Chapter 3: Ten recommendations to improve health care

Actions to end hallway health care and improve the design and delivery of Ontario’s health care system are needed. The Premier’s Council has a mandate to provide strategic advice to the government on how to address a broad scope of concerns heard from patients, providers, caregivers, sector leaders and as outlined in its first report. 

Strategic policy advice for government provides a clear, strong vision on the best way forward given available evidence, research and input from the community. The strategic policy advice in this report includes a range of actions designed to remove current barriers and introduce key enablers to create the sustainable, publicly–funded health care system patients deserve.

These recommendations are intended to shift the way we think about health care in Ontario. It’s not just about reducing wait times, or getting to the right number of beds, it’s about preparing our workforce to be ready for a new way to deliver care. More than a transformation of structure, these recommendations will support a fundamental change in culture and organization of health care service planning and delivery. It is time to build a robust community system and monitor how it’s working. It is time to build bridges between primary care providers, home and community services, and hospitals. It is time to build a system designed to keep Ontarians healthy, rather than just responding to sickness.

During a period of significant structural modernization, this report also provides guidance for a complex system that must keep pace with technological change and prepare for future challenges and opportunities. The following recommendations are designed to help keep the many moving parts and people working together towards one common objective: a better health care system for Ontarians.

Integration

Recommendations 1–3

These recommendations build on the work already underway in the province to create an integrated health care system in Ontario. They identify how health care should be integrated around patients and across providers to ensure it works for all our communities and for all of our patients, including children and youth.

Modernized approaches to health care service delivery, such as easy – and safe – access to digitized personal health information will be critical to the success of this work. A modern, integrated and primary care-driven health care system is a fundamental shift in how the government can help patients and providers navigate the health care system, and will improve patient, provider and caregiver well-being by putting patients at the centre of their health care decisions.

  1. Put patients at the centre of their health care. Patients should be well–supported and treated with dignity and respect throughout all interactions with the health care system.

What Will These Actions Accomplish?

These actions will provide the tools needed to build a system that patients and their caregivers feel comfortable with, and to know that the system is working well. Patient experience information will allow the government to course–correct when improvements are needed to ensure patients are at the centre of their own health care and satisfied with the system.

Innovation in Ontario

Patient Oriented Discharge Summary (PODS)

PODS provide patients with easy–to–understand instructions upon hospital discharge and facilitates a tailored and clear discussion between health care providers and patients about what to do when they return home. PODS were co–designed by patients and providers and piloted in eight Toronto–area hospital departments spanning adult, pediatric, rehabilitation, acute, and surgery in 2015. Results showed that patient satisfaction scores related to discharge experience increased using PODS. Not only did they benefit patients, but providers also reported that PODS gave their discharge conversations greater structure and didn’t add to their workload, enabling them to communicate the most critical information to their patients consistently and efficiently. PODS have been adopted in 25 hospitals across Ontario, reaching more than 80,000 patients annually, through the support of Health Quality Ontario and the Council of Academic Hospitals of Ontario’s Adopting Research to Improve Care (ARTIC) program. They are being further spread to 16 organizations across Canada through the Canadian Foundation for Healthcare Improvement’s Bridge to Home Collaborative.

  1. Improve patients’ and providers’ ability to navigate the health care system, simplify the process of accessing and providing care in the community, and improve digital access to personal health information.

What Will These Actions Accomplish?

Patients, families and caregivers feel a significant amount of personal responsibility for their own health outcomes. Staying healthy, taking preventative actions, and investing in their own health and wellness is important to Ontarians. These actions will help the system shift by ensuring patients have access and ownership of their own personal health information and giving providers a full patient record.

These changes would help multiple service providers identify the right supports to connect patients with integrated health care, regardless of the care setting. This would mean that barriers to sharing health information with patients, across providers and between care settings will be removed, and patients will have better access to coordinated and integrated services without having to share their personal story with multiple providers.

Innovation in Ontario

BASE eConsult: Connecting Primary Care Providers to Specialists Electronically

Building Access to Specialists through e–Consult (BASE) is an online platform connecting primary care providers with specialists.  It was developed to address the challenge of long wait times for patients requiring non–urgent care and guidance from specialists.  A secure web–based application allows primary care providers to request a consultation from a group of specialists, and a response is provided within one week. To date, 43,000 cases have been processed, with the following results:

  • In over 40% of eConsult cases, an in–person visit to the specialist was being contemplated but was deemed not to be required after the eConsult. This meant less unnecessary wait times for patients, and specialist resources were more available for the patients who needed them most. 
  • When a patient needed a specialist visit, those visits were often more effective and productive due to steps or treatments initiated based on the eConsult prior to the in–person visit.
  • In nearly 60% of cases, specialists provided information to help primary care providers deliver the best care for their patients, resulting in positive health care provider experiences.

  1. Support patients and providers at every step of a health care journey by ensuring effective primary care is the foundation of an integrated health care system.

What Will These Actions Accomplish?

Access to primary care is a key component of a successful health care system. Primary care providers have significant expertise; however, they often do not have the capacity to provide the entire range of comprehensive mental health and addictions supports patients need.

The actions listed above will ensure primary care providers have clear, established connections to community service providers, allowing patients to access the entire range of services they require. Children and youth – who typically have a connection to a primary care provider – will be easily connected to specialized community services, where and when required. Ontario Health Teams could be the vehicle to achieve integrated care at the local level.

Innovation in Ontario

Windsor Family Health Team

The Windsor Family Health Team expanded their service delivery through a Team Care Centre (TCC) model, in partnership with the City Centre Community Health Centre. This model serves the rostered patients of 100–125 solo primary care practitioners in the Windsor area, or approximately 200,000 people.

The TCC model provides solo primary care providers with an interdisciplinary team-based, patient–centred approach in mental health diagnosis, and treatment plans for individuals with mental health/addictions and complex care needs.  It also increases access to wrap–around services and programs to meet the health care needs of the community.

The success of this model is seen through 100 community physicians providing over 1,000 referrals since September 2018. Patient outcomes have improved, patient satisfaction rates have increased and unnecessary visits to health care providers have reduced. Moreover, mental health patients have experienced enhanced quality of life, and benefitted from improved care coordination and navigation.

Innovation

Recommendations 4–5

There are gaps in health services that can’t be addressed by offering more of the status quo. It is time to nurture innovative ideas and design new solutions to solve long–standing problems. These recommendations address the growing demand and opportunity to innovate in care delivery, particularly in the use of virtual care and by creating the right conditions for modern programs to scale across the province and deliver better care to patients.

As the population ages and patients’ needs become more complex, finding the right mix of services can be challenging for families and caregivers. Other factors, such as low population densities, can make it difficult to access specialists close to home. These recommendations address the pressing need to provide access to innovative, modern and publicly–funded health care options for all Ontarians, in all our communities.

  1. Improve options for health care delivery, including increasing the availability and use of a variety of virtual care options.

What Will These Actions Accomplish?

Patients and providers should be able to use technology to access health services in the most efficient way possible. Virtual visits and technology tools should be used to supplement in–person care but not replace it. This will mean that patients would have the choice to avoid travelling over two hours for a 15–minute health care appointment if it could be delivered through a virtual platform instead. This will make the health care system work better for patients by delivering care that fits into patients’ and families’ lifestyle, and also help improve access to services by reducing wait times and avoiding emergency department use.

Innovation in Ontario

Ontario’s Structured Psychotherapy Program

Ontario is delivering a Structured Psychotherapy Program to treat depression and anxiety. It is based on a UK program that has demonstrated treating depression and anxiety in the community pays for itself by reducing health care costs, decreasing disability and social assistance payments and increasing tax revenue.

Clients access a stepped–care pathway depending on their needs, participating in psychoeducation groups, using clinician–supported internet–based cognitive behavioural therapy (iCBT), self–management workbooks or in–person psychotherapy. Primary care providers support clients with medication and are kept up to date on their progress with data sent through electronic medical records.

Care is consistently delivered across four specialty mental health hospital hubs and multiple community sites. The program has demonstrated decreased use of acute care services and positive client recovery rates.

  1. Modernize the home care sector and provide better alternatives in the community for patients who require a flexible mix of health care and other supports.

What Will These Actions Accomplish?

Patients will have access to innovative options for receiving care and a mix of flexible services in multiple locations such as homes, community facilities and long–term care homes – including more options for models of care in the community and access to more wrap–around services. Innovative and flexible congregate care models – like campuses of care – would relieve pressure on hospitals by helping people stay in their communities longer and by providing new care settings for patients who are not yet able to return home after a hospital stay.

Taken together, these actions will create a full continuum of community–based care for patients and caregivers who require a more flexible mix of health care and related supports. These changes will mean that patients can stay in their homes longer and maintain their independence with an appropriate and broad mix of supports. This will help a wide range of patients, including children with complex needs who, with the right supports, could stay at home rather than spend more time in a hospital. Patients will have new options for receiving affordable, timely and appropriate care within their communities, and patients who need a place in a long–term care home for medical reasons will have access to the appropriate level of care.

Innovation in Ontario

Pine Villa Reintegration Care Model

Sunnybrook Health Sciences Centre, together with LOFT Community Services and SPRINT Seniors Care, collaborated to deliver an innovative, integrated care and accommodation model in Toronto. Pine Villa is a 69–bed transitional supportive housing site in a former retirement home, where clients are supported by personal support workers, Registered Practical Nurses, case managers, social workers and recreational therapists. It provides care in a community setting for clients who no longer need to be in a hospital but who are not yet able to return to their own home.  

At Pine Villa, clients regain their strength and independence outside the hospital.  Together with their caregivers, they are better able to make informed, realistic decisions about their future care needs and living arrangements. There is an on–site nursing clinic that supports the surrounding community, and clients at Pine Villa receive clinical support from an interprofessional team with expertise from hospital, mental health and addictions, and community support services. Caring for appropriate clients in the community, rather than in a hospital, is a less expensive solution for the health care system and benefits the patient by providing care in a more appropriate setting.

Efficiency & alignment

Recommendations 6–8

The health of a population is connected to certain economic and social factors, known as the social determinants of health. Having a job, eating healthy food and having a safe place to sleep are all foundations to good health; however, many of these economic and social issues are handled outside of the health care system in other ministries and governments. 

If we were to design a health care system from scratch, it could look very different than the health care system we have today. These recommendations will help us overcome traditional barriers and achieve an efficient and sustainable health care system thatdelivers high-quality care that is well–aligned with other services and supports.

Ontarians should be supported by wrap–around services and have access to a full continuum of care. These recommendations identify short– and long–term actions to unlock greater efficiency across government, and will go a long way towards providing coordinated, strategically designed and financially sustainable care in the province.

  1. Data should be strategically designed, open and transparent, and actively used throughout the health care system to drive greater accountability and to improve health outcomes.

What Will These Actions Accomplish?

Data should be used at the system–level to inform planning to improve system–wide performance; at a population level to inform health teams; and at the point-of-care to support clinicians with real-time data that helps inform their work. This data will enable accountability for the province and health service providers, and partners will be more accountable for improving patient outcomes. A modern health care system should be strategically designed to support the use of future technologies to improve care.

Patients may not feel the impact of these actions immediately, but implementation will go a long way in improving how services are planned, funded, organized and delivered. It will help the day–to–day work of health care providers by freeing up more of their time to provide care to patients, rather than spending time collecting and reporting data. Ultimately, better planning, service organization and provider support will result in better patient experiences for everyone receiving health care in Ontario.

Innovation in Ontario

MyPractice Reports

Physicians and administrators in Ontario are dedicated to quality improvement; however, they do not always have the comparable regional and provincial data they need to inform their improvement efforts. To help address this gap, Health Quality Ontario created personalized reports for the primary care, long–term care, specialist and hospital sectors. Using existing administrative health databases, these confidential reports give physicians data about their practice, and share change ideas to help drive quality improvement. Today, thousands of clinicians access this information.

Humber River Hospital Command Centre

The Humber River Hospital was North America’s first fully digital hospital, demonstrating how integrated technology solutions can deliver better value to the health care system and improve patient experience.

The Command Centre uses real–time data, advanced algorithms, predictive analytics and adherence to operating procedures to ensure timely, seamless treatment for patients. The centralized team staffing the Command Centre are able to quickly address patient care delays in an efficient and coordinated way. 

Using technology and communication, the Command Centre has allowed Humber River Hospital to provide its patients with faster tests and decrease their length of stay in hospital, and to serve approximately 4,000 more patients each year.

  1. Ensure Ontarians receive coordinated support by strengthening partnerships between health and social services, which are known to impact determinants of health.

What Will These Actions Accomplish?

Services should work in concert to support the best outcomes for Ontarians, regardless of which ministry, agency, organization or government is responsible for delivering a service. There are many areas where patients and taxpayers would benefit from greater integration between health and social services. For example, the Ministries of Health and Long–Term Care should continue to work with Infrastructure Ontario and the Ministry of Municipal Affairs and Housing to identify opportunities to utilize surplus provincial lands for health care delivery purposes. Similarly, ensuring strong collaboration between the Ministries of Health and Long–Term Care and the Ministry of Children, Community and Social Services is critical for improving the outcomes of children with complex needs.

Furthermore, as part of the broad review of long–term care home placement requirements, the Ministries of Health and Long–Term Care should engage other ministries about the delivery of social services to ensure alignment while system modernization occurs. Greater coordination, alignment and accountability will help ensure Ontarians are receiving the right mix of services, at the right time and place to support the best outcomes possible. 

Innovation in Ontario

Integrated Services for Homeless Individuals: Ottawa Inner City Health and the Targeted Emergency Diversion (TED) Program

Ottawa Inner City Health provides health care services to people with complex needs who are chronically homeless.  It offers primary care, palliative care, and mental health and addictions services in both shelters and supportive housing settings. The Targeted Emergency Diversion (TED) program provides 24–hr monitoring to homeless people under the influence of drugs and alcohol, and allows them to safely detox in the community rather than in hospital emergency departments. Evaluation of the program estimates that for every dollar spent on TED, two dollars are saved in paramedic and police services and emergency department visits. Moreover, homeless individuals receive person–centred care that meets their needs in a more appropriate manner. Based on their 2017 annual report, there were 1,501 unique clients admitted to the program with a total of 5,065 care episodes in the TED program. 

Mobile Integrated Health Response Teams

Niagara Emergency Medical Services (EMS) have partnered with local community partners to create integrated interdisciplinary response teams for non–urgent low acuity EMS callers. These response teams engage with clients and provide alternative pathways to connect them with the care or service they need through primary care, urgent care or other community health and social resources to avoid an unnecessary emergency department (ED) visit. The program includes technology and access to data, such as Clinical Connect, to ensure the response team is aware of care plans in place for these clients and to help ensure continuity in following their plan. Based on data from the Niagara EMS, some early results in 2018 showed:

  • 5% reduction in transports to ED for calls related to mental health, despite a 7% increase in mental health call volume in the region;
  • 2% reduction in transports to ED due to calls for falls (call volume for falls remained stable compared with previous year); and
  • 6% reduction in transports to ED due to calls for generally unwell (call volume for generally unwell remained stable compared with previous year).

  1. As the health care system transforms, design financial incentives to promote improved health outcomes for patients, population health for communities and increased value for taxpayers. 

What Will These Actions Accomplish?

A re–alignment of funding models will mean providers are supported by the right financial incentives to encourage integrated and collaborative health care service delivery that puts the patient at the centre of every health care decision and ensures they are cared for in the best setting to optimize their experience and outcomes. In the long term, patients will become more comfortable navigating an integrated system of health care, and these improvements will help contribute to the appropriate use of resources in addition to improved provider, system and funder accountability.

Innovation in Ontario

Bundled Care

How health care providers are compensated can be either an obstacle or an enabler to providing high–value care. Bundled care models provide a single payment for an episode of care, such as a hip surgery, knee replacement or cardiac surgery, across multiple settings and providers. With bundled care, services are integrated to create seamless transitions and ease a patient’s move from hospital to home. Providers share risks and gains and are incented to collaborate and integrate care and are accountable for quality outcomes.

In 2015, the ministry partnered with the Health System Performance Research Network (HSPRN) to evaluate the implementation of bundled care pilots across six sites. The findings included overall improvements in key measures such as:

  • A reduction in hospital length of stay by 1.26 days, on average; and,
  • A reduction in total costs within 30 days by $2,110 and within 90 days by $3,035.

In addition, patients reported positive experiences and engagement when asked about their care. Findings from surveys and interviews showed that:

  • 87% of surveyed patients reported a sense of involvement in the decision–making process.
  • 87% of surveyed patients reported receiving sufficient information about their condition prior to discharge

Capacity

Recommendations 9–10

These recommendations recognize the need to maximize existing capacity in the system and relieve immediate capacity pressures, while also working on a long–term plan to ensure we have the right mix of health professionals, services, beds and leadership skills to meet the population’s changing health care needs.

Health care capacity planning is a technical exercise that benefits from a clear vision. Determining the appropriate mix of beds and health care services in the community in the longer term (over 10 years from now) will require taking a detailed look at anticipated population needs in relation to the current mix of infrastructure and services.

The health care system of the future will be built in collaboration with leaders in our health workforce. Championing collaborative and interprofessional leadership development will ensure Ontario has access to the leadership talent it needs to deliver a patient–focused, modern and integrated health care system.

  1. Address short– and long–term capacity pressures including wait times for specialist and community care by maximizing existing assets and skills and making strategic new investments. Build the appropriate health care system for the future.

What Will These Actions Accomplish?

Effective health care governance requires system leaders to take strategic actions that support short– and long–term system objectives. No policy changes would be required to accomplish these goals; however, a shift in planning ideology would be significant. To ensure the long–term sustainability of the health care system, policy makers should shift their focus to designing and investing in a system that provides preventative, strategic and integrated supports while embracing technology and evidence–based solutions.  These actions will ensure patients have a system that is working for them at every step of the way by having consistent, reliable access to appropriate services.

Innovation in Ontario

Personal Support Neighbourhood Model

The Personal Support Neighbourhood Model was developed in 2018 to address Personal Support Worker (PSW) resource challenges and to improve patient care and provider satisfaction rates in Waterloo–Wellington. Traditional home and community care service models compensate PSWs based on the number of visits they make. This can lead to inconsistent weekly schedules, and corresponding income, and contributes to higher turnover rates and dissatisfaction among the PSW workforce.

The Personal Support Neighbourhood Model employs PSWs as full–time salaried staff to deliver care in urban communities. This model gives PSWs flexibility to deliver care in smaller increments of time, but more frequently, based on patient need. An early review of the model found that patient experience is improved through greater continuity of care (fewer PSWs per patient) and fewer missed visits. PSW provider experience is improved, as measured by a reduced workforce turnover rate and reduced absenteeism amongst staff. This model is an example of how cost–effective care can be delivered in urban communities with limited PSW staffing resources.

 

  1. Champion collaborative and interprofessional leadership development focused on system modernization capabilities.

What Will These Actions Accomplish?

Health care is moving in the right direction towards team–based integrated care, but it won’t work without effective leadership and the right mix of skills. Without partnerships throughout the health care sector and strong relationships with system leaders, significant transformative change will not occur.

The government has a responsibility and a role to provide clear direction to the sector, especially at such a moment of significant change. By providing clear expectations, transparent information, and leadership support and guidance, the government will enable system and culture change and will deliver the integrated and modern health care services Ontarians deserve.