Session Feedback Report from Patients First

Transcription

Consultation Session Results:
Patients First: A Proposal to Strengthen
Patient-Centred Health Care in Ontario
March 2016
2
Summary of Consultations
27 consultations were held between the months
of January to March.

February 9 – South Renfrew Health Link
Steering Committee
One consultation (with Primary Care Networks
7 & 8) was cancelled due to the weather
conditions; however, responses from this group
were collected via e-mail.

February 9 – St. Patrick’s Home
Community Development

Committee of the Board of Directors

February 10 – Indigenous Health Circle
Forum

Health service providers, administrators,
decision support employees;
February 11 – Champlain Network for
Long-term care Homes

February 17 – Rural Geriatric Network

Health Link coordinators/administrators;


Primary care providers (primary care and
family health team physicians, nurse
practitioners, nurses, and administrators);
and
February 18 –AROW Health Link Steering
Committee

February 18 – Champlain Support Network


Patients, families, consumers, members of
the general public
February 18 –Champlain Health Link
Coordinating Council


Approximately 80 participants were
patients, family members of patients,
consumers and members of the public.
February 19 – Regional Geriatric Advisory
Committee

February 22 – Prescott-Russell Primary
Care Network 1

More than 80 individuals were involved in
primary care including primary care
physicians, family health team physicians,
nurse practitioners, family health team
executive directors, and primary care
administrators.

February 23 – AROW Health Link Care
Coordinators Work Group

February 23 – Health Professionals
Advisory Council

February 24 – North Renfrew County
Health Link Steering Committee

February 24 – Champlain LHIN Decision
Support Network
Approximately 415 individuals participated in
these consultations. These participants
consisted of:

This is a chronological outline of the
consultations is provided below:

January 18 – ED/ALC Steering Committee
Meeting


January 28 –Additions and Mental Health
Network of Champlain
February 24 – Members of the Champlain
LHIN Community and Board

February 24 – Upper Canada Health Link

February 2 –CHC Executive Directors’
Network

February 4 – Network of Family Councils
of Champlain

February 4 – Prescott-Russell Health Link
3

February 25 – North Renfrew Primary
Care Network

February 26 – Alzheimer Society of Ottawa
and Renfrew County

February 29 – Residents of Champlain and
the Board

February 29 – South Ottawa North
Grenville Primary Care Network

March 1 – Central Ottawa Primary Care
Network

March 2 – Upper Canada and
Stormont/Dundas/Cornwall / Akwesasne
Primary Care Networks

North Lanark and AROW Primary Care
Networks
4
Table of Contents
ED/ALC Steering Committee .............................................................................................................................. 6
Addictions and Mental Health Network of Champlain ................................................................................... 8
Community Health Centre Executive Directors’ Network ............................................................................ 10
Network of Family Councils of Champlain..................................................................................................... 12
Prescott Russell Health Link ............................................................................................................................. 15
South Renfrew Health Link Steering Committee ............................................................................................ 17
St. Patrick’s Home Community Development Committee of the Board of Directors ................................ 20
Indigenous Health Circle Forum...................................................................................................................... 21
Champlain Network for Long-Term Care Homes .......................................................................................... 25
Rural Geriatric Network .................................................................................................................................... 27
AROW Health Link Steering Committee ......................................................................................................... 30
Champlain Support Network ............................................................................................................................. 32
Champlain Health Link Coordinating Council .............................................................................................. 35
Regional Geriatric Advisory Committee ......................................................................................................... 37
Primary Care Network for Prescott-Russell ................................................................................................... 41
AROW Health Link Care Coordinators Work Group.................................................................................... 46
Health Professionals Advisory Council ........................................................................................................... 48
North Renfrew County Health Link Steering Committee .............................................................................. 54
Champlain LHIN Decision Support Network ................................................................................................. 56
Members of the Champlain LHIN Community and the LHIN Board .......................................................... 60
Upper Canada Health Link ............................................................................................................................... 68
North Renfrew Primary Care Network ............................................................................................................ 71
Alzheimer Society of Ottawa and Renfrew County ........................................................................................ 73
Residents of Champlain and the LHIN Board ................................................................................................ 75
South Ottawa North Grenville Primary Care Network ................................................................................. 83
Central Ottawa Primary Care Network .......................................................................................................... 88
Upper Canada and Stormont/Dundas/Cornwall/Akwesasne Primary Care Networks............................. 94
North Lanark and AROW Primary Care Networks 7 & 8 .......................................................................... 102
5
ED/ALC Steering Committee
January 18, 2016
Participants: 20 individuals
Section 1 – More Effective Integration of Services & Greater Equity
Question
1.
2.
Feedback

Champlain is in a good position currently to undertake some of these
changes, providers are already working very well together,
recommendation that Champlain become an early adopter/champion
for these proposed changes.

How do we strengthen consistency
and standardization of services while
being responsive to local differences?
Important to consider and address access across all regions and
geographies, which Health Links have started to address (as well as
other local innovations that are started/under way), a greater
integration with primary care will be very beneficial (some are eager
for this as others may be less inclined), will go a long way towards a
better functioning health care system;
What do LHINs need to succeed in
their expanded role?

The proposed changes will bring great benefits to our system, need for
more cross-sectoral quality improvement plans
Section 2 – Timely Access to Primary Care, and Seamless Links between Primary Care and Other Services
Question
3.
Feedback
The proposed approach is intended to 
empower local communities and
providers to improve primary care.
Does our approach achieve this? What
else can we do to meet this objective?
Primary care sector has been siloed for many years and health care
system has been very fragmented, these changes will be short-term
pain for a long-term gain, important not to lose essential services and
programs that are working well today;
Section 3 – More Consistent and Accessible Home & Community Care
Question
4.
Feedback
What recommendations would you

have for LHINs if they assumed
responsibility for home and community
care?
Great opportunity to bring providers together across the entire
continuum, there will be significant change management implications for
those affected/involved, home and community care piece is critical, will
need to be careful to not create additional silos within the LHIN subgeographies;
6
Section 5 – A Path Forward
Question
5.
Feedback
What accountability measures need to 
be put in place to ensure progress is
being made in integrating health care
services and making them more
responsive to the needs of the local
population?
Timely changes, need for more accountability in the system to
streamline and connect all the pieces that make for a patient’s wellness
(holistic approach, which these changes will address), will be easier to
measure, important to be careful of self-interest;
7
Addictions and Mental Health Network of Champlain
January 28, 2016
Participants: 22 Health Service Providers, patients and families
Question
1.
Feedback
What other local organization 
can be engaged to ensure
patients are receiving the
care they need when they

need it? What role should

they play?
Volunteer and family organizations as well as peer support groups should be
acknowledged/ incorporated into coordinated care. These can have an impact on
recovery.
There are models of family based care that should be considered.
Pg10-11.priority populations (Francophones, aboriginal peoples, newcomers)
should be integrated and articulated in the 4 proposals. They aren’t reflected in
the 4 proposals although they are acknowledged up front in the document.
Another population of focus needs to be homeless individuals. Need to focus on
urban aboriginal people as well.

Menu/choices offered is important for clients and families (rather than a single
path or prescription.) Would be important to ask people what would help them in
their recovery.

Local areas should build from health links. Don’t have two conflicting sets of local
areas. All services should be contiguous within the geographies. Currently, some
health links cross traditional boundaries and may need to be realigned.

Not sure how the LHIN, as a funder, will effectively operate direct service delivery
(CCAC). What would that look like? Raises systemic and ethical issues. It is
unclear what will be different by simply transferring service provision to the LHIN.

Applaud that the planning will be more comprehensive (like in other jurisdictions)
and that LHINs will be responsible for planning the full spectrum of health care.

For people with mental health and addictions issues, need more from home care
services. They are not well equipped to meet the needs of these individuals today.

Will the changes just rearrange the deck chairs or will they be meaningful change.

There are good opportunities for addictions and mental health. Could now
implement and move forward on identified gaps. Bringing public health on board
will allow us to build a full continuum of health care services.

The move to a real system is where we should go.

Need to see a higher profile for more attention to mental health needs. There is
concern that mental health and addictions are an afterthought in the proposal.
Mental health and addictions is clearly underfunded (Drummond et al) and there
needs to be more investment. Can’t be dependent on only finding funds through
efficiencies in other parts of the system. Access, coordination and integration
improvements will fail without investment in more services.

Sub LHIN regions are concerning. What about acknowledging county boundaries
which represent service boundaries for many other services. Some of the
boundaries don’t align well with other parts of the system like Children’s Aid.
8

very limited access to psychiatrists (Cornwall) we need more service in general

The mental health nurses at CCACs are disconnected from the mental health and
addictions system. When changes happen to CCAC this resource should be
integrated into the mental health and addictions system.

If there are sub LHINs, will the boundaries be a barrier to services (my agency
serves across sub-LHIN areas)? The geographies will need to help in local
integration and planning but should not create service barriers. They can’t be mini
bureaucracies. This message needs to be reinforced by the Ministry going
forward.
Proposal 2: Bring the planning and monitoring of primary care closer to the communities where services are
delivered.
Question
2.
Feedback
How can we support

primary care providers in
navigating and linking with

other parts of the system?

local service needs engagement, outreach and building on peer relationships to
truly reach the community (not just admissions and referrals).
regional alignment and comprehensive continuum will be very valuable addressing
problems before they become complex and crisis.
acknowledge that much (20%) of primary care is mental health and addictions, but
primary care has no clear access point/ process and the default is the emergency
room. Could be centralized access. Would benefit from integrated information.
Primary care needs to be able to access mental health and addictions providers
for help but there are not enough resources. Need better points of access.
Question
3.
How do we create a
platform for further
service integration, such
as enhanced community
mental health and
addictions services?
Feedback

whatever is done it should have a mix of stakeholder representatives including
families, clients, LHIN funded providers and other non-LHIN funded resources
and providers for a comprehensive platform. Families need to be heard.

can look to organizations that have undergone a similar type of change to help
as it may be hard to change from within.

Mental health and addictions needs to be part of the transformation.
9
Community Health Centre Executive Directors’ Network
February 2, 2016
1.
Question
Feedback
Homecare contracting

Conflict of interest between LHIN planning versus LHIN delivery services. No need to
change mandate of LHIN. LHIN should stay in the current role of planning and
integration without governance of CCAC.

Opportunity for LHINs to build on primary integration by ensuring there is a solid
foundation for service accessibility. No need for people to go through bubbles to
receive services.

Decisions in the past were made based on ease of execution but not necessarily best
for integration. Role of LHIN is to integrate with current assets.

Need CHCs to take on lead roles in Health Links and in the new sub regions. Need
clarity on roles and responsibilities since CHCs best know their communities.

Care coordination is foundation in primary care. Transfer those activities from CCACs
into other primary care assets.

Need expanded resources in community to start serving non CHC clients.

Need to have an operational definition for care coordination and case management in
order to better understand scope of practice as well as current gap in system.

Patients ned to have a voice in terms of accessibility and equity of service delivery
Question
2.
3.
Care coordination
Sub-regions
Feedback

Health Links tells us that care coordination is important and community resources
are needed in addition to social services. These are better provided in CHC model

Consumers who use the service need to be part of planning & execution. Need to
look at investing in groups experiencing poor access and outcomes.

There is a huge cost having front line workers act as advocates and care
coordinators. They need to be freed up from this role to do their work.
 Better definition of LHIN boundaries. Keep in mind cross LHIN HSPs
10
Question
4.
Feedback
What recommendations do 
you have for LHINs if they
assume responsibility for
home and community care?
CCAC CEOs and boards are pushing hard to remain administratively separate
from LHINs. Should never happen. Layer of admin eliminated. One model
considered in NW LHIN is pulling primary care under Hospital Admin. Should
never happen as this will take primary care backward. Need to better define roles
and responsibilities in this new environment.

There is a real opportunity to integrate in community primary care models with
least amount of bureaucracy.

Need to maximize all primary models in order to deliver services closer to home in
communities to individuals who need them.

Vital to integrate care coordination and case management currently done by
CCAC front line into existing teams be it FHTs or CHCs. This will reduce burnout
and will enhance productivity.

There is a definite case for the cost currently being absorbed by system in terms
of frontline staff advocating for their clients to receive needed services. Not the
most effective use of front line expertise within the realm of Patients’ First
Section 4 – Stronger Links between Population & Public Health and other Health Services
Question
5.
Feedback
How can Public Health be

better integrated with the rest
of the health system?

PHU aligned with LHINs could create effective planning of services. Currently
PHU are expanding on their services and not aligning with LHINs.
Need for a performance management framework with clearly defined metrics to
gauge accountability of new relationship with PHU.

Currently challenge is that not all PHUs are not equally funded.

Remove duplication of common services with CHCs (ie sexual health clinics,
breast screening, falls prevention, etc)
11
Network of Family Councils of Champlain
February 4, 2016
Participants: 11 members of the public (family members of persons residing in long-term care homes)
Question
1.
2.
Feedback
How do we support care providers in a 
more integrated care environment?
Provincial direction seems to be that staying at home as long as
possible is a good thing but need to ensure the services are there to
support the caregivers. Otherwise, caregivers will get burnt-out. Need
more of a recognition that caregivers need support. Recognise that
eventually, people will need to go to long-term care homes. Can’t lose
sight of this.

The importance of quality respite services to the health of caregivers
needs to be recognized. Caregivers are often reluctant to temporarily
give up the care of their loved ones unless they are confident that the
care provided will be of the highest caliber. Transportation to and from
respite or an at-home model should be an essential component of
respite care.
What do LHINs need to succeed in their 
expanded role?

Do not change the boundaries of LHINs.
Agree and support that the LHIN take over the responsibilities for
planning and service delivery for home care

Needs to be a centralized navigation function that got lost in the
CCACs. There is hope the LHINs will play this role.

For the recipient of home care services, there are too many different
bodies to deal with when things aren’t going well (e.g. CCAC case
manager, retirement home director, home care agency nurse, different
home care agency personal support worker).

Navigation of the system will be huge when it gets bigger (i.e. when
primary care gets brought in)

Can’t lose sight of the fact that there will always be a need for quality
long-term care, despite the desire to keep people at home as long as
possible

There is a risk that resources for health prevention and disease
prevention might get diverted by the LHINs to other purposes.

There is a risk that the health system loses sight of strategic planning
and longer term visioning during the transition period.

Palliative care needs to be more prominently featured in the integrated
system

Need more affordable supportive housing in the community to be part
of the continuum of services
12
3.
How do we strengthen consistency and 
standardization of services while being
responsive to local differences?
With long-term care homes, need to get away from a hospital model in
our planning. The Eden Alternative is a really good approach. There is
a big difference when communities are directly involved in long-term
care homes.

The admission process to long-term care homes needs to be looked at.
Some people are being admitted because their place comes-up and
they don’t want to lose their spot.

Need more integrated living options like Perley and Bruyère Villages,
Schlegel Villages. Need to remove the barriers to moving from
supportive housing to long-term care homes that are in the same
community (i.e. village concept).

Should refer to Pat Armstrong’s report on Promising Practices in LongTerm Care Homes.

Sub-geographic regions is a good idea. Have advisory groups in each
region to get things done. However, there is a worry that the subgeographies could become another layer of bureaucracy

Privacy issues are often used as a deterrent to providing care. This was
often used by the CCAC case managers.

Hope that this will mean not having 7 case managers before someone
gets the care they need.

Will need to be mindful during the transition period to ensure continuity
of services and to ensure we are meeting the changes in need
associated with the change in demographic.

There is a need to integrate the planning of services provided by
specialist doctors with other health care services
4.
What other opportunities for bundling 
or integrating funding between
hospitals, community care, primary
care and possibly other sectors should
be explored?
There is hope that the funds that will be saved by streamlining the
CCAC organization will be reinvested in front-line care. However, not
clear how much money will actually be saved.
5.
What areas of performance should be 
highlighted through public reporting to
drive improvement in the system?

The key to making the Patients First proposal successful will be clear
accountability, streamlining, and measurement of performance.
Public reporting needs to be part of plan as it keeps people
accountable and creates the impetus for change.
13
Question
6.
7.
8.
Feedback
How do we create a platform for further 
service integration, such as enhanced
community mental health and

How do we support improved
integration through enhanced
information systems, data collection
and data sharing?
The needs of people with mental health are not well addressed in
the discussion paper.
The needs of people with dementia needs to be more featured in
the plans for integration.

In redesigning the system, need to make sure the navigation and
care coordination functions are well defined and coordinated. Too
many people responsible for navigating their own individual parts of
the system (responsibility is too diffuse).

Will also be important to have integrated information systems (i.e.
the patient’s information needs to flow from provider to provider).
How would we know whether the plan Comments on the paper
is working?
 Commend the Ministry for consulting on the paper

Happy to see that the LHINs will have a clear responsibility for
planning for long-term care

Disappointed that the paper did not address long-term care in any
meaningful way. Planning for the integrated health system needs to
include long-term care homes.

Discussion paper is a bit vague. Auditor General’s report is much
more focussed and practical.

Not a lot of strategy in the discussion paper: More focussed on
fixing.
14
Prescott Russell Health Link
February 4, 2016
1.
2.
3.
Question
Feedback
How do we strengthen
consistency and
standardization of services
while being responsive to
local differences?

In terms of equity, please keep in mind people with a Dual Diagnosis
(developmental disability and mental illness/addiction). With 2 ministries involved,
it needs to be clear whose mandate this is / who is taking the lead because this is
one of our most vulnerable populations and the system is not working for them as
it should

Equity x sub-LHIN geography will be important

One member recommended not combining Prescott- Russell with other counties
in Eastern Ontario. Look at political regions’ as sub LHIN regions. Perhaps not by
Health Link area either. Others felt HL geography would be a natural fit.
What other local

organizations can be engaged
to ensure patients are

receiving the care they need
when they need it? What role
should they play?

EMS / Community Paramedics are an integral part of a seamless health care
system and need to be included
Health Links is a good example of integrated services that reduce the chances of
duplication in H & CC (who’s going into the house)
Health Links support PC – those PCP’s who are involved see that

Good idea; full support (for Public Health)

Professional education system – need training around respect for other
professions; expectations raised in school about salary expectations – creates a
hiring challenge for those (orgs / teams) who need these professionals but don’t
have the $ to meet salary expectations

Family/caregivers – support needed; heavy burden felt when told it’s best to have
‘patient’ stay with you as long as possible (e.g. dementia). Service providers call
you all the time – you need to respond to them. Feel abused. Feel exhausted,
alone, just want to cry sometimes
What other opportunities for 
bundling or integrating
funding between hospitals,

community care, primary care
and possibly other sectors 
should be explored?

Invest in home and community care. I have not seen the investment promised by
the ministry years ago

Cutting costs is what this is all about – we need to cut costs where we can so we
can increase efficiency (and reinvest where needed)
No cuts to H & CC
Address disparities between hospital and community salaries
‘Don’t be palliative in February’ – end of fiscal year challenges lead to cuts in
service
15
4.
Question
Feedback
What is most important for

Local FHT recently surveyed patients – demand exceeds supply,
patients want PC 24 hours/day and they want it to include emergency
services; they want fast access at a time convenient to them. Felt that
public education was needed regarding the role of PC and the role of
other HC services (i.e. emergency)

FHT’s – many patients not with a FHT see a 2-tiered service. Many
would like to have access to a FHT ‘level of service’
Ontarians when it comes to primary
care?
5.
PC will need to address the needs of an aging population – going into
their home, providing palliative care. Some (PCPs) already provide
this; some do not
6.
What should the LHIN role be in

supporting providers in the delivery of
high quality, accessible primary care?
What do LHINs need to succeed in this
role?
It is going to be a challenge for the LHINs to ‘take on primary care’ –
requires a culture change – from physicians being autonomous to
being accountable to a population. The turn-around is going to be
difficult – good luck
7.
Question
Feedback
How can home care delivery be more
effective and consistent?

If service not available locally, need transportation options

Recommend having an ombudsmen for vulnerable H&CC clients – a
direct line to ministry to hear the stories and respond
Question
8.
Feedback
What can be done to ensure a smooth 
transition from the current system to
the one proposed in this proposal?


Everyone is willing to do this – to shift – need ministry and LHIN
support
In the health care system overall, need move us (providers) away from
a provider-centric model of care to a patient-centred model - a
transformational shift is required. Every provider wants to be the latter,
and entered the field to help clients/patients but institutions, rules, etc.
turned us (into the former)
Accountability of/for PC is essential
16
South Renfrew Health Link Steering Committee
February 9, 2016
Participants: 8 individuals – HL representative (1), consumer (1), HSP administrators (6)
Question
1.
2.
Feedback
Legislation will need to be changed in the various sectors – LHIN,
public health, CCAC.
care and possibly other sectors should 
be explored?

Would like to see more local solutions regarding delivery of services for
quality and best practices, flexibility, more appropriate services to
streamline and reduce costs
Is the Ministry downloading the authority to the LHINs?
The Ministry will need to delegate responsibility to the LHINs

*Cut those envelopes loose to increase effectiveness in use of funds

Are they suggesting organizations start discussions about pooling
funds?

*This will help break down silos and increase sharing

*Must be careful we are not setting up another level of bureaucracy
around shared funds

Integration at ground level?

*More local and provide more opportunities for collaboration and
sharing

*Remove privacy issues

*Share face time to have creative solutions

LHIN sub-regions? – Health Link Areas could be the sub-regions –
South Renfrew health link area is still so large and there are variations
within the health link area – maybe hubs. How granular do you go?
17
Question
3.
4.
5.
Feedback
How can we effectively identify, engage 
and support primary care clinician
leaders?

What is the most important for
care?

How can we support primary care
providers in navigating and linking with 

Seamless links between primary care and other services - more
coordination and linkage
Primary health care is the foundation and organized within sub-regions
– work with PCP for coordination, performance monitoring
Question – physicians are independent and deal with Ministry but there
is splitting as LHINs must deal with physicians but Ministry still holds
the purse strings
*Stand alone docs – more of a challenge
*Primary Care Network – need to evolve further, Primary Care
Providers (PCPs) are fundamental but not integrated. How do we
engage them?

*PCPs have bought into Health Link model of care – use that to
engage docs

*Health Link champion physicians – docs to docs – seek out
champions to help engage others

*Policy changes around remuneration and which models Ministry are
endorsing need to be examined

*When the CCAC is rolled into the LHINs there will be care
coordinators – can we retrain them to work using the health links model
of care – align them with primary care and the health links model of
care

*Can we integrate care coordination throughout the system instead of
just in primary care?
18
Question
Feedback
6.

7.
How can home care be better
integrated with primary care and acute
care while not creating an additional 
layer of bureaucracy?

Care coordination – leverage and use existing roles and enhance them
(GEM, ALP, CMH, Cancer Care, CHC) – care coordination is a function
not an organization or program – challenging due to who oversees
some of these roles especially the regional ones
Structures enable resources to be transferred according to the needs
of the patients – need to remove funding silos e.g. CCAC and CSS
Ministry is suggesting CCAC Board will no longer exist - LHIN would
have to assume role but would they stay the same size?

Operations need to be able to do their thing and report to the Board –
the LHIN Board may not have the necessary knowledge and skills –
succession planning and recruitment – would enlarging the LHIN Board
be required in order to meet the demands of the expanding role

LHIN role – planning, funding and integration of services – CCAC role
is delivery of services – LHIN legislation would need to change

CCAC has no direct accountability to the LHIN now

Get away from for-profit system
8.
Question
Feedback
How can public health be better
integrated with the rest of the health
system?

Public health helps us look at the social determinants of health

Fear that public health will move more into a medical model

? paramedic services and community response unit – Renfrew County
is under the County – what is their role? Shouldn’t they be included?

Rural input on any panels is important to remove Toronto-centric
planning

Public health engagement is critical to expand perspectives for full
continuum of care
9.
Question
Feedback
How can clinicians and health care
providers be supported in leadership
roles in continued system evolution?

Feedback to the Ministry on funding experience. It is very frustrating to
operate Health Links, another large change initiative, on one-time
funding. This is difficult for providers and patients.
19
St. Patrick’s Home Community Development Committee of the Board of Directors
February 9, 2016
Question
Feedback
1.
Supportive of overall approach to develop more integrated approaches
to care
2.
expanded role?
Concerned that the new roles of the LHIN in terms system planning
and service delivery for CCAC may lead to conflicts.
20
Indigenous Health Circle Forum
February 10, 2016
Participants: 9 Indigenous health service providers
Question
1.
2.
Feedback
expanded role?
LHINs will need funding to conduct research on what are the best
practices and support for data infrastructure to be able to evaluate.

Needs to be an equity framework when LHINs look at their planning
processes to make sure we are looking at it differently this time around.
It is assumed indigenous people are accessing care but they are not.
Northern issues become southern issues.

If going to have a medical home, need to ensure palliative care is part
of this. One of the key questions is where people want to die.
Anything that puts the person first and allows the person to put their
needs forward and services are organized around them is the way to
go.

Looking at how Health Links are evolving. However, for rural
indigenous communities, they already offer the offer a fully integrated
plan of are so Health Links might not add anything. When looking at
cost savings, they might get swallowed-up by hospital deficits and not
be reinvested in services. With Health Links, ended-up right where we
started. Still looking after our own people and offering our own
community our services.

Looking at developing more team approaches and hubs of services.
Willingness to work at integration.

There is a lack of equity with respect to funding that is provided to First
Nations for First Nations.

Administrative health of organizations is important.

Smaller organizations don’t have sufficient budget to be fully engaged
in integration and in First Nations health issues.

Standardizing services across the province is a good idea but there
needs to be flexibility for different cultures. Some directives don’t
accommodate cultural preference (e.g. Home First might be what some
cultures value but home is not necessarily where every culture wants to
be)

Aboriginal people should lead the way in defining what cultural safety is
and develop a standardized definition of what it means for everyone

The proposal document does not well address how different cultures
view health and wellness.

Key issue is patients first. Each community has to look at how it can
provide the best patient care in a patient- centered model.

Broader issues of leadership for Aboriginal people should not impact
patient care, particularly in cities. Patient care cannot be stalled while
21
waiting for things to happen at other levels.
3.

Minwaashin Lodge has been involved in a research project for the past
5 years with researcher Janet Jull. The project is specific to how to
approach First Nations, Inuit, and Métis women. Would be a good idea
to have a look at the tool that has been developed by the research to
see what is involved in it because it has been well received, even
internationally. Need Indigenous health professionals to work with
Indigenous patients. If can’t get sufficient workforce, need to transfer
knowledge about Indigenous health with mainstream providers. Use of
finding from research such as this would be helpful. Used the research
findings to use in a medicine wheel approach. Often approaches are
linear and don’t work as well with Indigenous culture. Is a very good
tool to encourage and empower Indigenous women
What other local organizations can be 
engaged to ensure patients are
receiving the care they need when they 
need it? What role should they play?
Might be a good time to reengage the chiefs on Ontario to see how we
gather data in a culturally sensitive way.
Health care workers should be working to scope to make best use of
their knowledge. This will allow planning for health force needs in the
LHIN and sub- regions.

Big question is who will define the sub-regions. Should be the
community members. Tends to be a certain level of manager with a
certain cultural background that determines this. Should be led by
primary care rather than hospitals. Will need to reimburse people for
their time to be involved.

When we look at health of Aboriginal people, it needs to be defined by
Aboriginal people. Want to be able to do like-to-like comparators.

Union of Ontario Indians and Chiefs of Ontario have not yet
communicated down to the First Nations communities.

Aboriginal health service providers should be involved in defining
performance indicators for other mainstream health service providers
(e.g. hospitals). Because right now, no data on how many Aboriginal
people use services and what their outcomes are. Know that when an
Aboriginal person goes into the emergency department, he or she does
not get the same care as everybody else. People assume Aboriginal
people get the same service but they don’t. There are studies that
demonstrate this.

It isn’t just about physicians and nurse practitioners. Need other health
professionals. Mental health is key.
22
Question
4.
Feedback
Does our approach achieve this? What 

Not having LHINs responsible for funding primary care is a problem
because it splits the accountability. Would rather have one “boss” that
provider can interact with.
Disagree with the proposal that primary care providers maintain the
choice of who they want to see. This means that some people don’t
have access, particularly underserved populations. There is a
disconnect in the proposal related to engaging physicians in the
transformation but allowing them to do whatever they want. This opens
it up to cherry picking, and health care providers being able to choose
to provide services to the worried well or the well. Would help to have
job descriptions for physicians and expectations based on the clientele
and hire appropriately for it.
There should be open access to patient information across providers
without primary care providers having to pay for access to hospital
information. Security and confidentiality is an issue.
Question
5.
Feedback

care?

Think it is a good idea that the LHINs will be taking over home care.
However, CCAC salaries tend to be higher than LHIN’s so will need to
be careful about job conflicts when the CCAC joins the LHIN.
When redeploying CCAC services, would be good to bring them closer
to home. Could have Aboriginal case managers that know the
populations.
6.
Question
Feedback
system?

How do Aboriginal populations fit into public health?

Needs to be a broader involvement at the strategic planning phase

Public health should be split into two streams: Public safety (e.g.
restaurant inspections, water safety, immunizations, etc.) and health
promotion (which would be more aligned to the LHIN’s mandate).

With public health, the value would be in health promotion but public
health units don’t do enough of it because often don’t have the funding.
There is a need for something to happen to make that happen. LHINs
will have to elevate this. Health promotion will need to be a star
because it gets lost. In relation to Aboriginal models of care, health
promotion is primary. Must be number one before we look at illness. It
is part of everything. Indigenous population’s health is getting worse.
So indigenous peoples need to be part of the process, part of the
planning.

Cultural safety needs to be a strong component of the strategy.
23
Education needs to be built in to the transformation.

7.
What additional connections would be 
valuable?
Good to be focussing on health and health promotion rather than
illness.
With public health, have not had a strong relationship in the past (have
cut-off services since First Nation community received funding for a
public health nurse). Could be because of public health’s
misunderstanding of its responsibility towards First Nations
communities.
8.
Question
Feedback
What accountability measures

Accountability goes both ways. The AHACs believe that accountability
goes both ways. Would like to know what is going on in hospitals. How
many people die due to errors? No accountability to clients, where we
are informed patients in the system. Should have an auditor general
that provides a report that identifies waste in funding, poor results and
gaps in care

We need an equity framework, a voice at the table and statistics on
Aboriginal health. Usually the invitations to the table are based on
number of Aboriginal people ie. population, not the rates of health
issues. For example, there are high rates of suicides and diabetes in
our population. Needs to be a planning entity for Aboriginal people that
has a mandate to plan, just like the Francophone entities that are
funded by the LHIN.

Some of the performance indicators for indigenous services are the
same as main stream and might get swallowed-up. Needs of smaller
communities might not get seen when combined with larger
communities and mainstream.

The true performance indicator as a physician is whether the patient
got the appropriate care in the right place.

Need to decide up-front what outcomes we are looking for. These
should be based on best practices. This will be essential to evaluate if
the changes that are being made were good ones.
need to be put in place to ensure
progress is being made in integrating
health care services and making them
more responsive to the needs of the
local population?
24
Champlain Network for Long-Term Care Homes
February 11, 2016
6 participants: Administrators of long-term care homes
Question
1.
Feedback
Sub-geographic regions make sense. The way to deliver services
needs to be different based on different realities of different regions.
Makes sense to align home care services to match the profile of the
population. There should be some shared accountability among
providers in a sub-region. This could be aligned within an existing
corporate infrastructure (e.g. hub and spoke models). Sometimes
hospitals might have the infrastructure to support this shared
accountability but don’t want to be more hospital centric.

Communities are not always organized geographically. Some
communities are organized linguistically or culturally. In thinking of subgeographic regions, there needs to be some flexibility to accommodate
the needs to communities that aren’t centered around geographies.

Health Links geographies feel like the right unit of focus. Health Links
now have an infrastructure that could be leveraged.

Long-term care homes are already very patient focussed.
Question
2.
Feedback

care?
With respect to the reorganization of the CCAC and it coming to the
LHIN, there is a lot of merit. The feedback long-term care homes often
hear from residents and families is about silos in the system. There is
still a lot of variability in the type and amount of home care services
people are able to access. This change would assist in reducing this
variability. However, some of the LHINs have not lived up to their
performance expectations, so if they aren’t strong themselves, how will
they be able to deliver better value and better care?

Will be important not to lose any direct services in this reorganization.

There have been concerns with the amount and levels of hierarchy at
CCAC. The LHIN should be mindful of the public perception of the
CCAC being top heavy and address this.

If we want to have an effective health care system, we have to make
sure that home and community care is well done.

Have experienced admission criteria for CCAC services changing
arbitrarily because the CCAC was trying to manage the budget which
has an impact on alternate level of care and the effective flow of
patients out of institutions. This is hard to accept when there are so
many layers of management and administration at the CCAC.
25

We will see an increased demand in the need for home care services.
Risk that with amalgamation of CCAC with the LHIN, people will take
on additional responsibilities so it will become more difficult to manage
caseloads and increased demand.

The data we have available for planning might not be showing the full
picture. When there is frustration with having to wait for services, the
people that are waiting for service may be purchasing private services
(e.g. in the retirement sector). However, when things go wrong or they
can’t afford enough service, they come back to the public sector. So
there may be pent-up demand.

The long-term care home of the future should have some ability to
serve as a transitional environment. People do improve once admitted
and could return to the community but often, there isn’t that discharge
option.

The long-term care homes have not really had a large role to play in
Health Links, but really do believe that they are the right way to go.
Question
3.
Feedback
For some of the initiatives in the proposal to work well, the long-term
care home legislation might need to be rethought. E.g. spousal
unification allows spouses to be together but if one of the spouses dies,
can’t easily get back to the community if the remaining spouse does
not need long-term care home level of care. E.g. selection of long-term
care homes. Some people are in hospitals or long-term care homes
choosing homes with very long waits which means they are occupying
a bed that could be used by someone else.

For the proposal to be successful, we will need to have different types
of case management than we have today.

We are sensing that the Ministry wants to move quickly but it would be
important to take the time to complete a thorough analysis of all
implications. In other examples when legislation has been pushed
through quickly, there are unintended consequences that we have to
live with for a long time.

The proposal does a good job of laying out the challenges we are
facing, but not sure if the changes that are being proposed will really
address those challenges.
26
Rural Geriatric Network
February 17, 2016
Participants: 10 individuals – health service providers
Question
1.
2.
Feedback
An ability to move resources wherever we see then fit best. One of the
barriers to collaboration has been the funding silos. When ideas come
up in a group as to how things might be integrated more effectively, it
gets botched because of the funding silos; you can’t move this from
here to here. So the hope would be to get rid of some of those silos
and make resources, whether they’re human resources or other types
more transferable between sectors of health.

See the care providers as employees of the system instead of
individual organizations. Allow resources to move freely through the
system and have the flexibility and willingness to deal with any surges
or capacities that you would need to support a particular area of the
system vs another.

Ease of sharing patient information: We don’t have documentation that
can be shared throughout all our regions.

Legislation that limits access to information by some providers i.e.
circle of care. Should expand a true circle of care. If we expanded the
circle of care, we would be better able to coordinate care. The circle of
care could be defined by the patient or caregiver. Have a look at the
legislation around medical records. Who owns that information/chart? If
that could be looked from a patient’s perspective.

Mandates of providers limit care. The focal point should be “We are in it
for the patient”.

How can we build a more trusting environment so that people can build
off of the work that other disciplines are doing. Patients are overassessed.
hospitals community care, primary

be explored?
Flexibility of being able to move resources between various health
sectors as the local priority dictates.
Would be interesting to look at lessons learned from areas that have
been piloting the idea of bundling funding for individual clients so that
the client is once again more in control of the various services they
acquire.

Look at funding follows the patient.

Geriatrics as a service is in a number of different parts of our system,
but most of them are small parts. If you can consolidate them to create
a larger critical mass, could there be efficiencies gained or re-shift
some of the indirect patient care resources so that they could be built in
to building some capacity in the direct care resources (equity of access
in a wide geography)?
27

Look at NP and primary care physicians’ funding support that it is
acceptable. Funding that is not just associated with a particular primary
care facility or not just with a particular family group.

There are opportunities just to re-engineer. So you don’t necessarily
need new dollars coming into the system.
Question
3.
Feedback

providers in navigating and linking with

Dedicated resources within the primary care setting to help with the
navigation.
A dedicated resource may assist in avoiding appointments. Health links
have started to do some of that, but it’s such a small component, so to
expand on that.

Glaring hole - What is the relationship with the clinical specialist?
That’s also a hole with health links; they have that absence of a
specialist.

Is there a way that we can utilize the teams and the resources to create
a greater stretch out in to the community to some of these other
physicians who don’t have these resources; i.e. social workers,
pharmacists, OTs, physios, etc.?

A lot of what we’re hearing is that a lot of family physicians don’t know
what the resources are out there. If they could have one place to go,
that would make it a lot easier for their practice and that person, would
be able to refer out to the proper services needed for the client.

While trying to be responsive to the needs of the patient as illness and
as health issues arise, we must also focus on the prevention end of
things.

Centralized intake/coordinated access: with one call from primary care,
there could be an appointment arranged directly with community
services to start that process of other service options.

Health links have identified quite often that many of the needs they’re
seeing in people brought to the ER could have been prevented if there
were more intervention at the prevention end of the continuum.

Can there be a look at funding for primary care physicians so that they
can spend the right amount of time with a frail or complex population?
28
4.
Question
Feedback

Contracted services make it hard to have a predictable level of care.
Competition can lead to variations is level of services.

Wider application of the PSS pilot – leads to better transitions among
services.

The Inter-RAI presents road blocks. Inter-RAI forces reassessments
and creates delays. As clients transition from one setting to another,
from one provider to another we should be able to use the specialist
assessment and recommendation and initiate services in a timely
manner (reduce number of reassessments).

We have to tackle the case manager role and make better use of
specialists.

The rural reality is different – As we look at sub geographies need to
look at equity.

LHIN sub-geographies need to be clearly defined or address issues
with border/bordering services. This has been an issue with LHINs. In
rural areas the geographies may need to be smaller (more granular).

LHINs should have more oversight on setting best practices around
specific conditions.
5.
Question
Feedback
system?

In Champlain we have good examples of collaboration between health
care and public health (example: falls prevention).

PH needs to be part of the health care system, involved in planning.
How can we be more pro-active and address needs sooner.

PH needs to identify opportunities for health beyond the well individual.
Modify delivery to address the needs of sub populations.

PH can build a bridge between community care and health care.

Is there a specific follow-up role for PH for some populations as they
are discharged from acute care?

Better transparency as to what resources are available – opportunities
to re-engineer how they do their work to target some priority
populations.

Need consistent messages between PH and health care.
29
AROW Health Link Steering Committee
February 18, 2016
Participants: 16 individuals – FHT physician (1) and Admin Lead (1), Health Link Care
Coordinators/Admin (4), representatives from various Health Service Providers (10)
Question
1.
2.
Feedback
IT solution is needed to increase communication and connectivity
among providers and patients. Patients need to be included.

be explored?

Change funding envelopes based on patient experiences and
population needs
Group patients/populations in a meaningful way and then fund
according to the entire continuum of care for the groups
Wrap resources around the patient and all team members would be
bundled

Bring retirement homes into the system

Stop using the terminology “health sectors”
Question
Feedback
3.
leaders?
4.
care?
5.
Need to ask and enable primary care practices to attend meetings –
primary care networks. Need funds and other resources to support
primary care clinicians to participate.

Align outcome and performance measures across all health sectors so
all are working toward the same thing

Link funding to performance in the sub-LHIN area


There is potential in primary care networks, but there is a need for
resources to support and evolve them.
Need funds to support the change.

Primary care needs data in order to inform performance

Need to put more focus on best practices and disseminate this
information among primary care

Consider methods/mechanisms to create a timely system for better
access.
30
6.
7.
Question
Feedback

Improve community services for rural clients to address equity issues

“one size does not fit all” - rural and urban needs are different


Look at the population and service needs within the geography
Need solid HR planning for home and community care (including home
maintenance, volunteers)
Need better technology enablers

Need agreements between primary care and Community care
providers

Ensure continued emphasis on transportation – particular issue in more
rural areas
8.
Question
Feedback
system?

Why aren’t we talking about social services in addition to public health?

Many patients need social supports, would be beneficial to integrate
more with social services

Public health needs to become more flexible – currently public health is
too directed in its mandate – needs to be more flexible

Public health is excited to participate in this consultation process –
want to better integrate with the health system

Public health should maintain its role to keep populations healthy – the
health system as a whole could benefit from the unique skills and
expertise of public health

Public health can assist with data for planning and performance
impacts

Differences between public health units (e.g. rural vs urban) could be
better addressed

There are services that public health can do that others don’t - good to
bridge these services
31
Champlain Support Network
February 18, 2016
Question
1.
Feedback
What do LHINs need to be successful 
in their role?

2.
Concerns regarding new sub-regions 
Ensure that the skillset of the LHIN board are appropriate to take on
CCAC.
LHINs will only be as successful as their Lead Agencies.
What will they be? How many of them?

Concerns that we are regressing rather than progressing.

Ensure a thorough investigation of the boundary model before
implementation and seek feedback on them before implementation.

How will new sub-regions affect the work/progress made by Health
Links?

Strong preference for fewest possible sub-regions in

Champlain as strong regions exist already.

Build on successes from current and past regional areas. (ie HL and
Communities of Care and current 3 sub-region model in Champlain)

Make sure to focus efforts on 95% of the population while HL looks at
the other 5%
3.
Homecare contracting

Patients first report seems to have overlooked Home care contracting –
how will it work?
4.
Appropriate training required

There was a mention that the Indigenous Cultural Competency training
would provide an excellent opportunity for understanding the best way
to serve indigenous populations.
32
5.
Question
Feedback
How should data collected from
patients be used?

Look at Caredove being used in the Waterloo Wellington LHIN

Look beyond clinical and statistical data to include data re quality as
well. Ie client satisfaction surveys are important.

Where is HQO in all of this? Use them rather than having each LHIN
do their own thing. This should be a provincial strategy. The excellent
Care for All Act is being too silent at this time.

Make sure to have each sector (primary care and CSS) ask the
question to one another of what each side needs to know from the
other sector.
Question
6.
7.
Feedback
What recommendations do you have 
for LHINs if they assume responsibility
for home and community care?

For profit organizations
Point reiterated that moving back to more sub-regions will not yield
savings
Currently there are CCAC regions that are aligned with Champlain’s 3
CSS regions as well as the 4 Public Health Units structure aligning
well. Why would we change this?

North Grenville and North Lanark are the anomalies that do not fit in
well and hence are not well aligned.

Significant concerns raised around debunking existing sub-regions and
starting from scratch

Currently service funding rates and client fees are a barrier to service
(ie Attendant Outreach services). LHIN should consider this.

LHINs should ensure that all documents are public – (ie contracts) so
that they can be critiqued. This is how CCAC works.

Strong cautions made in regards to LHINs delivering services via for
profit organizations. This does not protect the interest of not for profits.

Not for profits bring strong volunteer base which = resources and
keeps (mainly) seniors active

Establish CSS standards so that for profits have standards to adhere
to.

CSS can deliver well if they are funded appropriately. (ie PSS training
funding)
33
8.
Care Coordinators

Why limit Care Coordinators to Primary care settings? Suggestion to
collocate them in to CSS settings to increase learnings for CC.

Need to better define Care Coordination as a function rather than as a
part of a position.

We need Health System Care Coordinators rather than single sector
coordinators

HL have a great model for CC but we ned it to work for the other 95%
of the population

Consider the CC in the ARROW HL where the CC is being shared
outside of HL

Make sure that clients are at the centre of the activity and providers
work around them.
9.
Question
Feedback
How can Public Health be better
system?

They must share their data with LHIN providers to inform a full care
plan.

Falls prevention, Smoking cessation and other PH programs align well
with LHIN funded programs

Attain consistency with all PHUs. Currently they all run differently.

There are too many PHUs.

Current relationship between Champlain CSS providers and PHUs is
very positive. Champlain Capacity Developers rely on that good
relationship.

Be cautious of duplication of services ( is smoking cessation, foot care)

Have PH stick with mandate of Prevention so it flows well into CSS
services and beyond in the continuum of care
34
Champlain Health Link Coordinating Council
February 18, 2016
Question
1.
2.
Feedback

Kudos that health equity is mentioned in there.
Query impact of LHIN / CCAC integration –potential for roles to be in
conflict /issues related to structure

Like issue of better alignment with public health

Build on experience of Health Links

Clarify which geographies with flexible boundaries – e,g francophone
communities

Opportunity to consider after hours options /conflicting incentives

Need to support people with functional needs – e.g. supportive
housing, attendant care as prevention strategy-/ concern about
combining assisted living/supportive housing

Like sub-geographic region as concept most! Planned connectivity with
primary care a great step forward

be explored?


Look at existing partnerships working well
Leverage Existing partnerships with primary, hospital care in rural
environments (bundled care)
Funding geographies based on health status
Equity of pay for equal work must be in place.
Question
3.
4.
Feedback

leaders?

providers in navigating and linking with 

The partnership should be a two way street
Payment models should support collaborative planning
Decision support and quality improvement need to be in place
It is important to recognise the need to educate new
MDs about community support services

Need to have effective linkages – relationships to drive change

Concern emergency services not included

Support from primary care for sub-LHIN areas will require support
35
5.
6.
Question
Feedback


integrated with primary care and acute 
care while not creating an additional

Takeout some of the duplication in case management roles;/transitions
in care
Need to ensure equitable access through process
Needs to consider all community support
Impact of empowering frontline staff to do what they know needs to be
done

Not all community services created equally….

Rotations in caseload is an issue

Requires shift in accountability to patient from organisation

Work around have contributed to fragmentation

How can home care be better integrated with primary care and acute
care while not creating an additional layer of bureaucracy?
Question
7.
Feedback



Yes... supportive of approach – appears more patient-centred
Ministry needs to maintain stewardship role
Queried how can we engage patients’ support for the change process?
It should create opportunities to improve care coordination.
36
Regional Geriatric Advisory Committee
February 19, 2016
Participants: 25 individuals – health service providers
Question
1.
2.
Feedback
more integrated environment.
Legislation such as the Hospital Act is limiting. Sometimes a patient
could be seen by a member of the team such as SW, or a Nurse
Practitioner, and not necessarily a physician.

Use transition coaches as clients move between settings – decreases
duplication, ensures all recommendations are followed through on.
Especially needed for high risk clients and/or individuals with chronic
diseases.

Not limiting hours to daytime only, provide evening services.

Design care around patients. Some programs are thorough in
addressing one defined part of a patient’s condition and don’t look at
the whole. Design programs that address the complexity of each
patient.

Coordinated care needs to include primary care as well as specialists.
In hospital setting various disciplines can communicate and plan care
jointly. This type of real-time access to specialist is required for the
care of individuals in the community (beyond shared EMRs).

There is a disconnect with the discharges from hospital. Hospitals
could retain responsibility a few days after discharge.
be explored?
Streamlined Care Coordination: Within a patient centered approach
care coordination needs to be centralized. Sometimes there are
multiple organizations each with care coordinators caring for the same
patient, but there is not necessarily communication between the care
coordinators. There is an opportunity to streamline care coordination
(stratify clients, provide the right amount of care coordination and
enhance communication). The priority needs to be the care for the
patient, not the various organizations protocol/practices.

Primary Care as a sector: Need to strengthen primary care – needs to
evolve into its own distinct network.

Cross-sector collaboration: Sometimes coordination needs to include
other organizations/sectors – mental health, justice, municipal sectors,
ministry of education for programs that align, colleges and universities,
etc.

More education/information available to patients and families online, so
that when patients come for care, they are informed. Health literacy
should be linked with other provinces, targeting multiple levels of
education. Health literacy is poor.
37

Use equity impact assessment in planning: Some healthcare resources
are easily accessed in some of the rural areas, but not easily accessed
in other rural areas. How can access be made more easily available to
all?

Re-examining the role that a resource plays in a community. Could a
small hospital be made an urgent care center?

Reconsider LHIN boundaries.

Within integration reexamine roles and function of players. Can
hospitals expand their mandate?
Question
3.
Feedback


Level the playing field with primary care. Primary care physicians need
funding for admin support the same as other physicians in the system.

There needs to be regional tailoring across the Champlain LHIN based
on differing needs. Once a design of services is developed, then it can
be tailored.

The Ministry doesn’t know who the physicians are and where they are
or what type of medical practice they are involved in.

Physicians don’t have access to their own data, to analyse it and
understand it. Quality improvement interventions depend on this.

Service mapping would be beneficial so that physicians would know
what is available and how to access it.

One stop shopping – One navigator. Need to simplify access to clients.
The complexity can exist behind the scene.
This needs to be designed differently than Health Links.
38
4.
Question
Feedback

Can there be some type of protected means of contact between
physicians to get in touch with each other, with home care? Need
secure shared platform between all providers.

Not all population received required services: It is easy when patients
have physical problems, but more difficult when patients have mental
illnesses. These patients are not well served by homecare. Need to
ensure services fit with populations at risk.

Simplify scheduling of home care services. App?

Need consistency in PSW same homecare person can go to the same
patient’s home each week.

The business model that CCAC is funded on is flawed, which means
CCACs are powerless in changing the practice of private providers. It
adds layers and raises the cost. As we integrate should not transfer
business model.

Wage discrepancy: Community providers are paid so much less than
those in hospitals and retirement homes.

The use of the Inter RAI tool needs to be evaluated.

Need to decrease need for reassessment. Need to build trust between
providers. Use existing expert information. How can we get service in a
timely manner utilizing already existing information? Eg. Can DH info
be sent to Adult Day programs so that there doesn’t need to be another
assessment done before beginning a day program.

Patient Centered Model: Sometimes the patient needs on-going
maintenance of community supports instead of being discharged from
the support.

Patient and family education is needed.

Equity of services provided would be beneficial.

Sometimes families receive a certain type of assistance, but require a
different type of assistance (one size does not fit all).

Integrate sub-acute and post-acute
39
5.
Question
Feedback
system?

Align geographies of both LHINs and PH.

There is a strong overlap between primary care and prevention. How
can PH work better with primary care.

Data is essential to improve the healthcare system and social
determinants of health. PH has access to data.

Is there a way to integrate the over 400 primary care clinics, so that in
the event of a pandemic or other urgent health situation, they can be
part of the process?

There is a lot of opportunity to integrate health promotion across the
continuum, eg health education, awareness, etc.

Integrate the messages so that regardless of where someone goes for
care, they get the same message.
40
Primary Care Network for Prescott-Russell
February 22, 2016
Participants: 11 individuals - primary care physicians (6), nurse practitioner (1) and family health team administrators (3)
Question
1.
2.
Feedback
expanded role?
It isn’t clear how moving the CCAC functions to the LHIN will be more
efficient and cost effective. If it is all the same people and the same
way of operating won’t be better results. If put the CCAC case
managers in the primary care providers groups, this might actually
reduce access, not improve it.

Hopefully moving the CCACs to the LHINs would address the issue of
running-out of service by December (i.e. later in the fiscal year) when
funding runs-out.

Concern that the LHIN could move funding from primary care to
hospitals or integrate two family health teams for example if the LHIN is
given more responsibility for primary care. There is a double edged
sword to “hubs” because hospital administrators are able to attend
meetings and advocate for their needs but the front line providers are
not at the table to have their voices heard.
Sub-geographic regions make sense. However, we have some very
particular characteristics (for example our very close proximity with
Quebec). The Canada Health Act allows anyone to be seen anywhere.
This is not recognized and places a burden on providers.

The sub-regions would help with understanding the variation in
population need.

If want to build off existing Health Links regions, need to ensure there
is a bit more standardization across Health Links.

It is a problem that individual primary care groups are defining what
services they want to offer. Need some greater standardization.
41
Question
3.
4.
Feedback
leaders?
Concern that document uses the word leverage a lot. This could
equate to more work. There is a fear that well-running organizations
might be burdened with leverage issues without any additional funding.
As it stands now, the pay scale for many health professionals in below
LHIN salaries and wondering how to correct this.

The make-up of the FHT is based on the needs of the community. If
the programs aren’t fundamentally sound and interesting they need to
be revisited given that there are only so many resources to go around.
Each FHT will be unique unto itself because of differences in
resources.

In some areas, the primary care providers are also running the
hospital. They do all of primary care, and deliver babies, and cover the
hospital. This needs to be factored in.

The family health teams are inclusive so this is why there is variation
across FHTs. To understand this variation, need to speak to the FHTs
to understand uniqueness.

It is unrealistic to have different regions for Health Links and for subLHIN geographies and expect the providers to take on this role.

At one point, had a “hospital in the home program”, then it got
transferred to CCAC and fell by the way side. It was a good way to
foster transitions from hospital to home. This should be reinstated.

It is also a challenge to access resources. For example, referring
patients for interventions such as colonoscopies should not be
complicated. Should be able to send a referral and the next available
provider should be able to do the intervention. Could have easier ways
of triaging (centralized triaging) so primary care providers have an
easier time finding resources for their patients.

There are issues with accessing services through telehealth (such as
the telemental health program through CHEO). Approach has changed
because there is now a requirement for a nurse or a physician to sit-in
on the session with a psychiatrist. This does not seem reasonable
given that if a patient went to see the psychiatrist on his or her own,
there would not be another provider present for the visit.

There are some issues with negation and other rules that make
attachment difficult.

Need to be careful with attachment rates: Patients may be attached to
a primary care provider but if the provider is not close enough to where
the patient lives, won’t go see the primary care provider and will visit
the emergency department instead.
42
5.
patients about their primary care
experience be used? What data and
information should be collected and
publicly reported?

There is still some duplication in services. For example, if a family
health team refers a patient to a diabetes education clinic in a
community health centre, the patient is seen by 2 teams which is
inefficient. If a family health team does not have a program, it can’t
send the patient to the primary care provider that has the program.
(negation)

Primary care providers would be willing to work with each other to
share programs if there was a give and take. For example, some
programs could accommodate patients from another practice if there
was an ability to send patients to programs that the other practice
offers. If optimize utilization of programs get better efficiency.

The present system as we have it now contravenes the Canada Health
Act because there is not equal access. By signing-on to an individual
physician, could be excluded from other services because not all
physicians have access to the same range of services.

Primary care providers need greater support to be able to access data
contained in primary care electronic health records to determine if
practice is improving.

The performance measures that are currently in place are not likely the
ones that are the most important for PC. The measures don’t capture
patient behaviour (e.g. an appointment was offered but the patient
refused). Confuse urgency with convenience (does the patient need to
be seen the same day?). If really needed to see the urgent patients,
would see the urgent patients.

Some of the patients can be “seen” by phone. They were seen and had
their needs addressed, but this does not count.

There are many variables that contribute to targets being met or not
that our outside the control of primary care (e.g. hospitals, home care
services).

If want performance targets, will need to engage with physicians to
determine what appropriate measures are. Some data is of low value.
Right now, completing Quality Improvement Plans but this is imposed
by the Ministry. For example, Ministry wants to know number of
contacts with patients but this does not give an indication of quality of
the care provided during that contact. Important to identify measures
that speak to value. Not only how many patients we are seeing but are
they getting better.
43
6.
7.
What do you see as the most important 
areas for improvement in primary care?
Patients may be going into emergency rooms because of scheduling
issues. But this might also be driven by patient choice. There is no
accountability on the patient’s part to manage their own utilization of
services.

Most of the comments from patients of family health teams are that
patient expectations are not being met in terms of access. Would like
almost 24 hour access. Patients are not being well educated in terms
of capacity of primary care providers. Primary care practices should not
be penalized for patients’ choice (e.g. appointments are being offered
but patients would prefer different days or times). A lot of emphasis is
being placed on access but also need to educate patients.

There will need to be better ways of integrating primary care by
removing barriers to collaboration. There is a fear that solo
practitioners might lose their patients to more organized groups. There
is a two-tiered system in primary care. The Ministry proposal as it
exists will not address this.

A huge challenge will be that the FHTs get a budget but the
accountability for outcomes rests with the physician. The LHINs will not
have any control over physician behaviour. The LHINs will not have
levers to increase accountability.

The demographic profiles of physicians and patients are changing and
therefore practices are changing.

There are general terms that physicians need to abide by but can’t be
cookie cutter.

Want to include the patients’ voice in performance indicators but how
are you going to get it to ensure it is meaningful. May not be surveys
that will be the best way to capture the patients’ voice. However, if
don’t collect this, we will become provider centric.

There will need to be some support for primary care representatives to
be involved in discussions about new models of cares.

If I could add something to those suggestions, I would say that IHP
should be more involved in decisions concerning strategic orientation
and program development. For instance, having a mandatory IHP at
the Board level of any FHT could aim Patient’s need, and offer a
different perspective.
Need uniformity across the province about what is expected of
physicians and of patients. There is variation in accessibility. Will need
to work with the OMA to standardize expectations. There will need to
be clearly defined rules. Self-governance of physicians does not work.
The biggest problem right now is physician behavior and access. To
tackle this problem, need to adjust the contracts. If no structures in
place, people will do their own thing and take over.
44
8.

role?

The notion of associating Family Health Teams (FHT) with LHINs in not
very popular. Would like base funding to stay with the Ministry of
Health and special funding could go to the LHIN (would not have to ask
the Ministry for additional funding for local initiatives. Could deal with
the LHIN).
What might work is having a CCAC case manager assigned as a point
person to a family health team. This will help but it is complicated to get
integration with other parts of the system (in terms of accessing
patients’ information).
Question
9.
Feedback

population?
Historically, have seen different programs handed-off to the CCAC. Will
need to evaluate the true costs of this. Will be doing the same for FHT
programs.
Need some guidelines from the OMA in terms of what is expected of
physicians when they take on a certain caseload.
45
AROW Health Link Care Coordinators Work Group
February 23, 2016
Participants: 6 front line health professionals
Question
Feedback
1.
2.
What other opportunities for bundling

care and possibly other sectors should 
be explored?

Primary care providers need to be on board with the ideas and become
more knowledgeable about community resources. They need to go
beyond medical problems.
Communications among providers should be improved and supported,
particularly IT systems
IT systems need to better capture patient experiences
Mental Health and Addictions providers have been working together as
a system for a while and now working in Health Links. Further
integration with primary care for better patient care and outcomes is
needed – this is already happening in Renfrew County
Question
3.
4.
5.
Feedback

leaders?
Need more education and communication with Primary care providers
care?

Primary care providers need access to different health care disciplines
e.g. FHTs

Effective primary care networks need adequate admin supports and
resources as well as accountability for populations within a geographic
region. The voluntary, good-will approach only goes so far and can’t
rely on this for accountability.
Need forums to bring primary care providers together to interact and
develop relationships
46
6.
7.
Question
Feedback

Great idea to bring CCAC under the LHIN

Currently, there seems to be a level of accountability missing at the
CCAC, rigid processes, Case managers don’t go into homes, too many
hand-offs and too many people involved with each client.
Ensure CCAC services are more localized within a smaller geographic
area.

CCAC could have a pool of providers that people could access

Information from PSWs should be communicated to the client’s broader
care team
8.
Question
Feedback
system?

A greater link between the LHIN and Public health units would be
beneficial to fill service gaps e.g. dental care.

Ensure public health representatives are part of health system planning
tables and steering committees

Align public health with other parts of the system to provide additional
supports e.g. smoking cessation programs

Great idea to align public health and LHINs as Public health is working
in silos now. More accountability from public health would be good.

Some public health units focus on specific populations e.g. kids – what
about the other segments of the population? Sometimes their priorities
are not aligned to the rest of the health system – greater links would
improve this.

Ensure the same tools are being used in public health and in other
parts of the system – would help with consistent messaging

The current proposal in Patients First would help to address the many
challenges that currently exist with public health.
47
Health Professionals Advisory Council
February 23, 2016
Participants: 10 members of regulated health professions
Question
1.
2.
Feedback
The proposal speaks to a desire to organize things more efficiently.
Don’t see anything about personalized care for the patient and
individual relationships with care providers. Need to protect the
relationships patients have with their current care providers during any
transition in structure of organizations. Worried about liabilities to the
patient and care workers.

If we are successful and delivering services in an integrated way in
sub-geographic regions, we won’t need Health Links: The Health Links
way of providing care, will be the standard of care.
expanded role?
The proposal changes the LHIN’s focus from planning services to
delivering services. This might be an issue if the LHIN’s don’t spend
enough time furthering their work to better integrate the health system.
48
3.
It is a good idea to try to integrate all the various parts of the health
system. Support the general thrust of the proposal because the time
effort and energy wasted by patients trying to navigate the system is
disheartening.

There are many parts of the system that don’t even know that other
parts exist. A large proportion of people with chronic diseases have
mental health and addictions issues, yet these conditions are often
ignored.

There are issues with the CCAC contracted service providers. Several
are not local and are trying to coordinate services from a distance
which is not responsive to individuals’ needs and adds too many layers
of administration. These arrangements are also not conducive to
retaining good employees who get discouraged and leave. There are
concerns that these providers are private, for profit and that not all the
funds are going into service (i.e. if can offer the service for cheaper,
they make more profit). Not clear that “patient centered care” is the
priority for these organizations.

There are concerns about sub-LHIN regions and how these align with
other provincial initiatives that are being driven by other Ministries such
as service collaboratives, special needs strategy, poverty reduction
strategy, etc that all have their own geographic boundaries.

Are the sub-geographic regions population-based? The number of
people in the province is growing: Where are these individuals settling?
We need to think of a size of geography that takes into account travel
time to services.

Whatever criteria is used to define sub-geographic regions should be
based on access to services, not municipal or geographic boundaries.
Should not define sub-geographic regions in legislation as these will be
hard to change if don’t get them right from the outset. Also need to be
mindful that some services can’t be sub- divided and need to be
thought of on a whole-LHIN region (e.g. specialized services like
cancer care). Boundaries might need to be flexible as well to ensure
some people aren’t arbitrarily cut-off from services

It would be important for patients to maintain ability to choose where
they want to receive services. Geography becomes important when we
think of how long it takes patients to get to their providers or how long it
takes providers to get to patients. Geography is really about access to
services.
49
4.
receiving the care they need when they
Chiropractic services are not represented in the proposal. Want to be
part of the solution to better quality care but there are many barriers to
being involved, such as lack of public funds for chiropractic services.
There are limitations to utilizing the full spectrum of professions that
exist in the province. Various professions could be leveraged to reduce
wait times, deal with complex patients, round-out interprofessional
teams. This would be more cost effective.

No mention in the proposal of strengthening links with community
pharmacists as part of better primary care.

The proposal should ensure all professions are working to their full
scope of practice as this would improve quality and cost effectiveness
of health services. When we think of primary care, we think of
physicians, sometimes of nurses, but rarely of the other health service
providers.
5.
be explored?
Like how the proposal is trying to link everything: home care services,
public health (so we can focus more on prevention), keeping role of the
LHIN. But what is disheartening is that the proposal does not speak to
prevention of disease. Would hope that we would be doing more to
prevent chronic illness which would be more cost-effective. There is no
focus on children in the proposal, yet they are the ones we will be
caring for when their health is poor in the future.
6.
What areas of performance should be 
highlighted through public reporting to
drive improvement in the system?
When we look at best practices, how will these be shared in the
system? Not clear how we will set standards and how we will measure
quality of care. Perhaps there should be a link with Health Quality
Ontario. Who will address performance issues and how?
7.
Should LHINs be renamed? If so, what 
should they be called? Should their
boundaries be redrawn?
Ministry should not change the LHIN name. This would be a waste of
money.
50
Question
8.
Feedback

The responsibility for the patient’s care plan is currently too
fragmented. Would support the concept of having coordination teams
embedded in primary care.

We should build on existing primary care groups (such as family health
teams, community health centres) to link other services that patients
will require. However, will need to think of the sub-population that does
not have a family physician. Perhaps un-rostered patients could be
attached to the community health centres. They could have more
satellite offices, extended hours, telemedicine, home visits, have some
programs with the hospitals. Services that don’t belong in the hospital
could be divested to community health centres.

Health Quality Ontario has a number of metrics that they monitor. The
Patients First proposal does not speak to what metrics will be
measured to ensure the changes proposed are effective and are
improving care. Will be difficult to select the right metrics. Could
consider time it takes to access community based services. For people
that have complex illnesses, there is no discharge point from services.
Might measure whether we are able to maintain people’s current level
of functioning rather than trying to improve them. Patient satisfaction
should be an important measure. If we are truly patient centred, we
should be asking patients whether they are satisfied with access to
services. This would encompass most of the measures contemplated
in the common quality agenda. We will need to quantify some metrics
so we can manage expectations and correlate with patient satisfaction.
The Ontario Perception of Care is a good example of a tool that could
be used to measure satisfaction.
9.
publicly reported?
10.
When you think about what you expect 
from your primary care provider, how
will the proposed changes help
address what’s important to you?
There should be more specialization in primary care clinics (such as
pain management expertise) rather than having to go to specialists in
hospitals.
11.
If provide more funding to primary care providers to see patients when
they need to be seen, this would reduce visits to the emergency
departments for conditions that are not urgent. Why are services not
provided in the community by community resources instead of
hospitals?
51
Question
Feedback
12.

The fragmentation in the system is not conducive to good patient care.
Very receptive to the notion of better integration and sub-geographic
regions but the actual service delivery of home care services (the boots
on the ground), should be delivering the services in the sub- regions
(e.g. the Community Health Centre could employ the personal support
workers and nurses that deliver the home care services).
13.

From an acute care perspective, there is a big divide between the kind
of care provided in hospital versus the community. The care plan
developed in the hospital and the expertise of the hospital gets
dropped when the patient is discharged from hospital. The CCAC is no
longer a part of the interprofessional teams in the hospital so it can’t
play a role in facilitating the transitions back to the community.
14.

care?
Caution with merging the CCAC with the LHIN. Concern about conflict
of interest that is inherent when planners and funders also deliver
services. Don’t have a recommendation but this is something that we
will need to be mindful of. For example, if a hospital or a community
agency is going to the LHIN with a proposal, it might be in conflict with
the LHIN’s own proposals.

CCACs have struggled and tried to reinvent themselves over the year
and have not been successful. What will be different under the LHINs?
Something else will need to change otherwise, care at the front line will
not be any better and the LHINs will wear it. Is there anything we can
learn from the various models of home care provision that have been in
place in the province over the years? Home Care, vs CCAC, etc.

Having the LHINs take on the functions of the CCAC might drive down
some costs. There might be better flow of patients out of hospital.
52
15.
Question
Feedback
system?

Don’t think that the public health units should be duplicating what the
health service providers are doing in the community. Their role should
be more public awareness rather than service delivery. However, in
smaller communities, public health units could target populations at risk
based on the needs of the population. For example, if smoking rates
are high, public health could target youth to prevent uptake of smoking,
or teen pregnancies.
Question
16.
17.
Feedback
and data sharing?
Have had good experience embedding addictions and mental health
providers from one organization into other providers. Through purchase
of service agreements can obtain services from existing providers.
Purchase of service arrangements can strengthen existing providers.
Include in MOUs the requirement for providers to exchange
information. The LHIN could play a role in making certain these things
occur. The way to breakdown funding silos is to use purchase of
service agreements.

The proposal does not address needs to children with mental health
issues. Not clear how transitions to adult services will be addressed.
Many of these children will require services on an ongoing basis to
address chronic conditions. Need to clarify linkages with other
providers that are not included in the Ministry of Health (e.g. mental
health providers in schools).

Need electronic health records to be able to communicate about
patients across providers. Only then will we have a truly integrated
health system. This would reduce duplication and waste. Need to align
IT infrastructure in various providers to achieve this.
53
North Renfrew County Health Link Steering Committee
February 24, 2016
Participants: 16 individuals – FHT physician (1) and Admin Lead (1), consumer (1), HL Care Coordinators/Admin (3),
representatives from various HSP (10)
Question
1.
2.
Feedback

What other opportunities for bundling

be explored?
Support for planning at sub-LHIN geographies especially in rural areas
Savings generated from better integration of funding should go back
into the communities
Consider looking at Renfrew county as one sub-LHIN geography
although Health Links could remain as separate geographies
Question
Feedback
3.
leaders?
4.
care?
5.
There are some successful primary care engagement mechanisms
between primary care and home care e.g. CCAC Care Coordinators in
primary care practices, enabling technology for direct referrals – find
these successes across the province and learn from them

Identify primary care leaders to help with the change.

There needs to be training and supports for clinical leaders e.g. Telfer
Physician Leadership Course. There needs to be financial support for
physicians to participate and engage in these processes.
54
6.
7.
Question
Feedback

Look at care coordination as a function.

Care coordinators in primary care has shown to be very helpful but
recommend the ministry not limit care coordinators in primary care
settings only.
8.
Question
Feedback
system?

Great idea to have public health better integrated with the rest of the
health system. It makes a lot of sense to have closer partnerships with
public health.

Public health has excellent program resources to tap into e.g. falls
prevention and exercise classes

Public health has data and information about the population and social
determinants of health that would be helpful for planning purposes.
55
Champlain LHIN Decision Support Network
February 24, 2016
Participants: 15 decision support employees from all health care sectors.
Question
1.
2.
Feedback
expanded role?
Implementation will be a challenge. We will need to sustain pay equity
between the various sectors. Lose staff from primary and community
care to hospitals because of differences in pay. When moving to a
more integrated system, will need to be mindful of this.

Will need to also ensure equity in distribution of resources. Because
there are less resources available in hospitals, this is having an impact
on the workplaces which are becoming more stressful leading to sick
time and absences.

The alignment of population health and patient health may increase
responsibilities for all sectors. This increased responsibility may also
require additional resources, making it a priority to maintain public
health funding as it is shifted under the purvue of the LHIN.

It is perhaps a vote of confidence that LHINs will be more involved in
primary care. This should lead to better access. The LHIN can play a
huge role in making sure the various providers are doing a better job of
handing off between various organizations even if we can’t eliminate all
the silos.
Decision support function is funded by the Ministry of Health in Family
Health Teams. Have done a great job standardizing data collection.
Will the responsibility for decision support be shifted to the LHIN or will
the LHIN work alongside what is already working well.

How do initiatives such as community paramedicine that have been
created by family health teams and have been working very well but fall
outside the Health Links and are not funded by the LHIN fit? Can they
continue? Would there be funding for these?

Need some sort of framework to highlight the various initiatives that are
going on and some way to share information to avoid duplication.

Working at a sub-geographic level is a good thing. In Community
Health Centres already work this way. Elevating this to a system level
would help improve health of populations. Economies of scales might
be achieved in this way and the ability to leverage existing expertise.

It would be good to expand on Alternative Funding Plans to be more
regional. This could assist with better integration and coordination of
services.
56
3.
Hospitals work internally. There are sometimes barriers to working with
external partners and knowing what exists outside the hospital to
support patients to transition out of hospitals. Need better ways to
support patients in and out of hospitals. When patients need to
transition from acute services to rehabilitation services for example,
there can be breakdown in communication and challenges with handoffs. Need to improve the connections between different types of
services.

Would be good to have a centralized care coordinator to navigate the
patient through the system through the entire journey of a health
episode (across organizations and sectors). This is also useful within
single organizations as patients need to move between departments to
avoid break-down in communication. This would prevent waste and risk
for the patient.

It is problematic that the Community Support Services organization are
not mentioned in the proposal yet they are a key part of home and
community care. It is unclear what role is envisioned for this sector in
the proposed changes. If transforming CCAC, should include CSS
organizations in contributing to positive patient outcomes. Community
Support Services are in the process of developing standards for care
services.
57
Question
Feedback
4.
system?

5.
How can public health services in your
community be improved?
Unsure for Health Units that cross boundaries between LHINs how this
would work. They can’t be accountable to two LHINs and be funded by
two LHINs. Seeing the proposal as an opportunity for public health
units to be more engaged with primary care. Might provide some
opportunities to access funding for new services.

For public health there is concern about the right geographies. Many
public health boundaries align with municipal boundaries so it’s not
clear how place based interventions may be prioritized if they’re
meaningful in a small area context but not so for larger, sub-LHIN
regions. This arises from some ambiguity in the document where it
states “public health services would be managed at the municipal
level.” It’s not clear if this management would include local priority
setting. Part of the strength of public health is its ability to provide value
to local partners for the betterment of the health of the population.
Changing that context may adversely affect those partnerships if a
larger geography lens is used for priority setting

The orientation of the document including the naming of it as “Patients
First” starts with premise of care being required. This overlooks the
large role of primary prevention in maintaining population health which
is a principal function of public health units. While public health units
and LHINs may share areas of common interest there is a risk of
diverting population health priorities to those of individuals or groups
accessing acute care. This is particularly important as the effects of
primary prevention are often invisible in terms of the care sector as
healthy individuals don’t often interface the health system. There is
also a risk of considering a general term of “prevention” to apply to
secondary or tertiary prevention. Terminology needs to be clearly
defined, particularly “prevention” and “equity”; in the latter case whether
it refers to health equity or equity in access to care. The role of public
health in primary prevention needs to be acknowledged and protected,
particularly as population health is a Patient’s First priority.
58
Question
6.
7.
8.
Feedback

and data sharing?
Proposal does not speak much of mental health issues.
For most patients with chronic illnesses, there is presence of mental
health conditions. The system is good with dealing with physical health
but not mental health. Mental health services are in a different system.
Need to think of the person as a whole.

Unclear how the transformation will affect the use of technology. Each
hospital is deciding on its own what technology it should procure yet
this causes problems for integration. Should have one single system
for all providers which would be more efficient and more cost effective.
Even within large integrations, there is difficulty with connectivity. The
more different systems are put in place, the worse connectivity gets.
There are barriers to using single electronic health records even within
individual health organizations due to different reporting requirement
for different parts of an organization.

Systems such as CritiCall are not effective when it comes to
communication between providers to take on new trauma patients or
highly sick patients. New communication technology could play a major
role in improve transfer and uptake of patients for highly needed and
urgent services to ensure the provision of the full continuum of care the
patients need.

It isn’t clear how the Ministry will measure success of the proposal.
Readmission rates in and of themselves are not that helpful. Need to
know why the person is back in hospital (is it because the home care
service was not delivered?). Need a centralized scheduling system so
people know what services were ordered at hospital discharge and
what was actually received.

LHIN does not have patient-level data but CCACs do.

Need to make sure we don’t lose access to patient information in the
transition of CCACs to LHINs.
How would we know whether the plan 
is working?
There are currently too many layers and too many organizations in the
health care system. This makes it difficult for patients to navigate and
adds unnecessary complexity. It is hoped the proposal will help
address this.

Looks like the Ministry is stepping back from some things by pushing
accountability down to the LHIN. This is confusing in terms of what the
role of the Ministry is in creating a cohesive and consistent provincial
system. Despite the assertion of local needs, it may not lend itself to a
cohesive, consistent provincial system and may not exploit economies
of scale that may be helpful. It’s not clear to what extent this model has
been based on successes in other jurisdictions. Where do ambulatory
services provided in hospitals fit?
59
Members of the Champlain LHIN Community and the LHIN Board
February 24, 2016
Participants: 22 residents of the Champlain LHIN region that have experience using health services, caring for people that
need health care and volunteering on Boards of health services and other organizations
Question
1.
Feedback
Navigation is very important: Very difficult to navigate the processes
because they are new to people. Seniors need help navigating as the
system is not known to them. Need to have services that help navigate.
211 is a good example but the people that answer don’t always live the
experience of the people they are helping.

As a caregiver, there needs to be focus on families as caregivers.
Families can get lost in the system particularly those caring for youth
that are transitioning (youth transitioning from children to adult
services). Continuity of care needs more focus. There is a need for
more system navigation resources. These are hard to find.

See the proposal as a major step forward in the delivery of services. It
presents opportunities to include services that have not been included
in the past. The proposal around sub-geographic regions and public
health are good and are already being worked on in the Champlain
LHIN. Creating an integrated system, including primary care, is the
major step forward included in the document but will be the most
challenging. There are concerns with the timing of these changes: The
economic climate and the recent cuts to doctors’ fees will make it
challenging. The Ministry will need to smooth out the relationships with
providers so they can be willing participants in the changes.

The idea of district representation is superb. The Champlain region is
bigger than most of the provinces in Canada. Budgets for public health
need to be protected and there needs to be representation at the LHIN
level.

When delivering home care services, need to separate what is really
community care and what is early post- hospital care. The hospitals
should be provided some funds to help people get home earlier and
there should be protected funds in the community to keep people out of
hospitals. The LHIN will have to be very careful as it takes on a
responsibility for home care because it will not be able to meet all the
wants, needs and demands which are insatiable. There is a risk it will
be the whipping boy of the medical community. The result will be that
people (hospitals in particular and even politicians) can then say that
the LHINs have failed. It will be interesting too that it would be the first
time the LHINs cross over to service provision from planning, allocation
and monitoring. A precedent and a dangerous one at that.
60
2.
Like the document says there is a need for change. Need to reengineer
processes and use the resources that are available. Great that there is
the aspect of integration and the concept of monitoring and
measurement. There are weaknesses in the proposal such as
francophone issues. This is very important for Eastern Ontario.

Need to deal with the demographics of our society. Not all seniors have
access to resources to deal with their health issues. The teenagers are
often out of sight out of mind in the sense that they don’t always attend
to their health needs today, but their health issues that are not
addressed now will surface in the future and the health system will then
be affected.

Health Links is a good thing. eHealth is a good thing to address the
need to share information. My GP has to be able to access my
information. This is why patients have to take charge of their own
health and provide the information to their providers. Not everyone has
the courage to ask the questions of their providers because sometimes
don’t want to know.

Need to bring primary care resources to rural communities particularly
those that are francophone. There is a lack of primary care for the
francophone community. This is incredibly important as you get older.
Need to have health services closer to home for those that can’t drive
and can’t get into the city. The document touches on a lot of important
points. Appreciate the relationship that currently exists with the LHINs.
The system is very good once you get into the system and are sick, but
not very good at prevention. Embrace the “hub” model, the concept of
one-stop shop. Need to see the word “holistic” in the report. Wondering
what the linkages with the proposal’s “hub concept” with the Premier’s
community hubs. There should be linkages with other services outside
of health care. This would encourage healthier people and would put
less burden on the health system. Mental health and substance abuse
are big issues and need to have access to these services in rural
communities in French. There are needs that are currently unmet.

In support of developing groups of medical teams that are truly
interested in serving special populations in our communities so that
there are expertise that can be shared and a common understanding of
best practices that can be called upon by the broader medical sector.
61
3.
There is a lot of discussion about integration within the health care
system. However, the proposal does not speak to the need to integrate
with other Ministries. This is important for all, but particularly important
for children and youth with various needs.

Not all the Ministries involved in providing health funding are involved
in this proposal.

There have been some successes in our region with affordable
supportive housing particularly for seniors. Need more integration with
Ministry of Housing.

Since the new Board of Health has been formed in Ottawa, a lot of
good things have happened and would not want to lose these.

Volunteers are your most important assets. Hospitals have patient and
family committees. These are important and should be valued.

As a lesbian, important to receive culturally appropriate care. The
community health centres have a focus on equity of access to services.
Need to focus on vulnerable populations. The report does not speak to
vulnerable populations and hoping that this is simply a writing
oversight. In dealing with mental health issues, need to have access to
an interdisciplinary team as well as health promotion programs. This
helps develop a toolkit for the person to manage her own condition.
These programs are very strong at community health centres. Not
everything they offer is “primary care” but they are essential for keeping
people well. It costs less to keep people well than deal with crisis. For
example a meditation and movement course offered through the
community health centre helps promote health. Navigation and
advocacy are necessary in the design of the health care system. Not
everyone has support that can help with accessing services. Some
people don’t have the strength to ask the questions and fight for
themselves. The proposal flirts with the model of community health
centre’s model of care but it should be more explicit including cultural
competency, inter- professional teams, health equity, health promotion.
Hoping the community health centre success can be transferred across
the province.

We should have a clear definition and agreement on what “being” and
“doing” patient-centered healthcare actually is. Are we really clientcentered when CHCs are still closing during the lunch hour? I was
happy to be contacted and assigned a nurse navigator following my
cancer diagnosis, but that was the first and last time I ever saw or had
any communication with her. No navigation took place, I was on my
own to figure things out.
62
Question
Feedback
4.

What has to be strongly pointed out in the new plan is the need for
primary care providers (physicians and nurse practitioners) is to have
a closer relationship with those that are not in the health care system
(for example, Alzheimer’s Society). Right now, privacy laws don’t allow
this sharing of information to happen.
5.
The proposal’s focus on primary care does not address the fact that
the family doctors don’t have a lot of time to spend with individual
patients. Doctors don’t get paid to listen: They get paid to treat. One of
the good things that has been introduced is medication reconciliation.
But this needs to happen more and could be enabled by electronic
health records. Without them, there is a lot of communication back and
forth between hospitals and primary care providers. Concern that with
transformation, there will be loss of services and existing relationships
and linkages. Not sure that the LHINs have the capacity to take on the
infrastructure of the CCACs and there is a risk that patients will lose
services.
Question
6.
Feedback
from home and community care, how
The proposal is very high level. For people with chronic conditions that
want to stay in their homes, what works well is coordination of services
provided by community health centres, linkages with hospitals, and
access to an inter-professional team and outreach services (nurse and
physician). Home care services did not work well. Accessing the
assisted living services for high risk seniors program, which is a
program outside the CCAC, was challenging. Did not have anyone to
connect with. Had many different providers (15), and missed visits.
Ended-up hiring private help. Should build on what works. Having a
coordinator would be useful. If family is not able to provide
coordination, nurses end-up doing it which is not a good use of nurses.

The “Bringing Care Home” report recommendations, if implemented,
will improve the provision of home care services. Making these
changes on top of structural changes to the CCAC might be a lot at the
same time. Perhaps making the changes to the service delivery would
be more important. Otherwise, just changing the individual that
performs the functions will not make a difference. Structural changes in
and of themselves don’t produce better outcomes.
63
7.
8.
What is most important for you and
families you know when it comes to
your home care?
responsibility for home and
community care?

Need to better define what a caregiver is. Caregivers do a lot of the
jobs that health care professionals do. In fact, caregivers often have up
to 20 different professional jobs. Being a caregiver can be very lonely.
Become advocates for our sick person at home. Would need in home
care to assist to support the family health care team, not only the
professional health care team. Health care is not only an 8 to 4 job.
Often, can’t access services on the off hours. Going to the emergency
department is not appropriate.

The way in which community care is given and has ownership by the
Community, is of utmost importance in keeping people in their
communities and out of hospital care and peer wellness groups at the
grass level is also important. Whether for seniors, mothers,
disadvantaged, disabled or for youth, these types of groups can be
self- supporting and community building as well as forms to build health
and wellness in our community populations. One such model is the
Hans Kai program out of Winnipeg.

Should look at what the current CCAC service model is and try to
improve it before transitioning it to the LHINs. Otherwise, home care
will not be improved.

Like the integration of the CCACs and primary care that is proposed,
this should lead to better integration of care and services. Could help
reduce duplication of services. Could also provide better data for
monitoring and measuring. There might be better opportunity for
integration of information systems. However, there is a risk that current
initiatives will be lost during the transition. There will need to be
sufficient governance to ensure these important things, that are having
a positive impact, aren’t lost.

Improve health care system and other related, supportive services like
housing, etc. to serve clients where they are, rather than where the
system thinks clients should be (hospitals, professional health care
providers, clinics, various services like home care). The health care
system needs to move away from being hospital and institution centric.
For example, seniors would be well served by a community based
system that is not simply focused on 'keeping them out of hospital" but
"allowing them to live their lives fully where they want to be". The same
could be said of clients with life limiting illness, including those requiring
end of life care, and so on.
64
9.
Question
Feedback
system?

What is liked about the proposal is the concept of Patients First.
However, have been hearing about “patients first” in Ontario for the last
2-3 decades. Would like this concept better defined. The concept of
local community hubs is a good idea. Ensuring a broad range of
services across the lifespan are attached to these hubs with good
explanation of what comes next. There is a place for public health to
better integrate with primary care to offer services that would help keep
people healthy. Need continuity of caregivers and the information that
is provided between different providers. The information that flows
between hospitals and the community is abysmal. Need an attitudinal
change within the formal providers as well as expectations from the
community

In this region, there are positive relationships between the LHINs and
the public health units. There is a desire to continue with collaboration
around population health planning. Public health units have multiple
partnerships with a broad range of organizations in the community that
can ensure a focus on prevention and health promotion while the
LHINs have more of a focus on service delivery. There could be more
of a focus on community health. There is concern that public health
funding could be eroded. Will need to look at the governance model
between public health and the LHINs to ensure funding does not get
diverted away from health promotion. Need to ensure that public health
can continue to focus on population health issues such as safe water,
safe food. Need to look at the relationship of public health units with
municipalities.
65
Question
Feedback
10.
How do we create a platform for
further service integration, such as
enhanced community mental health
and addictions services?

Hoping that as LHINs are looking at indicators for services for people
with mental health conditions, that they will select indicators that are
more reflective of what is important and good service from person’s
perspective. Most of the indicators currently seem to be developed by
providers.
11.
and data sharing?

Should look at how other industries have succeeded. Often a small
innovation has allowed companies such as Coca Cola, McDonald’s to
have tremendous success. One innovation in health care that would
allow success would be a patient record that follows the patient. This is
not a novel idea but it still does not exist. A lot of systems don’t speak
to each other. For example, notes written in a patient record in
someone’s home by a palliative care physician/nurse/PSW can be
seen by the patient and family and visiting nurse, but does not reach
the oncologist or other providers. Having a patient record would push
for attitudinal change because more people would have access to
information.

It is atrocious that there is such time wasted to access information. This
is particularly important when people don’t have a lot of time left.
12.
There is a concern with the proposal: Disconnect between the
Ministry’s objective of Patients First and the difficulties the Ministry is
experiencing with MDs and RNs. If the people providing care are to be
sold on the idea of change, there needs to be a more respectful
relationship between the Ministry and the providers.

The document is good but some changes are needed to the proposal.
Health care should not be only based on “per person care” but also on
“disease based care”. For example, for people with Huntington’s
disease, they require a multitude of health service providers and lose a
lot of their abilities. The Ministry’s document is lacking in the support of
genetic diseases. These diseases require care in the community for a
very long time.

Agree that some changes need to be made to the care provided
through the CCACs. A lot of the people that work with CCACs are
concerned about what will happen to them, what their employment
status will be.

Proposal does not speak to bottlenecks into specialists. This is not
addressed but this is a big issue. There are a lot of delays in seeing
specialists.

Shocked that “patients first” is a new concept. It should really be
“people first”. We should not get lost in all the services and forget that it
is about “people first”. It is important that all the different providers are
more integrated together. Hopeful that some of the wasted efforts will
be diminished.
66

The proposal is a good start. Need to build the model. Won’t happen
tomorrow: Will take some time but need to start somewhere. Everyone
should take charge of their health.

There are too many small mistakes that are made in the health care
system that can cause distress and cost money to the health system.
For example, people sent home from hospital without being taught
what to do at home. Happy to see the CCAC shift into the LHIN. Has
been a challenge even though some of the CCAC programs are
excellent. Thought the word that would be used in the document would
be “clients” not “patients”. Important to use the right word from the start
otherwise spend time having to change the nomenclature. “Patients”
implies that we are focussing more on hospitals and sick people.

Although the document is called Patients First, the document actually
does not focus on patients and their needs.

Need to ensure groups or any organization reading this proposal will
take responsibility for making any of the proposed strategies happen
successfully.

The LHIN and Ministry need to consider how they “Model the Way” to
clearly demonstrate how it is or will become genuinely client or patient
centered themselves in support of this transformative reform. Need to
celebrate, encourage or recognize organizations and people that
clearly demonstrate how they model the way by making core
organizational values come to life, patient-centeredness being one for
them

We need to be serious and committed to making RESPECT,
COLLABORATION, COMPASSION, INTEGRITY, EXCELLENCE AND
RESPONSIBILITY become our modus operandi throughout the
Champlain region so that our system is transformed. The time has
come for each of us take some responsibility for making our system
more efficient and patient-centered. Walking our talk, modeling core
values and holding each other accountable for doing so is a
fundamental prerequisite to moving forward with any structural,
procedural or funding strategy. It’s the people that work within it that will
make our system better.
67
Upper Canada Health Link
February 24, 2016
Question
1.
Feedback
Aligning the sub-LHIN geographies with the Health Link areas, with a
minor variation or two, seems like a reasonable way to do it though
primary care may not link to this. For example, the Embrun / Russell
(primarily Francophone) population tends to go the Montfort Hospital.
There will need to be discussions at the sub- LHIN level about regional
differences that will not align with the Health Link geography.
2.
3.
Question
Feedback
How can we effectively identify,
engage and support primary care
clinician leaders?

There is a question about what an FTE is/involves but it doesn’t take
into account hospital work. There are exemptions for providing after
hours service if doing hospital work – our current after hours services
are provided at the hospital / in the ER. The idea of giving up hospital
practice to provide after-hours service is not feasible. We don’t have an
internal medicine group at the hospital to take care of that (provide
coverage).

Responsibility for performance improvement in primary care needs to
be accurately placed and tied to the appropriate person. For example,
Health Links cannot control ‘timely access to primary care’. Only
primary care providers can ensure that.

Collaboration is needed. There is a current state of negative
functioning between the Ministry and the OMA. PC providers will be
coming to a Primary Care Network meeting next week to be informed
and to assist the LHIN, but it will be a challenge because the proposal
is being viewed as the Ministry exerting their will.

Need more PC providers in our area; many of us are carrying a double
patient load. For example, the Cornwall area needs 10 more PCP’s
today. Advanced access to the system requires this, as does ensuring
access to PC for all Health Links patients.
Every emergency department needs a rotational shift of Nurse
Practitioners to triage the less urgent patients. A pilot with PA’s in the
ED was very successful at reducing wait times. NP’s would be even
better.
68
4.
5.
Question
Feedback

Ensure transparency, in terms of process, and equity across all subLHIN regions – have a worry that this won’t happen.

More than just CCAC – need consistency with respect to all services
no matter where you live.

Worry that it gets so standardized, that local context is not taken into
account. We have tools and clinical judgment to help us make
decisions about service needs

Common assessment tools – first we need to speak a universal
language and use the same assessment tools. This will speed things
up / reduce unnecessary delays

The majority of tools are screening (not assessment) tools and need to
be used as such.

Would like to see the LHIN take responsibility and ‘take the heat’ for
shortages
Not sure what the new version will look like
6.
Question
Feedback
system?

This allows for better access to Public Health information.

Recommend standardizing processes across health units (e.g. access
to vaccines)

This will bring the whole system more upstream. People (in need of
access to information and/or services) identified earlier.

There is a host of positives to come out of this

Need a way of knowing (e-notification) when my patients have received
flu shots, etc. through public health services
69
Question
Feedback
7.
and data sharing?

8.

People have a hard time considering another database. A portal that all
HSP”s could access - would the LHIN consider this?
It’s an exciting document; lots of potential
Concerned about the timeline – it is not reasonable; very ambitious.
However you need to start with a goal and be willing to work with it.

Buy-in will be the biggest challenge. No one likes change; especially
when a government suggests they will do what they want regardless of
the feedback they receive

There is not a lot of trust in our system. We do our own screening, our
own assessments
70
North Renfrew Primary Care Network
February 25, 2016
Participants: 13 participants: primary care physicians (9), nurse practitioner (1), Health Links project manager (1), family
health team executive directors (2)
Question
Feedback
1.
expanded role?
There should be a plan to integrate the CCAC resources in the subgeographic regions rather than centralizing them under the LHINs. The
LHINs don’t have the structures in place to absorb these functions.
2.
Renfrew’s geographic region is huge compared to the rest of the LHIN.
No acknowledgment that rural reality is different. This could mean a 2
hour drive. If CCAC resources are going to be put into sub-geographic
regions, need to make sure the same nurse isn’t covering too big a
geography.
3.

The document is silent on how much variation there will be from LHIN
to LHIN. Will the Ministry standardize its approach across the
province?
be explored?

There are concerns around costs. The only thing that is mentioned in
the document is participating in de- prescribing initiatives. There is an
acknowledgment that the integrated care networks will require
additional resources and it is unclear where the resources come from.
Making changes to the CCAC to save money is not likely the right thing
to do as the CCACs do a lot for patients. There is concern that current
case coordinators would be lost during the transition and a lot of
patients would fall through the cracks.
71
Section 2 – Timely Access to Primary Care, and Seamless Links between Primary
Care and Other Services
Question
Feedback
4.
publicly reported?

A lot of fear among the primary care providers about data. How is it
going to be collected and used to measure performance? Does not
take into account local reality (for example, if a family physician is
delivering babies on a particular day, can’t offer same day access to
primary care patients). Does not reflect reality of rural practices where
primary care is not only providing office hours in clinics.
5.
Does our approach achieve this?
Disappointed that the Patients First document does not speak to the
need for every Ontarian to be rostered to a primary care provider. This
would require ensuring that there are sufficient resources to roster
every person.
What else can we do to meet this
objective?

Primary care is a jumble of provider models. The document as
presented does not contain any direction about standardizing around a
particular care model.

Some of the provider models are left out such as solo provider models.
Emphasis of the document is on Community Health Centres and
Family Health Teams. What happens to the solo providers?

The opportunity to transform primary care under the banner of this
initiative is a great thing. We have a government that is engaged and
willing to make the necessary changes. It will be incumbent on us in
clinical care to get this right. The Minister has made big commitments
in terms of wanting everyone to have a primary care provider. This will
require a lot of effort and attention.

What are the next steps?
72
Alzheimer Society of Ottawa and Renfrew County
February 26, 2016
Participants: 10 caregivers
1.
Question
Feedback
How do we support caregivers in a

One-stop shopping – especially for individuals with Mental Health
issues and Dementia. Caregivers cannot track down all the services.

LHINs need to look at accountability – accountability with
subcontractors needs to reside at the LHIN. Caregivers should not
have to follow-up/deal with subcontractors. Currently caregivers work
with CCAC care coordinators but also need to work with
subcontractors.

Beyond integration need to look at how services are delivered – not
just integration with no change to management of program – need to
rethink the processes.

Clear understanding by providers of what is provided in subgeographies.

Need to look at equity. Equity does not mean identical services but
equitable access to what is needed.

CCAC website is not useful.

People with dementia and their caregivers are “the client” – need to
look at it as a business.

Need to ask “what do you need?” and not provide a pre- determined list
of services
2.
Question
Feedback
What is most important for

Primary Care need to have access to centralized waitlist for tests
(example: MRIs). Caregivers should not have to contact a number of
providers and be on numerous lists.

Greater access to after hours and weekend care.

All Primary Care providers should have some form of backup to
increase access when services are needed.

Patients should have access to their files electronically.

Access to booking primary care via e-mail or other electronic format.

Need to build capacity in primary care to guide where people where
they need to go/where to refer.

Primary care has to have a single point of contact in the system/ one
number (or person to call) or useful web tool to support navigation
care?
73
(decision trees).

Primary care needs to understand what it is like to live with Dementia.

Primary Care also needs to ask the question “What do you need?”
Question
3.
Feedback
How can we bring the focus on quality 
into clients’ homes?
We need to develop a process for measuring quality of services
provided in the home by agencies (assess and monitor).

Agencies need special dementia training.

Need consistency in care (fewer individuals working with one person).

Contracts cannot not be given only on the basis of lowest bidder. We
need to evaluate quality. MOHLTC needs to set standards.

Need better remuneration for individuals that work in the community
(lower wages than in hospital setting).

Reduce number of agencies currently providing services.

Need to ask “What do you need?” Agencies need to meet the needs of
the individuals in a meaningful way. Individuals need to be involved in
their care.
4.
Question
Feedback
What public health services do you
value in your community?

There is a general lack of knowledge of what PH offers.

Vaccination

PH should work more directly with people, more direct services.

MOHLTC needs to fund “prevention” services for dementia like Minds
in Motion. Keeps people active and can delay decline.
74
Residents of Champlain and the LHIN Board
February 29, 2016
Participants: 13 Members of the public, health service providers and partners
1.
Question
Feedback
What do LHINs need to
succeed in their expanded
role?

LHINs should be responsible and have the authority that goes along with the
responsibility. While the LHINs can make decisions, they often have to run to the
Ministry for approval, which wastes time and is paternalistic.

If the LHIN is going to be the great coordinator of services and coordinate the
sub-regions, the authority of the LHINs needs to be enhanced. The government
can’t allocate money and tie it up. The LHIN will need some money to be able to
incent change.

The LHIN could be in a conflict of interest with respect to the provision of health
care services and oversight of the system. There will need to be some
safeguards put in place to ensure strong governance to mitigate the potential
conflict.

Agree with the general thrust of the proposal but the devil is in the details. While
there is support for regionalization and communities planning for themselves,
the Ministry needs to play its stewardship role to ensure consistency across the
province. For example, performance metrics should be common. The Ministry
should support inter-professional teams to ensure better provision of patient
care.

Good that we are looking to bring greater consistency across the province.
However, this was the hope when the LHINs came on board as well, yet there is
a lot of variation across the LHINs.

The Champlain LHIN is in a unique position and the LHIN has demonstrated its
capacity to be innovative.

The LHIN has a large urban, as well as rural parts, and understands the different
needs.

Another key enabler to the successful implementation of the proposal is to look
at standardization of human resources and compensation. Some of the things
that are outlined in the document will require efforts on the union side. Will need
to ensure there is less difference between wages in hospitals and home care
services.
75
2.
How do we strengthen

consistency and
standardization of services
while being responsive to

local differences?
Fantastic that the focus in on the patient with emphasis on hard to reach patients
and vulnerable populations. Like that there is an emphasis on determinants of
health and the need for more integration across the system.
Heureux de voir la reconnaissance des besoins des francophones dans le
document. Va être important de renforcir la cascade d’imputabilité pour les services
en français du Ministère aux RLISS puis aux pourvoyeurs de services, d’autant plus
qu’il y aura de nouveaux pourvoyeurs sous les RLISS.

Les changements proposés vont nécessiter une meilleure identification des
francophones

D’avoir plus de secteurs sous les RLISS va aider à l’intégration du système. Les
sous-régions sont aussi vues comme une bonne chose, par contre, il va falloir
s’assurer qu’elles ne présentent pas des barrières à l’accès pour les francophones.

It will be important for the LHINs to focus to a greater extent on accessibility. There
is no mention in the document of the needs of people with disabilities.

People with disabilities, whether hearing loss, vision loss or other disabilities are in
our workforce. People with disabilities are left out of some of the parts of the
continuum of care.

Great that the document acknowledges that services are not currently equitable,
easily accessible or easy to navigate. The regional differences with access to
primary care and health literacy to access alternatives need to be acknowledged
and understood. The changes to the CCAC and the thought that some of the
functions could be better aligned to hospitals or other providers is welcome.
However, the realignment of CCAC services needs to have a regional planning lens
because the services are not always well aligned to the needs of the population.
Better linkages with public health is welcome. For example, could assist with falls
prevention particularly for those that don’t have access to a primary care provider.

People in more remote or rural areas are a group that has not been recognized in
the document.

It will be important for patients to be engaged at all levels of this initiative. We will
need to do a better job of having patient navigators to support people in
understanding the system, to answer questions. Will need to have people to talk to.

Service providers understand how linguistic barriers can be an impediment to
quality care and do their best to offer services in the person’s language or link with
other providers who can provide the service. However, service providers don’t
always know who is able to provide services in French. This will be required in order
to support professionals to refer their patients to the appropriate level of care.

Will need better access to technology to create an integrated system. Without it, not
sure how we will manage.

It will be important to put in place mechanisms to ensure consistency of the care
provider, i.e. the actual person providing care. There is a mixed bag of providers in
the community and need to ensure more consistency.
76
3.
What other local

organizations can be
engaged to ensure patients
are receiving the care they
need when they need it?
What role should they play?
Big supporter of putting patients first but this will require a culture change. The
concept of patients first is not broadly accepted. There will need to be broad
acceptance from management and the people providing services. Management of
all kinds of institutes will need to recognize that the system exists for the patients.
Most boards don’t recognize the need for or have patient representatives on their
boards.

L’entité de planification pour les services de santé en français a hâte de continuer à
collaborer avec le RLISS dans les changements à venir.

Need a stronger primary care and community sector so this is the right way to go.
However, it is a bit disappointing that there is no mention in the document about the
role hospitals would play in the system. Hospitals are an important part of the
system and consideration should be given to how they integrate.

Great that partnering and having people work together is a focus of the reforms.

Extremely supportive of health hubs, particularly in rural communities. In our region
we already have a hub we are looking at establishing one in the eastern part of
Ottawa and the Ministry is looking at how this could be replicated across the
province.

Small hospitals can play an important role in being rural health hubs and community
hubs for their regions.

There is a great model in eastern Ottawa to deal with non-urgent issues in primary
care through the Orleans Urgent Care Clinic. Why can’t we look at this and embed
in hospitals? Could help reduce ALC.

Community pharmacists can provide a lot of the key services that patients need,
particularly chronic disease management. The LHIN is encouraged to see how to
integrate pharmacists into the inter-professional team.
77
4.
What other opportunities 
for bundling or integrating
funding between hospitals,

community care, primary
care and possibly other
sectors should be

explored?
Strongly support the integration of the CCAC into the LHIN. That whole system is
flawed and there is too much investment in administration in the CCAC.
Support merging the CCACs with the LHINs. There should not be any for profit
contracted agencies. Health care should be not-for-profit.
There are a few red flags in the proposal. There are currently a lot of physician
payment models. Unclear how the LHINs will bring all these different groups in.

Unclear what is meant by integrated bundled care. This could mean non-silo
funding which will take a bit of doing. It is very clear from what we have heard from
the government and the LHINs that there is no more money so there is an
expectation that changes will have to be implemented within existing resources.
However, it is unclear how cost savings produced by successful programs like
community para-medicine can be captured and reinvested. It appears that when
savings are produced in hospitals or long-term care homes the only way to capture
the savings is to close beds and lay- off staff. The transformation will require the
saving and bundling of human and financial resources.

Bundled payments are an opportunity to further explore how money can follow a
person and how this can occur across providers.

It is hoped this initiative will save money. We can’t continue to spend increasing
amounts of money into health care. With more integration, there should be savings
if people don’t have to go to so many different places for services. Health hubs
could help with this and it might mean forcing physicians to be part of health hubs
rather than working on their own.

The Ministry should consider funding more community health centres as part of this
strategy.

If we are going to pursue bundled funding within sub- regions, recruitment of health
professionals will be an issue. It is difficult to recruit and retain health professionals
because in small communities, they are mostly part-time working with multiple
providers to get full-time work. Would be better to have more full-time positions by
bundling payments across providers. This would cut down on the amount of time
providers are on the road travelling great distances to see patients. If there was
more full-time work, people would be attracted to rural regions and their partners
would be more willing to join them.

The special relationship that the Medical Officer of Health will have to develop with
the LHIN CEO is important. But equally important is the special relationship that the
public health unit board will have to develop with the board of the LHIN. Will need to
ensure that there is no opportunity for the LHIN to dip-into the funding that comes to
public health from the municipality.

Integration of CCAC and LHIN will save some dollars but I think the efficiencies will
be, with further development of partnerships with community agencies, providing
support services and programs not delivered by the CCAC; integration of agencies
that have similar mandates; and streamlining of current processes. Also concerned
with governance of the LHIN and how this will be resolved.
78
Question
Feedback
5.

Like the idea of wrap-around services from primary care to community
support services to municipal services. This is a very good approach
but the problem is that there is overlap with other provincial initiatives
such as Health Links, the (OMA) report on primary care, the primary
care document. The Ministry and the LHINs have to get their heads
around what model of service they want. All models focus on subgeographic regions and LHIN. Need to determine what the focus needs
to be so we can get on with the work. The Romanow report of 2002
says a lot of the same things so it is about time we get on with it.
6.

Does our approach achieve this?
Will really need a strong inter-professional team in primary care to
support changes to happen.
What else can we do to meet this
objective?
Patients, caregivers and primary care physicians’ trust will need to be
rebuilt in order to support people to stay at home. Right now, not
always the confidence that services will be available. Will need to be
common messaging for the public about the services that are available
or not available.

Timely access to primary care and other services is an important
component of the plan however, the system •
issues stem between
the scopes of practice of health care professionals, how they interact
with each other or not, and defining who is responsible for what. This
issue could also be better managed with an electronic health record for
all involved in a patient’s care plan would have access to immediate
and update to date information. Scopes of practice should truly reflect
patient centered-care and not just words on a page. Health care
providers should not take for granted the voice of the caregiver as they
sometimes have a better understanding of the challenges the patient
faces on a day-to-day basis. Without this caring support, the patient
could deteriorate and be at greater risk of hospitalization or other
negative outcome.

The MOH introduced a new model of primary care in Ontario. Nurse
Practitioner Led Clinics that enable NP's in collaboration with IHP's to
deliver comprehensive primary care services---without any OHIP
billing. Nimbleness, creativity and responsiveness to changing client
needs and health trends enable the Glengarry NPLC to advance
creative programming e.g. (CCO initiatives; Provincial patient
experience pilot site; Advance Care Planning; Chiro Low Back Pain
programming, etc.) and achieve top level results provincially and LHIN
region in such areas a client experience; same day appointment; ER
diversion; and cancer screening practices. This model of care needs to
be expanded---additional clinics created as all NPLCs have data to
validate and demonstrate their value-- particularly regarding putting
patients/ clients first.
79
7.


role?
The physicians should come under the LHINs. Without this, there will
be a huge stumbling block.
C’est un avantage d’intégrer les soins à domicile avec la santé
primaire. Par contre, c’est problématique que les RLISS soient non
seulement responsable de la planification et du financement mais aussi
de la prestation des services. Ceci pourrait être un conflit d’intérêt.

Timely access to primary care will be an enabler but will require a
strategy to bring primary care into the system.

Wondering how LHINs will be involved in planning for human resources
and where primary care services should be delivered.
8.
9.
Question
Feedback

To enhance patients’ experience as they flow from hospital to home
environments, it would be good if there was greater standardization of
assessment tools so patients don’t need to be reassessed.

The support network for caregivers looking after people at home is not
adequate. The hours of service available is not sufficient and people
are burning-out. Caregivers are aging and will need care themselves.
Integrating the CCAC into the LHIN will need to come with access to
24/7 care.

care?
The CCAC needs to be scrapped. There needs to be opportunity for
organizations in sub-regions to allow the CCAC services to be provided
by these organizations (e.g. local hospitals). The CCAC has been a
money drag for a number of years. What the LHIN does with it is
another matter. Could take the case managers currently at the CCAC,
give them training and have them become care coordinators within the
Health Links or other models of service.

Would suggest that there is an opportunity to focus the functions of the
transitioned CCAC on its area of expertise such as nursing and
personal support. Rehab could be taken on by other organizations that
have this expertise.

Should be open to new models of care, for example access to
diagnostic imaging in long-term care homes. Could create a bit more of
a hub of service in long-term care homes given that they have the
physical space.
80
10.
Question
Feedback
system?

The integration of local public health units into the development of the
plans will be a big step forward.

Public health should be under the LHIN and so should the paramedic
services.

Public health and Emergency Medical Services were left out of the
LHINs when they were created. Good that we are playing catch up and
they are being brought in now. EMS should be included in the changes
as they are involved in some innovative initiatives that are supporting
primary care services particularly in the rural areas.

Public health should be the responsibility of the LHIN as there are
overlaps in services provided by other agencies and it could bring
system efficiencies and cost savings as well.
Question
Feedback
11.
The mental health and addiction information included in the plan is not
explicit enough – it does not provide enough information to truly
understand what and how the Ministry intends to move forward on this
issue. Mental health services should be fully integrated into health
services and these services should be covered. Mental health problems
such as depression and anxiety can have a major impact on the health
outcomes of a patient living with a chronic illness, life-altering illness or
terminal illness and have negative impact on their relationships with
their caregivers and their families. Mental health should be fully
integrated in the care plan of a patient and be included in the scope of
practice of all health care professionals. This issue needs to be
recognized to ensure positive outcomes for the patient.
12.
population?
Ce sera important de développer des nouveaux indicateurs de
performance pour mesurer le succès de la transformation,
particulièrement en ce qui a trait aux services en français.
81
13.
14.
and data sharing?

Will need an integrated health record across the province to enable the
proposed changes to be implemented.

An electronic health record should be a first priority in order to be
successful in the implementation of this plan. It should be considered an
essential element of integration to ensure that all health care
professionals involved in the patient’s care have immediate and update
to date access to his or her medical history. The patient or caregiver
should not have to repeat their story and the system should recognize
that not having an electronic health record should be considered a
system risk factor.

The government will need to change two pieces of legislation (one
related to CCAC contracted agencies and one related to union
contracts) if they truly want an integrated health system.
We should build on what we have already started to put in place, i.e.
Health Links. The system navigators that have been put in place to
work one-on-one with the patients and families would be very useful.
These individuals could help reduce the stress of the caregivers given
that they can have access to all the services that a person needs
82
South Ottawa North Grenville Primary Care Network
February 29, 2016
Participants: 18 individuals – nurse practitioners (3), Executive Director of CHC (1), Family physicians from various types of
practices (14)
Question
Feedback
1.

Currently, the LHIN gets funding from the Ministry and makes decisions
about who to give it to. If the LHINs are providing services, may be in a
conflict of interest in terms of funding decisions if they are to give
themselves funding for the services they deliver.
2.

One of the strengths of the document is the health equity piece. This is
one of the first times that the Ministry talks about this. There are
opportunities for providers to work together and breakdown silos to
make sure we are creating equitable access.
3.
The lack of contract between the Ministry of Health and the OMA is
problematic. It makes it difficult to engage in meaningful discussion
about proposed changes to the health system.
Question
Feedback
4.
clinician leaders?

Role of clinical leads is acknowledged by the Ministry but what is the
actual investment that would be made to support these roles.
5.
providers in navigating and linking
with other parts of the system?

Primary care is dependent on specialty care. There is a sense that
there are not enough doctors in practices. Believing that Ottawa is
over-serviced is a bit of a fallacy. Access to specialists is problematic
now and needs to be improved and more readily available.
83
6.


Primary care networks are already a means of bringing primary care
together. How are these different than the Integrated Care Networks
proposed in the LHIN document?
There will need to be a way to involve patients in the sub-LHIN regions.
In another province that went through regionalization by moving to a
regional health authority, it was a painful process. Some innovations
came of it, but needed time to get through the transition.

It is hoped that the CCAC care coordinators will be embedded in
primary care practices. However, the practices will need additional
resources to support the administrative work these people will generate
(for example, the care coordinators might ask office staff to fax referrals
for them).

Physicians are looking at stability of funding and the ability to run a
business. Said another way, physicians want the ability to provide good
care and equity in the availability of allied health professionals. Need to
ensure a respectful relationship and a good work environment.

When looking at overseeing from a data perspective and shared
resource perspective, how will the boundaries of sub-geographies be
determined? People come to primary care practices from anywhere
(where they work, where they live). How many people will cross over
boundaries?

Having a hard time understanding the vision of access in subgeographic regions. Makes it sound like all physicians could see each
other’s patients. This is already done is individual practices. Sharing
patients between practices is problematic because continuity of care is
important. Not sure why the Ministry is interested in making changes if
there is an acknowledgement that things are getting better.

How does the Champlain LHIN account for utilization by patients from
Quebec? This is unique to this region but needs to be factored in.

Nurse practitioners are falling by the way side in the discussions about
most responsible provider. Nurse practitioners are doing a lot to
provide evidence based care. The nurse practitioners are being asked
to see patients within 7 days post discharge. However, the statistics
that the nurse practitioners are producing are not being accounted for.
Bill 179 has been tabled but there are still barriers to access, efficiency,
and collaborative care.

To provide 7 day post-op visits, need to have the hospitals at the table.
Often primary care providers don’t even know that a patient has been
in the hospital. Hospitals need to be accountable for letting primary
care know.
84
7.

role?
Feel that the theories contained in the proposal are good, but worried
that the LHINs will need a lot more resources to do what is proposed at
a time where money is tight. Primary care providers are already doing
a really good job. How many more people are needed to police what
primary care is doing?

There will be greater control for the LHINs but this will also mean
greater accountability. This will require additional resources. LHINs will
need resources to be able to drill-down data, analyze it and feed it back
to the primary care practices.

The document outlines a hope that patients will have greater access to
allied health professionals. If we provide access to these services for
patients outside our Family Health Team, will there be more funding to
have more of these resources?

Today, all the providers have different data systems and they are not
interchangeable. How will the LHIN access this information for
performance management?

If a physician practice hires a contractor, it determines its own
evaluation criteria to decide if the contract was successful. It appears
that what is being proposed is that there would be a performance
contract negotiated between the Ministry and the OMA but then the
evaluation criteria lands at the local level. It will be problematic if the
LHIN is determining evaluation criteria without having responsibility for
funding primary care. The contractual relationship is between the OMA,
the Ministry, the practice and the individual physician. There are no
other models in the business world, where the organization setting the
performance expectations does not provide the funding.

I am hopeful that with the integration of different Primary Care models
under the LHIN, that there will be a much greater opportunity for
sharing knowledge, doing advocacy, and collaborating in general.
85
Section 4 – Stronger Links between Population & Public Health and other Health
Services
8.
Question
Feedback
system?

The sub-LHIN planning makes sense from a population health
standpoint but will also need to make sense with the structures we
already have in place (e.g. Health Links).

The part of the document about improving the health of those in your
neighborhood is something primary care providers learned in school.
However, we don’t have a lot of time to do this in the day-to-day as we
are too busy putting-out fires. So the piece on improving health will be
challenging. Would love to see the overlap between the high cost users
and whether focussing on them really improves the health of the
population. For health, we need healthy environments but these are not
mentioned in the document. Public health had not been consulted in
the development of this paper.

I am also happy that Ottawa Public Health will be under the LHIN – it
might offer the possibility of a more coherent approach to recording
and housing vaccination information.
86
Question
9.
10.
Feedback
population?
Patient satisfaction as a measure is problematic. A primary care
practice might have offered patients an appointment but they did not
accept it so they might respond that they are not satisfied with the
provision of same day access to services. Some patients don’t actually
want to be seen as quickly as offered. Need a better understanding of
how primary care practices will be evaluated and measured.

There is a lot of information that is not captured in the EMR that will be
important to determine performance. For example, the patient that is
offered an appointment by the receptionist but refuses it.

Access is more than same day or next day service. For example,
phoning a patient, faxing information, fitting 5 problems into a visit.
Patient satisfaction is not the be all and end all.

When we look at the indicators that have been chosen (such as a visit
to primary care within 7 days post discharge), some are international
standards. If the patient was really well cared for in the hospital, the
primary care provider should not have to see the patient right away.
Primary care providers have not been consulted on which patients
need to be seen within 7 days. Not everyone needs to be seen so
quickly.

It is also important to remember that the patients have a role to play in
this health care system. They also need to be accountable for their
behaviour. It is problematic when patients chose to visit different
physicians for the same problem or chose to go to the emergency
department when they could have seen their primary care provider.
Would be important to understand what is already being done and who
is providing what kind of care before making changes. Not all clinics
follow their contracts. Might be a question of making sure people are
following their contracts before making changes.

Minimally disruptive medicine. How do we get to a point where patients
are not patients? What are the comprehensive care pathways? We are
chasing the wrong thing.

Need to take a step back and determine what the purpose of the
proposed reform is. In the context of scarce resources, why are we
doing this now?

In the context of tight resources, it is questionable why the Ministry is
choosing to make investments where it is making investments (e.g. in
vitro fertilization, autism services).
87
Central Ottawa Primary Care Network
March 1, 2016
1.
2.
Question
Feedback

LHINs need to closed down or expanded – proposed changes are a
step in the right direction

Transfer of CCAC to LHINs creates a conflict of interest

Why did they decide to bring CCAC in house?

Sub-LHINs are not a bad idea BUT they need to be organized properly
and to be responsive to actual patient need. They have to be really
careful with the use of standardized screening tools to allocate services
and leave room for clinical judgement and consideration of SDOH.
Clinical leadership will be difficult. Maybe each LHIN should have a
leadership council – a lead and some other executive members to
move things along.

CCAC to LHIN is a foolish idea – the problem is not who is managing
the CCAC it is how they function – the whole contracting out process
and the expectations on the care co-ordinators are made to fail. They
are a completely opaque organization and communicating with them is
frustrating to the hilt. I never know what kind of care my patient is
getting – and many of my patients can’t really tell me either. There is
complete bureaucracy. Seriously I have been around a long time and
the home care service worked WAY better in the 1990s

I am interested in the change of CCAC with the LHIN. I hope this helps
rather than be disruptive.

Need to understand the high needs population as a major driver –
including social determinants – PCP can’t be accountable for social
determinants

Consider using technology to make us more accessible to patients;
Access and continuity of care do not necessarily require direct
encounters
88
3.
4.
Question
Feedback
providers in navigating and linking
with other parts of the system?

Concerned that Integrated Care Networks and Health Links must be
aligned– when we already have Health Links

CCAC should be working with PC to integrate - a great opportunity
which should also include mental health

Broader integration with transportation and housing - the integrator is
the family doc.

Commended access to information very fast through access to OACSIS

Would like to have access to information about the patient – and that it
be pushed to the providers

Concerned about transfer of information between practices

Consent should be universal / particular concerns regarding mental
health

Access to diagnostics /specialists in urgent fashion – current option is
the ER/ no access to POC testing, stat blood work

Integrating the other allied health services –e.g. Physiotherapy clinic
access is capped by Q2

MOH promoting walk-in clinics

How well do we understand the problems around access – referred to
QI survey in FHT – only 34% of patients said they could be seen same
day even though the clinic offered same-day services to anyone who
called or even showed up at the clinic between 8am-8pm M-F and
10am-2pm Sat and Sun. This suggests surveys may indicate poor
access when that is not the case ;Need better data- how you access
the team vs. provider

The metrics often rely on subjectivity – need to use objective metrics
such as third next available slot

Need a clearing house of information regarding information / referral –
electronic referral for all consults – regionalised electronic intake
process

Patient Satisfaction – concerned that it would be linked to physician
contracts – evidence suggest this does not work - example of patient
who wants antibiotics they do not need ; Consumerist lens

Need one EMR – PC
publicly reported?
89
5.


Has the ministry responded to the risks of not having a Physician
Services agreement?
Similar to circumstance 20 years ago – no PSA –and the issues
remain– Access, Access, And Access
Would be more inclined to participate and support the transformation if
the PSA were resolved.

Due to the lack of a PSA, many important voices are actively choosing
not to engage in these consultations. I can't really blame them for
making this choice. However, the lost opportunity to engage
experienced, knowledgeable, passionate frontline physicians carries
with it significant ramifications for the future success of primary care
reform in Ontario.

3 major barriers – capacity , evidence, (that regionalisation works) –
Evidence going to be used to make us accountable ; Metrics outdated
30 day readmissions). There needs to be transparency and a solid
evidence-base behind the process of selecting these metrics

Need to educate patients about cost of going to walk in clinic, when
they been given an alternative – or consider a surcharge. The
government contributes to this problem by advertising walk-in clinics in
tv ads and websites; these ads make no suggestion that patient
contact their PCP first.

Patients need to be accountable as well –cited examples of using walkin clinics

It is important to understand why it is important to have access. E.g.
Convenience vs ER avoidance

OCFP response devoid of transitions of care

TOH horrendous primary care partner – HRM often inadequate – The
role of hospitals as partners with primary care must be addressed

Appreciate MOHLTC is devolving – but not certain they understand
that concept and MOHLTC become integrated - and streamlined.

Concern people (in MOHLTC) driving the change are siloed

Performance not always dependent on PCP – Need to look at other
bottlenecks in system – diagnostics – Information should travel with the
patient

HHR – need to better inform trainees for specialist training

Raised issue of rostered patients being allowed to go outside (patient
pays in other jurisdiction)

Referenced co-pay as incentive to change patient behaviours

Incentives sometimes present risks in terms of compliance practice
guidelines – e. g risks of over- prescribing mammograms
90

Trust can be measured - Lack of communication erodes trust – if PC
didn’t know what is happening to their patients.

Integrate community resources with primary care – including social
workers – having a social worker would be a dream –Patients now
used to team based care - / doesn’t have to be in same practice - / but
should be provided by people who know them **

Need to consider needs of MDs who have been in practice a long time
– including retraining options in team based care.

Can MDs opt out – of incentive funding, of capitation models? What is
the government’s plan for fee-for service?

When the Patients First discussion paper states that “what we have
heard from Ontarian has been confirmed in a series of expert reports”
(pp 9, first sentence of 2nd paragraph), it’s worth noting that four of the
six expert reports – Auditor General, Expert Group of Home and
Community Care, Drummond Report and the Registered Nurses of
Ontario – are focussed on the problems in the home care system. For
primary care, its only HQO and the Primary Health Care Expert
Advisory Committee that are really aimed toward what family doctors
do.

Clearly the idea of local organization and having patients within our
catchment area makes it more likely we can make housecalls and
provide comprehensive care

One of the questions asked in Proposal 2 is how to effectively engage
and support primary care clinician leaders. The answer is both simple
and inconvenient: you have to be willing to compensate them for their
professional time.
6.
Question
Feedback

Focus on community centres / social housing and other community
hubs as centres of support

More funding to support in-home service for frail elderly, convalescence
7.
How can home care be better integrated
with primary care and acute care while
not creating an additional layer of
bureaucracy?
Make sure physicians are at the table but need to ensure these
minimise time away from patients.
8.

will the proposed changes help address
what’s important to you?
Concern the burden falls on caregivers
Do not know what CCAC offers – centralised quarter back for nonmedical care?
91
9.
Question
Feedback
system?

Need to consider broad health equity strategies as part of the approach
(MH, FLS, Indigenous Health, Maternal Health.)

E.g. Opportunities to better coordinate sexual health clinics of public
health with primary care

Tracking immunisation – electronic integration with primary care

Goals of integration cannot happen without connectivity
Question
10.
11.
Feedback

Concerned about option of patients self-scheduling (in terms of amount
of time)
Good care takes time – e.g. of military docs as quarterbacks – it needs
to be recognized

Can there be comparable incentives for administrators serving PC;
Need to consider 360-e.g doctor satisfaction

Risk that Docs will retire if they do not feel supported.

The timeline for these consultations seems far too short in order to
gather enough meaningful feedback to inform such a massive
restructuring of primary care. For example, many who wanted to attend
the consultation meetings in our LHIN couldn't because of the short
notice. This is one of the largest (if not the largest) overhauls of primary
care in Ontario's history. The consultation phase is critical for its
success.
How would we know whether the plan 
is working?


If it fails, it will fail spectacularly
As long as patients expect convenience, it is not possible to provide
hour to hour responsiveness, and be efficient.
Do not think life is going to easier for me – (as a doc)
92
Additional Comments:

I agree with most of the points as I had thought of them myself. It is difficult for me to feel my input is wanted as a
physician when the government will not sit down and discuss our PSA. We are in a bad situation when our personality
trait is to help but they take advantage of us knowing that’s what we do. I will continue to follow the information received.

I'm attaching a few reference documents I'd like to be included in the LHIN's feedback to the MOHTLC, as well as my
final comments for the Ministry.

With respect to the attached documents, one is a brief, one-page excerpt from a literature review I did as a part of my
Master's. The excerpt focuses on financial incentives/pay-for- performance in health care. There is insufficient evidence
that this approach improves patient outcomes, and there are unintended negative consequences that often result. The
second document is a paper looking at regionalization from an evidence-based perspective. Mark Dermer mentioned
this paper at the meeting last night. The third document is an excellent study published in JAMA in 2012 looking at the
outcomes of tying patient satisfaction to physician remuneration. Although higher patient satisfaction was associated
with lower ED use, it was also associated with increased hospitalizations, higher health system and prescription
expenditures, and increased mortality.
93
Upper Canada and Stormont/Dundas/Cornwall/Akwesasne Primary Care Networks
March 2, 2016
Participants: 19 Nurses, nurse practitioners, physicians, Health Links Coordinators, primary care administrators
1
2
Question
Feedback

It will be important for the Ministry to adequately supply the LHINs
accomplish the items proposed. The Ministry has a history of
downloading responsibility without adequate funding (e.g. Hospitals)
and then withdrawing funding when targets cannot be met.

LHINs are being made into the buffer between Ministry and the public.
This will give the Ministry the ability to hold the LHINs liable for “poor
outcomes” but give the Ministry the ability to limit funding or resources
needed to enable them to fund the programs needed to see the
“desired outcomes”. The LHINs are also not empowered to hold the
public accountable for misuse.

Could be a conflict of interest with the LHIN delivering services and
being the lead for CCAC


Need to acknowledge that needs in rural communities are quite
different. The cutbacks have caused challenges. For example,
physician practices have provided services such as lab services for
free. May no longer be able to sustain this. Patients will now have to
travel 30 kms to get a lab test done. This will have an impact on
patients.
Need to acknowledge that needs in rural communities are quite
different. The cutbacks have caused challenges. For example,
physician practices have provided services such as lab services for
free. Until the Government put the G489A fee code in the basket of
services for PEM models, practices were able to provide services at a
cost neutral level. (i.e. the amount billed equalled the expense paid for
physical space and staff). Currently physician offices have to decide to
pay for aservice that the Ministry pays for at private labs in the city.
There are no private labs in rural areas and therefore, if physicians can
no longer bear the cost of the service, it will be eliminated. Patients
would then have to travel 30 kms to get a lab test done. This will have
an impact on patients and quality of care as the quality metrics for
many chronic diseases are dependent on patients having access to lab
services. (e.g. Diabetes needs A1c, Renal Failure and Heart Failure
need regular blood work, patients on warfarin need frequent INR
testing). Imagine having to take your 90 year old grandmother for
weekly blood work in a town 30-40 km away on a weekly or monthly
basis in a Canadian winter!! By reducing access to lab services for the
highest need patients, there is the potential to INCREASE hospital
utilization as patients will “fall off the rails” without adequate monitoring.
94
3
Question
Feedback
clinician leaders?

Government is micromanaging the Ministry of Health.

OMA and physician relationship with the Ministry of Health had been
very good (in the last 15 years) until now because the government is
intervening. Doctors are now having to pay for the poor economy, for
Syrian refugees, for the need to find funds because of overspending or
poor decisions in other government departments.

Phone calls that physicians get to their offices are contemptuous. This
could be solved by making patients part of the system by making them
pay a fee if they go elsewhere than their primary care provider. Why
are patients allowed to go anywhere with their OHIP card?

Won’t have the Ministry come in and dictate how primary care practices
should work. Disheartening to see that the relationship between
physicians and the Ministry is broken.

Nowhere in the document does it describe what a FTE for primary care
is. Many physicians are working 80 hours a week (including paper
work, on call requirements, house calls, long-term care etc.). If looking
to leverage this into a 120 hour work week because have to cover ER,
manage inpatients at hospital, and after hours care, etc. this is a
problem. The smaller the hospital, the greater the impact because
primary care providers do a lot more than seeing patients in their
clinics. If Access and After Hours care requirements are implemented
(i.e. the current exemptions are eliminated from FHO, FHN
agreements) then physicians will have to give up hospital work and
then small hospitals will have no physicians to manage their inpatient
and ER services.

It is challenging when primary care physicians that also work in
hospitals retire: Need more than one person to replace them.

It can be frustrating to evaluate physician practice based on tests
performed, etc. Physicians do a lot more than the sum of all these.
Makes it seem like physicians aren’t doing anything.

Consider having a Nurse Practitioner Association of Ontario (NPAO)
LHIN rep at the LHIN table, NPs offer clinical expertise and are clinical
leaders

Senior practitioners often hold rosters of 1800-2400 patients. New
physicians 800-1500 (average about 1200). That means an office
needs 2 new docs to replace one “old” one.

In the patient care and consent world we often use the mantra “Nothing
about me, without me”. We need to bring this concept to the Ministry.
Physicians will not be part of transformation without consultation.
95
4.
How can we support

primary care providers in
navigating and linking with
There is little discussion in the paper about the integration of specialties. Primary
care needs access to specialists. Need to engineer the whole system, not just
parts of it. Specialties are only managed in so much as hospitals are managed.
Without the Ministry requiring sufficient access to specialty services, Primary Care
continues to struggle without specialty backup.

One of the reasons primary care providers stay connected to hospitals is to
provide a service to the community. They have better knowledge of the patient
when also caring for them in the hospital. This helps ensure continuity of care.

Care coordinators should be aligned to primary care practices. This would be
important to streamlining the communication and having better ways of
connecting. A pilot project aligning a CCAC care coordinator with a primary care
practice was beneficial as it allowed for better communication about the patient.
When the physician was working with the care coordinator, this helped keep
people out of hospital.

It is also important to have allied health services available. By adding a mental
health councillor and a part-time social worker, care has been greatly improved in
one practice where they were “lucky” to get special funding. However, access to
funding for allied health services is inequitable. A few “haves” and many “have
nots”. Increasing access to IHP’s would allow current physicians to maintain large
rosters but still provide access as some appointments would be able to be
diverted.
96
5.
How should data collected 
from patients about their
primary care experience be
used? What data and
information should be
collected and publicly
reported?
The concept of need is not defined and accountability for multiple points of access
(i.e. a patient being able to choose to use multiple different providers) is not
defined. Need versus want is not defined. Patients can be offered appointments
but they refuse because of convenience. This happens frequently. Perhaps not as
frequent in a smaller community because not a lot of other options. Patient surveys
that ask vague questions about access assume that any difficulty with access lies
with the provider and does not take in to account the patient portion of the decision
to accept an offered appointment. Using this as a metric for assessing Access as a
measure of Quality provides skewed data which leads to poor planning for quality
improvements.

Access is a slippery slope. Concern that if we work in sub-regions for a fixed
population, primary care may not be able to really influence the health of the
population. Performance management is problematic in that type of environment.
Particularly if tied to funding. Patients often go where it is convenient, not where
they live in a sub- geography.

The document states that Ontarian still have difficulty accessing care when they
need it. Should say want it. There is little evidence that people can’t get care when
they need it, or that this has a negative effect on their health. The only evidence
about the need for patients to be seen within 7 days comes from the Ministry of
Health.

Patients are used to getting fast service so expectations are high. Education of
patients is important.

A lot of patients come in with 7-10 problems in the same day. If patient satisfaction
is linked to amount of time spent with providers, this is problematic. The
performance measures are wrong. There needs to be some education of patients.
Some patients get offended if the physician need to limit the amount of issues to
be dealt with at one time.

If there are to be surveys of patients, questions need to point to actionable items.
Shouldn’t just ask the question for the sake of asking the question. The answer
should point to a direction for action. For example asking a patient if they have
“adequate access” is not helpful. Asking if they were offered and appointment
same day or next day for an urgent problem, would likely get a more useful
response. For non-urgent problems, there is no evidence that having access in 7
days or less makes any difference to outcomes. Again, “want” needs to be
separated from “need”.

Primary care physicians that provide palliative care need more time to travel and
do home visits. Providing palliative care services limits a physician’s accessibility
to see other patients the same day but this is not taken into consideration when
measuring patient satisfaction.
97
6.
The proposed approach is 
intended to empower local
communities and providers
to improve primary care.
Does our approach achieve
this? What else can we do
to meet this objective?
Extremely concerned that Ministry did not engage with primary care in preparing
the discussion paper. This was all done under a cloak of secrecy. Trust has been
broken. The fact that the Ministry is acting unilaterally without engaging physicians
has undone 15 years of hard work and collaboration. The changes proposed by the
Ministry will not be implemented until there are negotiations and a physician
services agreement in place. Physicians will not be willing to make any changes or
participate in implementation until then.

The distrust comes down to the LHIN level as well. The LHIN’s Primary Care
Physician Lead was put in a position where he was required by the Ministry
directive to deny that there was work happening at the provincial level. It is
completely unacceptable for a colleague to be put in such a position.

Need to figure-out negation. Why can’t patients be required to attend at their
Primary Care model office? If patients attend an alternative environment for nonemergency care, this should not be an OHIP service. Tying assessment of urgency
to CTAS is not adequate either as the nurse/provider assigning the CTAS level has
no accountability to the system to determine the correct level and CTAS levels at
initial assessment may be different than 3 hours later when the patient is actually
seen but there is no formula for “updating” a CTAS level if a patient’s status
deteriorates over time. E.g. a patient who presents with abdominal pain but no
fever or other vital abnormalities may be assigned a CTAS 4 on presentation but
then deteriorate due to an early presentation of appendicitis and actually be a
CTAS 3 or 2 by the time the physician sees the patient.

Primary care providers often have to see patients because they “woke up with a
sore throat” or because they need a sick note for an employer. Visits for selflimiting illnesses for employee sick notes should be required to be paid by the
employer. (The Ministry should fix this - it has the power to legislate such abuse of
the system as a “third party” visit.)

What we had prior to unilateral action was working. The effect of unilateral action
has been to create division when what is needed is increased collaboration. What
is needed is more physicians and equitable access to IHP’s, particularly in
underserved areas. Patients are starting to be abandoned because physicians are
leaving Ontario or not being replaced when retiring. New grads are not being well
treated and this will make it harder to recruit them. Physicians have invested a lot
into the health care system. Changing it mid-stream without involving doctors and
the public is unacceptable.

Why would anyone think that a system that was canned 20 years ago in Great
Britain would work here?

Concern that physicians will go work outside of Ontario or will not want to get into
family medicine.

The majority of people that give health care in the province aren’t familiar with what
is being proposed. But what could be improved in an individual practice is all the
administrative work that needs to be done to report, do committee work. This
needs to be looked at. If everybody in the system had more time to do what they
are supposed to do instead of having to do all the paperwork, they could offer more
same day appointments. Physicians got into health care in the first place to look
after patients, not to do so much paper work.
98
7

Immunize 20-20 is a little like the discussion paper: The voice of family doctors is
not there.

There is room for Family Health Teams to provide services to non-rostered
patients. For example, if providing an education session to the FHT’s patients,
could invite others to participate because the costs are the same. Could leverage
this room.

Ensuring that Nurse Practitioners are regarded as key players in primary care
system and that if data is going to be the driving force behind the evaluation of
health care practice and reform then NP practice needs to be accounted for.....

Recognize NPs as most responsible provider (MRP) Can't measure, unless
rostered to provider (refer to point above)

Need to remove barriers to practice to facilitate access- narcotics, MRI, CT etc.
(Bill 179).
What should the LHIN role 
be in supporting providers
in the delivery of high
quality, accessible primary
care? What do LHINs need
to succeed in this role?
One advantage the LHIN might have is understanding the local realities around the
role of primary care. Many primary care providers don’t just work 9 to 5 in clinics.
99
Question
8.
9.
Feedback

Public health could be letting primary care providers know about what infections
are being seen in the community.

Public health has a role to play in educating the public about how to manage their
symptoms.
What additional connections 
would be valuable?
Having a closer connection of primary care with public health would be useful to
know the immunization status of patients. If primary care practices were not
proving immunizations, patients would have to go to public health units. This year,
public health doled-out flu vaccines in very small allotments. Unclear why they did
this because physicians usually hold a full-day clinic and did not have enough
vaccines. This is inefficient. Public health needs to have more interaction with
primary care. Why would public health change what was working?
How can public health be
better integrated with the
rest of the health system?

Compared to Saskatchewan, vaccinations are very disorganized in Ontario in
terms of who does what. No communication to primary care about vaccines
received at Public Health, at pharmacies or school vaccines and yet primary care is
accountable for adequate immunization of their population.
Question
10.
Feedback
What accountability

measures need to be put in
place to ensure progress is
being made in integrating
health care services and
making them more
responsive to the needs of

the local population?
What is needed for collaboration, integration and coordination is reciprocal
accountability. Accountability at the moment is unidirectional. The Ministry never
holds itself accountable for holding up its end of a promise. Accountability also
needs to include the patients who are drivers of the system. The Ministry has a
responsibility to provide patient education around “Choosing Wisely”. The public
pays for the system and should know how they are a potential contributor to waste.

The Ministry wants to improve performance and accountability. However,
physicians are now spending too much time providing information to fulfill
obligations for performance and accountability. Systems are not designed to
extract information that is already being in- putted. Having better systems would
improve efficiency. For example, a nurse has to input information about fecal occult
blood tests into the electronic medical record but it would be simpler if the lab
would report on this directly. There is no way in current systems to indicate that a
patient declined a test yet physician performance is measured by how many
patients received a particular intervention. Patient choice needs to be factored in to
accountability measures.
If there is to be accountability for adequate follow up after hospital discharge, the
Ministry and eHealth must ensure there is adequate access to the information for
the Primary Care provider to act on. There is little point in seeing the patient in 4
days if the discharge summary takes 14 days to be sent.
100
11.
What can be done to ensure 
a smooth transition from the
current system to the one
proposed in this proposal?
12.
How would we know whether
the plan is working?
There is a perception that the proposed changes are a fait accompli and that the
consultations are just going through the motions. There is a belief that the Ministry
is likely preparing legislation at the moment and plans to table something soon
before consultations and feedback have been received and truly reviewed. Given
the Ministry’s recent history of unilateral action, there is no reason to trust the
Ministry/Government in its current state.

There is general agreement that improvement in collaboration, integration and
coordination is a good thing. However, it is unclear whether the solutions proposed
are the best ones and that there is any evidence that the changes will be effective
because there is a complete absence of specific implementation strategy and
targets in the document.

Proposal will not be implemented until there is an agreement in place with the
OMA.

Ideas are good but until there is open dialogue with physicians they will not move
forward.

The document states that the Ministry would retain its role in workforce planning in
collaboration with the LHIN. How does this fit with sub-geographic regions? Will
Ministry over-ride local decisions?
Additional Comments:

The complexity and time requirements of our work are ever increasing. between the “paper work”, CME, forms to
complete, prescriptions to renew and crises to manage, we have less and less time in a day. The Ministry has NO idea
how hard a good family physician has to work.

I often feel that as a province, and as a country, we need to start looking at the evidence for the tests that we are
encouraged to order. For example, the Ministry document stresses its commitment to monitoring MD's performance with
respect to breast cancer screening. Interestingly, the Canadian Task Force on Preventive Health Care states that
regular mammography decreases risk by only 0.13%. That is not very much. Furthermore, there is significant risk of
doing harm by regular testing. Although the Task Force does recommend screening women between 50-70 years of
age, this recommendation is “weak". In the age of a shrinking health care dollar, is it not time to seriously challenge our
“Gospel truth” beliefs regarding certain forms of screening? As long as we continue to pretend that our ability to prevent
cancer is better than it actually is, we are misleading our patients and taxing the Health Care system.

http://canadiantaskforce.ca/ctfphc-guidelines/2011-breast-cancer/risks-and-benefits-age-50-69/

In a similar vein, we need to begin the arduous task of deciding how we are going to deal with the Pandora’s box of
imaging. It is very common for further testing to be ordered for what we sometimes call “incidentalomas”. Small
unexplained (but most probably irrelevant) findings are discovered. This generates a cascade of followup tests to ensure
that these findings are “stable”. Further testing gives birth to new unexplained findings that also need to be monitored.
Most of this extra and costly testing is done not because we are genuinely worried, but because we do not want to risk
disciplinary action from the CPSO or, heaven forbid, a lawsuit. I would argue that if as a society, we want this extra
measure of "security" (?false security), physicians should not be penalized because of the astronomical cost of
providing this reassurance. If, on the other hand, we decide to reduce our over-reliance on high tech imaging, then I
would want to be supported by the Ministry, the CPSO and the CMPA.
101
North Lanark and AROW Primary Care Networks 7 & 8
Total Responses: 8 individuals
The scheduled meeting for the Patients First North Lanark and AROW Primary Care Network was cancelled due to the
weather conditions.
These questions were sent to these members to capture their thoughts/suggestions:
1) The Champlain LHIN is proposing that Health Link (HL) 7 and 8 be joined, creating a population of 166,000. What might
be the advantages and disadvantages of this change?
2) The Champlain LHIN is proposing that the sub-LHIN regions (Integrated Care Networks) for the delivery of primary care
and home care correspond to the Health Link geographical boundaries. (see section 3.0 of the Implementation “Snap
Shot” and Section 5.0 for more details).
a) In what ways do you think this could work to improve patient care and outcomes?
b) How could this be structured so that the work of primary care is enhanced?
c) Please provide any thoughts on governance structure.
3) What linking opportunities between primary care and the rest of the system do you see as being potentially most
valuable?
4) If the LHIN assumes direct responsibility for home and community care, what recommendations would you have?
5) Do you see an enhanced role for Public Health in an integrated system, and what might these roles be?
6) What risks and possible unintended consequences do you see, overall?
outcome which will be negatively reflected on the
physician. This could potentially lead to a dangerous
slippery slope where the physician’s actions could be
clouded by fear of having an unflattering patient survey.
Response 1
Firstly I am encouraged that the proposed overall
structure is pretty much what we have in place at our
clinic. For almost 20 years we have been providing
comprehensive care and offer patient access for 13 hours
a day on weekdays and 8 hours each on Saturday and
Sunday. We will continue to provide this access.
It puts the physician in a potentially compromising
position in my opinion. I believe that patient satisfaction
surveys are not an objective way to measure outcomes.
Secondly, in the current system there continues to be a
complete lack of accountability on the part of the patient. I
understand that politically this is a taboo topic but quite
frankly I do not care about politics. The blame continues
to be placed squarely on the physicians’ shoulders. I will
provide an example of lack of patient accountability. This
past Monday I was working my evening clinic which I
have been doing for the past 13 years, such that my
family which includes
There are aspects of this position paper that I do not fully
understand and there are catch phrases that I will not
even attempt to try and decipher, but I get an overall
sense of an overwhelming tilt towards “patient
satisfaction”. While I understand the responsibility of the
physician in ensuring that patients are satisfied with their
health care, I have 2 specific concerns with how this will
be monitored: 1. The lack of objectivity of patient surveys;
2. the complete lack of patient accountability in this entire
process.
4 young children knows that dad is simply not around on
Mondays. I saw at least 5 patients with “colds” who had
been seen by another doctor in the past 48 hours and
given a diagnosis of a viral infection. They were all
coming back because they were “unsatisfied” with their
previous encounter, were still not feeling better and were
wondering why they were not prescribed antibiotics. I sat
and educated each one of them why an antibiotic would
be inappropriate and not in their best interest, but I have a
With regards to my first concern, I will provide an example
of the pitfalls of patient satisfaction surveys. If patient A
comes in to the clinic with an upper respiratory infection
with a preconceived notion that they would like to leave
with an antibiotic, it is entirely possible that if the
physician determines that the infection is viral and
antibiotics are not needed, the patient will be subjectively
not be “satisfied”. This could then lead to a poor survey
102
feeling that upon leaving if they were asked to complete a
survey it likely would not be pretty. I strongly believe in a
co-pay system for patients that are conveniently being
seen on a walk-in basis by a physician that is not their
own. There is currently nothing stopping a patient with a
cold from being seen every day of the week, if not more
than that, until they get what they want. The public
system should not have to be responsible for funding this.
This is continuing to drain the system and nothing is ever
said about this by our politicians. A small co-pay for these
patients would go a long way to de- clogging our system
for non-urgent matters and would further encourage
patients to see their primary care physicians. In other
words, instead of the physician being financially negated
for their patient going elsewhere, the patient should be
negated and should have to take financial responsibilities
for their decisions. I gather this has never been discussed
because telling patients that they would need to pay for a
doctor’s visit would not exactly garner votes com election
time. In the meantime physicians continue to shoulder the
blame for the ever increasing costs to our system.
Also, one outcome measure, follow up within 7 days of
discharge from hospital, is difficult to implement without
engagement by the patient. I have all of my patients
called to book an appointment upon discharge. They may
or may not have other follow-up visits planned and
frequently do not want to see another health-care
professional so soon after discharge, especially if they
are feeling well. How will I be viewed if my patients do not
come for follow up?
Other outcome measures, A1C targets, percentage of
patients going for cancer screening, number of patients
getting a flu shot, are highly dependent on patient
motivation. How will this be addressed in the future?
My biggest concern with this document is the focus on
patient satisfaction. Patient satisfaction has been tied to
increased costs and increased risk of death, but I see no
mention of this. See attached reference article from
JAMA.
Every day, I see patient who expect antibiotics for viral
illnesses. These same patients have often already been
seen in other walk-in clinics despite being rostered to our
FHT. We have walk-in hours every weekday 5:00pm9:00pm. We cover weekends from 9:00am-5:00pm. When
my patients tell me that they've gone to another clinic. I
remind them of their obligation to come to ours or we pay
a penalty, they are either shocked or state "well, I couldn't
wait".
Lastly, in my opinion the title of this project should be
Healthcare First, not Patients First.
Response 2:
I have decided to focus on question 6 in the questions.
My first concern with the "Patients First" document is the
lack of patient accountability.
We all know that costs are soaring in health care. Every
day, I see patients who have not followed recommended
treatments and expect to have testing done because their
symptoms have not resolved. They expect MRIs, CTs,
ultrasounds, expensive blood work, but are not willing to
undertake the necessary lifestyle measures to improve
their health. Many of these costs are due to an
expectation that an outside intervention will cure a
condition that is benign and caused by poor lifestyle
choices. We have no way to ensure that, as a group, all
patients are getting the same care. Our patients compare
notes with each other and patients feel others are getting
better care when more investigations are done. Until all
physicians are following guidelines such as those on
http://www.choosingwiselycanada.org, we will continue to
spend time convincing patients that they don't need
investigations.
The number of patients who use after-hours care for
chronic issues is soaring. Little do the patients know,
after-hours care costs more.
In addition, same-day and next-day access has yet to be
shown as a measure that improves outcomes. My
research into open access suggests that it simply
improves patient satisfaction. In my personal practice,
appointments that are set aside for same-day and nextday access get filled with non-urgent issues such as
periodic health exams, diabetes checks, and for forms.
Urgent appointments also become redundant when, as a
group, our after-hours, urgent-care clinic is so accessible
and can cover for acute issues.
103
Response 3:
dissemination of knowledge about what is available
through LHIN 8 - for example in participating in COPD QI
project our team discovered about the COPD pulmonary
rehab program available in LHIN 8 - we would have
otherwise never known. Though if the program could
come into the FHIT itself we would probably be able fill it
very quickly.
Firstly, I am not too clear why the title, "Patients First"
was chosen. Was this a MOH or LHIN decision?
Regardless healthcare delivery is a partnership between
the patient, the physician, the other allied care providers
and the community and even the government. Patients
are not the only primary stakeholder in this process and
hence the title “Patients First " is very misleading and am
sure makes other providers in this process feel
uncomfortable. Patients are not customers, they do not
choose to be in this role of a patient, it is forced on them
out of necessity and often under misfortune
circumstances and hence their satisfaction is difficult to
measure objectively and will be impacted by their
perception, expectations ( realistic or unrealistic) and
emotional duress. The doctor-patient relationship seems
to lost in the title
Disadvantages - larger LHIN will have to account for more
needs- if funding resources are not provided in a timely
manner there will be lack of resources to account for the
larger population - funding resources have to be available
before we integrate.
2) LHIN ICN boundaries and Health Links correspond great only works if patients are forced to assign to their
PCP who is in their geographic sub LHIN- i.e. I practice in
LHIN 7, i have several vulnerable complex patients who
reside in LHIN 5 or 6 ; how or where would they access
homecare services through- would the PCP be required
to know all the processes and figure it out or should there
be a central triage board- example I was unable to have
my complex vulnerable patient residing in central Ottawa
access services via Arrow program in LHIN 7?
"Patients First". As articulated by one of my colleagues
(Dr. Andrew Kujavski) in his response to the same article,
a more suitable title would be "Healthcare First".
Secondly, to my knowledge physicians have never been
asked how they feel about assessments based on patient
satisfaction. I am recently participating in a QI projectaccessibility and efficiency- although thus far my ability to
get into a room to see my patient is
Would need to sort out first the addresses of patients and
how many actually live within the
SubLHIN of their PCP? Then figure out what to do if here
is a big discrepancy
100% late. Patients however have very positive
comments in the end. So solely objective scales for TNA,
accessibility, time spent with patient etc. is not going to
give a good and valid reflection of satisfaction. In addition,
cultural demographics of the patient population will play a
huge and significant role in such assessments. Likewise
performance measures thus far (preventive care
bonuses) have never taken into account for cultural and
demographic factors when calculations are made, thus a
physician who has a higher percentage of cultural
minority groups will fare much poorer than others (for
example- often it is very difficult to get many East Asians,
Somalians, Afghanistan patients to participate in such
screening programs, even though the
3) PCP- have the other systems come into the PCP - like
we have for DM education, STI clinic. Bring COPD into
the PCP and provide the training for say a NP to manage
this. Bring addiction and mental health services into the
PCP with shared access of the patient chartunfortunately right now STI clinic does not share any info
and patients often do not know what was treated for.
It is great that pharmacists provide flu vaccines but
pointless if they then refuse to inform the PCP of thiswhen we asked a pharmacy to send us at least a simple
fax informing the GP that the patient has been given their
flu vaccine ( noting that it impacts on data collection and
our fees) the response was that they could not do so as it
would be too costly and time consuming to do so- finding
a way to better integrate pharmacy services with the PCP
is imperative if they want to be more involved to work as a
team.
PCP has done their part and beyond to educate them.
Answers to Proposed Questions:
1) Combining LHIN 7 and 8 - I practice in LHIN 7 and
have many patients who geographically reside in LHIN 8.
In the same tone, I have some trepidation about retail
pharmacists playing a major role in advice on treatment
prescribing - after all they have a conflict of interest as
they make money out of the RX drug - it is not unusual for
Advantages- access of services combined, increase more
services to patients living in LHIN 8
as well patients living in west border of LHIN 7 are
probably accessing services in LHIN8 improved
104
a physician to get a pharmacist recommendation of a
more expensive RX - it is not the norm but it does happen
- out of all the healthcare providers in this integrated
team, the pharmacist sort of is in a class of its own and
their role needs to be very clear
6) Risks - the title of this document as mentioned above.
- How to manage or account for patients not living within
the LHIN
- No consideration of cultural diversity within patient
population as a factor in measuring satisfaction,
accessibility or even use.
4) Having home care case managers assigned to a subLHIN and they then rotate to each team practice on a set
schedule to assess patients and liaison with the PCP
team would help patients from decompensating, update
physicians of their status more rapidly, more physicians
may be willing to provide house calls or palliative care.
Less paperwork for the physician to do would help -
- No consideration that we expect patients to have
autonomy in the care process but we penalize their PCP
when a patient chooses to go to walk-in clinic X even
though they are fully aware that their physician or team
member is available
- important to ensure that all this data collection and
reports need to be simple and easy to interpret as most of
us physicians are already overburdened and limited with
time to be able to set aside time to evaluate these reports
- I have only personally looked at my HQ report once and
never at my SAR - depend solely on my EMR reports (I
think our team manager checks our SAR)
5) Public Health needs to take on a more clinical role - the
school board immunization process is an example of this
- sharing of info between public health and the PCP is
important; immunization records should be shared
between the two. Why can’t public health nurses provide
the missing vaccines rather than burden the physicians our after-hours clinic was bombarded by kids needing
vaccines with no access to their records if they were not
our patients- our clinic did not turn them away yet many
others did. In addition our FHIT nurses who were
scheduled to manage DM patients or well-baby checks
had to suddenly divert their attention to assessing the
immunization needs of these patients with no
forewarning.
Benefits- better integration and delivery of services
Hopefully better dissemination of knowledge of what
resources we have
Education, quality improvement opportunities
More sharing of care
Another example is where public health could play a
better role with direct care- hepatitis b patient and
tracking and ensuring that all members get tested and
offered vaccinations- why not do the work and make
standard lab reqs and public health tests everyone rather
than make each go see their MD or walk-in clinic, often
with no idea of what they are asking for due to language
barriers. OPH needs to also work with Quebec public
health as very often family members reside between both
locations. We have to remember that many Hull residents
work in Ontario and access primary care services in
OttawaCan Public health create satellite clinics within FHITS?
Thus, manage these issues with access to the patient
record without suddenly burdening the FHITS existing
resources. Or could these vaccination processes be
better handled by public health nurses directly in the
school giving the vaccines. If they can do it for hep B,
HPV, why not for missing vaccines?
105
Response 4:
5. Do you see an enhanced role for Public Health in an
integrated system, and what might these roles be?
1. The Champlain LHIN is proposing that HL 7 and 8 be
joined, creating a population of
Public health in Ottawa already does a good job of timely
information updates. In Ottawa at least I don’t feel
disconnected from public health
166,000. What might be the advantages and
disadvantages of this change?
6. What risks and possible unintended consequences do
you see, overall?
Includes rural and suburban areas that may have different
needs but makes the total area a larger number of people
in line with other areas.
I am hoping there will be 1 management structure
overseeing the whole health system so that it works
better together. I think that is the intention. I worry that
GPs may be asked to manage budgets – I’m not sure we
are the best to do that. I hope there will be patient
information and interaction. The users of the system have
to have input but also have to have some accountability
for how they use the system. I am concerned that targets
seem to be set by the ministry but they are not involved in
how things run and so may lose insight into what is a
reasonable target. I hope there is not an increase in
documentation and paperwork as I have too much
already. One think I hope will improve is less repetitive
form filling and questions of patients. Often the patient
has given the same information over and over and it feels
like the forms we fill are never read but re filled by the
next person. I’d like to see more general patient
information- what can they reasonable expect form their
health care system – perhaps starting in schools. Will
group home and CAS also be integrated? – I think they
should be
2. The Champlain LHIN is proposing that the sub-LHIN
regions (Integrated Care Networks) for the delivery of
primary care and home care correspond to the Health
Link geographical boundaries. (See section 3.0 of the
Implementation “Snap Shot” and Section 5.0 for more
details).
a. In what ways do you think this could work to improve
patient care and outcomes?
Already an active group that could be built on
b. How could this be structured so that the work of
primary care is enhanced?
Unsure
c. Please provide any thoughts on governance structure.
I am happy for LHIN to be governing body with input from
primary care
3. What linking opportunities between primary care and
the rest of the system do you see as being potentially
most valuable?
** In the LHIN framework plan there was mention of many
algorithms to help primary care know when to act. I am
not sure how helpful algorithms are to me. I get them, file
them – there are so many! - tend to forget I have one and
don’t use it... Re: cancer screening
More direct links between all providers esp. primary care
to home care and primary care to hospital care
4. If the LHIN assumes direct responsibility for home and
community care, what recommendations would you
have?
We had a case manager in our practice 6 years ago. It
was not as helpful as we thought ads there was so little
she could do within her budget constraints. Home care
will need better funding as well as better management.
106
accountable to the other as well as to the LHIN, and
cooperate with each other.
Response 5:
joined, creating a population of 166,000. What might be
the advantages and disadvantages of this change?
i. Primary Care governance structures can be quickly
dominated by far better resourced and aggressive
hospital managers. This must not happen with ICNs, and
it is undesirable because the hospital sector has poor
expertise in the field of primary care (emergency room
operation excepted). Primary Care and Public Health
should cooperate on population health initiatives.
Although primary care practices are traditionally
independent, the potential for cooperation, brokered
through a trusted ICN to which each practice contributes,
is high.
a. Advantages: Provides a critical population mass that is
similar to other health links, making it easier to justify
many types of common services within the HL. PCN 7
and 8 are already meeting jointly. The Queensway
Carleton Hospital, the Ottawa Hospital and the Heart
Institute are the main referring hospitals for HL7 and 8
b. Disadvantages: There are some long standing rivalries
between the 3 small hospitals in HL 7 and 8 that need to
be overcome. The geography is large. Lanark, Ottawa,
and Renfrew Counties have heretofore provided
most valuable?
Link geographical boundaries. (see section 3.0 of the
details).
a. Primary Care linked with Paramedicine Services could
be very valuable with regard to high needs Patients and
the reduction of hospitalization (see attached document).
b. Public Health, and pharmacies could link with primary
care on a de-prescribing initiative.
i. To date, population centers have been viewed as too
small to warrant certain services. Serving a population of
160,000 justifies the creation of more local health hubs
and bundled services which are easier for patients and
HCPs to access. The management of these services
would reflect local needs to a greater extent. Home
services, in particular, would be more visible and
hopefully, more accountable and better integrated with
primary care and the community resource center. Best
Practices within a sub-LHIN could be promoted through
an effective PCN. An effective PCN would ensure that all
patients have the opportunity to be enrolled in a primary
care practice, and that local access issues are identified
and addressed.
c. Primary Care and Community Resource Centers could
work together to structure adult day services appropriate
to rural and suburban areas.
d. Primary Care, Paramedicine, Health Links and
Retirement homes could link in order to reduce the high
hospitalization rates for retirement home residents.
e. Primary Care and CCAC could link to ensure that
patients get the home health services they require, and
that opportunities for local efficiencies in that regard are
created.
f. Primary Care and Hospitals could link to ensure that
ACS conditions reach the hospital structure minimally,
and that the primary care/secondary care interface is
understood and efficient. Communication and transitions
of care are other potential issues.
i. The sub-LHIN should be responsible for close
integration of home based services and primary care in
such a way that hospitalizations, emergency visits and
911 calls are minimized, and the patient feels, and is,
supported at home. This is the Health Link’s chief
mandate for high needs patients. The HL is also
mandated to achieve inter-sectoral cooperation. The
mandates of the sub-LHIN “Integrated Care Networks”
and Health Links need to be aligned, and one needs to be
107
have?
integrated system, and what might these roles be?
a. Population Health issues such as:
a. Home and community care workers should live in the
community which they serve as far as possible.
i. Immunization
ii. Health Promotion iii. Public policy
b. High needs patients should be surrounded with
whatever home and community care they need, in such a
way that they are unlikely to require hospitalization.
Therefore, for Health Links enrolled high needs patients,
care should be provided on a demand basis and funded
through hospitalization reductions. Although reductions in
services after stabilization may well be possible, patients
should remain on service, and recurrently monitored for
changes in home health care needs status. This may well
require an autonomously functional local team that
includes not only traditional health care workers such as
nurses, PT, OT and PSWs, but also mental health
professionals and the capability of bringing on
professionals who can deal with other determinants of
health issues such as housing, pet care, home safety,
financial management and so forth. The health care costs
incurred by this population justify a considerable funding
shift from hospital to community.
b. Public Health may have concerns that primary care is
unaware of which could be solved through joint action.
6. What risks and possible unintended consequences do
you see, overall?
a. Hospitals are at the mercy of the primary care system
in a way, being passive recipients of the failures of the
primary health care system. Primary Care could do a
much better job of preventing hospitalization – however,
the resources required to fund this transition exist in the
system are siloed and coveted. It may be beyond the
management capabilities of MOHLTC to ensure that this
transition from a hospital dominant system to a primary
care dominant system happens without undue impact on
the patient.
108
Response 6:
The main issues are communication. There is very little
communication coming from the LHIN administration
down to primary care at the moment.
Grouping the HL 7 and 8 makes sense to be
geographically - as well, by health problems, and
culturally - we are not that different from each other.
I am not sure how we can build a great system without
improved communication from the top down.
I think that services could be shared. The main issue
might be one of transportation - for instance there are
people in Kanata who use the bus to go to appointments.
They would not be able to go to an appointment out in
Almonte (ex that is currently where a COPD education
group is)
In summary without great communication, ramping up
CCAC services, and inclusion of public health and
primary care practitioners - the unintended consequences
will be a more costly system, with an increased frequency
of hospital readmissions, and less services.
However, hopefully it could mean that we could work at
making centres of excellence in our LHIN _ as per the
needs of our patient population - and continue to improve
the health of our community.
If you are able to engage the sub-LHIN areas - primary
care, improve communication, include public health and
ramp up CCAC, and also engage the public and educate
them on the use of health care services - could be a win
for our patients.
I would suggest that many of our patients come from
outside of our sub LHIN, currently. Are you thinking of
having them go to MDs in their own sub-LHIN area?
What about the PQ patients?
Linking up primary care with CCAC and the multiple other
services would only help our patients more. Ideally - to
keep them out of the hospital.
Community care at the moment is hit and miss. The
nursing side seems to be doing very well - but the OT/PT
is terrible. This past month, I know of two instances where
patients required OT/PT assessments and help within 2
days of hospital discharge - they were seen 10 days after
discharge. This is unacceptable. It will result in
readmissions to hospital.
Public health should be more integrated. There is often a
replication f services. There should be more leasing with
primary health care - and they should come under the
same LHIN umbrella. They should also be intimately
involved in helping plan out public health programs based
on the needs in each sub-LHIN area. Their expertise
should be used.
109
Response 7:
Several more general comments:
Questions 1 & 2:
This could be an opportunity to educate patients about
health issues, and appropriate/responsible use of health
care resources. Perhaps this education could be part of
academic curriculum e.g.: teach the concepts of
"Choosing Wisely", inappropriate use of antibiotics,
difference between cold/flu, what to do for each, when to
see a PCP...
Wonder how health-care funding can be made equitable
for regions with disparate socioeconomic class, and how
the challenges of offering services within a large
geographical area can be addressed.
Questions 3 & 4:
I see great opportunity for specialists to work more
closely/effectively with PCPs.
Finally, I hope "putting patients first" doesn't equate with
completely patient-led care. There are some patients who
unfortunately demand inappropriate tests/investigations,
refuse appropriate immunizations and pressure PCPs to
prescribe antibiotics for viral infections. Allowing such
individuals to provide feedback wrt their satisfaction with
their PCP may skew our healthcare system toward
undesirable outcomes. (In fact, there's evidence that
patient satisfaction unfortunately doesn't correlate with
positive health outcomes.) True patient-centred care
would stand firm in these issues.
e.g.: run specialty clinics out of the local FHT/ primary
care office (respirology, cardiology, geriatrics, derm, ob,
gyne...)
Have a CCAC presence locally - someone with whom we
can directly interact/communicate wrt our patients
requiring home care services.
Offer group CBT on site, parenting classes, community
diabetic clinics...
Questions 5 & 6:
I think Ottawa Public Health is scrambling at present, in
the wake of their difficulties managing the school-age
immunization program. This is of course an area in which
primary care and public health could be sharing info more
effectively. Sexual health clinics could operate out of local
sites, as could breast-feeding clinics...
110
Response 8:
joined, creating a population of
Not sure that any is needed. Simply providing opportunity
to share resources, share data, etc., would entice primary
care providers to avail themselves. Combined with
incentives that are related to measured endpoints
(access, patient satisfaction, etc.).
166,000. What might be the advantages and
disadvantages of this change?
Many differences between rural and suburban aspects of
the regions and most of West
most valuable? -----
Ottawa's patients’ needs are more similar to Ottawa
(urban)
have? -----
Link geographical boundaries. (see section 3.0 of the
details).
integrated system, and what might these roles be? ----6. What risks and possible unintended consequences do
you see, overall?
Biggest I can foresee is measuring things that sound
good (same day access, patient satisfaction with
encounter, etc.) that has little to do with good medicine
and good health measures.
Easier to monitor endpoints in a smaller region and able
to deal with smaller number of practitioners to change
practices, as needed.
Better sharing of resources.
111
112

Session Feedback Report from Patients First

Transcription

Documents pareils

here - Joey Kelly

Award Letter - CEO Recruitment (RFP#20150114)

Your Help F`.

HNHB Local Health Integration Network

Toronto Montessori Schools

The medico-legal aspects of intraprofessional care

Annie Gauthier