Mississauga Halton LHIN CSS and MH&A Quarterly Sector Meeting - - PowerPoint PPT Presentation

Mississauga Halton LHIN CSS and MH&A Quarterly Sector Meeting

December 14, 2011

Agenda

Welcome and Agenda Review Angela Jacobs 5 min Specialized Geriatric Services Priti Patel – Clinical Manager, Seniors’ Health Services Trillium Health Centre 15 min Community MH & A Investments

• ADAPT
• HHS
• THC
• Support & Housing Halton
• Highlight on STRIDE

Angela Jacobs Ian Stewart, Executive Director Claudia Barning, Mgr Outpatient Mental Health, Mary Lynn Porto, Mgr Outpatient Mental Health John Smith, Executive Director Anita Lloyd, Executive Director & Jan McCabe, Program Manager 35 min Corporate Communications – LHIN Acknowledgement Update on Healthcare Landscape Janine DeVito 20 min Surge Capacity Protocol Kristina Hall/Judy Bowyer 15 min Break 15 min Finance Updates Paulette Zulianello 10 min “6 Minute Updates” Selected HSPs 40 min Information Highways and Forms Module (CCIM) Judy Bowyer & Lisa Gammage 20 min CCIM Shared Assessment Protocols Monica Gabriel 30 min Closing Angela Jacobs 5 min

Next Meeting: March 2012

Specialized Geriatric Services

Priti Patel

Clinical Manager, Seniors’ Health Services Trillium Health Centre

Seniors’ Health Services

CSS and MH&A Quarterly Sector Meeting December 14th, 2011

What are Specialized Geriatric Services

Specialized Geriatric Services are: A range of health care services, which diagnose, treat and rehabilitate frail elders with complex and multiple medical, functional and psychosocial needs Provided on a consultative basis by an interdisciplinary team of health professionals Provided in a variety of home, ambulatory, acute care, long-term care and rehabilitation hospital settings Aimed at reducing the burden of disability by detecting and treating reversible conditions and recommending optimal management of chronic conditions SGS include both direct services by geriatricians and/or geriatric psychiatrists and services provided in affiliation with one of these medical specialists.

Reference: Regional Geriatric Program of Toronto

Target Population for SGS

65 years of age or older (or age-related needs), frail with complex and multiple medical, functional and psychosocial needs Issues that may prompt a need for SGS: Unexplained changes in health status Recent decline in managing day-to-day activities Multiple ER visits or admissions to hospital Polypharmacy or medication management Change in cognition Incontinence or constipation Psychosocial (e.g. caregiver/family issues, future planning) Recent or multiple falls Mobility or gait issues

Services We Provide

Central intake and triage** Seniors’ health clinic (includes urgent clinic**) Continence Program (clinics, home visits & public education)** Medical outreach service (home visiting)** Falls Prevention and Bone Health Program** Falls clinic Falls education and exercise program Geriatric consultation service for hospital patients Hospital Elder Life Program (HELP)** for hospital patients Geriatric emergency management (GEM) nurse in the Emergency Room ** New and/or expanded services through Aging at Home funding

Seniors’ Health Services

Community Corporate Wide Clinical Programs & Initiatives In-Patients

Knowledge utilization CNA certification workshop Seniors’ health bulletins LHIN representation Internal consultation team (ICT) Hospital Elder Life Program (HELP) Geriatric emergency management Centre-wide program initiatives Regional Outreach

• Medical outreach
• Continence home visits

Ambulatory Clinics

• Routine & urgent assessment
• Continence (regional)
• Falls & Strong &

Steady program

Partnership Evaluation Knowledge Relationships Care/Practice

Our Goals

Maintain / enhance quality of life Prevent disability Maximize health and function to help frail seniors live safely at home as long as possible

Central Intake & Triage

Central Intake and Triage

Enhanced staffing including 0.5 FTE RN Screens and triages referrals for: Trillium’s ambulatory clinics (Seniors’ Health Clinics - routine and urgent, Continence Clinic and Falls Clinic) Regional Seniors Health Outreach to the entire LHIN* Continence services (community-based clinics and home visits) to the entire LHIN*

*The Mississauga Halton Local Health Integration Network (LHIN) catchment area which includes the communities of Halton Hills, Oakville, Milton, Mississauga, and South Etobicoke.

Referral Criteria

Referrals received for individuals 65 years of age or older who are frail, have complex health needs, are experiencing geriatric syndromes, have had two or more hospital admissions within the past year, and/or have frequent ER visits Include any recent relevant clinical information e.g. medical history, labs, DI reports, consult reports with the completed (and signed) referral form To obtain a referral form, please contact our office at 416-521-4090. This form can also be downloaded from our website at www.trilliumhealthcentre.org.

Seniors’ Health Clinics

Seniors Health Clinics

This outpatient Clinic provides comprehensive geriatric assessment and treatment to older adults who live in the community. This includes those living in retirement homes or long-term care homes, as long as they are able to come to the clinic Frail older adults can also be seen urgently for medical/functional issues. Please indicate the urgent designation on the referral form A medical referral is required

Regional Continence Program

Regional Continence Program for Seniors

Three components: Continence clinics Continence home visits Public education Clients seen by a Nurse Continence Advisor (NCA) RN with a specialty in continence promotion Specialize in conservative treatment of incontinence issues Will provide written communication to family physician and specialist

Continence Clinics

For adults 65 years of age or older who are mildly frail but cognitively able and who: Go to the bathroom often, day or night Leak urine with activity or with a strong urge Have frequent UTIs Have problems with constipation or with bowel control Need to learn to use a catheter Self referral or referral by health care professional No cost to the patient Usually 2-3 visits for initial and follow up assessments

Continence Clinic: Locations

Oakville: Oakville Senior Citizen’s Residence North Mississauga: Heritage Glen Community for Seniors Milton: Allendale Long Term Care Home Mississauga/Etobicoke: Trillium Health Centre-West Toronto (this location accepts clients of all ages)

Continence Program: Home Visiting

For the frail elderly unable to access clinics Target Mississauga Halton (MH) CCAC populations: Stay at Home, Wait at Home, Frail Seniors Referrals only from physicians, MH CCAC or the Regional Seniors’ Health Outreach service

Continence Education

Ongoing education to the public and health care professionals Increase knowledge regarding incontinence issues and options available to manage, cure and treat incontinence Sessions cover such topics as the types of incontinence, the factors contributing to incontinence, conservative treatment of incontinence and healthy bladder habits Encourage individuals to seek help

Regional Seniors’ Health Outreach Service

Regional Seniors’ Health Outreach Services

Enhanced staffing increased FTE from 1.0 FTE (2006 – 2008) to 5.8 FTE (2010-2011) Current team includes Nurse Practitioners, Occupational Therapists, Social Workers and Pharmacist Provides medical outreach service for the entire MH LHIN* Medical referral is required Seen by outreach team followed by clinic visit with geriatrician at THC

• r HHS

Expansion to CVH in process

*The Mississauga Halton Local Health Integration Network (LHIN) catchment area which includes the communities of: Halton Hills, Oakville, Milton, Mississauga, and South Etobicoke.

Regional Seniors’ Health Outreach

Provides specialized geriatric services within the person’s home (including retirement homes) Incorporates communication & collaboration with the family physician and community partners Referrals are triaged to the Regional Seniors’ Health Outreach Team if: Client is housebound Client needs suggest a home visit would be beneficial accessibility (e.g. mobility, frailty) functional/safety assessment within their home medication adherence and management cognitive performance assessment caregiver and client supportive counseling recent or multiple ER visits or admissions to hospital

Falls Prevention & Bone Health Program

“Strong and Steady”

Strong and Steady

Falls Prevention and Bone Health Program includes: Initial assessment at the clinic by a physiotherapist and a nurse practitioner and/or a geriatrician Two-hour education and exercise session, twice a week for six weeks Follow up visit three months after program completion Eligibility: are well enough to be physically active can walk 25 meters, with a walking aid if needed are able to learn new information are able to get to and from program Physician referral required to attend

Thank You

For more information contact: Seniors’ Health Services Phone: 416-521-4090 OR toll free 1-888-271-2742 Fax: 416-521-4116

Community MH&A Investments

• MH LHIN

Angela Jacobs

• ADAPT

Ian Stewart, Executive Director

• Halton Healthcare Services

Claudia Barning, Manager, Outpatient Mental Health

• Trillium Health Centre

Mary Lynn Porto, Manager, Out-patient Mental Health

• Support & Housing Halton

John Smith, Executive Director

• Highlight on STRIDE

Anita Lloyd, Executive Director and Jan McCabe, Program Manager

2011-2012 Investment in Community Mental Health & Addictions

As part of the targeted priorities for base funding investments for the community sector, MH LHIN will be investing in the enhancement of services for youth and young adults with mental health & addictions.

Community Mental Health & Addictions

Health Service Provider Initiatives Base Funding - $ ADAPT TAY Addictions Workers 168,000 Halton Healthcare Services Expansion of Child/Adolescent support services for TAY 175,295 STRIDE TAY rehabilitation & employment program expansion 215,171 Support & Housing Halton TAY coordinator for the LHIN; TAY case manager for a Group Home 130,000 Trillium Health Centre TAY program expansion and development

• f internet based interventions modeled on

clinics in Australia 324,000 TOTAL: 1,012,466

New MH LHIN Funding for MH&A Services

• Community MH&A Investments

New MH LHIN Funding for MH&A Services (cont’d)

2011-2012 9,000 Nurses Commitment Funding

This is a workforce stabilization strategy that forms the cornerstone of Ontario’s Comprehensive Nursing Strategy. It is a key component of the province’s health resources strategy, HealthForceOntario which aims to ensure that Ontario has the right number and mix of qualified health care professionals now, and in the future.

Community Mental Health & Addictions

Health Service Provider Initiatives Base Funding - $ Trillium Health Centre Telemedicine Nurses for MH&A $211,847 Halton Healthcare Services Early Psychosis Intervention Program Nurses $170,042 Halton Healthcare Services Eating Disorder Program $116,700 TOTAL: $498,589

Community MH&A Investments

Transitional Aged Youth Services Providing the Best Journey into Adulthood

Community MH&A Investments

What we hope to achieve

The ADAPT TAY Services will be developed to meet the overarching

• bjectives of:

 Collaboration  Capacity Building  System Navigation  Information & Education  Increased Accessibility

Community MH&A Investments

How will we do this

 Collaboration: through formal & informal

partnerships

 Capacity Building: through increased

community service expansion

 System Navigation: through case planning

& management

 Information & Education: through

knowledge exchange

 Increased Accessibility: through linking

with providers who encounter these young people- post secondary, employment, service providers

Community MH&A Investments

Where will we begin?

 Hire 2 Addictions Specialists with mental

health experience to be added to existing Youth Services at ADAPT (presently in the interview process)

 Involve the new hires in the Transitional

Aged Youth planning table for harder to serve clients

 Work directly with other agencies who

have received funding

Community MH&A Investments

What will the program shape be

 Provide specialized assessment, intensive counselling and

case management services to youth 16-24 who have substance use and mental health concerns (individual, group and family work)

 Work directly with other service providers (education,

employment, housing, mental health, justice, recreation etc) to build capacity and assets of these young people and to reduce legal involvements and hospital admissions

 Provide additional supports to provide a more seamless

bridge to and from other programs such as CWMS, CCDP, Crisis.

 Provide an additional resource to assist with the transition

between youth and adult services

Community MH&A Investments

Some creative program ideas

 Provide a group program that not only addresses

the substance use concerns but also builds

• pportunities to practice skills to assist with
• independence. Increase developmental assets

and life skills for clients served.

 Provide opportunity for volunteerism and

community involvement

 Provide a group educational program for parents

• f young adults. Parenting is changing and we

need to respond.

 Work with other service providers to share these

• pportunities

Community MH&A Investments

Where will referrals come from

 Youth themselves  Parents, guardians and caregivers  Youth and Adult Justice systems  Secondary and Post Secondary Schools  All formal and informal partners who serve

this population

 Internal ADAPT referrals (CWMS,

Concurrent and Days Ahead programs)

Community MH&A Investments

What are the service targets

 Services will be provided in Oakville,

Milton, Georgetown, Acton and West Mississauga

 Each counsellor will have provided

service to 60 clients after one year = 1200 visits total

 Each counsellor will have provided

services to 60 parents/ caregivers after one year= 600 visits total

Community MH&A Investments

Outcomes

 Pre and post data will be collected to

determine where change has

• ccurred related to substance

involvement

 Determinants of health will provide

guidelines to outline success

 Hospital admission and legal

involvement data will be collected

Community MH&A Investments

Comments/Questions

 Specific program questions will need

to be forwarded to Jennifer Speers and she will respond

 Thank-you

Community MH&A Investments

Halton Healthcare Services

Claudia Barning

Manager Outpatient Mental Health Halton Healthcare Services

Transitional Age Youth Program

Mary Lynn Porto

Manager Outpatient Mental Health Trillium Health Centre

Transitional Age Youth Program

Mary Lynn Porto MHSc Manager Child and Adolescent Mental Health Adult Mental Health Community Mental Health

Community MH&A Investments

Vision: Healthy, resilient youth and young adults aged 16-24 Mission: To provide treatment, support and

• utreach to youth and young

adults experiencing mental illness, and their families, in order to promote healthy development, positive relationships and full social participation.

Community MH&A Investments

Program Goals: To improve the functioning of youth and young adults experiencing mental illness To promote healthy family functioning for youth and their families living with mental illness

Community MH&A Investments

Principles of Care



We recognize the uniqueness of the individual and his/ her family. To be responsive, supports, services and treatment offered will be individualized and comprehensive.



We recognize and value the involvement of the natural support systems of youth, including their family, friends and significant

• thers in supporting developmental growth.



We value youth centered care, and recognize the importance of the youth’s interests, dreams, and strengths in driving the care.



We value youth participation in the planning and delivery of services and promote youth–run groups and/ or activities.



We recognize the importance of a system of care in supporting the developmental and transitional needs of youth. This system of care includes the coordination and involvement of educational, employment, housing and financial resources.

Community MH&A Investments

Current Program

 Transitional Age Youth Committee:

Shared Management (Child and Adult Mental Health Staff)

 Dedicated Resources

Community MH&A Investments

New Investment

 3 FTEs (Social Worker, Occupational

Therapist, Case Manager)

 Additional Sessionals  Chat room

Community MH&A Investments

Update

 Recruitment  Chat Room

Community MH&A Investments

Support and Housing - Halton

John Smith

Executive Director Support and Housing - Halton

The overall objective of the TAY Project is to provide a person centred approach to the transitioning of youth into the adult M.H.&A. system in Mississauga-Halton via the TAY Protocol process

Transitional Aged Youth (TAY) Youth Centred Systems Integration Mississauga – Halton

Community MH&A Investments

• Four month pilot project to transfer youth to adult

M.H. & A. sector

• Co lead by youth & adult sector
• Multi sector community involvement
• New partnerships established
• 22 youth transferred, 2 fast tracked

Transitional Aged Youth (TAY) Youth Centred Systems Integration

Community MH&A Investments

• 6 - 8 youth per month would be transitioned into the adult MH & A system via

the TAY Protocol process

• Short term transitioning support to individuals “as necessary”
• Protocol and process to be promoted within the youth and adult system
• Educating both youth and adult sectors on the needs of the TAY
• Administrative support to transitioning sub groups and Steering Committee
• Develop enhanced strategies and linkages with appropriate partners
• A refined evaluation tool be developed and implemented
• Develop an early identification and planning toolkit to assist youth and the

youth system in transitioning

Transitional Aged Youth (TAY) Youth Centred Systems Integration

Key Outcomes – 1 FTE

Community MH&A Investments

• Purchase of a home via Region of Halton –

Halton Housing Task Force

• Shared living model for 5 youth at risk
• Renovations funded by CMHC – Home Depot
• No additional program support

LifeHouse Acton Youth House Intensive Case Management/ Life Skills Support

Community MH&A Investments

• Intensive case management/life skills support for 5 youth
• Housing stabilized – no homelessness
• 75% direct service – approximately 1365 units of service
• Reduced admissions to emergency rooms & hospitalization
• Regain positive & trusting relationships with family & friends
• Supported to move independently into the community, when

ready, & provided with transitioning support into the adult system & a more independent living situation.

LifeHouse 1 FTE – Life Skills Coordinator Key Outcomes

Community MH&A Investments

Mee eeting the the Empl Employ

• yment N

Need eeds of

• f the

the Commu

• mmunity

Supported Training & Rehabilitation in Diverse Environments

Community MH&A Investments

WHAT IS STRIDE . . .

Community MH&A Investments

STRIDE ON EMPLOYMENT

STRIDE recognizes that employment and earning power contribute significantly to a person's sense of dignity, personal recovery goals, independence and quality of life It has been estimated that 85% of people experiencing mental health issues are unemployed or under employed Experience has shown that for many of these individuals their lives can be transformed by something most of us take for granted - a job STRIDE is committed to creating

• pportunities for people facing mental

health issues to gain meaningful employment

Community MH&A Investments

ADMISSION CRITERIA

Community MH&A Investments

Must have a mental illness or disability / impairment that is continuous or recurring that results in a substantial barrier to competitive employment Must demonstrate a willingness to become involved in the STRIDE employment programs Must have the ability to set and work towards achievement of employment goals

Must possess a desire to decrease social assistance dependency

Individuals can self-refer! Referred by friends, family members or by a health care professional

• Community MH&A Investments

STRIDE SERVICES OFFERED

STRIDE ODSP OW

• ffers a variety of

job readiness services to individuals who are living with or recovering from mental illness and who are ready to either develop their careers in new areas or to return to a field in which they have had previous experience.

STRIDE is an approved

Ontario Disability Supports Program – Employment Supports

service provider. STRIDE is an approved

Ontario Works – Employment Supports

service provider.

Community MH&A Investments

EMPLOYMENT CONNECTIONS PROGRAM

The Employment Connections Program:

The client and Employment Specialists work in cooperation and consultation to assist in securing a job that reflects the client's abilities and work skills Employment Preparation activities include:

 Employment planning  Assessments and community supports coordination  Employment preparation activities e.g. resumes, interview practice  Job development which identifies available positions that match the abilities and career desires of individual clients  Job search training  Negotiation of employment, unpaid work placements and wage subsidies  Job coaching and long-term job retention support

Community MH&A Investments

SUCCESSFUL PLACEMENTS

Kitchen Help Customer Service Rep Piano Instructor

Shelf Stocker Light Duty Cleaner Shipper- Receiver

Admissions Coordinator

Personal Support Worker

General Labourer

Community MH&A Investments

WORKSITE TRAINING PROGRAM

The Worksite Training Program:

Our largest area of service is the operation of our Worksite Training Programs in North and South Halton. At these facilities, individuals develop their work skills in an environment which closely reflects what they will experience in a competitive workplace.

The benefits of our Worksite Training program:

 Preparation for competitive employment  Realistic work environment with flexible work scheduling  Learning and practicing vocational life skills in a supported workplace  Increased self-esteem and independence  Learning marketable skills such as Shipping & Receiving, quality control and Health & Safety  Earning a training allowance  Client work performance reviews completed  Team Leader Training

Community MH&A Investments

TAY

TRANSITIONAL AGED YOUTH PROGRAM

STRIDE has received funding from the Mississauga Halton LHIN to develop a new Transitional Aged Youth Employment Service Our objective is to expand our existing program services, to hire a Program Coordinator, two Youth Vocational Support Workers and two Youth Employment Specialists to create the new STRIDE Youth Employment Program that will assist youth facing barriers to employment, develop the broad range of skills, knowledge and work experience they will need to participate in todays job market.

The responsibilities of this program include:

Developing youth outreach activities Developing a planned process to connect with youth and engage them in the community Client-centered program designed to assess and respond to individual needs of youth facing barriers to employment Increase awareness of Transitional Aged Youth Engage with youth to determine their employment needs and interests Provide information for youth who may not be ready to deal with their employability issues, referrals to alternate supportive services such as other mental health and addiction programs Work with families, service providers and other support systems to provide the information needed to create an inclusive system whereby barriers are broken down and the right door

• pened to assist youth to transition successfully into the community

Community MH&A Investments

Please Visit us online at

WWW.STRIDE.ON.CA

Please Contact us at

(905) 693-4252

Ge Get t ST STRIDE w worki

• rking f

for

• r you!

you!

Community MH&A Investments

LHIN Acknowledgement and Update on Healthcare Landscape

Janine DeVito

Communications Lead MH LHIN

Liberal Platform Update: Making Ontario the Healthiest Place In North America to Grow Up and Grow Old

• Will continue building on strong foundation to reach goal of

ensuring that every Ontarian who wants family care can access it.

• Will ensure that Ontario keeps the shortest surgical wait times in

the country and that hospitals continue to reduce waits for the 2.5 million Ontarians who rely on our Emergency Rooms each year.

• Will continue investing in new hospitals and renovating existing

facilities.

• Will build on successful Aging at Home strategy to reform the

health care system to provide Ontarians, and especially our seniors, with the tools they need to receive care in the dignity of their own homes.

Liberal Platform Update: Making Ontario the Healthiest Place In North America to Grow Up and Grow Old

• Create Home Health Care
• Make it easier for family health givers
• Make home life safe and affordable for seniors
• Give seniors a place – Active Aging Strategy
• Keep people healthy
• Give Ontarians better food choices
• Better prepared to fight cancer
• Smoke Free Ontario
• Healthier children
• Tackling Mental Health

Caring for our Aging Population and Addressing Alternate Level of Care:

• Dr. Walker Report

Improve Access to Care Through Community Investments Improve Patient Flow Across the System Optimize and Differentiate Capacity Primary Care

• Early identification and management
• f high-risk frail seniors
• Integration of primary care sector
• LHIN primary care lead

Community Care

• Enhance and Align CCAC and CSS
• Assisted Living model of care
• Acute Home Care ‘Virtual Wards’

Improve System Coordination

• Improve care for special needs

(seniors with MHA)

• Integrated Care
• Improved Transitions

Assess and Restore

• Restore functioning of frail elderly so

they can return home after hospitalization

• Increase CCC and rehab capacity,

give ALC patients priority

• Employ short-term stays in LTC

before return home Role of Acute Hospitals in Seniors Care

• Promote Senior Friendly Strategy
• Community rehab capacity

improvement

• ALC transitional best practice

LTC Capacity

• Improve focus relating to transitions,

restorative capacity and respite care

• Create better environments for

seniors with special needs (MHA)

• Increase supply of beds

Enablers: MOH identifies provincial goals, LHINs ensure accountability, meet targets and objectives set by MOH, align incentives with outcomes and provide regional planning and forecasting models. HHR, IT, System wide efficient focus.

Upcoming Game-Changers

• Drummond Report – January 2012
• LHIN Review – Spring 2012
• IHSP 3 – Fall 2012

Community Holiday and Surge Capacity

Kristina Hall

Director, Health System Performance Management

Judy Bowyer

• Sr. Lead, Health System Performance Management

Mississauga Halton LHIN

Community Holiday and Surge Capacity

Anticipating a high holiday volume of hospital patients Hospitals are already at capacity Need to increase where appropriate, flow out of hospital

Community Holiday and Surge Capacity

Community Holiday and Surge Capacity

• Is your agency Administration open over the

holidays (December 23 to January 3)?

• Is your agency providing service over the

holidays (December 23 to January 3)?

• Will you be taking on new clients over the

holidays (December 23 to January 3)? Will this allow capacity in your service?

• Are you planning to discharge any clients the

week of December 18 to 24?

Community Holiday and Surge Capacity

Community Holiday and Surge Capacity

Next Steps

• Compile and share information with everyone on questions
• Information shared with CCAC

Next Steps

• Wherever possible, see if discharges can occur – make room to

assist with flow

• Provide suggestions for assisting with flow

Coming Up

• Committee volunteers needed for LHIN Community Surge Capacity
• Looking at identifying strategies for holidays, outbreak, hospital

backup and overflow

Community Holiday and Surge Capacity

Break!

15 Minutes

MH LHIN Financial Update December 14, 2011

Paulette Zulianello Manager, Finance & Risk

Finance Update – MH LHIN Finance TEAM

 Paulette Zulianello - Manager, Finance and Risk  Mirella Semple - Senior Lead Funding and Allocation  TBD-Senior Lead Funding and Allocation (Hospital and MH & Addictions)  Dominic Sloan- Manager, Corporate Services  Chak Lee - Finance Clerk  Maria Fernandes – Program Assistant  Monisha Kumar – Receptionist/Admin Assistant to Corporate Services

• OHRS/MIS due January 31/12
• Quarterly WERS – Q3 CATLite due Feb. 7 /12

Finance Update

Q3 Reporting Deadline Dates

In-Year Forecast Form -2011/12

 To be submitted by December 19th  Final opportunity to re-allocate surplus $ to other HSP within our LHIN before the year end.  Last year a total of approx. $1 million was clawed back and reallocated.  Form must be signed by your Executive Director or Chief Executive Officer.  Surplus funds will be recovered from your regular February and March subsidy payments

Questions?

“6 Minute Updates”

Selected HSPs

Joint Venture Agreement between Peel Senior Link; CANES Community Care; and the Etobicoke Services for Seniors

Ray Applebaum

Chief Executive Officer Peel Senior Link

“6 Minute Updates”

Joint Venture/Voluntary Integration CANES, Etobicoke Services for Seniors, and Peel Senior Link MH LHIN Quarterly Meeting December 14, 2011

• “6 Minute Updates”

Overview

• Welcome
• Walk through the agenda

Value Proposition

• Definition & Draft Statement

Business Case

• Definition & Case Statement
• Risks and Benefits of the Business Case

Next Steps

• What are our next Steps
• “6 Minute Updates”

 A project undertaken by two or more parties

to achieve a mutual objective. (coentreprise)

source: www.fin.gc.ca/finserv/gloss-eng.asp

• “6 Minute Updates”

Merger Consolidation Parent Corporation Management Service Organization Joint Venture or Partnership

• “6 Minute Updates”

 Does the valu

alue prop ropositi tion

• n fit with the Boards

strategic priorities and directions?

 Does the bus

usiness case se fit with the Boards strategic priorities and directions?

 What op

• pport
• rtunit

itie ies and ris risks present themselves through this proposed joint venture?

• “6 Minute Updates”

Definition Proposal Thoughts from the Group

• “6 Minute Updates”

 a business's promise to deliver the expected

experience with their product or service; a description of what, how and why a product

• r service is important to a customer; an

answer to why a consumer should buy a business's product or service

Source: www.cecausa.com/general_marketing_glossary.htm

• “6 Minute Updates”

Proposed: To enhance the service capacity, infrastructure, and sustainability of partner organizations in acquiring and retaining revenue streams consistent with common vision, mission and values

• “6 Minute Updates”

 Does the valu

alue prop ropositi tion

• n fit with the Boards

strategic priorities and directions?

• “6 Minute Updates”

Definition Case Summary Response to the Case

• “6 Minute Updates”

 Structured proposal that justifies a project for

decision-makers. Includes an analysis of business process performance and requirements, assumptions, and issues. Also presents the risk analysis by explaining strengths, weaknesses, opportunities, and threats.

Source: www.blm.gov/wo/st/en/prog/more/bea/Glossary.html

• “6 Minute Updates”

Partners

• Who is

involved

• Rational

Combined Offering

• What we bring

to the venture

• Common

Characteristics

• Work to date

Proposed Service Offerings

• Anticipated

Client

• Service

Offerings

Management

• f the

Agreement

• Governance

Responsibility

• Management

Responsibility

• “6 Minute Updates”

 CANES Community Care  Etobicoke Services for Seniors  Peel Senior Link

• “6 Minute Updates”

• Leading System Integration Opportunity
• New/Enhanced Revenue Stream-Sustainability
• Respond to Contracts trending towards

Bundled Services and One Source Provider

• Preparing for changes in political landscape

Municipal/Provincial/Federal

• “6 Minute Updates”

CA CANE NES ES ESS Peel S l Senio ior L r Lin ink Formed in 1982 Formed in 1983 Formed in 1981 107 Employees 84 Employees 130 Employees Mission/Vision Excellent seniors support services, community living safely with dignity, lead through partnerships Mission/Vision Committed to supporting seniors, @home/community, safely client centered, dignity, Leadership, excellence of operations, innovation, partnerships Mission/Vision Quality & valued seniors services, independence, dignity & respect Excellence, leadership, integration & innovation $5.2M Operating $3.8 M Operating $4.5M Operating 150,000 units of service 83,000 units of service 74,000 units of service

• “6 Minute Updates”

CA CANES ES ES ESS Peel eel Senio ior L Lin ink Accreditation Canada Accreditation Canada Accreditation Canada CW LHIN and CCAC Central LHIN & CCAC MH LHIN and CCAC Lead Agency in CW LHIN for Home at Last, Seniors Ride Connect + CW CCAC contracts Lead Agency CLHIN for Transportation, agency partnerships in 4 LHINs, AFP Award-Excellence Fundraising Lead Agency MH LHIN - ASSIST, CSP Portal, SDL; MIS/CSS & and GPDynamics/HRIS; Best Small & Medium Employer in Canada; and Metamorphosis Home at Last, Home Maintenance, Transportation, Supportive Housing, Caregiver Support, Family Health Team Adult Day Services, Supportive Housing, Transportation, In-Home Respite, Chronic Disease Self- Management, Home Help, 24-7 Short Stay, Caregiver Support 24-7 Personal Support and Homemaking (SDL), Medication Assistance, Essential Transportation, Foot Care, Active Living, Caregiver Support 12 Board Members 12 Board Members 12 Board Members

• “6 Minute Updates”

 Partnership/Collaboration Orientation  Entrepreneurial  Culture of Excellence  Recognized as Leaders and Innovators of

Service/Change

 Similar governance structures, and

management team style

 Excellent and Engaged governance Boards

• “6 Minute Updates”

• March 30, 2010 CEOs Initiated Conversation
• Joint Senior Management Session
• Miller Thompson, LLP drafted agreement
• Board Chairs/Executive Committee Engagement
• MH, CW, and Central LHINs approve Voluntary

Integration Dec 2011

• “6 Minute Updates”

 Accreditation Canada awards accreditation

status

 Partners Pre-Qualified with the OACCAC  Joint Venture Agreement – Draft 1 reviewed

by CEOs

 Draft 2 shared amongst joint Executive

Committee members

 Board Chairs met and agreed on next steps  3 Boards review and approve final joint

venture agreement and common resolution

• “6 Minute Updates”

 Language and content consistent with current

CCAC contract requirements

 Autonomy remains for providers

independence

 CANES Community Care serves as ‘participant

in charge’ for OACCAC pre-qualification document

• “6 Minute Updates”

 Advisory Services, e.g. legal and consultants

shared equally amongst partners

 Steering Committee – to govern and manage

the joint venture agreement

 Contract Management Teams – established

for each CCAC contract awarded

• “6 Minute Updates”

 Large scale CCAC contracts in three distinct

catchment areas: Central, Central West and Mississauga-Halton

 Larger projects focused on seniors that

spread across boundaries and are funded by

• ne or more of the 3 LHINs

 New opportunities of a large scale funded by

Federal/Provincial/Municipal governments to address the projected explosive growth in seniors over next 10 years

• “6 Minute Updates”

 Does the bus

usiness case se fit with the Boards strategic priorities and directions?

• “6 Minute Updates”

Opportunities and Risks

• “6 Minute Updates”

In learning about the joint venture

 What op

• pport
• rtunit

itie ies does this present?

 What ris

risks does this present?

 What are the nex

ext step eps of interest to you?

• “6 Minute Updates”

What are the next steps for the team?

• “6 Minute Updates”

Initiatives, Successes & Situations

Irene Zivko

Manager ACTT Summit Housing and Outreach

“6 Minute Updates”

Update on T.E.A.C.H. & Peer Support Groups for Concurrent Disorders

Lee Helmer

Director of North Halton Supports/TEACH Support and Housing - Halton

“6 Minute Updates”

“6 Minute Updates”

Information Highways and Forms Module (CCIM)

Judy Bowyer

• Sr. Lead, Mississauga Halton LHIN

Lisa Gammage

Co-Executive Director, Nucleus Independent Living

The Information Highway

Technology Working as an Enabler

• Technology needs to work for the frontline clinician
• Technology needs to work for those making decisions about healthcare
• Technology needs to enable the sharing of information to encourage

knowledge transfer and new knowledge acquisition “An investment in knowledge pays the best interest”

~ Benjamin Franklin

• Information Highway & Forms Module (CCIM)

The Information Highway

Technology Working as an Enabler

• Information Highway & Forms Module (CCIM)

• Information Highway & Forms Module (CCIM)

• Information Highway & Forms Module (CCIM)

The Information Highway

Applicability to Current and Future Projects and Other Stuff

• Information Highway & Forms Module (CCIM)

The Information Highway

Applicability to Current and Future Projects and Other Stuff

• Information Highway & Forms Module (CCIM)

CCIM Shared Assessment Protocols

Monica Gabriel

Project Manager, CCIM

Shared Assessment Framew ork

Monica Gabriel

What We’ve Learned

Assessments Increased sharing IAR

Shared Assessment Model / Business Process Mapping

Common Privacy Framework

Joint Assessment and IAR implementation

Technology How to Share Common Consent Processes Outcome and approach going forward:

• 123

Community Support Services Common Assessment Project (CSS CAP) Vision

Identifying Changing Needs

CSS Entry

Assessment Support For Independent Living

Easy Movement Between CSS Easy Movement Across Sectors

Client

Integrated Assessment Record Integrated Assessment Record

CSS Shared Assessment Model

• Client at the centre of care
• Referrals can come

from anywhere

• Health service providers

providing service contribute to all assessments (e.g., interRAI CHA)

• Hospitals may not provide

community services but may contribute to common assessments

• Constant collaboration and

communication

• Electronic viewing

(e.g., IAR, other LHIN- based initiatives)

• Detailed business processes and

rules

Underlying Assumptions:

Integrated Assessment Record Integrated Assessment Record

Provide Service Contribute to Common Assessment

Client Lead Assessor

Provide Service Contribute to Common Assessment Provide Service Contribute to Common Assessment Contribute to Common Assessment

• Communicate
• Communicate
• Communicate
• Communicate
• CSS
• CCAC
• Other

HSPs

• Hospita

l

• CSS Shared Assessment Flow

Assessment Completion & Overall Care Planning Service Planning & Delivery Care Planning Care Coordination & Collaboration Program-Related Assessment

(Optional)

Service Plan Development Service Provision and Support for Independent Living

• Integrated

Assessment Record Integrated Assessment Record

With Partner HSP Involvement CSS Entry

Client

Determination

• f Lead

Assessor Assessment

(From Service Provider HSPs and Others Involved in Care)

Shared Assessment Guideline

Area Highlights Governance

• LHIN CSS planning tables should

address shared Assessment as part of work plans

• Resource allocation considered at LHIN

level to support shared Assessment

Shared Assessment Guidelines

Area Highlights Privacy / Consent

• Organizations responsible for policies
• n privacy and consent
• LHIN planning tables consider supports

such as the Common Privacy Framework and data sharing agreements

Shared Assessment Guidelines

Area Highlights Client Role / Participation

• Client choice should be considered as

part of determining the Assessor Lead

• Client at the centre of the assessment

process

• Client

Shared Assessment Guidelines

Area Highlights Responsibilities

• Provincial
• LHIN / Regional Coordination –

local guidelines

• HSP
• Lead Assessor
• Contributing Community Support

Services Provider

Shared Assessment Guidelines

Area Highlights Assessment Process

• A single comprehensive assessment

will be conducted and shared within circle of care

• All assessment users will be

competent in conducting and interpreting assessments

• Clients have the right to decide the

level of assessment that they will accept

Shared Assessment Guidelines

Area Highlights Conflict Resolution / Agreement Mechanism

• LHIN Steering Committee and health

service providers will consider their

• wn policies and guidelines for

conflict resolution / agreement mechanism

• Standard conflict resolution

processes

Shared Assessment Guidelines

Area Highlights Transfer Mechanism

• The Lead Assessor can change at any

time during an episode of care

Shared Assessment Guidelines

Area Highlights Reporting Structure

• Ministry and LHIN will have access to

relevant reports

• Organizations will have access to

relevant reports for all the clients they support

Shared Assessment Working Group Guidelines (Part 2)

Determination of Lead

• Lead Assessor is determined by established criteria, including:

– Input from the client – HSP completes the most comprehensive assessment – HSP completes assessment as per legislation – HSP most involved with client (e.g., # of services, medical / care complexity, length of service) – HSP completes assessment having sufficient resources: human, financial, technical – HSP inputs assessment information and shares with other providers – HSP coordinates input from other providers in to the assessment

Contributing HSP

• Contributing HSP will be:

– A service provider that is not the Lead Assessor – Participating in the assessment and reassessment process – Communicating a significant change in need that might trigger reassessment – Actively participating in development, execution of care plan and service delivery

QUESTIONS?

• Next Meeting – March 2012