approved by the board on centretown chc october 30, 2018
TRANSCRIPT
CENTRETOWN CHC 2018-2020 STRATEGIC PLAN
www.centretownchc.org 613-233-4443
420 Cooper St, Ottawa ON
K2P 2N6
Every One Matters.
Chaque personne compte.
Approved by the Board on
October 30, 2018
Centretown CHC Strategic Plan 2018-2020
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CONTENTS
2018-2020 Strategic Plan _________________________________________ 1
About Centretown CHC ___________________________________________ 2
Our Mandate ____________________________________________________________ 2
Our History ______________________________________________________________ 3
Our Services ____________________________________________________________ 4
Our Planning Approach ___________________________________________ 5
Background _____________________________________________________________ 5
The Collaborative Strategic Planning Process __________________________________ 6
Centretown CHC’s Strategic Planning Process (2016-18) ________________________ 13
CCHC 2018-2020 Strategic Plan ___________________________________ 20
Our Vision, Mission & Values _______________________________________________ 20
Our Strategic Directions & Goals ____________________________________________ 21
Appendix I. Defining The System ___________________________________ 1
Appendix II. SWOT Analysis _______________________________________ 1
2018-2020 STRATEGIC PLAN
“Health equity for all members of our communities.”
Working as a collective to address the systemic barriers and
challenges to accessing health services Collaborative
North Star
Enhance Access
for People with Complex Needs
Demonstrate
Quality Through Impact
Leverage
Collective Capacity
Enhance
Organizational Health & Wellness
Our Strategic Directions
Our Mission We lead the way in improving health and wellbeing
for people and communities.
Our Vision Healthy caring communities where everyone matters.
Our Values Equity ▪ Empowerment ▪ Excellence ▪ Respect
By 2020, we will…
1.1. Identify hotspots of vulnerable individuals in CHC catchment areas and target health inequities in our communities ©
1.2. Improve care
coordination and health outcomes for clients with complex needs
1.3. Improve low-barrier
access to primary health care and addictions medicine for people who regularly use drugs and alcohol
3.1 Undertake a joint review of primary healthcare capacity to better understand current gaps and opportunities for improved client care ©
3.2 Be proactive in mitigating organizational risks ©
3.3 Use EMR technology to improve client care and operational efficiency
4.1 Implement an improved performance management system for staff
4.2 Assess options to improve our financial sustainability
4.3 Continuously improve the CCHC staff experience
2.1 Review our data to identify gaps in access to programs and services for priority populations ©
2.2 Identify and address inequities in the client experience and outcomes of our diverse clients
2.3 Adopt a social prescribing model to better integrate health and social services, and promote a greater sense of community belonging
Centretown CHC Strategic Plan 2018-2020
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ABOUT CENTRETOWN CHC
Figure 1. Centretown CHC's Catchment Area in Ottawa, Ontario.
Our Mandate
We are a nonprofit, multi-service Community Health Centre serving the Centretown,
Glebe, and Old Ottawa South neighbourhoods. Our interdisciplinary primary
healthcare and health promotion programs support the health and wellbeing of over
13,000 Ottawa residents (including 5,300 regular primary care clients) who access our
services every year.
In a fair and just society, one’s skin colour, religion, income level, gender identity, and
sexual orientation should not predict poor health outcomes. In ours, it sadly does. To
bridge these health inequities, Centretown CHC offers a full range of healthcare
services and health promotion programs, including specialty health clinics (i.e. urban
health, newcomer health, trans health), mental health & addiction services, diabetes
programs, early year programs, and community health promotion.
Centretown
Community Health Centre
Centretown CHC Strategic Plan 2018-2020
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These programs and services are delivered by a caring and diverse team of over 150
interdisciplinary health professionals, including doctors, nurse practitioners, nurses,
social workers, counsellors, dietitians, community developers, health promoters,
outreach workers, and peer workers. As a community-governed organization, we
work hard to respond to the evolving health and social needs of our community.
Our History
Centretown CHC has been playing an active role in improving its community’s health
and wellbeing since 1969. Over time, we have built a strong reputation as:
- an effective advocate for healthy policies at the municipal, provincial and
federal level;
- a committed ally to its LGBTQ+, Francophone, street-involved, vulnerable
elderly, low income, and newcomer communities;
- a high-quality provider of diabetes programs for the Champlain region.
Recent Developments at CCHC
2008 – Ontario launches Diabetes Strategy and expands CCHC’s Diabetes
Education program, later adding screening, and chiropody services.
2012 – CCHC receives its ‘Baby Friendly’ designation for its adherence to World
Health Organization (WHO) protocols that protect, promote, and support
breastfeeding.
2016 – CCHC plays a leadership role in Refugee 613, providing outreach and
low-barrier access to primary care for Syrian war refugees arriving in Ottawa.
2016 – CCHC introduces the Trans Health Clinic, providing wrap-around
services and improved access to hormone therapy for trans individuals in the
Champlain region.
2017 – CCHC receives its ‘French Language Services’ (FLS) designation from
the Ministry of Health and Long Term Care.
Centretown CHC Strategic Plan 2018-2020
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Our Services
We believe in an integrated approach to care that is holistic, non-discriminatory,
caring, and innovative. Our services are delivered in a variety of ways: 1-on-1 client
care, personal development groups, and grassroots community involvement.
As a French Language Services (FLS) designated Centre, we ensure high-quality
programs and services in both official languages. In an effort to provide culturally-
safe care, cultural interpretation services are also available for all clients who walk
through our doors, and a number of groups facilitated by our diverse staff are offered
in other languages frequently spoken in our catchment, including Mandarin, Arabic,
and Somali.
Centretown CHC Strategic Plan 2018-2020
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OUR PLANNING APPROACH
Background
Given that the 6 Ottawa CHCs shared similar mandates, client profiles, and pressure
points, a decision was made at the turn of the decade to formalize our partnerships
by engaging in a joint strategic planning process.
From 2012 to 2017, Carlington CHC, Centretown CHC, Pinecrest-Queensway CHC
and South-East Ottawa CHC worked towards common strategic directions, including:
i) enhancing the impact of their advocacy
ii) improving social capital among priority populations
iii) delivering high-quality programs and services, and
iv) strengthening the health of their respective organizations
The collaborative strategic plan allowed the 4 CHCs to join forces on a number of
priorities while still allowing each Centre to specify Centre-specific goals to their plan,
based on the unique needs and priorities impacting their communities.
Building on the success of this collaborative process, 2 more community health
centres (Somerset West CHC and Sandy Hill CHC) agreed to join the Ottawa CHC
collaborative strategic planning process for 2018 and beyond. A request-for-
proposals was posted in 2016 and Lansdowne Technologies Inc (LTI) was retained as
a consulting partner to the 6 CHCs, to assist with planning facilitation, strategic plan
development, and project management.
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The Collaborative Strategic Planning Process
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Phase 1: Literature Review and Environmental Scan (2016-2017)
Phase 1 of the collaborative strategic planning process involved scanning the
literature to identify best practices for planning within the context of primary
healthcare. LTI conducted a thorough literature review and presented its
recommendation that the 6 CHC Board of Directors adopt a planning framework
grounded in complexity theory (‘5-Level Framework’).
Using A Complexity-Based Approach
Understanding the domains to which managing healthcare resources in our
changing context belongs is crucial to selecting the appropriate planning and
management approach. As the Cynefin Framework tells us, complex problems are
distinct from simple or merely complicated problems (see Figure 2).
Centretown CHC Strategic Plan 2018-2020
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Figure 2. Cynefin Framework (by Dan Snowden)
The decision to use a planning framework adapted to complexity was informed by
the fact that CHCs operate in a complex, unpredictable, and unknowable space. To
illustrate the point, no amount of business intelligence could reasonably have
forewarned the CHCs of the impacts of the Syrian crisis, of the OC Transpo bus strike,
or of President Trump’s election and its effect on the cross-border migration of US-
based refugees. Yet these are some of the major events, over the past 5 years, that
have called upon the Community Health Centres to respond in significant ways.
Success in such an environment requires adaptable strategies built on first principles,
timely data for sense-making, and agile collaborative structures to respond to
emerging contextual factors. Only then can a course towards defined strategic
outcomes be maintained, regardless of which way the wind blows.
Problem Domains
Simple
‘known knowns’
there are rules in place (or best
practices), the situation is stable
and the relationship between
cause and effect is clear: if you
do X, expect Y
Approach:
"sense–categorize–respond"
Complicated
‘known unknowns’
The relationship between cause
and effect requires analysis or
expertise; there are a range of
right answers
Approach:
“sense-analyze-respond”
Complex
‘unknown unknowns’
Cause and effect can only be
deduced in retrospect, and
there are no right answers (but
instructive patterns can emerge)
Approach:
“probe-sense-respond”
Chaotic
Cause and effect are unclear
Events are too confusing to wait
for a knowledge-based response
Approach:
“act-sense-respond”
“… CHCs operate in a complex, unpredictable, and unknowable space.”
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Applying a 5-Level Framework
Figure 3. 5-Level Framework
The 5-level framework was recommended by LTI and ultimately selected by the 6
Ottawa CHC boards as the framework for collaborative strategic planning. It was
also recommended that planning timeframes be shortened to no more than 3 years,
in keeping with best practices for managing organizations in complex environments.
Finally, three options were presented for the implementation of the collaborative
strategic plan at each organization:
1) Added Plan: The collaborative strategic directions and goals are added to
individual CHCs’ strategic plans as needed, based on which Centres will be
taking an active role on any given collaborative strategy.
2) Shared Plan: The CHCs’ strategic plans all share the same set of collaborative
strategic directions and goals, and may add on other strategic directions
based on their organization’s or catchment’s priorities.
3) Enabled Plan: The CHCs’ strategic plans reflect the collaborative strategic plan
as subsidiary activities in their own strategic plans. These subsidiary activities
may be reflected as a strategic goal (e.g. “strengthen CHC collaboration”)
under one of their Centre’s strategic directions. It may otherwise be reflected
as a set of enabling factors supporting all of their Centre’s strategic directions.
Multi-board discussions held in January 13, 2018 resulted in consensus that the 6 CHC
Boards wished to move forward with a Shared Plan.
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Environmental Scan
In order to assess ‘where we are now’, LTI was commissioned to produce an
environmental scan with support from CHC planners. Delivered in Fall 2017, this 80-
page document helped to define ‘the system’ (see Appendix I), describe key trends
at various levels of the system, and highlight a number of opportunities / threats
facing Ottawa CHCs (see Appendix II). Population health statistics for Ottawa and
findings by key themes are presented in Figure 4 and Table 1, respectively.
Figure 4. Population health statistics for Ottawa from the 2017 Environmental Scan.
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Table 1. Summary of Findings by Key Themes
Global
Instability and
Trauma
• Regional conflict; religious, ethnic and LGBTQ+ persecution; and adverse weather
events linked to global warming are driving increases in immigrant, refugee, and
displaced persons. Many arrive in Ottawa with significant trauma loads and face
barriers to integration.
• The integration of trauma-informed healthcare, immigrant supports, and language/job
skills development is essential to newcomer wellbeing.
Health System
Redesign
• Patients First is rationalizing health systems within LHIN boundaries and newly defined
sub-regions. CHCs will benefit from developing a shared future-state vision of sub-
regional systems and CHCs’ role within them, in order to operate from the same
playbook when negotiating at sub-regional tables.
• The risk of the current government being unseated remains high. CHCs will be well-
served by monitoring provincial party platforms, engaging with all Ottawa MPP
candidates, and planning contingencies as the June 2018 provincial election nears.
Ottawa’s Aging
Population
• On the business side, chronic disease management, dementia, and care coordination
will increase encounter volumes and case complexity.
• On the organizational side, the increasing threat of corporate memory loss will need to
be monitored and planned for as a significant wave of front-line experts, care
providers, and senior executives reach retirement age.
• Strong succession planning, alongside forecasting and advocating for needed
resources and supports (i.e. for care coordination and home care), will help mitigate
these organizational stressors.
Health Equity
• The CHCs’ community governance model leads the way in promoting health equity,
but no framework yet exists to leverage CHC data to systematically identify and
address social disparities in: the determinants of health, access to care, patient
experience, or clinical / population health outcomes.
• Adopting a health equity framework and investigating opportunities (e.g. patient
portals) to expedite the collection of complete sociodemographic data for their
centres would help CHCs maintain their status as system leaders in driving an
evidence-informed health equity agenda.
Value-For-
Money
• The 2012-2017 collaborative strategic plan demonstrated the value of collective
action, allowing CHCs to make their mark while undergoing budget freezes. In light of
recent health system funding reforms (Excellent Care for All Act), as well as the Auditor
General of Ontario (AGO) audit of LHINs/CHCs, the impetus for efficiency remains high.
• By strengthening operational partnerships (together, and with key partners, e.g.
Ottawa Public Health) and better monitoring their collective impact, Ottawa CHCs
can continue to build on best practices, align resources to do more with less, and show
value-for-money.
Big Data, GIS,
eHealth, and
QI: Building
Learning
Organizations
• Ottawa CHCs are increasingly data-rich while analytic capacity lags. Meanwhile, the
opportunity cost of not leveraging business intelligence increases yearly as software
and capabilities grow.
• CHCs are encouraged to build pockets of excellence in GIS, big data, and eHealth to
glean new insights, spur efficiencies and champion innovations that will help CHCs
meet the growing demands of an aging population. Short-term secondments could be
used as a knowledge exchange pipeline.
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The environmental scan was circulated to all 6 CHC’s board members along with
other key documents (see Table 2) to inform their efforts in Phase 2.
Table 2. Collaborative Strategic Planning – Key Inputs
Organization Key Document
CHCs 2012-2017 Collaborative Plan’s Strategic Outcomes
2017 Environmental Scan
Champlain LHIN
2016-19 Integrated Health Service Plan (IHSP)
o Community Engagement Report for IHSP 2016-19
Champlain LHIN Service Accountability Agreement (SAA) Indicators
(2017-2020)
Health Quality
Ontario (HQO) Quality Improvement Indicators (2017-18) for primary care
Association of
Ontario Health
Centres (AOHC)
Key province-wide initiatives led by AOHC
o Advocacy Priorities & Key Messaging (e.g. Elections)
o ‘Vital 8’ outcome indicators
o ‘Count Every One’ data initiative
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Phase II: Strategic Planning (2017-2018)
Phase 2 of the collaborative strategic planning process involved engaging the 6
Ottawa CHC boards in a collective visioning exercise to determine the strategic
outcomes, guidelines, and directions that would guide our organizations.
Once the strategic directions were agreed upon by the 6 CHC boards, key
stakeholders – including staff, clients, community partners at each Centre – were
consulted in order to define, validate, and refine strategies to operationalize the
collaborative strategic plan as well as inform any Centre-specific directions/priorities.
After an approval-in-principle in Spring 2018 and some further refining by the 6 CHCs’
executive directors and senior management teams over Summer 2018, three
collaborative strategic directions were approved by the CHC boards in Fall 2018.
Our Collaborative ‘North Star’
“Health Equity for All Members of Our Communities” – Working as a collective to
address the system barriers and challenges to accessing health services.
2018-2020 Collaborative Strategic Directions
1. Enhance Access for People with Complex Needs
2. Demonstrate Quality Through Impact
3. Leverage Collective Capacity
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Centretown CHC’s Strategic Planning Process (2016-18)
Throughout the Collaborative Strategic Planning process, Centretown CHC was
concurrently engaged in a series of consultations with its staff, board members,
community partners, and community members, in order to inform its input into the
collaborative strategic directions, as well as to identify needs specific to its
community members and its organization.
Client & Community Member Consultations - Summer 2016
Between July and September 2016, clients were engaged with at over 20
group classes and community events across our various locations in Ottawa
Clients / community members were asked 4 key questions:
o what needs/struggles they face
o how accessible we are
o how they hear about our programs & services
o what it is that CCHC does for them (and how we could do this even
better)
Consensus:
o CCHC is a welcoming, inclusive space that clients value being able to
access
o Clients would find it difficult to replace CCHC in their lives
o Clients typically come to the Centre for more than 1 service
o Hear about our services/events mostly via word-of-mouth, staff, and
posters
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Key Themes from 2016 Client Consultation
Challenges
Faced
• Housing, food security and employment
• Prejudice (not feeling accepted or valued as newcomers,
people with mental health and/or addiction issues, LGBTQ+,
senior citizens, etc.)
• How to access/navigate system for health & social resources
• Social isolation: “if we are not explicitly included, we are implicitly
excluded”
Areas for
Improvement
• Client orientation; health system coaching
• Shorter wait times (Primary Care, Mental Health, Trans Clinic)
• Translation supports (Arabic, Mandarin, Cantonese)
• Better educate community partners about programs & services
• More accessible (legible) posters in lobby
New Services
• Cooking classes (requested by wide range of groups)
• More health promotion information (newcomers, seniors)
• Longer term programs (>6 weeks)
• Physical activity/exercise classes (seniors (incl. LGBTQ), moms,
newcomer women)
• More outreach to social housing (seniors, other homebound)
While some of these key themes have since been addressed by Centretown CHC in
CCHC’s 2016-17 and 2017-18 Operational Plans, other areas (i.e. decreasing social
isolation, strengthening newcomer health supports, improving outreach efforts) were
in need of a strategic focus, longer timelines, and/or more resources in order to
effectively remove the barriers to health and wellbeing reported by our community
members.
These themes received due consideration by CCHC’s Board and Senior
Management during the formulation of our 2018-2020 strategic goals.
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Client Experience Survey – Spring 2018
Between February and March 2018, clients waiting in our general or clinical
reception area were asked to complete our annual Client Experience Survey
The anonymous 4-page questionnaire asks a series of demographic and
service utilization questions, also inquiring about the quality and timeliness of
the care experience, outcomes, and overall satisfaction with CCHC.
Consensus:
o CCHC clients are highly satisfied with their care (99% agree)
o Clients feel that their CCHC providers involve them in decisions about
their care (96% agree)
o Clients feel more connected with their community as a result of their
involvement with Centretown CHC (90% agree)
Key Themes from Client Surveys [ themes mentioned by x% of sampled clients in comments ]
Key Insights
• High overall satisfaction with care experience and providers
• While most individuals from marginalized groups felt welcome at our
Centre (>90%), Homeless and Trans individuals were least likely to
agree that they always felt welcome and comfortable (83% each)
• 9% of clients with a disability reported experienced some form of
difficulty or discomfort when accessing Centretown CHC’s services
Areas of
Excellence
• Friendly, helpful staff [52%]
• Quality of programs/services [14%]
• Interdisciplinary care [9%]
• Location (easy to access) [9%]
• Warm welcome at reception [9%]
Areas for
Improvement
• Wait times (in clinic and for follow-up appointments) [6%]
• Access to certain types of appointments [3%]
• Sense of physical safety in the Centre, at times [2%]
• Negative experiences at reception [2%]
• Implement eHealth / electronic communications [2%]
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These findings were shared with CCHC’s board, senior management, and staff in
Spring 2018 and received due consideration during the formulation of our 2018-2020
strategic goals.
Community Partner Consultations – Spring 2018
In April 2018, over a dozen community partners operating in our catchment
were invited to attend a facilitated discussion to share observations about
client and community trends in the Centretown neighbourhood
Facilitated discussions centred around 5 key questions:
o What factors are most affecting your clients’ quality of life?
o Which client groups is your organization struggling to serve well?
o What key health issues/concerns require the most attention?
o What is Centretown CHC’s role in the community?
o What are the key opportunities for enhanced partnerships for 2020?
Consensus:
o Poor mental health, often accompanied by addictions, is a key driver of
the health needs being felt in our community; agencies are struggling
to serve clients with mental health issues well.
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o Traumatized refugees (especially families with children) have significant
needs around trauma-informed and culturally-safe care, overcoming
language barriers, employment, and early years/afterschool programs.
o Social isolation and poverty are the hallmarks of poor quality of life in
our catchment; seniors experiencing both are especially at risk.
o Limited / segmented services available for LGBTQ+ health care and for
mental health & addictions.
o Lack of housing supports (e.g. pest control, hoarding) for vulnerable
individuals lead to poor health outcomes and evictions.
o Need to strengthen referrals for vulnerable people via ‘warm bridging’
and better awareness of each others’ services and key staff.
o Centretown CHC is a community leader well-positioned to connect
local partners, as well as a convenient place to refer people with
complex needs, knowing that these needs will be met.
Board-Staff Consultations – Spring 2018
In April 2018, two to three staff representatives from each program joined
Board members in a facilitated planning session intended to identify potential
goals under each Strategic Direction and strategies to achieve these goals.
Note: at the time, the Strategic Directions had not yet been finalized and
were still known as ‘Access Leveling’, ‘Quality Improvement’ and
‘Strengthening Key Enablers’.
Strategic Directions
Issues Proposed Solution(s)
Access
Leveling
- Lack of identified staff with
culture, skills, language to
meet needs of hard-to-
reach individuals
(Indigenous, people with
addictions, Francophone)
- Lack of awareness about
our programs among
clients and community
partners
- More Francophone (FLS) and
Indigenous staff with lived
experience (e.g. MHA, LGBTQ+,
homelessness)
- Working with partners to better
understand:
o Each other’s scopes and
any gaps remaining
o Data on who is falling
through the cracks
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- Lack of continuity of care
/ wrap-around services for
vulnerable clients
- Stigma, social isolation,
lack of mobility keep high-
need clients outside of our
doors
- Increase outreach and warm
handovers for
homeless/marginalized
populations
- More case management
resources for complex clients
- Improve sense of belonging via
programming that engages
those most at risk of social
isolation
Quality
Improvement
- Need for high-quality
Francophone primary
healthcare (Haitian
refugees + existing
Francophone population
+ FLS designation)
- Could do better at
engaging our clients
- Integration between
programs / teams could
be better
- Not enough data (or lack
of data flow) to respond
quickly to different
communities’ needs
- Offer a full continuum of
services across
CHCs/agencies instead of
patchwork and
duplication of basic
services
- More Francophone (FLS) and
Indigenous staff with lived
experience (e.g. MHA, LGBTQ+,
homelessness)
- Explore options for enhancing
client engagement (e.g. client
advisory group and/or or other
mechanisms)
- Improve awareness of our
programs and services internally
and enhance strength of cross-
program collaboration
- Collect better data on client
needs and experience with
quality our services using health
equity lens
- Review interdisciplinary primary
healthcare assets and gaps in
the community (take into
consideration hours of service,
eligibility, service type,
geographic coverage)
Key Enablers
- Need better and more
timely data
- Need to strengthen our
ability to tell our stories (i.e.
advocacy, grants, brand
reputation, influencing
system change)
- Develop approaches to
monitoring our client data over
time using an equity lens and
communicating this data to staff
- Better understand the gap
between what we are seeing at
our Centre vs the true picture of
needs in our community (e.g.
who aren’t we seeing?)
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- Need to have more agile
and collaborative
structures / resources to
respond more quickly to
emerging community
issues
- Need better technology
to make healthcare
processes more efficient
and client-centred and
reduce burden on staff
- Flow data and stories from front-
line staff / analyst /
management to
communications to better tell
our story
- Work with Communications
specialist to coach key staff on
strategy (e.g. social media)
- CHC collaborative planning:
Define core vs specialized/sub-
regional services
- Plan across programs for priority
populations (e.g. vulnerable
MHA clients; isolated seniors;
LGBTQ+)
- eFaxing, EMR, email reminders,
tablets/kiosks for client
forms/registrations
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CCHC 2018-2020 STRATEGIC PLAN
Our Vision, Mission & Values
Our Vision
Healthy, caring, inclusive communities where every one matters.
Our Mission
We lead the way in improving health and wellbeing for people and communities.
Our Values
Equity / Empowerment / Excellence / Respect
Equity. We believe in recognizing and respecting diversity among people in our
communities to provide them with appropriate services that meet their varying
needs. We strive to break down barriers so everyone can enjoy access to the services
they need to be healthy. Equity is about recognizing differences among people and
treating people differently according to their needs in order to achieve equality of
access.
Empowerment. We value participation and believe in our clients’ and communities’
right to play an active role in determining what services are offered and how they
are delivered. To achieve this, we foster open and constructive dialogue and believe
in engaging in respectful, honest and clear communications practices. We strive to
provide all the support and information required to make informed choices and
participate in meaningful ways.
Excellence. We are committed to providing excellent services and strive for constant
improvement and innovation. We focus on best practices, evidence-based
approaches and ongoing evaluation to deliver effective and comprehensive
services that best meet our clients’ and communities’ needs. We ensure
accountable, efficient and effective use of resources.
Respect. We are committed to fostering an inclusive environment where everyone is
treated in ways that are fair, courteous and compassionate. We believe in valuing
one another’s opinions and contributions and giving full considering to these views
with an open and non-judgemental mind.
Centretown CHC Strategic Plan 2018-2020
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Our Strategic Directions & Goals
Individuals with 4 or more chronic conditions are defined as
medically complex individuals. If accessible, equitable and
interdisciplinary primary healthcare is not available to these
individuals, they are more likely to suffer from preventable
complications, to frequent the emergency department,
and to have poor quality of life. The CHC model of care is
ideally suited to keeping these individuals healthy and well.
GOALS
1.1. Identify hotspots of vulnerable individuals in CHC
catchment areas and target health inequities in our
communities. ©
1.2. Improve care coordination and health outcomes
for clients with complex needs.
1.3. Improve low-barrier access to primary health care
and addictions medicine for people who regularly
use drugs and alcohol.
INITIAL ACTIVITIES
1.1. Develop a community profile of complex and vulnerable individuals in the community
using a health equity lens.
1.2. Evaluate the implementation of Health Links and its impact on client outcomes.
1.3. Submit a funding proposal to Champlain LHIN for enhanced primary care and MH&A
outreach resources for street-involved clients.
By 2020 …
CHCs will ensure that clients with complex needs have
access to coordinated interdisciplinary care in Central
Ottawa via Health Links.
2020 Target: 44 Health Links
coordinated care plans (CCHC)
CCHC will reduce 30-day hospital readmissions for clients
with complex needs.
2020 Target: <9.5% 30-day hospital readmission rate for
Health Links clients
CCHC will improve client experience and continuity of
care for transient clients who use drugs and alcohol.
2020 Target: 200 more encounters/year with clients
who use drugs & alcohol due to
enhanced wrap-around services
ENHANCE ACCES FOR PEOPLE WITH COMPLEX NEEDS DIRECTION 1:
Centretown CHC Strategic Plan 2018-2020
22
e
Quality has many dimensions. While Centretown CHC
excels at providing effective, safe, timely, and client-
centred care to the most complex clients in our
community, we have never formally studied how equitable
the care that we provide truly is – at least not in a
systematic way. This will change in 2018-2020.
GOALS
2.1. Review our data to identify gaps in access to
programs and services for priority populations. ©
2.2. Identify and address inequities in the client
experience and outcomes of our diverse clients.
2.3. Adopt a Social Prescribing approach to better
support collaborative practice and promote a greater
sense of community belonging.
INITIAL ACTIVITIES
2.1. Develop a profile of clients served, including services accessed and client issues, using
a health equity lens.
2.2. Develop a health equity report card to monitor access, client experience, care quality
and outcomes for CCHC’s priority populations.
2.3. Develop a project plan for the implementation and evaluation of a Social Prescribing
strategy.
By 2020 …
Ottawa CHCs will have a system in place to monitor
inequities in access, client experience, and outcomes.
2020 Target: Adoption of CHC performance dashboard
with equity indicators
All Centretown CHC programs will have the information
they need to set annual equity-seeking goals.
2020 Target: 4 out of 4 CCHC programs use access maps
and the health equity report card to
set annual improvement targets
75% of clients involved in Social Prescribing pilot will report
a greater sense of community belonging.
2020 Target: 75% of monitored clients report an
improvement in their sense of
community belonging
DEMONSTRATE QUALITY THROUGH IMPACT DIRECTION 2:
Centretown CHC Strategic Plan 2018-2020
23
As the client journey and health outcomes of Central
Ottawans becomes an increasingly collective and
intersectoral responsibility, it is important to develop
collaborative practices that enable the sharing of best
practices, tools, and data systems so that our organizations
can collectively rise to meet the needs of the community.
GOALS
3.1. Undertake a joint review of Primary Care capacity to
better understand gaps and opportunities for improved
client care. ©
3.2. Be proactive in mitigating organizational risks. ©
3.3. Use EMR technology to improve client care and
operational efficiency.
INITIAL ACTIVITIES
3.1. Collaboratively define the scope and priority areas of the inter-CHC Primary Care
capacity review project.
3.2. Educate senior management and board members on the use of Sandy Hill CHC’s risk
management audit tool.
3.3. Undertake a cost-benefit analysis of potential EMR add-on services (e.g. eFaxing, client
kiosks).
By 2020 …
On-call providers will be able to access client records
and chart in the EMR when providing after-hours care.
2020 Target: Adoption of EMR data-sharing utility at the 6
Central Ottawa CHCs
Senior management will have adopted new tools and
processes to identify and manage organizational risks.
2020 Target: Adoption of new risk management tools and
processes captured in policies
Collection of up-to-date client socio-demographic (SD)
information will improve by +400%.
2020 Target: 50% of active clients will have up-to-
date SD information in the EMR
LEVERAGE COLLECTIVE CAPACITY DIRECTION 3:
Centretown CHC Strategic Plan 2018-2020
24
Technological advancement, changes in government
priorities, and the evolving nature of our work requires us to be
constantly adapting to our context to maintain high quality,
client-centred care. In order to deliver what the community
expects of us, it is imperative that we continually look to
strengthen our funding, our infrastructure, our processes, and
our people.
GOALS
4.1. Implement an improved performance management
system for staff.
4.2. Assess options to improve our fiscal sustainability.
4.3. Improve the CCHC staff experience.
ACTIVITIES
4.1. Finalize CCHC’s staff performance management tool in our HRM system.
4.2. Identify potential efficiencies and estimate cost savings.
4.3. Conduct a survey and consultations in order to better understand staff priorities.
By 2020 …
# staff who report getting timely feedback on their job
performance will improve by +50%.
2020 Target: 75% of staff agree that they get timely
feedback
# staff who report that there is strong support for training
in their area of work will improve by +40%.
2020 Target: 70% of staff agree that there is strong
support for training
# staff who would recommend CCHC as a place to work
will improve by +8%.
2020 Target: 70% of staff agree that they would
recommend CCHC
ORGANIZATIONAL HEALTH & WELLNESS DIRECTION 4:
Centretown CHC Strategic Plan 2018-2020
2
Every One Matters.
Chaque personne compte.
Follow us on Twitter: @CentretownCHC
Follow us on Facebook: @CentretownCHC
Follow us on LinkedIn: @CentretownCHC
420 Cooper St, Ottawa ON K2P 2N6 * 613-233-4443 * [email protected] * www.centretownchc.org
APPENDIX I. DEFINING THE SYSTEM
APPENDIX II. SWOT ANALYSIS Strengths
• Ottawa CHCs generally report high client satisfaction.
• Ottawa CHCs are increasingly data-rich (EMR, Be Well Survey,
Ottawa Neighbourhood Study, etc.).
• Ottawa CHCs have access to a significant number of
volunteers, many of whom have lived experience, as well as
cultural and linguistic competencies.
• Ottawa CHCs are generally becoming more efficient or
maintaining their efficiency over time.
• The practice of developing Centres of Excellence and referral
pathways among CHCs promotes service high-quality clinical
care.
Weaknesses
• Ottawa CHCs generally have limited analytical capacity and QI expertise
to make use of their client data for equity-informed quality improvement
(QI).
• Quality improvement is currently driven largely by a top-down (i.e. Health
Quality Ontario) approach rather than via client engagement.
• Low organizational maturity in program design, outcome evaluation, and
knowledge exchange make it difficult to identify, assess, and scale best
practices in group programming across CHCs.
Opportunities
• Greater use of eHealth tools like eVisits, patient portals, and
hospital eNotifications could lead CHCs to better patient
outcomes, higher client satisfaction, and significant efficiencies.
• The forthcoming integration of public health units within LHINs will
allow CHCs to better align their community development and
health promotion resources with Public Health for greater
impact.
• CHCs should explore the feasibility of becoming ‘Community
Hubs’ (and related capital funding opportunities) in order to
reduce barriers for clients needing access to social services.
• Given the recent residential school apology, TRC Calls to Action,
and growing impetus to recognize the rights of indigenous
peoples to culturally-safe care, CHCs have an opportunity to
explore partnership with Wabano to promote a shared health
equity agenda in service of indigenous communities.
Threats
• There is potential for already-high demand for newcomer health services
to be exacerbated by the recent trend of irregular crossings from US-
based asylum-seekers due to US ‘self-deportation’ policies.
• Ottawa’s aging population will significantly increase case complexity as
well as demand for chronic disease management, care coordination,
and home-based care over the next 10 years.
• The high likelihood of political turnover in the June 2018 provincial
elections casts doubt on the extent to which sub-regional healthcare
integration will proceed as planned.
• The number of individuals approaching retirement age has begun to
exceed the number entering the workforce. This trend will accelerate as
the 65+ population segment grows by 28% as a share of Ottawa’s
population by 2026. CHC loss of corporate memory and expertise poses
a significant organizational risk.