3 Ways Boards and CEOs Can Shun Scandal and Sustain a Positive Culture

Businesswoman leading collaboration session with postit note board.Boards and CEOs bear enormous responsibility for the well-being of their organization’s people. In turn, organizations rely on fully engaged and motivated employees to deliver on their mission. Much is written about how ‘trust’ affects each employee’s engagement. Employees should be able to trust their organization to provide a safe environment that evokes pride and provides ample support for them to thrive in delivering quality work to the communities they serve. Employees are also expected to share values aligned with their organization and to come to work each day prepared to do the best they can. Informed leaders know that most employees share this goal. So when employee performance goes amiss, it’s frequently because the culture, including the systems, processes and tools, impedes their success.

Leadership creates culture. To build a culture of trust, ‘walking the talk’ as boards and CEOs is imperative.

The rising number of harassment incidents recently making headlines is a wake-up call for all boards and CEOs. Sadly, in numerous cases, the issues were known and ignored. Employers’ responses to these incidents are also alarming. For me, it raises the question: What is the priority for boards and CEOs?

To mitigate media exposure crises, contracts are usually abruptly terminated but what about long-standing workplace harassment issues employees face each day? What’s the impact to emerging leaders who may view the way senior members (leaders or staff) behave as the way to lead or get ahead?  What message does it send to employees? Does it suggest inappropriate behaviour is ok, as long as you can get away with it, but if you’re caught, you will be fired? These characteristics don’t belong in organizations that espouse to be just, caring, learning and innovative.

When harassment issues emerge, we should ask: What kind of governance and leadership processes might have mitigated damage to the organization, its employees and stakeholders?

In my previous post, I addressed the relationship between the board and the CEO, how to ensure each can simultaneously fulfill their role in harmony through meaningful conversations, particularly generative dialogue, learning and a united workplan.

Boards and CEOs need this harmony to meet their key mandate: To advance the organization’s mission. This mandate includes protecting and growing the organization’s assets. To achieve this mandate, the board must provide effective board governance oversight and the CEO must efficiently manage the organization.

At the heart of this accountability is managing our most important assets – the employees who deliver on our organization’s mission.

Sustaining Trust

Here are 3 ways boards and CEOs can work together to support our employees and sustain a culture of trust:

#1. Seek out the story behind the data –

Boards monitor performance indicators to gain insight. This must include setting performance goals and monitoring indicators that relate to culture and people practices, such as employee engagement, turnover, sick time and grievances. Data only gives us part of the picture. Its complement is insight into the story behind the numbers.

You uncover this story through generative dialogue with the CEO. To work effectively, we must give board members opportunities to use their intuition and judgement to ask the CEO probing questions.

Boards and CEOs must also be open to feedback from all stakeholders. A leading practice in performance assessment is the 360° feedback process. This can be cumbersome and the traditional process alone is outdated in today’s dynamic environment.

With social media and rapid learning cycles, we can connect this process to more dynamic feedback loops. CEOs can gain more dynamic feedback and insight through tactics like trusted blogs, town halls and webinars. Board members should seek opportunities to connect with the broader stakeholder community, gain feedback on their organization’s reputation and how it looks from the outside. Employees also talk about their work environment and their experience reflects how the organization interacts with its stakeholders.

If boards and CEOs listen, while connecting internally and externally, they can’t be blindsided by a longstanding, toxic work environment.

#2. Watch employee interactions throughout the organization

Boards and CEOs must have visibility into the work environment and how employees interact at different levels. How the CEO engages with senior staff, how executive team members support committees or communicate in board meetings often indicates how these leaders interact with the entire organization.

From the governance level, CEOs and boards can also look at internal relationships by participating in key events, such as recognition ceremonies, learning sessions or celebrations. When board members observe how employees and leaders interact, they discover context behind the data presented to them. CEOs must also make it their priority to spend time with all teams to get insight into rapport or tensions between management and employees.

#3. Prioritize and structure HRs’ role appropriately –

Human Resources (HR) must directly report to the CEO. This structure enables HR to advise the CEO and give the board the support it needs to deliver on people practices oversight and the organization’s culture.

We must also remember the HR function is not responsible for the culture. Culture is the role of the CEO. However, we expect HR  to ensure all leaders and employees have the tools they need to apply leading practices to their work and fulfill their roles. Equally important, it must be a strategic partner in ensuring the work environment enables its people to create the best outcomes for the organization. This role includes having: policies that protect employees who come forward with complaints; processes and standards for investigating these complaints; and learning best practices so that everyone knows their responsibilities. The board must provide oversight to ensure these appropriate policies are in place and reassessed, as required.

Caroline and three other people participating in CN Tower Edge Walk
Toronto’s CN Tower has created a safe environment that fosters the trust visitors like myself need to attempt its Edge Walk. CEOs and boards must also create a safe workplace with a culture that gives employees the support they need to thrive.

There are no quick fixes to transform a contentious or negative culture. A long-term commitment to applying these 3 ways to foster the well-being of an organization’s people will start the journey.

Now is a good time to reflect on the past year, take stock of your organization’s culture and make plans to strengthen your long-term commitment to its people or most important asset.

What steps will you take in the new year to sustain a positive culture built on trust?  What needs to change, if anything?

I look forward to your thoughts on this subject.

Best wishes for the holiday season and for a positive 2018!

How CEOs and Boards Can Leverage 3 Keys to Soar in Unison

Leading Board of Directors meeting - with strong CEO as insight from Caroline BreretonIn my previous post, I identified 3 keys to enable successful leadership, outlining the leadership challenges Boards of Directors and CEOs, Presidents or Executive Directors face. Having served on and chaired Boards of Directors, as well as been accountable to one in my CEO role, I’ve lived the challenges and rewards.

Like ballroom dancers, boards and CEOs must find ways to cooperatively lead together and deliver on their accountabilities, without stepping on each other’s toes. Boards should only delve into operations when necessary and CEOs must appear to welcome detailed questions, even when they don’t.

Each party must develop a trusting, productive relationship with the other and clear accountabilities for the organization to flourish. If the relationship is not optimal, the entire organization flounders, as the CEO and management team struggle to meet new or unclear expectations from the board.

In the public and not-for-profit sectors, boards complete the accountability cycle back to funders and residents. And if you work in these sectors, you know how complex they are.

Patience runs thin for slower progress on strategies, when either the board or CEO changes. Boards organically change when their membership changes. Each cycle brings a renewed need to focus on the relationship and accountabilities as new board members offer their unique contributions. Yet sometimes boards and CEOs forget to put the necessary supports in place to ramp up quickly to a productive working relationship.

To successfully choreograph this dance, here are traditional and new approaches that have helped me leverage 3 keys: Listening, Learning and Leading, from both sides. I invite other CEOs and boards to retrace these steps as they forge their own paths to success.

Listening – From Meaningful Conversations to Generative Dialogue

An essential part of listening is having meaningful conversations so that we can uncover what’s really important.

Boards of Directors govern, while the CEO manages the organization. Yet both provide leadership to enable success, must meet specific accountabilities and make tough decisions.

Board decisions relate primarily to fiduciary and strategic issues. Understanding the context is essential for good decision-making and sometimes requires insight into operations. Structured reports and information can help but can only go so far. Meaningful conversation on issues fosters greater understanding. Coined by William Isaacs, as ‘Generative Dialogue,’ this kind of conversation is gaining more traction with some boards but is not yet common practice.

Generative dialogue mode enables the board and CEO, with their senior leadership, to delve deeper into an issue without overstepping each other’s accountabilities. Each party understands that the time spent on a topic must focus on listening to issues from all perspectives around the table.  The goal of the process is to reach a shared understanding of the context, before the decision is made.

One way I’ve found to achieve this goal is through scheduling educational sessions on topics of strategic or fiduciary importance prior to the board meeting and ideally a month or so before the decision must be made. This process allows board members to digest the information and complement their understanding with other reading/information before the decision-making meeting. In the limited time boards have together, we need to ensure they have what they need to effectively fulfill their role.

Learning – Using 360 Dynamic Feedback to Adapt, Grow and Thrive

Adapting what we know to the context of each scenario we land in is critical. Board members bring diverse skills from their professional and personal experiences and this diversity gives the board strength. However, applying these skills to board governance is different. For example, the way performance indicators are presented in one organization may not apply in another but they may work perfectly for a particular board and CEO. If you have an experienced information management professional on your board, they will apply the ‘nose in’ and ‘finger out’ concept, by asking questions to understand meaning and action plans without telling the CEO how to do their role.

Giving directors formal opportunities to learn about governance helps them adapt their knowledge to your board’s specific context. It is also important for the CEO to have a strong foundation in governance. Even better is learning together to create a shared understanding of best practices in governance.

Either way, learning through dynamic feedback is crucial. Good governance practices include the annual board survey, meeting evaluations and in-camera debriefs without the CEO to discuss board performance. These tactics may generate improvements to board process and even change the CEO and the management team’s expectations in a way that better supports the board or its priorities.

I think there’s another performance enhancing feedback process we usually miss:  Capturing how the CEO and senior management experience the board’s impact and effectiveness. CEOs change less frequently than boards but new board members change the context of the board/CEO relationship.

In welcoming feedback from the CEO and management team, boards role model the principles of continuous learning, which help us all grow.  To be effective, both parties should probe for tough feedback and follow through to make sustainable improvements. I believe we need to optimize the board/CEO relationship so that both can co-create the best future for the organization they serve. Then, at the centre of a successful public or not-for-profit sector organization, you’ll find a Board Chair focused on improvements and learning, as they adeptly share the CEOs feedback with their board

Leading – Uniting Leaders through Clear Expectations and a Solid Workplan

The Board Chair’s leadership makes or breaks the board’s effectiveness. While not always recognized as leaders, the Board Chair’s role determines the success of the board/CEO relationship. Their leadership must start with authentic intention and a genuine desire to serve the organization through their role. Of course meeting management, relationship building, communications and conflict management expertise make the Chair’s contributions even more effective.

Through its succession planning process, the board should define these skills as imperative and support aspiring chair candidates’ efforts to enhance these skills, during their tenure as members.

On the other hand, the Chair holds the CEO accountable for access to effective staff support to deliver on the board’s responsibilities. In setting expectations that the board will have good practices for doing its work, the Chair signals respect for the CEO.

Sounds wonderful but how do you achieve this balanced leadership? One tool I’ve found indispensable for making the CEO and board relationship most effective is having a comprehensive, annual workplan that:

  • Aligns with the organization’s strategic priorities
  • Fulfills its fiduciary responsibilities
  • Builds in generative dialogue time
  • Addresses the responsibilities of the board’s one employee: the CEO, President or Executive Director (through performance assessment, compensation and succession planning)
  • Accommodates its own governance processes (policies and procedures, board succession planning and board development)
  • Supports stakeholder engagement

Once developed, this workplan should serve as a central blueprint for the board’s work and the support needed from the CEO.

Boards play a central role in accountability. I’ve had the invaluable experience of seeing a community-based board step up to an enormous challenge and ensure that the organization it served flourished, even under extreme external forces.  This is how I’ve worked to master the dance between the CEO and board.

What works for you? I welcome your thoughts on these approaches to strengthen governance and the board/CEO relationship.

3 Keys to Make You a Successful Leader

Keys to effective leadership: listening, learning and leadingLeadership has been fundamental to our accomplishments for as long as we have shared stories of our successes and failures. Coordinating work or rather making the best use of an organization’s assets and the skills of its people, along with engaging everyone to advance a better future, drives us as human beings.

So why is effective leadership for positive change so challenging?

Frequently we hear people express their dissatisfaction with leadership. It’s hard to recall anyone writing about the thousands of exceptional leaders we have in the public or private sector. We tend to focus on the few outlier examples, positive or negative.

Different stakeholders express their expectations of leadership from their varied vantage points.

  • Clients/Patients/Customers no longer tolerate organizations that do not engage effectively with them, understand their needs and make a difference to their lives. We need to identify which principles guide our interaction with these priority stakeholders, particularly as this is our reason for being in health care or a service industry.
  • Employees are seeking a different work experience. The workplace is filled with different generations but it’s time to stop labelling them. Yes, we need to understand trends but each employee brings a unique contribution and their own expectations within a multigenerational team. In her “Body of Work,” Pamela Slim describes a workforce who sees their work and personal lives aligned with their drive, passion and values. How will we learn to lead in this environment? My experience in public service and complex environments, such as health care, suggests that it’s crucial for leadership to enable this alignment. This alignment creates a culture that retains talent, which is essential to success in any service or care industry.
  • Boards of Directors are challenged to understand a dynamic environment where they are expected to have their “nose in” but “fingers out” of the business. Can boards deliver on their accountabilities without duplicating the management function? Stakeholders are quick to lay blame if the organization fails to deliver on its mandate, as we have seen time and again. Balancing the governance accountability with the management/CEO role requires leadership in itself.
  • Funders expect their constituents to be satisfied. However, we have just begun to scratch the surface of understanding, through dialogue and big data, what constituents expect. How will we rapidly gain a better understanding so that we can be strategic and thoughtful about the changes we implement?

In previous posts, I have shared my teams’ successes, from working in a complex health care environment. These learnings also apply to other settings.

In upcoming posts, I am going to focus on what I believe are the important considerations for leaders to succeed in their roles. As Ontario’s employee demographic shifts during the next 10 to 15 years, leaders will need to get much better at rapidly learning how to effectively lead others and employees will need to ramp up their ability to collaborate.

I believe the following three attributes are keys to success, which I will focus on in upcoming posts

  1. Listening to gain insight – In my last post, I shared my perspective on how important listening is to our work with patients and families. A key part of listening is having meaningful conversations so that we can uncover what’s really important to our patients, so that we are in a better position to meet their needs. These listening strategies and approaches can effectively guide engagement with other stakeholders. I will explore how these strategies and approaches can improve interactions with boards, funders, residents and employees.
  2. Learning to adapt what we know to the context – Learning is a skill that must be mastered by individuals and organizations. In his book “Getting Everything You Can Out of all You’ve Got,” Jay Abraham addresses the issue of how to avoid the costly learning curve. He recommends we master the ability to borrow success practices from other industries and then apply them to ours. We need to understand that there are well established, proven ways to work with people to deliver what they as individuals need. The methods can be transferred. It’s coordinating the intervention or support and its outcomes that are unique to each individual. “Agile” is a term used frequently these days to describe how organizations learn and improve. It also describes the culture and leadership practices of successful organizations.
  3. Leading with authentic intention – In any business/sector/enterprise, leadership is essential to deliver on the mission or mandate its stakeholders set. In a guest Leadership Lab column I wrote for the Globe and Mail earlier this year, I described ways a leader can engage with their stakeholders to steer their organization through complex change.

Leaders will be successful if they listen and learn and apply that learning with their skills to lead an organization.

Recently Andre Picard wrote in the Globe and Mail about Dr. Philpott’s move from the health file to Minister of Indigenous Services. He listed the strengths she brings to her new, even more complex role. Among those strengths are many that all leaders need today. Most significantly for me he noted that: “her unofficial title will certainly be Minister of Social Determinants of Health.” Given our success locally incorporating this perspective into our strategies, I am excited to observe how this will impact outcomes for our Indigenous People and other areas of our health services. She will continue to “Listen, Learn and Lead.”

Please watch for upcoming posts where I will explore these three critical attributes.

What do you think about these three attributes? I’m particularly interested in hearing how, as leaders, we can more effectively lead multigenerational teams. What challenges do you face?

5 Ways to Engage Patients and Uncover Invisible Insights

Patient and care coordinator engagingIn my first post, I outlined five features of a patient-focused integrated health care system that I envisioned. The third was a system that: stays informed and measured by evidence from our patients and their families’ voices, as well as data drawn from assessments and social, economic and cultural (SEC) tools, among others.

There is a real opportunity for our health care system leaders to understand what our communities, patients and families consider to be the best quality care they can receive.  Some believe we have this answer in the depth of knowledge, research and clinical evidence that we have and use to guide decision-making. Clearly, patients tell us: we don’t. Clinical data only gives us partial answers.

We need to effectively engage patients, caregivers and families, actively listening to their voices to uncover invisible insights for the rest of the answers. Only then can we fully understand what’s needed to shape a patient-focused system.

In a guest Leadership Lab column I wrote for the Globe and Mail earlier this year, I described ways a leader can engage with their stakeholders to steer their organization through complex change and mitigate risks. We may not have all the answers but when we engage, we bring our team, partners, clients or patients and other stakeholders’ questions, concerns and fears to the surface.

Of all our stakeholders in health care, patients are our priority and it’s important for leaders to continuously engage them, not just during times of change.

Here are five approaches that I found invaluable in my work leading a home and community care organization (Mississauga Halton CCAC):

1. Having meaningful conversations with patients –

If you directly ask a patient what their goals are, they might find them hard to articulate. However, they may enthusiastically express their joy in watching their grandson fine-tune his hockey skills or playing cards with their friends.

A skilled care coordinator starts the patient assessment process by gently having a meaningful conversation with their patient to learn what’s important to them and through this process, subtly uncovers their goals. This conversation also elicits feedback on how the patient wants their care delivered. With this insight, we can form pledges to patients on how they will ‘receive’ care, not just how we deliver it.

In 2015, the Mississauga Halton CCAC launched the award-winning Care Coordination Program of Work to drive consistent quality in our care coordinators’ varied competencies, while providing this essential service.  One competency is communications and we set specific standards and training to help each care coordinator guide these meaningful conversations and effectively engage each patient.

2. Partnering with each patient, their caregiver and family members –

Next to patients themselves, their caregivers and families are in the best position to help care coordinators, service providers and other funded resources understand their specific goals. Actively listening to our patients and partnering with their families helps us deliver on their expectations. And meeting or exceeding a patient’s expectations makes their health care experience that much better.

Patients, caregivers and families want to work with us to make sure their needs or those of their loved ones are met. And when they talk about how care is delivered, their requests are practical. They want to be treated with respect, participate in the conversation and have the opportunity to influence care decisions. To meet these requests, care coordinators work with the patient and often their caregiver or family to co-create a care plan they all agree on.

Based on input from patients and caregivers, our CCAC developed a personalized patient information package called ‘My Story’ to support this process and help patients be confident with their care.

3. Facilitating formal patient engagement forums to inform programs & services –

In 2014, our CCAC established Share Care Council – a structured patient engagement forum of 15 patients, substitute decision-makers and family members. Council members volunteered their time quarterly to provide input into new programs and services, on behalf of our region’s residents.

What I found most interesting is when we asked specific questions about program planning for the future, we didn’t hear “We need more PSWs or more nursing care,” even though we were at the lower end of the funding per capita, per senior resident in our region. Our patients and families understood the constraints of the system. Instead, they told us about their care experience, how it made them feel and how our system design can do better with the resources we do have.

For example, we asked what respite care or caregiver relief means to them. They told us it is temporary care that substitutes for the care provided by their loved ones or family members. It enables their loved one/family member to recharge, so they can continue to provide support. More importantly, they explained how this respite needs to consider how the loved one provided care, by understanding what matters to the patient, such as the way a chair is placed, the specific supports they need for reading or the companionship they seek. Essentially, they want support beyond the clinical care requirements.

Council members showed us the health system is not fractured in their mind. That’s why they find it frustrating when the care they experience falls short. It doesn’t matter whether they are a primary care patient, a hospital patient or a home and community care patient, they are simply a patient – in need, stress or crisis.

Feedback from our council informed many successful initiatives, such as My Story, our Health Links Patient Partnership (HeLPP) program and our award-winning Seamless Transitions, a new approach to help patients transition from hospital to home.

I’m pleased that the Patients First Act requires each expanded LHIN to have a Patient and Family Advisory Committee, like our Share Care Council, to support community engagement. This requirement offers the potential to put patients first by actively using their voice to inform day-to-day planning.

4. Establishing an Ombudsperson office for managing formal complaints –

Complaints are tough and call for intense, specialized interactions. We created an Ombudsperson role and dispute resolution process to address patient complaints that were complex and escalated beyond the care coordinator and their manager.  In a true service culture, point of care teams are supported to resolve issues as soon as possible and as close as possible to the patient and family. However, in the “complexity” of our health system design, “complex” complaints often involve multiple stakeholders across the system. Point of care teams need additional support. This office receives complaints via varied sources – from the patient or caregiver to the Long-Term Care ACTION Line.  The team uses specialized negotiation techniques to focus on the needs of each party with the end goal of achieving the best solution for everyone.

Time and again, we discovered a communications breakdown at the root of an issue. To address it, we needed to ask questions and create opportunities to hear the assumptions behind it. In our information overload world, we can’t assume all input is based on the best or most up-to-date information. We found engaging, even in challenging circumstances, often leads to clarity, prompts dialogue and helps forge solutions.

5. Encouraging broad feedback through formal measurement tools –

Each year, a third-party research firm conducted a Client and Caregiver Experience Evaluation (CCEE) survey of our patients, as well as those at CCACs across Ontario.

This standardized tool invited patients to anonymously answer a series of standard questions about the quality of care they received and how they felt about it.

These provincial comparisons of our local performance gave us a consistent way to assess how well we met patient expectations and opportunities for improvement. For example, through a deep analysis of this information we were able to uncover the need for greater consistency in our communication with patients. As described earlier, this finding led to our investment in the Care Coordination Program of Work and a turning point in satisfaction results with our services.

Through sharing what’s important to them, patients and families will help us as leaders evolve our organizations, make the system adaptable and responsive to their needs, as well as those of the next generation to come.

“It’s far more important to know what person the disease has than the disease the person has” – Hippocrates

What do you think? Can you think of other ways to engage patients and their families?  Can you share an example of how engaging patients helped shape a successful decision or initiative?

Why Care Coordination is an Essential Health Service

Benefits to the Patient and the Health System

In just over a decade, Ontario is expected to see its number of seniors, 85 years and older, quadruple. As Ontarians age, they also develop more comorbidities, with 70 per cent of seniors expected to live with two or more chronic conditions by 2030. For these frail patients requiring services from multiple providers, accessing the right level of care at the right time is bound to be tricky.

That’s where care coordination comes in. It’s a fundamental health service that assesses and coordinates the most appropriate services for a person’s health needs. Through this process, care coordination facilitates smooth transitions between varying levels of care. Care coordinators are regulated health professionals with backgrounds in nursing, social work, occupational therapy, physiotherapy or speech therapy. They work directly with patients receiving care either in hospitals, doctors’ offices, community clinics, schools, or in their own homes.

Care coordinators take a holistic view of the person’s clinical and social status to identify the most appropriate services for the patient, such as nursing care, personal supports for daily living, occupational or physiotherapy, adult day programs, or help finding a primary care provider.

Reducing health risks

At the patient level, care coordination reduces health risks by ensuring that every patient receives health services to match their needs. Seniors with multiple chronic conditions rarely require the same level of care over a consistent period of time. Their health fluctuates. Sometimes they require intensive care, while at other times they may be able to live more independently, needing less care.

Care coordinators are crucial in helping patients and families weave through these different types and levels of care by assessing patients’ clinical statuses, monitoring their outcomes and adjusting the plan of care with all health care providers. They also focus on patient’s social determinants of health, such as income, housing status and social supports, which might affect their wellbeing.

As I mentioned in a recent post, “3 Steps to Addressing Socioeconomic Barriers to Achieve Better Outcomes,” patients with socioeconomic barriers can’t afford to follow health care directions if they don’t have the necessary social supports. Care coordinators have the means to link with other organizations and share information with partners in the patient’s circle of care to address socioeconomic issues through non-clinical supports. These supports could be help related to lifestyle changes or assistance in accessing social support services and volunteer programs.

Providing effective care coordination that addresses clinical and social determinants of health enables patients to live safely in their home. This health service spares patients the social impact of leaving the comfort of their home. It also saves the financial costs of hospitalization or a premature move to long-term care.

Optimizing Resources

An unnecessarily early move to long-term care isn’t just costly for the patient – it’s taxing on the entire health system, with long-term care costing $126 per day, compared to $42 per day for home care. Beds are also limited – the Mississauga Halton LHIN for example, has 25 per cent fewer beds per senior than the provincial average.

Yet we still see some patients moving prematurely to long-term care homes without first receiving Supports for Daily Living, Adult Day Programs, assisted living or home care – services that could help patients retain their independence for as long as possible, while easing the demand for beds in hospital or long-term care homes.

Without having a care coordinator involved in their care, patients might skip these crucial levels of care when they experience health crises and go to the hospital emergency department or seek a physician’s care. During crises, patients and their families may also rush to obtain care in a long-term home believing it’s the only solution. Many have difficulty understanding that with the proper supports, they may improve at home or in their community.

To optimize our province’s resources, we have to ensure that long-term care beds are reserved for patients with the highest needs. Care coordinators can help patients who don’t require services in long-term care by empowering them to remain at home and independent. They can also arrange for home and informal care services to help discharge seniors admitted to long-term care following an acute episode.

Evolving Care Coordination to Meet Patient Needs

To best serve our patients, care coordination must be consistent in its service delivery – something we learned after surveying the Mississauga Halton Community Care Access Centre’s (CCAC’s) patients and caregivers. Feedback from this survey showed that patients value consistency above all. Regardless of where they live, patients want to receive the same approach to care coordination and the same quality of care, as any other individual in the region.

Based on this survey’s findings and results from the Community Capacity Plan, the Mississauga Halton CCAC saw an opportunity to redefine and enhance the role of care coordinators.

We found care coordinators to be most effective when they’re connected to every part of the health system, serving as the single point of contact for patients to obtain services and information in their neighbourhoods. To facilitate this, our CCAC implemented the Care Coordination Program of Work, through three key phases:

1. Care Coordination Enhancement

To ensure patients receive consistent care, we trained care coordinators on the following eight core competencies, which serve as the foundation for delivering a patient-centred, holistic approach to care:

  • Assessment
  • Communication
  • Navigation
  • Quality and patient safety
  • Collaboration
  • Sustainability
  • Care transitions
  • Care planning

These core competencies modernized the way we deliver care by establishing consistent care practices for coordinated care planning.  They also leveraged technology and proactively engaged all those in a patient’s circle of care.

2. Neighbourhood Realignment

Because Socioeconomic and Cultural (SEC) statuses vary significantly across neighbourhoods, it’s important to have a strong understanding of the social, cultural and economic factors that impact the ability of people in those neighbourhoods to access care.

Our CCAC also realigned care coordination teams and caseloads to specific neighbourhoods within the Mississauga Halton region. This helped care coordinators hone expertise in the specific resources available in the dedicated neighbourhood where they work. With this knowledge, they can remove barriers to care, tailor services to patients and arrange for support from local resources.

3. Connecting to Primary Care

Finally, to deliver quality care, we must establish strong connected teams that wrap care around patients and in collaboration with their family physician or other primary care provider. To help achieve this, Mississauga Halton CCAC created the Primary Care Advisor (PCA) role. PCAs serve as the point of contact for primary care physicians in Health Links boundaries.

Through this relationship, they’re able to increase awareness of LHIN programs and services among primary care physicians and also gather feedback to improve patient outcomes and experiences.

Expanding the Role of Care Coordination

I’ve seen efforts to reimagine the role of care coordinators to become coordinators for the entire health system move forward, largely due to the eight core competencies that now guide and standardize care coordination in our region. Looking ahead, we need to understand that care coordination offers value among the broader circle of care, and that sometimes, there might be minimal involvement from partnered service providers.

Care coordination could be expanded to include other partners funded through community and social services, such as Development Services Ontario and Correctional Services for specific patient populations, rather than just through the health system. It could also involve coordinating care to include pharmacy, laboratory, imaging and physician services, which are beyond the LHINs’ current mandate.

What do you think? In what other ways do you see care coordination evolving?

3 Ways Collaboration Expands Health Care Capacity

We know that to help our patients achieve what’s most important to their wellbeing, we need to bring clinical care and social determinants of health together. But to realize a patient-focused, collaborative and integrated health care system, we must focus on fostering strong relationships with everyone in a patient’s circle of care.

As I mentioned in my first post, collaboration is a key feature of a sustainable, integrated health care system. It’s also at the root of home and community care. Care coordinators are connected throughout the health care system. They work with patients and families, hand-in-hand, to co-create tailored care plans that may involve nursing care, Adult Day Programs, personal support care, occupational or physical therapy, mental health and addictions or other services.

In fact, results from the CCAC’s Community Capacity Plan highlight the importance of care coordinators, patients and caregivers working together at multiple levels. The plan also cites the value of collaboration between multidisciplinary partners, such as health care professionals in acute, primary, long-term care, mental health, addictions and community services.

1. Collaboration Leads to Innovative Programs

Primary Care Advisors

While care coordinators collaborate with patients and caregivers at a clinical level, Primary Care Advisors (PCAs), who are currently unique to the Mississauga Halton LHIN, work as trusted points of contact for primary care physicians and gather feedback to improve patient outcomes and experiences. They also meet regularly one-on-one with primary care providers to keep them informed about LHIN-wide programs, services and initiatives.

Before meeting with PCAs last year for example, many physicians weren’t aware of the support and scope of expertise CCAC palliative nurse practitioners can provide to help them care for their patients and families.

Through the PCA-physician collaboration, which began in 2015, we’ve learned two important lessons:

  • We need to effectively coordinate services to address the socioeconomic and cultural (SEC) impacts on patients
  • Care conferencing, where multidisciplinary partners meet to discuss how patients’ needs are or can be met, is vital for the success of patients’ care plans
Health Links

Meanwhile, through the province’s Health Links initiative, we’ve seen multidisciplinary partners, including: primary care providers; specialists; care coordinators; other allied health professionals; community service providers; hospital clinicians; social workers; and those working in long-term care homes, engaging with each other to coordinate care for the top five per cent of our province’s patients with the most complex needs.

When it comes to health care, turf and structure don’t matter to patients. Patients don’t care where their care is coming from, or who developed the approach to their care. What matters to them is having maximum opportunity to achieve their health goals. That’s why Health Links, which has seen care coordinators going beyond their traditional roles, has succeeded.

And as this network expands, Health Links can evolve from a program approach to a philosophy of collaborative care where patients receive the level of care coordination they require to support their health. The term “Health Link patient” would then become obsolete, as patients with complex needs will simply receive timely and quality care to match their needs.

2. Collaborative Information Exchange Increases Knowledge

To evolve collaborative, innovative initiatives, health care providers need to share knowledge about the best ways to help patients and families succeed in their care plans.

As Ontario’s CCACs integrate with their corresponding LHINs through the Patients First legislation, one of the most valuable assets they can bring is their capacity to ethically share valuable knowledge and information about their patients. As I outlined in “4 Ways Big Data Informs and Manages Health Care Performance,” accessing patient data from experts across the continuum of care enables us to obtain a complete picture of each patient. We can also use it to learn about the broader population’s needs and identify opportunities to improve each patient’s experience.

As the CCACs and LHINs integrate, I also see a significant opportunity for LHINs to build stronger connections between primary care providers and community resources. Within this new structure, LHINs can become true collaborators, forging connections with various health care providers and creating new knowledge to share across the continuum of care.

To do this, we need to move beyond our walls and not let current management structures constrain our capability to exchange insights that help our patients. My philosophy has always been that structure exists to manage an organization, but to deliver on an organization’s mission and vision, we need to operate in teams across the continuum.

That means we need to share information, which has traditionally been one of the most protected assets in health care. Since their inception, CCACs have been working to integrate information from their Client Health Related Information System (CHRIS) or electronic patient health record system, in as many ways as possible. This integration includes connecting with hospitals and enabling health care partners to document patient updates online in CHRIS records. And as CCACs integrate with the LHINs, CHRIS will become a provincial asset, with information more readily accessible to those in each patient’s circle of care.

But sharing data isn’t enough. We also need to also collaborate on projects and share approaches that work. Ontario is known for its numerous pilot projects. We regularly see exciting new, innovative programs developed throughout the province. Unfortunately, we continuously fail to spread knowledge and increase awareness of approaches that work. We seem to be constantly reinventing the wheel. Why is that? One reason is that as a provider-driven system, individual providers are motivated to deliver innovative solutions that earn recognition, which may lead to increased funding. But our patients and families see the health care system as disjointed, bouncing them from one heath care silo to the next. We have to turn our thinking on its head and see success through our patients’ lens.

3. Working Together to Wrap Care around our Patients

For a long time, hospitals have been the hub of knowledge and care – but as I mentioned in my first post, clinical care alone can’t meet all patient needs. Those patients with complex and chronic needs often require health care services from multiple partners at the community level. The challenge so far is we have not deliberately designed a community care system that meets the needs of aging patients with complex needs. Our system is not set up to connect clinical care with other necessary supports to address socioeconomic issues and ultimately improve patient outcomes.

One way forward is to create “health care hubs.” Health care leaders can use existing assets in certain LHINs to develop these hubs, which would serve as physical spaces within communities that vary between neighbourhoods. These hubs could be attached to primary care practices, seniors’ centres, home and community care clinics, hospital urgent care centres or community health centres.

This holistic approach to care aims to bring the right care to the neighbourhood in which our patients live. In these community hubs, we’d see various health professionals – including care coordinators, geriatricians, professionals from Adult Day Programs and Falls Prevention Programs, neighbourhood-based nurses and personal support workers – working together to closely monitor their patients’ conditions.

Over time, this capacity to collaborate and wrap care around patients in their communities would be virtually everywhere.

As we continue to revamp the health care sector and develop new approaches to care, we have to rely on the experiences of our patients and their family members. To do this well, we need to learn more. We need to engage our patients to uncover invisible insights about their challenges and goals, which I’ll address in a future post.

What do you think? What other ways do you think collaboration can expand health care capacity?

3 Steps to Addressing Socioeconomic Barriers to Achieve Better Outcomes

Meet Sonia: she’s an 86-year-old woman born in Poland, who has outlived her husband, suffers from depression and diabetes and has just been discharged from hospital following surgery. She’s unable to afford the medication prescribed to her and has few family members or friends around to help her safely travel to a neighbourhood clinic and receive the proper follow-up care.

Sonia represents the dilemma many Ontario seniors will face in the coming years. We know that by 2030, 70 per cent of Ontario seniors will be living with two or more chronic conditions, similar to Sonia. What we don’t know is how many seniors like Sonia are being disadvantaged because of their socioeconomic living conditions. The fact that she has trouble communicating in English, that she has a small support network, and that she lives on a small income means she’s more likely to experience poorer health outcomes than individuals without these types of variables.

I believe that too few health organizations consider the added dimension of socioeconomic living conditions. Under tremendous pressures, teams work diligently to treat episodes of illness but often neglect important socioeconomic factors. When we are blind to these issues, we negatively affect the plan of care and the health outcomes patients strive to achieve.

1. Know your patients’ complete story and the neighborhood in which they live

Providing quality health care is no longer about simply shortening patients’ length of stay in hospital and getting them home as quickly as possible. Nor is it simply about caring for patients’ clinical needs. Only by tailoring care models in all care settings to specific populations, can we really meet the needs of individuals like Sonia.

The CCAC’s Community Capacity Plan, developed in collaboration with the Mississauga Halton LHIN, Central West LHIN and Central West CCAC, revealed that the care coordination we provide should be tailored to individuals based on: their diagnosis, the neighbourhood in which they live and other social determinants of health – those social and economic factors, including education level, income, race, gender, sexual orientation and place of residence, which influence health and wellbeing.

If we don’t address social determinants of health and the contributing factors in each patient’s situation, we’re putting people like Sonia at higher risk of health complications, poorer quality of life, hospital admissions and readmissions and avoidable emergency department visits.

The evidence supports this. Data from the Mississauga Halton Community Capacity Plan found that seniors from the highest-risk Socio-Economic and Cultural (SEC) group were more likely to move to institutional care, or long-term care, than those from low SEC groups. They were also 40 per cent more likely to visit hospital emergency departments than individuals with low SEC status.

These at-risk patients can’t afford to follow health care direction without the necessary resources. If their income is used to support five family members, or if they live at home with a small support network like Sonia, priorities are more likely to focus on paying rent and purchasing food than on filling prescriptions or paying for transportation to a health clinic, for example.

In fact, a Health Quality Ontario report found that one in 12 Ontarians surveyed, aged 55 years and older, didn’t fill their prescriptions or skipped a dose because of cost, while another study found that one in eight Canadians between 55 and 64 years old will occasionally skip prescription medications for the same reasons. If we know patients can’t afford their medications, we should certainly be approaching their care differently.

As I mentioned in my first post, “5 Features of a Sustainable, Integrated Health Care System,” bringing care out of institutions and closer to patients’ homes lets us tackle socioeconomic obstacles. By asking the right questions in all care settings, we can move beyond clinical diagnoses, to having meaningful conversations with patients, engaging their families, and providing more comprehensive support services at home, in the community and in hospital.

2. Identify individual and systemic barriers that create inequities

After implementing the CCAC’s Care Coordination Program of Work a recommendation from the Community Capacity Plan – we saw the realignment of care coordination teams and service providers within the Mississauga Halton region. We identified 26 neighbourhoods of roughly 10 square kilometres each, as relevant for organizing care delivery in the community setting.

We now have teams who will really know the gaps that exist, which will allow them to better provide comprehensive care in neighbourhoods in which their patients live. For example, high utilization of certain services in a region helps us uncover the specific challenges the population in the area faces. Teams can proactively consider not only the clinical care needs but the supports required to address the SEC issues that impact a patient’s care plan.

The questions now are, how can we overcome the challenges of involving family physicians, pharmacists, nurses, hospital physicians, and others in the continuum of care, so that we can collectively wrap care around individuals more effectively and efficiently? How do we create high-performing care teams across the diversity of the independent programs and services that are available in the community?

Dr. Kwame McKenzie, Medical Director of Underserved Populations at the Centre for Addictions and Mental Health (CAMH), led an initiative to identify ways in which we can improve health equity in the country. He helped develop the following eight questions that health care professionals can ask their patients during the assessment process, which would then be shared with other health professionals:

  1. What language would you feel most comfortable speaking in with your health care provider?
  2. Were you born in Canada? (If no, what year did you arrive?)
  3. Which of the following best describes your racial or ethnic group? (list provided)
  4. Do you have any of the following disabilities? (list provided)
  5. What is your gender?
  6. What is your sexual orientation?
  7. What was your total family income before taxes last year?
  8. How many people does this income support?

These are questions that we don’t traditionally think about asking. They can be asked once by any health care professional conducting a patient’s initial assessment – either a family doctor, hospital discharge planner, nurse or care coordinator. The value of asking these questions is that health care professionals are able to have patients’ socioeconomic information at their fingertips. When they meet with patients for the first time, they will have a deeper understanding of their needs and the kinds of individualized questions to ask, to build an effective care plan that will enable patients achieve their health goals.

By acting on this data, we’re better equipped to reduce unnecessary hospital and emergency department visits and entry to long-term care. We’re also able to identify trends with patients over time, to understand risks to certain populations in the region, and to connect patients with the appropriate services in their neighbourhood.

Some organizations have begun collecting data on patients’ socioeconomic situations using these eight questions. Now we need to find a way to consolidate and share this information with everyone involved in a person’s care. As of today, we don’t have the means to share SEC scores at a patient level. Even though care providers may understand the importance of SEC status, when information isn’t shared, we see ourselves entering into the familiar cycle of asking patients to repeat their story over and over again.

The CCAC will continue using equity data collection to inform the delivery of quality care through its Care Coordination Program of Work, to ensure that care is wrapped around the patient at the neighbourhood level. Through our Client Health and Related Information System (CHRIS), we have the means to link with other systems and to share this information with those in the patient’s circle of care. Being able to share information effectively is one of the characteristics of high performing, patient-driven health systems, and leads to my third step to addressing socioeconomic barriers: effective collaboration

3. Bringing together clinical and social determinants of health through collaboration

Hospital physicians, clinicians, nurses, family physicians, care coordinators and others in the continuum of care must collaborate to help patients achieve what is most important to their wellbeing. Frankly, our patients expect this of their care team. We need to bring clinical and social determinants of health together.

By asking Sonia questions related to her socioeconomic status, we would know she feels more comfortable speaking Polish, that she is still mourning the loss of her husband, which led to her depression, that poor eating habits contributed to her type 2 diabetes and that she has a very small support system at home – issues that cannot be addressed through medication alone, but also through lifestyle changes, volunteer programs and other non-clinical supports.

Creating effective, accountable inter-professional teams through strong relationships with everybody in a patients’ circle of care is a must. As I mentioned in my previous post, “4 Ways Big Data Informs and Manages Health Care Performance,” we need an integrated system focused on system planning and patient-driven care delivery operations to ensure that individuals with the greatest needs receive comprehensive, individualized care. This includes supporting care coordination, monitoring quality, patient outcomes and their experiences and service providers’ resource use.

Standardizing clinical care pathways – management plans that display goals for patients – are a great move forward to improving clinical care outcomes for Ontario residents. Knowing SEC information, which allows us to wrap necessary supports around patients to help them achieve expected outcomes, is necessary for the individualization of care plans.

In my next post, I’ll delve a little deeper into the importance of collaboration and the ways in which it can expand health care capacity.

What do you think? Are you collecting SEC data? How is it helping you provide more effective care?  

4 Ways Big Data Informs and Manages Health Care Performance

Big data for health

computer system graphic with home care images showing how big data informs and manages CCAC patient care In my first post, I outlined five features of the patient-focused integrated health care system that I envisioned. The third feature is a system that: stays informed and measured by evidence from our patients and their families’ voices, as well as data drawn from assessments and social, economic and cultural (SEC) tools, among others.  This post focuses on part of this feature: the value of big data in health care performance.

Today, physicians, therapists, nurses and other clinical experts each use different tools to assess patients’ needs and record pertinent information to manage their care. The clinical expert learns about each patient, their past, current conditions and needs but once a patient  moves from one setting, like a family physician’s office, to another, like a hospital, the process usually repeats. Time is lost to redundant questions and similar assessments, while some details remain a mystery, known only to one setting’s care providers.

In the home and community care sector, we securely share our assessments, plus other data, within and across our CCACs to uncover evidence-based insights that inform and manage our patient care decisions. And when a hospital discharges a patient to a CCAC, which coordinates care with their service provider, the patient’s information follows them. But these scenarios are the exceptions. CCAC also coordinates care with other organizations in the patient’s neighborhood but the ability to appropriately  share that information in real time is currently not a standard.

For patients like Yasmin, a frail senior admitted to the emergency department with a broken leg, the clock ticks while her frantic husband recalls her medical history. Tests are run to assess her bone density, anesthetic threshold and other details her family physician already has on file. Meanwhile the backlog of aging patients with urgent needs builds.

To meet the needs of a rapidly growing older population with multiple or complex care requirements, there’s a rising imperative for more integrated systems. We need to access data from clinical experts across the continuum of care to see a complete picture of each patient, learn about the broader population’s needs and identify system opportunities to improve people’s experiences.

Organizations are working to eliminate redundancies by creating one electronic health record (EHR) for each patient, which is shared and understood across the continuum of care, but much needs to be done.

At the Canadian Home Care Association’s 2015 summit, I heard about Belgium’s work as one of the first countries to share a single assessment record per patient between multidisciplinary clinical experts and across various care settings. Dr. Anja Declercqu outlined how BelRAI, its evidence-based assessment solution, enables home care organizations, hospitals and long-term care homes to securely exchange patient data with each other. She also cited challenges, as health partners were still learning to trust each other’s assessments, but their progress was impressive.

If Yasmin lived in Belgium, all clinical experts would quickly know her history and conditions, as she moved between care settings to have her fracture set and safely return home to heal – faster and at less cost.

With a more integrated system, we will be able collaborate and coordinate our patients’ care with other members of their care team. Working together, will also deepen everybody’s understanding about the unique contributions each sector brings to the continuum of care and foster conversations about what needs to improve.

We are moving closer to this ideal in Ontario and can increasingly use big data to:

1. Address each patient’s needs

Care coordination begins with thoroughly assessing each CCAC patient’s health care and social needs, as well as learning about their goals. Our care coordinators combine this assessment data with their clinical expertise to inform decisions around a care plan that will best meet their patients’ needs. Ontario’s CCACs are gradually adopting InterRAI, an international version of Belgium’s BelRAI assessment solution, recognized worldwide for supporting best practice patient care. It will empower our frontline teams to develop more personalized evidence-based care plans, centred on each patient’s experiences and goals.  And in a patient-focused, integrated system, a patient’s single, electronic health record will follow them, as they move between care settings, versus multiple records across the continuum of care.

2. Understand neighbourhood level needs –

Data also helps us understand the patient populations our organizations serve. It shows us people often live near those who are like them and may think, work and even approach their health care in similar ways.  Through our Community Capacity Plan study, we learned that a community care organization delivers better patient outcomes if they are familiar with the neighbourhoods where their patients live and receive their care. Our Care Coordinators need to know their local supports to an in-depth degree so they can develop a sustainable care plan aligned with their patient’s neighbourhood.

Knowing this, we developed Socioeconomic and Cultural (SEC) tools to help us understand a population or neighbourhood through data, such as income levels, average persons per dwelling and the percentage of dwellings owned, versus rented. For example, this data shows us that patients in a neighbourhood with a high SEC, are 40 per cent more likely to visit the emergency department, than those in other areas with a low SEC.

Viewed together with other population health information, these data points build a picture of a neighbourhood’s needs. These insights inform current home and community care services, including those to address a patient’s social determinants of health, as well as their clinical needs.

This data helps identify areas where services are inequitably distributed and is invaluable to long-term health system planning. When we plan neighbourhood clusters or community service hubs of services, there’s no need to arbitrarily put a pharmacy here or a chiropractor there. We can drive these decisions by evidence-based patient population needs, which we know, right down to the postal code level.

3. Coordinate care across the province –

I wonder if many realize that CCACs have an electronic health record for every patient they serve.  Our Ontario-wide Client Health and Related Information System (CHRIS) was developed by our provincial organization and CCACs. We rely on this web-based system to manage all aspects of each patient’s care, along with reporting and finances.

eHealth Ontario used CHRIS as a core part of its ConnectingGTA solution for CCACs and hospitals across the megacity to securely share electronic health information about its residents.

We’re now looking for ways to extend CHRIS access to other partners in the system. Then, it could take us beyond neighbourhoods to uncover regional trends and identify barriers that may be limiting patient outcomes.

4. Monitor and optimize resources –

Data doesn’t just inform patient care decisions, it can also manage ongoing performance. To help our teams decipher the data they need to manage all aspects of each patient’s care in real time, we developed ‘Insights.’ 

On a personal level, this interactive dashboard enables care coordinators to measure their own performance against consistent guidelines for exceptional care.

From a broader organizational perspective, clinical managers can use this tool to track resource use, patient outcomes and performance to identify issues or best practices. But why stop here? Insights can be adapted and its scope expanded to oversee performance in other care settings for an integrated people-focused system.

Our community capacity plan showed us one of our biggest opportunities lies in leveraging our current resources to build capacity, including the people, technology and processes that define how we use data.

In 2013, we looked at data across all care settings to build a comprehensive picture of our community’s needs in the next 10 to 20 years, particularly within the borders of our Health Link neighbourhoods. We saw how hospital, long-term care, community support services and CCACs currently use resources and we identified opportunities for improvement. And we used modeling to project what optimizing those resources would look like, if we had no new money to where we should invest to create the best outcomes for our patients, when resources are available.

If our health partners effectively leverage our assets, we have a shot at reaching Belgium’s ideal and optimizing our ability to care for people across Ontario.

With its Patients First legislation, the Ontario Ministry of Health and Long-term Care intends to establish sub-regions (LHIN sub-regions) within local health systems to plan performance improvement and more equitably integrate services at a community level.

Our CCAC has been moving in this direction for some time, re-aligning our care coordinators and contracted service providers around neighbourhoods that are similar to LHIN sub-regions. This model offers several benefits. Among others, these include addressing socioeconomic impacts and inequities, which I’ll discuss in my next post.

What do you think? Are there other ways we can leverage big data to improve patient outcomes and experiences?

3 Hurdles to Dodge in the Patients First Marathon

Patients First Hurdles

Image of runners hurdles with Patients First cover depicts obstacles the Ontario government health care leaders should watch out for with this legislation, particularly those impacting CCAC or home and community care, as outlined by Caroline Brereton.In my last post, I discussed three goals Ontario’s Patients First legislation can potentially realize, if health care leaders effectively leverage Community Care Access Centre (CCAC) assets (people, processes and technology), as well as other organizations’ assets.

On the flipside, I believe health care leaders need to dodge the following risks when implementing Patients First:

1. Working in Silos without a Shared Understanding of Vital Design Principles

We need to work collaboratively, with a shared understanding of the design principles that are essential to a high-functioning, sustainable system.

As I outlined in my last post, we have an opportunity to build stronger connections between primary care providers and community resources. This means designing a system that enables everyone in the circle of care to easily engage with each other in the course of patient care.  For this to succeed, all parts of the system must optimize resources and work collaboratively.  It is contemplated that the LHIN sub-regions will enable this collaboration and integration.

Implementing Health Link helped many patients with complex needs but it also put us precariously close to creating parallel systems to care for those patients. Once this challenge was recognized, changes were made to streamline care and use resources in a more sustainable manner.

This time, as we think about LHIN sub-regions we have an opportunity to step back and identify the shared system design principles that need to be in place, before we move forward.

2. Paying Scant Attention to CCACs’ Proven Culture and Leadership

There’s a risk that in integrating CCACs into the LHINs, health care leaders may pay insufficient attention to proven aspects of the existing home and community care’s culture and leadership. While not perfect, we know that to deliver care in the community, enter people’s homes, work with a diverse, virtually connected workforce and their supports, a unique culture is required. This culture is led by a dual focus on system planning and care delivery operations, which include supporting care coordination, monitoring quality, patient outcomes and service providers’ resource use to ensure those with the greatest need, receive care.

Conversely, LHINs currently require a different type of culture and leadership to meet different mandates, which exclude patient care.

Effectively integrating each organization’s culture and leadership is a huge challenge. CCAC assets (people, process and technology) will be under-leveraged if this part of the expanded LHIN’s mandate receives minimal attention. Focusing on system planning at the expense of leading care delivery, could also mean that one or thousands of patients stay in hospital longer than needed, due to oversight shortfalls. This is far from ideal when systems are constrained.

Understanding the magnitude of the responsibility they are taking on, LHIN board members raised early concerns about potential conflicts for new boards as they communicate their focus after integration. Boards will need support to pay significant attention to their care delivery operations to ensure they set high standards for care quality and oversight.

3. Assuming an Easy, One-Day Transition and Disrupting Vital Processes

Some people may assume integrating two distinct organizations is an easy process with an immediate transformation point, where teams cross over to a new governance structure with new projects. In doing so, they could put the opportunity to leverage existing CCAC assets and progress in peril.

Patients First impacts the expert implementation skills and other strengths within the current CCAC system. These skills include a solid understanding of the current home and community care system and service providers’ performance, plus the leadership to ensure patients/caregivers have quality experiences. It also has the potential to disrupt the support systems developed to manage care in homes and a virtual workforce.  These systems must be adeptly integrated as part of a long-term marathon, not a sprint. This work currently underway in the CCACs includes many strategies that are planned or in motion to continuously improve home care delivery.

There is a significant risk that through integration we will disrupt current culture, process, teams and technology without understanding their value in effectively reorganizing around the LHIN sub-regions. Current initiatives need to be recognized and supported post-integration day to maintain positive traction. It’s critical how attention to that work is prioritized, pre and post-integration.

Fortunately, the MOHLTC has enabled LHIN boards to expand from nine to twelve and has been explicit in requiring directors from CCAC boards to be given consideration. Having this voice of CCAC governance engaged in LHIN planning will help mitigate this risk to patient care disruption but there is an urgency to expand these boards sooner than later.

As with a marathon, we are in the warm up phase. If LHIN boards are expected to plan now for the post-integration transformation agenda, the voice of CCAC governance and leadership at the local level should be reflected in that planning. Ideally, LHINs and CCACs should share and have a continuity plan in place for moving the collective agenda forward post-integration, with ongoing support for strategic home care work in progress.

Patients First is a marathon with a long-term agenda. Ahead of the starting line, it needs CEOs and governance to establish the culture necessary to succeed. This culture requires full engagement of primary care, home and community care, hospitals, LHINs, public health and others to propel it.

My team is ready to move forward toward the long-term goal of a more sustainable, integrated health care system that puts patients at the forefront. Are you?

What do you think? Are there points you’d like to add?  Please share your comments at the bottom of this post.

3 Aspirational Milestones in the Patients First Marathon

Patients First Marathon

Image of Patients First baton being passed depicts goals the Ontario government health care leaders can realize through this legislation, if they effectively leverage CCAC or home and community care assets, as outlined by Caroline Brereton.Change is necessary for sustained and progressive success but it is rarely simple or easy. Such is the case with Patients First, new legislation that the Ontario government’s Ministry of Health and Long-Term Care (MOHLTC) first proposed on December 17, 2015 to improve the accessibility, integration and consistency of patient care across the province. This proposal has since progressed to Bill 41, the Patients First Act, which passed second reading on October 27, 2016. A key part of this legislation calls for integrating Ontario’s 14 Community Care Access Centres (CCACs) into their corresponding Local Health Integration Networks (LHINs).

Since its introduction, Patients First’s proposed design has and continues to evolve. The due diligence to advance this change is also shaping it by shining a light on high performing parts of the current system.

A noteworthy shift is the new context the MOHLTC placed around reintroduction of the legislation. Essentially, the narrative about CCACs has changed to be one about building on the strength of the current home and community care sector. Minister Eric Hoskins has said on numerous occasions: “This is not about fixing a broken system but leveraging the assets within the CCACs for the broader good.”

These assets include people, processes and technology. On the people side, initial integration talks cited the need to have CCAC care coordinators in hospitals and physicians’ offices as a key goal. Digging deeper, many learned that care coordinators have been working in hospitals and connected to physicians’ offices for years. In fact, this practice made it possible for care coordinators to help 210,000 Ontarians transition from hospital to home with a warm hand-off in 2015/16. We all know now this practice is working.

Instead, we need to focus on how to effectively optimize the relationships between care coordinators and so many parts of the system, such as primary care, acute care, working with home care providers, community resources and in patients’ homes. In my first post, Sam’s story demonstrates how our care coordinators use these relationships to help patients, even those with complex health and socioeconomic needs, to stay out of hospital.

The new system can also leverage process and technology assets. The MOHLTC is seeking a dashboard with readily accessible information to help it assess how the home and community care system is functioning, both pre and post-integration. There is now clear recognition that all CCACs use a dashboard, of various levels of sophistication, to provide oversight and inform decisions. Our care coordinators use Insights, an interactive dashboard, for multiple purposes, from planning patient visits to measuring their outcomes. The Ministry can adopt and adapt an existing CCAC dashboard.

This expanded understanding of the capacity to apply CCAC’s, as well as other’s assets, to the system’s greater transformation, opens opportunities for us to achieve several aspirational milestones or goals that put patients first. Here are three goals Patients First can realize, if health care leaders effectively leverage these assets:

Aspirational Milestones or Goals

1. More Engaged Primary Care Providers to Help Patients Achieve their Goals

A great benefit we can realize is having a system that makes it easier for primary care providers (including physicians, nurse practitioners and physician assistants) to interact with the broader community of support services that help patients achieve their goals.  This includes creating stronger connections between primary care and community resources that address a patient’s socioeconomic or cultural needs, as well as publicly funded services.

Through our care coordinators’ experiences, we know how crucially important primary care involvement is to ensure our patients have the best outcomes but it’s not easy for these providers to interact with our current, intricate community care system with its multiple access points.

Patients First legislation contemplates better understanding, planning and support for primary care and a future with expanded roles to complement their practice. These roles will involve primary care providers more closely in the planning for home and community care at the regional, neighborhood and patient level.  For example, this means that a family doctor will know that patients like Yasmin, a single, Urdu-speaking senior, who suffers from depression and diabetes, are connected with a local cultural or faith-based group, as well as home and community services.

2. Inserting the Voice of the Patient and Caregiver in Planning

The new Act sets a requirement for each LHIN to have a Patient and Family Advisory Committee to support community engagement. This offers the potential for LHINs to have and use a greater line of sight about what’s important to patients and families in their day-to-day planning.

All CCACs have experience with patient engagement strategies, and can bring that knowledge of how to involve patients and families into the LHIN’s planning work.

In 2014, we established Share Care Council – a highly structured and successful patient and caregiver advisory forum. It includes 15 patients, substitute decision-makers and family members, who volunteer their time to provide input into new programs and services. Share Care Council applies a carefully defined approach that authentically engages patients and caregivers to elicit their valuable input.

What’s eye opening is Share Care Council members’ responses to questions about how our programs can best meet their needs. We don’t hear “We need more personal support workers (PSWs) or more nursing care.” Instead, they tell us about their care experience, how it made them feel and how our system design can do better. It is less about the technical elements of care and more about the soft touches, social interaction and how these services are delivered that make the difference. For patients like Hilda, it’s having a PSW who knows how to braid her hair and set her up in the chair by the window when she leaves.

Through this requirement, the expanded LHINs can discover that when you carefully engage with patients and families on your journey of continuous quality improvement, their experience can drive development of meaningful programs and changes to care.

3. Organizing Home and Community Care around LHIN Sub-regions

A third advantage is the legislation’s shift to organizing delivery of home and community care around a LHIN sub-region, with consistent, service providers.

Our capacity plan research told us that people’s social, cultural and economic status often varies significantly between our neighbourhoods. So having care providers who are familiar with their patients’ neighborhood and its existing support resources (provincially funded and others) helps ensure successful home and community care delivery.

We also know that having a minimum number of consistent service providers who interact with our teams and patients/families builds strong relationships. Furthermore, this approach helps create high performing teams, whether virtual or in-person, in each patient’s circle of care.

With a goal of being able to identify local resources, numerous CCACs have begun reorganizing their care coordination and service provider teams around these LHIN sub-regions.

In our region, we’ve reorganized patient care around neighborhoods, so that patients, like Betty and Patty, can receive the services they need from consistent providers, who know their community and are located near their home. Organizing services around LHIN sub-regions or neighbourhoods gives service providers a greater connection with the communities where they deliver care.

I believe there’s much to be gained through LHIN sub-region planning but it’s complex work and should be viewed as part of a long-term vision or marathon.

 

On the flipside, implementing Patients First also poses risks, which I believe health care leaders need to dodge. I will outline three of these risks in my next post.

What do you think? Are there opportunities I’ve missed or points you’d like to add? Please share your comments at the bottom of this post.