Brampton Sub-Region Collaborative June 8 th, 2018
Agenda # Agenda Item To be Accomplished Lead Time 1.0 Welcome, Update and Introductions Members to review Agenda for the Meeting Members to receive update on Integrated Care priority area Sub-Region Collaborative Leads 5 minutes 2.0 Integrated Health Services Plan Sub-region collaborative members to engage Consultant 120 minutes in a facilitated discussion to support the development of strategic directions and priorities from the sub-region perspective. 3.0 Break 15 minutes 4.0 Report Back: Mental Health and Addictions Members share progress on sub-region collaborative initiative Work Group Co-Chairs 15 minutes 5.0 Report Back: Palliative Care Members share progress on sub-region collaborative initiative 6.0 Next Steps and Close-Out Sub-Region Director to provide an update on next steps Work Group Co-Chairs Sub-Region Director 15 minutes 10 minutes 2
W E L C O M E 3
Context Setting: Integrated Health Services Plan 5 Central West LHIN s INTEGRATED HEALTH SERVICE PLAN (2019-2022) A Healthier Community for All 4
Break 5
WORK GROUP UPDATES 6
Mental Health and Addictions 7
Project Background The purpose of this project is to understand the current state of mental health and addictions services in the Brampton Sub-Region by building on the work completed by the Mental Health & Addictions core action group of an asset inventory map of mental health and addictions services in the CW LHIN. By understanding the current state, capacity and population needs, the project aims to maximize current resources in the system by developing a multi-disciplinary approach/team that can cover a larger range of needs. 8
Project Goals and Objectives The goal is to increase access to and improve coordination of community mental health & addictions services in the Brampton sub-region. The initiative is to move from analysis to action: Project Objective #1: Develop a mental health & addictions asset inventory map that clearly outlines the burden, mandate and effective interventions/innovation in order to understand the system gaps and priority populations better. This current state analysis will identify gaps & current capacity of mental health and addiction services in Brampton sub-region. As well, it will help identify which gaps & priority populations need to be addressed first. Project Objective #2: Identify how to re-organize services within current funding by considering a multi-disciplinary approach/team that can rapidly respond to addressing gaps and covering a larger range of needs of priority populations. 9
Key Stakeholders Target population: Individuals who experience significant struggles with their mental health; Individuals who experience severe and persistent mental health issues with or without other complex challenges that limit their ability to function on a daily basis Brampton sub-region mental health and addictions working group members Include psychiatry and hospital representation in working group discussions Patient/Family representative (e.g. PFAC) Consider including non-traditional partners (e.g. Peel Children s Centre, Hope 24/7; other teams with a mental-health focus) 10
Project Scope In Scope Asset inventory map that includes data, gap analysis / current state of all Brampton patients/clients Review of best practice related to multi-disciplinary teams/models All working group members complete data sharing agreements to use CCP in HPG Driven by patient experience and evidence; leverage avenues such as CMHA Consumer Council; Test the multi-disciplinary team approach - start with FACTT Ensure there is a equity/cultural lens Reports to Sub-Region Collaborative Meetings for further input Collaboration with other Sub-regions Process should enable identification of patients with complex circumstances / priority populations Optimize existing resources (e.g. program, services, and technology) Use of the final report on System Access Model and understanding of the LHIN's refreshed vision for the model Look into adding non-traditional partners to include in the asset inventory map 5 11
Project Scope Out of Scope X Full implementation of the chosen/successful model e.g. FACTT Model (Flexible Assertive Community Treatment Team); X Mental Health Act and privacy legislation that can hinder treatment of a client; Justice System X Non-traditional providers for this fiscal year (e.g. LTC) 5 12
Project Metrics Updated mental health and addictions asset inventory map All mental health and addictions working group members completing data sharing agreements and coming on CCP in HPG [In development] 13
Project Timeline Jun-Jul: Finalize Asset Inventory Map Jul-Sep: Prioritization Matrix Nov-Feb: Finalize details of multi-disciplinary team Feb-Mar: proposal to sustain multidisciplinary team May 2018 Jun 2018 Jul 2018 Aug 2018 Sep 2018 Oct 2018 Nov 2018 Dec 2018 Jan 2019 Feb 2019 Mar 2019 Apr 1, 2018 Apr 1, 2019 Key milestones or dates for the project. Include start and end date. Milestone 7 14
Working Group Members: Roles and Responsibilities Name Organization Role on this Project Responsibilities Donna Perry Tracy Redden Jodi Pereira Shereen Rampersad David Smith Scott Brooker Andrew Raralio Donna Sherman Dr. Lawrence Loh Sharon Mayne Devine Ceri Harnden Baldev Mutta Amandeep Kaur Clinton Baretto CW LHIN Central Brampton FHT Heart House Hospice SHIP CMHA Peel Friends & Advocates of Peel and Surrounding Areas Friends & Advocates of Peel and Surrounding Areas CW LHIN Associate Medical Officer of Health at Region of Peel Catholic Family Services of Peel Dufferin Peel Children's Centre Punjabi Community Health Services Punjabi Community Health Services North Peel Family Health Team 8 15
Project Schedule Task/Milestone Start Date Finish Date Lead Resources Deliverables Status Finalize the 'placemat', work plan, group membership, proposed approach, joint work with other sub-regions Understand burden, current state, priority populations, current gaps; explore newcomer / refugee data (e.g. for rates of PTSD); Update inventory asset map Mar. Apr. - Draft LHIN materials - Work Group input In Progress - on track Understand current mandate, funding, populations served by CW LHIN MH&A organizations that work with MH&A populations Apr. Jul - Work Group input In Progress - not on track Learn about effective interventions / innovations / models (e.g. multi-disciplinary team model that can respond to larger range of needs Finalize Asset Inventory Map; Working group to learn about the MH&A System Access Model (SAM) final report Learn about the pathways work of Bramalea & NEMWW; Consider options for a multi-disciplinary approach/team that can rapidly respond to addressing gaps and meeting needs of priority populations (e.g. consider team structure, funding/resources, focus, response time indicators, what would success look like; what system gaps will be addressed first) - prioritzation matrix Jun. Jul. Jul. Sep. - MH&A SAM final report, 2016 - LHIN staff - Work Group input - Work to date of Bramalea & NEMWW draft MH&A pathways -Prioritization matrix & options for multi-disciplinary team approach to address gaps/meet pop needs. In Progress - not on track Test multi-disciplinary team structure(s) via PDSAs (Plan, Do, Study, Act - rapid cycles of tests of change) Sep. Nov. Finalize details of multi-disciplinary team, system gaps that can be addressed, priority pouplations that can be served better via this approach Learn about the pathways work of Bramalea & NEMWW; - Put together proposal to sustain multi-disciplinary team / grow team depending on outcomes achieved; Feb. Mar. Nov. Jan. Feb. Feb. 16
Palliative Care 17
Project Background Brampton Sub-Region members originally chose to test out different models of palliative care within our geography. However, knowing there was provincial work currently being done on models of care and best practices, we wanted to get the Brampton sub-region local system ready when implementation of this model happens. In order to get our system ready, we identified two key areas to focus on this fiscal year: (1) Educating Advanced Care Planning and Palliative Care 101 foundational courses to our Brampton collaborative members to get our system partners ready and able to support early ID; (2) Working with our primary care providers to support early ID and appropriate system navigation and support for those who are identified as early ID palliative 18
Project Objectives and Goals The goal is to increase access to and better coordinated palliative care services in Brampton sub-region. Objective #1: Increase the number of Brampton sub-region collaborative members who complete training in Advanced Care Planning and Palliative Care 101 to ensure system partners are aware of foundations of palliative care and to support early ID. Objective #2: Spread early identification of palliative care in primary care with the use of three questions/triggers. Desired outcomes include spread and scale of early ID in a few primary care physicians. Objective #3: Conduct a current capacity / comfort level survey with primary care physicians about what are the next steps if a patient is identified as early ID palliative. Objective #4: Develop a loop back mechanism (e.g. report / consult) after a referral / system navigation happens so physician is aware of the status of the patient 19
Key Stakeholders Key Stakeholders include: Brampton sub-region palliative care working group members Brampton sub-region collaborative members Physician group that is highly engaged in palliative care / interest in Early ID work BramEastFHT representative Central West Palliative Care Network Patient/Family representative (e.g. PFAC) 20
Project Scope In Scope Review of existing palliative care tools/resources for use by multiple sectors Optimize use of the CWPCN web site Collaboration with the Central West LHIN Palliative Care team and/or Network Build on existing practices amongst providers and standardize Joint work as appropriate with other Sub-regions Completion of training for working group members, Brampton collaborative members and primary care practices as may be needed to implement practice changes 5 21
Project Scope Out of Scope X Discussion of non-validated tools outside of best practice in Canada 5 22
Project Metrics Number of Brampton sub-region collaborative members & organizations who complete their training in Advanced Care Planning and Palliative Care 101 to support early ID. Number of education sessions completed by March 31, 2019. Number of primary care physicians implementing the three early ID questions/triggers. Number of early ID palliative patients identified by March 31, 2019. Number of identified early ID palliative patients admission to the hospital or visits to the ED since identification (if applicable) Current state analysis results - Number of physicians surveyed re: capacity/comfort level to refer and system navigate patients identified as early ID palliative Number of H&CC CCs educated in reporting back / consulting with primary care physician re: early ID palliative patients 23
Project Timeline Jun-Sep: Develop current capacity survey for primary care physicians Jul-Oct: Develop plan for early ID spread in primary care; Develop loop back mechanism for primary care physicians May-Dec: 75% Brampton SRC members complete training to support early ID Jun-Sep-Mar: Evaluation check-points May 2018 Jun 2018 Jul 2018 Aug 2018 Sep 2018 Oct 2018 Nov 2018 Dec 2018 Jan 2019 Feb 2019 Mar 2019 Apr 1, 2018 Apr 1, 2019 Key milestones or dates for the project. Include start and end date. Milestone 7 24
Working Group Members: Roles and Responsibilities Name Organization Role on this Project Responsibilities Donna Sherman Carolyn Acton Jehanara Chagani Donna Perry Shereen Rampersad Jodi Pereira Dawn Serrick Anne Marie Lang- Berkowitz Rosemary Crisp Tracy Redden Mandeep Grewal Clinton Baretto Nazira Jaffer CW LHIN S.R.T. Med Staff Palliative Care Network CW LHIN SHIP Heart House Hospice Holland Christian Homes North Peel FHT Extendicare Central Brampton FHT PCHS Clinical Lead / North Peel FHT Bethell Hospice 8 25
Project Schedule Task/Milestone Start Date Finish Date Lead Resources Deliverables Status Finalize the 'placemat', work plan, group membership, proposed approach, joint work with other sub-regions Participate in Advanced Care Planning training and Palliative Care 101; consider training opportunity for primary care providers and/or other primary care engagement activities Identify resources for use in the sub-region and LHIN Apr Jun - Draft LHIN materials In Progress - on track May Dec - LHIN-hosted training 75% of collaborative At Risk - not started or members complete this missed training Learn about the Queen Square FHT pilot with some physicians and early ID (as well as all PDSA efforts happening across the LHIN and primary care) May Jul In Progress - on track Review, understand, and standardize the palliative care clinical tools available for use in the sub-region and LHIN among primary care providers; Develop current capacity / comfort level survey with primary care physicians about what are the next steps if a patient is identified as early ID palliative. June Sep - tools per LHIN and CWPCN - what tools will this be (e.g. ESAS (not being done in primary are right now), PPS or Early ID) - Network web site - LHIN PC staff In Progress - on track Develop a plan for spread/scale of early ID in primary care in Brampton (staged approach); including a primary care physician engagement activities (e.g. OMA session; resources they can connect to; and CC alignment) Jul Oct. - LHIN PC staff Develop loop back mechanism via H&CC CCs re: identified early ID palliative pts Test PDSAs (Plan, Do, Study, Act - small tests of change) in other primary care providers with regards to early ID; learn from Queen Square FHT pilot; Ensure patient/caregiver feedback is sought; Sep. Jan. Conduct current capacity / comfort level survey with primary care physicians Evaluate project - checkpoints checkpoints - June, Sept. Mar. Mar. - work plan progress notes - work group and Collaborative input 26
Next Steps 1. Working groups will work with Project Specialists to continue to refine project management documentation 2. Next Sub-Region Collaborative Meeting: September 27