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Community Care Durham: Improving Health Care
Transcript of Community Care Durham: Improving Health Care
2013-2016 Integrated Health Service Plan
Community Care Durham:
Our Partner in Improving the Health Care Experience
Setting System Level Goals to Achieve the Triple Aim
A Focus on Seniors
Providing alternatives and better outcomes for older Ontarians and their caregivers
Health Links and Designing Care with Clients
Focusing on High-Users
Thinking and Doing Integration
The Hard Science of Improvement
The New Standard for Governance
Integration, Client-Driven Value and the Challenges of Governance.
1. defined pathways
2. clear delivery system
Customize the Experience.
Mergers/Amalgamations: Changes to Governance & Mgmt
Partnerships: Back Office. Lead Organizations
Transfers of Service
We cannot improve and sustain health outcomes for seniors without re-examining, and where needed re-shaping, the foundations of the health care service delivery model.
Much of the focus in the current health care landscape is focuses on improving transitions in care.
The most common means to improve transitions is through collaboration and coordination between health service providers.
Great progress has been made in improved transitions through collaboration.
Is it Sustainable?
A significant challenge to sustaining collaboration:
Not always addressing the root of the problem
Changes in leadership focus & accountability
Organizational capacity to support ongoing oversight and quality improvement.
Admission & Discharge Predictability.
Care Coordination. Case Management.
Electronic Health Information Systems.
Defined accountability for what care is delivered, at what quality and cost, and by whom.
(language & outcomes)
Our current system doesn't always speak to its parts, and more often doesn't communicate (our be understood) with its end-user.
Central East LHIN has the largest number of seniors (65+) in the province
Over the next 10 years we estimate the Central East LHIN’s frail population will increase by 25%, from 110,353 in 2011/12 to 137,530 in 2021/22 - 40% in Durham
7,604 people used 50% of CE LHIN’s inpatient hospital resources in 2011/12.
Of this group, 4,900 were seniors who spent an average of 43 days per person/year in hospital
Did You Know
Few seniors prefer Term Care compared to remaining at home.
123 of every 1000 Central East LHIN seniors aged 75+ require Long-Term Care, the third highest rate in Ontario.
ALL other LHINs have seen decline in demand.
Per capita supply of Long Term Care beds has decreased as a result of a growing seniors population.
Result: Wait time for long-term placement has increased
Why this Aim?
Ontario is introducing a new model of care at the clinical level where all providers in a community, including primary care, hospital, community care, are charged with coordinating plans at the patient level.
A Health Link will be:
person centred with strong mechanisms in place for the client voice:
focused on the high users initially;
designed around and accountable for system-level metrics;
accountable to the LHINs;
flexible and based on local need; and
required to involve primary care.
Health Links - Introduction
The Central East LHIN is proposing the establishment of 2 Health Links in Durham
North East Durham Health Link
West Durham Health Link
We expect to initiate the process in August/September 2013 for one of these Health Links
Community Care Durham will play an important role in both Durham Health Links!
Health Links in Durham
Expectations for Governance
Deliver increasingly client-driven services with demonstrated quality
Anticipate and assist the transitions into and out of the point of care
Align with Strategic Priorities of the LHIN
Look beyond organizational mandate and boundraries to improve outcomes for clients - Health Links
Be able to demonstrate value-for-money (Quality / Cost)
Adopt standardization imperatives on financial and service reporting, performance expectations, and client assessments (e.g., RAI-CH)
Your Story is Our Story
1974: A vision and blueprint for community-based services that help clients stay at home in their community
1975: Durham Region Social Planning Advisory Group accept the challenge of establishing a regional organization that would integrate services
1977: CCD is providing a comprehensive basket of services
2011 Home First: CCD partners with CCAC and Hospitals to provide coordinated discharge planning and enhanced services to people returning home after a hospital visit.
2011: CCD partners with CCAC to improved coordinated intake of community client referrals.
2012: CCD is the first to implement the Assisted Living for High Risk Seniors program in the Central East LHIN. Service is expanded 2012.
2013: CCD Participates in the Durham Community Health Services Integration, resulting in a expanded service delivery, reduced service duplication and improved system efficiency.
With no change, 3,400 additional Long-Term Care Beds required in 10 years
Standardize the System
Many of the barriers to integration are the legacies of provider driven-decisions customized to meet the needs of providers.
Customize the Experience
Integration will allow the system to respond to the unique needs of today and tomorrows health care client.