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?  

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.

5 Features of a Sustainable, Integrated Health Care System

Image of glass lens looking at health care team, from patient's perspective
“We need to build an integrated health care system from the patient’s perspective outward.”

Many thoughtful leaders have taken strides toward creating a sustainable, patient-centred, integrated health care system but we’re not there yet.  Our patients, their families and evidence tell us there are opportunities for improvement. Through our front-line experience caring for 11,600 patients each day, we also know that to deliver quality home care, we need an integrated system that wraps care around the patient.

As in any sector, sustainable success is rooted in engaged teams effectively connected first through a common goal.  Health care is no different. As many leaders agree, form must follow function.

When I arrived to lead the Mississauga Halton Community Care Access Centre (CCAC) six years ago, this meant re-building a siloed organization. We fostered interdependent teams by connecting them with shared, measurable goals and a united vision. For Ontario’s health care system today, this means building an integrated system of care from the patient’s perspective outward.

If we start with structure, it is like planning a house without a location. You could well design a house that’s set to fall or flood, if you don’t know it’s going to be built on a cliff or levee. It’s also precarious to plan without full context in a fluctuating environment like ours, with its aging population and continual changes to support their rising needs, from funding reforms to new providers and evolving technologies.

To see the patient’s perspective, we need to step back and ask: ‘Why’ does the current system fall short of delivering an experience that consistently meets or exceeds expectations? Why is it not consistently responsive to patients’ and their families’ needs?

Using Home & Community Care to Overcome Obstacles

When I worked for more than 18 years in acute care, we knew that engaged and cohesive teams generated better outcomes for most patient populations.  We worked hard to involve physicians right up to the discharge door but that’s where our care ended.  To make way for those with time-sensitive, urgent needs, we discharged patients once they no longer required acute level care but sometimes before their post-discharge care was in place.

Then hospitals began to change how they delivered care and began moving alternate level care (ALC) patients to places better able to meet their needs.  Leaders saw community as an enabler to support this transformation and achieve their hospital’s goals. We also started to understand that patients and families wanted to remain at home and out of institutional care, as much as possible.

However, we had a blind spot to the role and impact of primary care physicians, nurses, allied health professionals, community service agencies and others in the continuum of care but beyond the hospital’s walls. We also had yet to realize the vital role of caregivers and families. Community was a disparate anchor. People moved back and forth between community and acute care, often multiple times a year.

Challenges in delivering consistent care experiences for our patients increased as the number of aging patients, with chronic and complex needs, rose. Without comprehensive capacity and program planning, our blind spot included socio-economic or cultural status obstacles that stopped patients from reaching their goals. It’s hard to heal when you can’t afford medication or have no means to safely travel to a clinic. Subsequently, a short hospital stay with an early discharge is detrimental when a patient returns less than 30 days later. Patients expect and deserve better outcomes.

In bringing care out of institutions and closer to patients’ homes, we shed light on these obstacles. Through meaningful conversations and assessment tools, home and community care went beyond clinical needs to identify social determinants of health that affect our patients’ care experience. We started to address these challenges through care coordination, which significantly reduces patients’ health risks, among other benefits. We also engaged families and set-up patients’ support services before they left hospital.

For Sam, a 66-year-old, frequent emergency department (ED) patient, who suffered from COPD, alcoholism, diabetes, hearing loss and depression, plus fear of eviction from a derelict apartment – healing was secondary. By the time Sam’s family physician referred him to CCAC, he was malnourished and in a desperate state. Our care coordinator had to first get him an accessible phone, re-channel his OPGT funds to pay his bills and fix his fridge. Once she addressed these necessities, she could set up medication management and coordinate his care plan.

Health care resources alone can’t meet all patient needs. Patients, like Sam, often need multiple partners at the community level, such as mental health and addiction services, volunteer or cultural groups, to play a complementary role in helping them reach their goals.  The challenge is our system’s design is incomplete. We have not intentionally designed a community care system to meet the needs of aging residents with complex needs. It doesn’t optimize the value of community-based services or integrate them to improve patient outcomes. In a more cohesive system, health care and community partners might have closely monitored Sam’s condition and alerted CCAC sooner. It might have also co-located services together, such as placing on site showers with personal support workers (PSWs) at Adult Day programs, with counselling nearby, to help patients like Sam achieve their goals.

Seeking solutions, we collaborated with the Mississauga Halton LHIN, Central West LHIN and Central West CCAC to develop a Community Capacity Plan in 2013. For this study, we contracted specialized health care consult support to assess our region’s health service needs now and the growing, future mandate. Results highlighted the importance of using patient assessments and information across the continuum of care to support population-based planning. These include Socio-Economic and Cultural (SEC) tools that can identify a neighbourhood’s needs, right down to those shared by people within the same postal code level or uncover areas where services are inequitably distributed.

The study’s findings also underscored the value that our current resources and best practices bring to our local system.

But to meet our residents’ expectations, we must resist the temptation to assess patient needs only through our lens. To design the system, we need to bring together data brought by clinical teams with patients’ and families’ expectations and goals.

That’s why our strategic plan is centred on understanding the patient’s voice. We need to listen and let it inform how we modernize the system or mobilize existing resources. By engaging our patients, through varied approaches, including our patient and caregiver advisory forum, we’re hearing about their needs.

Armed with insights from our patients and with our assets, we’ve lived a glimpse of this integrated vision through our seamless transitions: hospital to home approach. It reduced hospital readmissions in the first 30 days by 52 per cent in the pilot with Trillium Health Partners’ Medicine units and opened an opportunity to reduce ALC rates. In another example, we’re making great strides with Health Link. Through this provincial initiative, we’ve reduced the number of times patients with the highest needs visit the ED.

These programs prove that individual organizations, like our CCAC, can improve patient outcomes but not in silos.

Through this evolution of home and community care, our research and proven programs, I can envision a patient-focused, integrated health care system that:

  1. Seamlessly works with multiple partners to identify and address socioeconomic impacts on neighbourhoods and their patients.
  2. Recognizes care coordination as an essential health service for patients and supports its ongoing professional development to ensure consistent quality of care.
  3. Stays informed and measured by evidence from our patients and their families’ voices, as well as data drawn from assessments and SEC tools, among others.
  4. Collaboratively delivers care for patients at multiple levels, from patient and care coordinator partnerships to multidisciplinary partners, in acute, primary and long-term care, as well as mental health and addictions and community services.
  5. Provides ongoing monitoring and adapts to patients and their caregivers’ changing needs.

In future posts, I will discuss these features in more detail, with global examples, as well as our tools, ongoing initiatives and results.

I believe we can collaborate virtually with our multidisciplinary and community partners to deliver comprehensive, dynamic care that reflects each patient’s current goals, journey and experience. This also means making each partner individually and collectively accountable for our patients’ well-being.

I welcome your thoughts and feedback.