULATION PYRAMID 2001 VS. 2016


Community Profile


Central East LHIN Variance Service Province

Average

Central East LHINAverage High Low

% Population 65+

% Lone Parent Families

% non-owned private dwellings

% Unemployment Rate (15yrs +)

% with less than grade 9 education

% non-completed high-school

% completed post-secondary education

% low income

Low birth weight babies (2001-03)

Infant Mortality per 1000 live births (2001-03)

Durham West

Durham North-Central

Durham West

(3 zones)

Durham West

Durham West

Haliburton Highlands

Durham North-Centre

(6 zones)

Scarborough Agincourt Rouge

Complete information for all areas can be found in the IHSP Technical Report. Cultural components can also be found on p.56 of this Executive Summary


Scarborough Cliffs-Centre





Durham West



Kawartha Lakes

13% 13%

23% 24%

32% 27%

6% 7%

9% 8%

26% 26%

49% 46%

14% 15%

6% 6%

5.4 4.5

24%

32%

44%

8%

11%

36%

53%

25%

8 %

6.7%

8%

17%

15%

5%

4%

18%

39%

6%

5%

3.4%


Health Services Provided in the Central East region


Central East LHIN Health Services by TypeMinistry of Health and Long-Term Care Data 2005-2006

Service # of providers Total Budget % of CE

Spending

Mental Health Services

Acquired Brain Injury Agencies

Long Term Care Homes

Community Services

Hospitals

Community Programs

Supportive Housing Sites

Agencies for Drug and Alcohol and Problem Gambling

Speciality Psychiatric Hospital

Psychiatric Out-Patient Medical Services

Long-Term Care Homes

Long-Term Care Beds

Supportive Housing Programs

Community Support Services

Elderly Persons Centres

Community Care Access Centres

Community Health Centres

Hospital Corporations

22

7

3

1

2

2

65

9,000

18

49

9

4

3

9

$37,273,843

$1,345,912

$311,628,145

$32,412,238

$171,454,264

$6,857,976

$1,019,997,566

2%

< 1%

20%

2%

11%

< 1%

65%


a PLaN For CHaNGE

Priorities for Change

our mandate first and foremost is to integrate the many disjointed parts of the current health care mix. Initially we are focusing on a limited, but critical, number of areas.

Priorities for change can be described as topics and/or representative target popu-lations that provide the greatest oppor-tunity for improved health outcomes and overall health system performance and sustainability. The four identified priori-ties for change have been determined through consultation and input from you, the residents of the Central East LHIN, and from consumers, formal and informal health care providers, networks and advisory teams.

They are:

Mental Health and Addiction Services

Seamless Care for Seniors

Chronic Disease Prevention and Management

Wait Times & Critical Care

There are many inter-relationships among these priorities for change that must be explored to truly realize an improved,

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integrated system of care. For example, many seniors live for years with one or more chronic conditions. Mental health and addiction problems affect people living in the community as well as those in long-term care or hospitals.

To capture the synergies between these priorities for change, several enablers have been identified by the LHIN. Enablers are common strategic themes that will be used to achieve our priorities for change.

Enabling Change to Happen: System Enablers

Cutting across the priorities for change are common themes or tools that will allow for better access and integration of services, improved patient outcomes, better use of human and financial resources and enhanced sustainability. These tools or enablers will help you and your health care providers find the right care in the right place at the right time.

Priorities for change are focused on the needs of people who need services (e.g., seniors), whereas Enablers are strategies focusing on better delivering that service.

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action items related to these themes are found in the individual priorities for change in the IHSP technical report. our initial enablers are:

E-Health The ontario Health Quality Council reports that “better, more widespread and integrated use of technology will mean improved decisions about care, more effective diagnosis and treatment, fewer medical errors, greater safety, increased efficiency, better access to services, better research on health care and how to run the system and infor-mation to support continuous health system improvement.”

The LHIN is now working on the devel-opment of a common, fully electronic health record focused on patient needs and the use of technology to support people to access the right care at the right time.

If the patient/client is to be at the centre of the system, the patient/client has to be included in the information network, given the capacity to contribute to and use the electronic health record and to communicate with the care team.

Shared Non-Clinical ServicesThe LHIN will work with providers to achieve back office efficiencies with the aim of making better use of health care dollars, finding ways to integrate services and share resources and infor-mation, reducing waste and duplica-tion. Providers will be encouraged

to share current tools and best prac-tices. By gaining back office efficien-cies, more of our existing financial and human resources can be dedicated to direct provision of health promotion and prevention, care and recovery.

Moving People Through the SystemThe LHIN will work with providers to improve the availability of services and access to transportation to services to eliminate uncertainty and confusion about where to go to get the right service. Gaps in the service will be addressed.

There will be better information for people and their caregivers and no “wrong door” to an integrated health service. we will improve client naviga-tion through the system, case manage-ment and transportation. The LHIN will support interdisciplinary team approaches to care and provide more co-ordinated access. we also aim to better support the person and their caregiver during transition between levels or types of care.

Safe Environments of Quality CarePeople should not be harmed by an accident or mistakes when they receive care. The LHIN will work with providers on improving the quality and effec-tiveness of health care services. The aim is to provide a safe environment, including the home, for health care consumers, health professionals and informal caregivers.


Health and Human ResourcesIn conjunction with provincial initia-tives to improve the supply of health care professionals, the LHIN will bring together health providers to improve local capacity for recruitment, training and retention of health care profes-sionals including doctors and nurse practitioners. In addition, barriers that limit the flexibility of health profes-sionals to provide services in the most appropriate place will be dismantled.

Performance dimensions

with your input, future priorities for change will change as required. what is less likely to change are the vision and objec-tives for your public health care system. while this Plan advances the immediate strategic directions of both the Province and the Central East LHIN community, it also contributes to the creation of a high-performing health care system. The Ontario Health Quality Council (www.ohqc.ca) described the features of such a health care system as:

PerformanceDimension

Ontario Health Quality CouncilDescription

Safe

Effective

Person-centred

Accessible

Efficient

Equitable

Integrated

Appropriately Resourced

Focused on Population Health

People should not be harmed by the care that is intended to help them.

People should receive care that works and is based on the best available scientific information.

Healthcare providers should offer services in a way that is sensitive to an individual’s needs and preferences.

People should be able to get the right care at the right time in the right setting by the right healthcare provider.

The health system should continually look for ways to reduce waste, including waste of supplies, equipment, time and information.

People should get the same quality of care regardless of who they are and where they live.

All parts of the health system should be organized, connected and work with one another to provide high quality care.

The health system should have enough qualified providers, funding, information, equipment, supplies and facilities to look after people’s health needs.

The health system should work to prevent sickness and improve the health of the people of Ontario.


The LHINs, in partnership with community residents, health service providers, and other provincial and municipal agencies and programs, will be a leading force in achieving these broad system goals. The strategy map (Figure 2, above) illustrates the process from priority for change to

Priorities for ChangeOur initial focus for system change

Mental Health and Addictions


Chronic Disease Prevention & Management

Wait Times & Critical Care

System OutcomesHow we will evaluate our strategies

Accessible

Effective

Efficient

Safe

People Centred

Integrated


EnablersCommon ways in whichwe will achieve our goals

Moving People Through the System

e-Health

Safe Environments of Quality Care

Health Human Resources

Back Office Transformation

Equitable


Tools & Actions

Community Engagement & Partnerships

Enhanced Cultural Competency

New Resources to Improve Capacity

Funding and Accountability Agreements

FIGURE 2: STRATEGY MAP

enabler to outcomes. Throughout this Plan, we will demonstrate how actions stemming from our identified priorities for change and enablers are making a direct contribution to the performance dimensions of a high-performing health care system.


There is also a need for more community services for people with addictive behav-iours, from eating disorders to alcohol, drug and gambling addictions, she says. “There should be a transitional place, a safe environment where people can spend a couple of months getting interim care, learning job skills and how to cope in the community.

PrIorITY For CHaNGE

Mental Health and Addictions

Mental Illness in the LHINPrevalence Rate. Physician Access.

The prevalence rate for a serious mental illness is 2.5 – 3% of the population, or approximately 43,700 people in the Central East LHIN.

According to the Ontario Health Insurance Plan, (OHIP) billings for 2004, 18% of the population over the age of 15 accessed a physician for mental health concerns in the Central East LHIN.

That adds up to 216,872 people.


Cheryl McCarthy of Courtice has concluded that the health care system is “broken” after her experiences in attempting to get help for her daughter who has anorexia, an eating disorder.

When her daughter first became ill at the age of 12, “we could not find anywhere to go for help,” she says. “There is no connection between agencies, no flow of information, and that has to change.”

When her daughter first developed the illness, there was not much media interest in eating disorders but they are the third most diagnosed illnesses among children, she says.

While the Hospital for Sick Children has an excellent program for children with eating disorders, it took a crisis situation before her daughter was assessed and treated, she says. There are long waits to get into such programs.

Her daughter has been in inpatient hospital programs five or six times over the past 10 years but still had to go through a reassessment to get into an outpatient program, she says. “The whole system is choked down with paperwork and dupli-cation and it doesn’t work.”

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The Impact of Mental Illness and addictions

Mental health and a positive sense of emotional and social wellbeing are funda-mental to the health of individuals, fami-lies, communities and society as a whole. Mental Health and addictions needs to be addressed from a population health approach that takes into account all of the physiological, psychological and social factors that impact health and illness. Such basics as safe and affordable housing, an adequate income, employment, education and a supportive network of family and friends are essential factors in facilitating wellness and promoting recovery from mental illness or substance use. The reality is that people with mental illness or addic-tions often face discrimination, poverty, homelessness and social isolation. These life situations exacerbate the mental illness or substance dependency and often cause serious physical health problems. Mental health and addictions problems (including problem gambling) affect a significant portion of the population.

People of all ages, cultures, education, and income levels experience mental illnesses. according to the Canadian Psychiatric association, “at least 20% of Canadians will experience some degree of mental illness during their lifetime that is serious enough to impair their daily functioning, and the remaining 80% will be affected by an illness in family members, friends or colleagues.” The Canadian Community Health Survey found that nearly 12% of the people between the ages of 15 and 64 suffer from a mental disorder or substance dependence in any one year (CIHI, 2002).

as many as 20% of people age 65+ suffer mild to severe depression, ranging from 5-10% of seniors in the community to as many as 30-40% of those in institutions.1

People with mental illness spend more days in hospital than for the treatment of cancer or heart disease combined.2 Mental Illness accounts for one in seven hospital-izations and one third of all days in hospital (CIHI, 2003; 2005).

Mental health is as important as physical health. and mental health factors can increase the risk of developing physical problems such as diabetes, heart disease, serious weight loss or gain and reductions in immune system efficiency. For example:

People with bipolar disorders have obesity rates two times higher than the general population.

People with physical health problems often experience anxiety or depression that affects their recovery.

Clinical depression occurs in 30% of people who suffer a stroke.

Health Canada reports that more than 30% of users of illicit drugs other than cannabis report harm to their physical health.

30% of people with a mental illness will also have a substance use challenge in their lifetime (termed a concurrent disorder). 37% of people with an alcohol use disorder (up to 53% if it is a drug disorder) will also have a mental illness (Kirby, 2006).

1 National advisory Council on aging-dealing with depression at http://www.nada-ccnta.ca/expression/13-32 Joint Paper of CaMH, oFCMHaP, CMHa-ont, 2001.

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Most mental health and addictions prob-lems remain untreated because of the stigma associated with admitting to these problems. The consequences of not receiving help can be tragic. More than 4,000 Canadians commit suicide every year and more than 90 per cent of suicide victims have a diagnosable psychiatric illness or substance abuse disorder.


Central East LHIN Mental Health & Addictions Access to Primary Care, Ambulatory ER Visits, and Hospital Inpatient Visits (2004-2005)

Service

An

xiet

y D

iso

rder

, S

om

ato

form

, an

d

Dis

soci

ativ

e D

iso

rder

s

Su

bst

ance

-Rel

ated

D

iso

rder

s

Mo

od

dis

ord

ers

Per

son

ality

dis

ord

er

Oth

er C

on

diti

on

s

Primary Care Access forMH&A Services* 49% 12% 10% 8% 9% 2% 1% 9%

The percentage of primary care diagnoses in the Central East LHIN is consistent with the Ontario percentage of 8% for substance-related issues and with a slightly higher percentage of people with anxiety disorders (49% versus 43%).

Ambulatory Emergency Room Visits** 33% 3% 11% 21% 27% 2% 2% 1%

For hospital ambulatory care and Emergency Room visits, the data for Central East LHIN is very similar to the Ontario data, with anxiety disorders accounting for the highest percentage of the visits (33%),followed by mood disorders (27%) and substance-related issues (21%). Together, these three disorders account for 81% of the total visits.

Hospital Inpatient Visits*** 10% 7% 23% 14% 39% 3% 3% 1%

For in-patient hospitalizations, when comparing Central East LHIN data with the Ontario average, the data is almost identical, with mood disorders accounting for 39% of admissions, and schizophrenic and other psychotic disorders 23%.

*Data from one year medical tables, MOHLTC, Population Health Planning Database, excluding institutional patients, percent total visits by diagnostic codes 290 to 319

**Data from MOHLTC, Population Health Planning Database, NACRS Table percent total visits by DSM IV Chapter 5 Block Codes

***Data from MOHLTC, Population Health Planning Database, DAD Table, percentage total visits by DSM IV Chapter 5 Block Codes

Del

iriu

m, D

emen

tia,

Am

nes

ic a

nd

oth

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cog

niti

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iso

rder

s

Sch

izo

ph

ren

ia a

nd

O

ther

psy

cho

tic

dis

ord

ers

Dis

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ers

Dia

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ose

d

in In

fan

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hild

ho

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, o

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ence

along with profound costs to quality of life, the economic costs of mental illness and addictions are estimated as amongst the most costly of all health problems.


what we Know

Mental health and addictions services have been engaged in a process of reform in ontario and across Canada for the past several years. Based on the Ministry of Health and Long-Term Care policy framework as well as the recommen-dations of the provincial Mental Health Implementation Task Force reports, there is a clearly articulated vision and opera-tional framework for a client-centred/client-driven mental health and addictions service delivery system in ontario and in the Central East LHIN.

Most recently, the Final report of The Standing Senate Committee on Social affairs, Science and Technology: Out of the Shadows at Last, Transforming Mental Health, Mental Illness and Addiction Services in Canada (Kirby report) was released in May 2006. after two and a half years of pubic hearings held across Canada, the Standing Senate Committee has made a total of 118 recommenda-tions, including key recommendations that affect the mental health and addic-tions “system” as a whole.

after countless hours of planning, the consumers, family members, health providers, community leaders and govern-ment policy-makers that were engaged in the Task Forces and Kirby reports have created a strong foundation to build upon in guiding the transformation of the mental health and addictions system.

recently, the MoHLTC has made signifi-cant investments in community-based mental health services, in particular for the seriously mentally ill population. Funding has been made available to expand crisis response services to operate 24/7, to provide crisis mobile outreach and crisis residential beds; to implement more aCT Teams and increase intensive case management services; to expand court support and diversion services; to imple-ment early intervention first episode psychosis services; to increase supportive housing; and to provide services to specialty populations (e.g. psychogeriatric, forensic, dual diagnosis, concurrent disor-ders, transitional age youth). Some recent investments in addictions services include community and day withdrawal manage-ment services.


what You Told Us

Mental health and addictions have long been “orphans” within the health care system. during our consultations, you told us people need mental health and addictions services that are fully inte-grated into the overall health care system that include health promotion and preven-tion of illness, acute care and community-based provision of proper services and supports. You also told us to improve navigation through the system with coor-dinated points of entry.

with the leadership of local health providers, a series of focus groups with members of various cultural and linguistic communities was held across Scarborough in June 2006. Participants spoke highly about hospitals and their family and wellness-centred programs, crisis teams, family physicians, commu-nity-based programs including case management and self-help, consumer and family programs and services offered in their same language and culture.

The groups, as well as the nine zone advi-sory teams made up of members of your community, reported on common issues across the LHIN and recommended that the health care system must address the stigma of mental health and addic-tions related illness and increase public awareness.

Mental illness and addictions prevention and early intervention, diagnosis and treatment are crucial. There is a lack of information on available resources and then, once these are found, there are long waiting lists for treatment services. Many people would have avoided hospitaliza-tion if they had known of, and received support services sooner.

They called for increased access to primary health care, the need for supported, affordable housing and employment opportunities and the lack of equitable access to culturally competent services by clients and families of ethnic cultural groups. Concerns expressed also included the high cost of public transportation, the stigma attached to mental health and addictions, lack of family support, and a lack of compassion or respect by some health professionals.


what we Have done

The Central East LHIN Integration Priority report (February 2005) called for the creation of a Mental Health and Addictions Network of service leaders to work with and inform the then-to-be-established Central East LHIN with respect to issues, needs and opportunities in mental health and addictions within the LHIN bound-aries. although the Central East LHIN didn’t formally open its doors until the fall of 2005, the Network held its first meeting in May 2005. Every organization that is directly funded by the MoHLTC (and even-tually the LHIN) and mandated to provide mental health or addictions services is considered a member of the Network. The membership currently represents 25 direct service community agencies, six hospitals and eight associate members.

The Network is able to provide advice using the perspectives of health care providers from their experience “in the field” and their ability to collaborate and consult at the front-line where the challenges to service provision and the opportunities for moving forward are most pronounced. The key purpose of the Network is to support the development and provision of high quality and leading edge mental health and

addiction services that are integrated with each other, with other sectors of the health care system and with their communities throughout the Central East LHIN by:

Providing a collaborative forum for information sharing, linking and innovation

working with and informing the Central East LHIN with respect to issues, needs and opportunities within the mental health and addictions systems

advising on strategies to facilitate system integration and growth

Linking with mental health and addictions networks in other LHIN areas

Preparing a mental health and addictions systems service development plan

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The Central East Mental Health and Addictions Network is advising the LHIN and working on integration, collaboration and partnerships.


what we will do

Here are some of the action steps for this priority for change. Further actions and details are available in the technical report.


Sample Action Steps

Safe

Effective

Person-centred

Accessible

Efficient

Equitable

Integrated



Develop a health resources recruitment, retention and training strategy for the mental health and addictions field.

Promote knowledge exchange focused on excellent program standards and learnings from CQI initiatives.

Develop an interdisciplinary team approach to care across agencies and across sectors (e.g. mental health and seniors, addiction and chronic disease prevention and management.)

Determine what core services should exist in different areas of the LHIN including what elements of service must be locally based and what elements can be regionally based in order to improve access to a continuum of services and supports.

Maintain an up-to-date publicly accessible inventory of agencies, programs and services.

Community mental health and addictions agencies to find ways to share resources and coordinate services.

Develop consistent data collection methodology and outcome measures for success to inform planning processes and funding decisions.

Develop a regional strategy to enhance cultural competency in service provision.

Develop formal partnerships with newly created primary care Family Health Teams and Community Health Centres to ensure inclusion of mental health professionals and addiction specialists in their interdisciplinary teams.

Develop in partnership with other government agencies a youth early intervention strategy that includes prevention education, early intervention and mechanisms to help people move from children’s through the youth and into the adult mental health system if necessary.

Work with the Mental Health and Addictions Network, health providers, consumer groups and family groups to reduce the stigma of mental illness and addictions and the discrimination against those experiencing them.

Promote health and prevent illness by influencing the broader determinants of health such as employment, housing, income and social support.


PrIorITY For CHaNGE


People of her father’s generation grew up at a time when there were no supports and people were taught not to ask for help, she says. It is now important to educate people as they approach senior age on what help is available, she says. “If they will accept help, they can have a better quality of life.”

She is concerned that too many seniors who don’t have family support fall through the cracks because they don’t qualify for Access to Care. “I worry about seniors without family support. With children now moving far from home, more seniors find themselves alone as they age.”

“The whole system relies on the help of the caregiver.”

Helen Edwards Lakefield, caregiver for her mother

“It is kind of mind-boggling a bit. At times I get tired.”

Bev Skinner Ennismore, caregiver for her husband

Judy Nemis is part of the growing “sand-wich generation,” squeezed between providing care for her 95-year-old father so that he can stay in his home and helping her 22-year-old son to estab-lish himself in his own home while she continues working as a registered nurse.

“It helps to have a good sense of humour,” Nemis says when asked how she copes with juggling the demands of caregiver, parent, grandparent, wife and nurse. Caregiver burnout is a problem for those looking after an ageing family member, Nemis who lives in Durham Region admits. “We have our frustrating days and we would all love to have respite,” she says.

Support groups for caregivers are impor-tant, she says. “You learn that you are not alone, you can throw ideas around and there is the opportunity of introducing your senior to others for possible relationships.”

In her case, she says, it helps to have a supportive husband and supportive group of friends.

She visits her father at least once a day to help out around the house, go grocery shopping and run errands such as picking up prescriptions. He receives Meals on Wheels service three times a week and regular Community Care phone calls.

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Priority For Change


People of her father’s generation grew up at a time when there were no supports and people were taught not to ask for help, she says. It is now important to educate people as they approach senior age on what help is available, she says. “If they will accept help, they can have a better quality of life.”

She is concerned that too many seniors who don’t have family support fall through the cracks because they don’t qualify for Access to Care. “I worry about seniors without family support. With children now moving far from home, more seniors find themselves alone as they age.”

“The whole system relies on the help of the caregiver.”

helen edwards Lakefield, caregiver for her mother

“It is kind of mind-boggling a bit. At times I get tired.”

Bev Skinner ennismore, caregiver for her husband

Judy Nemis is part of the growing “sand-wich generation,” squeezed between providing care for her 95-year-old father so that he can stay in his home and helping her 22-year-old son to estab-lish himself in his own home while she continues working as a registered nurse.

“It helps to have a good sense of humour,” Nemis says when asked how she copes with juggling the demands of caregiver, parent, grandparent, wife and nurse. Caregiver burnout is a problem for those looking after an ageing family member, Nemis who lives in Durham Region admits. “We have our frustrating days and we would all love to have respite,” she says.

Support groups for caregivers are impor-tant, she says. “You learn that you are not alone, you can throw ideas around and there is the opportunity of introducing your senior to others for possible relationships.”

In her case, she says, it helps to have a supportive husband and supportive group of friends.

She visits her father at least once a day to help out around the house, go grocery shopping and run errands such as picking up prescriptions. He receives Meals on Wheels service three times a week and regular Community Care phone calls.

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Why Seamless Care for Seniors?

increasing age can bring with it challenges such as physical and cognitive decline, multiple illnesses and increasing chronic conditions, leading to a need to access the health system more frequently.

Seniors are one of the fastest growing population groups in Canada.� Currently about 12% of Canadians are seniors and Statistics Canada has projected that percentage will rise to 19% of the popu-lation by 2021 and to 25% by 2041 when there will be more than nine million seniors.

What is known is that as the population ages, more people are at risk of devel-oping greater and more complex health care needs. this trend of complex needs for our ageing population has a significant impact on the individual, the caregiver, and our health system.

Impact on the Individualat a time when some bodily systems are in decline or may not be functioning at their best, seniors are expected to make many decisions about their health care, understand how and where to access the system and make their way through the myriad of services. Some may have the help of family or friends while others may not. While many conditions are treatable

3 in general, references to seniors are to those over the age of 65 but there are people between ages of 55 to 65 who require the same types of services, such as day programs and trans-portation, and many people well over the age of 65 who do not require these services.

and reversible, sometimes it only takes one event, such as a stroke or a fall, to change the entire dynamic of a senior’s – and their families’ – life.

Coordination and transitions of care are difficult for people with multiple health issues. as the number and range of interactions with health care providers increases, there is an inherent risk that health care for the individual will become fragmented and inefficient. Social factors such as low income or language barriers may also prevent individuals from accessing needed services. accessing the right care, in the right place, at the right time is often challenging for those who are in need of services, their caregivers and providers alike.

Falls and Seniors

Every year, falls account for 65% of injuries among seniors and are estimated to cost Canadians $2.4 billion annually. Nearly one third of seniors experience at least one fall per year.

Falls are one of the leading causes of death among seniors.



Impact on the Caregiver Caregivers, including families and friends, play important roles maintaining and moni-toring health and well being, providing knowledge about an older person’s condi-tion and supporting the older person to live independently. Family members and friends provide over 75 per cent of the care required by frail seniors in Canada. however, many organizations, including the World health organization, have highlighted significant concern with the potential for exhaustion and burnout of caregivers.

Impact on Your Community and Health Systemthe impacts of our ageing population on the demands, costs, performance and sustainability of our health system are extensive:

Statistics reveal that older persons are hospitalized nearly three times as frequently as younger persons, tend to have longer lengths of stay and account for a greater proportion of hospitalizations and surgical procedures.

in 1997-98, people aged 65 and older accounted for �5% of discharges from Canadian hospitals, 52% of patient days and nearly one-third of primary diagnostic and surgical procedures while they made up about 10% of the population.

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emergency department patients over the age of 65 years are more likely to arrive by ambulance, to be admitted to the intensive care unit, and to have co-morbid conditions. emergency physicians have identified the management of older patients as more time-consuming, more difficult and requiring more resources than management of younger adults.

elderly patients facing early discharge may be unable to initially cope with the transition from hospital to home and therefore cannot always be transferred quickly from hospital. they may require extended convalescence and careful discharge planning.

as most health care providers are aware, utilization of health care resources increases exponentially with age. the average dollar amount spent in Canada per 45-64 year old is approximately $2,000 annually. this rises to a little over $4,000 for a 65-74 year old, to about $8,000 for a 75-84 year old, and to an annual average of $16,000 for someone over the age of 85.4

� Specialized geriatric Services in the Central east region, in-formation relevant to System Development, March 2005, as per C.D. howe institute.

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What We Know

these are some sample facts on seniors in the Central east Lhin. More informa-tion is available in the technical report and environmental scan.

Our Ageing Communitythere were about 180,000 seniors living within the Central east Lhin in 2001, about 12.8% of the population. Facts and Figures #8 demonstrates the growth of our seniors population: the number of persons 65 years or older is expected to increase to approxi-

mately 265,000 by the year 2016, for an expected growth rate of 47.5%. over this same period, the projected growth rate for people over the age of 85 years is expected to grow by 91%. Diversity and Ageingthe growing cultural diversity of the population of Central east and the continued inflow of new immigrants, in particular but not exclusively within the southwest areas of the Central east Lhin, means that service providers from across the health care sectors are pres-sured to ensure access to care in multiple languages and to reflect cultural values related to ageing and health care. it is interesting to note that in Scarborough, 24% of the population are recent immi-grants who have arrived in Canada between 1996 and 2001 and almost 12% of Scarborough residents speak neither english nor French. as the immigrant populations’ familiarity with the health care system increases, the way that they access and utilize services will change.

Income and Ageingin Central east, the incidence of low income differs among zones and ranges from 6.�% of the population in Durham north-Central to 24.7% in Scarborough Cliffs-Centre, with the provincial average being 14.4%. throughout the commu-nity engagement processes the issue of low income and how it impacts access to health care was raised.


Age GroupsPlanning Area

Ontario (2001)

55yrs+

19.4%

22.9%

14.9%

38.6%

29.7%

28.0%

27.9%

21.9%

21.9%

21.7%

59.6%

65yrs+

11.0%

13.3%

7.6%

23.4%

18.5%

17.2%

17.4%

13.2%

13.2%

12.8%

47.5%

75yrs+

4.8%

6.0%

3.0%

8.8%

8.2%

7.6%

8.3%

6.0%

6.0%

5.7%

43.9%

85yrs+

1.0%

1.4%

0.6%

1.8%

1.9%

1.8%

2.0%

1.4%

1.4%

1.3%

91.3%

21.6% 12.5% 5.6% 1.3%

Seniors Population and GrowthCurrent % of Total Population (2001) and Projected Growth

Durham East


Durham West


Kawartha Lakes

Northumberland Havelock

Peterborough City and County

Scarborough Agincourt-Rouge


Central East LHIN (2001)

Central East LHIN Growth Projections 2001-2016 (%)


Growth in DementiaDementia affects roughly 8% of Canadians aged 65 and over. however, the preva-lence rises steeply with age, from about 2% among people aged 65 to 74, to 11% for those 75 to 84 and �5% for people aged 85 and over. in 2001, it was estimated that just over 15,000 people in Central east had a form of dementia. that number is expected to increase by nearly 57% by 2016. (See Figure �.)

Alternate Level of Carethere are many reasons why the current service system is experiencing chal-lenges in facilitating the effective and efficient movement of people through it. “Bottlenecks” or back ups in the system can occur for a variety of reasons including lack of availability/access to a particular service or an imbalance in the available levels of service compared to the demand of those requiring them. to illustrate this, consider the issue of alternate level of care or “aLC” patients.

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Source: Ministry of Finance population estimates. Dementia rates from the Canadian Study on Health and Aging. Depression and other disorders data from Health and Welfare Canada.

Percentage Growth from Base Year

Population Projections and Psychogeriatric Estimates for Central East LHIN

Year

0-64

65+

85+

Dementia

Depression

Other Disorders

FIGURE 3:

3� Central East Local Health Integration Network

alternate level of care is a designation that describes those in the hospital who are no longer in the acute phase of their illness but still occupy an acute care bed. the reasons why these people can not leave the hospital vary but it is generally because they are waiting for another type/level of service such as rehabilitation, complex care, supportive housing, home care or long-term care home placement.

the latter, awaiting long-term care home placement, is a significant aLC issue for several hospitals in the Central east Lhin. For example, in 2004, of the total aLC days for Peterborough regional health Centre, over 72% of the days were for patients awaiting placement in a long-term care home.

the ability of the Community Care access Centre (CCaC) to place individuals is compromised when access to beds in long-term care homes is limited. this situation causes ripple effects such that emergency departments can become overwhelmed due to the fact that there is a lack of access to acute care beds. the above example is a complex issue and will not be solved by a single solution or action, such as building more long-term care beds (see Facts and Figures #9).

additionally, the question must be asked whether all those awaiting long-term care actually require this level of support. Perhaps it is simply the lack of avail-ability of other community options that has precipitated the placement process. Seniors themselves must be now engaged in dialogue on the important questions of the preferred place of residence and supports needed to advance the principle of ageing-in-place.

ALC, Sustainability and Long-Term Care Projections

Building more long-term care beds may solve part of the ALC “bottleneck” – but it cannot be the only answer. Based on population projections over the next 10 years and the current long-term care bed complement, by 2016 Central East LHIN would require in excess of 2,000 additional long-term care beds!*

At an approximate cost of $140,000 per bed to build, the result would be $280M in capital costs, and an annual operating cost of over $100M

*Based on a target of 100 beds/1000 persons aged 75 and older



What you told Us

in our consultation and community-engagement process, several consistent themes emerged from what seniors, their caregivers and providers told us:

take a co-ordinated approach to providing services. there are some areas within the Lhin with complete gaps in services.

help seniors to move more easily through the system. information is not moving effectively among service providers and there is a lack of knowledge and understanding of existing services.

improve access to primary care.

remove language barriers; improve transportation options for improved access to services.

Focus more on wellness, giving people the means to create their own relevant health care solutions.

encourage best practices and improve quality care by addressing shortage of physicians and access to geriatric expertise.

•

•

•

•

•

•

What We have Done

the Lhin has established the Seamless Care for Seniors Network, comprised of seniors, caregivers and health and social service providers to provide advice to the Central east Lhin on priorities, goals and strategies needed to improve the system of care for seniors and their caregivers. the network is also a forum for communication, collabora-tion, knowledge exchange and innovation among stakeholders. the network is being chaired by a physician specializing in geri-atrics appointed by the Lhin.

Seniors themselves must be now engaged in dialogue on the important questions of the preferred place of residence and supports needed to advance the principle of ageing-in-place.


What We Will Do

here are some of the action steps for this priority for change. Further actions and details are available in the technical report.


Sample Action Steps

Safe

Effective

Person-centred

Accessible

Efficient

Equitable

Integrated



Improve access to supportive housing or long-term-care placement and safe and secure environments for individuals with cognitive impairments and at-risk behaviours.

Elevate the importance of evidence-based patient safety programs and initiatives, with particular attention to medication management, and falls prevention practices and programs.

Support an interdisciplinary team approach to care. Teams may include such members as a physician and/or nurse practitioner, pharmacist, social worker, dietician, and case manager.

Better support seniors and their caregivers at times of transition between levels or types of care.

Improve availability of services by defining types of core seniors-related services that should be available locally and regionally and improve linkages between community support services and hospitals, community care access centres, family health teams, community health centres and long-term care homes.

Improve access to information about the seniors’ service system in Central East. Address issues related to transportation services.

Enhance quality of care through improved efficiencies by sharing resources and expertise, integrating support and back office functions.

Provide needed supports to caregivers, to enable them to remain healthy and able to continue to provide support to their loved ones.

Improve co-ordination of care between providers, particularly during periods of transition including discharge from hospital, moving from long-term care home to hospital and back, to or from supportive housing or even internally within a hospital setting from one level of care to another.

Obtain understanding of rehabilitation needs of the complex geriatric population and expand capacity where needed.

Be a partner in promoting seniors’ healthy living.


Priority For Change

Chronic Disease Prevention and Management

Lyon now goes to the maintenance exer-cise program in Courtice twice a week and describes the effects as “absolutely wonderful. I can get out and am able to do things.”

Along with more information on what is available, there should be more facilities like the clinic in Courtice for people with chronic diseases, he says.

The clinic has another important benefit in getting people like Lyon mixing with others in the same condition. “It’s good to relax around people who have something in common with you,” he says. “It’s like a support group, it’s good therapy and it adds so much to quality of life.”

Simple things like tying shoelaces are a struggle for people like Reginald Lyon of Whitby who have Chronic Obstructive Pulmonary Disease including chronic bron-chitis and emphysema.

He has difficulty shaving because he has to wear a nasal cannula that provides oxygen 24 hours a day and he can’t leave home without calculating whether he has enough oxygen in his tank to get him home again.

“When you have trouble breathing, you need to be pushed to exercise,” he explains. That is why the respiratory reha-bilitation program in Courtice is so impor-tant to him, he says.

He says he “lucked” into finding the program in a clinic operated by Lakeridge Health. He was looking for a rehabilita-tion program and discovered many of the doctors he spoke to were not aware of any programs. “Doctors should have more information about these clinics,” he says.

“Finally, a doctor told me he had a colleague who knew a colleague, a respirologist in Oshawa who recommended the respira-tory rehabilitation program in Courtice.”

8


Why Chronic Disease Prevention and Management is a Priority

Chronic disease has a significant impact on residents and health care providers in the Central east Lhin. Chronic disease is different from an acute illness in that chronic diseases are rarely cured completely and may impact a person’s life for many years. examples of chronic disease include heart disease, cancer, respiratory disease, diabetes, arthritis, hepatitis C and hiV and chronic mental illness.

Impact on PeopleChronic disease is the leading cause of death in ontario and across Canada. in 2002, 74 per cent of all deaths were due to the following chronic diseases; cardio-vascular (i.e. heart and stroke – ��%), cancer (28%), respiratory diseases (8%) and diabetes (4%).

Chronic diseases can cause pain, limit mobility and impede daily living, thus having a significant effect on an individ-ual’s quality of life. When a person has a chronic disease, it is almost always a shared experience with family, friends and others doing what they can to provide support to the person.

Impact on Your Community and Health Systemthe total cost of illness, disability and death resulting from chronic diseases is about $�2 billion a year in ontario. More than 80 per cent of ontario residents over 45 years of age are living with at least one chronic disease and having one can lead

to another. among these people, �4% have arthritis, �0% have high blood pres-sure, 12% have osteoporosis, 9% have diabetes, 8% have asthma, 6% suffer from depression, 4% have been diag-nosed with cancer and 2% are living with the effects of stroke.

Preventing and effectively managing these diseases would save hospital, drug and physician costs, not to mention the costs that individuals and society bear as a result of chronic disease.


Risk Factor 2000

18.7%

12.4%

17.5%

2003

14.9%

13.9%

19.3%

% Change

3.8%

1.5%

1.9%

Central East LHIN Risk Factors

Smoking (Age 12+)

Obesity (Age 18+)

Heavy Drinking (Age 12+)*

*Defined as more than 5 drinks in one sitting, 12 or more times per year.

Chronic Disease Related Risk FactorsDespite increased awareness that healthy living mitigates the risk of chronic disease, residents in the Central east Lhin as else-where continue to expose themselves to the dangers of chronic disease. For example, in 200�, over 50% of the popu-lation in Central east Lhin was consid-ered to be physically inactive, the second highest rate in the province.

Social Determinantsan ageing and growing population is increasing demand for chronic disease services. in addition, as the population ages the prevalence of individuals with more than one chronic condition (co-


morbidity) increases. in communities such as Scarborough and West Durham there is increased pressure on chronic disease services; in addition to rapidly growing populations there is significant ethnic and cultural diversity. For example, the prevalence of Chronic Kidney Disease in asian populations and the necessity to deliver culturally appropriate services/supports in a variety of languages adds further strain to already stretched chronic disease programs.

Hospitalizations for Chronic ConditionsCentral east Lhin hospitalization for chronic disease is similar to the province as a whole. the top three chronic condi-tions resulting in hospitalization in Central east Lhin during 200�-04 were cardiovas-cular disease (42.7%), respiratory disease (12.6%), and arthritis (11.4%).

hospitalizations in each of the Lhin’s nine planning zones were for the most part, consistent with this rank order. average age of individuals with selected chronic diseases admitted to hospital ranges from 42-70yrs. average length of stay for cardiovascular diseases is 7 days while mental illness, which accounts for only �.6% of admissions, is 15 days.


Prevalence of selected chronic conditionsSource: Canadian Community Health Survey 2003

Chronic ConditionCentral

East LHIN ONTARIO

67,500

5.4%

71,000

7.9%

30,400

2.4%

195,100

15.5%

101,500

8.1%

228,400

18.2%

475,400

4.6%

530,400

7.2%

273,100

2.7%

1,515,600

14.7%

854,000

8.3%

1,798,500

17.5%

Diabetes

Population (age 12+) with Diabetes

% of Population (age 12+) with Diabetes

Heart Disease

Population (age 30+) with Heart Disease

% of Population (age 30+) with Heart Disease

High Blood Pressure

Population (age 12+) with High Blood Pressure

% of Population (age 12+) with High Blood Pressure

Chronic Bronchitis

Population (age 12+) with Chronic Bronchitis

% of Population (age 12+) with Chronic Bronchitis

Asthma

Population (age 12+) with Asthma

% of Population (age 12+) with Asthma

Arthritis / rheumatism

Population (age 12+) with Arthritis/rheumatism

% of Population (age 12+) with Arthritis/rheumatism

Differences in hospitalization can result from various circumstances such as the range of hospital services, availability of non-hospital community supports, the ability of the individual and family to manage their care and in the instance of admissions for arthritis, possibly access to pain management in the community.

Prevalence of Chronic Conditions in Central East LHINthe percentage of individuals over the age of 12 in Central east Lhin with chronic conditions is very similar to that of the province; with slightly higher rates of diabetes, heart disease, high blood pres-sure and arthritis/rheumatism.

�0 Central East Local Health Integration Network

Focus on Diabetes and Chronic Kidney DiseaseDiabetes is a growing chronic disease in Canada. in 2005 over 2 million Canadians had diabetes – and this is projected to grow to over � million by 2010. type 2 diabetes accounts for over 90% of diabetes cases. Factors influencing the growth in type 2 diabetes include an ageing population, increasing obesity and physical inactivity. national costs related to diabetes are esti-mated to grow by 75% between 2000 and 2016 (up to $8.14 billion).5

5 ohinma et al (2004), Canadian Journal of Diabetes – the Projected Prevalence of Diabetes in Canada 200-2016

With the growth in the prevalence of diabetes has come a current growth in chronic kidney disease, and ultimately, with the failure of the kidney, end stage renal disease (eSrD). eSrD has increased significantly across Canada, resulting in a noticeable rise in the demand for dialysis services:

From 1997-2001, the number of patients treated for eSrD in Canada increased by almost 20% (Cihi, 2004). of new patients in 2001, 55% were 65 years of age or older, increasing the rate from 5�/100,000 patients 65 years or older in 1997, to 68/100,000 in 2001.

annual growth in eSrD has been estimated at 12% within toronto for 200�-201�. in the communities of Durham and the counties of northumberland, Peterborough, haliburton and the City of Kawartha Lakes an annual prevalence rate increase of 6.5% was projected to 2017.

highlights from the soon to be released, iCeS atlas “Predicting the growth in Dialysis Services in ontario 2006-2010”, project that the Central east Lhin will have the largest number of people using dialysis services of all Lhins in the gta by 2010. the number of people using dialysis services is projected to grow from approximately 500 in 1998 to over 1500 by 2010.

•

•

•

Diabetes and Primary Care2004

In 2004 Ontario, 621,130 individuals saw a physician for diabetes care; of these individuals 83,151 were from Central East LHIN.

As such, in 2004, 13.4% of all patients seen by a physician for diabetes care were from Central East LHIN, this was the highest of all 14 LHINs.

Almost 80% of individuals with diabetes in the Central East LHIN are cared for only by their family physician; this is consistent with the provincial average.


Integrated Health Service Plan �1

What We Know

in response to the growing need for services, health care service providers and government have, for the most part, developed programs focused on specific diseases. But there are often common needs among people with chronic diseases, for example education on their condition, eating properly, physical rehabilitation, peer support groups and supports for caregivers.

activity to prevent the development of chronic diseases can be targeted toward influencing the individual choices a person makes or toward influencing the population as a whole. For example, successful tobacco prevention interven-tions in Canada have combined individu-ally targeted interventions such as clinics on using the nicotine patch with regula-tory legislative initiatives to create smoke free buildings and fines for retailers who sell tobacco to minors.

equally important to preventing or delaying the on-set of chronic disease is providing effective comprehensive management and treatment for those living with chronic diseases. effective chronic disease programs offer system-atic care for the chronically ill, through early identification and assessment, diag-nosis, timely interventions based on best-practices, education on the disease, and follow-up. a systematic approach which considers the various needs of the whole person and their caregivers (i.e. family or friends) will improve quality of life of those affected and strengthen the health care system by reducing demand for acute care and building the necessary communi-cation linkages and working relationships between primary care providers/physi-cians, specialists, in-home providers, pharmacists and other community health care partners.

While there are numerous chronic disease prevention initiatives across ontario, researchers have found there is need to strengthen the infrastructure in such areas as human resources and informa-tion technology. Cutting the duplication of activities and improving the ability to communicate and transfer best practices is also needed.

Everyone benefits when effective and co-ordinated chronic disease prevention and treatment programs are in place.


researchers have also found the most appropriate and effective roles for health care providers in improving general popu-lation health have not been very clearly described. in ontario, there has been little agreement on the most effective way to orient the various prevention and management programs and initiatives into a common chronic disease preven-tion and management system.

a shift in thinking regarding health care is needed to support effective chronic disease prevention and management. the transformation involves an orienta-tion shift from illness to wellness so that prevention becomes a priority at all levels of the health care continuum.

For its part, the health care system in Central east Lhin needs to adopt an over-arching framework for collaborative planning and service delivery that reflects the unique and complex requirements of those living with, and at risk of developing, a chronic disease. our current health care system was designed to manage acute, not chronic long-term illnesses.

Despite the significant prevalence of chronic disease, and similar needs of chronic care clients, best-practices inter-ventions have not been adequately docu-mented nor well-disseminated.

the current chronic disease preven-tion and management service system is heavily reliant on the hospital sector for funding. Programs may be at risk when hospitals seek to reduce their spending. Few of the programs have had adequate resources to collect and analyze the data essential for planning, identifying best practices and conducting evaluations. as a result of these limitations, in ontario:

Less than 10% of diabetics receive all the guideline-based care they require;

60% of asthmatics are not properly controlled - only 48% are taking their medications properly;

Less than �0% of people with high blood pressure (hypertension) have their blood pressure properly controlled;

Less than 50% of patients with clinically significant depression are treated properly;

only 60% of patients 65 or older with a history of a Myocardial infarct(Mi) are on statins;

approximately 20% of patients with heart failure are readmitted within 60 days. 6

6 Sources: hindmarsh, 2006; rachlis, 2006; MohLtC, 2005

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•

•

•

•

•


What you told Us

During our community engagement sessions, you re-emphasized the role for the individual, health care providers, public health units and the community, including government, in improving chronic disease prevention.

individuals are becoming more informed about healthy living and health care. Knowledge is the first step but the behav-iour change that promotes a healthier lifestyle is more difficult to achieve. empowerment of the individual comes from knowledge and a supportive home, workplace, community and health care system to help make change happen.

the community needs to urge all sectors, including health, education, justice, labour, social services, housing, transportation, technology and recreation to work together to improve individual and population health and reduce inequity.

there is a need to improve the ability of consumers, caregivers and service providers to identify what services exist and how to access these services. People desired cultur-ally competent chronic disease prevention and management programs delivered by comprehensive inter-disciplinary primary health care teams.

Finally, you told the Central east Lhin to adopt a framework for collaborative plan-ning and service delivery that reflects the unique and complex requirements of those living with, and at risk of developing, a chronic disease.

“We understand rural communities like Haliburton have difficulties accessing health care. While we have public transit here in Scarborough, a single mom on social assistance with three kids and no babysitter has obstacles to overcome to get to a doctor.”

Bruce MacDougall West hill Community Services

�� Central East Local Health Integration Network

What We have Done

the Lhin and community stakeholders have begun the process of creating a Chronic Disease Prevention and Management Network, to be comprised of citizens, caregivers and health and social service providers. the network will provide advice and assist the Central east Lhin on achieving its objectives for chronic disease prevention and manage-ment. the network is also a forum for communication, collaboration, knowl-edge exchange and innovation among stakeholders. the Lhin has appointed two physicians to co-chair the network, one physician from primary care and the other hospital-based.


Sample Action Steps

Safe

Effective

Person-centred

Accessible

Efficient

Equitable

Integrated



Partner with diabetes care/education providers to identify issues and develop strategies related to delivering effective care and support to people with diabetes and their caregivers.

Initiate a chronic disease prevention program to provide support to health care providers in terms of education and training about evidence-based best practices.

Improve linkage with community mental health workers/programs to address depression, which may be associated with chronic condition.

Increase support for individuals to self-manage their disease and its progression. Improve access to respite programs for caregivers and to pain management programs for people with chronic disease.

Pursue chronic disease models that provide care in the community along with co-ordinating travel supports among health and other community service providers.

Use technology to reduce the distance between people with chronic disease, their family physician/care team specialists. Explore the use of existing community-based video conferencing facilities to provide improved access to chronic disease specialist consultations.

Identify opportunities for co-ordinated visits and common scheduling.

Implement a consistent self-management program for people with chronic disease for Central East, along with co-ordinated cross-disease education programs.

Providing equitable access to stroke programming (t-PA) for the residents in Durham Region. This is a significant gap that requires resources and immediate attention.

Develop a Central East LHIN knowledge base for cardiovascular disease, stroke, chronic kidney disease and diabetes, respiratory disease and arthritis. Knowledge building will include an assessment of how consumers and caregivers move through the system of care in Central East.

Develop a comprehensive understanding of cardiac care services at the provincial and Central East LHIN level. Such a cardiac care strategic plan would need to identify the services that exist and the appropriate levels of care to be provided locally/centrally for the full continuum of cardiac care services including strategies to accommodate transportation/transfer requirements.

Work with Family Health Teams and other primary care providers to enhance the ability of primary care practitioners to deliver effective chronic disease prevention and management. Develop inter-disciplinary care teams and primary care support for people with chronic disease who do not have a regular family physician.

Work with CKD service providers across the LHIN to consider the issues identified and the strategies proposed in the existing multi-year strategic ESRD Plans (Toronto and Durham HKPR District Health Council’s ESRD reports 2004) and the May 2005 GTA Dialysis Access Task Force report.

The LHIN will utilize the Chronic Disease Prevention and Management Framework proposed by the Ontario Ministry of Health and Long Term Care. We will use the framework to build enhancements to the system of care and supports for people with chronic disease. Actions must include the development of partnerships involving individuals with chronic diseases, the health care service providers, and the community.

Collaborate with non-health sector community providers such as housing, social services and transportation to strengthen public and provider awareness of the impact of broader determinants of health on effective prevention and management of chronic diseases.

the top three chronic conditions resulting in hospitalization in Central east Lhin during 200�-04 were cardiovascular disease, respi-ratory disease and arthritis. incidence of diabetes is very much on the rise. therefore, the network will focus initially on these four chronic disease areas:

Cardiovascular disease and stroke

Chronic kidney disease and diabetes

Respiratory disease

Arthritis and related conditions

What We Will Do


•

•

•

•



Sample Action Steps

Safe

Effective

Person-centred

Accessible

Efficient

Equitable

Integrated



Partner with diabetes care/education providers to identify issues and develop strategies related to delivering effective care and support to people with diabetes and their caregivers.

Initiate a chronic disease prevention program to provide support to health care providers in terms of education and training about evidence-based best practices.

Improve linkage with community mental health workers/programs to address depression, which may be associated with chronic condition.

Increase support for individuals to self-manage their disease and its progression. Improve access to respite programs for caregivers and to pain management programs for people with chronic disease.

Pursue chronic disease models that provide care in the community along with co-ordinating travel supports among health and other community service providers.

Use technology to reduce the distance between people with chronic disease, their family physician/care team specialists. Explore the use of existing community-based video conferencing facilities to provide improved access to chronic disease specialist consultations.

Identify opportunities for co-ordinated visits and common scheduling.

Implement a consistent self-management program for people with chronic disease for Central East, along with co-ordinated cross-disease education programs.

Providing equitable access to stroke programming (t-PA) for the residents in Durham Region. This is a significant gap that requires resources and immediate attention.

Develop a Central East LHIN knowledge base for cardiovascular disease, stroke, chronic kidney disease and diabetes, respiratory disease and arthritis. Knowledge building will include an assessment of how consumers and caregivers move through the system of care in Central East.

Develop a comprehensive understanding of cardiac care services at the provincial and Central East LHIN level. Such a cardiac care strategic plan would need to identify the services that exist and the appropriate levels of care to be provided locally/centrally for the full continuum of cardiac care services including strategies to accommodate transportation/transfer requirements.

Work with Family Health Teams and other primary care providers to enhance the ability of primary care practitioners to deliver effective chronic disease prevention and management. Develop inter-disciplinary care teams and primary care support for people with chronic disease who do not have a regular family physician.

Work with CKD service providers across the LHIN to consider the issues identified and the strategies proposed in the existing multi-year strategic ESRD Plans (Toronto and Durham HKPR District Health Council’s ESRD reports 2004) and the May 2005 GTA Dialysis Access Task Force report.

The LHIN will utilize the Chronic Disease Prevention and Management Framework proposed by the Ontario Ministry of Health and Long Term Care. We will use the framework to build enhancements to the system of care and supports for people with chronic disease. Actions must include the development of partnerships involving individuals with chronic diseases, the health care service providers, and the community.

Collaborate with non-health sector community providers such as housing, social services and transportation to strengthen public and provider awareness of the impact of broader determinants of health on effective prevention and management of chronic diseases.


Waiting for health services can place a heavy stress on people and their families. People may not find the care they need nor be aware of services that could help them be healthier; sometimes those services are in great demand and people have long waits for therapy or treatment that would make a real difference to individual and family distress and quality of life.

Public opinion polls have consistently shown that timely access to care is a high priority for people, health care providers and the public at large. Waiting for emer-gency care – particularly in peak periods – has also been a re-occurring theme in Canadian and international media for some time.

Priority For Change

Wait Times and Critical Care

in fact, wait times can be seen as a proxy measure of how effectively, efficiently, and appropriately resourced your health system is functioning. Delays in emer-gency departments, surgical procedures, and diagnostic services cannot simply be addressed by adding additional resources. While not diminishing the importance of appropriate capacity, the Lhin recognizes that sometimes the flaws and delays are latent within the design and opera-tions of a particular service. there are also systemic challenges like insufficient access to home, prevention and rehabili-tation programs that drive up demand for acute and emergency services. Solutions at solving wait times and improving access must be multi-faceted.

9


What We Know

Surgical and Diagnostic Wait Timesin its plan to increase access and reduce wait times for five major health services (cancer surgery, cardiac procedures, cata-ract surgery, hip and knee replacements, and Mri and Ct scans), the Provincial government also calls for a multi-pronged approach that includes increasing the number of new procedures to elimi-nate the backlog developed over the last decade, investing in new equipment such as Mri machines and extending hours of operation, standardizing best practices to improve patient flow and collecting and reporting accurate, up-to-date data on wait times to allow better decision making and increase accountability.

Critical CareFor some services, like the life-saving capacity of critical care hospital units, waiting is not an option. Critical care is a vital resource for people who have serious life-threatening disease or injury. these units, also referred to as the intensive Care Unit (iCU), are staffed with highly trained nurses and physicians providing one-to-one care, employing highly sophisticated drugs and technologies.

if critical care resources are unavailable, patients requiring life-saving assistance will be at risk. the iCU is also a central hub of other hospital services to which patients are transferred from other areas of the hospital. a lack of access to the iCU can create a “bottleneck,” hindering the optimal flow of patients from the emer-gency and surgical rooms or other hospital wards – resulting in cancelled surgeries and longer wait times.

although the relative numbers of critical care beds in a hospital are small, they are very resource intensive. it has been esti-mated that while critical care resources account for only 5-10% of a hospital’s bed-occupancy, they consume as much as �4% of hospital budgets. given its overall expense and importance to optimal patient flow, the 2005 report of the ontario Critical Care Steering Committee (2005) described critical care as a “make or break” point for other hospital services.7

the 2005 report also projected that without concerted efforts to improve quality and efficiency, faced with growing environ-mental challenges (e.g., population growth,

7 http://www.health.gov.on.ca/transformation/wait_times/wt_re-ports/criticalcare_0�05.pdf


ageing population) ontario would require an additional 25-50 critical care beds each year for the next 20 years! the typical cost for operating one critical care bed in our Lhin (excluding physician payments) is approximately $500,000 per year. While additional critical care beds have been created, and more will be needed, the Critical Care Strategy is working on a series of innovations that will maximize the value and quality of the province’s current critical care resources.

Emergency Departments (ED)the prescription of the Critical Care report provides sound advice for other areas affected by delays and resource challenges. For example, the hospital emergency Department and ambulance effectiveness Working group (2005) concluded that the principal cause of ambulance offload time delay is a lack of capacity to treat hospital in-patients (such as in the iCU), leading to prolonged emergency Department Length of Stay (eD LoS) and eD overcrowding. the Working group also concluded that implementa-

tion of best practices will enable hospi-tals to improve performance and achieve benchmarks contained among the group’s 15 recommendations. among these are:

equitable and medically appropriate distribution of those patients requiring eD care.

timely access to diagnostic imaging, laboratory testing and specialty consultation and disposition.

timely transfer to an in-patient unit, other facility or home.

Likewise, a key component of the Provincial Critical Care Strategy is the establishment of a province-wide system for critical care performance measure-ment and quality improvement that will increase efficient and effective critical care service delivery.

•

•

•


how are We Doing?

Surgical and Diagnostic Wait TimesSince 200�, Central east Lhin hospitals and Community Care access Centres have been active participants in the Provincial Wait times Strategy.

Unfortunately, priority targets for wait times in each of the 6 areas have yet to be met. the good news is that since the data has been collected, the trend has been to shorten waits. you can get wait time information hospital by hospital at: www.health.gov.on.ca

Emergency Departmentsemergency Department length of stay is measured from the time the patient is first registered or triaged in the eD until the time


Service Priority Level 4Access Target

(in days)

84

182

182

%Completed within Target

93%

84%

81%

Current(Jun-Jul 06)vs. Baseline

(Aug-Sep 05)

-21.1%

-22.6%

-33.1%

Cancer surgery

Cataract surgery

Hip replacement

182

28

28

64%

35%

63%

0.0%

0.0%

-9.8%

Knee replacement

MRI

CT

*90% completed within: The point at which 90% of the patients have completed surgery or have had their exam, and the other 10% are still waiting.Source: http://www.health.gov.on.ca/transformation/wait_times/wait_mn.html

Central East LHIN Wait Time Trend Analysis90% of Procedures Completed Within*

the care provider discharges the patient from the eD. this measure includes time waiting for assessment or treatment and time spent receiving care. the Canadian institute for health information (Cihi), concludes that patients accessing emer-gency departments from hospitals in the Central east Lhin wait on average about one hour from the time they register and are triaged to the time they see a physi-cian for assessment. Patients on average wait another hour from the time they see a physician to the time they are discharged. this overall time is similar to the provincial median wait time for patients accessing an emergency department across ontario.8

8 Data Source: 200�-2004 national ambulatory Care reporting System (naCrS) collected by the Canadian institute for health in-formation (Cihi). the data include patient-specific information from 16� ontario facilities providing care in emergency departments.


even among the eD patients, however, there is a large variation in the severity of illnesses and injuries. one way of categorizing the severity of illness for eD patients is the Canadian triage and acuity Scale (CtaS), a ranking system from one (immediate) to five (non-urgent) that is designed to help ensure that patients who need immediate care get seen first.

according to the data, the majority (75%) of patients seen in eDs located in the Central east Lhin in 200�-2004 were triaged as either urgent (CtaS iii) or less-urgent (CtaS iV). those requiring imme-diate (CtaS i) or emergent care (CtaS ii) represented less than 10% of all eD visits in the Central east Lhin. this finding, along with those presented elsewhere in this Plan (e.g., mental health, addictions, primary care access, and pain manage-ment impacts on eD use) raises important questions around the factors that affect waiting times, such as the appropriate uses of emergency departments.

Central East LHIN Critical Care Resourcesa recent inventory revealed that there are a total of 127 Critical Care beds in the Central east Lhin. not all iCU beds, however, are equal in their capacity to deal with acute care patients. Making up this total there are:

81 – Level 3 critical care beds. these units can provide the highest levels of care to patients who require advanced or prolonged respiratory support alone, or basic respiratory support together with the support of at least two organ systems.

�6 – Level 2 critical care beds. these beds can provide care to patients who require more detailed observation or intervention including support for a single failed organ system, short-term ventilation, post-operative care, or patients “stepping down” from higher levels of care.

•

•

Central East LHIN ED Visits2003-2004

530,000 patients visited an emergency department located in the LHIN. This represented approximately 12% of all emergency department visits in Ontario. The largest percentage (39%) of these patients were between 19 and 45 years of age.



as currently configured, there are not enough critical care resources to meet the demands of our population. nor is there wide availability of specialized services related to critical care, such as neuro-surgery, cardiac surgery, burn units or trauma, within this Lhin. however, a key goal of the Lhin critical care strategy is to improve the coordination and “system-behaviour” of our current resources. While individual hospitals continue to have their own critical care units, one vision is to see all these resources working optimally together to create a “virtual single system of critical care” in the Central east Lhin that provides services to people regard-less of where they live. a recent snapshot of Criticall data shows this goal is far from being obtained. (note: Some patient refer-rals are not captured by Criticall Data.)

a snapshot of all Criticall referrals in the Central east Lhin in March and april, 2006, showed that 975 patients required transfer to another hospital. of these, only 6% of these patients were transferred to another Central east Lhin hospital, the rest were sent to facilities in neighbouring Lhins (89% going to the toronto Central Lhin). a majority (60%) of these patient trans-fers were for services not provided in the Central east (e.g., neurosurgery, cardiac surgery, trauma, burn).

given that the Central east Lhin is dependent on other regions for special-ized services, partnerships and transfer agreements with other Lhins will require development. however, patients are being referred outside the region despite the needed service being offered locally. By developing the self-sufficiency of the Central east Lhin critical care and surgical network, more people will receive care closer to home.

ICU Criticall Referrals2005-2006

Patients Accepted and Not Accepted by Central East LHIN Hospitals.

Of the patients not accepted, 83% was due to a lack of an ICU bed.


23%Accepted

35%Not Accepted referrals from outside CE LHIN

42%Not Acceptedreferrals from

CE LHIN


What We have Done

Central Lhin has established a Wait Time Working Group to provide guidance and oversight in this important provincial priority area. the working group will produce regular reports on the wait time trends in Central east and progress in reducing wait times.

to improve the quality and coordina-tion of existing critical care resources, the Ministry and the Central east Lhin appointed a local physician to serve as our Critical Care LHIN Leader. the prin-ciple duties of this position are to:

Support critical care service delivery planning and coordination across the Lhin;

Lead critical care surge capacity planning, rehearsal and event management in the Lhin;

Support critical care performance measurement and improvement across the Lhin;

Support demand forecasting, resource allocation and priority setting in the Lhin; and

represent the Lhin at a new provincial table to address operational issues in critical care.

•

•

•

•

•

as a first step in this process, the Central east Lhin Critical Care Leader has engaged local physician leadership, informing them of the strategy, learning more about local critical care issues, and developing the partnerships necessary to move forward collectively. an inventory of existing crit-ical care resources and issues within the Central east has been completed.

recently the government has announced a multi-faceted approach to eD wait time reduction. While details of this plan are not fully known, Central east Lhin hospi-tals received $1.47M for emergency room Process improvement. an additional $2.5M has been earmarked by the Province for emergency Department Coaching teams and an emergency Department Flow toolkit to help hospitals identify and attend to areas where eD operations can be improved. the Coaching teams will use updated eD guidelines and the eD toolkit to help hospitals implement best practices and standardize processes. these measures will help reduce unneces-sary delays, increase bed availability and improve the throughput of patients.


What We Will Do



Sample Action Steps

Effective

Accessible

Efficient

Integrated


Conduct a critical care health human resources needs assessment and explore coordinated recruitment.

Produce regular progress reports on the wait times in the Central East LHIN.

Hospitals in the Central East LHIN will participate in the Provincial Wait Time Information System and other quality improvements.

Establish ED task group with physician leadership to identify best practices, short, medium and long-term goals for ED wait time reduction.

Wait Time Task Group to facilitate inter-facility working partnerships that will improve access according to provincial targets.

Explore an “always available” critical care bed concept for ICU referrals between Central East LHIN hospitals. Institute compulsory use of Criticall to better track patient referrals and system performance.

At a minimum, The Scarborough Hospital, Rouge Valley Health System, Lakeridge Health (Oshawa) and the Peterborough Regional Health Centre will have instituted an intensivist led management model for their critical care units 24/7 by 2008.


integration BeginS With PriMary Care

improving the co-ordination of health care begins with primary care, family physicians in group or individual prac-tices and nurse practitioners. as the most common entry point into the health care system, primary care serves a pivotal role both in prevention and continuity of care as well as a “navigator” to other health services.

the government has recently invested significant resources in developing Family health teams. these are interdisciplinary teams structured to provide comprehen-sive patient-centred primary care services. there are seven Family health teams in various stages of development within the Central east Lhin.

access to primary care was a recurring theme through all community engagement sessions. While the Lhin does not have accountability for primary health care, with the important exception of commu-nity health centres, there does exist a significant opportunity for the Lhin and primary care providers to develop strong and effective linkages to collectively build better systems of co-ordinated care.

What We have Done

the Lhin has already embarked on a process of physician engagement. Physicians can be found serving on our collaboratives, networks and task groups. together, the Lhin, physicians and other health care professionals will continue to find effective ways to collaborate in achieving our common health care goals.

Access to Primary Care

The number of family physicians in the Central East LHIN is the second lowest among the 14 Ontario LHINs, with 68 per 100,000 compared to the Ontario average of 89 per 100,000.


10


CULtUraL CoMPetenCe

Understanding Health within Our Multicultural Fabric

What We Know

Some groups may have a greater biolog-ical predisposition to certain health condi-tions than others. racial, ethnic, linguistic and gender differences in health status can also result from membership in specific social and occupational classes, as well as the systematic experience of discrimi-nation and prejudice. health status differ-ences of visible minorities can also result from inequitable access to care, and there is increasing evidence that their social and economic environment may be threatening their health. and while many new immi-grants show equivalent or superior health status to native Canadians upon arrival, their health status has been shown to deteriorate over time. Patients who expe-rience language barriers have been found less likely to have a usual place of care, receive preventative services or return for follow up. they are at greater risk of non adherence, more likely to progress, and have higher rates of emergency room use and hospitalization.

another critical factor in improving the health of our communities – and a theme that was raised consistently by community residents – is the importance of culturally competent strategies and services that will reach people marginalized as a result of their ethnicity, language, race, gender, sexual orientation, economic status or reli-gious affiliation. equity is a key component of an effective health care system, and without understanding how these factors influence health status in our society, the chances of improving the overall health of the population is near impossible.

11


the need to appropriately address the health needs of cultural-defined groups has led to calls for health care providers and health systems to develop what is termed “cultural competence.” a frequently cited, but complex definition is: “a set of congruent behaviours, atti-tudes and policies that come together in a system, agency or among profes-sionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations.” Developing


Planning Area

Ontario

% with noknowledge

of Englishor French

%ImmigrantPopulation

% Recent

ImmigrationPopulation

%Visible

MinorityPopulation

0%

0%

0%

0%

0%

0%

8%

4%

0%

3%

10%

9%

8%

24%

14%

10%

62%

50%

10%

32%

0%

1%

0%

2%

1%

0%

12%

12%

0%

6%

2%

2%

1%

20%

5%

2%

72%

50%

0%

30%

2% 27% 5% 19%

Central East LHIN Diversity



Kawartha Lakes

Durham West

Durham East




Haliburton

Central East LHIN

cultural competence can be seen as a process of gaining sensitivity, aware-ness and knowledge, and then skills and competence. it requires understanding the communities served, and the cultural influences on their health beliefs and behaviours, and it means tailoring health care delivery to meet their social, cultural and linguistic needs. in doing so, inequi-table access and health disparities can be reduced and detection of culture-specific diseases increased.


there is evidence that culturally-based disparities can be improved through: inter-preter services; recruitment and retention policies of minority staff; provider training in cultural competence; coordinating with health workers in the community and traditional healers; culturally competent health promotion; including family and/or community members in program and service design and care-giving; adminis-trative or organizational accommodations; and location and language of service.

Culture has an impact on attitudes about health status, acceptance or rejection of treatment, the likelihood of following treat-ment protocols and opinions about health care providers. therefore, it is equally important to provide education on “healthy living,” as well as the role of primary care, home health supports, nurses and allied health professionals.


Sample Action Steps

Accessible Equitable

Person-Centred

Develop a publicly available list of services presently available to the uninsured.

Create a publicly available inventory of existing culturally competent health services.

In the first instance, an inventory of linguistic competency will be created for French, Mandarin, Cantonese, and Tamil-speaking communities.

What you told Us

in specific engagements with recent immigrants and cultural communities in the Scarborough community, the Lhin heard first hand about the hardships of newcomers in accessing insured health services, as well as the need for continued education on the range of appropriate services available to them. Specifically, these new Canadians referred to the three month wait period for ontario health insurance Plan (ohiP) and the need for assistance to learn how to navigate, and advocate within the health system.

What We Will Do

the theme of cultural competency can be found throughout each priority for change in this Plan. the Central east Lhin will look to the plans of the Mental health and addictions network as a key first step in expanding cultural competency throughout all health care services. as an additional starting point, the Central east Lhin will:


iMProVing SerViCeS For the CentraL eaSt FranCoPhone CoMMUnity

Unlike other definable communities, there is a historical and legislative obligation in ontario to ensure that health services are available in French for Francophone ontarians. While the Central east Lhin has not been formally designated as a French Language Services area, the French Language Services act (FLSa) and

Local Health Integration Act call for both the Ministry of health and Long term Care and Lhins to actively engage, and plan for, their French-speaking communities. even without this formal FLSa designa-tion, the Central east Lhin believes the inclusion of the Francophone community in health care planning is consistent with its values of comprehensive engagement and cultural competency.

What We Know

Despite a strong web of community connections, this population can access French-language health services in only one CCaC and a single long-term care home (both in Scarborough). a comparison with neighbouring Lhins in the greater toronto region shows that Francophones in the Central east Lhin are not benefiting from the range of services provided elsewhere.

What you told Us

in keeping with its commitment and practice to timely and relevant commu-nity engagement, the Central east Lhin has directly engaged members of the Francophone community on two occa-sions. the following represents the collective findings and directions from these two events. it was also clear that ongoing engagement of the Francophone community in health care planning was an essential ingredient to building trust and affecting real change.


Total FrenchPopulation 2001

Planning Area

140

760

1,590

1,075

5,230

4,205

445

6,215

19,660

Central East LHIN Francophone Population


Kawartha Lakes



Durham East

Durham West




Central East LHIN TOTAL

12


Access, Integration and Innovationenhanced and coordinated access to health services in French is a critical issue for Francophones; this includes full access to a continuum of services in French, from birth to death, from hospital care, and primary care to home care.

Consistent with all communities in the Central east Lhin, Francophones also face challenges over transportation. to help address the needs for access and transpor-tation difficulties, participants suggested the idea of a single point of access for French-language primary care services that would act as single-point of entry for clients and a “hub” for multi-disciplinary primary care services. Such a hub could allow for both a critical mass of health professionals and mitigate transportation issues through improved coordination of services.

AccountabilityFrancophone residents focused on the need for the provision of accessible and quality French language services. Participants spoke of the need for distinct FLhS perfor-mance measures, accountability mecha-nisms and funding issues.

Health Human Resourcesthere is a strong need to deal with the issue of recruitment and retention of French-speaking health professionals, specifically primary care physicians. although partici-pants recognized that this issue does not fall directly under the authority of the Lhin, it was felt that the Lhin leadership can be involved in the development of a strategy to attract and retain French-speaking health professionals.

A Forum to deal with French Language Health ServicesFrancophones cited the need for an ongoing, sustainable table for French language health services planning in the Lhin context. a response to this sugges-tion is largely dependent on the pending regulatory direction provided by the Lhin legislation as well as on the collective direction of the gta-area Lhins.


What We Will Do

Success in meeting the needs of this community will require a spirit of coop-eration among many participants, notably residents of the French-speaking community, neighbouring Lhins, the French Language health Services office of the Ministry of health and Long-term Care, and the FLhS office of the Central South West region (région de Centre-Sud-ouest). the Central east Lhin is committed to doing its part in making this success a reality.


Sample Action Steps

Accessible

Effective

AppropriatelyResourced

Integrated

End-stage goal to designate or establish a primary care hub for French-language health services within Central East LHIN or in conjunction with neighbouring LHINs.

Designate one (or more) health service providers to provide French-language services in the Central East LHIN: acute care hospital (1); long-term care home (2); community care service including Personal Support Workers (1); community mental health agency (1); and community addictions agency (1). This will be achieved within 3 years. In addition, work with the emerging Central East CCAC to provide adequate and accessible services in French.

Notwithstanding provincial direction, the Central East will establish a single Francophone Collaborative that would have the same roles and responsibilities of the geographically-based Collaboratives.


FirSt nationS anD aBoriginaL heaLth

Partnerships to Create Better Understanding and Health

First nations/inuit tuberculosis rates are ten times higher than for other Canadians.

rates of rubella are seven times higher for First nations than for other Canadians.

the highest prevalence of depression in Canada is among aboriginal women.

What We Know

the alderville First nation, Curve Lake First nation, hiawatha First nation and Mississaugas of Scugog island First nation are present in the Central east Lhin with a total of approximately 12,000 residents. Less than one percent (0.9%) of the resi-dents of the Central east Lhin are persons of aboriginal identity, compared to 1.7% of ontario’s population.

•

•

•

Despite marked improvements in the average indicators of health in Western nations, good health is not enjoyed by all. While the health status of Canada’s aboriginal population has been improving over the past 20 years in areas, such as life expectancy and reduction of infant mortality, they have a poorer self-rated health status than the non-aboriginal population and a higher prevalence of many chronic and acute conditions. For example:

on average, First nations males live seven years less than other Canadian men, and First nations females live five years less than other Canadian women.

First nations and Métis people have higher rates of chronic diseases, such as diabetes. type 2 diabetes affects them three to five times more than the general Canadian population.

•

•

13


Community capacity building and empow-erment is an important strategy not only for promoting health but for gaining a better understanding of local expertise and resources, gaps in capacity and how to address these.

Successful programs are ones that build networks and partnerships, increase community awareness and participa-tion at all stages and employ community resources effectively. active involvement of the aboriginal community – among community members and leaders – has been found to be vital to addressing health needs and concerns, instilling a sense of commitment and ownership, defining decision-making roles, and balancing local input and knowledge with health strategies that have been successful elsewhere.

incorporating cultural models directly into the design and implementation of treat-ment and prevention programs can benefit a local community’s cultural revitalization efforts at the same time as enhancing the cultural relevance and effectiveness of health programs. health initiatives in aboriginal communities must reflect the residents’ health beliefs and attitudes, and reflect their understanding of disease and its causes. importantly, aboriginals view health from a holistic perspective as a balance between the physical, emotional, mental and spiritual. initiatives should address all of these components of health and well-being.

Moving Forward

the Central east Lhin looks forward to a learning partnership with its First nations and aboriginal citizens, as well as the aboriginal health planning author-ities. While unique needs and their solu-tions will be determined by aboriginals for aboriginals, this integrated health Service Plan’s focus on the health of the “whole person” with consideration given to the interdependency of health, social and economic environment and culture is consistent with the aboriginal approach to health. For that reason, the outcome of this Plan’s efforts to create a system of coordinated health care may be recognized as an important tool by our aboriginal partners. Furthermore, the Central east Lhin welcomes aboriginal participation in Lhin-wide networks (Seamless Care for Seniors, Chronic Disease Management and Prevention, and Mental health and addictions) so that our actions may be informed by their lived experience and focus on holistic health and community healing.


ConCLUSion

Optimism Abounds!

in the future, service or funding require-ments consistent with this Plan will be established and monitored through accountability agreements between the Central east Lhin and health service providers. it is important to note, however, that the priorities for change outlined in this Plan should not be seen as the sum total of our health care system or the interests of the Central east Lhin. the daily activi-ties of providing high quality, effective and safe care in a number of areas not profiled in this plan continue on an ongoing basis. therefore, the Lhin will focus on meeting the funding requirements of all health service providers to allow them to do their jobs. But the status quo is not acceptable. the integrated health Service Plan is not a research or advisory paper – it’s a docu-ment for change and action!

“Having funding flow through the LHINs should have a significant effect. There should be more clout at the local level.”

Maureen gmitowicz - resident of Brooklin

We are committed to the development of a high-performing public health care system that you, the people living and working in Central east, want for your-selves and your loved ones.

Community engagement and the integrated health Service Plan repre-sent the first phases of this commit-ment. in this plan, we have focused on a limited number of priorities for change that should have a significant impact on both the design and performance of the local health system, with an end goal to improve the health and wellness of the residents of the Central east Lhin.

as broad as this Plan is, it is only the beginning of a process of ongoing activity and sustained improvement. the actions set out in this plan will be carried out over the next three years. the Lhin in partner-ship with members of your community – the networks, Collaboratives, health care providers and various other planning tables – will be meeting over the next few months to prioritize action steps, develop joint work plans and establish both interim goals and performance targets. each year the ihSP will be revised according to our shared achievements, lessons learned, and emerging trends in our community. ihSP Progress reports will be made avail-able to the public.

1�


the Central east Lhin has yet to assume the funding and accountability authority as outlined in the Local Health Integration Act, 2006, but the immediate expectation is that all health service providers within the region will review – and possibly revise – their own strategic planning to be consistent with the themes and activities set out here. individual health service providers will continue to have unique goals according to their organiza-tional mission, however the Central east Lhin expects that they will bring forward contributions and opportunities to move this Plan forward. this may include iden-tification of integration opportunities with other health care providers consistent with the priorities and principles of this Plan, as is now required under the Local health integration act. yet, this expectation of the Central east Lhin is not premised solely on the dictates of legislation, but on the foundational belief that the solu-tions required to address the problems of our health care system rest within the system itself – in particular, those closest to providing care.

to conclude, we turn full circle to the starting assumption in this journey of change: For the ihSP to be successful, it must be seen as the community’s plan, with shared ownership and accountability for its goals, strategies and objectives. in other words, you and your community could not be expected to assume owner-ship and responsibility for the Plan if there was no opportunity to be involved in its creation.

now, with the ihSP complete, we can ask the question: Were we successful? Ultimately, only you – the people of the Central east Lhin – can answer this question. But we have made every effort to involve the community in creating this plan. When one considers the 8,100 hours of volunteer time contributed, it is easy to conclude that this Plan would not have been possible without the community’s support!

the Central east Lhin, with the support of your community neighbours, has truly begun the process of fundamental change through an alignment of strategy, people and information. to be sure, more work has to be done on creating the right conditions through the use of funding and incentives – but without the strong foundation laid out here, it is doubtful if progress in this subsequent area would be possible. it is with confidence that the Central east Lhin, through community engagement and this ihSP has, as one author puts it, ”unleashed the creative potential of [the] local delivery system by tapping into the internal collective intel-ligence and wisdom of those who deliver care [so they] will become the catalysts for significant improvements into the health care delivery system within their communities.” 9

9 Ball and Verlaan-Cole

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Please continue to access the central east lHIn website at www.centraleastlhin.on.ca or contact us at 1-866-804-5446 to find out how your public health care system is being transformed.

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