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Toronto Central CCAC’s 2014-2015 Quality Improvement Plan

One step closer to our vision of

‘Outstanding care - every person, every day’

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Introducing the Toronto Central CCAC Quality Improvement Plan for 2014-2015

Toronto Central CCAC is pleased to introduce our 2014-2015 Quality Improvement Plan (QIP).

The QIP is one of the many ways our CCAC demonstrates how we are moving forward on the

goals of our Strategic Plan for quality improvement. On our website, we have a range of

information for the public on CCAC performance measures and quality improvement including

our Strategic Plan, Annual Reports, and Accountability Agreement with the Toronto Central

LHIN, long-term care waitlists, and Strategic Plan measures. In addition, there is external

information on our CCAC’s performance in the Ontario CCAC Sector Annual Quality Report and

on the home care reporting page of Health Quality Ontario.

Two years ago, the Toronto Central CCAC launched a new strategic plan centered wholly on

improving the quality of care we deliver to clients and caregivers. Our 2012-2016 Strategic Plan

called ‘Opening our hearts, opening our minds’ was designed to help us see the endless

possibilities for driving quality and client experience to the highest possible level, in keeping with

our definition of quality*.

We launched our Strategic Plan with four goals:

1. We will relentlessly pursue every option to deliver what is most

important to every client.

2. We will support our clients to live the fullest and healthiest lives

possible.

3. We will unleash the potential of our people.

4. We will drive the highest possible care integration for our client

populations who need it the most.

Through every year of our strategic plan, we get closer to achieving

these goals, and our QIP is one of the ways we can report our

progress.

The Toronto Central CCAC Strategic Plan and Quality Improvement Plan reflect a time of

unprecedented challenges facing Ontario’s health system. The global economic crisis is forcing

governments to scrutinize public sector spending and change how public services are delivered.

There has never been a greater need to find the most cost-effective way to deliver health care

services and to creatively achieve this goal by improving quality at every level. It was these

challenges that inspired the Ontario Government to create the Excellent Care for All Act (2010),

designed to hold health care providers accountable for creating a positive patient experience,

for delivering high quality health care, and for publishing annual Quality Improvement Plans that

commit organizations to make specific improvements. The Toronto Central CCAC believes that

improving the quality of care and the patient experience is our health care system’s top priority

and we are pleased to share how we are contributing to that priority in 2014-2015.

*At Toronto Central

CCAC, quality means

coming to work every

day to make things

better…

better for our clients,

better for our

caregivers, better for

our partners, and

better for each other.

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The Focus of our Quality Improvement Plan for 2014-2015

The Toronto Central CCAC has three areas of focus for targeted improvement in quality for the

year. The first is client experience, the second is to reduce wait times for our clients with the

most complex health issues, and the third is to reduce falls. These three priorities align with

three of the quality dimensions of the Quality Improvement process – client centered care,

access, and safety and also are directly related to the following Toronto Central CCAC strategic

plan goals:

We will relentlessly pursue every option to deliver what is most important to every client

A positive Client Experience (client centered care) Reducing wait times for our clients with the most complex health issues (access)

We will support our clients to live the fullest and healthiest lives possible.

Reducing falls (safety)

The Toronto Central CCAC is working with our 20+ contracted service provider partners to

make sure that their quality improvement priorities for 2014/15 align with ours. By working

together on the same priorities for quality improvement, CCACs and our service providers will

be better able to improve our performance in these areas. By July 1, 2014, all of our service

providers will be required to report to us how they will support our quality improvement priorities.

Improving Client Experience

Improving the experience of our clients and caregivers is at the heart of our strategic plan. The

Toronto Central CCAC has developed an evidence-based approach to improve the care

experience of the clients and families we serve.

The 14 CCACs use a common telephone-based patient and caregiver experience evaluation

administered by NRC Canada, which enables us to compare client experience results across

the province. Early results our first survey four years ago showed

Toronto Central CCAC lagged behind other CCACs. We took a

serious look at what was driving our results and how we could do

better. Analysis of client feedback showed that we needed to improve

our communications with clients and families, including: listening to

and understanding what’s most important to them; delivering care

with courtesy and respect; and being informed and up-to-date on their

care needs.

The following is key information about our most recent survey:

1802 clients surveyed in 2012/13

Response rate for the survey is 24.3%

“Talk to me to find

out what’s most

important.”

Toronto Central

CCAC Client

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Clients were surveyed in 8 different languages (the 8 most common languages spoken

in the City of Toronto)

The overall client experience rating reported in the QIP is based on a summary of the following

three survey questions:

Overall how would you rate the services that you received from the CCAC and any of the

individuals who provided care to you?

Overall, how would you rate the management and handling of your care by the CCAC?

Overall how would you rate the (nursing, personal care or rehabilitation therapy)

provided by the service provider organization?

The survey reflects an overall positive experience (meaning a rating of good, very good or

excellent) on these three questions. Comparative results for ‘overall experience’ for all 14

CCACs are reported by Health Quality Ontario.

Over the last three years, we have seen improvement in our client experience survey results. By

2013/14, Toronto Central CCAC had moved up to the provincial average.

Indicator Year

1

Year

2

Year

3

Year

4

Provincial

Avg Year 4

Overall Experience 85% 88% 86% 93% 93%

In 2014/15, we will continue our efforts to support a better client experience. We are pleased

with the client experience results we’ve achieved and want to see these results maintained over

time. Given the effort it has taken to improve our client survey results and the effort it will take to

maintain over time, it is our goal to continue delivering a client experience score of at least 90%

of our clients reporting a positive experience with our CCAC.

Reducing wait times for our clients with the most complex health issues

Access is an important measure of health care quality and timely access to services is very

important to clients. There are different ways to measure access, including waiting lists and wait

times. Toronto Central CCAC does not have waiting lists for services, but we do measure our

performance for wait times.

For clients who are living at home and call the Toronto Central CCAC because they need home

care, the time they wait for services to start has been going down, with a median wait time to

first service dropping from 11 days in 2011 to 6 days in 2013 for all clients. We continue to make

improvements for people to get the care they need as quickly as possible.

In February 2013, the Premier of Ontario announced a provincial budget commitment to further

reduce CCAC wait times for clients receiving nursing care and for clients with complex* care

needs receiving personal support services, with a goal of having services start within 5 days.

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For 2014/15, the Toronto Central CCAC has targets for:

- TBD% of all clients who need nursing care to receive it within 5 days (from the time that

the CCAC made arrangements for the care to be delivered); and

- TBD% of all clients with complex* care needs requiring personal support to receive it

within 5 days (from the time that the service was authorized by the CCAC).

(TBD – expected confirmation of results by Ministry of Health and Long-Term Care in April 2014)

Over the next two years, the 5-day wait time target will expand to other populations of clients

served by the CCAC. Although this is the first time that Toronto Central CCAC has set public

targets for wait times, ensuring access to care has been an area of our focus for several years.

It is our goal to improve the full experience through the client’s eyes, from the time they first

contact the CCAC, to the time we have a conversation with them about their care needs, to the

time that a service provider visits them in their home. We have made improvements in our call

centre and are making additional changes to our intake process for newly referred clients. We

will be working with our service providers to ensure that access continues to be a priority and

clients who need care the most get access as soon as possible. Our activities this year will

include improving how quickly CCAC staff see newly referred clients and ensuring our service

providers set up first visits as quickly as possible according to the needs and wishes of our

clients.

(* A client with ‘complex’ care needs can be described as someone who has one or more health/chronic health conditions who

requires high levels of care coordination, whose health status may be unstable and unpredictable, and who is unable to manage

their care on their own. In other words, their need for care is higher and more urgent than may be experienced by other types of

clients. There is a common definition used by all CCACs to determine if a person’s needs are ‘complex’.)

Reducing Falls

For the last 5 years, Toronto Central CCAC has been concerned that as we see clients who are

more complex and have multiple chronic health conditions, our clients are reporting a higher

rate of falls year over year. Falls are a leading cause of emergency department visits and

hospitalizations for frail seniors. Falls at home are self-reported by patients and are documented

by CCAC Care Coordinators using our standardized assessment tool, the RAI-HC (Resident

Assessment Instrument – Home Care).

Our CCAC is doing research to understand how to best target our falls prevention programs to

support the client populations that would benefit the most. In 2013/14, we launched a test

project to provide education on falls prevention and also expanded our physiotherapy services

with additional funds provided by the Ministry of Health and Long-Term Care.

In 2014/15, we will be expanding our falls prevention program and focusing on clients who have

already reported that they have fallen at least once and are therefore at higher risk of having a

second fall. 2014/15 will be the first year that we collect data on falls prevention for this specific

population. Using the data we collect this year, we will be able to set an improvement goal and

target for 2015/16. All of this work is in addition to our regular activities to help prevent falls for

all clients who are potentially at risk.

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Emergency Department Visits and Hospital Readmissions for CCAC Clients

The Ministry of Health and Long-Term Care and Health Quality Ontario have access to hospital

data that allows them to report on two important measures of health system performance, (1)

Emergency Department visits and (2) hospital admissions (and readmissions) for every

Ontarian, including those receiving CCAC services. As much as possible, CCACs should be

reducing unnecessary Emergency Department (ED) visits and hospital admissions by ensuring

that our clients receive the right care at the right time. While it is not always possible to prevent

a hospital visit, our goal is to make sure that we are able to support clients to stay at home as

long as possible. Up until very recently, Toronto Central CCAC, like most other CCACs, did not

have access to hospital data that would allow us to know when our clients accessed hospital

services.

In 2013/14, our CCAC worked with the Toronto Central LHIN to launch a LHIN-wide data

reporting system that includes hospital and CCAC data as well as data from community support

services and primary care. This new system means that starting in 2014/15, Toronto Central

CCAC will have regular access to information about the care our clients receive from other

organizations, including knowing when our clients are admitted to hospitals or receive care in

emergency departments. Having this information will help us to set targets for reducing hospital

admissions and emergency department visits for our clients in the next 1-2 years.

In the meantime, until we have access to data to measure our progress, Toronto Central CCAC

is working closely with partners on the integration strategy described in the next section, to

provide more coordinated and integrated care to support our clients with the most complex/high

needs health conditions. These are the clients who are most at risk of needing to visit

Emergency Departments or be readmitted to hospital for care.

Integration and Continuity of Care

We know that clients and caregivers interact with many different

service providers and organizations, and that at times the health

care system can seem complicated and fragmented. As health care

providers, we must create an environment where our clients see

and experience a single health care team, working together with

them, communicating effectively with each other, and ensuring that

every client receives the care they need, when they need it. For our

most complex and vulnerable clients, the gap they experience

between their primary care, hospital and community care teams

can lead to higher safety risks and poorer health outcomes. For our

system, it often means frequent emergency department visits and

hospitalizations that are avoidable and unsustainable.

This is why Toronto Central CCAC has made one of our strategic

plan goals to ‘drive the highest possible care integration for our

“I meet with [ICCP Care

Coordinator] every two

weeks or so. She is very

thorough and she does

everything she says she’ll

do. [She is available]

anytime. I phone her

about everything. She

arranged for the hospital.

Oh, yes [she speaks with

my doctor]. This is the first

time the doctor ever came

to my home.”

- Toronto Central

Integrated Care Client

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client populations who need it the most’. Click here to learn more about our strategy for

integrating care for complex populations.

Risks and Challenges

The 2012-2016 Strategic Plan and 2014/15 Operational Plan, both of which are the basis for our

2014/2015 Quality Improvement Plan, were developed with extensive consultation from the

clients and communities we serve, service delivery partners as well as CCAC staff, leadership

and the Board of Directors. The commitments and targets in this QIP have been shared with

staff, service providers, leadership and Board members. Ongoing progress towards our QIP

commitments and targets will be communicated to all key stakeholders. Each team in the

organization has their own work plan and targets that align with the Strategic Plan, Operational

Plan, and Quality Improvement Plan and they are accountable for achieving the performance

results. Although Toronto Central CCAC leadership is confident that we will be able to achieve

the targets and goals in our QIP, we anticipate some risks and challenges this year, including:

1) Increasing complexity and needs of the people we serve – Ontario serves one of the

highest need/highest complexity home care populations in the world. Many people who

previously would have received care in hospitals or long-term care are now being

supported at home by the CCACs. With substantial change and development facing the

health system, we anticipate that 2014/15 will bring even greater demands on the CCAC

including supporting more clients in the community as we continue to focus on reducing

hospital stays and reducing the number of people moving to long-term care.

2) Increasing demands on the CCAC – Over the last few years, we have seen the roles,

services, and expectations of CCACs expanding. This includes delivering Health Care

Connect, which is a program of the Ministry of Health and Long-Term for helping find

family doctors for patients, as well as adding new nursing programs for palliative care,

clients who need acute care support after a hospital discharge, telehome care, and

mental health and addictions support for children in schools. Most recently, the

government asked us to take on the responsibility for delivering physiotherapy in

retirement homes and other group living environments. While the CCAC has

successfully delivered on all its new commitments, the additional responsibilities also

place pressures on our resources and our people. We anticipate that changes in the

health system will bring even greater demands and expectations of the CCAC in

2014/15 and beyond.

3) Funding pressures – In the last 3 years, Toronto Central CCAC has had a 29% growth in

the number of our highest complexity/highest need client groups. While we have

received annual funding increases from our Local Health Integration Network, the

pressures of the changing client needs has meant that the CCAC has to find more

innovative ways to improve our operations and care delivery in order to balance our

budget by year end. There are limitations to this strategy and we are concerned about

our capacity to keep pace with the growth in number and complexity of our client

population.

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We were successful last year in balancing our budget by year end by implementing several

financial management strategies. However, the financial pressures will continue into 2014/15.

Information management

The CCACs in Ontario are one of the only health care sectors that benefit from a fully electronic

shared health record for all our clients. We also share a common assessment tool, the RAI-HC

that standardizes how we evaluate the needs of our clients. Toronto Central CCAC uses these

information sources as well as client feedback and safety reporting, to inform a comprehensive

reporting system that helps us better understand the needs of our clients, perform advanced

planning, evaluate our performance, and set improvement goals.

Accountability for Quality Improvement

Each year, the Toronto Central CCAC Board of Directors establishes performance goals and a

performance evaluation for the CEO. This performance plan includes goals and targets for

quality improvement. The goals and targets in the QIP are included as part of the overall

performance plan for the CEO. For overall performance, 6% of the CEO’s salary is held back

(called “pay-at-risk”) if certain performance targets are not met, and an additional 6% of the

CEO’s pay is dependent on specific quality goals being achieved.

In addition to the QIP, the Board of Directors produces an Annual Report to the community that

highlights performance results and quality improvement activities of the CCAC. The Board’s

Client Service and Quality Committee is responsible for oversight of client experience, client

safety, and quality of care. It fulfills this role by setting annual improvement goals for quality,

reviewing regular reports of CCAC performance metrics and targets, reviewing client experience

survey results and action plans, and monitoring the rates of client safety and quality incidents.

Sign-off I have reviewed and approved our organization’s Quality Improvement Plan ____________________________________ William Yetman Chair, Board of Directors ___________________________________

Myra Libenson

Chair, Client Service and Quality Committee _____________________________________ Stacey Daub, Chief Executive Officer

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Community Care Access Centre Quality Improvement Plan

Quality dimension Objective Measure/IndicatorCurrent

performance

Target for

2014/15Target justification

Planned improvement initiatives

(Change Ideas)

Methods and process

measures

Goal for change

ideas (2014/15)Comments

Falls for Long-Stay Clients: Percentage of adult long-stay home

care cl ients who record a fa l l on their fol low-up RAI-HC

assessment

32.4% - TC CCAC is

developing a loca l

fa l l s measure to

assess the impact

of our fa l l s

reduction program

– see measure

below

1) The TC-CCAC wi l l launch a fa l l s

reduction plan targeted at cl ients

who are the highest ri sk for fa l l s

Completion of the

fa l l s reduction plan

31-Mar-15

1) The TC-CCAC wi l l develop a fa l l s

prevention education/intervention

program

Number of front-l ine

s taff tra ined in fa l l s

prevention

100%

2) The TC-CCAC wi l l launch this fa l l s

reduction plan to a l l adult long-stay

home care cl ients who report a

previous fa l l

Number of cl ients who

record a fa l l on the

RAI-HC who receive

fa l l s education

100%

To reduce the

number of

unplanned ED

vis i ts among

home care

cl ients

Unplanned Emergency Department Visits: Percentage of home

care cl ients with an unplanned, less -urgent ED vis i t within

the fi rs t 30 days of discharge from hospita l

4.4% NA Aiming to review

current

performance and

develop targets in

2014/15

1) Further develop data col lection

and reporting mechanisms

Completion targeted

for this fi sca l year

31-Mar-15

To reduce

avoidable

hospita l

admiss ions

among home

care cl ients

Hospital Readmissions: Percentage of home care cl ients who

experienced an unplanned readmiss ion to hospita l within

30 days of discharge from hospita l

15.1% NA Aiming to review

current

performance and

develop targets in

2014/15

1) Further develop data col lection

and reporting mechanisms

Completion targeted

for this fi sca l year

31-Mar-15

1) Investigation of Nurs ing services

that fa l l outs ide the target service

range (outl iers )

Review those cl ient

cases that do not

meet the target to

identi fy service

barriers

90% of outl ier

cases reviewed

2) Measure percent of Nurs ing

services del ivered outs ide target

range that are due to patient

preference

Percent of cl ients

requesting nurs ing

service begin outs ide

target range

90% of outl ier

cases reviewed

3) Develop processes to measure

time between referra l and Care

Coordinator assessment

Process development

completed during this

fi sca l year

31-Mar-15

1) Investigation of PSW services for

complex cl ients that fa l l outs ide the

target service range (outl iers )

Review those cl ient

cases that do not

meet the target to

identi fy service

barriers

90% of outl ier

cases reviewed

2) Measure percent of PSW services

for complex cl ients del ivered

outs ide target range that are due to

patient preference

Percent of cl ient

requesting PSW

service begin outs ide

target range

90% of outl ier

cases reviewed

3) Develop processes to measure

time between referra l and Care

Coordinator assessment

Process development

completed during this

fi sca l year

31-Mar-15

Number of front-l ine

s taff tra ined in

Changing the

Conversation

100%

Percent of cl ients who

report that we

understand what i s

most important to

them, out of a l l

cl ients surveyed in the

CTC phone survey

90%

2) Implement a new cl ient

experience tra ining video with a l l

front-l ine CCAC and Service Provider

s taff

Number of front-l ine

s taff tra ined

100%

CHANGE

To reduce fa l l s

among long-stay

home care

cl ients

Repeat Falls for Long-Stay Clients: Percentage of adult long-

stay home care cl ients who report a repeat fa l l a fter

receiving fa l l s education/intervention, out of a l l adult long-

stay cl ient who have reported a fa l l

To be collected in

2014/15

NA Aiming to measure

current

performance and

develop

improvement

targets for 2015/16

Our CCAC has conducted

research to understand

how to best target our fa l l s

prevention programs to

support the cl ient

populations that would

benefi t the most. We have

developed an intervention

program and wi l l be rol l ing

i t out in 2014/15.

>90% Aiming to

mainta in our

cl ient experience

rating at an A+

(90% or higher)

92.6% 1) Implement Changing the

Conversation with a l l front-l ine s taff

Five-Day Wait Time for Home Care: Nurs ing Services

2014/15

Safety

AIM MEASURE

Effectiveness

TBD with

information from

the Ministry

TBD with

information from

the Ministry

TBD with

information from

the Ministry

Client-centered

To reduce service

wait times

Client Experience: Percent of home care cl ients who

responded “Good”, “Very Good”, or “Excel lent” on a five-

point sca le to any of the fol lowing cl ient experience survey

questions

• Overa l l rating of CCAC services

• Overa l l rating of management/handl ing of care by Care

Coordinator

• Overa l l rating of service provided by service provider

To improve cl ient

experience

Access

Five-Day Wait Time for Home Care: Personal Support Services

for complex cl ients

In 2013/14, our CCAC worked

with the Toronto Centra l

LHIN to enable access to

information about ED vis i ts

and hospita l readmiss ions .

In 2014/15 we wi l l use this

information to measure

current performance and

set targets for reducing

hospita l admiss ions and

emergency department

vis i ts for our cl ients .

TBD with

information from

the Ministry

TBD with

information from

the Ministry

TBD with

information from

the Ministry

It i s our goal to improve the

ful l experience of access to

home care services through

the cl ient’s eyes , from the

time they fi rs t contact the

CCAC, to the time we have a

conversation with them

about their care needs , to

the time that a service

provider vis i ts them in their

home.

In 2014/15, we wi l l

continue our efforts to

mainta in our cl ient

satis faction results over

time.

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Using Evidence to Improve Client Experience

Toronto Central CCAC delivers care in partnership with over 20 community agencies which

have contracts with the CCAC. Care delivery is provided by hundreds of home care staff (care

coordinators, nurses, physiotherapists, personal support workers, social workers, and others)

who work for different organizations. Our challenge was to take our client experience feedback

and then figure out how to implement a change that would provide a higher and more consistent

level of client experience, regardless of which staff member provided care or who they worked

for.

Building a culture of care that is focused on understanding what is most important to the people

we serve involves many steps. It started with shifting our model of care to focus on the different

populations1 of clients we serve and aligning our staff teams to better support those populations.

Delivering care by client population enabled our Care Coordination teams to better develop their

skills and knowledge of the care needs of the people they serve.

In addition, using the results from our client experience survey, we have worked with hundreds

of front-line staff across all our community partners on an improved approach to client

communication called "Changing the Conversation". Following a pilot with clients in our end-of-

life program, we are building a culture of care that is shifting from 'task first to 'talk first’,

including listening and understanding what's most important to the people we serve and then

working with them to deliver care based on that.

Another change we have made in 2013/14 was to introduce 102 neighbourhood care teams, in

which teams of home care workers are assigned to deliver care to clients in high density

apartment buildings or neighbourhoods. The goal is to improve continuity of care and

communication between clients and members of the CCAC care team.

Wait lists versus Wait times

Wait lists (when people wait for the service they need because it is unavailable either because

of funding issues or human resource shortages) are different from wait times (the time that

clients wait between being referred to the CCAC for services and when services actually start).

Toronto Central CCAC does not have wait lists for any of our services. However, in some

cases, clients with less urgent care needs may wait longer for their services to start.

1 Examples of our client populations include children with complex medical care needs, seniors whose health is

severely compromised, adults with complex and chronic health issues, persons requiring care for mental health, short-term acute care or rehabilitation following a hospital stay, and end-of-life care.

2

Understand falls

Using research data from researchers at the University of Waterloo, we know that as we serve

clients with more complex health care issues at home, these clients have a higher likelihood of

experiencing a fall. When we adjust the rate of falls to take into consideration the increasing

medical complexity of our clients, we see that the rate of falls is relatively stable. This means

that the increasing rate of falls is correlated with the increasing complexity of our clients and

their health needs. Comparisons to other jurisdictions show that Toronto Central CCAC

supports one of the home care client populations with the highest, most complex care needs

anywhere in the world. Clients with complex care needs are often sicker, frailer, have multiple

chronic health issues, and are taking more medications as compared to other home care clients

– all of these issues contribute to a higher risk of instability and falls. And as we serve more of

these clients, we can expect a higher rate of falls to happen at home.

Toronto Central CCAC’s Integrated Care for Complex Populations

This part of our strategy includes providing intensive care coordination for clients with complex

needs that coordinates care at every step through the health system. It also means that the

CCAC recognizes that we are only one part of a client’s care team – and that to be effective,

home care must be integrated with primary care, community support services, hospital care and

other health and community services.

Over the last few years, the CCAC has been building better relationships with family doctors in

primary care practices across the city. Our team of advanced practice nurses, care

coordinators, pharmacists, and partner service providers work in integrated teams to provide

wrap-around care to support our clients with the most complex care needs. All of our highest

needs clients now also have an Emergency Department Transfer Package, that is known to

EMS staff and which ensures that each client’s essential medical history accompanies them

when they need to return to the hospital. Our integration strategy for working closer with primary

care was a proto-type for the introduction of Health Links by the Government of Ontario in the

fall of 2012. Last year we introduced Rapid Response Nurses to the integrated care team

supporting our clients with the most complex care needs. Their role is to visit our highest need

clients within 24 hours of their discharge from hospital, confirm they are taking the right

medications, and ensure that they have a visit to their family doctor booked within a week.

In 2014/15, the Toronto Central CCAC will continue to expand our primary care integration

strategy by creating relationships with more primary care practices and by working with the

expanding Health Links to increase capacity to serve the highest needs clients. In 2014/15,

Toronto Central CCAC will also lead the development of the West Toronto Health Link, which is

in an area of the city that is underserved by primary care and other services as compared to

other communities.