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Table of Contents

APPENDIX 1: THE FRAMEWORK FOR PLANNING ..................................................... 3

APPENDIX 2: THE PROVINCIAL CONTEXT ................................................................ 5

APPENDIX 3: PROFILE OF THE MISSISSAUGA HALTON LHIN ................................... 7

APPENDIX 4: ENVIRONMENTAL SCAN OF THE MISSISSAUGA HALTON LHIN ........ 17

APPENDIX 5: COMMUNITY ENGAGEMENT STRATEGY .......................................... 48

APPENDIX 6: COMMUNITY ENGAGEMENT STAKEHOLDERS ................................. 53

APPENDIX 7: IHSP PRIORITY DEVELOPMENT AND CONTEXT ................................ 55

APPENDIX 9: BIBLIOGRAPHY ................................................................................ 82

Contact Information

Telephone …………………………………………………… 905.337.7131 1.866.371.5446 Address …………………………………………………… 700 Dorval Drive, Suite 500 Oakville ON L6K 3V3 Email ……………………………………………………. [email protected] Website ……………………………………………………. mississaugahaltonlhin.on.ca

mailto:[email protected]

http://www.mhlhin.on.ca/

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APPENDIX 1: THE FRAMEWORK FOR PLANNING

The Integrated Health Service Plan (IHSP), as directed by the Local Health System Integration Act, must align with provincial health priorities and also reflect local priorities based in part on information obtained through community engagement. The LHIN CEOs, through their joint discussions, also identified pan-LHIN priorities that were to be addressed at a local level by all LHINs over the next three years. In consideration of these requirements, the Mississauga Halton LHIN identified a three-pronged approach for the development of its 2013-2016 IHSP:

1. Provincial Direction Alignment 2. Environmental Scan 3. Community Engagement

Ensuring alignment with the province’s direction and LHIN system imperatives required a comprehensive review of several foundational documents including:

• Ontario’s Action Plan for Health Care • The Walker Report • The Drummond Report • Changing the Conversation: Defining

Future System-Wide Leadership Imperatives for the Health Care System - LHIN CEO Think Tank Summary Report, April 17, 2012

The Ministry of Health and Long-Term Care, Health Analytics Branch supported a provincial LHIN Environmental Scan, developing a comprehensive review of the demographics and health resource utilization for each LHIN. This detailed

report is included within these appendices. A report reflecting the data for all LHINs will also be made available on the LHIN’s website. This environmental scan, along with a review of specific programs and services/initiatives funded by the Mississauga Halton LHIN over the past six years, helped guide the identification of key priority areas for the upcoming three years. In preparation for engaging the broader community on local health system priorities, the LHIN reflected on the common themes within the foundational documents and also highlighted areas for future focus considering the progress made within the LHIN during the course of the two prior IHSPs and the current state of our health care system. Also taken into consideration was the fact that we are now embarking upon a time of significant change within health care in the Province of Ontario that will require a new focus. Draft priority areas were identified for community consultation. These priorities were not specific to any one population or group, but were designed to address issues that were common across the continuum of health care services, irrespective of the client group. This approach was intended to foster ideas that helped to reduce the silos within health care and provide a more integrated systems approach to service delivery. It was expected that initiatives identified to address specific priority areas may, however, be specific to unique populations or service types.

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The proposed priority areas for our initial community engagement were:

1. Right Care, provided at the Right Time, in the Right Place

2. Faster Access and Stronger Linkages with Family Health Care

3. Ensuring Health Care Transitions are smooth

4. Increasing Community Capacity 5. Keeping our Citizens Healthy

The community engagement strategy implemented by the LHIN is noted within Appendix 5. Following community consultation and a comprehensive review of the literature that aligned with the draft

priorities (noted in Appendix 8), draft priorities were developed for the IHSP. For these draft priorities, key goals and strategies to achieve these goals were also developed, to help provide a framework that would support achievement of our local priorities. Big dot measures of success were also identified. A second round of consultation was conducted with key stakeholders, including a task group of members from the Mississauga Halton LHIN Board. Following these consultation sessions and incorporating feedback received, the final Mississauga Halton 2013-2016 Integrated Health Service Plan was written, along with this accompanying Appendices document.

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APPENDIX 2: THE PROVINCIAL CONTEXT

Between 2003-04 and 2011-12, health sector funding increased at an average rate of 6.1 percent annually, for a total increase of $17.9 billion. A key driver of future health care costs – in addition to general inflation and changes in technology – and a factor in the sustainability of the system is the fact that the population of Ontario is getting older, and as people age, they require more health care. Specifically, in 10 years there will be 43 percent more seniors in the province than there are now and in 20 years there will be twice as many1. Without changing how we deliver care in Ontario, in 20 years the health care system would cost $24 billion dollars more per year than we currently spend2. In light of substantial fiscal pressures, the provincial government has stated, “Funding for the health care system cannot continue to grow at past rates.” The way we currently operate must change. In order to address these concerns, the Ministry has articulated the following priorities within its Action Plan for Health:

1. Keeping Ontario Healthy This priority focuses on keeping people healthy by supporting healthy habits and lifestyle changes. In addition to tackling childhood obesity, smoking and cancer screening, the province will continue to work on better management of chronic conditions. This priority will also mean a renewed emphasis on preventative and proactive care so chronic conditions are managed, reducing the number of hospitalizations a person will require,

1 Ontario’s Action Plan for Health Care, p.7 2 Ontario’s Action Plan for Health Care, p. 7

easing the strain in emergency rooms and inpatient beds across the province. LHINs across Ontario have been working with local providers on chronic disease prevention and management strategies for many years and a strong foundation is in place to build upon.

2. Faster Access and a Stronger Link to

Family Health Care This priority identifies faster access to primary care, more ways to access family health care resources and the introduction of quality measures to family health care as a key component to have a fully integrated system. In 2008-09, the rate for unplanned readmissions to hospital was 15 percent in Ontario, which the Ministry considers high compared to other jurisdictions. Reducing hospital readmissions, to which primary care can play a large role, will have an important effect on the sustainability of the health care system.

3. Right Care, Right Time, Right Place The Right Care means care informed by what the best scientific evidence and clinical guidelines have determined is the best care for you. It eliminates unnecessary procedures and tests, making resources available for those who need them most. The province and the LHINs will work with Health Quality Ontario to translate evidence into tools and guidelines that can help providers’ person-centred and evidence-based care into practice.

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Care At the Right Time means having faster access to the care you need. This could mean telemedicine or supports to help you stay at home longer, in your community, close to your family and friends. Care In the Right Place addresses several serious issues in the health care system. One of the most pressing is the challenge of Alternate Level of Care (ALC) consumers, who are in hospital beds but would be best cared for in the community with support services to help maintain and improve their quality of life. Community care costs a fraction of what it costs to keep an individual in a hospital bed. In addition, the province is launching a Seniors Strategy, building on the successes of the Aging at Home program. The Seniors Strategy places renewed focus on keeping people from being unnecessarily admitted to hospital.

To support the Action Plan’s goal of providing more community-based care for seniors, the 2012 provincial budget will increase funding for home and community service by four percent

annually over the next three years3. The expansion of community-based care and the call to empower LHINs to shift resources to where the need is greatest will be based on local needs and plans developed throughout this IHSP.

32012 Ontario Budget, page 28

System Imperatives To support the high-level priorities of the Minister’s Action Plan, Ontario’s LHINs have collectively identified several system imperatives. These imperatives will guide decisions LHINs make regarding the allocation of resources among providers and the programs and projects to be funded at the local level. Enhancing Access to Family Health

Care will not only ensure people have timely access to a primary care provider but will also support the appropriate use of hospital and clinic resources.

Enhancing Coordination and Transitions of Care for Targeted Populations focuses on key populations of “high-needs” consumers and those at risk of becoming “high-needs” consumer. The health care system will provide coordinated plans of care for these targeted populations to assist them to get the right care when and where they need it.

Implementing Evidence-Based

Practice to Drive Quality will support consistent coordinated responses to high-priority quality issues in the system. By reducing adverse events in all care settings (e.g. hospital, long-term care, community/home) Ontario’s LHINs can build on the many quality initiatives currently implemented by health care providers. In partnership with Health

http://www.health.gov.on.ca/en/ms/ecfa/healthy_change/docs/rep_healthychange.pdf

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Quality Ontario and other key stakeholders, LHINs will work to develop coordinated plans to reduce adverse incidents that impact the quality of care and embrace best evidence-based decision making.

Holding the Gains will help Ontario’s

LHINs make sound choices about local projects by ensuring that

achievements made to date are not lost as new priorities are developed and they are moved forward. A challenge for all organizations that periodically refresh their strategic directions, LHINs must be sure to protect the many advances they have made in improving wait-times, value for money, transparency and accountability.

Enhancing Access to Family Health Care

Enhancing Coordination & Transistions of Care for Targeted Populations

Implementing Evidence-Based Practice to Drive Quality

Holding the Gains

SYSTEM IMPERATIVES

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APPENDIX 3: PROFILE OF THE MISSISSAUGA HALTON LHIN Population Characteristics

The total Mississauga Halton LHIN area is subdivided into six sub LHIN planning areas, identified as Halton Hills, Milton, Northwest Mississauga, Oakville, Southwest Mississauga and South Etobicoke. Our population is the fifth largest amongst all LHINs, representing 8.8 percent of the total provincial population. Between 2006 and 2011, the Mississauga Halton LHIN population increased by 12 percent. The average rate of growth in the Province of Ontario for this same period was 5.6 percent. The population of our LHIN is predicted to continue to grow above the provincial

average between now and 2030. By 2015, we will grow by a rate of 10.1 percent, by 2020 we will grow 21.5 percent, and by 2030, it is projected we will have grown by 45.8 percent. Analysis of total population distribution in 2010 identified that the greatest population is located in Northwest Mississauga (371,036) followed by Southeast Mississauga (362,560), Oakville (191,138), South Etobicoke (110,457), Halton Hills (63,572) and Milton (62,150). Residents of Mississauga Halton predominately live within large urban centers (87 percent) with only 1.7 percent living in small rural areas.

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The population of seniors within the LHIN will grow substantially over the upcoming years. In 2010 there were 71,659 people aged 65 to 74 and 57,966 people aged 75 years or greater. By the year 2030, it is projected that the population of people aged 75 years and greater will reach 82,000. This represents an increase of 143.4 percent from 2010.

Distribution of seniors across the Mississauga Halton sub LHIN areas shows that the greatest density of seniors aged 75 years and greater is located in South Etobicoke (6.9%), Oakville (5.5%), Northwest and Southeast Mississauga (4.6% each), Halton Hills (4.5%) and Milton (3.8%).

Projected Change in MH LHIN Population

Year Total LHIN Population LHIN Population Age 75+ # % Growth from

2010 # % Growth

from 2010 % of Population Age 75+

2010 1,160,904 - 57,303 - 4.9% 2015 1,278,466 10.1% 69,989 22.1% 5.5% 2020 1,410,955 21.5% 86,319 50.6% 6.1% 2030 1,693,170 45.8% 139,498 143.4% 8.2%

Source: intelliHealth, Population Projections LHIN. Accessed July 26, 2012

This map shows the number of persons aged 65 or older by Dissemination Area in the MH LHIN, as per the 2006 Census.

The DAs with the largest numbers of persons aged 65 or older are found in Mississauga and South Etobicoke, but there are pockets with large numbers of seniors throughout the MH LHIN.

Persons Aged 65+ by Dissemination Area (DA)

Central West LHIN Waterloo Wellington

LHIN

Mississauga Halton LHIN

Hamilton Niagara Haldimand Brant LHIN

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Diversity Cultural diversity within the Mississauga Halton LHIN continues to grow. Based upon the 2006 Canadian Census results, a total of 43.2 percent of the population identified themselves as immigrants, the third greatest in the province compared to a provincial average of 28.3 percent. Of this total group, 8.4 percent were recent immigrants who had arrived within the Mississauga Halton LHIN area between 2001 and 2006.

The Mississauga Halton region is home to approximately 18,540 people who identified their mother tongue as French (2006 census). Under the inclusive definition of Francophones adopted by the Office of Francophone Affairs in January 2010, the

number of Francophone people within the LHIN increased to 35,730. The city of Mississauga is a designated community under the French Language Services Act (FLSA), which requires identified agencies to provide services in French when required. The LHIN continues to work with the Francophone community to increase access to services in French. A significant advance in this area has been the collaboration with a Family Health Team in Mississauga. One of two sites operated by the team is funded for dedicated service in French for Francophone families.

The MH LHIN is one of the most diverse LHINs, with 36% of the population being a visible minority.

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Within the Mississauga Halton community, 0.4 percent of the population or approximately 4,400 people self-identify themselves as Aboriginal. The greatest numbers of Aboriginal people live within the Halton Hills community. The Mississauga Halton LHIN has one of the smallest numbers of Aboriginal residents compared to other LHIN areas, primarily due to the fact that there is no First Nation reserve located within the LHIN boundaries. Knowing that the Mississauga Halton LHIN is a culturally diverse community, it is important that we recognize that the health status and behaviours relating to accessing

health services differ across the population. For example, the immigrant population is more likely to have visited their family doctor at least once in the past year and more likely to have an annual flu shot than Canadian-born citizens. When considering health risk factors, the immigrant population reported significantly lower rates of heavy drinking, obesity and smoking although they reported higher rates of physical inactivity than Canadian-born citizens. Rates for chronic conditions such as diabetes, heart disease and hypertension are higher in the immigrant population than Canadian-born population.

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The residents of the Mississauga Halton LHIN are relatively healthier and have a greater life expectancy when compared to people living in other areas of the province. Although we do have lower rates for the incidence of certain diseases such as ischaemic heart disease (lowest in the province); lung cancer (3rd lowest); colon, rectal, lymph and blood related cancers (all 2nd lowest in the province), they do affect a large number of our residents and their families and place demands upon our health care delivery system.

Mississauga Halton LHIN Health Profile, June 2011

MH LHIN compares unfavourably to Ontario *Per 100,000 population

Source: Statistics Canada. 2011. Health Profile. Statistics Canada Catalogue no. 82-228-XWE. Ottawa. Released June 28, 2011. http://www12.statcan.gc.ca/health-sante/82-228/index.cfm?Lang=E

http://www12.statcan.gc.ca/health-sante/82-228/index.cfm?Lang=E

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MH LHIN compares unfavourably to Ontario


MH LHIN compares unfavourably to Ontario





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Health Service Utilization - Hospitals The demand for hospital acute care services continues to rise. Between 2006 and 2011, the number of people accessing hospital based care rose by four percent. While residents from other surrounding LHIN areas received 20.8 percent of acute care services in Mississauga Halton LHIN hospitals, 24.7 percent of the acute care services in hospitals outside of our LHIN were provided to Mississauga Halton LHIN residents. The Mississauga Halton LHIN has significantly reduced that number of consumers waiting for ALC while in hospital. Between September 2008 and April 2012, there was a 45 percent reduction in the total number of hospital based ALC individuals. Within the same period there was a 79 percent reduction in the number of ALC consumers waiting for placement in a long-term care home. The percentage of people accessing a long-term care home from hospitals in Mississauga Halton was lower than the provincial average. This is a direct result of the introduction of the Home First philosophy and increased community based services and home care services to support

people with higher care needs in their own home. Although this represents a significant improvement, the needs of people waiting for ALC continue to be a concern and area requiring improvement to ensure the provision of the right care in the right place at the right time. Emergency department pressures continue to exist. Between 2006 and 2011 there was a 13.4 percent increase in the number of visits to Mississauga Halton LHIN hospital emergency departments. Although this increase is locally significant, it is the second lowest increase in the Province of Ontario. Of significant concern is the number of people with mental health and/or substance abuse issues accessing hospital emergency departments. Between 2006 and 2011, visits noting mental health or substance abuse as the main reason for the visit increased by 16.9 percent. Visits for other main reasons by people who also had mental health or substance abuse issues increased by 23.4 percent.

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MH LHIN Emergency Room Utilization

Health Service Utilization - Community The number of people receiving home care services provided by the Mississauga Halton Community Care Access Centre (MH CCAC) increased by 8.6 percent from 2006 to 2011. The most significant increase, 29.8 percent, was in clients aged 85 years and older. The second largest increase, 12.1 percent was in the age group of 75 to 84 years. The increase in clients over the age of 75 years was targeted through programs such as Stay at Home and Wait at Home that were designed to assist older people to remain living in their individual homes and delay or even prevent the need for long-term care home placement. Although there has been an increase in the number of CCAC clients over time, the rate of clients per 1000 population is the lowest in province. A focus

on supporting individuals with high needs and utilizing the support of community support service agencies to assist people who do not require intensive CCAC services has influenced this lower client rate. Along with the increased focus on higher need seniors by the CCAC, Community Support Service (CSS) agencies also focused on individuals with increased need levels more than previous. This increased attention to seniors with higher levels of care was predominantly experienced by the adult day service, respite service, and service for daily living (SDL) agencies. The provision of enhanced services in the community has resulted in a decrease in the

This graph illustrates the number of visits to an Emergency Department in the Mississauga Halton LHIN over the past four years by hospital site.

Five of the six hospital sites in the MH LHIN saw an increase in the number of ED Visits in 2010/11 from 2009/10, which is reflective of the increase of total ED Visits in the MH LHIN (up to 344,732 in 2010/11 from 330,489 in 2009/10).

The Credit Valley Hospital recorded the highest volume of ED Visits in 2010/11 for the Mississauga Halton LHIN.

Source: NACRS, CIHI. Ambulatory All Visits Main Table.

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number of people on the wait list for placement into a long-term care home. Mississauga Halton has the lowest rate of long-term care beds per 1000 people aged 75 years and greater. This low rate of beds has created a situation of having the third longest median wait time to placement in the province. Long-term care homes within the MH LHIN operated at 99.5 percent utilization in 2011. The provision of enhanced community services has also assisted to ensure that those people placed into a long-term care home have immediate need for the services provided. Long-term care homes have also seen an upward shift in the needs level of their clientele. The

introduction of people with different and greater needs has required homes to increase the skill set and capacity of staff to support the clients being accepted. Additional supports provided through programs such as the nurse led outreach teams in long-term care and Behaviour Supports Ontario (BSO) have supported long-term care homes through this transition. These are all examples of how service providers in the Mississauga Halton LHIN are working together to ensure that people in our community receive the right services in the right place at the right time.

Health Human Resources in the Mississauga Halton LHIN One of the main limitations in the development and delivery of additional amounts of service to meet the growing needs of our community is related to the availability of qualified people to deliver the services. Of primary concern for residents of Ontario and the Mississauga Halton LHIN is timely access to a family physician. In 2010 there were 893 family physicians and 716 specialist physicians in the community which represents a 10.6 percent increase from 2006. Mississauga Halton has the fourth lowest supply of family physicians for every 10,000 people. This rate has not changed significantly from the level in 2006. The availability of registered nurses in the Mississauga Halton LHIN is significantly lower than the average for the Province of

Ontario. In 2010, the rate of registered nurses for every 100,000 people was 600 as compared to the provincial average of 953. The relatively low number of nursing staff has significant implications for both hospital and community based care. Nursing service represents the highest number of service visits of home care service provided by the MH CCAC. When comparing the availability of other selected health care professionals to the provincial levels, Mississauga Halton LHIN has lower availability for midwives, occupational therapists and optometrists. The Mississauga Halton LHIN has a higher availability of pharmacists as compared to the provincial average.

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APPENDIX 4: ENVIRONMENTAL SCAN OF THE MISSISSAUGA HALTON LHIN

This Environmental Scan was prepared for use by all Local Health Integration Networks (LHINs) as a key background paper for each LHIN’s third Integrated Health Service Plan. This scan provides an overview of a number of key characteristics of local populations, services, utilization and health impacts.

The document has not been designed for the general reader, but rather for providers, public organizations (both governmental and non-governmental) and health service providers. It presents both key characteristics of health and health care in each LHIN as well as a comparison to Ontario overall and to other LHINs.

The development of a local Integrated Health Service Plan requires far more insight than can be provided by a scan of this nature. However, it was developed to help begin to set local priorities and activities and further discussions around them. As well, it was designed to support the development of measureable baselines to assess the impact of targeted change.

The information presented in this scan was proposed by the LHINs collectively and the information prepared by members of the Health Analysis Branch of the Ontario Ministry of Health and Long-Term Care. For the first time, readers are able to understand the status of many important health system attributes and directly compare them.

Demographics (Ministry of Finance estimates and projections) • In 2011, the Mississauga Halton LHIN

was home to 1,179,800 people, 8.8% of the population of Ontario.

• Between 2006 and 2011 the LHIN’s population increased by 12%, the highest growth rate among LHINs in the province.

• In 2011, compared to other LHINs, Mississauga Halton had a relatively low proportion of seniors aged 65+ (11.3%). This has increased slightly from 10% since 2006. By 2016, seniors will account for 13.0% of the LHIN’s population; by 2021, it will be 14.6%.

• Mississauga Halton is projected to have high population growth over the next 5-10 years. Between 2011 and 2016 the population is projected to increase by 121,800 residents (an additional 10.3%); by 2021 the population will have increased by 21.6% (compared to a projected increase of 13% for Ontario overall).

Population characteristics (Census) • In 2011, 87% of the population of the

LHIN lived in a large urban population centre (100,000+), while only 1.7% lived in a rural area.

• In 2006, compared to Ontario, a smaller proportion of residents report English as their mother tongue (60% vs. 70% for Ontario) and 1.7% of the population include French as their mother tongue.

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Population characteristics – cont’d • In 2006, a large proportion of the

population was immigrants (43.2%). Over 8% were recent immigrants, having arrived in Canada between 2001 and 2006 (higher than the Ontario rate of 4.8%).

• In 2006, 36.2% of the people living in the LHIN were visible minorities compared to 22.8% in Ontario overall.

• In 2006, educational attainment levels among LHIN residents of working age were high. Less than 10% of the population aged 25-64 do not have a

completed certificate, diploma or degree (the lowest rate in the province) and close to 70% of the working age population has a completed post-secondary education (the second highest rate provincially).

• The 2011, the unemployment rate was among the lowest in the province.

• In 2006, the proportion of those living in low-income was 13.3%; lower than the provincial rate of 14.7%.

Socio-demographic characteristics, Mississauga Halton LHIN


Ontario Comments

Population, 2011 (MinFin)* 1,179,791 13,372,996 % population aged 65+ 11.3% 14.2% 2nd lowest LHIN % population aged 75+ 5.0% 6.6% 2nd lowest LHIN Population growth, past 5 years (2006-2011) (MinFin) 12.0% 5.6% Highest LHIN Projected population, 2016 1,304,262 14,195,099 Projected population, 2021 1,438,419 15,067,531 % growth forecasted, 2011-2016 10.3% 6.2% 2nd highest LHIN % growth forecasted, 2011-2021 21.6% 12.7% 2nd highest LHIN % living in a rural area (2011) (Census) 1.7% 14.1% % living in a large urban centre (2011) (Census) 87.0% 69.3% 3rd highest LHIN Socio-demographic characteristics (% population) English Mother Tongue 59.1% 69.8% French Mother Tongue 1.7% 4.4% No knowledge of English or French 2.6% 2.2% Immigrants 43.2% 28.3% 3rd highest LHIN

Recent immigrants (2001-2006) 8.4% 4.8% 3rd highest LHIN Visible minorities 36.2% 22.8% 3rd highest LHIN Aboriginal Identity 0.4% 2.0% 2nd lowest LHIN Labour force participation rate (aged 15+) 70.9% 67.1% 2nd highest LHIN Unemployment rate, 2011 (aged 15+) 6.8% 7.8% 3rd lowest LHIN Without certificate/degree/diploma (aged 25-64) 9.0% 13.5% Lowest LHIN Completed post-secondary education (aged 25-64) 68.8% 61.4% 2nd highest LHIN Living in low-income 13.3% 14.7% *(MinFin) Ministry of Finance estimates and projections

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Population Health A: Births, Life Expectancy, Deaths

Births and Maternal Outcomes

• During FY 2009/10, there were 12,845 births to 12,650 women in Mississauga Halton LHIN hospitals.

• 63% of births were to women over the age of 30 (higher than the provincial proportion of 54.8%) and 9.8% were to women under the age of 25 (lower than the provincial average of 17%).

• The rate of smoking during pregnancy among women giving birth in the LHIN is among the lowest in the province while the rate of breastfeeding right after birth is among the highest.

• The rate of caesarean deliveries is lower than the provincial average.

• The percentage of newborns classified as “small for gestational age” is higher than the provincial average, whereas the percentage classified as “large for gestational age” is lower.

• The rate of pre-term births is among the lowest in the province.

Births and Maternal Outcomes FY 2009/10 (unless otherwise noted)

Indicator Mississauga

Halton Ontario

Total births in Mississauga Halton LHIN hospitals 12,845 138,775 Total births by Mississauga Halton LHIN residents 12,463 138,720 Number of women who gave birth in Mississauga Halton LHIN hospitals 12,650 136,221 Number of Mississauga Halton LHIN women who gave birth 12,215 136,169 % of women who smoked during their pregnancy 6% 12% % of mothers breastfeeding right after birth, 2009 93% 88% Distribution of maternal age (%)

<20 1.4 3.6 20-24 8.4 13.4 25-29 27.1 28.2 30-34 38.6 33.4 >=35 24.6 21.4

Rate of Caesarean delivery (%) 25.8 28.3 Rate of pre-term birth less than 37 weeks (%) 6.4 8.2 % births small for gestational age (%) 10.6 9.0 % births large for gestational age (%) 8.9 10.4

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Mortality & Potential Years of Life Lost (PYLL)

• Mississauga Halton residents have a higher life expectancy (at birth and at age 65) compared to Ontario overall.

• Crude mortality and PYLL rates are lower than the province. This may be because there is a lower percentage of elderly residents in the LHIN than in Ontario.

• Ischaemic heart disease and cancers (Lung, Breast, Colon, rectum, anus, lymph, and blood) are leading causes of death and PYLL.

• The top 10 leading causes of death account for 52% of deaths.

• Mortality and PYLL rates for many of the specific leading causes are the lowest or among the lowest in the province.

• Injury related deaths (Transport accidents, Intentional self-harm) are in the top 10 leading causes of PYLL. Together these account for 335 PYLL for every 100,000 residents (higher than the PYLL rate for Ischaemic heart disease, which is the leading cause).

Life Expectancy, Mortality and Potential Years of Life Lost

Mississauga

Halton Ontario Comment

Life expectancy at birth (yrs), 2007/09 83.1 81.5 3rd highest in province

Life expectancy at age 65 (yrs), 2007/09 21.1 20.3

Mortality (2007)1

Total deaths, 2007 4,848 86,945 2nd lowest in province

All cause mortality rate per 100,000 population 448.1 679.6

% of deaths that were premature (age <75) 39.7% 37.7%

Top 10 leading causes of death, 2007 (rate per 100,000)

Ischaemic heart disease 58.4 110.9 Lowest in province

Dementia and Alzheimer disease 33.3 42.0

Cancer of lung & bronchus 31.1 48.7 3rd lowest in province

Cerebrovascular diseases 25.3 41.5 Lowest in province

Cancer of colon, rectum, anus 16.5 24.5 2nd lowest in province

Cancer of lymph, blood & related 14.9 19.6 2nd lowest in province

Chronic lower respiratory diseases 14.6 28.3 2nd lowest in province

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Mississauga

Halton Ontario Comment

Cancer of breast 12.9 15.3

Influenza and pneumonia 12.5 15.8 2nd lowest in province

Diabetes 12.4 23.5 Lowest in province

Age specific mortality rate, 2006-07 average

00-19 28.9 40.4 Lowest in province

20-44 49.4 71.0 Lowest in province

45-64 303.7 419.2 2nd lowest in province

65-74 1,274.3 1,639.2 2nd lowest in province

75+ 5,992.0 6,619.9

Potential Years of Life Lost (PYLL), 2007

PYLL rate, per 100,000 population 0-74 3,275.3 4,628.1 2nd lowest in province

Top 10 Leading causes of PYLL (rates per 100,000 age 0-74)

Ischaemic heart disease 280.4 456.6 2nd lowest in province

Perinatal conditions 239.8 288.7

Cancer of lung & bronchus 231.1 341.3 3rd lowest in province

Intentional self harm 226.9 269.7

Cancer of breast 164.3 158.0

Congenital malformations, deformations, chromosomal 148.4 143.6

Cancer of colon, rectum, anus 120.1 152.9 2nd lowest in province

Cancer of lymph, blood & related 119.4 145.0 2nd lowest in province

Transport accidents 108.4 231.9 2nd lowest in province

Cirrhosis and other liver diseases 75.4 126.7 2nd lowest in province

1. Mortality/PYLL numbers and rates for Mississauga Halton may be under-estimated because 196 deaths of city of Mississauga residents and 1,202 deaths of city of Toronto residents could not be assigned to a LHIN area because of missing postal codes.

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Population Health B: General Health & Risk Factors

General Health Risk Factors

• Three out of five Mississauga Halton LHIN residents say they have very good or excellent health, and three out of four report very good or excellent mental health. This proportion decreases with age. Among those aged 75+ only 36% report very good/excellent health.

• Approximately 9% of LHIN residents say they usually experience moderate or severe pain/discomfort (lower than most other LHINs), and 26% say they experience activity limitations because of long-term physical or mental health problems. Not surprisingly, prevalence of pain/discomfort and activity limitation increases with age.

• 27% of residents report that most days were ‘quite a bit’ or ‘extremely’ stressful, the second highest prevalence among LHINs in the province.

• 91% of LHIN residents report having a regular medical doctor (same as the provincial average).

• 26% of LHIN residents received a flu shot in the past year; significantly lower than the provincial rate of 31%. However, the rate of flu shots is higher among the LHIN’s seniors (60% among those aged 65-74, and 67% among those aged 75+). Over time, the proportion of residents getting a flu shot has declined.

• Approximately 17% of LHIN residents are smokers, 17% are heavy drinkers. Almost half the population (49%) is overweight or obese. Mississauga Halton has lower rates of smokers, heavy drinkers, and overweight/obesity than most other LHINs.

• Mississauga Halton LHIN residents are also more likely to consume 5+ servings of fruits/vegetables per day (i.e., the rate of inadequate fruit/vegetable consumption is the second lowest among LHINs and significantly lower than the provincial average).

• Approximately half the population is physically inactive (similar to provincial average).

23

General health, risk factor prevalence: Mississauga Halton LHIN 2009-10

% of population, aged 12+

Miss. Halton LHIN Ontario

LHIN Rank

(1-14) LHIN Trend over time

Very good or excellent self perceived health (+) 60.0 60.7 8 -

Very good or excellent self perceived mental health (+) 74.8 74.1 5 -

Days that are ‘quite a bit’ or ‘extremely’ stressful (age 15+) (-) 27.0 24.1 13 -

With moderate or severe pain/discomfort (-) 9.4 11.9 2 -

With participation/activity limitations sometimes/often (-) 26.1 28.5 4 -

Have a regular medical doctor (+) 90.9 90.9 8 -

Received flu shot in the past year (+) 25.6↓ 31.4 14 unfavourable

Risk Factors

Are daily or occasional smokers (-) 17.3 19.0 3 -

Are heavy drinkers (-) 17.0 16.2 4 -

Are overweight or obese (aged 18+) (-) 48.8 52.3 3 -

Are physically inactive (-) 48.6 49.2 8 -

Consume < 5 servings of fruits/vegetables daily (-) 52.0↓ 57.4 2 -

↑ LHIN result is significantly higher than Ontario.

↓ LHIN result is significantly lower than Ontario.

Ranks: Low ranks (e.g., 1) is ‘better’

24

CHRONIC CONDITIONS: Prevalence, Mortality, Hospital Separations and Hospital Days of Stay for Selected Chronic Conditions • 33% of Mississauga Halton residents

(aged 12+) have a chronic condition and 12% have multiple conditions.

• The prevalence of arthritis (12%) and multiple chronic conditions (12%) is significantly lower in the Mississauga Halton LHIN as compared to the province, and ranks the lowest as compared to other LHINs.

• Prevalence of multiple chronic conditions increases dramatically with age; 45% of LHIN residents aged 65-74 and 51% of those aged 75+ have two or more chronic conditions.

• Chronic conditions account for six out of 10 deaths, one out of five acute hospital separations, and one out of four acute hospital days for LHIN residents.

• Heart disease (including ischemic heart disease (IHD) and congestive heart failure (CHF) and stroke account for 11% of all hospital days and 7% of all acute care separations for LHIN residents. However the LHIN’s mortality and hospitalization rates for these conditions (as well as all other chronic conditions except asthma) are lower than provincial rates.

• Hospitalization rates for arthritis, diabetes, IHD and stroke are the lowest in Ontario.

• 14% of the population aged 65-74 has heart disease. The prevalence increases to 20% among those aged 75+.

• The LHIN’s mortality rate from diabetes and stroke is decreasing and ranks the lowest in Ontario. Cancer mortality rates are also the second lowest in Ontario.

• The rates of hospitalization for arthritis, asthma, cancer and IHD have been decreasing over the period of 2005/06 to 2010/11.

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Condition MISSISSAUGA

HALTON Ontario Comment Trend

Prevalence (2009&2010), rate per 100, aged 12+ Arthritis (aged 14+) 12.2↓ 17.2 Lowest -

Asthma 8.0 8.4 -

Cancer 1.5† 1.9 NA

COPD (aged 35+) 3.3† 4.2 Decreasing

Diabetes 6.6 6.9 Increasing

High blood pressure 16.6 17.4 Increasing

Heart disease 4.1 4.9 NA

Suffer from effects of stroke 1.0† 1.1 NA

Have a chronic condition 32.9 37.0 3rd lowest NA

Have multiple chronic conditions1 11.8↓ 15.2 Lowest NA

Diabetes prevalence, aged 18+ (BDDI) 9.0 9.7 NA

↑ LHIN result is significantly higher than Ontario. ↓ LHIN result is significantly lower than Ontario.

† High sampling variability-estimate must be used with caution

Mortality rate per 100,000

Hosp separation rate per 100,000

Hosp days rate per 100,000 LHIN Trends

Condition MH

LHIN Ontario MH

LHIN Ontario MH

LHIN Ontario Mortality Seps Days

Arthritis 2.3 2.9 230.1 329.9 1182.7 1613.7 Decreasing Asthma 0.5 0.7 40.6 38.1 103.5 103.2 Decreasing Decreasing

Cancer 142.4 198.1 346.5 421.3 2796.5 3799.5 Decreasing Decreasing

CHF 7.3 10.2 115.4 157.2 1142.6 1524.2 Increasing COPD 14.1 25.9 103.5 183.2 821.4 1492.8 Decreasing

Diabetes 14.0 23.2 56.0 93.1 501.2 923.9 Decreasing Hypertension 4.1 6.1 11.7 16.5 63.8 92.6 Increasing Decreasing

IHD 63.7 112.4 255.8 379.4 1442.8 2103.7 Decreasing Decreasing Decreasing

Stroke 19.1 31.6 100.4 132.8 1291.9 1691.9 Decreasing

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Current utilization projections by LHIN of Patient Residence based on Population Demographics to FY 2015/16

Population change and aging

• Mississauga Halton LHIN’s population is expected to increase 10.1% over the next five years, substantially greater than Ontario overall (6.2%). By 2015, its population will be just over 1,278,000 people, compared to 1,160,000 in 2010. Of all LHINs, the Mississauga Halton LHIN will have the third largest percentage population growth, after Central and Central West.

• Despite high growth, it is expected that the population aged 65 and older in the LHIN will have increased by a proportion slightly less than that of the province overall (1.7% versus 1.8%).

Projected utilization, FY 2015/16

• In percentage terms, all sectors included in this analysis will likely have higher growth than the province overall. All sectors will have growth above 10% over five years.

• As with many LHINs (and the province overall), the highest percentage change is likely to be in those sectors associated with aging such as long-term care and complex continuing care. However, Mississauga Halton LHIN’s population is notable because of potentially higher percentage change in some high-volume sectors such as acute care separation and total days and emergency department visits.

Mississauga Halton actual (FY 2010/11) and projected (FY 2015/16) utilization, by sector

Sector Measure FY 2010/11

(Actual) FY 2015/16 (Projected) Change % change

Acute Separations 79,416 92,081 12,665 15.9% Total days 424,055 504,643 80,588 19.0% Ambulatory oncology and renal dialysis clinics Visits 89,679 108,003 18,324 20.4% Emergency departments Visits 321,383 360,473 39,090 12.2% Day surgery and cardiac catheterization Visits 91,059 105,255 14,196 15.6% Complex continuing care Active cases 1,725 2,181 456 26.4% Days 164,533 202,425 37,892 23.0% Long-term care Active cases 7,032 8,941 1,909 27.1% Days 1,677,446 2,090,169 412,723 24.6% Mental health Active cases 2,948 3,259 311 10.5% Rehabilitation Admissions 2,614 3,223 609 23.3% Home care Active clients 42,652 50,694 8,042 18.9%

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ANALYSIS OF ACUTE CARE UTILIZATION

• There were 64,062 acute separations, 322,522 acute days, and 360,498 total days from Mississauga Halton LHIN hospitals in FY 2010/11. Separations and total days increased between FY 2006/07 and FY 2010/11, while acute days remained stable. ALC separations and ALC days both increased by 47% for Mississauga Halton hospitals over the same period.

• The average total and acute lengths of stay and the average RIW were lower in Mississauga Halton LHIN hospitals compared to Ontario.

• Residents of other LHINs accounted for 20.8% of the acute separations from Mississauga Halton LHIN hospitals in FY 2010/11.

• The percentage of ALC days in Mississauga Halton hospitals was the second lowest in the province in FY 2010/11.

• 29.0% of ALC days from Mississauga Halton LHIN hospitals were discharged to LTC, which was smaller than the corresponding proportion for Ontario hospitals (34.8%). Compared with the province, greater proportions of ALC discharges from Mississauga Halton LHIN hospitals went to CCC and rehabilitation.

• Mississauga Halton LHIN residents had the lowest acute separation rate in the province. Compared with the province, LHIN residents had lower acute separation rates for all age groups.

• 24.7% of separations by Mississauga Halton LHIN residents were from hospitals outside the LHIN in FY 2010/11.

• ALC separations and ALC days for Mississauga Halton LHIN residents increased by 54.6% and 57.4%, respectively between FY 2006/07 and FY 2010/11.

• Mississauga Halton LHIN hospitals had the largest proportion of acute days in the province for two CMGs: 545-Vaginal delivery, no other intervention, and 026-Ischemic event of central nervous system.

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Acute care hospital utilization, Mississauga Halton LHIN, 2010/11 Indicator Mississauga Halton LHIN Ontario†

% change LHIN, 2006/07 to 2010/11

LHIN of hospital Acute separations 64,062 956,360 4.0 Total days 360,498 6,276,849 3.5 Average total LOS 5.6 6.6 Acute days 322,522 5,230,240 0.0 Average acute LOS 5.0 5.5 Average RIW 1.33 1.50 % Inflow acute separations 20.8 ALC separations 2,987 54,677 47.3 ALC days 37,976 1,046,577 47.1 Average ALC LOS 12.7 19.1 % ALC days (of total days) 10.5 16.7 Proportion of total ALC days by discharge destination: Home without support 8.1 7.5 Home with support 15.2 13.2 Long-term care 29.0 34.8 Complex continuing care 23.2 18.7 Rehabilitation 14.9 9.6 Another facility‡ 1.6 3.5 Deceased 8.2 12.7 LHIN of patient Acute separations 67,354 946,099 4.3 Acute separations/1,000 population 58.0 71.6 -5.3 Age-specific acute separation rates/1,000 population 0-19 24.1 28.5 20-44 47.0 54.2 45-64 50.2 61.0 65-74 121.4 143.8 75+ 277.9 282.3 Total days 394,075 6,218,634 5.6 Average total LOS 5.9 6.6 Acute days 350,645 5,174,042 1.7 Average acute LOS 5.2 5.5 Average RIW 1.40 1.50 % Outflow acute separations 24.7 ALC separations 3,272 54,528 54.6 ALC days 43,430 5.5 57.4 Average ALC LOS 13.3 19.2 †LHIN of patient results for Ontario exclude out-of-province residents ‡Includes acute and ambulatory facilities

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Acute care days by top 10 CMGs, by Mississauga Halton LHIN hospitals, FY 2010/11

Mississauga Halton LHIN Ontario Comment

Case Mix Group+ # % # %

(545) Vaginal Delivery, No Other Intervention

12,210 3.8 147,316 2.8 Largest % in province

(196) Heart Failure Without Coronary Angiogram

9,925 3.1 144,943 2.8

(138) Viral/Unspecified Pneumonia 8,559 2.7 116,205 2.2 (810) Palliative Care 8,459 2.6 129,077 2.5 (139) Chronic Obstructive Pulmonary Disease

7,907 2.5 162,544 3.1

(026) Ischemic Event Of Central Nervous System


(321) Unilateral Knee Replacement 5,436 1.7 81,733 1.6 (537) Primary Caesarean Section 5,114 1.6 80,765 1.5 (487) Lower Urinary Tract Infection 5,029 1.6 63,977 1.2 Not in provincial top 10 (654) Other/Unspecified Septicemia 3,960 1.2 62,645 1.2 Not in provincial top 10 All Other CMGs 248,575 77.1 4,163,671 79.6 Total 322,522 100.0 5,230,240 100.0

Emergency Department Utilization • In FY 2010/11, there were 344,732 ED

visits to Mississauga Halton LHIN hospitals and 13.4% of these visits were by residents of other LHINs. Between FY 2006/07 and FY 2010/11 there was 13.4% growth in ED visits to Mississauga Halton LHIN hospitals compared to 6.4% growth for Ontario.

• From FY 2006/07 to FY 2010/11 in Mississauga Halton LHIN hospitals, the number of visits in all triage levels increased with growth of 15.1% for CTAS IV & V, 8.6% for CTAS III, and 21.7% for CTAS I & II. In Ontario hospitals over the same time period, CTAS IV & V visits decreased by 10.3%.

• Among all LHINs, Mississauga Halton LHIN hospitals had the second largest proportion of ED visits in CTAS I & II and the third lowest proportion of CTAS IV & V visits in FY 2010/11.

• The 90th percentile EDLOS was slightly longer in Mississauga Halton LHIN hospitals (8.9 days) compared to Ontario hospitals (8.2 day) sin FY 2010/11.

• There were 322,511 ED visits by Mississauga Halton LHIN residents in FY 2010/11, and 15.1% of these visits occurred in other LHINs. Between FY 2006/07 and FY 2010/11,

30

there was 13.1% growth in ED visits, and 2.6% growth in the ED visit rate for LHIN residents.

• Mississauga Halton LHIN residents had the second lowest ED visit rate in the province in FY 2010/11. ED visit rates for residents were much lower than the provincial average for all age groups.

• In FY 2010/11, Mississauga Halton LHIN residents had the second largest proportion of CTAS I & II visits in the province.

• Among all LHINs, Mississauga Halton LHIN resident had the third lowest rate of ED visits best treated in alternative primary care settings, much lower than the provincial rate in FY 2010/11 (7.3 versus 23.3).

• Among all LHINs, Mississauga Halton LHIN hospitals had the smallest proportion of ED visits for examination and other health factors and the largest proportion for kidney and genitourinary tract diseases.

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Unscheduled emergency department visit utilization, Mississauga Halton LHIN, FY 2010 / 2011

Indicator Mississauga Halton

LHIN Ontario†

% change LHIN, FY

2006/07-FY 2010/11

LHIN of hospital Visits‡ 344,732 5,582,867 13.4 # visits by CTAS level I & II (resuscitation/emergent) 74,768 870,879 21.7 III (urgent) 152,598 2,301,596 8.6 IV & V (less urgent/non urgent) 116,985 2,387,466 15.1 % visits by CTAS level‡ I & II (resuscitation/emergent) 21.7 15.6 III (urgent) 44.3 41.2 IV & V (less urgent/non urgent) 33.9 42.8 90th percentile EDLOS (hours) 8.9 8.2 % Inflow visits 20.6 LHIN of patient Visits‡ 322,511 5,488,869 13.1 ED visit rate/1,000 population 277.8 415.5 2.6 Age-specific ED visit rates/1,000 population 0-19 years 276.6 413.5 20-44 years 243.1 383.6 45-64 years 246.8 363.7 65-74 years 337.3 470.4 75+ years 635.1 751.6 # visits by CTAS level I & II (resuscitation/emergent) 71,778 859,100 26.2 III (urgent) 146,162 2,267,331 10.5 IV & V (less urgent/non urgent) 104,188 2,339,959 8.9 % visits by CTAS level I & II (resuscitation/emergent) 22.3 15.7 III (urgent) 45.3 41.3 IV & V (less urgent/non urgent) 32.3 42.6 % Outflow visits 15.1 ED visits best treated in alternative primary care settings /1,000 population age 1-74, age-standardized

7.3 23.3

†LHIN of patient results for Ontario exclude out-of-province residents ‡Includes visits with missing/unknown CTAS level

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Unscheduled emergency department visits by top 10 Major Ambulatory Clusters, Mississauga Halton LHIN hospitals, FY 2010 / 2011

Mississauga Halton LHIN Ontario Comment

Major Ambulatory Cluster (MAC) # % # %

(21) Trauma, coma and toxic effects 80,661 23.4 1,112,707 19.9 (06) Diseases and disorders of the digestive system

44,408 12.9 609,138 10.9

(05) Diseases and disorders of the circulatory system

29,099 8.4 398,792 7.1

(09) Diseases and disorders of the skin and subcutaneous tissue and breast

26,973 7.8 522,954 9.4

(03) Diseases and disorders of the ear, nose, mouth and throat

24,394 7.1 543,647 9.7

(11) Diseases and disorders of kidney and genitourinary tract


(08) Diseases and disorders of the musculoskeletal system and connective tissue

20,559 6.0 355,078 6.4

(01) Diseases and disorders of the nervous system

20,233 5.9 304,628 5.5

(04) Diseases and disorders of the respiratory system

19,909 5.8 352,806 6.3

(20) Examination and other health factors 12,772 3.7 345,451 6.2 Smallest % in province All other MACs 43,479 12.6 697,599 12.5 Total 344,732 100.0 5,582,874 100.0

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Analysis of Day Surgery and Cardiac Catheterization Visits

• In FY 2010/11, there were 85,516 day surgery and ambulatory cardiac catheterization visits to Mississauga Halton LHIN hospitals. Residents of other LHINs accounted for 24.0% of the visits in FY 2010/11.

• Between FY 2006/07 and FY 2010/11, there was 10.3% growth in Mississauga Halton LHIN hospital day surgery and cardiac catheterization visits.

• There were 91,059 day surgery and ambulatory cardiac catheterization visits for Mississauga Halton LHIN residents, and 28.6% of these visits occurred in hospitals outside the LHIN. There was growth in the

number of visits for LHIN residents over the period, but a decrease in the visit rate. This indicates that the increase in visits was less than the rate of population growth during the period.

• The day surgery visit rate for Mississauga Halton LHIN residents was less than the provincial average.

• The day surgery visit rate was highest for residents aged 75 and older. The Mississauga Halton LHIN rate for this age group was comparable to the provincial average, while rates were lower than the province for all other age groups.

Day surgery and ambulatory cardiac catheterization visits, Mississauga Halton LHIN and Ontario, FY 2010/11

Indicator Mississauga Halton LHIN

Ontario % Change FY 2006/07-FY

2010/11

LHIN of hospital Visits 85,516 1,238,803 10.3 % Inflow 24.0 LHIN of patient Visits 91,059 1,230,218 9.6 % Outflow 28.6 Visits per 1000 78.4 93.1 -0.5 Age Specific Visits per 1,000 population 0-19 years 17.5 23.4 20-44 years 46.8 50.8 45-64 years 115.9 128.2 65-74 years 220.8 246.4 75+ years 245.7 245.8

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Analysis of Inpatient Rehabilitation Utilization Adult Inpatient Rehabilitation

• In FY 2010/11, there were 2,434 admissions to inpatient rehabilitation units in Mississauga Halton LHIN hospitals and residents of other LHINs accounted for 16.8% of these admissions.

• Between FY 2006/07 and FY 2010/11 admissions to Mississauga Halton LHIN hospital rehabilitation units decreased by 2.5%.

• In FY 2010/11, there were 2,614 inpatient rehabilitation admissions for Mississauga Halton LHIN residents, and nearly 23% were treated in hospitals outside the LHIN. While the number of admissions increased 3.1% for LHIN

residents between FY 2006/07 and FY 2010/11, the admission rate declined by 16.4%.

• The inpatient rehabilitation admission rate for Mississauga Halton LHIN residents was higher than the provincial average.

• Residents aged 85 and older had the highest rehabilitation admission rate. Compared with the province, Mississauga Halton LHIN residents had lower admission rates for those aged 18 to 64 years and had higher rates for residents aged 65 and older. Mississauga Halton LHIN had the highest admission rates in the province for residents aged 75 and older.

Adult inpatient rehabilitation admissions, Mississauga Halton LHIN and Ontario, FY 2010/11


Ontario % change FY 2006/07-FY 2010/11

LHIN of hospital General admissions 2,434 26,307 -2.5 Special admissions 3,403 Total admissions 2,434 29,710 -2.5 % Inflow 16.8 LHIN of patient Total admissions 2,614 29,536 3.1 % Outflow 22.5 Admissions per 100,000 aged 18+ 290.9 281.5 -7.8 Age-specific admissions per 100,000 18-44 years 24.3 29.1 45-64 years 138.8 166.7 65-74 years 693.6 658.2 75-84 years 2,222.6 1,579.7 85+ years 4,136.8 2,353.7

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Analysis of Mental Health Indicators Mental Health and Substance Abuse Emergency Department Visits

• In FY 2010/11, there were 9,677 unscheduled ED visits for Mississauga Halton residents where the main problem was a MH/SA condition. There were 11,988 visits in total or 2,311 additional visits with a MH/SA condition in any of the diagnostic fields.

• Between FY 2006/07 and FY 2010/11, there was 16.9% growth in visits with a MH/SA main problem diagnosis and 23.4% growth in visits with a MH/SA condition in any diagnostic field.

• Mississauga Halton LHIN residents had the lowest MH/SA ED visit rates

in the province. The main problem visit rate increased by 6.1% over the period, while there was 12.0% growth in the any problem visit rate, between FY 2006/07 and FY 2010/11.

• Visits with a MH/SA main problem diagnosis accounted for 3.0% of all ED visits for Mississauga Halton LHIN residents.

• The ED visit rates for MH/SA conditions were highest for residents aged 20-44 years. The MH/SA ED visit rates for Mississauga Halton LHIN residents were lower than the provincial average for all age groups.

Unscheduled emergency department utilization for mental health and substance abuse conditions, Mississauga Halton LHIN and Ontario Residents, FY 2010/11


Ontario % change FY 2006/07-FY

2010/11

LHIN of patient Main problem visits 9,677 191,575 16.9 % of total ED visits 3.0 3.5 Any problem visits 11,988 239,978 23.4 % of total ED visits 3.7 4.4 Main problem, visits per 1,000 8.3 14.5 6.1 Any problem, visits per 1,000 10.3 18.2 12.0 Main problem, age-specific visit rates per 1,000

Age 0-19

5.3 8.9

20-44 11.2 19.9 45-64 7.9 14.5 65-74 5.9 9.1 75+ 8.8 11.9

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Utilization of Adult Designated Mental Health Beds

• In FY 2010/11, there were 2,490 admissions to and 2,615 active cases that received treatment in adult designated mental health units in Mississauga Halton LHIN hospitals. There were 2,466 discharges from these units with a total length of stay of 37,879 days. The average length of stay in Mississauga Halton LHIN mental health units was 15.4 days compared to 31.2 days for Ontario. Residents from other LHINs accounted for 21.8% of the active cases treated in Mississauga Halton LHIN.

• Active cases, admissions, discharges, and days increased for Mississauga Halton LHIN hospitals between FY 2006/07 and FY 2010/11.

• Mood disorders (41.7%) and schizophrenia and psychotic disorders (33.8%) accounted for the largest proportions of active cases in Mississauga Halton LHIN hospitals in FY 2010/11. Compared with the provincial average, Mississauga Halton had smaller proportions of active cases for mood disorders and substance related disorders and

larger proportions of active cases for cognitive disorders and ‘all other’ conditions.

• There were 2,949 active cases, 2,770 admissions, and 2,765 discharges for Mississauga Halton LHIN residents from Ontario adult designated mental health units. Approximately 27% of Mississauga Halton LHIN resident active cases received treatment in hospitals outside the LHIN. Compared with the provincial average, Mississauga Halton LHIN residents had lower rates of active cases, admissions, discharges, and total days per 100,000.

• While the number of active cases, admissions, discharges, and total days for Mississauga Halton LHIN residents increased between FY 2006/07 and FY 2010/11, the active case, admission and discharge rates for residents declined.

• Compared with the province, Mississauga Halton LHIN residents had lower rates of active cases for all age groups.

37

Adult designated mental health unit utilization, Mississauga Halton LHIN hospitals and residents, FY 2010/11



2010/11

LHIN of hospital Active cases 2,615 58,357 4.6 Admissions 2,490 53,853 2.9 Discharges 2,466 53,698 3.2 Total Days 37,879 1,677,774 24.8 Average Length of Stay 15.4 31.2 % Inflow Active Cases 21.8 % of Active Cases by SCIPP Group Schizophrenia & Psychotic Disorders 33.8 33.7 Cognitive Disorders 6.0 5.0 Mood Disorders 41.7 43.6 Personality Disorders 4.4 3.7 Substance Related Disorders 5.5 8.4 All other 8.6 5.7 LHIN of patient Active cases 2,949 55,937 5.4 Admissions 2,770 51,578 3.4 Discharges 2,765 51,700 4.3 Total Days 57,135 1,623,783 31.4 Average Length of Stay 20.7 31.4 % Outflow Active Cases 27.2 Active Cases per 100,000 311.5 508.3 -5.5 Admission per 100,000 292.5 468.7 -7.3 Discharges per 100,000 292.0 469.8 -6.5 Total days per 100,000 6,034.2 14,755.0 17.8 Age-Specific Active Case Rates per 100,000 15-19 213.6 396.7 20-44 384.7 612.3 45-64 272.1 503.9 65-74 213.5 331.2 75+ 246.1 285.5

38

CIHI Mental Health Indicators The following indicators were taken from the CIHI Health Indicators 2012 edition. The CIHI analysis uses different selection criteria and data sources; therefore, results may differ from those shown in the utilization of adult designated mental health units section.

• In FY 2010/11, the rates of mental illness hospitalizations and patient days for Mississauga Halton LHIN residents were significantly lower than those for the province.

• Mississauga Halton LHIN had the lowest rate of self-injury hospitalizations in the province in FY 2010/11.

Mental Health Indicators, Mississauga Halton LHIN, FY 2010/11†


Indicator Ontario

Mental illness hospitalizations (rate per 100,000, 15+) 275 409 Mental illness patient days (rate per 10,000, 15+) 348 485 Patients with repeat hospitalizations for mental illness, (%, 15+)† 10.9 10.5 30-day readmission for mental illness (%, 15+) 10.5 11.5 Self-injury hospitalizations (rate per 100,000, 15+) 38 63

†With the exception of patients with repeat hospitalizations for mental illness, which is for FY 2009/10.

Wait Time for Community Services

• In FY 2011/12, vocational/employment programs and ACT teams had the longest median wait times among the community MH services in Mississauga Halton LHIN. The median wait times for Mississauga Halton ACT teams, case management, counselling/treatment, early intervention, and vocational programs were greater than the medians for Ontario.

• Among the SA services provided in Mississauga Halton LHIN, residential treatment and case

management had the longest median wait times in FY 2011/12. The median wait time in the LHIN was longer than that for the province for case management, community treatment, initial assessment/ treatment planning, and residential treatment.

• For problem gambling services provided in Mississauga Halton LHIN, initial assessment and community treatment had median wait times of four days each.

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Median wait time to next available treatment slot for community mental health, substance abuse and problem gambling services by service type, Mississauga Halton LHIN service providers, FY 2010/2011 - FY 2011/2012

Service Type

Mississauga Halton LHIN Ontario

FY 2010/11

FY 2011/12

FY 2010/11

FY 2011/12

Community Mental Health Services Abuse Service 0 2 Assertive Community Treatment Team 0 120 30 31 Case Management 15 16 1 1 Counselling and Treatment 29 27 6 14 Diversion and Court Support 0 0 0 0 Early Intervention 8 13 0 3 Short-Term Crisis Support Beds 0 0 0 0 Support Within Housing 16 14 48 71 Vocational/Employment 181 136 14 14 Substance Abuse Services Case Management 18 22 1 0 Community Day/Evening Treatment 1 5 Community Medical/Psychiatric Treatment 77 62 Community Treatment 14 15 7 8 Community Withdrawal Management Level 1 0 0 0 1 Community Withdrawal Management Level 2 1 1 1 1 Initial Assessment/Treatment Planning 14 16 7 7 Residential Medical/Psychiatric Treatment 100 71 Residential Supportive Level 1 12 11 Residential Supportive Level 2 0 0 Residential Treatment 42 48 32 29 Problem Gambling Services Community Day/Evening Treatment 0 0 0 0 Community Treatment 4 4 5 5 Initial Assessment/Treatment Planning 4 4 4 3 Public Awareness 1 1 Residential Treatment 43 32

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ANALYSIS OF COMPLEX CONTINUING CARE (CCC) UTILIZATION Complex Continuing Care

• In FY 2010/11, there were 1,625 CCC active cases treated in Mississauga Halton LHIN hospitals. Residents of other LHINs accounted for 11.8% of these active cases.

• Mississauga Halton LHIN hospital active cases increased by 24.9% between FY 2006/07 and FY 2010/11.

• In FY 2010/11, there were 1,725 CCC active cases for Mississauga Halton LHIN residents, and nearly 17% were treated in hospitals outside the LHIN. There was substantial growth in both the number and rate of active cases for LHIN residents over the period.

• Mississauga Halton LHIN residents CCC active case rate was lower than the provincial average.

• The active case rate was highest for residents aged 90 and older. The CCC rates for Mississauga Halton LHIN residents were higher than the provincial average for those aged 85 and older, but were lower than the province for the younger age groups.

Table: Complex continuing care active cases, Mississauga Halton LHIN and Ontario, FY 2010/11



2010/11 LHIN of hospital Active cases 1,625 28,698 24.9 % Inflow 11.8 LHIN of patient Active cases 1,725 28,534 24.6 % Outflow 16.9 Active cases per 100,000 population 148.6 216.0 13.1 Age specific active cases per 100,000 population 0-64 years 28.7 48.1 65-74 years 365.6 498.3 75-79 years 1,015.8 1,129.1 80-84 years 1,719.8 1,991.6 85-89 years 3,441.8 3,251.3 90+ years 5,074.0 4,442.4

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HOME CARE UTILIZATION Active Home Care Clients

• In FY 2010/11, there were 42,652 active home care clients in the Mississauga Halton LHIN.

• Compared to all LHINs, Mississauga Halton had the lowest rate of home clients, at 36.7 home care clients per 1,000 population.*

• The rate per 1,000 population of active home care clients in the LHIN, however, increased slightly by 1.2% between FY 2007/08 and FY 2010/11.

• The number of home care clients in the LHIN increased by 8.6% between FY 2007/08 and FY 2010/11. The largest increase was seen in clients aged 85 and older (29.8% increase) followed by those aged 75-84 (12.1% increase).

• Compared to Ontario, the rates of active clients per 1,000 population were lower in the Mississauga Halton LHIN for all age groups. *

CCAC Services by Type

• In the Mississauga Halton LHIN, there were 516,879 home care visits and 1,671,158 home care service hours provided in FY 2010/11. Nursing visits accounted for the largest number of home care visits and combined personal support work and homemaking hours accounted for the largest number of home care hours in the LHIN.

• The rate per 1,000 population of home care service visits (445.2) was the second lowest in the province and the rate of home care service hours (1,439.5) was the third lowest in the province in Mississauga Halton LHIN in FY 2010/11.

• Mississauga Halton LHIN had the lowest rates per 1,000 population for nutrition and dietetic visits, speech language therapy visits, and social work visits in Ontario. It also had the second lowest rate per 1,000 population for nursing visits in the province in FY 2010/11.

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Home Care Clients and Services in Mississauga Halton, FY 2010/11

Indicator Mississauga Halton Ontario % change LHIN,

FY 2007/08 to FY 2010/11

Number of Active Clients All ages 42,652 691,393 8.6%

<=18 6,116 92,607 -13.9% 19-44 3,682 53,566 2.5% 45-64 7,626 133,316 11.3% 65-74 5,852 104,527 7.4% 75-84 11,035 176,197 12.1% >=85 8,341 131,180 29.8%

Rate of Active Clients per 1,000 Population

All ages 36.7 52.3 1.2% <=18 21.9 31.9

19-44 8.4 11.2 45-64 24.4 36.1 65-74 81.7 107.9 75-84 264.9 284.5 >=85 533.3 534.3

Number of Visits All Visits 516,879 8,563,029

Nursing Visit 359,202 5,701,931 Respiratory Services 123

Nutrition and Dietetic 1,437 45,249 Physiotherapy 28,587 426,841

Occupational Therapy 31,523 473,130 Speech Language Therapy 10,863 234,645

Social Work 1,309 51,783 Psychology 339

Case Management 83,958 1,622,364 Placement Services 6,624

Number of Hours All Hours 1,671,158 22,361,396

Nursing Shift Hours 102,202 1,617,524 Personal Support Work (PSW) 10,285 1,744,611

Homemaking (HM) Hours 74,686 Combined PSW & HM Hours 1,543,068 18,632,255

Respite Hours 15,604 292,320

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Indicator Mississauga Halton Ontario % change LHIN,

FY 2007/08 to FY 2010/11

Rate of Service Visits per 1,000 Population

All Visits 445.2 648.2 Nursing Visit 309.4 431.6

Respiratory Services 0.009 Nutrition and Dietetic 1.2 3.4

Physiotherapy 24.6 32.3 Occupational Therapy 27.2 35.8

Speech Language Therapy 9.4 17.8 Social Work 1.1 3.9 Psychology 0.03

Case Management 72.3 122.8 Placement Services 0.5

Rate of Service Hours per 1,000 Population

All Hours 1,439.5 1,692.7 Nursing Shift Hours 88.0 122.4

Personal Support Work (PSW) 8.9 132.1 Homemaking (HM) Hours 5.7

Combined PSW & HM Hours 1,329.2 1,410.4 Respite Hours 13.4 22.1

*The rate of visits noted does not reflect on the level of intensity of service provided; MH LHIN visits are provided at a higher level of intensity, but lower frequency level

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Long-Term Care: Supply, Demand, and Time to Placement • Mississauga Halton LHIN has the lowest

LTC bed supply rate and the second lowest rate of LTC residents.

• Additionally, the rate of clients waitlisted is lower than the provincial average. Therefore, the demand rate for LTC beds is the lowest in the province.

• Although the rate of waitlisted clients is relatively low, the LHIN has the third highest overall median time to placement (TTP) and the highest TTP for clients from the community.

• For clients from acute care, the median TTP has increased steadily from 24 days in 2006/07 to 64 days in 2011/12.

LTC supply, residents, waitlist and demand (number and rate per 1,000 population aged 75+); Median TTP placement, Dec 31, 2011

Mississauga Halton Ontario Comments (for LHIN)

# Rate1 # Rate

LTC Bed Supply

Long stay beds, including interim 4,103 76,769 Short stay respite & convalescent care

50 868

Total beds in operation 4,153 69.4 77,637 87.6 Lowest2

LTC residents 4,081 68.2 75,126 84.7 2nd lowest LTC beds waitlist 1,008 16.8 20,146 22.7 LTC demand (residents + waitlist) 5,089 85.0 95,272 107.5 Lowest Median time to LTC Placement (in days)

Overall 140 - 89 - 3rd highest From Acute Care only 64 - 48 - From Community 195 - 114 - Highest

1 Rate per 1,000 population aged 75+ 2 In Ontario; in comparison to other LHIN areas

Primary Care Groups and Enrolment Health Care Connection (HCC) Registrations & Referrals (All and Complex/Vulnerable Patients) • 834,200 Mississauga Halton LHIN

residents (71% of eligible residents) are enrolled with a primary care enrolment model (PEM). This is an increase of 2% over the past year.

• 589 physicians in the LHIN are part of a primary care group. There are 46 primary care groups in the LHIN.

• The Health Care Connect Program began in February 2009. Between February

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2009 and April 2012, approximately 4,250 LHIN residents have registered with the program and 89% have been referred to a family health care provider.

• In the past year (2011/12), there were almost 2,000 registrations and 81% of them (1,600) were referred.

• Approximately 6% of those registered with HCC are categorized as “complex vulnerable”.

• In 2011/12 there were 127 complex vulnerable people who registered with HCC (6%) and 97% of them (123) were referred to a family health care provider.

HEALTH CARE SYSTEM AND PATIENT SATISFACTION Health Care System Satisfaction • Almost 70% of residents in the

Mississauga Halton LHIN believe that the quality of care in the province is excellent or good.

• Mississauga Halton LHIN residents reported the highest levels of excellent or good availability of care in their community (76.4%). 80% rated the quality of care in their community as excellent or good.

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Patient Satisfaction with Health Care Services • Among those who had received some

kind of health care services in the past year, just under 90% rated the quality of that care as excellent or good.

• The LHIN had the lowest proportion of residents who reported that the quality of care received from a hospital was excellent or good (76.9%).

• Among those who had received hospital care in the past year, the Mississauga Halton LHIN had the lowest proportion of residents who reported being very or somewhat satisfied with the care provided.

↓ Significantly lower than Ontario ↑ Significantly higher than Ontario


Ontario

Health care system satisfaction Availability of care in the province – Excellent/Good 69.7% 67.2% Quality of care in the province – Excellent/Good 78.1% 75.4% Availability of care in the community – Excellent/Good 76.4%↑ 66.4% Quality of care in the community – Excellent/Good 80.0% 75.4% Patient Satisfaction with Health Care Services Quality of care received - Excellent/Good 89.7% 88.4% Patient satisfaction with care provided - Very/Somewhat satisfied 87.9% 88.1% Quality of hospital care received - Excellent/Good 76.9% 83.9% Patient satisfaction with hospital care provided - Very/Somewhat satisfied 76.6% 83.3% Quality of physician care received - Excellent/Good 91.3% 91.2% Patient satisfaction with physician care provided - Very/Somewhat satisfied 89.2% 91.2%

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Human Resources Physicians

• From 2006 to 2010, the total number of physicians in Mississauga Halton LHIN increased by 10.6% from 1,455 to 1,609. Over the same period, Mississauga Halton population grew at a similar rate (10.2%).

• The total number of physician to population rate remains relatively unchanged at 138.1 physicians per 100,000 population in 2006 and 138.6 in 2010.

• The number of family physicians to population rate in Mississauga Halton was slightly lower than the province in 2010, but had much less specialists per 100,000 population.

Nurses

• From 2006 to 2010, the total number of nurses in Mississauga Halton

increased by 12.3% reaching 6,966 from 6,203 while the nurse to population rate increased from 588.7 nurses per 100,000 population to 600.0.

• Compared to the province, Mississauga Halton had much lower RNs, RPNs, and NPs rates per 100,000 population in 2010.

• The number of NPs in Mississauga Halton increased by five-fold (437.5%) between 2006 (8) to 2010 (43).

Regulated health professionals

• In 2009, Mississauga Halton had less midwives and occupational therapists per 100,000 population than the province, but similar rates in the other regulated health professions.

Physicians, nurses and regulated health professionals, 2009 and 2010: MH LHIN

# Professionals Rate per 100,000 population, 2010

Mississauga Halton

LHIN, 2010 LHIN % change

2006 - 2010 Mississauga Halton LHIN

Ontario

Family physicians 893 10.7% 76.9 88.0 Specialists 716 10.5% 61.7 100.3 Total physicians 1,609 10.6% 138.6 188.3 Registered Nurses (RNs in general class) 5,615 6.0% 483.7 710.9 Registered Practical Nurses (RPNs) 1,308 46.0% 112.7 230.4 Nurse Practitioners (NPs = RNs in extended class) 43 437.5% 3.7 11.2 Total Nurses 6,966 12.3% 600.0 952.6 Selected professions: # Professionals, 2009 Rate per 100,000 population, 2009 Midwife 19 1.7 3.1 Occupational Therapist 225 19.8 32.1 Optician 224 19.8 17.4 Optometrist 126 11.1 12.8 Pharmacist 931 82.1 78.9

Notes: Audiologist and speech-language pathologist data were not available by LHIN in 2009. Psychologist and dentist data in 2009 were not reported due to issues with LHIN assignment, with more than 50% of data reported in the unknown LHIN category.

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APPENDIX 5: COMMUNITY ENGAGEMENT STRATEGY Community feedback and input on local needs and priorities was solicited to help define the LHIN’s priorities and respective strategies or action plans to be articulated within the IHSP. Consultation was conducted on the following five themes:

1. Right Care, provided at the Right Time, in the Right Place 2. Faster Access and Stronger Linkages with Family Health Care 3. Ensuring Health Care Transitions are Smooth 4. Increasing Community Capacity 5. Keeping our Citizens Healthy

“Reach Out and Touch” Campaign

Echoing the community engagement slogan, our team reached out to the Mississauga Halton community through a variety of engagement forums and received considerable input on the five proposed health care priorities as well as feedback in general on the local health care system.

Over a nine week period from May to July 2012, the Mississauga Halton LHIN connected with stakeholders using seven different approaches:

• 21 presentations about the IHSP were delivered to existing committees which the LHIN chairs or participates in, inviting feedback through the online survey

• 14 focus group sessions were held within existing committees which the LHIN chairs or participates in

• 44 focus groups were held within community based organizations or groups

• 5 community forums throughout the MH LHIN were held, open to the general public

• Television spot on “Aging in Peel” inviting feedback

• Online and paper based survey

• Friends and family social media campaign inviting feedback through the online survey

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Through this campaign, 1,929 people were informed about the IHSP and their input was solicited. From those contacts, we had a response rate of 61percent, receiving feedback from 1,183 people. The community engagements planned, facilitated and led by LHIN staff, although labour intensive, were one of the most valuable components of the process of developing our local strategy. Both consumers and providers shared their experiences, good and bad, within the current system. Hearing these stories truly highlighted the successes and challenges in the system which were often felt by all involved and also across many sectors. The engagements also allowed us to strengthen existing relationships with known groups. Feedback from service providers was extremely positive, reflecting how much they valued the fact that we were open to their concerns and receptive to their complaints. This will support future work together as we move forward on the strategies within this plan. We are confident they will see their voices reflected in the document.

In addition to strengthening existing relationships, these engagements also provided us the opportunity to build new relationships. We were invited to meet with different organizations and groups which have had no prior contact with the LHIN. Their willingness to welcome us and share their time and thoughts was beneficial. It allowed us to move beyond the typical perspectives we hear and consider health from different vantage points. These newly formed connections will also be advantageous as we move forward with this strategic plan, particularly as we look to build partnerships beyond the health sector.

Engagements were held at over 44 different agencies. The engagements were organized to target a diverse group of stakeholders addressing:

• The continuum of the life span(obstetrics, paediatrics, youth, adults, seniors, palliative)

• Various environments where care is provided (hospitals, long-term care homes, community)

• A range of conditions/diagnostic groups (physical disability, visual impairment, kidney disease, etc.)

• Various cultural groups (Afghan, Black, Chinese, Francophone, Métis, South Asian, etc.)

• Groups focused on marginalized communities (Coalition for Affordable & Accessible Housing, East Mississauga Community Health Centre, Homelessness Prevention Initiative, etc.)

• Providers from different health care sectors (Primary Care, Hospital, Community Care Access Centre, Community Support Services, Long Term Care)

For a listing for all groups engaged please see Appendix 6.

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Community Engagement Data Analysis

The transcripts from each engagement session and the data gathered from the surveys were analyzed and coded to identify common themes found across the

various sessions held. The data shared below identifies the prevalent themes that were found within each priority area

. RIGHT CARE, PROVIDED AT THE RIGHT TIME, IN THE RIGHT PLACE

• Information on full range of health care services available in the region

• Service navigation • Client /person-centred care approach • Health care providers must have a

full understanding of the service system

• Access to timely family health care (primary care)

• Alternate models of care

• Alternate service options • Increased community capacity -

CCAC/home care services, respite and caregiver support services, mental health services, children's services, palliative and residential hospices, more family physicians

• Transportation • Electronic Records

FASTER ACCESS AND STRONGER LINKAGES TO FAMILY HEALTH CARE

• Improved access to family physicians/health care

• Use of alternate professionals such as nurse practitioners, midwives, allied health

• Improved knowledge of service system by physicians

• Increased integration with other services - alternate models such as Independent Health Facilities, Family Health Teams, one stop location for service, more clinics with longer hours of service

• e-record to improve timely information and sharing

• Person-centred approach • Increased collaboration and

information sharing with other providers, including community providers who are in the circle of care

• Better understanding and trust of community providers

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ENSURING HEALTH CARE TRANSITIONS ARE SMOOTH

• e-record to allow ease of information sharing between health service providers

• Client centred approach to service • Service integration and continuity of

care− more information sharing • Service system knowledge to know

what options there are for other services

• Service navigation/navigator to provide support to client/family during transitions

• Service flexibility while waiting for transitions

• Decreased wait times and timely access to new services

• Increased communication between health service providers around care plans and use of more standardized care plans

INCREASING COMMUNITY CAPACITY

• More home care services • Flexibility of services to meet client

needs • Integration of agencies and services,

not just addition of other services − comments indicated that the system lacks coordination, has duplication and is disjointed

• Alternate service models discussed included integrated continuum of care under one agency

• Need for increased service system knowledge, for consumers and providers

• Services must be person-centred and responsive

• Service navigation support to assist families make successful transitions or access services

• Oversight or check in services for seniors who may be living alone or isolated

• Caregiver support and respite services with flexible hours

• Peer and survivor support services − this could be for seniors and also mental health and addictions consumers

• Senior socialization services and increased rehab/activation services

• Consideration of bringing service to people to reduce issues with transportation − include things such as mobile health teams for check-ups/treatment

• Service quality • Residential hospices

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KEEPING CITIZENS HEALTHY

• Health promotion and disease prevention campaigns − focus on healthy lifestyle, proper nutrition and fitness

• Integration of services so that people can receive support for more than one issue in one stop and receive comprehensive care/support

• More mental health and addictions services and education of all types

• Additional services for seniors and caregivers

• Increased service system knowledge • Partnerships for healthy

neighbourhoods – planning tables for health, education, social services

The draft priority areas of focus were supported as key priorities for the region from the engagement sessions as well as the on-line survey. Major concerns that the community has with health (as noted from the on-line survey):

• Reduction of wait times • Lack of access to services, in

particular, family health /primary care services

• Mental health and addictions services • Improved services and care for

seniors in home

• Lack of system coordination and health service provider/caregiver communication

• Increased information / knowledge of services available

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APPENDIX 6: COMMUNITY ENGAGEMENT STAKEHOLDERS Stakeholders from the following organizations participated in community engagement sessions for the IHSP (many of these engagements were held at the community organization):

• Aboriginal Community Forum • Acton Seniors’ Recreation Centre • ADAPT • Adult Day Program Support

Groups • Canadian National Institute for

the Blind • Child Development Resource

Connection • Coalition for Affordable and

Assistive Housing in Halton • Commissioner of Health Services • Credit Valley Hospital • East Mississauga Community

Health Centre • ErinoakKids • Francophone Community Forum • General Public attending 5

Community Forums held in each Sub LHIN area

• Georgetown Seniors Centre • Halton Health Services • Halton Public Health • Heart House Hospice • Homelessness Prevention

Initiative • Hope Pace Centre • Info for Seniors • Kiwanis Club – Georgetown • Métis Nation of Ontario • Mississauga Halton Community

Care Access Centre • Mississauga Halton Diabetes

Regional Coordinating Centre

• Mississauga Halton LHIN Citizen’s Reference Panel

• North Halton Mental Health Clinic

• Northridge Long Term Care Home • Nucleus Housing • Oakville Seniors Centre &

Residence • Ontario March of Dimes • PAARC • Peel Public Health • Peel Senior Link • Primary Care Community Forum • Rotary Club of Mississauga City

Centre • Sheridan Villa • STRIDE • Summit Housing & Outreach

Programs • Support & Housing Halton • TEACH • Trillium Health Centre • United Way – Oakville • United Way – Peel • United Way of Peel Black

Community Advisory Council • United Way of Peel Chinese

Advisory Council • United Way of Peel South Asian

Advisory Council • Voices for Change Halton • Waterford Long Term Care Home • West Oak Village • Wyndham Manor

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IHSP engagements were also held within the following committee meetings: • Alternate Level of Care

Transitional Operations Group • Clinical Integration Program

Oversight Committee • Community Support Services

Community Action Planning Steering Committee

• Community Support Services & Mental Health & Addictions Sector Meeting

• Diabetes Connect • Health Professional’s Advisory

Committee • Integrated Client Care Project

Palliative (ICCP) Executive Sponsor Meeting

• ICCP Meeting • Maternal Newborn Child & Youth

Regional Integration Steering Committee

• Primary Health Care Steering Committee

• Renal Integration Regional Integration Steering Committee

• Self-Management Task Group • Supports for Daily Living

Leadership Group • Transitional Aged Youth Steering

Committee • Table de concertation

Francophone • West GTA Stroke Network

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APPENDIX 7: IHSP PRIORITY DEVELOPMENT AND CONTEXT The Ministry’s vision is Keeping Ontario Healthy, and focuses on Better Access, Better Quality and Better Value. The Mississauga Halton LHIN’s vision directly aligns with the provincial direction: “A seamless health system for our communities – promoting optimal health and delivering high quality care when and where needed”. The principles of person-centredness, quality and health equity need to be embedded in all priority areas and be at the forefront of how business is approached and conducted. This approach aligns with the provincial direction, our Board direction and the consistent feedback we received from our community. Based on the analysis of the community engagement feedback, a review of the literature, and consideration of/alignment with Ministry direction (Action Plan), LHIN CEO identified system imperatives, MH LHIN Board identified priorities 2012 and the existing Mississauga Halton LHIN IHSP priorities, the following priorities were identified for the IHSP 2013-2016:

1. Accessible and Sustainable Health Care

2. Family Health Care When You Need It

3. Enhanced Community Capacity

4. Optimal Health - Mental & Physical

5. High Quality Person-Centred Care

These headings, while similar to the current IHSP priorities, do not specifically reference distinct populations (i.e. seniors and mental health and addictions). The titles for these priorities were selected to reflect the need to break the silos within sectors and populations. Our stakeholders articulated repeatedly that often there is a need to achieve the same goal regardless of the disease process or age of the client. These priorities support a systems approach focusing on key strategies to meet the needs of the varied stakeholders who require health care (i.e. children, seniors, mental health and addiction clients as well as others). The priorities were also framed to bring the community feedback to life – to support buy-in from all stakeholders – and foster a partnership approach to successful achievement of our local priorities.

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ACCESSIBLE AND SUSTAINABLE HEALTH CARE Improving access to care has been a significant focus for the Mississauga Halton LHIN over the past six years. The importance of being able to access the appropriate care in a timely matter continues to be critical to the quality and sustainability of the health care system. Wait time performance for Emergency Department treatment as well as selected procedures, such as hip and knee replacements and MRIs, has been a prime focus, both at the LHIN level and provincially. Many innovative initiatives developed over the past several years to support improving access to care have yielded positive outcomes. The Mississauga Halton LHIN has also worked to significantly reduce ALC rates, which have a significant impact on consumer flow. Implementation of the Home First philosophy, in addition to increased community based and home care services, have successfully supported a decrease in ALC consumers by 45 percent. Over the next three years, the LHIN will continue to strive to decrease wait times and maintain

those indicators that have reached the targeted rate.

Another significant focus in the Mississauga Halton LHIN’s work has been the development of regional programs. This work has allowed standardized access to programming across the region through consistent

eligibility and improved quality of care through the identification and implementation of best practices. Success has been seen in specialized geriatrics and various programs such as cardiac and neurosurgery. Work continues to progress in chronic kidney disease, diabetes, palliative care, stroke, maternal-child care, rehabilitation and complex continuing care. Focus on the development and enhancement of regional programs will

continue to be of importance for the role they play in improving access, quality and sustainability.

Navigating the health care system can be confusing, overwhelming and complicated for both consumers and clinicians. Consumers find the journey through the system more “daunting than the disease itself” (OFCP, 2011).

“Hospitals often do not connect effectively with community supports in developing an appropriate and sustainable discharge plan, which results in increased hospital use. An acute care hospital needs to be aware of community supports and proactively contact these services at the time of admission, not when the individual is being discharged.”

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Clinicians spend an inordinate amount of time searching for the appropriate services for their clients. Avoidable readmissions are not linked solely to hospital activity; they are often the result of poor coordination within the health care system (Avoidable Hospitalization Advisory Panel, 2011). The entire health care team, across the continuum of care, including the community, must work together as an integrated system to ensure efficient access to care and services needed. However, this coordinated approach will take time because many players are involved. Stakeholders discussed challenges in the current system where requests for the CCAC cannot be placed more than two days prior to discharge, yet two days was often insufficient to get the necessary services and equipment in place for a safe discharge. With the focus on ALC consumers, this planning cannot afford to wait until the individual is medically ready for discharge. Planning for such transitions must begin early in anticipation of the discharge or any other transition. This will allow for increased involvement of family health care and community care in planning for the next stage of care and an increased likelihood that necessary services will be in place at the next destination. A great range of services exist within the Mississauga Halton LHIN. The challenge is keeping informed and up-

to-date on all that is available. This was heard from virtually ALL stakeholders: consumers, family caregivers, family health care providers, hospital and community based staff. Frustrations expressed by consumers and caregivers focused on the inability of their care providers to support them in navigating the health care system, either because they do not understand the resources available (wait lists, eligibility criterion, etc) or are completely unaware of them. This results in consumers feeling they are left by themselves with the huge burden of finding the appropriate services to meet their care needs. The Change Foundation (2012) advocated for a map or guide to help consumers and caregivers navigate through the system which would enable consumers, during points of transition, to understand where they were going next and where they could find the care they were seeking.

“One of the challenges is knowing what ALL the options are. I recently had to research everything on my own for my elderly parents. It would have been much easier if I had been given a list of all services available.”

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Consultations with health service providers identified challenges that were twofold. Providers often felt unaware of the existing resources they could call upon to support their consumer’s care and had no simple, centralized way of accessing such information. This challenge existed in their knowledge of services across the full continuum of care – everything from specialists to CCAC to community services and long-term care. Consequentially, this lack of awareness resulted in multiple referrals being made, some of which were inappropriate, longer wait lists, and often frustration for consumers and providers when they reached the top of the wait list only to find out that they did not qualify for services. Providers also discussed the frustration they felt when the services they provided were not well understood by other providers. With increased understanding of the services and resources, providers will be in a better position to support consumers during their transitions. They will be able to give consumers

and their families a clearer sense of the next steps and the options available. With providers having this information, it has the potential to facilitate greater involvement of consumers in making decisions about their care. Research shows that 1 percent of the population consumes approximately 50 percent of health care services utilized each year. A focus on ensuring that this population, who are considered to be high users of the health care system and at high risk for being readmitted into hospital, receive coordinated care including smooth transitions is prudent. These consumers will benefit from new programs in the Mississauga Halton LHIN such as the Intensive Client Care Project currently underway or the Rapid Response Nurse initiative which was recently launched. These initiatives will provide support in navigating the system and ensuring appropriate supports are in place during transitional periods. By meeting the needs of complex,

All too often health care professionals only provide partial information. Not because they are neglectful, but simply because they focus (primarily) on their area of expertise.”

“Make sure there is someone to act as a link between both services when the patient doesn’t know to proceed or is unable to do so on their own.”

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vulnerable consumers (high users) more effectively and efficiently, care and sustainability will be improved. Ontario is currently undergoing a Heath System Funding Reform. This will shift the health care system away from the current global funding system towards Patient-Based Funding (PBF). Under PBF, organizations will receive funding for the number of individuals they care for, the services delivered, the evidence-based quality of those services and the specific needs of the population they serve. This will allow

health care to be delivered in a more cost effective way and improve the quality of care for consumers.

Quality Based Procedures are also being implemented. These procedures allow for the identification of best practices for specific consumers who require similar care. This will promote the standardization of care and ensure quality care is being delivered at the right time in the right place. By following these best practices, the system will achieve even better quality and efficiencies.

GOAL #1: Improve access to services to improve consumer flow, quality and safety Strategies to move us forward:

Establish new ways of working in and with Emergency Departments to reduce wait times

Develop innovative and collaborative approaches to reduce unnecessary hospital stays and avoidable hospital admissions and readmissions

Leverage evidence-based practices to reduce wait times for priority surgical services (i.e. hips, knees, cataracts, cancer, cardiac bypass)

Integrate services to support regional programs and system effectiveness

GOAL #2: Support consumers, families and health care professionals to navigate the health care system Strategies to move us forward:

Begin planning for transitions early and include all care providers, including informal caregivers and family health care

Enhance provider awareness and knowledge of the health care system and available resources

Provide service navigation to consumers and their caregivers during transitions within the health care system

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GOAL #3: Improve sustainability of the health care system

Strategies to move us forward:

Develop regional, integrated capacity plans to support health system funding reform (i.e. integrated orthopaedic capacity plan) and implement funding for selected health programs based on the needs of consumers (quality based procedures)

Focus on seniors and those individuals who utilize a significant proportion of our health care resources and how to meet their needs with greater efficiency

Work in partnership with health care providers and partners to explore maximizing scope of practice, utilizing services in different ways to improve access

Manage growth in capacity required as a result of population increases and aging

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FAMILY HEALTH CARE WHEN YOU NEED IT Family health care is the gateway into our health care system. It includes preventative health care, screening and early detection of illness, coordination with hospitals following an admission including appropriate follow up, and facilitation of smooth transitions across clinicians, settings and services (Primary Health Care Planning Group, 2011). As the first point of access for people seeking health care within the Mississauga Halton LHIN, a strong family health care system is needed to achieve better outcomes and improve the quality and sustainability of the system as a whole. Access to family health care continues to be a provincial priority (Ministry of Health and Long-term Care, 2012). Despite the fact that 71 percent of Mississauga Halton residents are

registered in a primary care enrollment model, many people still cannot find a family doctor (Health Analytics Branch (HAB), 2012). This is particularly true for vulnerable populations such as those with mental health and addictions or complex medical conditions. Both consumers and health care providers reported the experiences of consumers with complex needs being denied access to family health care services. Health Care Connect, launched in 2009, has demonstrated success in referring people with complex needs to a family health care provider with a 97 percent success rate in 2011/12 (Health Analytics Branch, 2012). Strategies to ensure orphaned consumers have regular access to a consistent family health care provider are needed to support family health care when you need it. Having a regular family health care provider is only one piece of the puzzle. People also need to be able to access this provider when they require care. Currently 18 percent of

“My doctor retired. It took me a while to get another doctor. The ones my doctor suggested were really far from where I lived or worked. Every doctor I called was not accepting new patients. It was not an easy process.”

““I had a good experience with Health Care Connect. They found me a doctor in two days.”

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Canadian physicians provide same or next day appointments and 44 percent have arrangements for after hours care (Health Council of Canada, 2011). Consumers described having to wait a long time before their scheduled appointment – anywhere from three days to three weeks. For these people, despite having access to family health care, when it is not provided in a timely manner, they often resort to using the Emergency Department. Preference for more convenient access to family health care providers through improved hours (evenings and weekends) and different modes of communication (phone and email) was also identified. Caregivers described the challenges of having to take time off work to take their aging parent to health care appointments. The lack of convenience again results in poor continuity of family health care and suboptimal use of health care resources. People turn to other options such as walk in clinics and the

Emergency Department, even when they recognize their condition could be treated by a family health care provider (Primary Health Care Planning Group, 2011; CIHI, 2012).

If people can access family health care when it’s needed, it will enable them to stay healthier, and potentially reduce the need to be admitted to hospital. People who accessed their family health care from a group model of care called a Family Health Team generally had positive reports. They had an easier time getting an appointment – if it was urgent, they could be seen by another doctor in the group. It was felt that the doctor had more time to see them. Through the implementation of these interdisciplinary teams, access to family health care is improving. Health care providers echoed their support for family health care models which were interdisciplinary in nature. They felt it improved the quality of care consumers received as well as fostered better continuity of care as the various professionals were all part of the same team versus

“When I call for an appointment, it is often three to four days. This is very cruel when I am suffering and in pain. I have to wait for four days when I’m in pain. That’s not reasonable. That’s why people go to the Emergency Department.”

“Doctors can’t know it all. They need to rely on other disciplines to address social issues and chronic disease.”

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merely within the circle of care. Research strongly supports the use of team based family health care (Health Council of Canada, 2010). Care from a multi-disciplinary team allows consumers to benefit from a range of expertise and also increases access to doctors by allowing each team member to address health issues within their scope of practice instead of relying solely on the doctor. Currently, only one third of Canadian physicians report practicing within interprofessional teams, despite evidence that these models enhance both consumer and provider experience (Adolph, 2011). Expansion of team based family health care is recommended to improve both the quality and accessibility of care and to impact the sustainability of the health care system.

Family health care has been referred to as the quarterback of the health care system; coordinating all the different players within a consumer’s health care team (Drummond, 2012). However, there appears to be a

disconnect between family health care and other providers within the health care system creating poorly coordinated care (The Change Foundation, 2012). This challenge of making good links across the different sectors of care was observed by consumers and felt by both family health care and specialty care providers alike.

Family health care providers, as generalists, need to address a wide range of issues within their daily work. They need to recognize what they can effectively and safely manage, and when a condition is reaching the point beyond their level of expertise. This is a fine balance which depends on the level of comfort and knowledge of each individual provider. One family care provider reflected that in the days of doctor’s lounges, you could connect with a specialist for a bit of advice and manage a person’s condition a bit longer. However, as family health care providers spend less and less time in hospitals; these opportunities are few and far between. The result is increased referrals to specialists for

“If you have one stop shopping, it is more convenient for patients, and all staff can communicate better because they are part of a team.”

“We need to link all the providers to family doctors. When I go to the hospital, my family doctor needs to know that. It’s just common sense.”

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what specialists consider to be more basic levels of care. This practice increases wait times for specialists and is not the most effective use of limited resources. For people with complex medical needs, the role played by family health care providers impacts the overall quality, safety and appropriateness of the health care they receive across the system (Health Council of Canada, 2010). The risk of error, duplication and wasted resources increases as the complexity of care increases. These consumers typically have multiple interactions with a variety of health care providers which amplifies the need for good coordination of care. Ideal family health care is where an individual’s medical history is documented and the coordination of all the necessary services takes place. This allows for improved monitoring of a consumer’s condition, better access to care and fewer errors in care. Health Links are a new way of coordinating local health care for patients who often receive uncoordinated care from several different providers, resulting in both gaps and duplication in the care provided. Coordinating care is an important step in improving the services available to patients with complex conditions. Typically, these patients are seniors, have multiple chronic diseases and mental illness. These patients often default to the emergency department for care and are repeatedly re-admitted to hospital

when they could be receiving care in the community. Health Links will encourage greater collaboration between existing local health care providers, including family care providers, specialists, hospitals, long-term care, home care and other community supports. With improved coordination and information sharing, patients will receive faster care, will spend less time waiting for services and will be supported by a team of health care providers at all levels of the health care system. Health Links put family care providers at the centre of the health care system. By bringing local health care providers together as a team, Health Links will help family doctors to connect patients more quickly with specialists, home care services and other community supports, including mental health and addiction services. For patients being discharged from hospital, the Health Link will allow for faster follow-up and referral to services like home care, helping reduce the likelihood of re-admission to hospital. Patients with the greatest health care needs make up five percent of Ontario’s population but use services that account for approximately two-thirds of Ontario’s health care dollars. Better coordination of care for these patients will result in better care and significant health system savings that can be devoted to other patients, ultimately improving the sustainability of public health care.

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Exploring avenues to foster mentoring relationships between family health care and specialists will be beneficial for consumers, physicians and the health care system as a whole. Several models of such mentorship exist. Through the use of telemedicine, family physicians are able to send images of dermatological issues to dermatologists to get feedback on the suggested next steps. This potentially eliminates the need for a referral unless it is warranted, saving the four month wait time for the consumer thus preventing the condition from continuing to progress. It also builds the capacity of the physician at the family health care level for the future. A similar mentorship model is being launched through the Ontario Renal Network where nephrologists will be available to consult with family health care providers to support the management of chronic kidney disease (CKD) through promotion of early detection, appropriate and timely referrals and equipping providers with the knowledge and confidence needed to manage CKD. Another barrier encountered in coordinating care is the poor flow of consumer information. Consumers discussed that they often felt that they were providing their family health care provider with the necessary information − from specialist visits to hospitalization details. Family health care providers indicated they experience significant delays in receiving reports and sometimes never

receive them at all. 12 percent of Canadians and 23 percent of Canadians with chronic conditions and poor health reported that test results or medical records were not available for their appointments while 18 percent found their specialist did not have basic medical information from their family doctor at their appointment (Health Council of Canada, 2011). A key enabler to improving the flow of consumer information is the implementation of Electronic Health Records (EHR). Information sharing with family health care providers who are using an Electronic Medical Record (EMR) has become easier. EMR adoption by community based physicians and selected practitioners continue to grow steadily as reported each quarter by OntarioMD. Presently, Ontario has funded nearly 9,000 of the approximate 16,000 community based physicians to adopt an EMR. The adoption level within the Mississauga Halton LHIN has been steadily increasing over the past few years. As of August 2012, the Mississauga Halton LHIN was at 58 percent adoption, 8 percent below the provincial average. Efforts will continue to expand functionality by expanding integration of various systems. This will include family health care providers being able to access hospital reports and laboratory results (through OLIS) from their offices. Through significant investments, gains in family health care have

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resulted in linking more people with family health care and shifting the models of care from solo to group practice, including the development of interdisciplinary family health care teams (Primary Health Care Planning Group, 2011). Continued efforts in

these areas will enhance both access and linkages to family health care. A well developed family health care sector effectively linked with the rest of the system is critical to successful health system integration (Change Foundation, 2011).

GOAL #1: Improve access to family health care Strategies to move us forward:

Leverage Health Care Connect to support consumers who want or need a family health care provider to get one, particularly for those people who are admitted to hospital or frequently visit the Emergency Department

Improve access to same-day or next-day appointments and after-hours care including home visits and mobile clinics

Increase access to multi-disciplinary health care teams

GOAL #2: Increase linkages between family health care and other health care providers to improve communication, coordination and integration across the continuum of care Strategies to move us forward:

Improve coordination of care between providers (particularly for complex consumers who are at high risk for readmission or high users of the system) through the development of Health Links

Increase capacity of family health care providers to manage an increased complexity of consumer care through the provision of consultations with specialists

Improve communication with family health care providers through consistent and timely sharing of consumer information

Leverage technology (i.e. electronic medical records, portals, Ontario Telemedicine Network) to promote sharing of information between providers

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ENHANCED COMMUNITY CAPACITY There has been much discussion on providing the most appropriate care in the most appropriate place. Many people can be cared for at home or in their community instead of staying in hospitals and/or long-term care homes. As our population ages, the shifting emphasis on providing care in the community is an opportunity to transform the health care system. In order to accomplish this, the right community supports need to be available. As we make this shift in our approach to care, the capacity within the community needs to exist in terms of the volume of services available for a variety of populations including seniors, mental health and addictions and complex, vulnerable consumers.

Despite significant investments by the LHIN in community programming to support the Aging at Home strategy, stakeholders discussed challenges in meeting the demand. It was identified that consumers may apply for services, however, while on the wait list, their situation can deteriorate, resulting in hospitalization. It is through this hospitalization that they then become a priority and begin to receive service. Community services need the capacity to be more responsive and prevent this avoidable hospitalization. In addition to capacity, we also need to consider the breadth of services that are needed to support someone to continue to live in their home and avoid institutionalization. Medical care and support with activities of daily living (ADL) like baths is routinely provided, however, doing laundry, grocery shopping, shoveling snow – activities known as Instrumental Activities of Daily

“People show up in the emergency department when they are at their wit’s end. We think, “How did they get this far with NO supports in place? How did they fall through the cracks?” If they got more services prior (to this crisis) they might have avoided this.”

“Sometimes what someone needs is very simple and it’s not medical. I need someone to do my shopping for me, but because it’s not medical, I can’t get support for it.”

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Living (IADL) – are not covered. Admittedly, these IADL are not provided because they don’t fall into the category of health care. They are often available for an additional fee for those who can afford to pay privately. Unfortunately, IADL services are often the tipping point between staying at home and having to be institutionalized. Since Aging at Home is truly a priority, we need to explore how we can better support individuals with such tasks that enable them to stay at home.

Medication errors in the community, where there is little medical oversight, can be very problematic and are one of the key issues related to hospital readmissions. After a hospitalization, consumers may come home with new medications. However, understanding how to take new medications or how new medications interact with previously prescribed medications is a challenge for many people. For others, it is simply remembering to take medications on a routine basis that is a challenge. Medication reconciliation

and oversight will be a focus in the LHIN over the next three years. Providing support for medication management is one of the electronic health system initiatives that can improve care within the community. The goal of the Drug Information System and ePrescribing project is to improve the health of Ontarians through optimal medication management. To enable this goal, the strategy has committed to purchase and implement a Drug Information System, create a comprehensive medication profile for all Ontarians and provide clinical decision making tools including adverse drug interaction flagging to healthcare providers. This project is currently under review with the Ministry. The needs of the caregiver are paramount, as homecare is only designed to be a complement to their support (Health Council of Canada, 2012). It is critical that informal caregivers have the supports necessary to enable them to continue to support their loved one in the community. Whether it is through education on how to manage aggressive behaviours or safe transfers, informal caregivers need sufficient training on how to manage aspects of their loved one’s care safely. In the case of palliative care, caregivers also need support to manage the anticipated challenges of supporting a loved one to die at home. Caregivers need respite to ensure they do not burn out. Stressed or injured

“We need additional human resources with the right skill set to enable us to meet the needs of residents who are becoming increasingly more complex.”

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caregivers become unable to provide care to their loved ones and may significantly compromise their own health as well (Health Council of Canada, 2012). The Mississauga Halton LHIN recently launched plans for a caregiver strategy recognizing the critical role caregivers play in the continuum of care. Development of this strategy will be a key focus for the LHIN over the next three years. Capacity in the community also relates to ensuring community based providers have the skills necessary to meet the needs of the increasingly complex individual. This is an opportunity to ensure professionals are working to their full scope of practice (Drummond, 2012). Additional training may be required to build skills if proficiency does not exist. With the shift to earlier discharges and more care being provided in the community, building a skilled work force in the community is essential to ensuring high quality care. As we continue to build community services that are closer to home, we need to ensure services meet the needs of consumers and their caregivers. Two-thirds of Canadians report difficulties accessing care in the evenings, weekends and holidays (Change Foundation, 2011). We need to listen to consumers and caregivers to understand how they can best be supported in their homes and communities. Is it easy to access services? How easy is it for the

patients being served to get around? Care needs to be provided in a timely and convenient manner – minimizing the need to go to multiple locations for services (Change Foundation, 2011). Services only provided between the hours of 9-5, Monday to Friday, are not enough. Services need to be delivered in a way that makes sense and makes the right thing to do, the easiest thing to do. There are many services that could be bundled together to provide a more seamless, integrated service. One existing example within the region is the provision of baths for fragile seniors while attending a day program. This allows the person’s hygiene needs to be met, decreases the risk of back injuries to the caregiver and supports less disruption to the family’s home schedule. Similar concepts could be expanded to programs serving many varied populations to provide more one-stop health care services. The convenience will increase uptake of important health services or testing and the sustainability of programs through centralized delivery. Consumers faced challenges in knowing “what’s out there”. How can the community service sector simplify the navigation process for consumers and providers alike and provide a seamless, integrated community care experience? Are there partnerships or integration opportunities that could be explored to provide more coordinated services? Community centre models,

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where a range of services are available to a population within one location, seem like a promising approach. The province has identified the priority of providing services as close to home as possible (Ministry of Health and Long-term Care, 2012). The best strategies for accomplishing this goal will be explored as we move forward in transforming community care.

Transportation was identified as a significant barrier to many people attempting to access necessary services. Challenges result from the

need to cross municipal borders, the expense of frequent trips and extensive commute times which can be exhausting for consumers. Other examples included seniors feeling unsafe when having to cross a busy six lane street to catch the bus, or consumers with mental health issues feeling too anxious to travel by public transport by themselves, therefore forgoing attending treatment sessions. Methods to improve the accessibility of programs, either by supporting transportation or by bringing programming to a more accessible location, need to be explored. Technological solutions such as Telehomecare (i.e. monitoring devices) as well as eConsults, through the use of the OTN, may eliminate the need for such extensive travel. By serving people appropriately in the community, the entire health care system will benefit. Receiving care in the home will improve the person’s experience. The risks to consumers are reduced. More support with daily tasks will result in fewer hospitalizations and placements. Hospital beds are free for those who need them. And the system is more sustainable as a whole.

“We need to look at who is not engaged in health care. We need street nurses, mobile health buses that go to food banks and shelters to ensure these populations are engaged and their health doesn’t get to the point that it becomes catastrophic.”

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GOAL #1: Enable people to stay in their homes longer Strategies to move us forward:

Manage the volume of services in the community to reduce wait times and meet demand for vulnerable populations such as seniors, palliative consumers and those with mental health concerns and addictions

Provide support for medication management and instrumental activities of daily living such as meals and homemaking to avoid institutionalization

Support caregivers by providing adequate training, respite and coordination of service

Ensure appropriate staffing through enhanced training to attract skilled staff to serve consumers with complex needs in the community

GOAL #2: Provide integrated services that bring care closer to home


Create community centres for health where people can access integrated services that address more than one need in a single stop

Address transportation challenges or bring programming to convenient locations (home or community based) to meet the needs of specific target groups

Maximize use of technology to bring care closer to home

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OPTIMAL HEALTH - MENTAL & PHYSICAL Chronic disease is the leading cause of death in Ontario and responsible for six of 10 deaths in the Mississauga Halton LHIN (Public Health Ontario, 2012; Health Analytics Branch, 2012). Over 50 percent of Ontarians aged 45-64 have at least one chronic condition. Chronic disease in children and adolescents is on the rise.

Approximately half the population in the Mississauga Halton region is obese and physically inactive (Health Analytics Branch, 2012). Due to the obesity epidemic, we are raising the first generation of children whose life expectancy is expected to be lower than their parents (Olshansky, et al, 2005). One in five Ontarians, whether adult or child, will develop some form of mental illness (Baeumler, 2012; WHO, 2000). These largely preventable diseases diminish our quality of life, economy and communities. Now is the time to do a better job of preventing them (Public Health Ontario, 2012). The current health care system was developed to deal with acute care – treating people once a health problem

has developed rather than focusing on an approach that might prevent problems or lessen the effects. Due to the aging population and the fact that lifestyle problems such as obesity are creating health conditions such as diabetes, we need to emphasize and shift our focus on preventing poor health. Chronic diseases are frequently inextricably linked to many other diseases (Pirisi, 2012). For example, people with diabetes often have heart disease, high blood pressure, high cholesterol, obesity and are at risk for kidney failure and stroke. These common links exist both in terms of the factors that place one at risk for the disease, or once diagnosed, what one must do to manage the disease (i.e. healthy eating and exercise is a prevention and management strategy for many conditions). Health care

“Prevention needs to be a focus not just management of disease.”

“We need to move away from focusing on people’s time in hospitals – that’s just the tip of the iceberg – a tiny sliver of our life. We need to focus on the things that take you into the hospital. This is the huge iceberg below the water.”

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however is typically organized into silos by disease, so we tend to have separate programs for each condition in terms of how they can be prevented or managed.

In the Mississauga Halton LHIN, chronic disease leaders (including Mental Health and Addictions) within the region have been examining commonalities of chronic disease and discussing how a more integrated approach could be implemented. People should be treated holistically rather than according to the checklist of conditions they have. An integrated model for chronic disease prevention and management will offer a more coordinated and seamless model of care for chronic disease resulting in better quality of care and a more efficient system for all involved.

The provincial action plan states “Helping people stay healthy must be our primary goal and it requires partnership” (Ministry of Health and Long-Term Care, 2012). Keeping people healthy is a responsibility that must be shared across various levels of government to make a difference. We also need to collaborate with non-government partners in sectors beyond the realm of health as the factors that influence our health

branch out into many areas (Public Health Ontario, 2012). Stakeholders discussed a wide range of potential partnerships − from schools to recreation to private sector − to encourage healthy living.

Seventy percent of the Mississauga Halton LHIN’s population is employed. Partnering with the workplace is an example of a

“Elevated cortisol levels are common in people with depression. And, in what may be a vicious circle, excess cortisol leads to an accumulation of abdominal fat. Likewise, many antidepressants and antipsychotics lead to weight gain, and yet people with depression may lack the energy or motivation to plan healthy meals or pursue physical activity.”

“CNIB provides us with a support group. Before CNIB, I sat in my room and cried. We call one another and share our challenges. It’s heaven.”

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relationship that could have far reaching effects. Employers can play an instrumental role in promoting healthy lifestyles through workplace policies. As drivers of the health care system, the LHIN is well positioned to lead by example. Through accountability agreements, health service providers will be encouraged to implement programs, strategies and policies to encourage their employees to adopt a healthier lifestyle.

Partnering with consumers for their expertise with lived experience is another powerful partnership to support the development of new peer support initiatives. Opportunities to connect with people with similar backgrounds have been found to be very beneficial for both consumers and caregivers (Ainbinder et al., 1998; Kerr&McIntosh, 2000; Law, King, Stewart & King, 2001). Bonds form when facing common issues, therefore peer support creates enhanced sharing of information and a sense of partnership as well as a reduction in feelings of isolation and distress often experienced by consumers with complex health care needs or their caregivers (Law et al., 2001; Singer et al., 1999). Success has been seen in

pediatrics, mental health and addictions as well as seniors. Through added support from peers, use of health care resources may be better utilized through ease of navigation or even decreased stress and increased coping. These connections are a highly valuable resource that are yet untapped for many applications. As chronic conditions affect many people in the Mississauga Halton LHIN, it is important that we continue to not only treat people with chronic conditions, but increase our collective efforts around awareness and preventative measures, improve health promotion and ensure that those people living with chronic diseases receive the information and supports necessary to better self-manage their care.

“The goal needs to be everybody healthy, not everybody cared for.”

“Health is much more than patching up people once

something has gone wrong. The ideal health system

would put more emphasis on preventing poor health.”

- Drummond Report

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By focusing attention on health promotion and prevention of disease, the health of our communities will improve. People will enjoy a better quality of life and live longer. They won’t need health care services as

often or as intensively. Chronic disease costs Canadians more than $90 billion a year in lost productivity and health care costs. By investing in these areas, the rising costs associated with chronic disease will decrease, improving the sustainability of the health care system

GOAL #1: Increase healthy habits and prevention of disease


Leverage existing resources for chronic disease and develop an integrated model and approach to chronic disease prevention and management that supports individuals through their lifespan

Partner with public health to support approaches to healthy lifestyles and disease prevention

Promote healthy workplace policies, leading by example through the work of our health service providers

GOAL #2: Build partnerships for healthy communities Strategies to move us forward:

Develop partnerships across various sectors such as municipalities, public health, education and social services to collaborate on issues relating to or impacting on health such as the social determinants of health

Leverage the expertise of people with lived experience and expand/develop peer support initiatives and networks

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HIGH QUALITY PERSON-CENTRED CARE The Mississauga Halton LHIN has identified quality as a key priority for 2013-2016. With the establishment of a Board Sub-Committee focused on Quality, the Mississauga Halton LHIN will provide leadership to ensure that transparent mechanisms and plans are in place to drive quality health care service, patient safety and system effectiveness. As evidence of the increased demand for measurable performance and quality measures, hospitals are required to establish quality committees and to prepare annual quality plans, and the Ontario government is placing greater emphasis on a wide array of quality issues. The expectation in the Excellent Care for All Act is that this requirement will be expanded to all health service providers in the future.

Over the next three years, the Mississauga Halton LHIN will strive to establish a quality culture across the local continuum of care ensuring that the LHIN’s health service providers have developed the capability and capacity required for this quality focus. In addition, the LHIN will ensure that controls and accountabilities are in place to address areas of quality health care service, patient safety and system effectiveness as it pertains to improved consumer outcomes and continuous improvement to the system. Further, the LHIN will utilize this information on quality as a means of informing future funding decisions

and decisions to support, foster or facilitate integration initiatives.

A culture of quality needs to be further embedded within community care. Many of the issues that have been identified as challenges in other sectors of health care affect consumers similarly in the community, for example, communication between providers in the community. Often times, there are multiple providers who serve a consumer daily. They require a mechanism to communicate any changes, either in the care plan or the consumer’s status, to the next provider. Community based professionals rarely have the luxury of handing off at shift change, so other mechanisms need to be explored. Examining appropriate quality outcomes that could be measured within the community sector would also be of value. Building a health care system that is sustainable for future generations is key. The system needs to provide value not only economically, but also value related to health outcomes. Scientific evidence should influence both how care is delivered and how the system is funded. Health care providers should be funded based on their ability to ensure better consumer outcomes. Clinicians need evidence translated into concrete tools and guidelines that can be readily used. Providing these resources will ensure the best quality care possible and a

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more sustainable system.

The electronic health system will provide significant support in this area as it strives to improve access to the information that is required to manage the health system. Through the collection and reporting of data in a standardized fashion, the LHIN and its providers will have an improved ability to track health outcomes and develop a better understanding of the health of the region’s population over time. This will allow data to be utilized to plan health care services and allocate funding in an informed manner. The electronic health system will also assist in improving adoption of best practice guidelines through the implementation of processes that cue clinicians to screen or provide specific interventions on a routine, evidence informed schedule.

Through listening to the experiences of consumers of our health care

services, clear ideas emerged about what adds value to our health care system, what needs fixing and what’s missing (Change Foundation, 2012). We need to put consumers in the centre of everything we do. After all, it is the individual and the quality of their experience that our system should be driven by, rather than what works best for clinicians and institutions. Our system needs to be flexible to meet the needs of consumers and caregivers. People value having adequate time during appointments, being able to access caregivers by phone between appointments, and receiving active follow up and help coordinating their care. People want to be treated with respect, to have their preferences about their care options taken seriously and their feelings acknowledged. There are practical changes health care providers can make to improve the service provided to consumers and increase their engagement in their health care. And we want consumers to be engaged. Engaged consumers are involved in decision making, actively participate in managing their care, and share their preferences and priorities with providers (Health Council of Canada, 2011). Currently, 48 percent of Canadians with a regular family health care provider feel engaged in their health care. Patients playing this active role in maintaining their health are more

“When I go for blood work, there is no follow up. They won’t even tell you on the phone; I have to come in for this. If they told me last week, I could have slept for a week.”

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satisfied with their care and feel better about their overall health. This leads to better use of health services and resources. By increasing consumer engagement, we will transform not only the way care is provided, but also the outcomes for consumers. There are various levels of consumer engagement from which the health system can benefit. Engagement at a personal care level focuses on the relationship that the provider has directly with an individual. However, consumer engagement can be broadened to more of a systems level, whether focused on using their experience to influence the planning of a specific program of care or having consumer input when developing policy or strategy to drive the health system as a whole (Health Council of Canada, 2011). The community engagement completed for this IHSP is an excellent example of how feedback from consumers has been utilized to inform the strategic directions for health care in the region. Patient experience is defined as “the sum of all interactions, shaped by an organization’s culture that influence patient perceptions across a continuum of care” (Beryl Institute, 2012). Yet very little is known about the person experience. Typically, the focus has been on easy to measure phenomena or processes such as satisfaction. Yet only 15 percent of physicians routinely gather and

review data on their consumers’ satisfaction and experience with care (Health Council of Canada, 2011). Patient satisfaction surveys only provide a superficial examination of how the system is working. We need to develop metrics beyond patient satisfaction that will support us to understand the person’s experience.

Hearing directly from consumers and families will illustrate how the system is truly working and guide service improvement and development. An excellent person experience is linked to quality of life and generally yields better care and outcomes. Understanding consumer needs and their experience with the care received will support providers in responding to identified gaps and contribute to

“Patients should have a say about the quality of care they received before the doctors get money from the government for “treating” the patient. This would diminish…the feeling that you are being raced through (your appointment) without time to explain what you have to say.”

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improved quality of care (Corpus Sanchez, 2012). By developing a better understanding of the person experience, we will be able to be responsive to the needs of our customers. The health care system is a business and as such, must listen to its customers. Consumers need to be involved in the planning and designing of health care services as a means to improve the quality of care and strengthen the accountability in the system. They need to be included in the process in an active and meaningful way. We must ensure that we engage consumers and their families in the development of solutions, measure the person experience and involve the voice of the consumer in both planning and decision making processes (Corpus Sanchez, 2012). Better results will be achieved through more active consumer involvement in the design, continuous improvement of the health care system and a greater focus on customer service. One in five people experience a diagnosable mental illness. It is critical to ensure that the services available within our region meet the demands of this population in a timely manner. Significant work is already underway within the Mississauga Halton region to ensure that mental health and addictions services are easier to navigate and access. The fear and lack of understanding of mental

illness makes addressing and overcoming it more challenging. We will collaborate with various partners to raise awareness, reduce stigma and build acceptance of these prevalent challenges within our communities.

To successfully promote the health of our communities, health care providers need to understand the context of the consumer’s life. Individual’s health concerns need to be addressed with an understanding of their living conditions and social supports. Research shows that poverty has a significant impact on health. People with low incomes tend to have poor access to the basics that enhance good health such as safe and affordable housing, nutritious food and stable, adequately paid jobs (Barnes, 2012). To achieve good health, it is critical that the social determinants of health are considered. By developing partnerships with sectors that provide services impacting on health status, healthier communities can be built. A person’s cultural background must also be considered. Different cultures have varied preferences and beliefs on how health is defined. These beliefs may discourage people from following medical recommendations, particularly if the services aren’t delivered in a culturally sensitive manner. Language barriers may also play a role. By working in collaboration with the French Language Services Entity (Reflet Salvéo), Aboriginal leaders and

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groups who serve the culturally diverse and vulnerable populations living in our LHIN, we can ensure that existing services are being well utilized and explore opportunities to modify services or develop new ways of delivering services to better meet the needs of Francophones, Aboriginal/First Nations people and other distinct groups living in our region.

Enhancing the person experience is not a choice, but a necessity. The Excellent Care for All Act identifies the need to improve the quality and value of the consumer and caregiver experience. A focus on person experience leads to better care outcomes, improved quality of life and quality of care. Person-centred care is compassionate, cost-effective health care.

GOAL #1: Continue to support and foster a quality culture across the continuum of care


Implement The Excellent Care for All Act at a local level to embed a culture of quality within all LHIN health service providers

Develop mechanisms for tracking quality of care, safety and system effectiveness as it pertains to desired outcomes

Implement consistent care pathways and standardized care plans (i.e. discharge plans)

Use scientific evidence to support effective utilization of health care dollars

GOAL #2: Value people’s experiences to support system improvement


Identify person experience metrics and use to guide service improvement and development

Ensure services are flexible to meet consumer and caregiver needs

Include people with lived experience as active members of planning and quality improvement teams

Develop a LHIN-wide customer service focused approach

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GOAL #3: Apply a health equity lens for the delivery of health care services


Raise awareness and decrease stigma to minimize marginalization

Focus on the most vulnerable populations and develop awareness and understanding of health equity issues to support those in need

Support the provision of services which are linguistically and culturally competent

Work in collaboration with the French Language Service Entity (Reflet Salvéo) and Aboriginal leaders to leverage existing capacities and explore new opportunities to meet the respective needs of the Francophone and Aboriginal communities

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APPENDIX 9: BIBLIOGRAPHY 1. Primary Healthcare Planning Group. Strategic Directions for Strengthening Primary Care in Ontario. 2011.

2. Tetley, Adrianna. Letter to ASsistant Deputy Minister (Acting). May 28, 2012.

3. Stukel, Therese A, Glazier, Rick and Schultz, Sue. Multispecialty Physician Networks: Improved Quality and Accountability - "The Medical Neighborhood". s.l. : Institute for Clinical Evaluative Sciences.

4. Kasperski, Janet M. Celebrating Quality in Family Practices: Creating a Primary Care Quality Improvement Strategy. s.l. : Ontario College of Family Physicians, 2011.

5. Hanna, Aura. OMA Principles and Recommendations: Models and Processes of Delivery for Specialty Care. s.l. : OMA Health Policy Department, 2011.

6. Haist, Sandy and Oake-Vecchiato, Jo-Anne. Improving Chronic Disease Management in your Community. s.l. : Trillium Health Centre, 2008.

7. Ontario Agency for Health Protection and Promotion, and Cancer Care Ontario. Taking Action to Prevent Chronic Disease: Recommendations for a Healthier Ontario. s.l. : Ontario Agency for Health Protection and Promotion, and Cancer Care Ontario, 2012.

8. Primary Healthcare Plainning Group. Strategic Directions for Strengthening Primary Care in Ontario. s.l. : Primary Healthcare Plainning Group, 2011.

9. Institute for Clinical Evaluative Sciences. Seven More Years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario. s.l. : Institute for Clinical Evaluative Sciences, 2012.

10. Health Council of Canada. Self-Management support for Canadians with Chronic Health Conditions. s.l. : Health Council of Canada, 2012.

11. The Credit Valley hospital. Primary Care in Western Mississauga 2020. s.l. : The Credit Valley hospital.

12. Health Council of Canada. How engaged are Canadians in their primary care? s.l. : Health Council of Canada, 2011.

13. —. How Do Sicker Canadians with Chronic Disease Rate the Health Care System. s.l. : Health Council of Canada, 2011.

14. —. Getting it Right: Case Studies of Effective Management of Chronic Disease Using Primary Health Care Teams. s.l. : Health Council of Canada, 2009.

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15. The Credit Valley Hospital and Health Care Centre. Enhanced Acute Care Management of Congestive Heart Failure in Long Term Care. s.l. : The Credit Valley Hospital and Health Care Centre, 2012.

16. Canadian Institute for Health Information. Disparities in Primary Health Care Experiences Among Canadians With Ambulatory Care Sensitive Conditions. s.l. : Canadian Institute for Health Information, 2012.

17. —. Diabetes Care Gaps and Disparities in Canada. s.l. : Canadian Institute for Health Information, 2009.

18. Association of Ontario Health Centres. Community-governed health centres announce commitment that all providers will work to full scope of practice. s.l. : Association of Ontario Health Centres, June 28, 2012.

19. Health Council of Canada. Beyond the Basics: The Importance of Patient-Provider Interactions in Chronic Illness Care. s.l. : Health Council of Canada, 2010.

20. The Halton Region. The citizens' priorities. The Halton Region. [Online] August 8, 2011. [Cited: August 31, 2012.] http://www.halton.ca/UserFiles/Servers/Server_6/File/PDF/citizens_priorities/ActionPlan_Citizens_Priorities.pdf.

21. Health Quality Ontario. 2011 Quality improvement plans: An analysis for learning. Health Quality Ontario. s.l. : Health Quality Ontario, 2011.

22. MH CCAC. Strategy synergy - Finding the common thread. MH CCAC, Metamorphosis. s.l. : MH CCAC, 2011.

23. Ministry of Finance. Ministry of Finance. [Online] February 15, 2012. [Cited: August 31, 2012.] http://www.fin.gov.on.ca/en/reformcommission/chapters/summary.html.

24. Ministry of Health and Long-Term Care, Health System Accountability and Performance Division. Stocktake Summary and Action Items. s.l. : Ministry of Health and Long-Term Care, Health System Accountability and Performance Division, 2012.

25. Ontario Ministry of Finance. Chapter 5: Health. Ontario Ministry of Finance. [Online] February 15, 2012. [Cited: August 31, 2012.] http://www.fin.gov.on.ca/en/reformcommission/chapters/ch5.html.

26. RWS Advisory. Drummond vs. Duncan - Comparing Health Care REform in the Drummond report and the 2012 Ontario Budget. s.l. : RWS Advisory, 2012.

27. Solutions to Hospital and Long Term Care Demand Consultation Notes. Exploring Ideas to reduce hospital and long term use in the Mississauga Halton LHIN. s.l. : Solutions to Hospital and Long Term Care Demand Consultation Notes, 2012.

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28. Town of Oakville. Council's Strategic Plan and 2011-2014 Work Plan. s.l. : Town of Oakville, 2012.

29. United Way - Peel Region. Impact Investment Strategy Update. s.l. : United Way - Peel Region, 2012.

30. Barnes, S. How the social assistance program causes poor health. Wellesley Institute. [Online] November 24, 2011. [Cited: August 31, 2012.] http://www.wellesleyinstitute.com/housing.

31. —. Why Toronto's Rich and Poor are hospitalized for different reasons and what we can do about this. Wellesley Institute. [Online] June 7, 2012. [Cited: August 31, 2012.] http://www.wellesleyinstitute.com/news.

32. Homelessness and Health. Homelessness and Health in the Region of Peel: Evidence informed recommendations for a Peel Model of Service Delivery to a vulnerable population. s.l. : Homelessness and Health.

33. John Howard Society of Toronto's Housing Program. Effective, Just and Humane: A case for client centered collaboration. s.l. : John Howard Society of Toronto's Housing Program, 2012.

34. KPMG and OrgCode Consulting. Edmonton Homeless Commission. s.l. : KPMG and OrgCode Consulting, 2012.

35. Murphy, K., Glazier, R., Wang, X., Holton, E., Fazli, G., & Ho, M. Hospital Care for All: An equity report on differences in household income among patients at Toronto Central LHIN. s.l. : Centre for research on inner city health.

36. St. Michael's Hospital and the institute for Clinical Evaluative Sciences. Ontario Women's Health Equity Report. s.l. : St. Michael's Hospital and the institute for Clinical Evaluative Sciences, 2012.

37. The Randolph group. Peel Homelessness Health Strategy. s.l. : The Randolph group, 2012.

38. The University of British Columbia. Integrating Social Determinants of Health and Health Equity into Canadian Public Health Practice: Environmental Scan 2010. The University of British Columbia. [Online] April 19, 2011. [Cited: August 31, 2012.] http://read.chcm.ubc.ca/2011/04/19/integrating-social-determinants-of-health-and-health-equity-into-canadian-public-health-practice-environmental-scan-2010/.

39. Wellesley Institute. Housing plus income plus food = health. Wellesley Institute submission to UN food expert. Wellesley Institute. [Online] May 9, 2012. [Cited: August 31, 2012.] http://www.wellesleyinstitute.com/housing.

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40. Women's college Hospital - Equity and Community Advisory. Impacts of Changes to Interim Federal Health Program for Refugees. s.l. : Women's college Hospital - Equity and Community Advisory, 2012.

41. Baeumler, B. Bryan Baeumler talks about healthy foundations. Yourhome.ca. [Online] June 29, 2012. [Cited: August 31, 2012.] http://www.yourhome.ca/homes/article/1218751.

42. Commisso, C. The faces of Halton's Housing Gap. p1. s.l. : The faces of Halton's Housing Gap, 2012.

43. Community Networks of Specialized Care. Complex Case Planning: Dual Diagnosis. s.l. : Community Networks of Specialized Care.

44. Homelessness Partnering Initiatives Sub-committee. Recommendations from the HPI Sub-committee Planning Session held on September 8, 2011. s.l. : Homelessness Partnering Initiatives Sub-committee, 2011.

45. The Evolution of Collaborative Mental Health Care in Canada: A Shared Vision for the Future. Kates, N., Mazowita, G., Lemire, F., Jayabarathan, A., Bland, R., Selby, P., et al. 2010, The Canadian Journal of Psychiatry, pp. Vol 56, No 5, 1-10.

46. Mental Health Commission of Canada. Changing Direction. s.l. : Mental Health Commission of Canada, 2012.

47. Ontario Mental Health and Addictions Strategy Advisory Group. Ontario Mental Health and Addictions Strategy - System Design Theme Group Paper. s.l. : Ontario Mental Health and Addictions Strategy Advisory Group.

48. Improving Canadian health care. Adolph, R. 2011, CMA Magazine, pp. 20-23.

49. Canada, Health Council of. Seniors in Need, Caregivers in Distress: What are the home care priorities for seniors in Canada? s.l. : Health Council of Canada, 2012.

50. Health Council of Canada. Progress report 2012: Health care renewal in Canada. s.l. : Health Council of Canada, 2012.

51. Cosgrove, D., Fisher, M., Gabow, P., Gottlieb, G., Halvorson, G., James, B., et al. A CEO Checklist for High-Value Health Care. s.l. : Institute of Medicine of The National Academies, 2012.

52. Panel, Long Term Care Innovation Expert. Why Not Now? A bold 5 year strategy for innovating Ontario's system of care for older adults. s.l. : Long Term Care Innovation Expert Panel, 2012.

53. NORTHSTAR. A novel nurse practitioner acute care model in the community for Canada's current and future aging population. s.l. : NORTHSTAR, 2012.

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54. The Change Foundation. Loud & Clear: Seniors and Caregivers speak out about navigating Ontario's health system. s.l. : The Change Foundation, 2012.

55. Health Quality Ontario. 2011 Quality improvement plans: An analysis for learning. s.l. : Health Quality Ontario, 2011.

56. MH CCAC, Metamorphosis. Strategy synergy - Finding the common thread. s.l. : MH CCAC, Metamorphosis, 2011.

57. Ministry of Finance. Ministry of Finance. http://www.fin.gov.on.ca/en/reformcommission/chapters/summary.html. [Online] February 15, 2012. [Cited: August 31, 2012.] http://www.fin.gov.on.ca/en/reformcommission/chapters/summary.html.

58. Ministry of Health and Long-Term Care, Health System Accountability and Performance Division. Stocktake Summary and Action Items. s.l. : Ministry of Health and Long-Term Care, Health System Accountability and Performance Division, 2012.

59. Ontario Ministry of Finance. Chapter 5: Health. Ontario Ministry of Finance. [Online] February 15, 2012. [Cited: August 31, 2012.] http://www.fin.gov.on.ca/en/reformcommission/chapters/ch5.html.

60. RWS Advisory. Drummond vs. Duncan - Comparing Health Care REform in the Drummond report and the 2012 Ontario Budget. s.l. : RWS Advisory, 2012.

61. Solutions to Hospital and Long Term Care Demand Consultation Notes. Exploring Ideas to reduce hospital and long term use in the Mississauga Halton LHIN. s.l. : Solutions to Hospital and Long Term Care Demand Consultation Notes, 2012.

62. The citizens' priorities. The citizens' priorities. The Halton Region. [Online] August 8, 2011. [Cited: August 31, 2012.] http://www.halton.ca/UserFiles/Servers/Server_6/File/PDF/citizens_priorities/ActionPlan_Citizens_Priorities.pdf.

63. Town of Oakville. Council's Strategic Plan and 2011-2014 Work Plan. s.l. : Town of Oakville.

64. United Way - Peel Region. Impact Investment Strategy Update. s.l. : United Way - Peel Region, 2012.

65. Ball, T., & Sekaly, G. What's Changing? Discovering your system's shared reality & shared vision. s.l. : Managing Change, 2006.

66. Health Council of Canada. Turning what we know into action: A commentary on the National Symposium of Patient Engagement. s.l. : Health Council of Canada, 2012.

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67. The Change Foundation. Integration of Care: The perspectives of Home and Community Providers. s.l. : The Change Foundation, 2011.

68. —. Winning Conditions to improve patient experiences: integrated healthcare in Ontario. s.l. : The Change Foundation, 2011.

69. Bierman, A. S. Avoidable Emergency Room visits, Hospital Admissions, and Readmissions in Ontario. s.l. : Project for an Ontario Women's Health Evidence-Based Report, 2010.

70. House Calls - RNs play a pivotal role in helping seniors stay at home for as long as they can. Burke, J.-M. 2009, Registered Nurse Journal, pp. 20-22.

71. Dr. Baker, R. G. Enhancing the Continuum of Care: Report of the Avoidable Hospitalization Advisory Panel. 2011.

72. Jaakkimainen, L. Primary Care and Chronic Disease Management. s.l. : Institute for Clinical Evaluative Sciences, 2010.

73. Wodchis, W., Camacho, X., Dhalla, I., Guttman, A., Lin, E., & Anderson, G. What can we work on? s.l. : Health System performance Research Network.

74. Complex diseases -Innovative solutions. Pirisi, A. 2012, UofT Medecine, pp. 14-17.

75. Health Analytics Branch, Ministry of Health and Long Term Care. Palliative Care in Ontario. April 2012.

76. Olshansky, S. J. Ph.D., et al., et al. A potential decline in life expectancy in the United States in the 21st Century. s.l. : New England Journal of Medecine, 2005.

77. The first 2,000 days of life. Kaye, M. 2012, UofT Medecine, pp. 8-12.

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