South East LHIN Board Meeting: AMH Redesign, Pre-Reading December 16, 2013

1. South East Local Health Integration Network Transforming Addictions and Mental Health Services to Better Serve Our Residents South East LHIN Board Meeting: AMH Redesign, Pre-ReadingDecember 16, 2013

2. Table of Contents

3. Purpose of this Presentation • The South East Local Health Integration Network (SE LHIN) has been collaborating with the 22 Addiction and Mental Health (AMH) providers to redesign the AMH sector. • For the last seven months, the Redesign Task Force (12 nominated individuals representing AMH agencies, Executive Directors, front-line staff, psychiatrists and a consumer representative) have been focused on redesigning the current AMH sector and tasked with creating options to create a system. • A system where where we plan, work and collaborate together to meet the needs of the residents of the South East region. • This presentation provides details on the ‘case for change’, the features and elements of the new AMH system and three governance options.

4. Purpose of this PresentationReminder of the LHIN’s Role • As per the Local Health System Integration Act, 2006, the LHIN’s objects are (section 5): • To promote the integration of the local health system to provide appropriate, coordinated, effective and efficient health services; • To engage the community of persons and entities involved with the local health system in planning and setting priorities for that system, including establishing formal channels for community input and consultation; • To ensure that there are appropriate processes within the local health system to respond to concerns that people raise about the services that they receive; • To develop strategies and to co-operate with health service providers, including academic health science centres, other local health integration networks, providers of provincial services and others to improve the integration of the provincial and local health systems and the co-ordination of health services; • To bring economic efficiencies to the delivery of health services and to make the health system more sustainable;

5. Purpose of this Presentation Expectations of the LHIN Board - Today • Today: • The SE LHIN Board is asked to review and consider the documentation provided today and to ask questions on the ‘case for change’, the Redesign process, the Individual Experience, elements, the governance options and the stakeholder engagement processes. • On April 23 2013, the LHIN Board confirmed that the status quo is not an option • At the June 2013 Visioning Day Session, the South East LHIN Project Team guaranteed its commitment to act to transform the system to meet the needs of clients and patients. • SE LHIN governors are asked to focus on the client feedback for the ‘case for change’ and to consider the impact on residents if we don’t transform the AMH sector. • At this stage, the SE LHIN Board is NOT being asked to recommend a governance option. A commitment has been made that there will be further engagement of AMH governors and administrators.

6. Purpose of this Presentation Expectations of the LHIN Board - February • January and February 2014: • An opportunity for questions and clarification will be included on the agenda at the January Board meeting. • A final presentation and opportunity for questions will be included on the agenda at the February Board meeting. • The SE LHIN Board will be asked to provide a decision on the options for governance at that time. • Implementation planning will commence in March 2014.

7. Agenda

8. Agenda

9. Introduction and Objectives

10. Introduction and Objectives • Objectives: • To obtain a full understanding of the ‘Case for Change’, Vision, Individual Experience, Elements and Governance Options • To understand the role of the LHIN and Governors and the decision required (and when) • To understand the next steps in the process and provide advice as to any additional information the LHIN Board may require in order to make a decision in February, 2014

11. Case for Change: Why are we doing this?

12. Case for ChangeSummary • The Client Experience: • Residents, clients/patients, providers and other stakeholders have said that while the care received has been very good, there remain multiple and recurring problems: • Duplication of services • Duplication of assessments • Difficulties in transitioning between providers • Difficulties in accessing services • Insufficient volume of services to satisfy demand • Stigma often faced in accessing services

13. Case for ChangeSummary • Demographics and Rising Utilization: • The number of individuals requiring AMH services continues to increase. Given that we have to work within the resources we have available in the South East region, the impact of the increase in volume will put pressure on the existing capacity. • 72% increase in individuals treated for substance abuse (2007 to 2011) • 11% increase in volume of patients (2009 to 2011) • In 2011, the South East LHIN had the 3rd highest rate for new referrals, 4th highest number of individuals served, and the 3rd highest inpatient/resident days in the province (per 1000 population). • The number of patients re-admitted to the hospital for either addictions or mental health related conditions continues to be very high. This indicator is a reflection on how well the system is (or is not) working for patients. • 18.4 - 22.5% re-admissions within 30 days for addictions related conditions from Q2 2011 - Q1 2013 • 17.1 - 19.7% re-admissions within 30 days for mental health related conditions for the same timeframe.

14. Case for ChangeSummary • By working together collaboratively across the system to standardize processes and tools, share resources, reduce duplication and increase knowledge of the services and programs that are available, we can increase capacity and reduce readmissions. • There is existing collaboration in the SE LHIN region. There is an opportunity to harness the momentum and collaboration for the purpose of a system wide redesign, to more effectively achieve improved outcomes.  • Local leaders are in the right position to focus on the client/patient perspective and to create a system that meets the needs of the client/patient. • Globally, and within Canada, the literature and practices underscore the need for cooperation and collaboration at a system level between AMH providers. • AMH is a priority for the Ontario government. The SE LHIN is operationalizing this priority for the region’s residents which was highlighted in their Integrated Health Services Plan 3: Better Integration, Better Health Care.

15. Case for ChangeClients have told us the system needs to change! • “I would like more proactive care and there being more responsibility for people with Addiction and Mental Health. Stop “dumping” us.” • “I feel lost when I am in the system, I don’t get told the information I need to know and the coordination between the hospital and community doesn’t exist. I was left with no support.” • “No matter where you live, I would like everyone to have equal access to support.” • “There needs to be more access to services, to psychiatrists and to medication. We go to the ED as there is no other accessible service.”

16. Case for ChangeClinicians have told us the system needs to change! • “It’s not that the system is broken and we have to fix it, rather we do not have a system in the first place and need to create one.” • - Health Links Leads “Duplication and delay conditions for decreased quality of service exist NOW. The onus is on the client to have to do multiple consents, tell multiple stories, make sure all pieces are connected, navigate through the system themselves.” - Psychiatrist “A circle of service encompassing all is critical to ensure we have conditions to be successful versus the parallel system we have today” - Psychiatrist • “By not having access to an integrated record of history, by having to wait for multiple consents to be signed, the patient is delayed in receiving treatment and/or of receiving treatments that have been tried before but have not previously worked”. - Psychiatrist

17. Case for ChangeClients have told us the system needs to change! Client Video: Note for pre-reading deck: If the video link does not work by clicking on the image above, please access the video through the following URL: http://www.youtube.com/watch?v=Esv037Vtr_4&feature=youtu.be

18. Case for ChangeClients have told us the system needs to change! • The South East LHIN has held a number of engagement sessions in 2012 and 2013 across the entire LHIN Region. These sessions have provided a rich source of evidence to inform the decision to redesign the AMH system.

19. Case for ChangeClients have told us the system needs to change! • Consistent areas for improvement were identified in: • Access to care (e.g. lack of 24 hour access, inequitable access to psychiatric care based on geography) • Inconsistencies between services • Multiple assessments and duplication • Transitions especially between hospital and community • Insufficient volumes of services • Stigma often faced in accessing AMH services, and in accessing other health services. • These areas for improvement have also been confirmed by: • Psychiatrists • Executive Directors • Front line staff • Physicians • Other sector partners, such as housing, children and youth services

20. Case for ChangeClients have told us this before! • The areas for improvement noted earlier are consistent with those identified through multiple studies, task forces and engagements since 1999. Some items of note include: • 1999: Making It Happen • Recommended comprehensive continuum of care, streamlined access to services through a central referral, shared model of care, enhanced capacity through adoption of best practices, system accountability and responsibility • 2001: Berkeley Report • Recommended district (HPE) wide governance structure, one Consumer Survivor Initiative, common assessment and referral, specialty services managed district-wide but delivered locally, family network • 2002: South East Mental Health Implementation Task Force • The proposed model reflects a regional or district entity with 3 geographic councils with common baskets of services

21. Case for ChangeClients have told us this before! • 2006: Out of the Shadows at Last: Transforming Mental Health, Mental Illness and Addiction Services in Canada • Recommended the need for a recovery-oriented system, development of a more responsive service, better integration of services, common basket of services available across the lifespan • 2009: Every Door Is the Right Door • The most recent Ministry document on Addictions and Mental Health reform • 2010: Select Committee on Mental Health and Addictions • Recommendations include the consolidation of Addictions and Mental Health programs and services, availability of a core basket of services, access to system navigators, reflection of importance of housing, support for families and caregivers. • Clearly, we must stop planning and take action!

22. Case for ChangeWe have tried to move forward on a number of initiatives but have been challenged • There is a regional network and the 22 AMH providers meet regularly. In total, there are approximately 45 planning groups in the South East LHIN focused on a range of AMH issues • Local members have participated in planning since at least 1999 • There have been a number of sub-regional initiatives, spearheaded by community members and the LHIN • Our experience and the feedback we have heard is that these initiatives have been challenged by geographical restrictions, by current capacity, consensus building challenges, relationship challenges and a lack of accountability. Examples include: • Common access form (CSR) took 18 months to gain agreement and launch • Concurrent disorder study confirmed the opportunity for service improvement through building staff capacity but has taken 3.5 years to move from study to recommendation with minimal implementation • Establishment of privacy and data sharing agreements in KFLA took over 12 months

23. Case for ChangeThe Role of the LHIN • Residents have clearly identified a need for change • The data clearly indicates that the need for AMH services for the population will increase • High readmission rates for AMH clearly shows that the current status quo is not working for clients • Similar opportunities for improvement have been identified as early as 1999, but actions since then have obviously not delivered the desired improvement for clients or clinicians. • It behooves us as stewards of the South East local health care system to respond and to transform the AMH sector for clients/patients, families, providers and the residents of the LHIN.

24. Vision, System Outcome Goals and Criteria for Evaluation

25. Vision, System Outcome Goals and Criteria for EvaluationOverview • The next section provides an overview of the SE LHIN’s vision, the provincial government’s vision, our system outcome goals and draft evaluation criteria for the SE LHIN Board to use when considering the AMH governance option recommendation.

26. Vision, System Outcome Goals and Criteria for Evaluation Vision for the Addictions and Mental Health System Provincial Vision • An Ontario where every person enjoys good mental health and well-being throughout their lifetime, and where all Ontarians with mental illness or addictions can recover and participate in welcoming, supportive communities. (Open Minds, Healthy Minds, Ontario’s Comprehensive Addiction and Mental Health Strategy) South East LHIN Vision • Ensure patients receive the right care at the right time in the right place, enhance capacity of providers and the system, and reduce stigma. (South East LHIN Integrated Health Services Plan: Better Integration, Better Health Care, 2013-2016)

27. LHIN vision (aligns with Ensure patients receive the right care at the right time in the right place, enhance capacity of providers and the Province and system, and reduce stigma Providers) System Access to equitable, Improved patient The health of the Sustainability of the Outcome consistent and quality care experience population is improved system Goals IMPLEMENT PLAN REDESIGN Phase Implementation of the redesigned Plan for the redesign of the Mental Redesign of the Mental Health and Mental Health and Addiction System Health and Addiction sector Addiction sector South East LHIN and Mental Health South East LHIN and Mental Health Develop Project Plan through review and Addiction providers work and Addiction providers work Process of existing work and stakeholder collaboratively to implement the new collaboratively to redesign the sector engagement (KPMG) model for the system using the Project Plan as guidance - Implementation : FY 2014/15 2015/16 Timing Complete by March 2013 Complete by February 2014 Transform from a Sector to a System where we plan, work and collaborate together for the purpose of our residents Vision, System Outcome Goals and Criteria for Evaluation Project Structure Implementation Plan Complete by June 2014

28. Phase 1 Phase 2 IMPLEMENT REDESIGN 3. LHIN Board 2. Options approval of 2. Implement redesign of the system • Develop Implementation Plan • for the redesign of the system 1. Visioning Development redesign Model April – June February – June 2014 2013 July 2014 – July - 2015/16 November 2013 February 2014 Each Phase will be supported by the Project Plan Vision, System Outcome Goals and Criteria for Evaluation Project Structure

29. Vision, System Outcome Goals and Criteria for Evaluation Project Structure • Redesign Task Force Members: • Cate Sutherland: ED, Addictions Centre • Michelle Murray: ED, Lennox & Addington Addiction and Community Mental Health Services • Laurie Dube: ED, Leeds and Grenville Mental Health • Linda Peever: Director of Mental Health, Brockville General Hospital • Mae Squires: Program Operational Director, Critical Care and Mental Health Programs, Kingston General Hospital • Karin Carmichael: Program Administrative Director, Providence Care • Dr. Susan Finch: Psychiatrist • Dr. O’Brien: Clinician • Garry Laws: Consumer • Lucille Zuikier: Consumer • John Ostrander: Tri County Addictions Services (Brockville) • Siobhan Andress: Frontenac Community Mental Health and Addiction Services • Dr. Roumen Milev: Psychiatrist

30. Vision, System Outcome Goals and Criteria for Evaluation Project Structure • Expert Panel Members: • Ruby Brown: Principal, Mandala Management (former Chief Transition Office to realign mental health services within Alberta) • Janet Davidson: Deputy Minister of Health, Government of Alberta • Nick Kates: Acting Chair and Professor, Department of Psychiatry and Behavioural Neurosciences at McMaster University • Dr. Ken Le Clair: Professor and Chair of the Division of Geriatric Psychiatry at Queen’s University • Donna Rogers: ED, Four Counties Addiction Service Team

31. Vision, System Outcome Goals and Criteria for Evaluation Outcome Goals for the Future State System • Access to equitable, consistent and quality care across the South East LHIN • Improved patient experience - The system is reflective and responsive to the legitimate expectations and needs of the population • Health outcomes – The health of the Addiction and Mental Health population is improved • Sustainability of the system - Accountability at an organizational level shifts to accountability at a regional level

32. Vision, System Outcome Goals and Criteria for Evaluation How Will the Board Assess Governance Options? • The SE LHIN Board must ensure decisions are reflective of a balance of effective and efficient use of public resources and provide a high standard of service to the public. • Governance option evaluation criteria for each outcome goal was presented at the last Board meeting. • In response to feedback, this criteria has been defined and weighted to enable the Board to rank the governance options for consideration in February. • Note the criteria is ONLY to evaluate the governance options. The intention of the redesign is that regardless of the option chosen, the elements and the individual experience will be operationalized. • The South East LHIN Board will not be making a decision/recommendation today.

33. Vision, System Outcome Goals and Criteria for Evaluation LHIN Board Governance Option Evaluation Criteria

34. Vision, System Outcome Goals and Criteria for Evaluation LHIN Board Governance Option Evaluation Criteria: Accessibility

35. Vision, System Outcome Goals and Criteria for Evaluation LHIN Board Governance Option Evaluation Criteria: Patient Experience

36. Vision, System Outcome Goals and Criteria for Evaluation LHIN Board Governance Option Evaluation Criteria: Health Outcomes

37. Vision, System Outcome Goals and Criteria for Evaluation LHIN Board Governance Option Evaluation Criteria: Sustainability

38. Vision, System Outcome Goals and Criteria for Evaluation Discussion • Are there any questions on the ‘Case for Change’? • Are there any questions on the evaluation criteria?

39. Principles, Individual Experience and Elements of the Redesign

40. Principles, Individual Experience and Elements of the RedesignAMH Redesign Principles • These principles are a reflection of the work of the Redesign Task Force and the engagements to date. They have been cross-referenced to the principles in Ontario’s Open Minds, Healthy Minds and Ontario’s Comprehensive Addiction and Mental Health Strategyto ensure alignment. • Individuals have access to equitable, consistent and quality care across the South East LHIN. • Legitimatelocal needs will be considered when planning for services and supports. • Services will address the socioeconomic determinants of health. • There will be outreach into the communities (i.e. in the workforce and schools). • All transitions within the AMH system will be experienced as an internal transfer. • A competency-based framework willsupport the AMH workforce. • Communities and services will work together to eliminatestigma and discrimination. • Individuals and their families will have choice and the opportunity to make informed decisions about their personal care and support.

41. Principles, Individual Experience and Elements of the RedesignAMH Redesign Principles (cont’d) • Social inclusion will support the individual throughout their journey. • Services will improve quality of life in a sustainable way – the system will be supported by continuous evaluation andProviders will be held accountable for the value of care they provide. • The AMH Redesign recognizes biopsychosocioculturalinter-dependent and diverse aspects of the individual experience. • The AMH redesign will create a system in which regardless of a person’s age, cultural or linguistic identit,y they will be provided the services and supports to enable recovery and a state of well-being that fits with their expressed choices or needs.

42. Principles, Individual Experience and Elements of the RedesignAMH Redesign Model • The Redesign Task Force has developed the individual experience, the “elements” to bring to life the individual experience and provided their collective wisdom and insight on the governance options Individual Experience Means to bring to life individual experience Change Management and Evaluation Foundational structures

43. Principles, Individual Experience and Elements of the RedesignIndividual Experience

44. Principles, Individual Experience and Elements of the RedesignFeatures of the AMH Redesign

45. Principles, Individual Experience and Elements of the RedesignFeatures of the AMH Redesign

46. Principles, Individual Experience and Elements of the RedesignElements of the Redesign – Overview • The next six slides are a synthesis of the ideas the Redesign Task Force provided on processes, structures, collaboration and leadership (termed “elements”) that will be required to “bring to life” or deliver on the “ideal experience”.

47. Principles, Individual Experience and Elements of the RedesignElements of the Redesign – Process (1/2)

48. Principles, Individual Experience and Elements of the RedesignElements of the Redesign – Processes (2/2)

49. Principles, Individual Experience and Elements of the RedesignElements of the Redesign – Structures (1/2)

50. Principles, Individual Experience and Elements of the RedesignElements of the Redesign – Structures (2/2)