South East Local Health Integration Network Transforming Addictions

South East Local Health Integration Network Transforming Addictions and Mental Health Services to Better Serve Our Residents South East LHIN Board Meeting: AMH Redesign, Pre-Reading December 16, 2013

Table of Contents Slide Purpose of this Presentation 3 Agenda 7 Introduction and Objectives 9 Case for Change: Why are we doing this? 11 Vision, System Outcome Goals and Criteria for Evaluation 24 Principles, Individual Experience (including Service Features) and Elements of the Redesign 39 Governance Structures for Integration 54 Redesign Options 63 Next Steps 84 Appendix A: Stakeholder Feedback - Appendix B: Literature Review - Appendix C: Project Plan - Appendix D: Visioning Session Summary Report - Appendix E: Communiqués - Appendix F: Frequently Asked Questions 2

Purpose of this Presentation • The South East Local Health Integration Network (SE LHIN) has been collaborating with the 22 Addiction and Mental Health (AMH) providers to redesign the AMH sector. • For the last seven months, the Redesign Task Force (12 nominated individuals representing AMH agencies, Executive Directors, front-line staff, psychiatrists and a consumer representative) have been focused on redesigning the current AMH sector and tasked with creating options to create a system. • A system where we plan, work and collaborate together to meet the needs of the residents of the South East region. • This presentation provides details on the ‘case for change’, the features and elements of the new AMH system and three governance options. 3

Purpose of this Presentation Reminder of the LHIN’s Role • As per the Local Health System Integration Act, 2006, the LHIN’s objects are (section 5): • To promote the integration of the local health system to provide appropriate, coordinated, effective and efficient health services; • To engage the community of persons and entities involved with the local health system in planning and setting priorities for that system, including establishing formal channels for community input and consultation; • To ensure that there appropriate processes within the local health system to respond to concerns that people raise about the services that they receive; • To develop strategies and to co-operate with health service providers, including academic health science centres, other local health integration networks, providers of provincial services and others to improve the integration of the provincial and local health systems and the co-ordination of health services; • To bring economic efficiencies to the delivery of health services and to make the health system more sustainable; 4

Purpose of this Presentation Expectations of the LHIN Board - Today: • The SE LHIN Board is asked to review and consider the documentation provided today and to ask questions on the ‘case for change’, the Redesign process, the Individual Experience, elements, the governance options and the stakeholder engagement processes. • On April 23 2013, the LHIN Board confirmed that the status quo is not an option • At the June 2013 Visioning Day Session, the South East LHIN Project Team guaranteed its commitment to act to transform the system to meet the needs of clients and patients. • SE LHIN governors are asked to focus on the client feedback for the ‘case for change’ and to consider the impact on residents if we don’t transform the AMH sector. • At this stage, the SE LHIN Board is NOT being asked to recommend a governance option. A commitment has been made that there will be further engagement of AMH governors and administrators. 5

Purpose of this Presentation Expectations of the LHIN Board - February January and February 2014: • An opportunity for questions and clarification will be included on the agenda at the January Board meeting. • A final presentation and opportunity for questions will be included on the agenda at the February Board meeting. • The SE LHIN Board will be asked to provide a decision on the options for governance at that time. • Implementation planning will commence in March 2014. 6

Agenda

Agenda 1. 0 Introduction and Objectives 3. 0 Overview of the AMH Redesign Case for Change Vision, System Outcome Goals and Criteria for Evaluation Principles, Individual Experience and Elements of the Redesign Discussion Governance Structures for Integration Discussion 4. 0 Redesign Options Discussion 5. 0 Next Steps 2. 0 Paul Huras 9: 45 – 10. 00 Sherry Kennedy/ Jennifer Payton 10: 00 – 11: 00 KPMG 11: 00 – 11: 30 KPMG 11: 30 – 12: 30 Sherry Kennedy 12: 30 – 12: 45 8

Introduction and Objectives

Introduction and Objectives: • To obtain a full understanding of the ‘Case for Change’, Vision, Individual Experience, Elements and Governance Options • To understand the role of the LHIN and Governors and the decision required (and when) • To understand the next steps in the process and provide advice as to any additional information the LHIN Board may require in order to make a decision in February, 2014 10

Case for Change: Why are we doing this?

Case for Change Summary The Client Experience: • Residents, clients/patients, providers and other stakeholders have said that while the care received has been very good, there remain multiple and recurring problems: • Duplication of services • Duplication of assessments • Difficulties in transitioning between providers • Difficulties in accessing services • Insufficient volume of services to satisfy demand • Stigma often faced in accessing services 12

Case for Change Summary Demographics and Rising Utilization: • The number of individuals requiring AMH services continues to increase. Given that we have to work within the resources we have available in the South East region, the impact of the increase in volume will put pressure on the existing capacity. • 72% increase in individuals treated for substance abuse (2007 to 2011) • 11% increase in volume of patients (2009 to 2011) • In 2011, the South East LHIN had the 3 rd highest rate for new referrals, 4 th highest number of individuals served, and the 3 rd highest inpatient/resident days in the province (per 1000 population). • The number of patients re-admitted to the hospital for either addictions or mental health related conditions continues to be very high. This indicator is a reflection on how well the system is (or is not) working for patients. • 18. 4 - 22. 5% re-admissions within 30 days for addictions related conditions from Q 2 2011 - Q 1 2013 • 17. 1 - 19. 7% re-admissions within 30 days for mental health related conditions for the same timeframe. 13

Case for Change Summary • By working together collaboratively across the system to standardize processes and tools, share resources, reduce duplication and increase knowledge of the services and programs that are available, we can increase capacity and reduce readmissions. • There is existing collaboration in the SE LHIN region. There is an opportunity to harness the momentum and collaboration for the purpose of a system wide redesign, to more effectively achieve improved outcomes. • Local leaders are in the right position to focus on the client/patient perspective and to create a system that meets the needs of the client/patient. • Globally, and within Canada, the literature and practices underscore the need for cooperation and collaboration at a system level between AMH providers. • AMH is a priority for the Ontario government. The SE LHIN is operationalizing this priority for the region’s residents which was highlighted in their Integrated Health Services Plan 3: Better Integration, Better Health Care. 14

Case for Change Clients have told us the system needs to change! “I feel lost when I am in the system, I don’t get told the information I need to know and the coordination between the hospital and community doesn’t exist. I was left with no support. ” “I would like more proactive care and there being more responsibility for people with Addiction and Mental Health. Stop “dumping” us. ” “No matter where you live, I would like everyone to have equal access to support. ” “There needs to be more access to services, to psychiatrists and to medication. We go to the ED as there is no other accessible service. ” 15

Case for Change Clinicians have told us the system needs to change! “Duplication and delay conditions for decreased quality of service exist NOW. The onus is on the client to have to do multiple consents, tell multiple stories, make sure all pieces are connected, navigate through the system themselves. ” Psychiatrist “By not having access to an integrated record of history, by having to wait for multiple consents to be signed, the patient is delayed in receiving treatment and/or of receiving treatments that have been tried before but have not previously worked”. - Psychiatrist “It’s not that the system is broken and we have to fix it, rather we do not have a system in the first place and need to create one. ” - Health Links Leads “A circle of service encompassing all is critical to ensure we have conditions to be successful versus the parallel system we have today” - Psychiatrist 16

Case for Change Clients have told us the system needs to change! Client Video: Note for pre-reading deck: If the video link does not work by clicking on the image above, please access the video through the following URL: http: //www. youtube. com/watch? v=Esv 037 Vtr_4&feature=youtu. be 17

Case for Change Clients have told us the system needs to change! • The South East LHIN has held a number of engagement sessions in 2012 and 2013 across the entire LHIN Region. These sessions have provided a rich source of evidence to inform the decision to redesign the AMH system. Session Who was engaged? Integrated Health Services Plan 2012 IHSP engagement incorporated CSR feedback and also included multiple stakeholder discussions over the period of approximately June to December 2012. Clinical Services Roadmap Public engagement took place from March to May 2011. Development of Project Plan: February 2013 Consumer Focus Group Session (12 individuals). Representatives were present from Belleville, Madoc, Picton, Trenton, Bancroft, Napanee and Kingston. Visioning Session: June 17 th 180 attendees, 40 of which were clients Mental Health Support Network South East Ontario Recovery Session: November 2013 Over 140 consumers were engaged on the individual experience AMH Redesign Survey: Closed November 2013 Completed by 49 Patients/Clients and 31 Family Members or Caregivers Validation Session: December 2 nd 200 attendees, 30 -40 of which were clients 18

Case for Change Clients have told us the system needs to change! Consistent areas for improvement were identified in: • Access to care (e. g. lack of 24 hour access, inequitable access to psychiatric care based on geography) • Inconsistencies between services • Multiple assessments and duplication • Transitions especially between hospital and community • Insufficient volumes of services • Stigma often faced in accessing AMH services, and in accessing other health services. These areas for improvement have also been confirmed by: • Psychiatrists • Executive Directors • Front line staff • Physicians • Other sector partners, such as housing, children and youth services 19

Case for Change Clients have told us this before! • The areas for improvement noted earlier are consistent with those identified through multiple studies, task forces and engagements since 1999. Some items of note include: • 1999: Making It Happen • Recommended comprehensive continuum of care, streamlined access to services through a central referral, shared model of care, enhanced capacity through adoption of best practices, system accountability and responsibility • 2001: Berkeley Report • Recommended district (HPE) wide governance structure, one Consumer Survivor Initiative, common assessment and referral, specialty services managed districtwide but delivered locally, family network • 2002: South East Mental Health Implementation Task Force • The proposed model reflects a regional or district entity with 3 geographic councils with common baskets of services 20

Case for Change Clients have told us this before! • 2006: Out of the Shadows at Last: Transforming Mental Health, Mental Illness and Addiction Services in Canada • Recommended the need for a recovery-oriented system, development of a more responsive service, better integration of services, common basket of services available across the lifespan • 2009: Every Door Is the Right Door • The most recent Ministry document on Addictions and Mental Health reform • 2010: Select Committee on Mental Health and Addictions • Recommendations include the consolidation of Addictions and Mental Health programs and services, availability of a core basket of services, access to system navigators, reflection of importance of housing, support for families and caregivers. Clearly, we must stop planning and take action! 21

Case for Change We have tried to move forward on a number of initiatives but have been challenged • There is a regional network and the 22 AMH providers meet regularly. In total, there approximately 45 planning groups in the South East LHIN focused on a range of AMH issues • Local members have participated in planning since at least 1999 • There have been a number of sub-regional initiatives, spearheaded by community members and the LHIN • Our experience and the feedback we have heard is that these initiatives have been challenged by geographical restrictions, by current capacity, consensus building challenges, relationship challenges and a lack of accountability. Examples include: • Common access form (CSR) took 18 months to gain agreement and launch • Concurrent disorder study confirmed the opportunity for service improvement through building staff capacity but has taken 3. 5 years to move from study to recommendation with minimal implementation • Establishment of privacy and data sharing agreements in KFLA took over 12 months 22

Case for Change The Role of the LHIN • Residents have clearly identified a need for change • The data clearly indicates that the need for AMH services for the population will increase • High readmission rates for AMH clearly shows that the current status quo is not working for clients • Similar opportunities for improvement have been identified as early as 1999, but actions since then have obviously not delivered the desired improvement for clients or clinicians. • It behooves us as stewards of the South East local health care system to respond and to transform the AMH sector for clients/patients, families, providers and the residents of the LHIN. 23

Vision, System Outcome Goals and Criteria for Evaluation

Vision, System Outcome Goals and Criteria for Evaluation Overview • The next section provides an overview of the SE LHIN’s vision, the provincial government’s vision, our system outcome goals and draft evaluation criteria for the SE LHIN Board to use when considering the AMH governance option recommendation. 25

Vision, System Outcome Goals and Criteria for Evaluation Vision for the Addictions and Mental Health System Provincial Vision • An Ontario where every person enjoys good mental health and well-being throughout their lifetime, and where all Ontarians with mental illness or addictions can recover and participate in welcoming, supportive communities. (Open Minds, Healthy Minds, Ontario’s Comprehensive Addiction and Mental Health Strategy) South East LHIN Vision • Ensure patients receive the right care at the right time in the right place, enhance capacity of providers and the system, and reduce stigma. (South East LHIN Integrated Health Services Plan: Better Integration, Better Health Care, 20132016) 26

Vision, System Outcome Goals and Criteria for Evaluation Project Structure LHIN vision (aligns with Province and Providers) System Outcome Goals Phase Process Timing Ensure patients receive the right care at the right time in the right place, enhance capacity of providers and the system, and reduce stigma Access to equitable, consistent and quality care Improved patient experience The health of the population is improved Sustainability of the system PLAN REDESIGN IMPLEMENT Plan for the redesign of the Mental Health and Addiction sector Redesign of the Mental Health and Addiction sector Implementation of the redesigned Mental Health and Addiction System Develop Project Plan through review of existing work and stakeholder engagement (KPMG) South East LHIN and Mental Health and Addiction providers work collaboratively to redesign the sector using the Project Plan as guidance South East LHIN and Mental Health and Addiction providers work collaboratively to implement the new model for the system Complete by March 2013 Complete by February 2014 Implementation Plan Complete by June 2014 Implementation : FY 2014/15 - 2015/16 Transform from a Sector to a System where we plan, work and collaborate together for the purpose of our residents 27

Vision, System Outcome Goals and Criteria for Evaluation Project Structure 1. Visioning Phase 1 Phase 2 REDESIGN IMPLEMENT 2. Options Development 3. LHIN Board approval of redesign Model April –June 2013 1. Develop Implementation Plan for the redesign of the system 2. Implement redesign of the system February – June 2014 July November 2013 July 2014 – 2015/16 February 2014 Each Phase will be supported by the Project Plan 28

Vision, System Outcome Goals and Criteria for Evaluation Project Structure Redesign Task Force Members: • Cate Sutherland: ED, Addictions Centre • Michelle Murray: ED, Lennox & Addington Addiction and Community Mental Health Services • Laurie Dube: ED, Leeds and Grenville Mental Health • Linda Peever: Director of Mental Health, Brockville General Hospital • Mae Squires: Program Operational Director, Critical Care and Mental Health Programs, Kingston General Hospital • Karin Carmichael: Program Administrative Director, Providence Care • Dr. Susan Finch: Psychiatrist • Dr. O’Brien: Clinician • Garry Laws: Consumer • Lucille Zuikier: Consumer • John Ostrander: Tri County Addictions Services (Brockville) • Siobhan Andress: Frontenac Community Mental Health and Addiction Services • Dr. Roumen Milev: Psychiatrist 29

Vision, System Outcome Goals and Criteria for Evaluation Project Structure Expert Panel Members: • Ruby Brown: Principal, Mandala Management (former Chief Transition Office to realign mental health services within Alberta) • Janet Davidson: Deputy Minister of Health, Government of Alberta • Nick Kates: Acting Chair and Professor, Department of Psychiatry and Behavioural Neurosciences at Mc. Master University • Dr. Ken Le Clair: Professor and Chair of the Division of Geriatric Psychiatry at Queen’s University • Donna Rogers: ED, Four Counties Addiction Service Team 30

Vision, System Outcome Goals and Criteria for Evaluation Outcome Goals for the Future State System 1. Access to equitable, consistent and quality care across the South East LHIN 2. Improved patient experience - The system is reflective and responsive to the legitimate expectations and needs of the population 3. Health outcomes – The health of the Addiction and Mental Health population is improved 4. Sustainability of the system - Accountability at an organizational level shifts to accountability at a regional level 31

Vision, System Outcome Goals and Criteria for Evaluation How Will the Board Assess Governance Options? • The SE LHIN Board must ensure decisions are reflective of a balance of effective and efficient use of public resources and provide a high standard of service to the public. • Governance option evaluation criteria for each outcome goal was presented at the last Board meeting. • In response to feedback, this criteria has been defined and weighted to enable the Board to rank the governance options for consideration in February. • Note the criteria is ONLY to evaluate the governance options. The intention of the redesign is that regardless of the option chosen, the elements and the individual experience will be operationalized. • The South East LHIN Board will not be making a decision/recommendation today. 32

Vision, System Outcome Goals and Criteria for Evaluation LHIN Board Governance Option Evaluation Criteria System Outcome Goals Accessibility Patient Experience Health Outcomes Sustainability Access to equitable, consistent The system is reflective and The health of the Addictions and Accountability at an and quality care across the South responsive to the legitimate Mental Health population is organizational level shifts to East LHIN expectations and needs of the improved accountability at a regional level population Reducing or eliminating System responsiveness to Reduction in 30 -day repeat Improved capacity within the barriers to access (e. g. meet client needs at the Emergency Department visits system with the resources translation, transportation, initial point of contact with (both Addictions and Mental currently available (e. g. childcare etc. ) the sector Health clients) reducing duplication of Same basket of services Coordination of services and Reduction in 30 day readmits services, improving processes offered across the LHIN knowledge exchange among for Addictions and Mental and patient flow Standardized process for care/service providers Health issues improvement, etc. ) accessing services Client satisfaction with their Reduction in patients Accountability agreements Reduction in waitlist for journey to access system and designated as ALC due to include regional perspective Addictions and Mental Health with care provision challenging behaviours clients Reduction in stigma –social Reduction of unnecessary acceptability hospitalization related to lack Minimizing gaps in transition of service coordination or or issues with transition provision Reduction in crisis intervention needed for existing Addictions and Mental Health clients

Vision, System Outcome Goals and Criteria for Evaluation LHIN Board Governance Option Evaluation Criteria: Accessibility Criteria Accessibility 5 Point 3 Point 1 Point Access to equitable, consistent and quality care This option will reduce This option will or eliminate barriers to increase access have minimal or access but no impact in consistently across eliminating the region barriers to access This option will considerably simplify moderately feature minimal and standardize the simplify and simplification/ AMH system for clients standardize the standardization of AMH system for the system for clients This option will allow This option will us to offer significantly allow us to offer a more services closer to moderately more minimal number home services closer to of services closer home to home This option will allow us to provide equitable access to tertiary and specialty services across the region This option will allow us to provide moderately equitable access to tertiary and specialty services across the region This option will allow us to minimally provide equitable access to tertiary and specialty services across the region Weight 4 3 2 1 Score = Pts X Weight

Vision, System Outcome Goals and Criteria for Evaluation LHIN Board Governance Option Evaluation Criteria: Patient Experience Criteria 5 Point Patient Experience 3 Point 1 Point Weight The system is reflective and responsive to the legitimate expectations and needs of the population This option will considerably enhance the patient’s experience and satisfaction This option will considerably improve patient flow and allow us to work together to better refer patients, manage patients and transfer patients This option will somewhat enhance the patient’s experience and satisfaction This option will minimally enhance the patient’s experience and satisfaction This option will moderately This option will have a improve patient flow and minimal impact or no allow us to work together to impact on patient flow better refer patients, manage and allow us to work patients and transfer patients together to better refer patients, manage patients and transfer patients This option will moderately This option will minimally significantly allow for meeting management of the complex issues presented by clients complex issues presented by clients across the continuum of care presented by clients across the continuum of (beyond health sector) across the continuum of care (beyond health sector) This option will enable This option will minimally significantly better moderately better impact coordination of services and knowledge exchange This option will somewhat This option will minimally considerably enhance service delivery staff experience and satisfaction staff experience and satisfaction 5 4 3 2 1 Score = Pts X Weight

Vision, System Outcome Goals and Criteria for Evaluation LHIN Board Governance Option Evaluation Criteria: Health Outcomes Criteria Health Outcomes 5 Point 3 Point 1 Point Weight Improves patient safety by optimizing clinical expertise and standardizing clinical practice This option will significantly reduce 30 -day repeat ED visits This option will moderately reduce 30 -day repeat ED visits This option will minimally reduce 30 -day repeat ED visits 1 This option will significantly reduce unnecessary hospitalization related to lack of service coordination or provision This option will moderately reduce unnecessary hospitalization related to lack of service coordination or provision This option will minimally reduce unnecessary hospitalization related to lack of service coordination or provision 2 Score = Pts X Weight

Vision, System Outcome Goals and Criteria for Evaluation LHIN Board Governance Option Evaluation Criteria: Sustainability Criteria Sustainability a regional level 5 Point 3 Point 1 Point Weight Accountability at an organizational level shifts to accountability This option will lead This option may lead to a financial stable financially stable and sustainable AMH system This option will not lead to a financially stable and sustainable AMH system 3 This option will moderately This option will 2 significantly improve efficiencies and moderately improve efficiencies and direct resources from administration to service resources from administration to delivery administration to service delivery This option will allow for a This option does not 1 for regional balance of regional and allow for regional accountability local accountability Score = Pts X Weight at

Vision, System Outcome Goals and Criteria for Evaluation Discussion • Are there any questions on the ‘Case for Change’? • Are there any questions on the evaluation criteria? 38

Principles, Individual Experience and Elements of the Redesign

Principles, Individual Experience and Elements of the Redesign AMH Redesign Principles • These principles are a reflection of the work of the Redesign Task Force and the engagements to date. They have been cross-referenced to the principles in Ontario’s Open Minds, Healthy Minds and Ontario’s Comprehensive Addiction and Mental Health Strategy to ensure alignment. • Individuals have access to equitable, consistent and quality care across the South East LHIN. • Legitimate local needs will be considered when planning for services and supports. • Services will address the socioeconomic determinants of health. • There will be outreach into the communities (i. e. in the workforce and schools). • All transitions within the AMH system will be experienced as an internal transfer. • A competency-based framework will support the AMH workforce. • Communities and services will work together to eliminate stigma and discrimination. • Individuals and their families will have choice and the opportunity to make informed decisions about their personal care and support. 40

Principles, Individual Experience and Elements of the Redesign AMH Redesign Principles (cont’d) • Social inclusion will support the individual throughout their journey. • Services will improve quality of life in a sustainable way – the system will be supported by continuous evaluation and Providers will be held accountable for the value of care they provide. • The AMH Redesign recognizes biopsychosociocultural inter-dependent and diverse aspects of the individual experience. • The AMH redesign will create a system in which regardless of a person’s age, cultural or linguistic identit, y they will be provided the services and supports to enable recovery and a state of well-being that fits with their expressed choices or needs. 41

Principles, Individual Experience and Elements of the Redesign • The Redesign Task Force has developed the individual experience, the “elements” to bring to life the individual experience and provided their collective wisdom and insight on the governance options Individual Experience Change Management and Evaluation Means to bring to life individual experience AMH Redesign Model Foundational structures 42

Principles, Individual Experience and Elements of the Redesign Individual Experience 43

Principles, Individual Experience and Elements of the Redesign Features of the AMH Redesign • Service users have centralized access to AMH system AND there is also an outreach element to pull users into the system • Service users are tethered to the system such that they have easy and simple access to reenter the system as needed • Service users can access a common basket of services in their region (standard across the South East Region) • Triaging of needs so that service users who have complex requirements receive transitions supports (i. e. dual diagnosis, with housing and employment etc) • Seamless transitions between acute and community and vice versa (services are natural integrators) • Coordinated and integrated service delivery within AMH with formal connections to primary care, housing, children and youth, justice, employment programs 44

Principles, Individual Experience and Elements of the Redesign Features of the AMH Redesign • AMH services and supports model “One team, one plan” • Intentional Peer Supports available to service users throughout their experience in the AMH system • The system is designed to support linguistic and cultural needs (i. e. Francophone, Indigenous) of the residents of the South East LHIN • Individuals and their families will have a voice as essential partners in system design, policy development, and program and service provision, and the opportunity to make informed decisions about their personal care and support • AMH system to focus on continuous quality improvement and there will be capacity to support training and education 45

Principles, Individual Experience and Elements of the Redesign – Overview • The next six slides are a synthesis of the ideas the Redesign Task Force provided on processes, structures, collaboration and leadership (termed “elements”) that will be required to “bring to life” or deliver on the “ideal experience”. 46

Principles, Individual Experience and Elements of the Redesign – Process (1/2) Processes Clear knowledge of available services and how to access them Clear and consistent common service access processes Service access coordinated with housing and other providers Clear roles and responsibilities for all ‘professionals’ to provide seamless, coordinated and appropriate services and supports Formal processes for referrals/transfer and/or communicating changes in plan Formal processes for complex individuals (e. g. ED diversion strategies) Evidence-based care, services and supports Standardized tools, protocols and pathways (e. g. medication algorithms and clinical pathways) Formal processes for peer support for MHA Formalized knowledge transfer and exchange (to share current and leading practices) Centralized workload management Wait list management (i. e. web-based, bed board) 47

Principles, Individual Experience and Elements of the Redesign – Processes (2/2) Processes Focus on housing Social inclusion processes Transportation Support Employment support Formal processes to support immediate re-entry/access when required Formal processes to include re-entry plan, safety plan, fast-track re-entry for clients Formal processes to identify and respond to decline in functioning and provide client and/or family appropriate services/supports Regional decision making framework on transitions Consistent pre-screening tools (i. e. in family physician offices, schools, health units) 48

Principles, Individual Experience and Elements of the Redesign – Structures (1/2) Structures Centralized/streamlined service access model (no duplication) Comprehensive range of services and supports across the continuum (i. e. safe housing) to capture biopsychosocial spectrum (Service Inventory) Best practice models (i. e. wrap around, collaborative care, case management) – Services that go to where the client is Model includes community-based programs such as ‘Clubhouse’, broad programs, vocational, volunteer, and drop in (i. e. after hours programming) System Advisors and Navigators Formalized agreements (MOUs and protocols) to support shared service – includes strategies for conflict resolution Resource and referral system to match capacity and resources to needs across the LHIN 49

Principles, Individual Experience and Elements of the Redesign – Structures (2/2) Structures Workforce optimization with collaborative care approaches – virtual integrated team for client Competency based workforce Resources mobile at local level Integrated structures (with housing, employment, etc. ) Joint/funding mechanisms Communication structures One team, one plan Support experience of receiving hospital care in the home Policy development in collaboration with clients Therapeutic Transitional Housing, i. e. Emergency Shelters 50

Principles, Individual Experience and Elements of the Redesign – Leadership System leadership that drives accountability such as a regional agency focused on: Quality and continuous improvement, Ensures integration and coordination, Maximizes resources, and Ensures data quality in Addiction and Mental Health services Build upon transformational leaders across front-line, management and governance levels Leadership supports access to specialist(s) or specialized team(s) Leadership supports system transformation – manages risk and resolves conflict Service overlap with partners ‘System’ ownership of the client, not ‘organization’ ownership Transparency and support for people who provide services 51

Principles, Individual Experience and Elements of the Redesign – Collaboration Formalized collaboration across the MHA continuum and transitions as well as across sectors (i. e. Cancer Care Ontario model) Build upon relationships Trust Respect Communication Willingness to collaborate Formalized collaboration across the MHA continuum and transitions as well as across sectors (i. e. strong linkages with primary care, social services, supportive housing, community health, municipalities) Collaboration as foundational to supporting client, family and community Inter-agency collaboration Shared responsibility Communication, trust, respect and accountability 52

Principles, Individual Experience and Elements of the Redesign Discussion What questions or comments do you have on the individual experience, features or the elements? 53

Governance Structures for Integration

Governance Structures for Integration The Ideal System: Defined Twenty Years Ago… • Networks of organizations that provide, or arrange to provide, a coordinated continuum of services to a defined population and who are willing to be held clinically and fiscally accountable for the outcomes and the health status of the population being served • Organized delivery systems typically embrace all levels of care – primary, secondary, tertiary, restorative/rehabilitative and long-term • The key characteristics of an organized delivery system are the organization’s breadth, depth and geographic dispersion • Intake and assessment model (i. e. Central intake) – One client One Record • Equitable access to a continuum of services and supports, regardless of where one lives • 24/7 access (web or telephone) which includes crisis services • Service Delivery Models: Recovery, Case Management, Wraparound, Collaborative Care etc. • Regional structure to establish service delivery model requires structures, processes, leadership and a culture of collaboration 55

Governance Structures for Integration Comparison of Integrated Delivery Systems with Regional Health Authorities (Leatt, Pink & Guerriere, 2000) Typical Characteristics of an Integrated Delivery System Typical Characteristics of a Regional Health Authority Membership is defined by consumer choice Membership is defined by geography Consumers can choose among multiple systems in large urban centres Consumers have no choice of system Money follows the consumer Money does not follow the consumer Competition among systems for consumers No competition for consumers IDS manages all essential health issues RHA does not manage physicians, drugs and other services System revenue is determined by capitation payment for each enrolled consumer RHA revenue is based on historical provider budgets or capitation for geographically defined population Practitioner payment mechanism is primarily capitation Practitioner payment mechanism is primarily fee-for-service Financial incentives to providers for good performance – quality of care, clinical outcomes, productivity and consumer satisfaction No financial incentives to providers for good performance System-wide and provider-specific information systems Provider-specific information systems only Widespread adoption of clinical guidelines and pathways that transcend providers Variable adoption of clinical guidelines and pathways that are provider-specific Primary care focus Ad hoc focuses 56

Governance Structures for Integration Leading Practices: Network Governance (Suter et al. , 2007) The delivery of addictions and mental health services and support is too complex for a one-size-fits-all solution. It is important for decision makers to understand the principles and processes of successfully integrated health care systems in order to customize a model which is the best fit for their particular organization or to choose an optimal set of complementary models according to patient needs across the system. • There is no single best model for health and human systems integration. • Multiple models have been proposed at the system level as well as the program level that might guide practice. • System level models focus on change management and key system dimensions. • Program level models focus on care processes such as case management, co-location, home care, population health management, and primary care. • Progressive or sequential models are adaptable to both system level and program/services level. These models propose several steps to achieve increasing levels of integration. 57

Governance Structures for Integration Principles of Successfully Integrated Health Systems (Provan et al, 2007) • Strong governance structure that includes community and physician representatives; members have input to planning and operations • Autonomous not-for-profit corporate organization that is independent of government and accountable to its rostered members, providers and government • System-level strategic planning and decision making which encompasses both the financing and delivery of medical services • Flatter and more responsive organizational structure that utilizes the skills and talents of employees to a greater degree • Centralization of only those functions that offer substantial savings or coordinate advantages • Accountability for the health status of the defined population • Linkages with external stakeholders, government, and the public • Organizational structure promotes coordination; integration of leadership and management; single care-management structure which manages care across settings and levels of care; clear communication processes • Introduction of management structures and financial incentives to influence providers’ attentiveness to the costs and quality of services rendered; performance oriented 58

Governance Structures for Integration Overview of Design Characteristics Sub-regional Lead Organization Structure • Distinct administrative entity set up to manage the network (not a “service provider”) - manager is hired Optimal Number of Members • Many Decision-Making • Mixed Advantages • Efficiency of day-to-day management, strategic involvement by key members, sustainable Problems • Perception of hierarchy, cost of operation, complex administration, loss of local perspectives Network members that are collectively involved in network governance Stronger relationship Weaker relationship 59

Governance Structures for Integration Overview of Design Characteristics Sub-regional Lead Organization Structure • Administrative entity (and sub-regional lead organization) is a major network member/service provider Optimal Number of Members • Many Decision-Making • Centralized Advantages • Efficiency, clear network direction • Retains local perspectives Problems • Domination by lead organization, lack of commitment by members Network members that are collectively involved in network governance Stronger relationship Weaker relationship 60

Governance Structures for Integration Overview of Design Characteristics Sub-regional Lead Organization Structure • Distinct administrative entity set up to manage the network (not a “service provider”) - manager is hired Optimal Number of Members • Many Decision-Making • Mixed Advantages • Efficiency of day-to-day management, strategic involvement by key members, sustainable Problems • Perception of hierarchy, cost of operation, complex administration, loss of local perspectives Network members that are collectively involved in network governance Stronger relationship Weaker relationship 61

Governance Structures for Integration The South East Region AMH Providers • There are 22 community Addiction and Mental Health service providers/programs that are funded by the South East LHIN, providing a range of programs and services. The LHIN may not be the sole funder of these providers/programs. • Addictions Centre Hastings and Prince Edward • Brockville and Area Centre for Developmentally Handicapped Persons • Brockville General Hospital • Canadian Mental Health Association, Leeds. Grenville Branch • Community Care Access Centre School Services • Frontenac Community Mental Health and Addiction Services • Hotel Dieu Hospital – Mental Health • Kingston Community Health Centres • Kingston General Hospital • Tri County Addiction Services • Youth Habilitation, Quinte • Lanark County Mental Health (Perth Smiths Fall District Hospital) • Leeds and Grenville Mental Health • Lennox and Addington Addiction and Community Mental Health Services • Mental Health Services Hastings and Prince Edward • Mental Health Support Network South East Ontario • Providence Care • Quinte Health Care • Salvation Army Harbour Lights Centre • Sexual Assault Centre for Quinte and District • Sexual Assault Centre Kingston • The Brock Cottage

Redesign Options

Redesign Options Overview • It was noted throughout the redesign process that experience and evidence tells us that governance structures are not the ONLY answer, but they are a critical component of the solution through enabling the implementation of the elements that will “bring to life” the ideal experience. • Seven governance options were presented to the Redesign Task Force based on leading practices and an extensive literature review. • These options have been narrowed to the three discussed today by the Redesign Task Force and have also been shared with a wide group of stakeholders. • A description is provided for each governance option. Benefits and risks as identified through stakeholder engagement to date has been summarized and is also presented. • At the close of the section, a few slides are included to compare how elements might look if implemented under each of the three governance options to provide greater clarity. • Feedback received between December 2013 and February 2014 will be presented and will also serve to inform the Board on its governance option decision at the February Board meeting. 64

Redesign Options South East Region - Current State Ministry of Health and Long Term Care Other Ministries South East LHIN 2 Mental Health Peer Support Programs 1 CCAC 2 Community Addictions and Mental Health Services 4 Addictions agencies/ services Regional Programs 5 specialty services (i. e. sexual assault centre and Youth Hab) 5 Hospitals Municipalities Academic Health Sciences Community Primary Care Psychiatrists Providers and Specialty Physicians Public Health and EMS Justice Housing Social Services Employment Transportation 4 Mental Health agencies/ services 65

Redesign Options Option 1: Partnership Model • Development of a partnership model where AMH providers work collaboratively to provide seamless care for clients/patients across the South East region • Objective is to build on what is working well in specific sub-regions and to replicate across the region • System navigators (function) may be required to connect clients/patients with other providers and cross-sector partners (i. e. housing, etc. ) 66

Redesign Options Option 1: What might this look like? Ministry of Health and Long Term Care South East LHIN 2 Mental Health Peer Support Programs Other Ministries Regional Programs 2 Community Addictions and Mental Health Services 5 specialty services (i. e. sexual assault centre and Youth Hab) Municipalities Academic Health Sciences Community Primary Care Psychiatrists Providers and Specialty Physicians Public Health and EMS Justice Housing Social Services Transportation 5 Hospitals 1 CCAC 4 Mental Health agencies/ services 4 Addictions agencies/ services 67

Redesign Options Option 1: Benefits and Risks Benefits Risks • Build on work that has already been done, build on existing system leaders • Provides immediate ownership and implementation • Least intrusive and least expensive • Can provide standardized service/quality • Aligned with processes, leadership and collaboration • Allows for system planning • LHIN could provide a year for agencies to implement elements (prioritized) and meet system outcomes • This model can evolve; if it isn’t working it can evolve to Option 2 • Lack of transformation - May be perceived as status quo; would be hard to demonstrate how it is different to serve providers and clients • Challenges with agreements in the past; could take years to get sign-off • Lack of consideration for conflict resolution • Lack of incentives 68

Redesign Options Option 2: Regional Model with Community Governance • Development of a number of integrated AMH community centres (each has a Board and Executive Team) • These centres provide an agreed upon and consistent common basket of services and could include housing, employment services (and link to Health Links) • A regional “entity” provides specialist services (such as eating disorders), conflict resolution and measures and monitors performance of community centers • The regional “entity” Board includes representation from the AMH community center Boards and hospitals, peer support etc. The community centres report to the regional “entity” • Options for numbers: • 7 Centres – align with 7 Health Links and/or current hospital configurations • 3 Centres – align along LHIN geography • Note: The population in the portion of Lanark that naturally flows into the South East LHIN for service, will be considered for inclusion (to be discussed further with Champlain LHIN) 69

Redesign Options Option 2: What might this look like? Specialist services (e. g. eating disorders) South East LHIN Performance Management and Measurement AMH Regional Entity Academic Health Sciences Community Conflict Resolution AMH Centre Seniors AMH Centre • Common basket of AMH Services Formal links to housing, social services Mobile Outreach Health Links Service Collaborative Psychiatry Hospital of AMH Services Formal links to housing, social services Mobile Outreach Health Links Service Collaborative Psychiatry Hospital • Adult Children & Youth • • • Peer Support • • Peer Support AMH Centre • Common basket of AMH Services • Formal links to • • • housing, social services Mobile Outreach Health Links Service Collaborative Psychiatry Hospital Peer Support 70

Redesign Options Option 2: Benefits and Risks 71

Redesign Options Option 3: Regional Entity with Local Satellites • One South East Region AMH Agency with satellite offices throughout the region (# to be determined) – single service, single provider – one Board, one Executive Team • The Agency prescribes the levels of services and staffing requirements at each satellite office • Satellite offices provide a common basket of services • Local community committees (i. e. consumer groups) are developed to ensure that local needs are reflected in the satellite offices • The Agency works collaboratively across sectors (i. e. with housing, etc. ) 72

Redesign Options Option 3: What might this look like? Specialist services (e. g. eating disorders) South East LHIN Performance Management and Measurement SE Region AMH Agency Academic Health Sciences Community Seniors Satellite Office A Satellite Office B Satellite Office C • Common basket of AMH Services Formal links to housing, social services Mobile Outreach Health Links Service Collaborative Psychiatry Hospital • Adult Children & Youth Conflict Resolution • • • Peer Support • • Peer Support Satellite Office D • • • Peer Support 73

Redesign Options Option 3: Benefits and Risks 74

Redesign Options The Fundamentals to System Transformation The more we transform the system, the more we must rely on people to collaborate within the system. We recognize that structures and processes are critical to achieving high performing mental health and addiction systems; however, a deliberate focus on enabling leadership and promoting a culture of collaboration is fundamental to system transformation. Through-puts Inputs Vision, Mission, Values Provincial Strategy SE LHIN Mental Health & Addiction Services System Redesign Legislation Accountability Outputs & Outcomes Community Capacity Needs-based Population Health Governance Common Language Relevant Ministries Improved client experience South East LHIN Mental Health & Addiction HSPs Regional Programs Other providers (e. g. Health, Education) Access to equitable consistent and quality care The health of population is improved Sustainability of the system Mental Health & Addiction Professionals 75

Redesign Options Comparing the Options 76

Redesign Options Comparing Elements of AMH Redesign Processes: Common Service Access Common service access (CSA) is an effective and efficient way to link families and individuals to appropriate services and supports. CSA clinicians determine the most appropriate services and supports for clients and their families, redirect referrals, divert use of the emergency department, estimate risk, establish priorities, triage clients and their families to specialized services and recommend interim alternatives for client and families facing a long wait for services and supports. CSA system for a geographic area must match community needs and priorities. Option 1 Option 2 ■ CSA system is established based on ■ CSA system is established within service level agreement between 22 new governance structure: AMH organizations/agencies and at Regional Entity and 3 -4 AMH least 76 programs Centres (entities) Option 3 ■ CSA system is established within new governance structure: SE Region AMH Agency and 3 -4 satellite offices ■ Lead organization(s) (centralized or sub-regional) identified to establish CSA programs with oversight TBD ■ Each AMH Centre will establish CSA ■ The SE Region AMH Agency will program and there will be centralized provide oversight and support to 3 -4 oversight by AMH Regional Entity satellite offices ■ Funding for CSA will be shared amongst participating AMH organizations/agencies and evaluated by LHIN ■ Funding for CSA will be managed by ■ Funding for CSA will be centrally each AMH Centre with oversight by managed by SE Region AMH Regional Entity Agency 77

Redesign Options Comparing Elements of AMH Redesign Structures: Common basket of services along continuum The five tiers describe the continuum of addiction and mental health services and supports in order of increasing complexity/intensity. Promotion and prevention is threaded throughout the other four tiers. Four of five tiers will be available within all local communities and specialized treatment will be available at the sub-regional or regional levels. Option 1 ■ 22 organizations/agencies use partnership to collaboratively plan and coordinate AMH services and supports; Option 2 Option 3 ■ Continuum of services and supports is designed within new governance structure: AMH Regional Entity and 3 -4 AMH Centres (entities) ■ Continuum of services and supports is designed within new governance structure: SE Region AMH Agency and 3 -4 satellite offices ■ The AMH partnership will complete ■ Each AMH Centre will provide the inventory of services and supports full continuum of services and will work together to realign supports and there will be services and supports across the centralized oversight by AMH continuum; note that not all agencies Regional Entity will have the capability to deliver the entire basket of services ■ The SE Region AMH Agency will provide oversight and support to 3 -4 satellite offices 78

Redesign Options Comparing Elements of AMH Redesign Leadership & Culture of Collaboration System leadership drives accountability and focuses on: quality and continuous improvement, integration and coordination, resource optimization, risk management and performance management. Transformational leaders shift from organizational ownership to system ownership of improving the client experience. Formalized collaboration across the AMH continuum and with other sectors to support clients, families and communities. Collaborative relationships build upon existing relationships, trust, respect, communication and willingness to collaborate. Option 1 Option 2 Option 3 ■ Operational and clinical leadership will from 22 organizations/agencies work will be established within the new be established within the governance together to collaboratively plan and governance structure: AMH structure: SE Region AMH Agency coordinate AMH services and Regional Entity and 3 -4 AMH and 3 -4 satellite offices supports Centres (entities) ■ The SE Region AMH Agency will work ■ The AMH partnership will be used to ■ Each AMH Centre will work across the SE LHIN to promote system shift from organizational to system together to shift from ownership. This means that system organizational to system ■ The SE Region AMH Agency will priorities would potentially take ownership. collaborate with other sectors precedence over organizational ■ 3 -4 AMH Centres will collaborate priorities with other sectors ■ 22 organizations/agencies will collaborate with other sectors 79

Redesign Options Comparing Elements of AMH Redesign Hospital governance Within option 2 and 3, hospital AMH services are provided through the AMH centre or satellite offices respectively (service and supports will still be provided at the hospital site). As many clients and staff have shared concern about the transition between hospital and community, the RTF members provided the collective wisdom that if hospital AMH supports and services were “housed” with other AMH services and supports, that the transitions between acute and community could be seamless and the experience would be the same as an internal transfer. Option 1 ■ Current state – no change for hospital governance in Option 1 ■ Partnership agreements between a hospital and 15 agencies will be required to delineate transition protocols, priorities and accountabilities Option 2 Option 3 ■ Local AMH Centres are responsible ■ AMH services and supports provided by for setting strategy, setting hospital are provided through the local performance expectations , defining satellite offices. tools and processes, managing admissions, budgeting and evaluation ■ Local AMH Centres are responsible for setting strategy, setting performance of hospital AMH expectations , defining tools and services processes, managing admissions, ■ Hospital governors will retain budgeting and evaluation of performance responsibility for ensuring appropriate of hospital AMH services delivery of AMH hospital services in ■ Hospital governors will retain accordance with Public Hospital Act responsibility for ensuring appropriate obligations (similar to CCO) delivery of AMH hospital services in ■ AMH Centre Board may include accordance with Public Hospital Act hospital governors obligations (similar to CCO) ■ Hospital governors will be representatives on the AMH Board 80

Redesign Options Comparing Elements of AMH Redesign Leadership Provides Oversight: Performance Management Performance management includes activities which ensure that goals are consistently being met in an effective and efficient manner. Managing employee, organizational and system performance and aligning to shared objectives facilitates the effective delivery of strategic and operational goals. System leadership will be required to drive performance management and improve overall AMH system performance. The establishment of an AMH system-wide culture of continuous quality/process improvement and a rigorous approach to performance management will be required. Option 1 ■ 22 organizations/agencies develop, implement and evaluate standard approach to performance management ■ Organizational strategies and goals continue to be key driver ■ System performance goals and metrics established and are translated to organizational level ■ 22 organizations/agencies share their approaches to quality/process improvement and ‘spread’ plan established Option 2 Option 3 ■ AMH Regional Entity and 3 -4 AMH ■ SE Region AMH Agency develops, Centres (entities) develop, implements and evaluates one implement and evaluate standard approach to performance management approach to performance ■ System performance goals and metrics management established and distributed to satellites ■ System performance goals and ■ The SE Region AMH Agency metrics established and are establishes a comprehensive approach translated to AMH Centre level to quality/process improvement and ■ AMH Regional Entity and 3 -4 AMH internal ‘spread’ plan established Centres share their approaches to quality/ process improvement and ‘spread’ plan established 81

Redesign Options Comparing Elements of AMH Redesign Culture of Collaboration: Health Links will bring local health care providers together and ensure that people are at the centre of their care. Health Links will give family doctors the ability to connect patients with specialists, home care services and other community supports, including AMH services and supports. For patients being discharged from hospital, it allows for faster follow-up and helps reduce the likelihood of readmission to hospital. This will result in better patient care and strengthen partnerships in the community. Coordinating care is an important step in improving the services available to clients with addictions and mental health issues. Option 1 ■ 22 organizations/agencies establish a consistent approach for collaborating with the respective 7 Health Links ■ 22 organizations/agencies align with their respective Health Links while regional programs establish working relationship with all 7 Health Links ■ Clients/families have better transitions between providers Option 2 Option 3 ■ AMH Regional Entity establishes a ■ SE Region AMH Agency establishes consistent approach for collaborating a consistent approach for with the respective 7 Health Links collaborating with the respective 7 Health Links ■ 3 -7 AMH Centres align with their respective Health Links while ■ 3 -7 satellite offices align with their regional programs establish working respective Health Links while relationship with all 7 Health Links regional programs establish working relationship with all 7 Health Links ■ Clients/families have fewer providers and better transitions 82

Redesign Options Discussion What questions do you have about the Redesign options? What concerns do you have about the Redesign options? What do you like about the Redesign options? What other information would you like to know to make a decision in February? 83

Next Steps

Next Steps Stakeholder Engagement Tactics Newsletters/Communiques - continue Website and Social Media - continue Roundtable Sessions – to be completed • Targeted stakeholder sessions and one-to-one meetings: • Aboriginal and Indigenous – 2014 • Housing – November 29 and December 6 • Children & Youth – November 25 • Primary Care – January 2014 • Police and Correctional Service – January/February 2014 • Francophone – January/February 2014 • Full day Validation Session with multiple stakeholders – December 2 • Additional Addictions and Mental Health engagement session (Executive Director’s)– December 10 Additional AMH Governance engagement opportunity – early February 2014 85

Next Steps Overview Presentation of the AMH Redesign Options to LHIN Board December 16, 2013 Additional Engagement Sessions – EDs and unique populations January 2014 Additional AMH Board Engagements Early February 2014 LHIN Board Decision on Preferred Governance Structure for the Future February 2014 Development of Implementation Plan Components March – May 2014 Provider/ Administrative/Clinical Support Teams LHIN Board Decision to Launch Implementation Plan June 2014 86

Next Steps Overview of South East LHIN Decisions • Decision to launch the Redesign March 2013 • The question of “why” are we doing this has been answered in the ‘case for change’ and the decision by the SE LHIN Board to launch In March 2013. • Decision on governance model February 2014 • The question of “what” are we going to do to make this ‘live’ is being informed by the work of the Redesign Task Force, Expert Panel, stakeholder feedback, and application of the SE LHIN Board Governance Option Evaluation Criteria. • Decision on timing and nature of implementation (e. g. phasing) June 2014 • Answering the “how” and “when” questions will be made after the development of a detailed implementation plan with all necessary components delineated to enable a considered and successful implementation within the resources we have available. 87

Next Steps Implementation Considerations • The Implementation Phase will continue to involve on-going and extensive stakeholder engagement • As a first step, we need to develop an Implementation Plan. This will include: • Development of an implementation plan outline (describing necessary components) and process • Creation of implementation planning teams to develop key components. Examples may include (to be confirmed): • Clinical Advisory Team: common basket of services, tools, protocols and processes, competency framework. • Administrative Advisory Team: agreements, privacy tools, enabling technology plan, other back office services, transportation • Financial Advisory Team: location of services, HR plan, costing • Transition Planning Team: overall management and leadership, ongoing engagement, client and clinician/staff support in transition, evaluation • Creation and launch of an ongoing communications and stakeholder engagement plan 88

Next Steps Implementation Considerations – Addressing Unspoken Fears • Where am I in these models? • By changing something I’ve created, does this mean I have failed? • How do I prepare myself for change (system, organizational and personal)? • Considerations • Need to pay close attention to these fears during the implementation/transition phase • Need for early transition planning considerations – it is never too early • Need to remain focused on a collaborative process 89

Next Steps Our Commitment that we have made to stakeholders and partners • A decision has not been made • This is not the only opportunity to share perspectives • We are committed to creating a system that is focused on the client • We are committed to a collaborative approach 90

Thank You

Contact Jennifer Payton South East Local Health Integration Network (613) 967 -0196 ext. 2249 jennifer. payton@lhins. on. ca Amanda Pieris KPMG (416) 777 -8771 akpieris@kpmg. ca 92