Final Integration Plan

Transcription

1 Final Integration Plan Hospital and Community Health Services Integration - Haliburton County and the City of Kawartha Lakes A facilitated integration process of the Central East Local Health Integration Network November 11, 2013

2 Integration Planning Team Membership The Integration Planning Team membership was comprised of senior leadership representatives from the participating organizations supported by a Facilitator. Staff from the Central East LHIN served as project support. Name Doreen Anderson-Roy, Manager of External Relations & Administration, Community Support Services Catherine Danbrook, Chief Executive Officer Varouj Eskedjian, President and CEO Brian Payne, President and CEO Gena Robertson, Executive Director Maureen Ruttig, Executive Director Kate Reed, Team Lead, Implementation and Integration Katie Cronin-Wood, Communications Lead Ritva Gallant, Team Lead, Financial and Risk Management Laura Wise, Health Planner Lynn Huizer, Facilitator Organization Victorian Order of Nurses -Peterborough, Victoria, Haliburton Community Care City of Kawartha Lakes Haliburton Highlands Health Services Ross Memorial Hospital Supportive Initiatives for Residents in the County of Haliburton (SIRCH) Community Care Haliburton County Central East LHIN Central East LHIN Central East LHIN Central East LHIN

3 Table of Contents Integration Planning Team Membership... Table of Contents... Executive Summary... i 1. Preparing for Integration The Community Health Services Integration Strategy Evolution of the Community Health Services Strategy The Hospital and Community Health Services Integration Planning Process in Haliburton County/City of Kawartha Lakes Demographics and Context for Haliburton County and City of Kawartha Lakes Haliburton County The City of Kawartha Lakes (CKL) Current State of Hospital and Community Services Identification of Integration Opportunities Evaluation Criteria Analysis Process Developing the Models Governance Models One Entity in Haliburton County Confirmation of Two Entities in the City of Kawartha Lakes Service Realignment Models Hospice/Palliative Care Services Adult Day Services and Acquired Brain Injury Day Services Volunteer Coordination Strategic Alliance between HHHS and RMH Economic Impact Future Integrated Governance and Service Delivery Model Communications and Stakeholder Engagement Transition Planning Conclusion Appendices... 27

4 Executive Summary This Hospital and Community Health Services Integration Plan provides the information required by the Boards of the six organizations who participated in the facilitated integration process in Haliburton County/City of Kawartha Lakes and the Central East Local Health Integration Network (Central East LHIN) Board to make an informed decision on the proposed integration measures impacting LHIN-funded hospital and community-based health services in these areas. The six organizations participating in the facilitated integration process include: Community Care Haliburton County (CCHC) Community Care City of Kawartha Lakes (CCCKL) Supportive Initiatives for the Residents of the County of Haliburton (SIRCH) VON Canada, Ontario Branch, Peterborough Victoria Haliburton (VON) Haliburton Highlands Health Services (HHHS) Ross Memorial Hospital (RMH) The six organizations based their work on the aims first articulated in the LHIN s Community Health Services Integration Strategy that was launched in February 2012, specifically to design and implement cluster-based service delivery models through integration of front-line services, back office functions, leadership and/or governance to: improve client access to high-quality services, create readiness for future health system transformation and, make the best use of the public s investment. An Integration Planning Team (IPT), representing all participating organizations, was responsible for the development of the Integration Plan. A Terms of Reference (see Appendix A) and a set of Principles (see Appendix B) to guide the facilitated integration process were established at the onset of the process. As part of the process, the IPT carried out their due diligence in understanding the history and current state of the participating organizations. Various models of future state governance and service delivery were explored and evaluated using a standard set of evaluation criteria. Boards of Governors were kept apprised of the planning work of the IPT and their feedback was solicited throughout the process. Targeted stakeholders and the broader community were also engaged to share their thoughts on a preferred DRAFT Integrated Governance and Service Delivery Model that proposed a three-entity model for the delivery of LHIN-funded hospital and community services in Haliburton County and the City of Kawartha Lakes. Based on this due diligence and engagement, the IPT recommends the following integration opportunities: One Entity in Haliburton County The creation of One Entity (one organization) in Haliburton County for the delivery of LHIN-funded hospital and community based services would be achieved through a voluntary merger between CCHC and HHHS. It would include the transfer into the One Entity of the accountability to deliver hospice/palliative care services currently provided by SIRCH and Adult Day Program services currently provided by VON. In addition, the accountability for coordinating Foot Care services in Haliburton County would be transferred from VON to the One Entity. i

5 Confirmation of Two Entities in the City of Kawartha Lakes In the City of Kawartha Lakes, two existing entities (two existing organizations) involved in the integration process RMH and CCCKL would retain their own governance and leadership as they continue to deliver their existing services. However, the accountability for delivering Adult Day Program services (primarily for seniors) in the City of Kawartha Lakes would be transferred from VON to CCCKL. Accountability for Adult Day Programming for individuals with an acquired brain injury would transfer to Four Counties Brain Injury Association from VON. A more formal Partnership/Memorandum of Understanding for any future hospice/palliative care services would be created between RMH and CCCKL. Volunteer Coordination SIRCH would explore a new model for volunteer recruitment (VolunteerMatch) in Haliburton County. As a pilot project, SIRCH could be contracted by the One Entity (and other organizations) to recruit, screen and orient new volunteers and offer additional services to organizations coordinating volunteers, thus reducing duplication and leading to a "one-stop-shop" for volunteers. Strategic Alliance between Haliburton Highlands Health Services and Ross Memorial Hospital HHHS and RMH already share a variety of services and have now created a Strategic Alliance that has resulted in the identification of a number of additional back office and leadership initiatives. Additional opportunities are continuing to be explored and opportunities to expand these kinds of initiatives to other community organizations will be investigated. Small Rural Northern Hospital Transformation Fund (SRNHTF) Funding received from the government through the SRNHTF has supported the hospitals in realizing a number of initiatives that have now been included in this Integration Plan and could be used as a catalyst for future integration activities. The Strategic Alliance initiatives that have been supported by the SRNHTF are summarized below: Information Technology/Management and Communications A shared IT department and communications network would be established between the One Entity in Haliburton County and RMH. Procurement The expansion of a shared inventory management system led by RMH would allow RMH to assume the responsibility for procurement for the One Entity in Haliburton County. Pharmacy RMH would provide pharmacy services for the One Entity in Haliburton County to support the hospital and emergency departments. Mental Health Services RMH and the One Entity in Haliburton County would jointly recruit a single Mental Health Director to establish a regionally integrated Mental Health program. Diagnostic Imaging (DI) RMH would provide DI leadership to the One Entity to oversee the expansion of diagnostic imaging services in Haliburton County. Cardiac Rehabilitation RMH is committed to working collaboratively with providers in Haliburton County, including HHHS and the Haliburton Highlands Family Health Team, in order to improve access to high quality cardiac rehabilitation programming. ii

6 Referral Sources (Long-Term Care, Hospital, CE CCAC, Health Practitioner, Clinic, Family/Caregiver, Schools, Other Agencies, Self) Services Services Future State Services and Access As the following diagrams illustrate, clients currently receive LHIN-funded services through a number of doors. In the proposed future state, the intent is to streamline the number of doors individuals need to enter in order to receive service. The expectation is that the patient/client experience would be improved through a better alignment of services, there would be improved access to high quality services through enhanced standardization, there would be a better understanding for the public and providers alike of what services are available and streamlined processes would be in place to assist with navigating the system. Ultimately, Haliburton County and the City of Kawartha Lakes would be better positioned to meet the needs of the residents into the future as demands for services increase. CURRENTSTATE HALIBURTON COUNTY Supportive Initiatives for the Residents of Haliburton County (SIRCH) Adult Day Programs Long-Term Care Victorian Order of Nurses (VON) Supportive Housing Community Care Haliburton County (CCHC) Haliburton Highlands Health Services (HHHS) Hospice/ Palliative Services Community Support Services Hospital Inpatient and Outpatient Services Ross Memorial Hospital (RMH) Hospital Inpatient and Outpatient Services Community Support Services CITY OF KAWARTHA LAKES Community Care City of Kawartha Lakes (CCCKL) Victorian Order of Nurses (VON) Community Health Centre Supportive Housing Hospice/ Palliative Services Adult Day Programs iii

7 Potential Savings for Reinvestment The IPT conducted a financial analysis of all possible integration opportunities as they developed their models and recommendations. In the City of Kawartha Lakes, the confirmation of the two existing entities does not realize significant savings at the present time and in fact, an analysis of a potential merger between RMH and CCCKL revealed the significant cost that would be incurred if the two organizations merged into a new entity. However, it should be acknowledged that since 1985, significant integration, and the associated savings, improved access and efficiencies, has already occurred in the community sector in the City of Kawartha Lakes with the integration of Community Support Services, the Community Health Centre, Hospice Kawartha Lakes and Community Care Village Housing being merged under the leadership of CCCKL. Under the models being recommended in this Integration Plan, the potential savings would be derived primarily through the integration of back office supports in Haliburton County. The IPT estimates that approximately $113,000 could be saved on an annual basis and reinvested, specifically in Haliburton County, should HHHS and CCHC voluntarily merge into One Entity and take on the accountability for hospice/palliative care and adult day programs currently delivered by SIRCH and VON respectively. With the goal of retaining and leveraging the skills of existing staff, the implementation of the One Entity in Haliburton County will require using some of the savings to support equity in staff compensation, future training and development. The IPT recognizes that this investment would support the goal of providing consistent standards and high quality in the delivery of services to local residents. An expectation of the integration is that the current service levels would be maintained and wherever possible, additional savings would be invested in providing more front-line services. Stakeholder Engagement Throughout the facilitated integration process, the IPT ensured that they were updating their stakeholders on the process, outcomes achieved to date and next steps at every opportunity. This included providing information to their stakeholders at all of their open board meetings, staff town halls, volunteer and client meetings. The Central East LHIN website was the central repository for monthly bulletins and the information was repurposed in each of the organizations newsletters and on their websites. News releases were distributed to the local media and updates sent to local elected officials to keep everyone informed. Targeted engagement with health and social service partners assisted the development of a DRAFT Integrated Governance and Service Delivery Model. Broad engagement with staff, clients and their caregivers, local residents and other health service partners resulted in 111 survey responses. Several common themes emerged including: Change Management/Communications Improved Access The importance of local decision making Impact on Volunteers and Staff In reviewing the feedback, the IPT recognized the importance of continuing to communicate and engage with local community residents, clients/consumers/patients and their caregivers, local iv

8 government leaders, staff, volunteers, other health and social service providers and the media. This will be of critical importance during the transition planning required prior to implementation of the integration plan Transition Planning The IPT has identified several strategies to support the successful transition toward the creation of One Entity in Haliburton. The strategies include: Establishing an advisory committee with representation of all integrating organizations to support the transition Developing principles to guide the transition Creating a cohesive implementation and communication strategy to ensure Boards, staff, volunteers and the larger community understand the integration and are kept informed of the process Determining a governance and service delivery structure for the One Entity Creating a strategic plan to integrate cultures Addressing human resources, labour harmonization and union transition issues Minimizing transition costs In the City of Kawartha Lakes the transition of accountability for Adult Day Services will consider coordination with existing services with no service interruption. A clear communication strategy will be provided to ensure the community and clients are aware of how to access services when needed and to support community and client awareness of the change in service providers. The IPT recognizes that one-time transition costs will be incurred, such as legal and human resources, as a result of the development of the One Entity in Haliburton County. It is anticipated that these costs will be minimal and, with more detailed transition planning, increased savings could be realized. Every effort will be made to implement the transition activities in a way that is timely and minimizes transition costs. Some of the transition costs could be funded by the Small Rural Northern Hospital Transformation Fund. v

9 1. Preparing for Integration 1.1 The Community Health Services Integration Strategy On February 22, 2012, the Central East LHIN Board of Directors approved a Community Health Services (CHS) Integration Strategy to address demographic pressures, adjust to changing expectations of patients and families and to meet provincial expectations on improving access, quality and value for money. The Strategic Aim for the Community Health Services integration was to design and implement a geographic-based service delivery model for Community Support Services (CSS) and Community Health Centre (CHC) agencies by 2015 through integration of front-line services, back office functions, leadership and/or governance to: improve client access to high-quality services, create readiness for future health system transformation, and make the best use of the public s investment. Community Support Services (CSS) help clients maintain their safety and independence while living at home and are delivered in the home and /or in locations around a client s community. CHCs provide primary health and health promotion programs for individuals, families and communities. CHCs work with individuals, families and communities to strengthen their capacity to take more responsibility for their health and wellbeing. In addition, some hospitals provide CSS programs in their hospital locations. This includes Haliburton Highlands Health Services. In launching the strategy, the LHIN identified a number of Group 1 agencies that would be directed to participate in the facilitated integration process in each of the clusters. Group 1 agencies included those single or multi-service health service providers (HSPs) who provided services within a clearly defined region within the Central East LHIN (including LHIN services provided through municipalities.) The integration planning began with this group based on the LHIN s determination that integration would most likely achieve the greatest return on investment. Agencies that were categorized as Group 2 (HSPs with broader affiliations cross LHIN, provincial, national) and Group 3 (serving multiple LHIN clusters or a specific client population) were to be included in later phases of the strategy although they could request to be included in the early timing. The Central East Community Care Access Centre, which has a single governance structure for the Central East region was not included in the CHS Integration Strategy. The Community Health Services Integration Strategy recognized that in the Central East LHIN: The population is aging with increasing prevalence of chronic disease and mental illness; The consumer is informed and expects a customer-driven approach to the health care experience with attention provided to improving the client and caregiver s healthcare journey; There is a shift in the healthcare delivery system to improve patient outcomes and access to care, and toward support for health promotion and wellness; The need to meet the healthcare needs of communities within available and sustainable resources - maximizing customer value for money invested; 1 P a g e

10 The current service delivery system must change to achieve the objectives of the Excellent Care for All Act (2010), the Minister of Health and Long-Term Care s Action Plan (January 2012), areas for improvement identified in the Drummond Report (February 2012) and the 2012 Ontario Budget (March 2012). In addition, the integration strategy is intended to reduce risks currently facing the community health services sector such as: Governance: Sustaining governance and succession of small organizations and enabling stronger system stewardship. Management and Back Office: Stretched/sub-optimal operational supports to management (HR planning, IT investment) which limits the sector s ability to identify, monitor and achieve improved performance. Fundraising and Volunteering: Over-reliance on fund-raising and volunteerism puts key services at risk. Significant infrastructure is required to support both. Human Resources Planning: Challenges in recruitment and retention of the skill mix required to deliver services. Client Services: Challenges related to any of the above create direct challenges to client services. This has been the consistent example of all of the Central East LHIN integrations to date. The implementation of the CHS Integration Strategy process started with 10 Durham Cluster agencies in April In May 2012, the Haliburton County process began with participation from HHHS, SIRCH and CCHC. However, it was recognized that Haliburton County was unique to other parts of the Central East LHIN, because of its relative geographic isolation, distinct population and socioeconomic realities and that these differences presented a unique opportunity in Haliburton County to create a comprehensive, integrated service delivery system that included primary care, hospital services, and community-based health care. As a result, two critical partners, the Central East Community Care Access Centre and the Haliburton Highlands Family Health Team were included on the Haliburton County IPT because of their significant contribution to service delivery to local residents. 1.2 Evolution of the Community Health Services Strategy Just as governance and service delivery models were being contemplated by the Haliburton County IPT, developments at the provincial level required adaptation of the Central East LHIN Community Health Services (CHS) Integration Strategy. These developments included the introduction of Health Links and the Small Rural Northern Hospital Transformation Fund (SRNHTF). Health Links In the summer of 2012, the province introduced a new model of care called Health Links where, at the clinical level, all providers in a community, including primary care, hospital and community care are charged with coordinating plans at the patient level. While Health Links will look different in every region, they will be based on a sound framework with specific principles consistent across the province to ensure provincial goals and outcomes are prioritized: 2 P a g e

11 Person-centred planning with strong mechanisms in place for the patient voice to be heard; Build on existing delivery organizations and leverage current capacity and best practices; Representation across sectors with joint accountability for attainment of results; Common targets and metrics; Evaluation built in from the start; and Funding remains flexible to ensure resources are focused where they can be used to deliver results. Small Rural and Northern Hospital Transformation Fund In , the government provided $20M in one-time funding to small, rural and northern hospitals across the province. In the Central East LHIN, $989,900 was allocated to the two designated small and rural hospitals - Campbellford Memorial Hospital (CMH) and HHHS. The objective of the fund is to improve the collaboration between small and rural hospitals and community services to create integrated networks. The fund is intended to: Ensure patient access to core acute care services, including Emergency Department, surgical, medical and obstetrical care; Ensure collaboration with community services, including primary care, home care, mental health and addiction services and community support services; Respond to community needs for post-acute care and palliative services, as appropriate; and, Improve the quality and safety of services for patients and ensure good value for money. This funding provided an opportunity to support: 1. The CHS integration planning work, as well as 2. The hospital integration projects that were being initiated between RMH/HHHS. It also served as a catalyst to other integration opportunities by removing implementation cost barriers. Hospital and Community Health Services Integration Strategy The Health Links initiative and funding to support Small Rural and Northern hospitals precipitated the need to adjust the Community Health Services Integration Strategy. On November 28, 2012, the Central East LHIN Board of Directors approved a plan to combine all three complimentary initiatives - the Community Health Services Integration Strategy, Health Links, and the Small, Rural and Northern Hospitals Transformation Fund. The plan demonstrated how the three initiatives could converge and result in an effective execution strategy that would still achieve the LHIN s goal and long-term vision of the redesign of the health care system. An additional consideration that required an adjustment in the strategy was that the minimum population threshold for a Health Link requires that the City of Kawartha Lakes be included with Haliburton County. Clinical linkages without Community Support Services linkages could represent future obstacles for effective integration of clinical services. Consideration of Community Health Services integration should therefore include both Haliburton County and City of Kawartha Lakes. 3 P a g e

12 Therefore, the Haliburton County integration process was broadened to include the City of Kawartha Lakes and the IPT was reconstituted to include Community Care City of Kawartha Lakes, Ross Memorial Hospital and VON. While the Central East Community Care Access Centre and Haliburton Highlands Family Health Team were no longer required to participate, it was recognized that their input as stakeholders was important in the development of any DRAFT models. The importance of the participation of these two partners in the establishment of a future Health Link in the area was also deemed critical. In providing the Small, Rural and Northern Hospitals funding to HHHS, the Central East LHIN stipulated that the funds were available to promote the outcomes of the facilitated integration process, given the obvious synergies between the intent of the fund and the re-defined process that was now to be launched in Haliburton County/City of Kawartha Lakes. 1.3 The Hospital and Community Health Services Integration Planning Process in Haliburton County/City of Kawartha Lakes With the re-launched process underway in January 2013, senior leadership from the following organizations formed the Haliburton County/City of Kawartha Lakes IPT and began to meet on a weekly basis to develop the integration plan: Community Care Haliburton County (CCHC) Community Care City of Kawartha Lakes (CCCKL) Supportive Initiatives for the Residents of the County of Haliburton (SIRCH) VON Canada, Ontario Branch, Peterborough Victoria Haliburton (VON) Haliburton Highlands Health Services (HHHS) Ross Memorial Hospital (RMH) To review the IPT Terms of Reference, see Appendix A. The work of the IPT focused on understanding the current state of services, identifying gaps and barriers in service delivery, analyzing options for the design of integrated services, engaging governors, stakeholders and the community for input, identifying risks and mitigation strategies and the development and implementation of a communications and community engagement strategy. Principles Guiding Integration To support the facilitated integration, the Central East LHIN sought consensus with the six organizations on a set of foundational Principles to guide the integration process, dialogue and outcomes undertaken with the participating organizations. All parties recognized at the onset of the process that specific details, strategies and tactics supporting integration would evolve throughout the process and that the Principles were intended as foundational guides, subject to revision only with the support of all parties. The full set of Principles agreed to by all parties is included in Appendix B. 4 P a g e

13 Role of the Governors The IPT members were supported by a board member from each organization. This Governance Liaison position was the IPT member s central point of contact, from a governance perspective, for the integration process and participated as required in check-in meetings and was responsible for sharing the team s progress with their respective boards. Implementation Planning Team Process The process of developing this integration plan proceeded along the following critical path: Critical Project Path Date Kick-Off for HSP Governors January 11, 2013 Develop Preliminary Project Schedule January 2013 Approve Principles, Establish Planning Team, Approve Terms of February 2013 Reference SRNHTF Plan and Submission to MOHLTC February 2013 Governors Update #1 February 2013 Literature Review April 2013 Current State Development April 2013 Options Analysis Apr 26, 2013 Governors Update #2 May 2013 Stakeholder/Community/Government Relations Engagement (Targeted and Broad) #1 June 2013 Integrated Model Options Determined June 21, 2013 Governors Update #3 July 2013 DRAFT Integrated Governance and Service Delivery Model August 2013 Governors Update #4 September 2013 September- Stakeholder Engagement (Targeted and Broad) #2 October 2013 November 11, FINAL Integration Plan 2013 Up to and Decision on Integration Plan Boards and Membership including December 5, 2013 December 18, Decision on Integration Plan Central East LHIN Board 2013 SRNHTF Final Report to MOHLTC December 2013 Transition Planning and Implementation January 2014 March 2015 Integration Implementation Complete April 1, 2015 Legend Approval Milestones Updates for Governors Central East LHIN/Planning Team Activities Stakeholder Engagement 5 P a g e

14 Literature Review As part of the facilitated integration process, the Haliburton County/City of Kawartha Lakes Integration Planning Team (in partnership with the Northumberland County Integration Planning Team) commissioned a literature review to document the evidence base on regional rural health service delivery models. Specifically, the team was looking for evidence that integration-type activities improve client access to high-quality services, create readiness for future health system transformation, and make the best use of the public s investment. The review identified, analyzed and compared various service delivery models supporting small, rural hospitals and community integrations from other jurisdictions. All authors writing on the subject agreed that there are unique challenges to delivering health services in rural areas. These challenges foster a prime environment for inventiveness, and make it possible for smaller hospitals, community health centres and community support service providers to be more innovative in overcoming the challenges of providing comprehensive and coordinated health care to residents. Some of the success factors for integration of rural health services include: Effective Leadership Financial Incentives - transitions and on-going Information and Communication Technology, and mobile / point-of-service technologies Flexibility among integrated institutions Adequate workforce Localresources/expertise/support Evaluation/measurement system Implementation of change management strategies was seen as necessary for organizations to build trust as organizational cultures are not easily changed. Therefore, ensuring enough time is allowed to gain full commitment to patient-centered care is recommended with strong, committed leadership at all levels to address concerns/anxieties of the workforce. The full literature review and compendium documents can be found at: iterature_review_overview_of_key_findings.pdf 2. Demographics and Context for Haliburton County and City of Kawartha Lakes 2.1 Haliburton County Haliburton County is comprised of several rural municipalities including Algonquin Highlands, Dysart et al, Minden Hills and Highlands East. According to the 2011 Census, Haliburton County has a population of 17,026. It is recognized that the population more than doubles in the summer months to over 40,000 with an influx of vacationers. Of the permanent population, approximately 50% are over the age of 50 with 25% of the population being over 65 years of age. Haliburton County has two larger towns, Minden and Haliburton. The balance of the population is dispersed across the rest of the County. Given the County covers approximately 4,071 square kilometers, the population density is very low, creating challenges for accessing services. While many organizations visit the County to provide service, there are few that actually call Haliburton County their home base. This also creates some disparities in access to service. 6 P a g e

15 2.2 The City of Kawartha Lakes (CKL) The City of Kawartha Lakes also has a very geographically dispersed population of 73,214 people residing across 3,067 square kilometres. Lindsay is the one large urban centre and is home to approximately 25% of the CKL population. There are several small towns and communities within CKL including Bobcaygeon, Fenelon Falls, and Omemee. Similar to Haliburton County, the summer sees an influx of a large number of seasonal residents. The residents of the City of Kawartha Lakes are slightly younger than Haliburton County with 42% of the population over 50 years of age and 21% over the age of 65 years. Similar to Haliburton County, there are challenges in accessing services. 3. Current State of Hospital and Community Services Each of the six agencies involved in this facilitated integration process have a long and successful history of providing services to their local residents. Together, they provide a wide variety of acute care, long-term care, primary care and community-based support services from locations across Haliburton County and the City of Kawartha Lakes and spend over $115 million annually to deliver services of which over 70% or $81 million is provided by the Central East LHIN. Other funding from provincial government programs, service billings, grants, fundraising activities and donations make up the funding difference. Below is an overview of the services provided by the organizations. For a more detailed description of services provided by each organization see Appendix C for the History of Organizations and the Current Service Summary. 7 P a g e

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17 Referral Sources (Long-Term Care, Hospital, CE CCAC, Health Practitioner, Clinic, Family/Caregiver, Schools, Other Agencies, Self) Services Services The diagram below illustrates the doors that people currently go through to receive LHIN-funded hospital and community services delivered in Haliburton County/City of Kawartha Lakes. Clients can receive a range of hospital and community services through a variety of referral sources. The categories of services have been grouped into Adult Day Programs, Long Term Care, Supportive Housing, Hospice/Palliative Services, Community Support Services and Hospital Inpatient and Outpatient Services. CURRENT STATE HALIBURTON COUNTY Supportive Initiatives for the Residents of Haliburton County (SIRCH) Adult Day Programs Long-Term Care Victorian Order of Nurses (VON) Supportive Housing Community Care Haliburton County (CCHC) Haliburton Highlands Health Services (HHHS) Hospice/ Palliative Services Community Support Services Hospital Inpatient and Outpatient Services Hospital Inpatient and Outpatient Services Ross Memorial Hospital (RMH) Community Support Services Community Care City of Kawartha Lakes (CCCKL) Community Health Centre CITY OF KAWARTHA LAKES Victorian Order of Nurses (VON) Supportive Housing Hospice/ Palliative Services Adult Day Programs 9 P a g e

18 4. Identification of Integration Opportunities 4.1 Evaluation Criteria As a first step in preparing for the analysis of options for integration, the IPT identified decision making criteria that could be used to evaluate any integration options by mapping the guiding Principles for the facilitated integration process to the PAN LHIN Priority Setting & Decision Making Framework Toolkit. The PAN LHIN Priority Setting and Decision Making Framework is a common toolkit used across all LHINs and has a consistent set of criteria to facilitate transparency and accountability to support priority setting and decision making processes. For the full Pan LHIN Decision Making Toolkit, please visit the LHIN web site at and click on Resource Documents Planning Decision Making Framework/Health Equity Assessment. Below is the decision making criteria used by the IPT to evaluate the integration options. See Appendix D for the full evaluation criteria with explanations. Decision-making Step Decision-making Criteria Description Compliance Screen Legislative Barriers Are there legislative barriers that would prevent implementation? Compliance Screen Strategic Alignment Does the option align with the strategic direction of the Province and the LHIN's Integrated Health Service Plan including: Community First Seniors: save 320,000 LTC days Vascular: 25, 000 more vascular days at home/ in the community Palliative: 12, 000 more palliative days at home/ in the community MH&A: 15, 000 more MH&A days at home/ in the community Decision Criteria Economics & Cost Realignment Is the option going to increase value for the key stakeholders, the public? Will costs be reduced allowing for more efficient service provision and/or the movement of funds to front-line services? Decision Criteria Quality Will HSPs continue to provide services that are of consistent standards and high quality to clients? Will quality decline? Decision Criteria Service enhancement including: - increasing access -ensuring equitable access -improving population health -avoiding service redundancy -reducing a gap Will changes improve/ equalize access to services, enhance the health of the population, result in the provision of services, fill an unmet need or reduce the number of providers offering a similar service? Would services decline? Decision Criteria Client Experience & Continuity of Care Which option will best meet clients' needs and minimize service disruption? Will continuity across the continuum of care be improved or hampered? Decision Criteria Autonomy Local governance that understand their communities will have the ability to influence service provision and their own destiny Decision Criteria Adaptability and Sustainability Will service providers be able to sustain changes made and be enabled to adapt to future system changes? Decision Criteria Implementable/Practical Realities Are there any major barriers that would prevent the proposed changes from being implemented successfully? Decision Criteria Capacity to Engage the Community in: -Fundraising -Volunteering Will the organization's ability to recruit local volunteers and fundraise be maintained/enhanced? Final Screen Do no Harm Is there a risk that is so profound that it cannot be mitigated or managed? 10 P a g e

19 4.2 Analysis Process The Planning Team adopted a four-part process to analyze the integration options: Part 1 was the identification of the applicable health service providers and type of integration the option is considering. Part 2 was the identification of pros and cons (advantages and disadvantages) for each option. Part 3 was the identification of risks, an assessment of how likely a risk would occur, its impact and potential mitigation strategies. This also includes identification of a risk threshold i.e. risks that are acceptable and those that are unacceptable. Part 4 was the identification of high-level estimates of savings for reinvestment and any associated one-time transition costs. To access the Facilitated Integration Toolkit, please visit the Central East LHIN website at and click on Developing the Models Governance Models The IPT began their analysis by reviewing a variety of governance structures. Nine governance models were identified and assessed against the evaluation criteria. The models ranged from one single governing entity to six governing entities. Based on the analysis, the IPT narrowed the options to three possible governance models. See Appendix E for the full range of models reviewed. See Appendix F for the full analysis of all nine models. The IPT then prioritized three governance models for further consideration. On May 31, 2013 the IPT met with governance representatives from the six organizations to seek their feedback on these three possible governance models: Two Entities by Geography; Three Entities; Four Entities. In the lead up to the meeting, each of the boards had met separately to consider the models and the meeting on May 31, 2013 provided the governance representatives with an opportunity to share the thoughts of their full boards. As a result of the direction received at the May 31st meeting with Board representatives, the IPT spent additional time further developing the Three Entities model using Part 4 of the LHIN s facilitated integration toolkit: Part 4 identification of high-level estimates of savings for reinvestment into Front- Line services and any associated one-time transition costs. Due diligence associated with Part 4 included a review of wage harmonization estimates and the impact that this would have on future organizational structures. The IPT also solicited opinions from legal experts in order to confirm risks and possible mitigation strategies. 11 P a g e

20 Potential Shared Management Structures Pictured below, The Three Entities by Geography model provides the foundational structure of the Integrated Governance and Service Delivery Model. The three entities represent one entity in Haliburton County and two entities in the City of Kawartha Lakes. Board of Directors Haliburton County One Entity Board of Directors Ross Memorial Hospital Board of Directors Community Care City of Kawartha Lakes CEO CEO CEO Management Structure Management Structure Management Structure Hospital Services & Community Services Hospital Inpatient & Outpatient Services Community Services & Community Health Centre Haliburton County Hospital and Community Services City of Kawartha Lakes Hospital Services City of Kawartha Lakes Community Services Partnerships and collaboration opportunities to work together at the operational level e.g. shared/purchase service arrangements One Entity in Haliburton County The IPT is recommending one entity be created in Haliburton County through a voluntary merger between CCHC and HHHS and the transfer into the one entity of the accountability for some services currently provided by SIRCH and VON. SIRCH and VON would continue as existing entities but would no longer have an Accountability Agreement with the LHIN to provide these LHIN-funded services in the current locations. Benefits to be realized include: 12 P a g e Haliburton County residents will maintain local autonomy and local management over Haliburton County-specific services There would be improved efficiency and effectiveness in coordination and oversight by the One Entity through the streamlining of frontline and back office functions that would result in potential cost savings for reinvestment Access to the community support services currently delivered by the separate organizations HHHS, SIRCH, VON and CCHC would be coordinated so that people would have one service delivery door to walk through

21 The recruitment, retention and management of volunteers supporting the One Entity could provide more opportunities for local residents who want to support their local health care organization. Could lead to improved recruitment and retention of staff by providing equitable compensation and future training and development opportunities typically found in larger organizations Offers several opportunities to improve access to services, streamline the continuum of care and create standardization for the delivery of services while maintaining local autonomy Would provide clients and their caregivers with access to a broad range of services through a larger organization Service volumes would be maintained and potentially enhanced by reinvesting savings identified. One entity could provide a single point for administrative functions such as finance, human resources, payroll, information technology, procurement to name a few which could result in savings for reinvestment. Risks and Mitigations considered by the IPT include: Continuity of Service Provision was considered be an important area for the IPT to consider with the integration of services in Haliburton County. The One Entity in Haliburton County will be a much larger organization and may not have the specialized skills that the smaller organizations have developed over many years of experience. A significant mitigation factor has been the existing commitment to quality service delivery by all the Haliburton County organizations involved in this integration. Through previous integration work the organizations have committed to maintain service delivery quality and levels so that the community and clients will see no disruption in services. Organization Cultural Integration will occur with the voluntary merger of CCHC and HHHS into one entity and the transfer of accountability of services from SIRCH and VON to the one entity. Haliburton County community members expressed a fear of loss of control of community services in that services could become more hospital focussed. The IPT plans to address these concerns through transition planning that could include representation from integrating organizations at different levels and stages of the transition planning and implementation. It should also be noted that HHHS already provides not only acute care but community support services as well. Change management strategies will be required to support staff and volunteers through the transition. Labour Harmonization Costs will be incurred as HHHS, CCHC and VON are unionized environments. The IPT completed a financial analysis that examined the potential costs for the creation of the one entity model. The analysis showed that non-labour costs saving could be used to offset the labour costs. The cost of the one entity model is not a significant enough risk to stop the integration Confirmation of Two Entities in the City of Kawartha Lakes In the City of Kawartha Lakes, the two existing entities RMH and CCCKL would continue with their own governance and leadership. The accountability for some services would be transferred from VON to CCCKL and Four Counties Brain Injury Association. 13 P a g e

22 Benefits include: City of Kawartha Lakes residents will maintain local autonomy and local management over City of Kawartha Lakes-specific services Two entities avoids the high cost of salary harmonization for RMH and CCCKL Integration work lays the foundation for future growth Recognizes the significant integration work already completed in the community Risks and Mitigation: The two entity model did not present any significant risks as services would be provided by two existing entities. The transfer of accountability of VON Adult Day Services did not present any risks. In the City of Kawartha Lakes, the confirmation of the two existing entities does not realize any significant savings at the present time and in fact, analysis of a potential merger between RMH and CCCKL revealed the significant cost that would occur if the two organizations merged into a new entity. However, it should be acknowledged that since 1985 significant integration has already occurred in the City of Kawartha Lakes with the integration of Community Support Services, the Community Health Centre, Hospice Kawartha Lakes and Community Care Village Housing into CCCKL Service Realignment Models Following their analysis of the most effective governance structure, the IPT began determining the services that could be realigned to the one entity. Using the agreed upon evaluation criteria the IPT assessed LHIN-funded services (excluding long term care) being delivered in Haliburton County and the City of Kawartha Lakes. Based on the analysis the IPT agreed that the three areas with the most potential to reduce service duplication and transfer accountability into a multi-service provider in both geographies were Hospice/Palliative Care Services, Mental Health Services and Adult Day Services. Below is the summary of each of these services Hospice/Palliative Care Services The accountability for delivering hospice/palliative care services in Haliburton County would be transferred from SIRCH to the One Entity. In the City of Kawartha Lakes, a formal Partnership/ Memorandum of Understanding for current and any expanded service delivery for hospice services would be created between RMH and CCCKL. This could then lead to better coordination of palliative care services, volunteer and staff training and public education between the One Entity in Haliburton County, RMH and CCCKL. Several advantages could be realized by integrating hospice/palliative care services. The continuity of care could be improved between inpatient and community services. As well, primary care would be more involved with a potential further linkage to Health Links as it is implemented in Haliburton County and City of Kawartha Lakes in the next year. 14 P a g e

23 Volunteers are a critical part of hospice/palliative care service delivery. The IPT identified a change from a small community service organization to one larger entity could potentially impact the loyalty of volunteers. Engaging volunteers early in the transition process will support continued volunteer loyalty to hospice service delivery. This is anticipated to be part of the change management strategies Adult Day Services and Acquired Brain Injury Day Services The VON would transfer the accountability and funding for Adult Day Services in Haliburton County to the one entity. In the City of Kawartha Lakes, Adult Day Services in Lindsay would be transferred to CCCKL. Benefits include: Increase flexibility in programming of Adult Day Services in a larger multi-service organization Streamlining the number of providers offering the same service Continued delivery of current service volume The VON Acquired Brain Injury Adult Day Service would transfer to Four Counties Brain Injury Association. This is a highly specialized service and the IPT recognized the need to align this specialized program with an organization that has the expertise in delivering specialized ABI adult day programs. Benefits include: Continued delivery of current service volume Strengthening expertise in delivering specialized programs Volunteer Coordination As part of the one entity model there is an opportunity to investigate a new model for volunteer recruitment (VolunteerMatch) in Haliburton County. As a pilot project, SIRCH could be contracted by the One Entity to recruit, screen, orient and train volunteers, thus reducing duplication and leading to a "one-stop-shop" for volunteers. Volunteers are an important component of service delivery for CCHC, VON, and SIRCH and provide critical roles to support HHHS through two hospital auxiliaries. As well, Haliburton County has over 50 not-forprofit organizations that use volunteers with each doing its own recruitment of volunteers. While some organizations don't screen or train, those that do often vary greatly in their processes. Some have formalized structures and policies for these activities, with clear expectations and evaluation criteria. Others do not. Overall, however, a great deal of time, energy and resources are spent on recruitment, screening, training and maintaining files/data. Potential volunteers in Haliburton County, who often are new retirees moving up to the area, have no idea what is available or where to go to find the information. They currently have to find out about and approach each non-profit organization individually to determine what they do, and apply to each one they are interested in -- a process which includes multiple intake processes, having references checked multiple times, filling in extensive amounts of paperwork and perhaps obtaining several police checks. Each agency orients the volunteer differently and separately. There have been concerns expressed by 15 P a g e

24 many not-for-profit organizations that there is duplication of service and competition for volunteers. VolunteerMatch will be a new program that could be funded in part initially by the Small Rural Northern Hospital Transformation Fund for the first two years. It is anticipated that VolunteerMatch will be financially viable with no base government funding within two years. Volunteer coordination will become a costeffective way to maintain volunteers for member organizations. See Appendix G for the full proposal Strategic Alliance between HHHS and RMH There are currently a number of integration activities that have been underway between RMH and HHHS for some time. Examples of the current integration activity are Laboratory Services, Medical Devices Reprocessing, and Shared Information Technology. The Small Rural Northern Hospital Transformation Fund was an enabler to support a further in-depth review of RMH and HHHS operational integration opportunities. See Appendix H for the full operationalreview pertainingtotheuseofsrnhtf. This review: 1. Identified opportunities for operational integration between RMH and HHHS and evaluate/prioritize viable opportunities. 2. Provided the IPT with an evaluation/prioritizing of each opportunity. 3. Expanded consideration of integration opportunities to other member organizations as agreed by the IPT. As a result, HHHS and RMH expanded their Strategic Alliance identifying a number of back office and leadership integrations that could be implemented by the two hospitals and possibly extended to the One Entity if it is created. The Strategic Alliance is supported by a Master Agreement which sets out the parameters of the Alliance and includes individual service level agreements specifying the detail of the service provided and associated financial arrangements. Service level agreements which currently exist or are in development include: a. Mental Health Program Leadership b. Information Technology/Management and Communications c. Procurement d. Pharmacy e. Diagnostic Imaging f. Cardiac Rehabilitation a. Mental Health Program Leadership Improved access to Mental Health Services was identified as a need in the Haliburton County/City of Kawartha Lakes communities. RMH and the One Entity in Haliburton County prepare to jointly recruit a single Mental Health Director to establish a regionally coordinated Mental Health program. This program would be delivered across both geographies. 16 P a g e

25 Benefits include: Increased coordination and communication across Haliburton County and City of Kawartha Lakes leading to improved quality and consistency of acute and primary care mental health services across the two geographies Better coordination with community-based Mental Health and Addictions providers as well as tertiary service providers. An opportunity to increase linkages with other partners, including police and Emergency Medical Services The SRNHTF will support 50% of the costs of this position, with the two hospitals contributing the other 50% through their respective mental health budgets. Future sustainability of the position will be addressed through a review of the outcomes achieved. Implementation of Mental Health Leadership in Haliburton County and the City of Kawartha Lakes will involve many existing mental health and addictions service providers. Engaging these organizations will be key to supporting the building of more integrated mental health system. b. Information Technology/Management and Communications A shared IT department and communications network would be established for the One Entity in Haliburton County and RMH. While this initiative will not result in immediate savings, upgrades and IT projects in the longer-term will be less costly. Information Technology/Management and Communications also includes the implementation costs of extending a telephony system between HHHS and CCHC as they form the One Entity. c. Procurement The expansion of a shared inventory management system led by RMH would allow RMH to take on responsibility for procurement for the One Entity in Haliburton County since RMH receives better pricing due to higher volumes. While there would be some additional fees for RMH for increasing volumes to include the One Entity s inventory, it is expected that the reduced cost of purchases will result in savings for reinvestment for Haliburton County that will cover these costs. d. Pharmacy RMH would provide the One Entity in Haliburton County with Pharmacy services to support the hospital and emergency services through a single pharmacy program for both organizations. This would lead to cost savings for the One Entity in terms of drug acquisition and improved safety and quality as the hospital upgrades to the use of electronic medication cabinets. e. Diagnostic Imaging RMH would provide diagnostic imaging leadership to the One Entity in Haliburton County to oversee the expansion of diagnostic imaging services (e.g. ultrasound) and the potential introduction of mammography services in Haliburton County to minimize travel for Haliburton County residents. 17 P a g e

26 f. Cardiac Rehab As a key partner in the establishment of a LHIN-wide cardiac rehabilitation program, RMH is committed to working collaboratively with providers in Haliburton County, including HHHS and the Haliburton Highlands Family Health Team, in order to improve access to high quality cardiac rehabilitation programming. This process is in the early stages with discussions amongst partners just recently initiated. 4.4 Economic Impact Harmonization Costs A financial analysis was conducted of the costs of labour and non-labour associated with a single governance model in Haliburton County. This option identified the voluntary merger in Haliburton County between CCHC, HHHS, and the transfer of the accountability for some services at SIRCH and at VON, Peterborough, Victoria and Haliburton to the One Entity in Haliburton County. The analysis revealed a potential cost impact of $71,000 annually based on all additional expenses including rent revenue loss, additional space requirements, salary and benefit harmonization. This is an increase of approximately $18,000 from the earlier cost impact of $53,000 based only on salary and benefit harmonization. Potential Reinvestment Opportunity The IPT estimated that approximately $113,000 could be saved on an annual basis and reinvested, specifically in Haliburton County, if HHHS and CCHC voluntarily merged into One Entity and took on the accountability for some of the services currently delivered by SIRCH and VON. These savings are a result of expected efficiencies in back office and administrative functions in the One Entity model. With the goal of retaining and leveraging the skills of existing staff, the implementation of the One Entity would require using some of the savings to support equity in staff compensation, future training and development. The IPT recognizes that this investment would support the goal of providing consistent standards and high quality in the delivery of services to local residents and that the balance of the savings, estimated at approximately $42,000, could be invested in providing more front-line services. As noted previously, in the City of Kawartha Lakes, the confirmation of the two existing entities does not realize any significant savings at the present time and in fact, analysis of a potential merger between RMH and CCCKL revealed the significant cost that would be incurred if the two organizations merged into a new entity. The cost was a significant enough risk to not proceed with a full merger between these two organizations. 18 P a g e

27 4.5 Future Integrated Governance and Service Delivery Model The Integrated Governance and Service Delivery Model could lead to a number of changes in how local residents would access the LHIN-funded health services currently delivered by the six organizations involved in this integration initiative. The diagram on page 9 showed how people currently access services from the participating organizations. The diagram below illustrates how people would access services in the future. The service delivery door to existing LHIN funded services that are related to this process in Haliburton County would be the One Entity and the service delivery doors to existing LHIN-funded services related to this process in the City of Kawartha Lakes would continue to be RMH and CCCKL. 19 P a g e

28 20 P a g e

29 21 P a g e Overview of Current and Future State Service Delivery Model