Waterloo Wellington CCAC

Streamlining Services For High and Lower Need Patients

Building Community Capacity - A Collaborative Planning Initiative for

CCAC and CSS

Context

WWCCAC strategic plan work underway is positioning the organization for the future. WWCCAC is defining its target population and will focus services on moderate to high complex patients. The context of this initiative considers the findings in the Sinha Report.

Excerpt from Dr. Sinha’s Report – Living Longer, Living Well

KEY RECOMMENDATION : Enhance the Provision of Home and Community Care Services

“The Ministry of Health and Long Term Care should support the LHIN’s their CCAC’s and CSS agencies to formalize a collaborative Standardized Care Model that can allow acuity based wait-lists and Care Coordination assignments between CCAC’s and select CSS Agencies. This will allow both sectors to provide publicly funded personal support services in each LHIN. This will allow both sector organizations to play to their strengths and better address client needs.”

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Context Cont’d

The volume of client referrals to CCACs from the hospitals has increased (due to initiatives to reduce hospital length of stay and ALC days and improve patient flow)

The increased volume of higher acuity clients on CCAC caseloads adds tremendous pressure on CCAC budgets and lower needs clients may end up waiting for service

The Seniors Strategy for Ontario recommends that LHINs, CCACs and CSS agencies formalize a Standardized Collaborative Care Model and collectively build the capacity to enable CSS agencies to provide PSW services to lower needs clients

WW CCAC’s strategic planning work aligns nicely with this opportunity to work collaboratively with the LHIN, CCAC and CSS sector to consider how to: Best serve the lower acuity home care clients Collectively build capacity across the community sector Deliver the best value for money Effectively facilitate patient flow through the healthcare system

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Context Cont’d

The WW LHIN envisions greater system capacity, improved patient satisfaction and outcomes and more effective transitions with greater patient support through the continuum of care through the efforts of this initiative

KEY DRIVERS INCLUDE A DESIRE TO: Create “Early -Single Entry Point -Coordinated Access” to care Shift CCAC resources to higher needs– higher acuity clients Find better solutions through a more robust CSS Network for lower needs –

lower acuity clients Ensure services are “targeted” Focus on transitions to better suited partner providers within the CSS Network Engage all stakeholders through the process Ensure the process is transparent and open

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Project Overview – Mission and Success

Work in partnership with the WWLHIN, CCAC and CSS sector to develop a plan that will enable CSS agencies to provide personal support worker services to certain categories of home care clients

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A collaboratively developed plan that establishes the strategy, processes, structures, roles, capacity and operations required to shift the care of some categories of home care clients from the CCAC to CSS agencies

A well-defined implementation plan that identifies the key tasks, roles, responsibilities and considerations for all partners to ensure clients receive the support they require from the CCAC and CSS agencies

The collaborative development of key governance and accountability terms and agreements to ensure that all parties clearly understand their relative authorities, accountabilities and responsibilities

Project Mission

Project Success

Project Overview – Scope

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In Scope

Out of Scope

An Environmental Scan of Leading Practices for this client population

Stakeholder Engagement

A Business Plan identifying benefits, risks and recommended operational processes, policies, roles and responsibilities

Implementation Plan with Accountability Tools (i.e. Draft Memorandum of Understanding)

Implementation of Recommendations

Award of PSW Business to CSS Agencies

Transition of CCAC Clients to CSS Agencies

Project Advisory Committee

The advisory committee has met three times since the project inception - March 7th, April 3rd and April 30th. It is expected the committee will met another 4 times before the completion of this project

Communiques of each meeting will be available on our website and sent directly to key stakeholder networks.

Comments, feedback and questions are welcomed by Gloria Cardoso, WWCCAC Senior Director – Planning, Communications & Community Engagement, at Gloria.Cardoso@ww.ccac-ont.ca or (519) 748-2222 ext. 5541

Cathy Harrington, co-lead of the CSS Network and Executive Director of the Community Care Concepts is also willing to take questions and comments. Cathy can be reached at cathyh@communitycareconcepts.ca or (519) 664-1900

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Gloria Cardoso Waterloo Wellington CCAC – EXECUTIVE LEAD

Cathy Harrington Community Care Concepts – Co Lead

Michelle Martin Victorian Order of Nurses

Joanne Young Evans Guelph Independent Living

Dale Howatt Community Support Connections

Lisa Bitonti-Bengert Waterloo Wellington LHIN

Barry Monaghan Waterloo Wellington CCAC

Leanne Murray Waterloo Wellington CCAC

Martina Rosza Waterloo Wellington CCAC

Dana Khan Waterloo Wellington CCAC

Project Overview – Guiding Principles

The advisory committee developed the following Guiding Principles for the Initiative To Be Patient/Client-Centred To Be Data Driven And Evidenced-Based To Position The Community Sector For Greater

Capacity To Prepare For The Future To Better Utilize Resources By Leveraging Technology To Ensure Policy Alignment To Be Fiscally Responsible and Ensure Value for

Dollars

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Project Plan

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We are here

MayAprilMarchAdvisory Mtg.

June July

Project Management, Monitoring, and Control ProjectPlan

Data Collection and Analysis

Project Launch

Environmental Scan of Leading Practices

Business Plan Development

Stakeholder Engagement

Benefit and Risk Analysis

Implementation Planning

Milestone Milestone

Contracted Service Provider Advisory Committee

First Advisory Mtg.

Advisory Mtg. Advisory Mtg.

Advisory Mtg.

CSS network engagement

CSS network engagement

Advisory Mtg.

Contracted Service Provider Advisory Committee

We are here.

Early Project Considerations

Appropriate stakeholder representation in the project structure

Clear roles and responsibilities for project members

Ensure the planning process is open and transparent

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Project Structure Considerations

Establish the list of all key stakeholders early in the project

Provide multiple channels and opportunities to provide input to the plan

Ongoing communications and updates – all stakeholders have easy access to all relevant planning information

Identify barriers and risks that may limit the degree of stakeholder support for the project

Broad Stakeholder Engagement Considerations

Current Project Undertakings

Data Collection and Analysis Current utilization, wait list, number of health human resources (HHR) Services offered - (service type offered) Current active patient volume (separated by service type)Environmental and Jurisdictional Scan of Leading Practices Research and present innovative models of community sector partnership

for target populations e.g. lower need persons Identify key model considerations and dependencies (infrastructure,

capacity etc.) Assess state of local sector readiness based on degree of change in various

models Identify preferred model options

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Key Stakeholder Engagement

CSS Network CCAC Contracted Service Providers Advisory Committee SGS, Retirement homes Planned Phone Interviews:

WWLHIN MOHLTC - Catherine Brown OCSA - President and CEO OACCAC Key LHIN Senior Leaders who have successfully help build CSS Capacity

MH, Champlain, Central East, Toronto Central Key CCAC Senior Leaders who have work underway to transition lower need

population to CSS MH CCAC, Champlain

CSS Thought Leaders across the province Survey:

CCAC’s

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Stakeholder Engagement Findings Highlights April 9th CSS Network Meeting

It is simplistic to think in terms of ‘low’ and ‘high’ needs clients

Can’t base evaluation solely on RAI scores (blend of art and science)

Broad range of services and providers

Need to determine where there is capacity

Don’t forget about (specialty services, ABI, rec centres and wellness, dementia)

How will care coordination be differentiated for CCAC and CSS?

April 16th Contracted Service Provider Advisory Committee

What will be the impact on SP PSW market share?

CCAC transitioning to higher need population is consistent with other CCAC’s provincially

PSW’s may choose to go to a CSS agency if the population care is lighter

What are the HHR considerations knowing PSW’s are in demand. What are the union implications if staff are moving from one organization to another?

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Immediate Next Steps

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Next Steps Completion Target

1 Final draft environmental and jurisdictional scan Mid May

2 Finalize data collection and analysis Mid May

3 Stakeholder Interviews Ongoing

4 Draft Benefit and Risk Analysis Week ofMay 12th

Questions

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Do you have any questions or comments about the project?

Do you have suggestions for us as we consider this planning moving forward?