Presented by: Farrah Hirji, Director, System and Sub-region Planning and Integration Kelly Kay, Executive Director, Seniors Care Network Marilee

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1 Presented by: Farrah Hirji, Director, System and Sub-region Planning and Integration Kelly Kay, Executive Director, Seniors Care Network Marilee Suter, Director, Decision Support

2 Provide current status of Central East LHIN Strategic Aim Performance Metrics Provide an update on Central East LHIN Seniors Strategy-related initiatives Next Steps Appendix 1 Supporting Metrics Appendix 2 Investments 2

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4 Seniors Strategic Aim: Continue to support frail older adults to live healthier at home by spending 20,000 fewer days in hospital and reducing Alternate Level of Care days for people aged 75+ by 20% by Assumptions: The Central East LHIN Age 75+ population will increase by 16.3% by The number of long term care home (LTCH) beds in the Central East LHIN will remain static during the 3 year time period of this strategic aim. 4

5 Cumulative Days Saved 14,659 1,914 7,738 Based on 2016/17 performance, Central East LHIN is not currently on track to reach 20,000 days saved by / / / / / /19 Projected Total Length of Stay 279, , ,810 Estimated Total Length of Stay 277, , ,888 Cumulative Days Saved 1,914 7,738 14,659 5

6 Cumulative Days Saved (%) 12% 15% 17% Based on 2016/17 performance, Central East LHIN is not currently on track to reduce Alternate Level of Care days for people aged 75+ by 20% by / / / / / /19 Projected Alternate Level of Care (75+ (%) 30.0% 33.2% 36.3% Estimated Alternate Level of Care 75+ (%) 26.6% 27.4% 28.4% Cumulative (%) 11.5% 14.7% 17.4% 6

7 Indicators Time Period for Current Performance Baseline CE LHIN Target* Current Performance Current Status Direction of Trend CCAC 90th Percentile Wait Time for Home Care Services From Discharge to First Service (in Days for Hospital Clients) (Goal is to decrease 90th percentile wait time ) Clients With MAPLe Scores High And Very High Living In The Community Supported by CCAC (Goal is to increase clients with MAPLe Scores high and very high living in the community with CCAC support ) Falls-Related ED Visits in older adults aged 75+, Rate per 1,000 (Goal is to decrease falls-related ED visits ) Low-Acuity Emergency Visits for LTCH residents, Rate per 1,000 (Goal is to decrease low-acuity ED visits for LTCH residents ) Individuals on LTC Wait List, Rate per 1,000 (Goal is to decrease number of individuals on LTC wait list) 16/17 Q /17 Q ,477 16/17 Q /17 Q /17 Q *Targets that are shown in bold text are formal targets. Other targets are calculated as 10% greater or less than the baseline (depending on the desired direction of the indicator) 7

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9 In January 2017, the Central East LHIN announced the appointment of Dr. Jennifer K. Ingram as the Seniors Physician Lead. Dr. Ingram works with the Seniors Care Network, and collaborates with regional and local health service providers to influence the system in caring for older adults. Key activities for 2017/18 include: 1. Recruitment and retention of specialized geriatricians in the Central East LHIN; 2. Integration of community Geriatric Medicine and Geriatric Psychiatry Programs; 3. Support of Memory Clinics and the development of skills among primary care to appropriately manage seniors needs; 4. Development of standards for training and implementation of capacity evaluations; and 5. Identification of opportunities for enhanced collaboration with geriatric psychiatry and geriatric medicine. 9

10 ADPs play a key role in supporting individuals and their caregiver(s) in leading active and meaningful lives. The individuals who may benefit from ADPs include: Older adults with complex and long-term medical, physical, social and/or cognitive conditions. Seniors who are at risk of avoidable hospital admission/readmission, emergency departments visits, ALC, or other care issues, if not adequately supported in the community. The Central East LHIN supports ADPs across all sub-regions serving over 2,500 frail, at-risk individuals across the Central East LHIN each year. 10

11 Sub-region Scarborough North/ Scarborough South Durham West/ Durham North East Northumberland County/ Peterborough City and County Haliburton County and City of Kawartha Lakes Health Service Provider Targeted Individuals Served Service Delivery Relative to Lower Corridor of Target 2016/17 Carefirst Seniors & Community Services Association % Les Centres d'accueil Héritage % Scarborough Centre for Healthy Communities % Senior Persons Living Connected % TransCare Community Support Services % Yee Hong Centre for Geriatric Care % Brain Injury Association of Durham Region % Community Care Durham % Oshawa Senior Citizens Centres % Regional Municipality of Durham % Four Counties Brain Injury Association % Victorian Order of Nurses for Canada - Ontario Branch % Community Care City of Kawartha Lakes % Haliburton Highlands Health Services % Total 2,805

12 ALS-HRS assist older adults to maintain their independence and remain in their homes for as long as possible. High-risk seniors are supported at home through the assistance of both scheduled and non-scheduled personal support services, homemaking, security checks, and reassurance services on a 24/7 basis. The Central East LHIN invests more than $14M in annual base funding to support ALS-HRS across all seven sub-regions. ALS-HRS serve over 1,240 individuals across the Central East LHIN each year. 12

13 Sub-region Health Service Provider Targeted Individuals Served Service Delivery Relative to Lower Corridor of Target 2016/17 Scarborough North/ Scarborough South Durham West/ Durham North East Haliburton County and City of Kawartha Lakes Carefirst Seniors & Community Services Association % TransCare Community Support Services % Yee Hong Centre for Geriatric Care % Community Care Durham (Oshawa and Courtice) Community Care City of Kawartha Lakes % % Haliburton Highlands Health Services % Across Sub-regions Victorian Order of Nurses for Canada % Total 1,580 13

14 Exercise classes help seniors stay active and improve and maintain balance, strength, and mobility. Falls prevention classes are taught by a physiotherapist or other regulated health care professional. The Central East LHIN invests $1.3M in annual base funding to support 248 exercise and 634 falls prevention classes across sub-regions. Nine Lead Agencies have implemented exercise and falls prevention classes, including classes offered for Francophone patients, cardiovascular patients, and individuals with dementia. 14

15 Sub-region Lead Agency # Exercise Classes # Falls Prevention Classes Service Delivery Relative to Lower Corridor of Target 2016/17* Scarborough North/ Scarborough South Durham West/ Durham North East Northumberland County Peterborough City and County Haliburton County and City of Kawartha Lakes Carefirst Seniors and Community Services Association % TransCare Community Support Services % Community Care Durham % Oshawa Senior Citizens Centres % Community Care Northumberland % Community Care Peterborough % Community Care City of Kawartha Lakes % Haliburton Highlands Health Services % Across Sub-regions Cardiovascular Rehabilitation & Secondary Prevention Program Total N/A * The targets for Exercise and Falls Prevention have been under prolonged review by the Ministry of Health and Long-Term Care. Assessments of performance relative to targets should be treated with caution.

16 The Ministry of Health and Long-Term Care funded Attending Nurse Practitioners (NP) to work in Long-Term Care Homes (LTCHs) across the province in both 2015 and The Central East LHIN was allocated $614,275, to support five full-time Attending NPs. Three of the full-time Attending NP positions are being incorporated into the Nurse Practitioner Supporting Teams Averting Transfer (NPSTAT) program to help strengthen the primary care that residents receive in LTC. Six LTCHs were selected in 2015 and 2017 to receive Attending NP services, including: 2015: The Altamont Care Community (Scarborough) and The Wexford Residence (Scarborough); and 2017: Victoria Manor (Lindsay), Golden Plough Lodge (Cobourg), Ballycliffe Lodge Nursing Home (Ajax), and Bay Ridges Long -Term Care (Pickering). Two Nurse Practitioners have been hired to service three of the four designated LHIN homes. Applicants have been received for the last position with interviews expected in October. 16

17 Behavioural Supports Ontario (BSO) is focused on supporting older people in LTCHs and the community with responsive behaviours associated with cognitive impairments due to complex mental health, addictions, dementia, or other neurological conditions, and their caregivers. As of the 1 st Quarter of 2017/18, BSO supported more than 1,000 care partners of LTC and community residents (combined). Program efforts have aided in continuing low rates (less than 0.5%) of transfers to Emergency Departments for the primary reason of responsive behaviours. $892,828 of new funding in 2017/18 brings total the BSO investment the Central East LHIN to $6,285,790, which supports 83.7 FTEs in LTCH and the community. Program accomplishments include: Metric LTCH residents supported per quarter (average) /17 (Year-end) 2017/18 (Q1) 3,700+ 4,215 BSO patients served in the community 2, Staff trained in BSO approaches 1,

18 Over $10.8 M invested in Central East LHIN Geriatric Assessment and Intervention Network (GAIN) teams to provide specialized geriatric care, which supports frail seniors, living at home or in retirement residences, who have multiple complex medical and social problems. Frail older adults experiencing changes in support needs, safety concerns, psychosocial and mental health concerns or frequent health service usage will benefit from these services. Program accomplishments include: Metric 2016/17 (Year-end) 2017/18 (Q1) Patients served (cumulative) 13,931 3,482 Visits 28,896 7,709 Patients receiving case management 2, Patients with moderate to severe dementia Patients with advanced frailty 1,

19 Geriatric Emergency Management (GEM) programs provide specialized geriatric emergency management services to frail seniors in the Emergency Department (ED) within nine hospital locations in the Central East LHIN. GEM nurses are positioned within an ED to deliver targeted, emergency geriatric assessment to frail seniors in the ED. GEM nurses help seniors access appropriate services and/or resources that will enhance functional status, independence, and quality of life. Majority of patients seen are over the age of 85. Program accomplishments: A large proportion of referrals include specialized geriatric programs (i.e. GAIN, NPSTAT and BSO) and primary care. The majority of referrals (53.7%) are made to the Central East LHIN. Metric 2016/17 (Year-end) 2017/18 (Q1) Individuals served 4,367 1,067 Referrals to alternate sources of care (following targeted geriatric assessment) 4,052 1,053 19

20 Nurse Practitioners Supporting Teams Averting Transfers (NPSTAT) provide direct clinical care to LTCH residents across all sub-regions in the Central East LHIN by responding to acute and episodic changes in the resident s condition to reduce unscheduled transfers to a hospital. When LTCH residents are hospitalized, NPSTAT helps coordinate transitions back to the LTCHs, which can decrease hospital length of stay, enhance continuity of care, and provide support and resources to LTCH staff to help manage returning LTCH residents with increasingly complex medical needs. Program accomplishments include: Metric 2016/17 (Year-end) 2017/18 (Q1) Individuals served 5,611 1,054 ED transfer rate 1.7% 1.9% Capacity building activities provided Facilitated LTC repatriations from ED

21 Overseen by a committee comprising representatives from all Central East LHIN hospitals who collaborate to promote and provide strategic direction and leadership for the Senior Friendly Care (SFC) Strategy. The vision is to move from discrete initiatives to a comprehensive, coordinated approach to seniors' care and to foster a culture where senior friendly care is woven into the fabric of an organization. Mandate is evolving to include non-acute care organizations providing health care to seniors. A new draft Provincial Senior Friendly Care Framework has been developed and circulated to Central East health service providers for input. 21

22 This Primary Care-based regional program supports cognitive health and quality of life for adults and seniors living in the community while ensuring the patient s family physician maintains a central role in their patient s care. PCCMS enhances the capacity for timely detection, diagnosis, and treatment of dementia. A mobile team, hosted by Alzheimer Society of Durham Region in collaboration with Seniors Care Network, consists of Social Workers, Behavioural Support Ontario Nurses, and Occupational Therapists. Works collaboratively with family physicians in memory clinic locations in Durham and Scarborough. Two new teams are developing in Northumberland and Haliburton. Program accomplishments include: Metric 2016/17 (Year-end) 2017/18 (Q1) Total visits Referral rate (to specialist services) 9% 1% 22

23 The Central East LHIN has been funding A&R initiatives since A&R is one component of a larger, cross-continuum, integrated model of care for frail seniors. A&R initiatives: Support high-risk frail seniors to live in the community and maintain their functional independence for as long as possible; Decrease caregiver burden by improving health outcomes; and Facilitate the adoption of clinical best practices for community dwelling seniors. The Central East LHIN currently funds four projects. These programs are: Northumberland Hills Hospital Assess and Restore Intervention; Ross Memorial Hospital Assess and Restore Mobile Team; Care after the Care in Hospital (CATCH) program: Scarborough and Rouge Hospital Centenary Site; and Virtual Ward for Frail Seniors: Scarborough and Rouge Hospital General Site and Carefirst Seniors & Community Services Association. 23

24 A&R initiatives in the Central East LHIN have resulted in: Decreased unplanned readmission to hospital within 30 days of discharge from hospital; Increased primary care follow-up within seven days post-acute hospital stay; and Overall improvement of function for frail seniors enabling them to live in the community for as long as possible. The Central East LHIN will be issuing an Expression of Interest (EOI) to evaluate all project proposals that comply with A&R eligibility criteria set by the Ministry of Health and Long-Term Care and priorities identified by the Central East LHIN to ensure a fair and transparent process for distributing base funds. 24

25 Service Plan Activity Update October Implement Coordinated Access Model developed, submitted for LHIN review 2. Engage the Central East LHIN to co-lead the development of an Accountability Framework of Specialized Geriatric Services (SGS) programs/providers 3. Develop and implement regional Performance Management systems 4. Participate in the development of provincial SGS Performance Management systems 5. Continue to partner in the development of primary care based initiatives Seniors Care Network now designated as a Strategic Lead for the Seniors Aim Ongoing development of systemlevel indicators Undertaking development of Provincial Seniors experience indicators Continued support and development of PCCMS 6. Implement a Knowledge Translation Strategy Framework developed 7. Develop and implement the competency framework for interprofessional Comprehensive Geriatric Assessment 25 Competency Framework developed and published

26 Service Plan Activity Update October Advance the Dementia Action Plan Working with partners to map existing services to Ontario Dementia Strategy 9. Develop and implement an SGS research agenda Currently engaged in five active applied research projects 10. Develop a SGS evaluation Framework Framework developed 11. Support gerontology/geriatric related continuing professional development across the network 12. Implement the Citizen Engagement framework 13. Advance the adoption of Senior Friendly Care across the Central East LHIN To launch Training Needs Assessment survey Ongoing 14. Develop a communication framework for SGS Ongoing Participating in Provincial roll-out of Senior Friendly Care Framework 26

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28 Continue to implement Seniors Strategic Aim initiatives as outlined in the Integrated Health Service Plan and 2017/18 Annual Business Plan. Continue to collaborate with the Seniors Care Network, Seniors Physician Lead, along with key stakeholders and partners, to design, implement and evaluate programs that strengthen integrative health services and their delivery for frail seniors. Better understand frail senior populations at a sub-region level and opportunities to meet their health needs to support them living at home. Integrate seniors health within sub-region planning. Spread programming and address any gaps at the sub-region level. 28

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31 Goal: Continue to support frail older adults to live healthier at home by spending 20,000 fewer days in hospital by 2019 Cumulative Days Saved = Projected Total Length of Stay Estimated Total Length of Stay Projected Total Length of Stay (TLOS) represents a projection of what the total length of stay would potentially be based on three years of historical data Estimated TLOS represents the actual length of stay for each fiscal year. Estimated values based on aim assumptions are used until actual values are known. 2016/17 values are actuals Goal: Reduce Alternate Level of Care (ALC) days for people aged 75+ by 20% by 2019 Cumulative Days Saved (%) = (Projected ALC days Estimated ALC days ) / Projected ALC days Projected Alternate Level of Care (ALC) represents a projection of what the percentage of ALC days would be based on three years of historical data Estimated Alternate Level of Care (ALC) represents the actual percentage of ALC days for each fiscal year. Estimated values are used until actuals are known. 2016/17 values are actuals 31

32 10/11 Q1 10/11 Q2 10/11 Q3 10/11 Q4 11/12 Q1 11/12 Q2 11/12 Q3 11/12 Q4 12/13 Q1 12/13 Q2 12/13 Q3 12/13 Q4 13/14 Q1 13/14 Q2 13/14 Q3 13/14 Q4 14/15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 16/17 Q3 16/17 Q4 Wait Time (days) CCAC 90th Percentile Wait Time for Home Care Services From Discharge to First Service (in Days for Hospital Clients) (Goal -decrease) UCL LCL CE LHIN Center UCL LCL ON 0.0 Analysis: In the 4 th Quarter of 2016/17, the 90th Percentile Wait Time for Home Care Services (Discharge to First Service) Hospital Setting (all clients) for Central East LHIN experienced a slight increase from 8 days in the 3 rd Quarter. The 90 th Percentile Wait Time across Ontario was 7 days during the same time period. 32

33 12/13 Q1 12/13 Q2 12/13 Q3 12/13 Q4 13/14 Q1 13/14 Q2 13/14 Q3 13/14 Q4 14/15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 16/17 Q3 16/17 Q Clients with MAPLe Scores High and Very High Living in the Community Supported by CCAC (Home and Community Care) (Goal - increase) UCL LCL Analysis: Central East CCAC client volume in 2016/17 continued to exceed the Multi-Sector Service Accountability target of 6,000. This would imply that the Central East CCAC was doing a better job at keeping clients in the community than expected. The goal of the Seniors Aim is to keep clients in their homes and in their community and this is a positive correlation. 33

34 10/11 Q1 10/11 Q2 10/11 Q3 10/11 Q4 11/12 Q1 11/12 Q2 11/12 Q3 11/12 Q4 12/13 Q1 12/13 Q2 12/13 Q3 12/13 Q4 13/14 Q1 13/14 Q2 13/14 Q3 13/14 Q4 14/15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 16/17 Q3 16/17 Q4 Rate per Falls-Related Emergency Department Visits in older Adults, age 75+, Rate per 1,000 (Goal - decrease) 20.0 UCL 15.0 LCL CE LHIN Center UCL LCL ON 0.0 Analysis: The rate of falls-related Emergency Department visits in older adults in Central East LHIN continues to be comparable to the Provincial rate (20.5 per 1,000 versus 20.4 per 1,000 provincially in the 4 th Quarter of 2016/17). This indicator excludes patients living at home with homecare and patients living in Long-Term Care Homes. The goal is prevention of falls and subsequent visits to the Emergency Department. 34

35 10/11 Q1 10/11 Q2 10/11 Q3 10/11 Q4 11/12 Q1 11/12 Q2 11/12 Q3 11/12 Q4 12/13 Q1 12/13 Q2 12/13 Q3 12/13 Q4 13/14 Q1 13/14 Q2 13/14 Q3 13/14 Q4 14/15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 16/17 Q3 16/17 Q4 Rate per Individuals on LTC Wait List, Rate per 1,000 (Goal - decrease) UCL LCL Ce LHIN Center UCL LCL ON 0.0 Analysis: As in previous years, the rate of individuals on wait lists for Long-Term Care (LTC) per 1,000 in the 75+ population continues to increase. Across the 14 LHINs, Central East LHIN has the highest rate of waitlisted LTC patients per 1,000. This disparity has been highlighted by the IHSP Environmental Scan and is one of the key reasons for identifying Seniors as a priority population. 35

36 10/11 Q1 10/11 Q2 10/11 Q3 10/11 Q4 11/12 Q1 11/12 Q2 11/12 Q3 11/12 Q4 12/13 Q1 12/13 Q2 12/13 Q3 12/13 Q4 13/14 Q1 13/14 Q2 13/14 Q3 13/14 Q4 14/15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 Rate per Low Acuity Emergency Visits for LTCH residents, Rate per 1,000 (Goal - decrease) 35.0 UCL LCL CE LHIN Center UCL LCL ON 0.0 Analysis: In the 2 nd Quarter of 2016/17, which is the most up-to-date reporting available, the Central East LHIN rate increased to 24.9 Low Acuity ED visits per 1,000 LTCH residents, which is above the provincial value of 20. However, the overall trend is a decrease. Initiatives such as LHIN sub-regions, Community Investments, and Hospitals and Community Health Services integrations are expected to reduce ED demand by facilitating ED avoidance and diversion, and by supporting individuals post-discharge. The goal is for the residential care population to receive quality and non-hospital end-of-life care in order to reduce transfers to the ED. NPSTAT collaboration is a key player in the Central East LHIN Behavioural Supports Ontario strategy, which will have a positive impact on ED diversions from LTCH for behavioural reasons. 36

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38 Sub-region Health Service Provider Additional 2016/17 Allocation Carefirst Seniors & Community Services Association $25,104 Scarborough North/ Scarborough South St. Paul L Amoreaux Centre $41,840 Scarborough Centre for Healthy Communities $16,736 Yee Hong Centre for Geriatric Care $20,920 Durham West/ Durham North East Oshawa Senior Citizens Centres $154,800 Victorian Order of Nurses for Canada - Ontario Branch $83,680 Total $343,080 38

39 Sub-region Health Service Provider Targeted Individuals Served 2017/18 Allocation Carefirst Seniors & Community Services Association 348 $1,511,871 Les Centres d'accueil Héritage 20 $59,142 Scarborough North/ Scarborough South Scarborough Centre for Healthy Communities 104 $341,189 Senior Persons Living Connected 287 $1,162,321 TransCare Community Support Services 121 $453,963 Yee Hong Centre for Geriatric Care 259 $1,400,333 Brain Injury Association of Durham Region 160 $325,912 Durham West/ Durham North East Northumberland County/ Peterborough City and County Haliburton County and City of Kawartha Lakes Community Care Durham 261 $970,140 Oshawa Senior Citizens Centres 272 $1,182,751 Regional Municipality of Durham 127 $519,968 Four Counties Brain Injury Association 105 $214,739 Victorian Order of Nurses for Canada - Ontario Branch 494 $1,270,987 Community Care City of Kawartha Lakes 192 $551,019 Haliburton Highlands Health Services 55 $210,212 Total 2,805 $10,174,547 39

40 Sub-region Health Service Provider Additional 2016/17 Allocation Scarborough North/ Scarborough South Durham West/ Durham North East Haliburton County and City of Kawartha Lakes Carefirst Seniors & Community Services Association $235,812 Yee Hong Centre for Geriatric Care $235,302 Community Care Durham $265,062* Victorian Order of Nurses for Canada $450,921 Community Care City of Kawartha Lakes $5,586 Haliburton Highlands Health Services $7,317 Total $934,938 * The funding was made available in 2016/17 but declined by the health service provider due to its assessment it could not operationalize the funding in-year. The same investment has been made in 2017/18. 40

41 Sub-region Health Service Provider Targeted Individuals Served 2017/18 Allocation Carefirst Seniors & Community Services Association 332 $2,345,456 Scarborough North/ Scarborough South Durham West/ Durham North East TransCare Community Support Services 192 $1,073,404 Yee Hong Centre for Geriatric Care 159 $1,627,747 Victorian Order of Nurses for Canada 48 $3,586,919* Community Care Durham (Oshawa and Courtice) 314 $4,144,135 Victorian Order of Nurses for Canada 57 * Northumberland County Victorian Order of Nurses for Canada 99 * Peterborough City and County Haliburton County and City of Kawartha Lakes Victorian Order of Nurses for Canada 191 * Community Care City of Kawartha Lakes 121 $1,223,231 Haliburton Highlands Health Services 67 $912,885 Total 1,580 $14,913,777 Note: The targets for individuals served include Assisted Living Services for High-Risk Seniors (ALS-HRS) and Supportive Housing, as affected health service providers report combined numbers for these services to the Central East LHIN. The allocations are reflected in the relevant 2017/18 Multi-Sector Service Accountability Agreements. * The funding allocated to the Victorian Order of Nurses is recorded as part of the Scarborough North/Scarborough South subregions, but also supports service provision in four additional sub-regions as noted. 41

42 Sub-region Scarborough North/ Scarborough South Durham West/ Durham North East Lead Agency # Exercise Classes # Falls Prevention Classes 2017/18 Allocation Carefirst Seniors and Community Services Association $170,400 TransCare Community Support Services $254,500 Community Care Durham $162,720 Oshawa Senior Citizens Centres $133,920 Northumberland County Community Care Northumberland $151,200 Peterborough City and County Haliburton County and City of Kawartha Lakes Community Care Peterborough $216,960 Community Care City of Kawartha Lakes $77,280 Haliburton Highlands Health Services 5 12 $23,520 Across sub-regions Cardiovascular Rehabilitation & Secondary Prevention Program 10 0 $24,000 Total $1,214,500 42