2015/16
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Constant Caring in<br />
a Year of Change<br />
Mississauga Halton CCAC<br />
<strong>2015</strong>/<strong>16</strong><br />
Annual Report to the Community
Board of Directors’ Message<br />
We govern in interesting times<br />
On behalf of the Mississauga<br />
Halton CCAC Board of<br />
Directors, we are proud to<br />
volunteer our skills and leadership to represent<br />
the health needs of people across our region. We<br />
invite you to read a summary of our role on page<br />
30 of The Faces of Care.<br />
Welcome to our <strong>2015</strong>/<strong>16</strong> Annual Report to our<br />
Community. It was an extraordinary year for<br />
several reasons.<br />
1. We launched a new Strategic-Plan <strong>2015</strong>-2020<br />
that makes “people the point of care” and<br />
focuses on:<br />
• Making Meaningful experiences and<br />
outcome for people<br />
• Modernizing the health system<br />
• Mobilizing professionals and technology to<br />
make health care work for people<br />
2. We oversaw the responsible use of funds<br />
and achieved a balanced budget despite<br />
an increase of 13 per cent of patients with<br />
complex care needs; and we earned the<br />
confidence of 95 per cent of patients who<br />
would recommend our organization to family<br />
and friends.<br />
3. We received and responded to the proposal to<br />
change health care at home, entitled, Patients<br />
First: A Proposal to Strengthen Patientcentred<br />
Health Care in Ontario, released by<br />
the Ministry of Health and Long-Term Care on<br />
December 17, <strong>2015</strong>. That proposal calls for the<br />
elimination of the CCAC Boards of Directors.<br />
On behalf of patients and caregivers in this<br />
region, we are building on our history of<br />
collaboration with our LHIN Board colleagues<br />
that began in 2013. Since January 20<strong>16</strong>, we’ve<br />
re-focused our attention on the Patients First<br />
discussion paper. If the ministry’s proposal<br />
is implemented, we will use our governance<br />
expertise to ensure stability in the system during<br />
the transition for patients and for our teams of<br />
dedicated staff.<br />
As we continue our leadership in 20<strong>16</strong>/17, we<br />
remain focused on governing this outstanding<br />
organization, while educating decision-makers<br />
to better understand what is required to care<br />
for patients in our community today and for<br />
the forecasted exponential growth of patients<br />
in the future. As experienced governors of the<br />
Mississauga Halton CCAC, we are using our vital<br />
insight to protect patients through this significant<br />
proposed change.<br />
Dieter Pagani, Chair,<br />
Mississauga Halton CCAC Board of Directors<br />
Roshan Sapra Don Taylor<br />
Rhonda Lawson Laurie Cabanas Rhonda Chou Kareen Hall-<br />
Clarke<br />
Ray Gilbert Steve Heck Frank Kelly Sona Khanna Ebere Morgan Erika Domijan<br />
2<br />
Community<br />
Member
CEO’s Message<br />
Focus on care our constant in a year of change<br />
We learn our strength<br />
when we are challenged<br />
with change. I experienced<br />
and thrived through changes in health care<br />
throughout my career, from my beginnings as a<br />
nurse to executive positions in acute care and to<br />
my role as CEO of the Mississauga Halton CCAC<br />
<br />
for the past six years.<br />
<br />
It is with tremendous pride that we look on fiscal<br />
year <strong>2015</strong>/<strong>16</strong> as a year that we enhanced our<br />
ability to “make people the point of care.” With<br />
our unwavering focus, we cared for a total of <br />
48,000 patients, serving 1,369 more people in<br />
<br />
our region than in the previous year. We were<br />
<br />
not distracted by proposed changes to the CCAC<br />
<br />
sector. Indeed, we realized an increase of 27 per<br />
cent positive employee engagement, as all teams<br />
<br />
continued to focus on caring for patients.<br />
<br />
The past year also saw our CCAC achieve <br />
enhanced care coordination and effective <br />
collaboration. I am proud to highlight just four of<br />
our accomplishments.<br />
<br />
1. Our Care Coordination Program of Work<br />
is the most significant change we’ve ever<br />
undertaken to enhance the care and support<br />
that patients and caregivers experience; <br />
I invite you to read the overview and watch <br />
the video featured on page 5. <br />
<br />
2. Insights is a game-changer for helping our<br />
<br />
care coordinators keep a crucial line of sight to<br />
each of their patients.<br />
<br />
Insights is<br />
<br />
much<br />
<br />
more<br />
than a simple dashboard; it is an evidencebased,<br />
real-time, customized summary of each<br />
patient, helping us to better manage the many<br />
aspects of each patient who is in our care.<br />
3. In partnership with the Primary Care Network<br />
and our LHIN, we developed a primary care<br />
provider data base. The first of its kind in<br />
Ontario, the data base is an accurate, single<br />
source of primary care providers working<br />
across our region, including up-to-date<br />
physician profiles. This tool also enables direct<br />
<br />
communication to physicians’ offices to<br />
<br />
share important patient information in<br />
real time.<br />
<br />
4. Another innovation, DocSearch, is a medical<br />
specialist electronic compendium that helps<br />
primary care providers know which specialists<br />
<br />
are in their region and available for referrals to<br />
<br />
see their patients.<br />
<br />
Thriving in ambiguity also means contributing<br />
our expertise and experience to inform important<br />
proposed changes in our health system. We<br />
produced an organizational overview to help<br />
leaders making changes to our health system<br />
understand that “it takes a team to care for<br />
patients.” We are pleased to share The Faces of<br />
<br />
Care with you.<br />
<br />
As we celebrate the care we provided to<br />
patients and families in <strong>2015</strong>/<strong>16</strong>, we continue<br />
in 20<strong>16</strong>/17 with the next phase of our Care<br />
Coordination Program of Work – care<br />
coordinator and contracted service provider<br />
neighbourhood realignment, which will provide<br />
greater consistency and closer collaboration with<br />
patients and families. We will also expand our<br />
vital partnerships with health care organizations<br />
throughout our region in pursuit of our goal<br />
of an integrated, sustainable system of care<br />
implemented for people in this region and<br />
<br />
beyond.<br />
Sincerely,<br />
Caroline Brereton, CEO,<br />
Mississauga Halton CCAC<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
3
Care Coordination Program of Work:<br />
“Making People the Point of Care”<br />
Through our innovative Strategic Plan <strong>2015</strong>-2020<br />
initiative, the Care Coordination Program of<br />
Work, we completed an extensive, evidencebased<br />
professional practice re-design of our<br />
care coordination approach to better meet the<br />
needs of all patients in the Mississauga Halton<br />
region, including those enrolled in Health Link.<br />
Our new rigorous, enhanced care coordination<br />
ensures that patients receive consistent care that<br />
integrates their services where they live, in their<br />
own neighbourhoods.<br />
While every patient is unique, our new approach<br />
to care coordination removes variability; it’s<br />
consistent for all patients. Regardless of where<br />
patients live in our region, they will receive the<br />
same care coordination approach, the same<br />
quality of care and compassion.<br />
Patient-centred Design<br />
Share Care Council: We engaged our patient<br />
and family advisory forum to understand how<br />
care coordinators can provide more consistent<br />
experiences for patients and carers. They<br />
recommended the following.<br />
“Support me in my journey from illness to<br />
wellness (or illness to palliative) by becoming my<br />
care coordinator who oversees all of my care –<br />
my trusted advisor, advocate and coach.”<br />
Community Capacity Plan key findings:<br />
• Care coordination reduces health risk, but<br />
is most effective when one person/entity<br />
is responsible for coordinating care across<br />
multiple providers<br />
• Health and social programs in Mississauga<br />
Halton region, including care coordination, need<br />
to be targeted at specific patient populations<br />
that take into account a patient’s socioeconomic<br />
and cultural status, diagnosis and<br />
place of residence<br />
Client and Caregiver Experience Evaluation<br />
(CCEE): A quarterly third-party, independent<br />
survey of patients and carers revealed that<br />
consistency in care experiences matters most.<br />
Achievements<br />
1. Care Coordination Enhancement<br />
A Care Coordination Framework was implemented<br />
for all care coordinators, including eight core<br />
competencies and new care practices for care<br />
planning and care conferencing. The framework<br />
focuses on teaching, evolving and coaching care<br />
coordinators to consistently deliver care with skill<br />
and confidence.<br />
“The health care system is difficult to navigate;<br />
do more to make sure my care plan meets my<br />
needs. I need a life plan that tells me what will<br />
happen next.”<br />
Community Capacity Plan: This unprecedented<br />
study helps determine the care needs of older<br />
adults now and in the future.<br />
4
The skills, knowledge and behaviours<br />
associated with each core competency<br />
defines our expectations of how care<br />
coordinators will interact with patients<br />
and families to support optimal care<br />
experiences, every time.<br />
Training does not stop at our<br />
doors. Care coordinators practice<br />
this compassionate approach with<br />
patients in their homes and they<br />
are supported by professionals who<br />
conduct a thorough quality practice validation<br />
and provide real-time feedback on their patientcentred<br />
approach.<br />
Already, several care coordinators are<br />
demonstrating mastery of multiple skills,<br />
including writing care plans in a way that are<br />
meaningful to patients and families. Owen, a<br />
78-year old patient says, “My care coordinator<br />
took the time to explain things to me. She was<br />
extremely knowledgeable and very helpful. She<br />
linked me to services I did not know were there,<br />
and she took time to answer my questions. It<br />
was like she really cared.”<br />
2. More help for Patients and Families<br />
Patients and carers told us they need a written<br />
life plan. Our new patient package, My Story,<br />
is a customized resource binder of important<br />
information that patients use to track their care<br />
at home. The foundation of My Story is a onepage<br />
care plan, focused on patients’ personalized<br />
life goals. Care coordinators co-develop this care<br />
plan with patients and families and ensure all<br />
those in the circle of care understand and follow<br />
the plan. It also includes a section dedicated<br />
to managing medications and equipment,<br />
information on the roles of different community<br />
providers, tips for falls prevention and our Patient<br />
and Caregiver Bill of Rights.<br />
Learn how one of our expert care coordinators, Natoya Hylton,<br />
applied our new care coordination approach to help her<br />
patient, Betty, recover at home.<br />
We developed a complementary carer support<br />
guide, A Helping Hand While Caring for Your<br />
Loved One, with local resources to support<br />
carers, including adult day programs, tips to<br />
reduce stress and avoid burnout, advance<br />
care planning tools, videos and diseasespecific<br />
resources.<br />
Neighbourhood Realignment<br />
We know that to deliver the care that patients<br />
and carers need and want, we must establish<br />
strong, connected teams that wrap care<br />
around patients.<br />
To realize this goal, we realigned our care<br />
coordination teams to neighbourhoods where<br />
patients live. With extensive collaboration<br />
and careful planning, starting July through to<br />
December 20<strong>16</strong>, we are realigning our contracted<br />
service providers to respond to patients’ demand<br />
for consistent nursing, rehabilitation and personal<br />
support services from people who “know them<br />
and their unique needs.”<br />
We’ve designed and implemented a consistent,<br />
interdisciplinary team approach to help achieve<br />
what’s most important to patients.<br />
Click here on Care Coordination Program of<br />
Work to learn how our new neighbourhood care<br />
coordination approach benefits all patients and<br />
families in the Mississauga Halton region.<br />
5
Patient-Centred Care in<br />
<strong>2015</strong>/<strong>16</strong><br />
91.7%<br />
of our patients<br />
with complex care<br />
needs received their<br />
first personal support<br />
worker (PSW) visit within five days<br />
after their assessment. *<br />
5 Days<br />
95.6%<br />
of all patients<br />
received nursing<br />
care through<br />
home visits<br />
or clinics, within five days after<br />
their assessment. *<br />
84%<br />
of all our patients<br />
discharged from<br />
hospital were not readmitted<br />
within the first 30 days<br />
(excluding planned admissions). **<br />
96.2%<br />
of all our<br />
patients<br />
discharged from hospital did not<br />
visit the emergency department<br />
within the first 30 days. **<br />
Cared for<br />
48,000<br />
patients, including 13%<br />
more patients with complex<br />
care needs than in 2014/15.<br />
6<br />
95%<br />
of patients said<br />
they would<br />
recommend the Mississauga<br />
Halton CCAC to their family<br />
and friends. ***<br />
Notes:<br />
* Internal data, based on<br />
Ministry of Health and Long-term<br />
Care indicators, average for April 1,<br />
<strong>2015</strong> to March 31, 20<strong>16</strong> (Q1 - Q4<br />
<strong>2015</strong>/<strong>16</strong>).<br />
** Available hospital statistics, average for<br />
July 1, 2014 to June 30, <strong>2015</strong> (Q2 - Q4<br />
2014/15 & Q1 <strong>2015</strong>/<strong>16</strong>).<br />
*** Based on independently conducted<br />
Client & Caregiver Experience<br />
Evaluation, average from April 1<br />
to December 31, <strong>2015</strong> (Q1 - Q3<br />
<strong>2015</strong>/<strong>16</strong>).
Fiscal Year <strong>2015</strong>-<strong>16</strong> Results<br />
Overall Totals <strong>2015</strong>-<strong>16</strong> 2014-15 % Change<br />
Average number of patients served per month <strong>16</strong>,421 15,898 3.3%<br />
Total number of patients served 48,000 46,631 2.9%<br />
Programs<br />
Number of Palliative patients 2,053 2,010 2.1%<br />
Number of visits to care for Palliative patients 345,211 330,640 4.4%<br />
Number of patients on Stay at Home, Wait at<br />
Home - LTC, and Wait at Home Enhanced programs 987 925 6.7%<br />
Fast Facts <strong>2015</strong>-<strong>16</strong> 2014-15 % Change<br />
Percentage of patients and caregivers who would<br />
recommend our services to family and friends 95.36% 96.10% -0.7%<br />
Financial results ($ in ‘000s) <strong>2015</strong>-<strong>16</strong> 2014-15 % Change<br />
Fiscal Year <strong>2015</strong>-<strong>16</strong> Results<br />
Revenues $<strong>16</strong>6,677 $159,468 4.5%<br />
Operating expenses<br />
Administration 7,442 7,<strong>16</strong>4 3.9%<br />
IS, Plant, and Other 7,085 6,852 3.4%<br />
Patient Care 151,759 145,842 4.1%<br />
Total Operating expenses $<strong>16</strong>6,286 $159,859 4.0%<br />
Net Surplus / (Deficit) $391 $(391)<br />
37.4%<br />
Visits by Age<br />
in <strong>2015</strong>/<strong>16</strong><br />
23.4%<br />
7.1%<br />
12.0%<br />
7.7%<br />
12.4%<br />
Contracted Services<br />
in <strong>2015</strong>/<strong>16</strong><br />
10.5%<br />
8.9%<br />
28.5%<br />
52.1%<br />
Operating Expenses<br />
in <strong>2015</strong>/<strong>16</strong><br />
91.3%<br />
4.5%<br />
4.3%<br />
0-18<br />
19-54<br />
55-64<br />
65-74<br />
75-84<br />
85+<br />
Personal Support/Respite<br />
Nursing<br />
Medical Supplies and Equipment<br />
Rehabilatation Services<br />
Administration<br />
IS, Plant, and Other<br />
Patient Care<br />
Notes: <br />
Financial results are based on audited financial statement.<br />
7
Vision<br />
Outstanding Care – every person, every day.<br />
Mission<br />
To deliver a seamless experience through the health system for people in<br />
our diverse communities, providing equitable access, individualized care<br />
coordination and quality health care.<br />
Etobicoke Office<br />
401 The West Mall<br />
Suite 1001<br />
Etobicoke, Ontario M9C 5J5<br />
8:30 a.m. to 4:30 p.m.<br />
Milton Office<br />
611 Holly Avenue<br />
Unit 203<br />
Milton, Ontario L9T OK4<br />
Mississauga Office<br />
8:30 a.m. to 4:30 p.m.<br />
Mississauga Office<br />
2655 North Sheridan Way<br />
Suite 140<br />
Mississauga, Ontario L5K 2P8<br />
8:30 a.m. to 4:30 p.m.<br />
Our Access Care Team is available<br />
from 8:30 a.m. to 9:00 p.m.<br />
We have offices and staff located in<br />
the following hospitals. No referral is<br />
required to contact them.<br />
Trillium Health Partners (THP)<br />
Mississauga Hospital, Queensway Health<br />
Centre, Credit Valley Hospital<br />
Halton Healthcare (HH)<br />
Oakville Trafalgar Memorial Hospital<br />
Georgetown Hospital, Milton District Hospital<br />
310-2222 (CCAC)<br />
no area code required<br />
www.healthcareathome.ca/mh<br />
www.mississaugahaltonhealthline.ca