Integration Review Project - Reference Document

Integration Review Project

Reference Document: Research, Pathway & Toolkit

April, 2016

I N T E G R AT I O N R E V I E W P R O J E C T

Reference Document, April, 2016

Prepared by OPTIMUS | SBR © 2016 All rights reserved P a g e | 2

TABLE OF CONTENTS

APPENDIX 1: INTEGRATION PATHWAY IN THE TORONTO CENTRAL LHIN ........................ 4 1.1 Exploration ................................................................................................................ 6

1.2 Feasibility .................................................................................................................. 6

1.3 Planning and Implementation ................................................................................... 6

1.4 Figure 1: Detailed Integration Pathway for Toronto Central LHIN ........................... 8

APPENDIX 2: INTEGRATION TOOLKIT FOR TORONTO CENTRAL LHIN HEALTH SERVICE PROVIDERS ................................................................................................... 11

2.1 Who Should Use the Integration Framework and Toolkit ...................................... 11

2.2 Tool 1: Strategic Options Assessment ..................................................................... 13

2.2.1 Why Use this Tool?..................................................................................... 13

2.2.2 Who Should Use this Tool? ........................................................................ 13

2.2.3 How Should This Tool Be Used? ................................................................. 14

2.2.4 Tool: Strategic Options Assessment ........................................................... 15

2.2.5 Scoring: Confidence Scale .......................................................................... 17

2.2.6 Confidence Scale and Integration Spectrum .............................................. 18

2.3 Tool 2: High-Potential Partnership Identification ................................................... 19

2.3.1 Why Use this Tool?..................................................................................... 19



2.3.4 Tool: High Potential Partner Identification and Evaluation ....................... 20

2.4 Tool 3: Due Diligence to Assess Feasibility .............................................................. 30

2.4.1 Why Use this Tool?..................................................................................... 30



2.4.4 Tool: Due Diligence to Assess Feasibility ................................................... 31

2.5 Integration Implementation Considerations .......................................................... 45

2.5.1 Committed Leadership and Board ............................................................. 45

2.5.2 Communication and Engagement .............................................................. 46

2.5.3 Change Management ................................................................................. 46

2.5.4 Dedicated Resources .................................................................................. 47

APPENDIX 3: IMPLEMENTATION PLAN DETAILS FOR RECOMMENDATIONS ................... 48

APPENDIX 4: DETAILED SUMMARIES OF RESEARCH ..................................................... 53 4.1 Defining “Integration” in the Toronto Central LHIN ............................................... 53

4.1.1 Integration Framework: Not just Mergers, but a Spectrum of Activities .. 54




4.1.2 Defining Integration: A Complex Task ........................................................ 56

4.1.3 Outcomes of Integration ............................................................................ 59

4.1.4 Integration Success Factors........................................................................ 61

4.1.5 Measures of Integration............................................................................. 63

4.1.6 LHSIA and Other Considerations ................................................................ 64

4.2 Summary of Engagement Findings: Clients, Patients, and Providers ..................... 66

4.2.1 Toronto Central LHIN Engagement: Interview Findings ............................ 66

4.2.2 Jurisdictional Review Findings.................................................................... 69

4.2.3 Client/Patient Focus Groups ...................................................................... 72

4.2.4 Health Service Provider Focus Group ........................................................ 75

4.2.5 Survey Analysis ........................................................................................... 77

4.3 Summary of Data Analysis Activities ....................................................................... 93

4.3.1 Wait Times for Mental Health and Addiction Services .............................. 93

4.3.2 Care Best Managed Elsewhere .................................................................. 94

4.3.3 Total Margin ............................................................................................... 96

4.3.4 Percentage of Budget Spent on Administration ........................................ 99

4.3.5 Cost per Unit of Service and Individuals Served per FTE ......................... 101

APPENDIX 5: BIBLIOGRAPHY ..................................................................................... 104




1. Appendix 1: Integration Pathway in the Toronto Central LHIN

The process of exploring integration, assessing feasibility, and conducting planning and

implementation of integrations is generally the same, no matter if those involved are

programs/services of hospitals or community agencies, nor if there are two, three or more

programs/services exploring integration. Of course, there will be specific nuances that are

associated with each situation, but broadly, the processes and requirements of integration are

also similar if voluntary or facilitated by the Toronto Central LHIN; the difference between these

situations is how and when the LHIN supports efforts.

The Integration Pathway, designed for Toronto Central LHIN, was informed by leading practices,

the practices of other LHINs, and the perspectives of local providers. The pathway describes a

process by which the Toronto Central LHIN-funded programs and services can explore and pursue

integration efforts across the entire integration spectrum, including program/service linkages,

coordination, structured collaboration, program/service transfer and full integration (i.e.

organization mergers).

The Integration Pathway outlines the start to finish process of an integration and can be broken

down into three major steps: exploration, feasibility, and planning and implementation. The

diagram on the next page provides a high-level overview of the common activities along the

Pathway. For each activities we have indicated the supporting tools as well as the LHIN’s

involvement. Please note that the LHIN’s involvement has been more explicitly described for each

degree of integration in the recommendations section of this document. In addition, a more

detailed pathway that expands on the high-level version can be found in Appendix 0.




Determine if integration would

achieve desired goals

Determine what partners would be

ideal to integrate with

Conduct high-level feasibility study (including MOU)

If results of feasibility study are positive,

conduct in-depth due diligence review

Upon decision to “not stop” integration by

LHIN, conduct detailed planning for

integration

Integration Planning

Hospital

Voluntary

Complete H-SIP if require LHIN

resources

Community

HSP to develop Letter of Intent and Business

Plan for the LHIN

LHIN and/or HSP to develop Business Plan

for the Board

HSPs to Submit Business Plan to the

LHIN Board

Integration Implementation

Facilitated

Strategic Options Tool

Supporting Toosl

Facilitate conversations Share knowledge i.e. Integration Toolkit Provide supporting data analysis support Direction to explore integration as a strategic option

Role of LHIN

N/A Review and decide not to stop business plans (LHIN Board only) LHIN sets integration metrics and reporting schedule with HSP, for two years

post-integration

High Potential Partner Identification and Evaluation

Support the identification of partners if there is lack of sector momentum or if the tool does not provide an ideal partner

Initiate/ facilitate multi-party discussions or sector, geographical, or service-level HSP group meetings

High Potential Partner Identification and Evaluation

Support data analysis Facilitate multi-party discussions Provide leadership support for assessing feasibility, conducting

assessment

H-SIP Review and approve H-SIP Provide financial and/or project management support to

community agencies to complete all aspects of due diligence

Letter of Intent Template

Business Plan Template

Voluntary Facilitate conversations between parties as needed to mitigate

potential barriers Facilitated Determine if integration will achieve desired outcomes and

facilitate the process as needed. Write the business case for submission to the LHIN Board

Due Diligence to Assess Feasibility

N/A

Project Plan Provide advice based on experiences and key learnings Provide LHIN leadership in facilitating the planning and

implementing activities if required Offer communication support (i.e. strategy, language,

stakeholder forums) Provide 3rd party facilitation and mediation, project

management

Provide financial assistance, one-time costs (i.e. Project Manager, Decision Support resources, etc.)

Provide IT/IM implementation and cost support Offer legal advisory support

EXP

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Role of HSPs




1.1 Exploration

The Pathway begins with an exploration phase, where the program/service will assess if an

integration will achieve desired goals using the Strategic Options Assessment Tool (Section 2.2).

This tool can also be used to help Health Service Providers (HSPs) understand the level of

integration that might be most beneficial to their unique situation. Next, an HSP will identify and

evaluate high-potential partners using the High-Potential Partner Identification and Evaluation

Tool (Section 2.3).

In the event that the tool does not identify a suitable partner, or there is limited sector

momentum, the LHIN could support the HSP in identifying potential partner(s). Once it has been

determined that there is potential benefit internally, representatives of the HSP would then

initiate discussions with potential partners to see if they are willing and ready to pursue the next

phases of integration, and what it might look like.

1.2 Feasibility

Once an HSP has identified an ideal partner(s) who is interested in integrating, a high-level

feasibility study should be conducted by the partners using the High-Potential Partnership

Identification and Evaluation Tool (Section 2.3). Following this study, the HSPs should create draft

terms of reference and scope the level of integration required to achieve the desired benefits.

HSPs would then evaluate if they have sufficient resources to complete a due diligence review. If

additional resources are required, a Health System Improvement Plan (H-SIP) can be submitted

by a community HSP to the LHIN to request LHIN support, including one-time funding. Hospitals

are not expected to require LHIN one-time funding for integration costs. The HSPs considering

integration would then undergo a formal due diligence process using the Due Diligence Tool

(Section 2.4). In the event that the due diligence review identifies barriers to integration that

cannot be mitigated independently, the LHIN might be a helpful resource to support the HSPs in

mitigating some of the barriers, if the integration should be continued.

1.3 Planning and Implementation

After the Due Diligence has been completed and the HSPs have decided to move forward with the

integration, they should draft and submit a business plan and letter of intent to the LHIN, initiating

a 60-day review period by the LHIN. During this process, the business plan is reviewed by the LHIN

Board. A LHIN Board decision to “not stop” the integration must be made before the integration

can formally be implemented.




The HSPs would then begin to implement the integration. There are some instances where HSPs

might decide not to integrate but the LHIN may want to facilitate the integration when the

benefits of the integration are high. In this case, the LHIN staff would develop the business case

for facilitated integration for submission and approval by the LHIN Board.




Figure 1: Detailed Integration Pathway for Toronto Central LHIN

Complete Strategic Options Assessment to Identify the Degree of Integration that

Should be Considered

Yes

Should Integration be a

Strategic Option forthe Entity?

Complete High-Potential Partnership Identification

Worksheet to Identify Opportunities for Partners

Initiate discussion with high-potential partner’s Key

Leaders or Decision Makers (i.e. Program Lead, Board

Chair etc.)

YesAre there High-Potential

Opportunities for Partners?

No

Select Preferred High-Potential Partner

End

Explore Integration

No

Is there interested from external key stakeholders

to pursue the integration?

Yes

Yes

Have external keystakeholders identified

other high-potential partners?

No

Yes

Do the partners agreethat integration should

be explored?

No

Exploration

Go to: Feasibility [A]

Start/EndIntegration

ToolDecisionProcess Step

Legend

Off-page connector

(go to)

Off-page connector

(from)




Can identified barriers be mitigated independently or with

LHIN support?

Have any significantbarriers to integration

been identified?

NoBegin due diligence processYes

Do you have sufficient resources to

complete full duediligence?

Develop and submit Health System Improvement Pre-

proposal Form (H-SIP) (community HSPs only)

No

Receipt of resources to proceed with due diligence

Yes

No

Do all partners want topursue integration?

Yes

Does one partner want to pursue integration

strongly?

No

No

Y

YesDiscuss possibility of

facilitated integration with LHIN

Does the LHIN want to pursue the integration?

Yes

No

Conduct high-level feasibility study

Draft an agreement to explore integration,

including terms of reference and scope

Advise LHIN that integration is being explored

Feasibility

Go to: Planning and Implementation [B]

Go to: Planning and

Implementation [C]

End

From: Exploration

[A]



Legend

Off-page connector

(go to)

Off-page connector

(from)




Does the LHIN Boardwant to NOT stop the

integration?

HSP Planning and Implementation of

Integrative Activities

Yes

Create and Submit an Integration Business Plan

and Letter of Intent to the TC LHIN

No

Pursue facilitated integrationLHIN develops business case

for facilitated integration

Planning and Implementation

From: Feasibility[B]

From: Feasibility

[C]

TC LHIN informs HSPs that the integration is stopped

End



Legend

Off-page connector

(go to)

Off-page connector

(from)




2. Appendix 2: Integration Toolkit for Toronto Central LHIN Health Service Providers

2.1 Who Should Use the Integration Framework and Toolkit

The Integration Framework and Toolkit should be used to help frame thinking about strategic

options if you are:

A leader of a Toronto Central LHIN funded health program, service, or organization

A Board member representing a Toronto Central LHIN-funded health program, service, or

organization

The Toronto Central LHIN

The Integration Framework and Toolkit have been designed for Leaders and Board members of

the Toronto Central LHIN-funded Health Service Providers (HSPs) that are making strategic

choices when situations such as the following are apparent:

HSPs are missing defined targets and have self-identified the need to integrate

HSPs are providing similar programs and services;

HSPs are offering care and supports to similar populations/clients/patients within a

defined region or geography; and/or,

There are opportunities to make a positive impact on the Toronto Central LHIN’s Strategic

Plan goals.

The Integration Framework and Toolkit will help Leaders, Board members and the LHIN with the:

Exploration of integration (of whatever type and level) as a legitimate and valid strategic

option;

Assessment of feasibility of potential integration opportunities; and,

Decision-making and implementation planning of integrative efforts.

These materials can be applied to integrations that are program/service-level and care pathways

as well as those relating to organizations, regions, and systems. The tools can also be used to

stimulate discussions and guide conversations with multiple Boards and/or Leadership

representatives. They may also be completed by an individual and then discussed with a broader

group, to support a conversation about strategic integration opportunities.

The tools and content are aligned with the current the Toronto Central LHIN Strategic Plan 2015-

2018, and are informed by leading practices drawn from integration activities within Toronto

Central and other LHINs as well as from integration literature.




All tools and content have been designed for integrations along the spectrum of integration.

Three tools have been developed to support decision-making throughout the Integration

Pathway:

1. Strategic Options Assessment – to support exploration of integration as a strategic option

and to help identify the type of integration that might be most appropriate

2. High-level Partner Identification and Evaluation Tool – to identify, prioritize and evaluate

high-level partnerships between two or more programs, services, or organizations

3. Due Diligence to Assess Feasibility – to provide a detailed list of considerations and

required tasks to be completed to ensure that a potential integration will be beneficial to

all relevant groups

The Integration Toolkit also provides considerations for planning and implementation of

integration activities.




2.2 Tool 1: Strategic Options Assessment

Should I think about integration? What type?

2.2.1 Why Use this Tool?

The Strategic Options Assessment Tool helps decision-makers explore ways of working differently

within their local environments through integration. Integration refers to a full spectrum of

activities that can be used to drive change to achieve goals:

In alignment with the Toronto Central LHIN’s Goals, the tool should be applied to situations when

there is opportunity to create a “healthier Toronto,” deliver “positive patient experiences,” and

improve “system sustainability.” Strategic options for integration apply to situations when:

HSPs are missing defined targets and have self-identified the need to integrate

HSPs are providing similar programs and services;

HSPs are offering and care and supports to similar populations/clients/patients within a

defined region or geography;

HSPs in a defined region or geography are offering care/services specific to a care

pathway, or to clients/patients with specified conditions; and/or,

There are opportunities to make a positive impact on the Toronto Central LHIN’s Strategic

Plan goals.

The tool encourages users to be forward thinking and consider factors that are likely to contribute

to the Toronto Central LHIN’s Goals over the next two years.

2.2.2 Who Should Use this Tool?

You should use this tool to help you think about strategic options if you are:

A leader of a Toronto Central LHIN-funded health program, service, or organization




A Board member representing a Toronto Central LHIN-funded health program, service,

or organization


The tool can also be used to stimulate discussions and guide conversations with multiple Board

and/or Leadership representatives. It may also be completed by an individual and then discussed

with a broader group, to support a conversation about strategic integration opportunities.

2.2.3 How Should This Tool Be Used?

No matter what your role, you can use this tool to guide and support thinking on strategic options

for your Toronto Central LHIN-funded program, service, care pathway, organization, region or

system. The tool is meant to be directional and exploratory to support decision-making, and is not

intended to be definitive.

Follow the steps below to use the Strategic Options Assessment Tool:

Step 1: Identify what is being assessed

Identify the health/health-related program, service, care pathway, organization, region, or system

that you would like to assess.

Step 2: Review the expectations

Review the list of expectations in the second column. For each expectation, ask:

If everything continues in the same way as today (beyond your organization’s normal

improvement activities), indicate your level of confidence that IN TWO (2) YEARS, you will be doing

the following?

Record a number from 1 to 3 in the right-side column to indicate your level of confidence, where

3 is high, and 1 is low:

3 = High Level of Confidence that if we keep doing things the same, in 2 years we will be

meeting or exceeding this expectation

2 = Medium Level of Confidence that if we keep doing things the same, in 2 years we will be


1 = Low Level of Confidence that if we keep doing things the same, in 2 years we will be





Step 3: Determine your total confidence score

Add the numbers in the right hand column for each of the three sections, and write your subtotals

where indicated, in the grey boxes. Then, copy the subtotals into the relevant boxes at the bottom

of the tool, and add the three subtotals together to get a “Total” number. Write the total number

in the bottom right box beside “Total.”

Step 4: Assess integration options

Using the confidence scale, see where your total score fits on the integration spectrum to identify

what type of integration might be most beneficial for your situation. Please think critically when

interpreting results – based on what you know about your situation and environment, does this

make sense and validate what you have been thinking already?

Step 5: Use the Partner Identification and Evaluation Tool

If you believe that integration, of any type and level, is an option for you, continue on to the

Partner Identification and Evaluation tool.

2.2.4 Tool: Strategic Options Assessment

Toronto Central LHIN

Strategic Goal Expectations

If nothing changes, how will we be doing in 2

years?

If everything continues in the same way as it is today (beyond normal improvement activities), indicate your level of confidence that IN 2 YEARS, you will be meeting these expectations?

Rating Scale: 3 = High Confidence 2 = Medium Confidence 1 = Low Confidence

A Healthier Toronto

Changes are regularly made that measurably improve outcomes for the population of Toronto

New clients/patients are admitted/registered on a regular basis

Effective referrals and client/patient transitions are regularly made to a range of different services to support clients/patients‘ needs beyond what are offered at my organization







years?

Partnerships with others who operate in similar and complementary program/service areas are well established and effective and continue to grow

Quality/Performance improvement is a key focus, and current performance on quality measures is satisfactory or better.

Information is being appropriately used and shared between relevant external programs/services

“Healthier Toronto” SUBTOTAL

Positive Patient Experiences

Changes are regularly made that measurably improve client/patient experiences

Clients’/ Patients’ waits for all services are within the top 50th percentile of my sector

Client/patient satisfaction scores are consistent and are generally high (best 50th percentile)

The community is regularly engaged in conversations about our organization’s relevance, value and impact

Client/patient safety is a key focus, and performance on safety measures is high

“Positive Patient Experiences” SUBTOTAL

System Sustainability

Changes are regularly made that improve efficiency in program/service delivery

The budget is regularly balanced or in surplus position

Staff and Volunteer satisfaction scores are consistent and are generally high

Performance targets set by the funder(s) are regularly being met.

Programs/Service capacity and volumes are managed well

Sufficient administrative infrastructure is in place to support operational and/or service delivery activities (HR, IT, Finance, other Admin, etc.)







years?

A business continuity plan is complete and sufficient to mitigate reasonable financial risks

A succession plan is complete and sufficient to manage leadership transition risks

Long term relevance of program/service offerings is expected

“System Sustainability” SUBTOTAL

“Healthier Toronto” SUBTOTAL

“Positive Patient Experiences” SUBTOTAL

“System Sustainability” SUBTOTAL

TOTAL SCORE

2.2.5 Scoring: Confidence Scale Total Score

20-30 Lower Confidence, Higher Risk – Expectations for activities to produce results that will positively contribute to the Toronto Central LHIN’s Goals are low. Sustainability and relevance may be of concern in the longer term, so an integration may be a strategic option to consider in the near term. Look for opportunities to merge or transfer programs/services to build your confidence that the Toronto Central LHIN Goals will be positively impacted, and that would ensure relevance and sustainability.

31-50 Medium Confidence, Medium Risk - Expectations for activities to produce results that will positively contribute to the Toronto Central LHIN’s Goals are in the mid-range; some expectations are being met or exceeded, others are not being achieved. Some focused attention is required to ensure that sustainability and relevance are maintained over the long term, and integration may be a strategic option to consider if these are threatened. Look for opportunities to collaborate or transfer programs/services within the local system that are likely to build your confidence that the Toronto Central LHIN Goals will be positively impacted, and that would ensure relevance and sustainability.




Total Score

51-60 High Confidence, Low Risk – Expectations for activities to produce results that will positively contribute to the Toronto Central LHIN’s Goals are high, and you are confident that sustainability and relevance are not at risk. Although you may not require strategic integrations to build your confidence in these areas, you may continue to seek strategic collaborations and partnerships as appropriate. In addition, your strong health positions you to support others who are at higher risk. Seek opportunities that would create mutual value in the local system, and that would be expected to positively impact progress on the Toronto Central LHIN’s Goals.

2.2.6 Confidence Scale and Integration Spectrum

Depending on your total score, you might consider integration of different types to support

achievement of expectations:

Low Confidence, High Risk (Scores 20-30)

Medium Confidence, Medium Risk (Scores 31-49)

High Confidence, Low Risk (Scores 50-60)




2.3 Tool 2: High-Potential Partnership Identification

With whom might I explore integrative efforts?

Would it work and help us achieve our goals?


The High-Potential Partner Identification and Evaluation Tool helps decision-makers explore how

they might work with others to pursue integration opportunities:

In alignment with the Toronto Central LHIN Goals, the tool should be used when opportunities

have been identified to create a “healthier Toronto,” deliver “positive patient experiences,” and

improve “system sustainability,” and when there is a need to focus thinking on who should be

considered in an integrated model or system.

The tool encourages users to consider a range of factors that are important when assessing

potential integration partners.


You should use this tool to help you think strategically about high-potential integration partners

(one or more) if you are:



or organization


The tool can also be used to stimulate group discussion and guide conversations with multiple

Board and/or Leadership representatives. It may also be completed by an individual and then




discussed with a broader group, to support a conversation about strategic integration

opportunities and high-potential partners.


No matter what your role, you can use this tool to guide and support strategic thinking about

high-potential integration partners (one or more) for your program, service, care pathway,

organization, region or system. The tool is meant to be directional and exploratory to support

decision-making, and is not intended to be definitive.

Follow the steps below to use the High-Potential Partner Identification and Evaluation Tool:

2.3.4 Tool: High Potential Partner Identification and Evaluation

Step 1: Defining and Ranking Context-Specific Criteria of Ideal Partner(s)

Using your working knowledge of your program, service, organization, or care pathway, the first

component of this worksheet is to help you identify the criteria that would define your ideal

partner(s) for integration.

Identifying these criteria will help you to assess and prioritize specific opportunities for integrative

efforts with potential partners that are aligned with your specific needs and priorities, and that

would contribute to the Toronto Central LHIN Goals. Your partner(s) could be other programs,

services, links along a care pathway, organizations, regions or components of a system that you

think could help achieve mutual goals.

1. Consider Toronto Central LHIN goals identified on the left side and add other criteria that are

important to your situation. For each goal, complete the criteria that can be achieved through

a new partnership. Examples of criteria to include might be:

Will reduce wait times for services

Will reduce overhead costs

Will create opportunities for our staff

We have a current trusting relationship with each other

We will be better positioned to be a sustainable entity

All integrations should ultimately help achieve the Toronto Central LHIN Goals, as well as your

own specific criteria.

Toronto Central LHIN Goal Criteria for Partnership Ranking




Considering each goal, what is most important to you when considering potential strategic partner(s)?

Rank your responses to the previous column in order of importance

(1 = Highest importance)

A Healthier Toronto – focus on improving health outcomes for the population

Example: Our clients/patients would have access to new services they need

Positive Patient Experiences – focus on seamless transitions, access, inclusivity, and cultural sensitivity

System Sustainability – focus on transparency, efficiency and innovation for quality and value

Other Goals important to your situation

2. Review your list of criteria for your ideal partner(s). In the column on the right, rank the

criteria, where “1” is the most important criteria for an integration to achieve. When ranking,

consider what success would look like for your situation and which of your criteria would best

get you towards that goal.

Step 2: Identify Potential Partner to Evaluate

You know your operations best, and what will work. Write down a list of five potential partners,

who could be programs, services, links along a care pathway, organizations, or components of a

system that you think might be good candidates for integration. For example:

Program X at Agency A is similar to Program X at Agency B

Multiple agencies in the same area all provide slight variations of Program X for the same

population

Agency B offers Program X, which would really complement Agency A’s programs in a new

way




Think of potential partners that are “natural” fits as well as those that are a bit more “out of the

box”. You may include partners that provide very similar types of services to a similar group of

people in a similar geography. Other partnership opportunities may be with those who provide

services in comparable ways, in different parts of the continuum of care, or in neighbouring

geographies, or to different client or patient groups. In some cases, a group of programs or

services may be identified as a potential partnership.

Write the names of these potential partners in the right-side column of the chart.

Options to Evaluate

Potential Partner A

Potential Partner B

Potential Partner C

Potential Partner D

Potential Partner E

Step 3: Evaluate the Potential Partners Against Ideal Partner Criteria

To evaluate options for strategic integration partners, use the following table to compare each

partner against the most important criteria for your situation. To use the table, follow these

instructions:

1. The top five (5) high-ranked criteria that you established in Step 1 can be listed in the left

hand column where indicated. The remaining criteria (6 to 15) is taken from the best

practice research on factors for integration success. If there is overlap with the criteria

you developed in step 1 they can be removed.

2. The five (5) high potential partners that you listed in Step 2 can be listed across the top

row, from A through E.

3. Complete each row in the table by considering whether integration with the high

potential partner would lead to success for that criteria. Please use the following rating

scale to evaluate the options and enter values for each of the cells within the row:

1 = Negative Outcomes Expected - would likely result in poorer outcomes on this

criteria

2 = Neutral Expectations - would likely result in about the same outcomes as

current on this criteria

3 = Positive Outcomes Expected - would likely result in better outcomes on this

criteria




For example, if an integration between you and partner A would likely achieve

significant improvements on Criteria #1, then a score of 3 would be entered in the

cell where A meets 1.

4. For each column A through E, add the numbers and write them in the bottom row,

indicated “Total.” High-potential partner(s) have the highest total score and should be

prioritized for further consideration to determine if integrative efforts should be pursued

further.

Top Ranked Criteria (From Step 1 Table)

Potential Partners (from Step 2 Table)

A. B. C. D. E.

You

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1

#1: Additional Criteria (Take from Step 1)










A. B. C. D. E.

Lead

ing

Pra

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es

#6 Population: The integration will ensure that relevant populations are better served.

#7: Service: The integration will strengthen/enhance existing programs and services and reduce gaps in service.

#8: Leadership: Leaders from each potential partner have an aligned vision and are committed to the integration.

#9: Culture: Potential partners have a similar culture and share a common vision for their culture.

#10: Mission, Vision and Values: Potential partners have strategic plans that are in alignment.






A. B. C. D. E.

#11: Business & Operations: The integration will streamline business operations or better support back office functions.

#12: System Priorities: Integration aligns with system level strategic directions (Toronto Central LHIN, MOHLTC, other).

#13: Financial Health: The integration enhances the financial health of the potential partners.

#14: Geography: The integration will ensure relevant catchments are covered efficiently and better.

#15: Governance: Potential partners have governance structures, policies, procedures and processes that are aligned.






A. B. C. D. E.

Total (sum of responses for each column)

Scoring

If total is 36-45, the partnership has high potential to use integration of some form to achieve positive and desired outcomes; proceed to evaluate feasibility

If total is 22-35, the partnership has medium potential to use integration of some form to achieve positive and desired outcomes; proceed to evaluate feasibility

If total is 15-21, the partnership has low potential to create value in alignment with your priorities; revisit other partnership opportunities.

Step 4: With the proposed partner in mind, review the Toronto Central LHIN Health Goals to

validate fit with overall LHIN objectives

Using the table below, consider each integration guiding principle as applicable to the proposed

integrative effort, and estimate to the best of your ability whether the proposed partnership for

integration would maintain, improve or reduce success in each area. The right-hand column can

be used to write down ideas and rationale. There is no scoring system for this tool.

Guiding Principle Description and Desired Outcome of Guiding Principle

Would integration maintain, improve or reduce success on this principle? Why?

Toronto Central LHIN Goal: A Healthier Toronto

Integration should improve transitions along the continuum of care

The integration will streamline transitions along the continuum of care, leading to fewer clients/patients missing needed care.

This principle speaks to the Patients First: Ontario’s Action Plan for Health Care. The “Patients First” mandate focuses on connecting services – delivering better coordinated and integrated care in the community, closer to home.






It also aligns to the Toronto Central LHIN’s vision of a health care system which will provide coordinated plans of care for targeted populations to assist them to get the right care when and where they need it.

Integration should create healthier communities in Toronto Central LHIN

The integration will improve overall health of communities by minimizing health disparities and responding to the needs of at-risk populations or those with poor health outcomes.

This principle also speaks to social determinants of health and at-risk populations. It promotes wellness and ensures individuals are proactively receiving the services they need to live healthier lives.

It also focuses on “high-needs” clients/patients and those who might become “high-risk” populations. It ensures that high-needs clients/patients receive coordinated care to assist them to get the right care when and where they need it.

Toronto Central LHIN Goal: Positive Patient Experiences

Integration should enhance client/patient health outcomes and experience

Integration will improve the quality of programs and/or services provided, leading to better health outcomes and client/patient experiences.

This principle is focused on enhancing the type and quality of services provided to clients/patients across the Toronto Central LHIN. It focuses on creating services based on what people need and say is important to them to improve their overall experience.

It aligns closely with the IHI’s Triple Aim framework that describes an approach to optimizing health system performance.

Improving the client’s/patient’s experience of

care (including quality and satisfaction);

Improving the health of populations; and,






Reducing the per capita cost of health care.

In addition, this principle speaks to the ability of the partners to meet health indicators that are set by the Toronto Central LHIN and Health Quality Ontario.

Integration should improve access to care

Integration will enhance access to programs and/or services for populations or geographies in the Toronto Central LHIN.

This principle speaks to the Patients First: Ontario’s Action Plan for Health Care. The “Patients First” mandate focuses on improving access – providing faster access to the right care.

This principle supports equitable access to services across the entire Toronto Central LHIN regardless of geographical location or unique needs. Clients and patients should be able to easily navigate through the system to find what they need.

Toronto Central LHIN Goal: System Sustainability

Integrations should be broad reaching and have system-level impacts

Integration will link together different sectors such as health, public health, housing, social services, justice and many others to collaboratively improve the health of the broader population through clear care/support pathways for clients/patients.

Integrations should help programs/services work better together in small regions or areas to provide focused care that addresses the holistic, broad and unique needs of the local communities.

This principle focuses on bringing together different sectors to coordinate services across the Toronto Central LHIN. It promotes a culture of planning for large-scale system change that will positively impact clients/patients rather than planning at the individual service provider level.






Integrations should create sustainability and organizational stability

Integration will enhance the operations and financial stability of the partners as a whole, leading to an enhanced ability to meet yearly performance and financial targets. It will also lower costs of care per client, without negatively impacting quality.

This principle speaks to the Patients First: Ontario’s Action Plan for Health Care. The “Patients First” mandate focuses on protecting our universal public health care system – making decisions based on value and quality, to sustain the system for generations to come.

It is about making sure that financially sustainable businesses are operating today and in the future and are providing the best value for the populations served as well as for staff and volunteers, to support effective succession planning.

Integrations should create organizational efficiencies

Integration will maintain or increase organizational efficiencies and reduce unnecessary costs, as well as duplications of services or functions across the Toronto Central LHIN.

This principle speaks to the delivery of key clinical services and business operations which improve client/patient outcomes at the same or lower cost.

It also focuses on business efficiencies that may be gained in terms of back office integrations that may enhance capacity in human resources, finance, admin, IT/IM, as well as reporting capabilities.

Overall Guiding Principles and Requirements

Strategic Alignment

The vision for the integration is aligned to the Toronto Central LHIN’s Strategic Plan, as well as with Ministry directives.

Interest in Integration

A strong level of interest exists amongst key stakeholders (i.e. senior management, the Board etc.) to investigate the possibility of an integration to achieve a common vision.




2.4 Tool 3: Due Diligence to Assess Feasibility

After a thorough and focused review, should integrative efforts

proceed?


The Due Diligence Tool helps decision-makers explore the feasibility of the potential integration

opportunity, to identify issues that would either support or impede success upon implementation.

The Due Diligence Tool encourages users to consider the different operational and governance

factors that are important when exploring integration. Assessment includes review of the

following factors, either internally or by seeking expert advice:

Strategy;

Programs and services;

Finance;

Legal;

Human Resources;

Infrastructure and space;

Information Management; and,

Marketing, communications, and fund development.


You should use this tool to help you think strategically about the feasibility of integration if you

are:



or organization





A subject matter expert tasked with assessing feasibility of an integration

The tool can also be used to stimulate group discussion and guide conversations with multiple

Board and/or Leadership representatives. It may also be completed by an individual and then

discussed with a broader group, or to support a conversation about due diligence and feasibility

issues related to the high-potential partner(s).


No matter what your role, you can use this tool to guide and support strategic thinking about the

feasibility of an integration for your program, service, organization, care pathway, region or

system. The tool is meant to be directional and exploratory to support decision-making, and is not

intended to be definitive.

2.4.4 Tool: Due Diligence to Assess Feasibility

Follow the steps below to use the Due Diligence tool:

Step 1: Determine the relevant feasibility criteria for your situation

Using the tool below, both partners in the integration should review the list of due diligence areas,

and depending on the type and level of integration being considered, choose which factors are

important to review in deep detail, and how these should be reviewed.

Using the columns on the right side, indicate whether to include an assessment of each line item,

and how the assessment can be completed. In the column marked “Type of Assessment to be

Completed” write a number to indicate one of the following options:

0 = Assessment on this item is not required

1 = Check if item is available, no further action required. A simple response is required to

indicate if an item is in place or not to satisfy the requirement

2 = To be assessed, internal capacity and expertise is available. The item needs further

review and analysis to make an assessment decision, and this can be completed internally

3 = To be assessed, internal capacity and expertise is not available - If the item needs

further review and analysis to make an assessment decision, which cannot be completed

internally. There is a need to seek external expertise or support




Step 2: Complete the due diligence reviews and report findings

Review the list of items for which you have indicated 1, 2, or 3. This is the task list to guide the

due diligence activities between partners. Use the following methods to support in the more

detailed due diligence assessments:

Review of historical and current operating and financial statements

Review of strategic plans and documents

Discussions with key subject matter experts on program areas, as well as legal, privacy,

finance, HR, administration, IT, space/facilities, etc.

Discussions with Board members, Senior Leaders, staff and clinicians, physicians, and

clients/patients, volunteers

Note: Toronto Central LHIN has funds available for community agencies to support feasibility

assessments for integration purposes. Please visit the Toronto Central LHIN website to obtain the

Health Services Improvement Plan (H-SIP) form for submission of a funding request.

Step 3: Assess Feasibility

Using the output of Step 2 task list, consult the right people and engage in the right analyses to

determine if the integration is feasible. If all relevant Boards and Senior Leadership agree that

integration should be pursued, advise the Toronto Central LHIN of the joint intent. A business case

for integration will be required for submission to Toronto Central LHIN.

Note: The list of Due Diligence items in the chart below was compiled for more comprehensive

integration situations between partners. Many of these items are not relevant for integrations

that are more focused on collaborations only.




Due Diligence Tool Category

Type of Assessment to be Completed

0 = Assessment on this item is not required 1 = Check if item is available, no further action required 2 = To be assessed, internal capacity and expertise is available 3 = To be assessed, internal capacity and expertise is not available

Due Diligence Findings

Strategic Alignment

Mission, Vision, Values

Strategic Plan

Operating Plan Programs and services

Overview of programs and services

Delivery strategy

Locations

Client/patients base and volume and activity trends

Client/patients satisfaction Policies and procedures (including regulatory

compliance)

Material contracts and suppliers

Funding arrangements and budget

Major projects underway








Finance and Funding

Finance

Any evidence of indebtedness

Lines of Credit or securities

Other financial arrangements

Any financial obligations, liabilities, agreements, or guarantees

Funding agreements

Correspondence: with lenders, compliance/non-compliance

Cash flow projections

Organization, programs, services finances

General Ledger Detail

Banking Arrangements (e.g. loan facilities, deposit accounts)

Financial and Tax

Financial statements (audited and unaudited), including balance sheets,








income statements and statements of change in financial position and valuation/appointed actuary reports

Tax returns

Any MOHLTC or LHIN operational reviews

List of all taxes, duties or charges unpaid

Copies of all letters and reports regarding significant accounting issues or tax disputes

List of fixed assets with depreciation schedules

Finance and System Control

Key financial systems and related controls

Review internal and external audit reports

Finance Material Contracts & Suppliers

Accounting Policies & Procedures

Real Property, Leases & Contracts

Commitments for fixed asset additions








Property and lease contracts, and related such as mortgages

Any risks related to property and/or leases Assets and Equipment

Inventory list for the organization

Equipment leases and contracts

Trust & Gift Donation Information

Donation Policy

Any risks to donor support Miscellaneous

Pro-forma financial position and projections

Generalized risk assessment and enterprise risk management documentation

Insurance coverage, policies and claims

Audit Reports Legal

Governance








Corporate and management organizational

chart, and list of current officers, directors, and members of the organization

Board Governance policies and Board Minutes

Review of a list of strategic alliances, partnerships

Copies of Letter Patent, Special Act status, Supplementary Letters Patent, Articles of Continuance or equivalent documents of the organization with all amendments to date

Copies of the By-laws of the organization with all amendments to date

Agreements between the organization and any directors, officers, employees or members

Legal Entity Structure (including subsidiaries)

Articles of Incorporation & Bylaws Legal Matters

Legal Counsel (internal & external)








Active, pending or threatened material claims, actions, investigations, arbitrations or other proceeding

Compliance certificate, manuals and procedure manuals

Orders, rulings, judgments or decrees of all courts, administrative agencies or tribunals and all settlement agreements or other agreements requiring or prohibiting any present or future activities, imposing any continuing obligations or restrictions on the organization or otherwise materially and adversely affecting the business practices, operations or condition of the organization or any of its assets or property

Review criminal action involving the organization or employee related to the area of integration

Copies of all past and present privacy policies related to the collection, use and disclosure of personal information

Summaries of all past and present cases of non-compliance or alleged non-compliance








with any material statutes, orders, rules or regulations relating to the assets or business

Outstanding privacy complaints against the organization

Copies of all documents which involve any constraints on a change in control or change of corporate structure or ramifications upon a change in ownership

Information as to any actual or potential contingent liabilities which would not be included in any of the above

Miscellaneous

Required licenses, permits, registrations and authorizations and approvals relating to the organization or its authority to perform its operations

List of trademarks, patent, registered copy rights and trade secrets

Human Resources

Employees, Systems, and Policies

HR Systems (e.g. payroll)

HR Policies and Procedures








Employee Satisfaction & Performance

List of employees

Compensation and Benefits Copies of agreements with employees,

former employees, independent contractors and dependent contractors

Pension plan structure, funding obligations, employee benefits not covered by benefit plans

HR Material Contracts & Suppliers

Collective and Employment related agreements

Collective bargaining agreements and letters of understanding

Status of negotiations and any outstanding grievances

Summary of unfair labour practice complaints, and related activities

List of any temporary employment or staffing agencies

Occupational Health








Health and safety record, policies, reports, complaints, claims, and concerns

Employment attestation that the organization is in compliance with all legally mandated training and safety requirements

Infrastructure

Environmental Matters

Overview of Owned & Leased Premises

Value & Liens (Owned Premises)

Physical Condition

Space Utilization

Occupancy Costs

Major Projects Underway

Building Services Staff

Material Contracts & Suppliers (e.g. leases, mortgages, maintenance, security)

Policies & Procedures








Health, Safety & Environmental Risks

Government notices, orders, enquiries, material correspondence or third party complaints concerning environmental matters

Internal reports on environmental matters that have been prepared for, or presented to management

Review building machinery and equipment

Search at local governmental authorities to confirm there are no outstanding infractions, municipal work orders or open permits

Historical and future capital expenditure requirements

Significant contracts for the purchase of materials, supplies or equipment

Information Management

Systems and applications architecture, including profiles

Hardware

Information security








Business recovery plan

Budget and forecast


Material contracts and suppliers

Policies and procedures

Services provided by any third-party service providers including all information system license, lease and maintenance contracts

Web site(s), location of the server(s) hosting the Internet web site(s), related agreements

License agreements displayed on the Internet web site(s) and list of all legal disclaimers on the Internet web site(s)

Marketing, communication, and fund development

Community relations & advocacy strategy and priorities

Community relations & advocacy staff, policies and procedures, and major projects

Foundation structure and financial position (if applicable)








Fund development strategy and plan

Fund development results and forecast


Donor base

Policies and procedures




2.5 Integration Implementation Considerations

After the decision to pursue integration has been made, careful and thoughtful planning is

essential to ensure a successful integration implementation. Although each integration is unique

and will require its own individual implementation plan, a few common factors are more likely to

result in success if applied well, no matter what type of integration is being implemented:

1. Committed Leadership and Board

2. Communication and Engagement

3. Change Management

4. Dedicated Resources

The following sections provide some discussion and considerations for each of these topics.

Additional information and templates to support implementation efforts can be obtained through

the 2012 WoodGreen Integration Toolkit, From Strategy to Implementation: An integration toolkit

for community-based health service providers,1 which can be accessed here:

https://dl.dropboxusercontent.com/u/86669743/From%20Strategy%20to%20Implementation%

20%20An%20integration%20toolkit%20for%20community%20based%20health%20service%20p

roviders.pdf.

2.5.1 Committed Leadership and Board

A very common theme drawn from integration experiences has been the importance of

committed leaders and Board members, who share a common vision for the integration and who

are optimistic about what it can achieve. Some stakeholders refined this further, to suggest that

the CEO, Executive Directors and Board Chairs are the most essential drivers of integrations,

because without the full commitment of any of these individuals, the integration would likely fail.

Also to be acknowledged, is the unwavering commitment the senior leadership needs to make to

the integration, as staff anxieties might be high and there is a significant amount of time, effort

and energy needed to successfully move through barriers and potential doubt of others. Many

leaders across the LHIN are inexperienced in integration and the complexity of the processes, and

will require both internal and external support to confidently lead integrative change.

Implementation Tip: Involve the Leaders and Boards in all integration discussions that contribute

to visioning, so that they may champion the message and encourage it among other stakeholders.

Make sure that they are part of “making the case” for integration, and buy-in to the rationale.

1 (WoodGreen, 2012)

https://dl.dropboxusercontent.com/u/86669743/From%20Strategy%20to%20Implementation%20%20An%20integration%20toolkit%20for%20community%20based%20health%20service%20providers.pdf






2.5.2 Communication and Engagement

It is commonly agreed upon that communication is an essential tool that will lead to success or

failure of integrative efforts. Communication should be used strategically.

In the exploratory and feasibility stages, open communication is not appropriate at all times.

Discussions should remain with a select audience, including the Toronto Central LHIN CEO, until

the intention to move forward is confirmed, or at least highly likely. At this point, staff, volunteers,

community partners, clients/patients, and other relevant stakeholders should be engaged to

inform planning and implementation in direct ways.

Once the intent to integrate is made public, it is the responsibility of both the LHIN and the

partners to engage with the broader community, including patients, clients and families, to ensure

that the intended integration plan will achieve outcomes aligned with what the community needs

and that it will demonstrate the right kind of value.

The LHIN’s involvement in any integration can cause anxiety amongst providers, especially those

who do not understand the potential for a supportive relationship. The LHIN should consider this

as it has conversations with providers and as opportunities are realized.

Implementation Tip: Leaders and Board members of HSP and senior leaders of the LHIN are

encouraged to speak openly and transparently about their intentions as they apply integration

and system transformation efforts, and continue to engage all communities in integration

discussions.

2.5.3 Change Management

Following change management processes from the inception of the idea of integration, right

through to implementation, is a critical component to any integration. This includes consistent

and targeted communications, openness and transparency. Stakeholders have discussed that a

change management strategy can never be implemented too early in an integration, and should

continue long after implementation efforts have stopped.

Change management literature is often based on the practices of John Kotter, and his 8 steps for

managing change. The following graphic has been adapted from his work:2

2 (Kotter, 2014)




Implementation Tip: Apply Kotter’s 8-Step process for managing change early in integration

discussions; understand and communicate why the integration should happen, build commitment

around a vision, move forward with quick wins and sustain successes.

2.5.4 Dedicated Resources

Integration cannot be done well off the side of one’s desk. Using dedicated resources to support

integrations are key to planning, implementing and managing efforts to a successful new model,

no matter what the size and scope of the change. Resources that are often leveraged include a

dedicated project manager, the use of defined working groups and functional groups, and the use

of third-party, unbiased facilitators. Financial support and subject matter expertise, internal to

the LHIN or external, are available to support integration exploration, assessment of feasibility, as

well as planning and implementation activities.

LHINs across the province provide varied levels of resources and support depending on their

integration philosophies and the types of integrations in front of them. See Recommendation X

for a guide as to how the Toronto Central LHIN is able to provide support.

Implementation Tip: Speak with the LHIN early in integration discussions to get supports that

might be needed, and to check alignment with local priorities. This can reduce challenges later in

the process.




3. Appendix 3: Implementation Plan Details for Recommendations

Implementation Plan details have been developed to complement the recommendations

presented in the main document. The following chart depicts the overall proposed timelines to

implement the set of recommendations.

The table below outlines the implementation steps in more detail, for each of the

recommendations.




Create a Culture of Integration and Change

Recommendation Implementation Step Timeline

Recommendation 1: Create a shared understanding across the Toronto Central LHIN that integration means a spectrum of activities – not only organizational mergers – to create desired change, including partnerships, collaborations, transfers and consolidations of programs, services, and back office administrative functions within and across sectors.

1.1 LHIN should agree internally on a common definition of integration, and the associated activities.

Q1 16/17

1.2 LHIN should add “integration” to the agenda for all major meetings and forums, external and internal, to discuss progressions

Q2 16/17

1.3 LHIN should develop a communications schedule that includes announcements of integrations at regular intervals (ie. Through news blasts, communiques, presentations, etc.), and opportunities for stakeholders to have open dialogue on the topic.

Q2 16/17

Drive Effective System Performance

Recommendation 2: The Toronto Central LHIN should establish Sub-LHIN Region Integration Tables tasked with system planning, and identifying, prioritizing, and coordinating integrations that will create better client/patient outcomes and experiences, especially in community mental health and addictions, home and

2.1 Using the Sub-LHIN geographies, the LHIN should identify partners who are operating in the same Sub-LHIN region, and facilitate them to form an Integration Table; leverage SAAs to encourage participation

Q2 16/17

2.2 LHIN should support each Table to define its terms of reference and create a memorandum of understanding to formalize their work together; this might include roles and accountabilities, the identification of a Table Lead, guiding principles, requirements for knowledge and information sharing and performance expectations

Q3 16/17

2.3 Provide any necessary facilitation support to ensure that Tables are meeting at least on a quarterly basis to work towards the objectives in their terms of reference

Q3 16/17 ongoing




community care, and primary care services and programs, consistent with existing Service Accountability Agreements, the Toronto Central LHIN’s agreement with the Ministry of Health and Long-term Care, and the Toronto Central LHIN’s Strategic Plan priorities.

2.4 In the future, Tables may form sub-committees to address specific challenges related to care delivery, ie. Developing a common IM/IT strategy, consolidating local intake and waitlist, etc.

Q1 17/18

Recommendation 3: The Toronto Central LHIN should drive system change by identifying, encouraging, and if needed, facilitating and supporting integrations that will have a measureable positive impact on the health of the population in Toronto Central LHIN and beyond, consistent with existing Service Accountability Agreements, the Toronto Central LHIN’s agreement with the Ministry of Health and Long-term Care, and the Toronto Central LHIN’s Strategic Plan priorities.

3.1 Using data and the output of engagement activities (this Project and Patients First consultations), prioritize the sectors or neighbourhoods that require the most change to improve outcomes; data suggests that four of the five Sub-LHINs have high rates of service utilization that could be addressed (except North)

Q3 16/17

3.2 Develop focused action plans in collaboration with local providers to address challenges

Q4 16/17

3.3 Implement the local action plans and evaluate results. Q1 17/18

Build Capacity and Success for HSPs

Recommendation 4: To build the viability and effectiveness of

4.1 LHIN should work with partners to improve the reliability and validity of the HSP360 system, so that its data can be used in decision-making

Q3 16/17




health service providers, the Toronto Central LHIN should actively work with those HSPs which are struggling to meet performance targets to identify and act upon strategic options that may include a range of integration solutions.

4.2 LHIN should analyze the reporting of individual organizations to determine if there are performance issues that can be mitigated, or if integration should be suggested, and facilitate accordingly

Q1 17/18

Recommendation 5: The Toronto Central LHIN should facilitate inter-HSP conversations at the HSP governance level about the benefits and realities of integration to create Toronto Central LHIN-wide momentum for Voluntary Integration strategies.

5.1 LHIN should host regional Governance-to-Governance meetings quarterly with integration as a standing topic. Forums should allow for providers to promote and discuss integrations across the spectrum that are underway or complete

Q2 16/17

5.2 Create opportunities in the forums for the groups to strategize together on how to achieve system-level goals through integration, supporting them to identify potential opportunities for themselves, along the spectrum

Q2 16/17

5.3 Evaluate the effectiveness of the forums in driving voluntary integration Q1 17/18

Sustain and Build on the Success of Voluntary Integrations

Recommendation 6: The Toronto Central LHIN should create and maintain an integration knowledge centre to share the successes and challenges of integration and to support those exploring, assessing, planning and implementing integrations in Toronto Central LHIN.

6.1 LHIN should work with providers to develop the requirements of an integration knowledge centre, to understand what it should include, what level of detail, who should have access, how it should be accessed, etc.

Q4 16/17

6.2 LHIN should build and house the integration knowledge centre to specifications and assign a role to maintain it on an ongoing basis

Q4 16/17

6.3 LHIN should communicate that the resource is available, and make it part of the conversation, where providers should go to gain valuable information that can help them in their own integrations

Q2 17/18

6.4 Consider opportunities to grow the centre to include integration details from other LHINs, and the implementation considerations for doing so

Q2 17/18




Recommendation 7: The Toronto Central LHIN should widely launch the Integration Toolkit to enable Health Service Providers to explore, assess and plan for Voluntary Integrations.

7.1 LHIN should review and validate the contents of the Integration Toolkit Q1 16/17

7.2 LHIN should use the Toolkit as a key discussion point in all meetings and opportunities where it could be helpful, including the Sub-LHIN Integration Tables, Governance-to-Governance forums, and other meetings related to system or provider performance

Q2 16/17

7.3 LHIN should evaluate the impact and relevance of the Toolkit’s content on a regular basis, and make any required updates

Q2 16/17 ongoing




4. Appendix 4: Detailed Summaries of Research

4.1 Defining “Integration” in the Toronto Central LHIN

Integration does not just mean “merger.” The Integration Review Project has considered the

term “integration” to represent a wide variety of collaborative activities – everything from the

“business as usual” types of partnerships and collaborations, to program and service level

transfers, to regional coordination, through to mergers. The emphasis of the Project’s work is on

the mid-range of activities, when they make sense, and when they will advance the Toronto

Central LHIN’s Strategic Goals of a “Healthier Toronto,” “Positive Patient Experiences,” and

“System Sustainability.” The Strategic Plan is summarized in the following image:3

3 (Toronto Central LHIN, 2014)




The strategic framework was used as a foundation for the development of the Integration Toolkit

and Recommendations, to support discussions on when and how programs and services might

integrate “to transform the system to achieve better health outcomes for people now and in the

future.”

The tools and content that are provided in the Toolkit are directly aligned with the Goals listed in

the Strategic Plan. When using these tools to make decisions, the user will be supported to think

about topics and ideas that are relevant within the local context and direction. Specific criteria

that should be considered when looking at integration as a strategic option were developed.

Program/service integration should be an option when the following are possible:

Same or improved client/patient outcomes and experiences

Strengthened transitions along the continuum of care and smoother care pathways

Same or improved access to care

Improved sustainability and program/service stability

Same or improved “value for money”

Same or improved health of the community overall, including factors beyond “health”

4.1.1 Integration Framework: Not just Mergers, but a Spectrum of Activities

Integration refers to a variety of activities that involve people, programs and services working

together in new ways towards a common vision. The Integration Review Project has focused

attention on integration activities that fall within the middle of the spectrum indicated below, as

it is expected that these activities have the highest potential to create system-level change in the

near future.




While integrations are multidimensional and highly complex, dividing the concept into more basic

components can help with understanding the various ideas at play. Kodner identifies 5 dimensions

of integration to consider: foci, types, levels, degree, and breadth, which are included in the

schematic above.4 Each of these dimensions are relevant regardless of the integration situation

and context, and can be further described by the following:

1. Foci: Looking at integrations from a population perspective can give a sense of what

groups in a community will benefit from it. For example, the goal can be vulnerable

groups such as persons with disabilities or populations with chronic complex illnesses

such as seniors. Nevertheless, an integration can have an impact on the entire

community.

2. Types: Different types of integrations focus efforts on coordination of back office and

support functions only, or may define relationships at all levels of the organizations.

Organizations can also have professional relationships or integrated clinical services for

coordinated delivery with aligned processes. The focus can also be on culture and values,

alignment of organizational policies and incentives or both.

3. Levels: Integrations happen at different levels of an organization including funding (e.g,

pooling of funds), administration (e.g., joint procurement), organization (e.g., common

ownership), service delivery (e.g., integrated information systems) or clinical practice

(e.g., standard diagnostic criteria).

4 (Dennis Kodner, 2009)




4. Breadth: The breadth of the integration can range from similar organizations such as two

community health centres to a combination of different organizations what bring

together different services, such as a home care agency and a long-term care facility.

5. Degree: Finally, there are different degrees of integrations that involve linkages and

collaborations or a more structured coordinated approach with defined process,

responsibilities and funding. A full integration entitles a consolidation of funding,

responsibilities and resources to deliver services across the entire continuum of care.

4.1.2 Defining Integration: A Complex Task

From the legislative perspective, integration involves a range of activities, from service

coordination, partnering and transferring services to ceasing operations. It can also refer to

strategic transactions such as amalgamations. The concept of integration, however, does not have

a single universally accepted definition.

Within the context of health care, integration definitions often involve terms or concepts related

to continuity of care, expanded scope to include social services (e.g. housing and meals), the need

to be cost-effective, to address complex health needs, and to focus on population-based care.5

People who hear the word “integration” often have different understandings of its meaning

depending on the context and their role. Depending on one’s perspective, values and desired

outcomes of integration can be quite different, as can be seen in the following table:

Table 1: Views of Integrated Care by Stakeholder6

Clients/patients Providers Managers Policymakers

Seamless care

Easy access and navigation

Interdisciplinary team work

Coordination of services

Services across institutional boundaries

Combined funding streams

5 (Armitage, Suter, Oelke, & Adair, 2009) 6 (Dennis Kodner, 2009)




Clients/patients Providers Managers Policymakers

Aligned performance targets

Interprofessional teams

Inter-agency relationships

Shared culture

Regulations facilitating integration

Funding arrangements

World Health Organization Perspective on Integrated Health Services

The World Health Organization (WHO) understands integrated health services within the context

of “the organization and management of health services so that people get the care they need,

when they need it, in ways that are user-friendly, achieve the desired results and provide value

for money.”7 This is consistent with Ontario’s focus on “working with providers across the care

continuum to improve access to high-quality and consistent care, and to make the system easier

to navigate – for all Ontarians.”8

The WHO identified that a common definition used is “The management and delivery of health

services so that clients/patients receive a continuum of preventive and curative services,

according to their needs over time and across different levels of the health system.”

This definition can refer to a group of services that can be organized and delivered together to

ensure appropriate care and patient experience throughout the continuum. For example, an

integrated program for Diabetes Type 2 can be a “one-stop shop” for all interventions required to

control diabetes and prevent complications. It can be done through a decentralized model, where

multiple locations work together or it can be centralized under the same roof, focusing on

coordination and efficiency. Integration across the continuum may also include arrangements of

services that address needs of clients/patients at different stages of their life-cycle, for example

for chronic conditions such as HIV/AIDS.

The WHO definition can also refer to a network of facilities providing coordinated and

complementary health services, managed by a single person or Leadership Team that is able to

have a strategic perspective of what services are needed and when (e.g., a project manager for

Health Links in Ontario), focusing on appropriate and timely referrals and coordinated care.

7 (World Health Organization, 2008) 8 (Ontario Ministry of Health and Long-Term Care, 2015)




Under the same definition, integration can also be a set of policies and directives that enable the

organization of services in a way that coordination and service gaps can be addressed, including

governance structure, roles, responsibilities and accountabilities. An example is Patients First: A

Proposal to Strengthen Patient-Centred Health Care in Ontario, which emphasizes coordination

and connection to increase access to care.

The commonality between the different arrangements above is that integration denotes working

across sectors to coordinate health services and/or other determinants of health (e.g., social

services) with mechanisms in place to enable cross-sectoral funding, regulation and management

of service delivery. The key is to identify the most appropriate sector/s and mechanisms by which

healthcare services will be delivered and which linkages between organizations are needed.

Types of Integrations

Alberta Health Services conducted a literature review in 2007 to understand the definitions,

processes and impact of health systems integration.9 The authors identified a lack of universal

definition which made the search less specific. Working with the definition provided by The

Canadian Council on Health Services Accreditation in 2006, they saw integration as “services,

providers, and organizations from across the continuum working together so that services are

complementary, coordinated, in a seamless unified system, with continuity for the client.”10 This

statement summarizes the common elements from previous definitions about what an

integration aims to accomplish, and leaves opportunity to select one of the many mechanisms by

which integrations can be accomplished:

Virtual integration involves contractual relations with no common ownership by which a network of organizations work towards the common goal of providing health care to a given population.

Vertical integration involves affiliations between organizations, sharing a common governance structure, financial and clinical responsibilities as well as human and physical resources.

Horizontal integration involves collaborations between health care providers of the same level of service, but from different organizations.

Functional integration involves shared corporate services such as finance, administration, human resources and information management.

Clinical integration involves organizing clinical activities with focus on integration of patient records systems, service delivery processes and best practice guidelines.

9 (Suter et al., 2007) 10 Ibid.




Toronto Central LHIN Definition of Integration

The Toronto Central LHIN has also identified a working definition of integration. Legally,

integration is defined by the Local Health System Integration Act, 2006 (LHSIA) as a spectrum,

including:11

a) Coordinated services and interactions between different persons and entities,

b) Partnerships between persons or entities in providing services or in operating,

c) Transfer, merge or amalgamation of services, operations, persons or entities,

d) Start or cease providing services,

e) Cease to operate or to dissolve or wind up the operations of a person or entity.

Informally, “integration of services consists of effective communication and collaboration

between health services to create a cohesive system for the patient.”12

Without common terminology it can be a challenge to conceptualize what the literature says

about integration. However, the current working definition within the Toronto Central LHIN is

well aligned with Ontario's context and can be used to define the activities and mechanisms for

integration, keeping in mind common system goals regarding quality and efficiency. While all

forms of integration may be useful for achieving a set of outcomes, this preliminary research

focuses on integrated delivery systems.

4.1.3 Outcomes of Integration

The outcomes that can be expected from integrations of all types and levels are neither consistent

nor widely proven in the literature. “Very few studies reported on the impact of integration and

tended to focus on perceived benefits rather than empirically derived outcomes.”13 Preparation

for integration and the process by which it is done may be just as important as the type or area of

integration. This can be seen in writings related to integration success factors, which are outlined

in the following section of this document, and the importance of due diligence and the post-

implementation process is also supported by business literature.14

The following table summarizes integration outcomes based on two literature reviews: “Health

systems integration: state of the evidence” from the International Journal of Integrated Care,15

and “Getting to Integration: Command and Control or Emergent Process” from The Innovation

11 (Ontario Government, 2016) 12 (Toronto Central LHIN, 2014) 13 (Armitage et al., 2009) p. 5 14 (Alex, Lajoux, & Weston, n.d.) 15 (Armitage et al., 2009)




Journal.16 A represents improvement, a represents no evidence of improvement, and a ?

represents limited or unclear outcomes.

Table 2: Summary of Reported Integration Outcomes

Study Health systems integration: state of the evidence

Getting to Integration: Command and Control or Emergent Process

Financial Improvement

US organized delivery systems: better financial performance ()

UK community health care trusts: reduced cost per patient ()

US community hospitals: integration does not immediately improve financial performance ()

Short-term acute care hospitals: positive effect on financial success ()

Integrated multidisciplinary community-based care: less cost ()

Cost of integrated hospital systems vs hospital non-systems: no cost benefit ()

Organization Improvement

Integrated health and social care organizations: improved job satisfaction, teamwork, communication ()

UK community health care trusts: workload and staffing problems ()

Service Improvement

Hospital utilization: reduced ALOS () Toronto Health Networks: improved access ()

Organizational change literature: limited evidence of improved clinical care (?)

Clinical Outcomes

Regional health authorities: Limited

effect (?) Integration of Mental Health and

Addictions: program level evidence of improvement (); limited system level integration improvement (?)

While the above table focuses on desired outcomes, there is also the potential for negative

outcomes related to decreased staff and client/patients satisfaction, “decreased flexibility to

anticipate or accommodate important environmental changes,” and the risk that “some patients

may be marginalized or excluded through the standardization of services.”17

16 (Lurie, 2009) 17 (Lurie, 2009) p. 7 & 18




4.1.4 Integration Success Factors

Several articles identified in the Literature Scan outlined factors seen to impact the success of

integrations based on reviews of other literature or the author’s experiences with integration.

In the article, Ten Key Principles for Successful Integration, which is based on a systematic review

of health systems integration literature, ten principles are identified for successful integration.

These principles are seen to be “independent of type of integration model, healthcare context or

patient population served.”18 The 10 principles are:

Table 3: Ten Key Principles for Successful Health Systems Integration19

# Principle Further description

1 Comprehensive services across the care

continuum

Cooperation between health and social care organizations Access to care continuum with multiple points of access Emphasis on wellness, health promotion and primary care

2 Client/patient focus Client/Patient-centred philosophy; focusing on clients’/patients’

needs Client/patient engagement and participation Population-based needs assessment; focus on defined population

3 Geographic coverage and rostering

Maximize client/patient accessibility and minimize duplication of services

Roster: responsibility for identified population; right of client/patient to choose and exit

4 Standardized care delivery through

interprofessional teams

Interprofessional teams across the continuum of care Provider-developed, evidence-based care guidelines and protocols

to enforce one standard of care, regardless of where clients/patients are treated

5 Performance management

Committed to quality of services, evaluation and continuous care improvement

Diagnosis, treatment and care interventions linked to clinical outcomes

6 Information systems State of the art information systems to collect, track and report

activities Efficient information systems that enhance communication and

information flow across the continuum of care

7 Organizational culture and leadership

Organizational support with demonstration of commitment Leaders with vision who are able to instill a strong, cohesive culture

18 (Esther Suter, 2009) 19 (Esther Suter, 2009)




# Principle Further description

8 Physician integration Physicians are the gateway to integrated healthcare delivery

systems Pivotal in the creation and maintenance of the single-point-of-

entry or universal electronic patient record Engage physicians in leading role, participation on Board to

promote buy-in

9 Governance structure Strong, focused, diverse governance represented by a

comprehensive membership from all stakeholder groups Organizational structure that promotes coordination across

settings and levels of care

10 Financial management Aligning service funding to ensure equitable funding distribution

for different services or levels of services Funding mechanisms must promote interprofessional teamwork

and health promotion Sufficient funding to ensure adequate resources for sustainable

change

While these principles appear to be focused on clinical services, although “social care” is

mentioned, it may be possible to apply the lessons to all sectors of the Toronto Central LHIN

system.

Another article, Making Integration Work Requires More than Goodwill, also highlights the

importance of governance, and in this case, learnings about governance from projects that

integrate across organizational, geographic, and provider boundaries.20 As in Ten Key Principles

for Successful Health Systems Integration, the importance of representation from all stakeholder

groups was stated. Additionally, the author highlighted the importance of governance related to

decision-making, seeing “the bigger picture,” and leadership.

Decision-making: Integrated decision-making at the governance level was required. As

the author describes, “what became evident was that without a clearly defined

infrastructure and decision-making process, decisions progressed through each

partnering organization’s process, adding to the complexity and time required. Questions

and problems would recycle through unclear processes, slowing decision-making and

delaying project progress and deliverables.”21

Seeing “the bigger picture”: Board members needed to see the “big picture” and “not

only… represent their constituency.”22 Focusing on clients and patients of the system

became a rallying point around which Board members from different organizations could

align.

20 (Linda Smyth, 2009) 21 (Linda Smyth, 2009) p. 44 22 (Linda Smyth, 2009) p. 44




Leadership: Leadership was another governance attribute that was seen as a learning

about what creates successful integration. “Boards need to make decisions that will force

the organization to stretch beyond its perceived capacity. This is very relevant to

integration. Our projects required stakeholders to move beyond past history and

experience, and step outside the silos and away from the protection of familiar turf,

organizations, professions or jurisdictions.”23

Another article, however, cautioned against “command and control” type governance for degrees

of integration that do not include mergers, and stated the need for building trust and collaborative

relationships in networks, since success “depends on the willing commitment of many

independent parties.”24

The article, A Truly Integrated Health Care System, cautioned that even health care organizations

that deliver care across the continuum under one organization name, may not be actually

operating in an integrated manner.25 “Consider key functions and determine whether they should

be centralized, or at least standardized, for geographies and entities. While many traditional

functions — finance, human resources, marketing, information technology, purchasing — already

may be centralized into system functions, others may be proliferating around the system in

different silos. Care management, physician recruitment, risk management, patient safety, and

staff education and training are just a few functions that can benefit from integration within the

system, and they are often not coordinated effectively.”26

Again the importance of leadership, governance, communication, and performance

measurement were noted as factors enabling successful integration. Additionally, this author took

a more operational view, and spoke of the importance of ensuring action plans and

accountabilities of each business unit are articulated and the link to overall vision and goals made

clear.

4.1.5 Measures of Integration

A number of instruments have been developed to measure integrated health care delivery,

however, there is “no unified or commonly agreed-upon measurement instrument,” but rather a

“diversity of approaches to measure integration across health-care sectors.”27 A systematic

review in 2014 found 23 measurement tools that met the review’s criteria, and included

23 (Linda Smyth, 2009) p. 45 24 (Lurie, 2009) 25 (Jacobs, 2015) 26 (Jacobs, 2015) 27 (Lyngsø, Godtfredsen, Høst, & Frølich, 2014) p. 4




organizational elements.28 Methods/tools for information collection found in the review included

“questionnaire survey data, inpatient data/clinical files analysis and different qualitative methods

such as interviews, observations and workshops.”29 This systematic review identified 9

organizational elements that categorize the metrics the integration instruments measured as

evidence of integration, with most instruments only including 3-4 elements, including:30

IT/information transfer/communication and access to data

Organizational culture and leadership

Commitments and incentives to deliver integrated care

Clinical care (teams, case management, clinical guidelines and protocols)

Education

Financial incentives

Quality improvement/performance

Measurement

Patient focus

(Note: bolded bullets indicate the top 3 most common elements within the tools reviewed)

While this systematic review identified organizational elements, there was no evidence provided

as how to weight each of the elements during measurement.

4.1.6 LHSIA and Other Considerations

LHINs are granted their authority through the Local Health System Integration Act, 2006 (LHSIA),

which also includes requirements related to integration activities.

According to LHSIA, activities that are defined as an act to integrate include:31

to co-ordinate services and interactions between different persons and entities,

to partner with another person or entity in providing services or in operating,

to transfer, merge or amalgamate services, operations, persons or entities,

to start or cease providing services,

to cease to operate or to dissolve or wind up the operations of a person or entity

There are several mechanisms, as outlined in LHSIA, through which integration is allowed to

happen. These integration mechanisms are:

Voluntary (HSP initiated)

Facilitated or Negotiated

Required

28 (Lyngsø et al., 2014) 29 (Lyngsø et al., 2014) p. 4 30 (Lyngsø et al., 2014) 31 (Ontario Government, 2016)




Funding

The following chart is derived from the Local Health Services integration Act, 2006 (LHSIA) and

identifies which types of integration applies to specific integration activities.32

Table 4: LHSIA Integration Types and Activities

Additional information about integrations and the integration process within the Toronto Central

LHIN can be found at: http://www.torontocentrallhin.on.ca/en/forhsps/intergration.aspx

The full LHSIA legislation can be found at: https://www.ontario.ca/laws/statute/06l04

Further information about LHSIA, including regulations and amendments, can be found on the

MOHLTC’s website, at: http://www.health.gov.on.ca/en/common/legislation/lhins/default.aspx

32 (Central East Local Health Integration Network (LHIN), 2010)

http://www.torontocentrallhin.on.ca/en/forhsps/intergration.aspx

https://www.ontario.ca/laws/statute/06l04

http://www.health.gov.on.ca/en/common/legislation/lhins/default.aspx




4.2 Summary of Engagement Findings: Clients, Patients, and Providers

4.2.1 Toronto Central LHIN Engagement: Interview Findings

Over 70 interviews, including between 1-3 participants per interview, had been completed with

health service providers across the Toronto Central LHIN. Themes that have been established

include the following:

Overarching Findings

1. Use of Defined Criteria and Due Diligence

Stakeholders agree that the potential for integration should be evaluated based on a set of criteria

relating to successful integrations, and against a set of guiding principles related to the “big

picture”. Will the integration, most importantly, improve health outcomes and client/patient

experience? Will it decrease system spending? Upon identification of high potential integration

opportunities, in-depth due diligence processes should occur to validate any assumptions.

Engagement Findings: Clients/Patients and Population

2. Focus on Outcomes, Quality and Experience

Parties undergoing an integration often think about how the integration will impact the

client/patient’s overall health, outcomes and experience. Decisions are often made around

improving the experience, outcome and quality of care for the client/patient.

3. Access to Care

Access to service is particularly important for a complex and diverse geography like the Toronto

Central LHIN, which has pockets of high-needs populations with varied needs all over the City.

Services often reside in historical locations that may or may not be where the services are needed

most today. Access to the right services, at the right time and in the right place is a local and

provincial focus and integrations are commonly seen as a way to improve access to services in

different neighbourhoods to support these directions.

4. Better Transitions

Across the Toronto Central LHIN, parties are integrating to create better transitions for

clients/patients across the continuum of care. There is a particular focus on integrating services

between the community and primary care to ensure clients/patients move seamlessly through

the system. Within these integrations, parties are looking for technology enabled solutions to

keep them connected, and to share information appropriately and effectively.




5. Social Determinants of Health and Underserved Communities

With the diversity of people living across the Toronto Central LHIN, stakeholders have reported

that it is important to address the needs of at-risk populations in new and innovative ways, by

bringing organizations and programs together that can address the person as a whole. There is a

focus on wrapping services such as housing, transportation, and other community services around

the individual.

6. Relevance

The diverse cultural needs of the Toronto Central LHIN have evolved over time, services that were

relevant 20 years ago, may not be relevant today. There may be opportunities for parties to

revitalize services and/or programming through integrative efforts to better meet the needs of

the today’s population.

Engagement Findings: Organization-level

7. Alignment at Strategic Level

Parties who have relatable and aligned Vision, Mission, and Values statements, as well as

underlying philosophies of care, are reported to be much more successful in the long term, no

matter what type of integration has occurred. The vision ensure the parties are headed in the

same direction today and into the future. The mission or mandate ensures there is alignment in

what the entity is focused on achieving and how it plans to achieve it. Values ensure the expected

behaviors of staff are similar and that from a cultural perspective individuals will be like minded

and work well together.

8. Alignment of Governance

Readiness of the Board is essential to integration success. Involving Board leadership in visioning,

planning, and other integration activities heightens the buy-in of these individuals, who can then

positively drive momentum throughout the organization. The Board plays an important role in

helping parties assess impacts and risks associated with the integration, and offer a strategic

perspective that brings in concepts of fiduciary accountability, liabilities, and broad risk, especially

related to organizational reputation. In larger scale integrations, conversations within and

between Boards should happen early in the process and communication should be maintained

throughout. As the organization moves forward with an integration process, it should also think

about what the future governance structure and operations will look like to ensure there is a

common future vision.

When integrative efforts are smaller, they are not anticipated to structurally change the

organization or governance structure, or do not bring any additional risk or funding needs, as in




the case of a strategic partnership or service level transfer. The Board may sometimes choose to

be removed from the process.

9. Strong and Committed Leadership

Integration is an intimidating endeavor, especially for those who do not understand the process

or impacts. Having a leader in place who provides consistent, transparent, open, and clear

messaging is cited as a key factor in mitigating uncertainty and supporting transitions. In addition,

it is important to have commitment and trust built between the leaders of the two parties

undergoing an integration. To ensure success the leaders of the organization need to be

committed to working together towards a common future vision, and communicate this vision

consistently and regularly.

10. Alignment of Organizational Culture

Cultural differences between integrating parties is often cited as one of the main reasons that

integrations fail. Ensuring that cultures are aligned, or can be appropriately aligned, is an indicator

of long-term success.

11. Infrastructure and Supports

Integrations can often lead to enhanced business operations and efficiencies. Smaller and less

sophisticated organizations can lack adequate business processes and resources needed to

support yearly reporting and operations. If a small party integrates with a larger party, the smaller

party can gain additional back office supports. If two well established parties come together with

sufficient infrastructure already in place, back offices can be merged and additional resources can

be used to support other needs within the organization, service or program. Although,

integrations don’t always save money, they can enhance the operations and create capacity to

support other needs within the organization, service or program, and allow leaders to focus on

service delivery rather than administration.

12. Performance and Sustainability

Sustainability is one of the top reasons that parties integrate. Current fiscal pressures are forcing

organizations to do more with less while meeting more complex targets. It is increasingly difficult

for smaller organizations to exist with these additional pressures. As a result, more and more

entities are looking for integration opportunities with others, and are choosing their ideal partners

proactively.

13. Alignment of Service Delivery Model

Alignment of programs and services is often the first criteria that parties assess when considering

an integration. Alignment of services might mean the addition of new complementary services,




the enhancement of an existing service or the expansion of a current service to a new location.

The goal of aligning services is always to better serve the client/patient.

Engagement Findings: System

14. Local and Provincial Priorities

The concept of integration is one that is embedded and focused on in both local and provincial

strategies such as: the Toronto Central LHIN’s IHSP 4 and Strategic Plan, Patients First: Action Plan

for Health Care, and other applicable directives, such as Open Minds, Healthy Minds, and Living

Longer, Living Well. It is essential that all integrative efforts are aligned with these priorities, and

that they anticipate and are able to flex with future directives and trends, given that their intent

is usually to be a long-term arrangement. A common concept brought up by stakeholders was

they would align all strategic initiatives with the local and provincial priorities because funding

follows these directions.

15. Identification of Broad Integration Opportunities

When asked about particular sectors and populations within the Toronto Central LHIN that could

benefit from integrative efforts of various forms, those that were highlighted most frequently

include mental health and addictions, home and community support services, and primary care,

as well as wrap-around services related to social determinants of health. Discussions highlighted

many opportunities for all types of integrations, both vertical and horizontal, service level and

organizational.

4.2.2 Jurisdictional Review Findings

17 interviews had been completed with Ontario LHINs and other key informants external to the

Toronto Central LHIN, with additional interviews planned to be completed in the short-term.

While findings reinforce the themes identified in the Toronto Central LHIN interviews, this section

will focus on how other LHINs support integration. Themes for this section include:

Span of Integration

The definition of integration within the Local Health Services Integration Act, 2006 (LHSIA) is

significantly broad and interviewees indicated that LHINs needed to make a conscious decision as

to what they consider integration to be for the purposes of completing formal voluntary,

facilitated, or required integration processes.

Initiation of LHIN Involvement

HSPs who voluntarily engage, or are facilitated through integrative processes, are often facing

significant problems related to long term sustainability, such as continued or anticipated financial




deficits, not meeting targets required by funders, inability to hire and retain proper staff and

volunteers, service delivery challenges, or dwindling donations. When these situations are

identified, the HSP and/or LHIN have open conversations with management and the Board to

clearly define the problem and using data to support a more detailed understanding.

Some LHINs proactively approach HSPs they see as having challenges, while other LHINs look to

the HSPs to take the lead. All LHINs consistently report that voluntary integrations are preferred,

and that the LHIN should have the most minimal role possible. Completing the formal integration

processes for all types of integration activities, including coordination, was seen as extremely

burdensome from administrative and resource perspectives, and LHIN support is often required

in various ways to drive efforts forward.

Throughout integration processes, the LHIN’s involvement changes depending on the needs of

the integrating parties. For example, the LHIN may be providing no support, financial support,

project management and facilitation support, and/or full leadership. LHIN involvement can be

thought of as a spectrum.

Identifying the Integration Stream

An integration process may take either a voluntary, facilitated, or required integration stream,

depending on the specific context. Voluntary integrations were by far the preferred stream of

integration due to the increased levels of buy-in and thus, higher perceived chances of long term

success.

Facilitated integration was seen as necessary when:

The rationale and business case for an integration is very clear and positive, but the

parties are struggling to build momentum independently

The LHIN Board will not be able to make a decision about whether to stop the integration

within the allotted 60 days (a facilitated integration allows for more time for discussions

and decision-making)

An integration that would otherwise move forward stalls due to one specific person

(attrition, changing attitudes, etc.). Integration discussions are often very relationship-

based, and if one of the individuals involved moves on to another role the integration may

lose momentum when it otherwise would have moved forward to completion.

Facilitating integration was seen differently across interviewees, with some seeing facilitation as

formalized integration processes, with full direction and action on behalf of the LHIN, while others

saw it as informal activities to help support HSPs in their own processes to explore integration,

including varied levels of financial support, check-in meetings, third-party involvement, etc.

Some LHINs cited examples where they would consider an integration to be “facilitated” when

they use certain incentives to create action. For example, some use the direction of funds through

accountability agreements to encourage certain types of integration activities. This action




essentially forces an entity to look for other options to remain sustainable, and to make decisions

in their interest.

Regardless of how facilitation was seen, the LHINs were always engaged early in the processes

and were able to provide some form of informed support to the processes before a letter of intent

to integrate was sent to the LHIN. The letter of intent initiates the 60-day time limit of the LHIN’s

due diligence processes.

Continual Engagement and Communication

Interviewees identified that when the LHIN is involved in integrative efforts, continual

engagement with health service providers (HSPs) is needed before embarking on an official

integration process, and then consistently throughout the decision-making processes. The

engagement processes often start by focusing on mutual opportunities for both the HSP partners

and the LHIN. The LHINs consider opportunities to be those areas that are aligned with local and

provincial priorities, with a specific focus on the client and patient. It was seen as important to

not assume that integration is the answer to any problems, but to examine whether integration

would help to solve the problem identified in the most logical way.

General communication of broad LHIN integration directives was also seen as important in the

overall processes. If integration of any sort is an objective of the LHIN, then the LHIN should

communicate what this means for HSPs, as well as to clients and patients. It was mentioned that

some leaders and board members across the LHIN have limited experiences with integration, and

require support to understand when integration would be beneficial, how one might investigate

and pursue integration, and to be connected to simple tools and resources to support decision

making.

Integration Support Mechanisms

Many LHINs provide supports to integrative partners to enable integration, which can take various

forms, including:

Data extraction and analysis support to complete due diligence and implementation;

Access to LHIN senior leaders and project managers to discuss benefits or challenges to

integration and the integration process;

Temporary support from LHIN staff to perform the significant work required to examine

the desirability of integration and then if desired to prepare for the integration;

Communications support;

Integration implementation support, including project management and financial

resources; and,

“Seed funding” to help HSPs assess or prepare for integration.

In addition to the themes described above, interviewees identified a number of areas for which

they hoped to achieve greater integration across their LHINs, including:




Mental Health and Addictions;

Home and Community;

Complex Continuing Care, Rehab, and Convalescent Care; and,

Regional clinical integration.

For regional clinical integration, some LHINs have already, or are currently looking at, integrated

models that include multiple HSPs that provide specialty and general care within a clinical area,

collaborating on a regional plan that addresses many of the goals of integration as discussed in

the context of the Integration Review Project. Examples of clinical areas of focus include

orthopedics, ophthalmology, and stroke care.

4.2.3 Client/Patient Focus Groups

Clients and patients from the Toronto Central LHIN were engaged through a series of focus groups

and a select number of supplementary interviews. A total of three client and patient focus group

were conducted, two at the WoodGreen office and one at Four Villages CHC, representing over

30 clients and patients. The focus of the discussion was on understanding their expectations for a

better local health care system. Participants were of different ages, represented a series of

different demographics across the Toronto Central LHIN and had also interacted with the system

in varied ways, both positive and negative. Five additional client/patient interviews were

conducted by phone to supplement the focus groups.

Key findings from engagement activities with clients and patients are below:

Things we like:

Access

Availability of same day scheduling at my primary care doctor’s office

Multi-service agencies and CHCs, where I can go and see my doctor,

physiotherapist, dentist, and social worker in the same place work really well; the

holistic versus linear approach to care at my local CHC

Walk-in clinics are really helpful and important, keeping us away from the

emergency department

OHIP coverage of services

Experience

Most of our providers pay attention to our needs and care about us

We have options and choices of services

Things we don’t like:

Access to Information/Education

It is hard to find information when we need it. We want to understand what we

need (or don’t need) for certain procedures at specific times (i.e. Physicals,

screenings, etc.)




It’s hard to know when I have to pay for a service and what else to expect when I

interact with the system

Our health information is not shared enough. We want all of the people involved

in our care to know about us and to be working together to help me meet my

goals. We don’t want to keep repeating ourselves every time we meet someone

new.

We don’t always have access to our test results

Experience

Scheduling of services inefficient for us and for our providers

Too much paperwork for us and for our providers

Some of our providers are too busy entering information into their computers to

pay attention to us and what we need, and they appear rushed

Transitions throughout Continuum

When being discharged from hospital, there is poor follow through by the

community – I have to actively seek out the next provider and drive my care

myself; it can be really hard to navigate. We need more case managers who can

help us leave the hospital and be cared for in the community

It’s really challenging to get timely appointments with specialists

Some people with Mental Health and Addiction diagnoses do not feel they are

taken seriously because of their diagnosis and feel that they are managed by

drugs, when they don’t really need them. People with mental health and

addictions issues are often also involved in the justice system; the vicious cycle

does not consider peoples’ unique needs.

Translation Services

Some individuals cannot call a doctor because they can’t speak English.

Sometimes these individuals do not see a physician regularly which can lead to

further health complications

We need to consider non-English speaking populations. It’s hard to find GPs that

can speak non-English languages

Some hospital do not have translation services that we need

Funding Barriers

Immigrant populations have limited OHIP coverage. This is a barrier for us to

access health services

Drug costs are a barrier to accessing treatments

Dental, nail care, eye care, hearing, vaccine costs are not covered - it is hard for

us to afford these services

Customer service skills of GPs

Some doctors lack cultural competence

Doctors don’t always relate to us and deliver messages in a “human” way




Doctors don’t always take the full time to listen to our needs and understand

what is wrong before prescribing medication. Sometimes we feel rushed through

our appointments

Wait times in the ER are very long

Clinics are not optimally designed – in one clinic clients/patients had to take a

number but this was not clearly marked and some clients/patients waited hours

for their appointment because they didn’t see the sign

Family and Caregiver Strain and Burnout Clients/Patients have to rely on the families and caregivers to manage them at

home. Some clients/patients do not have supportive networks and may not get

the care they need in the community

Our Suggestions for the Future:

Expand and Enhance Services

Make home and community services easier to access and more available – want

more visits and longer visits to help with things beyond immediate medical needs

(housekeeping, rehab, friendly visits, etc.)

Coordination/link with charity organizations to support transitions into the

community i.e. cancer society, local food banks etc.

Ensure Person-Centred Care

Consider all aspects of us as people with unique needs – without addressing the

fact that we have issues with money and homelessness, our health isn’t going to

improve. Similarly, we have unique language, ethno-cultural needs that need to

be considered.

Encourage providers to keep a customer experience perspective

Involve us in decisions, we have a lot to say and contribute!

Invest in All Parts of Health

Invest in transportation services that are cheap and easy to access, because

without these I can’t get to my appointments and will end up in an ambulance

Invest in supportive housing and assisted living – rent supplements are not

enough to deal with our social and health needs. Programs that offer multiple

services that help me in all of these areas are preferred. Suggest looking at

housing from a bigger picture and have one single ministry focused on this rather

than spread across multiple ministries.

Share Information Effectively

Share information wisely and when it will support better experiences and

outcomes

Make sure specialists are communicating with our family physicians, and not

through a paper that they give me to take over




Create one number that we can call to get information on all that is available in

our health care system, as well as social services, and that can actually help

connect us to them

Leverage community groups and networks to share information about what is

available and to connect each other to services

Develop guidebooks to help seniors who may not know where or how to access

services. i.e. senior’s guide - plain language guide for what you should think about

when you become a senior

Implement Language Specific Services Provide language services that meet the local needs of the community

Using an app to help immigrants learn English

Widen the scope of some small organization

Small organization offer value to particular communities

The scope of these providers should be expanded to better suit the needs of the

local community. This would require more money to hire more people

4.2.4 Health Service Provider Focus Group

On February 11th, a group of about 25 leaders from various health service providers gathered at

the OPTIMUS | SBR offices to participate in a facilitated 2-hour focus group on the topic of

facilitated integrations. The questions to be addressed during the session were as follows:

When should the Toronto Central LHIN become involved in integrations?

How can the Toronto Central LHIN best support organizations as they consider and

implement integrations of varying types?

Where might there be opportunities across the Toronto Central LHIN to create value for

clients, patients and families through integration?

The group first engaged in a discussion in which many of their questions and concerns about the

Integration Review Project were raised, then participants were broken out into four smaller

working groups which rotated through four stations, each with a different topic. Rooms 1, 2, and

3 asked participants to “role play” and consider the perspectives of the LHIN, HSPs broadly, and

clients/patients, and by addressing questions in the Eco-Cycle Framework. The general questions

of this framework are below, but additional contextual questions were provided to support each

group’s thinking.




The fourth room was focused on the Draft Toronto Central LHIN Integration Pathway – the process

diagram that was revised based on the February 5th meeting was enlarged and posted, and

participants reviewed it from an external perspective to see how it could work, clarify issues and

language, etc.

Participants were brought back together at the end of the session for a brief wrap up discussion

to highlight key findings and discuss next steps. Key themes were related to:

A desire for active LHIN support for integration, when it makes sense

Focusing on creating improvement in services from a client/patient perspective

Preserving networks and relationships through changes in how services are provided

Engagement and involvement of HSPs in the planning process for integration initiatives

The output of the session is summarized below:

Conservation (What do we want to keep and build upon?):

Toronto Central LHIN funding for support resources related to integration activities

Relationships with staff, volunteers and communities

Continue addressing/acknowledging fear/reluctance/risk aversion

Exploration (What new things should we try?):

Providing information to create a greater understanding of needs, existing resources,

gaps, and overlaps

Toronto Central LHIN to be proactive in approaching organizations using data; data-based

decision-making

Establish leading practices; Shared standards across HSPs

Coordinate planning, through gathering similar minded agencies (through 3rd party) or

creating subsector service tables to be involved in prioritization of new funds through a

transparent process




When expanding service, look to current providers first rather than new providers so that

economies of scale can be increased

Coordinated access points that cater to new clients/patients and respect relationships

already built

Looking at integration from a client/patient perspective, improving transitions

Increased focus on local considerations

Creative Destruction (What do we want to get rid of?)

Redesign MSAAs to focus on joint rather than individual accountabilities; re-examine

functional centre alignment

Let go of HSP internal focus and consider client/patient perspectives

Avoid indicators that are not aligned to community care philosophies

Break down silos within LHIN and across boundaries

Testing (Success Criteria) (How will we know we are successful?)

Staff satisfaction

Number of voluntary integrations

Health equity metrics lens

Number of clients/patients served

Value for money

Right care, right time, right place

Access and coordination

Fewer service gaps

4.2.5 Survey Analysis

A broad survey was developed and distributed to health service providers across the Toronto

Central LHIN in February, 2016. The survey was open for 3 weeks and received 146 responses in

total. The survey was composed of 12 questions, some of which were closed response types,

others open text response. No questions required mandatory responses.

The following section provides an overview of the findings for each of the 12 questions, which

have informed the development of the Integration Framework, Toolkit, and Recommendations.




Respondents’ Characteristics

1. To which of the following types of organizations do you belong?

Response Chart Percentage Count

Community Health Centre 32.6% 30

Community Support Service Agency

29.3% 27

Home Care Agency 3.3% 3

Hospital 13.0% 12

Long-Term Care Home 8.7% 8

Mental Health & Addictions Agency

18.5% 17

Primary Care Practice (e.g., FHG, FHT, etc.)

0.0% 0

Funder or Policy Development

3.3% 3

Other, please specify... 10.9% 10

Total Responses 92

2. Which of the following populations are served by your organization?


Adults 85.9% 79

Aboriginal Populations

47.8% 44

Children & Youth 52.2% 48

Complex Needs 67.4% 62

Ethno-specific Groups

57.6% 53

Persons with Disabilities

78.3% 72

Franco-Ontarians 31.5% 29

Mental Health & Addictions

68.5% 63

Seniors 81.5% 75

Other, please specify...

27.2% 25

Not Applicable 2.2% 2

Total Responses 92

3. In which of the following Toronto Central LHIN sub-regions does your organization operate?





West Toronto 7.9% 7

North Toronto 3.4% 3

Mid-West Toronto 13.5% 12

Mid-East Toronto 13.5% 12

East Toronto 24.7% 22

More than one Sub-Region

37.1% 33

Total Responses 89

4. What is your role within your organization?


Board Member 13.0% 12

Health Care Clinician

7.6% 7

Administrative Professional, non-management

3.3% 3

Administrative Professional, management

12.0% 11

Senior Executive 55.4% 51

I do not work at a Health Care Organization within Toronto Central LHIN

1.1% 1

I am a Health Care System User, residing in the Toronto Central LHIN

0.0% 0

Other, please specify...

7.6% 7

Total Responses 92




5. Has your organization been part of an integration?


Yes 41.9% 39

No 58.1% 54

Total Responses 93

Voluntary Integration: Success Criteria

6. When considering the potential for an integration of any form, it is important to evaluate the

likelihood of success by comparing the relevant parties on a set of defined criteria. From your

perspective, what are the most important criteria that should be considered when making

decisions about pursuing a voluntary integration?

Not at all Important

Somewhat Important

Neutral Important Very Important

Total Responses

Culture: Parties have a similar culture and share a common vision for their culture.

1 (1.2%) 4 (4.9%) 8 (9.8%) 27 (32.9%) 42 (51.2%)

82

Mission, Vision and Values: Parties have strategic plans that are in alignment.

1 (1.2%) 2 (2.4%) 6 (7.3%) 33 (40.2%) 40 (48.8%)

82

System Priorities: Integration aligns with system level strategic directions (Toronto Central LHIN, MOHLTC, other)

0 (0.0%) 4 (4.9%) 4 (4.9%) 42 (51.2%) 32 (39.0%)

82

Financial Health: The integration enhances the financial health of the parties.

1 (1.2%) 7 (8.5%) 7 (8.5%) 39 (47.6%) 28 (34.1%)

82

Service: The integration will strengthen/enhance existing programs

1 (1.2%) 0 (0.0%) 2 (2.4%) 19 (23.2%) 60 (73.2%)

82




Not at all Important

Somewhat Important

Neutral Important Very Important

Total Responses

and services and reduce gaps in service.

Population: The integration will ensure that relevant populations are served or better served.

1 (1.2%) 0 (0.0%) 2 (2.4%) 18 (22.0%) 61 (74.4%)

82

Geography: The integration will ensure relevant geographies are covered efficiently.

1 (1.2%) 6 (7.4%) 14 (17.3%)

38 (46.9%) 22 (27.2%)

81

Business & Operations: The integration will streamline business operations or better support back office functions.

1 (1.2%) 7 (8.5%) 13 (15.9%)

45 (54.9%) 16 (19.5%)

82

Governance: Organizations have governance structures, policies, procedures and processes that are aligned.

4 (4.9%) 8 (9.8%) 14 (17.1%)

34 (41.5%) 22 (26.8%)

82

Leadership: Leaders from each part have an aligned vision and are committed to the integration.

0 (0.0%) 1 (1.2%) 4 (4.9%) 24 (29.6%) 52 (64.2%)

81

Of the 82 responses received, the majority of people indicated that all of the criteria listed are

either Important or Very Important. Those that were emphasized the most as being Very

Important are:

1. Population: The integration will ensure that relevant populations are served or better

served.

2. Service: The integration will strengthen/enhance existing programs and services and

reduce gaps in service.

3. Leadership: Leaders from each part have an aligned vision and are committed to the

integration.




Question 7 followed up on this list, by asking:

7. From your perspective, are there any other important criteria or success factors (not included

in the list above) that Health Service Providers or the Toronto Central LHIN should consider when

determining if an integration might be beneficial?

Themes and questions from the responses are provided below:

Strategic Communication

1. A communication strategy that holds all parties accountable for community engagement

a. A transparent plan should be socialized with clear definitions on improved

performance outcome measures

2. Community engagement needs to commence at least six months prior to integration

a. There must be open and healthy debate/dialogue to address any conflicts and/or

barriers, and in so doing develop trust

3. There needs to be an internal and external change process that creates a clear and honest

picture of the integration benefits

a. Staff will need to know how the integration will result in achieving better service

delivery, improve access to and quality of services offered

Change management

1. Adequate time for planning, transitioning and evaluation

2. Considerations must be given to determine if/should unique and population specific

programming be preserved

3. How will existing agreements/allegiances with various agencies be handled?

Stakeholder buy-in

1. Is there a shared commitment to a common vision?

a. There must be support and alignment among the boards and senior management

b. Is addressing the broader social determinants of health a common value for the

organizations?

2. All organizations should benefit in some way from the integration

a. Is there an understanding of the true costs of undertaking an integration?

3. Are the parties prepared to be in integration mode now and into the distant future?

a. To what extent is there mutual understanding, support and protection for the

work of the respective agencies?

Organizational culture

1. Is there an organizational fit?

2. The core motive for integration should not be monetary savings. Integrations typically

cost more than anticipated, and don’t deliver on promised savings

a. What are the goals of the integration – and do all parties share those goals?

b. Will there be an opportunity to share leading practices?

3. Are staff energized by /satisfied with the idea of an integration?




a. The employees, clients/patients and supporters all need to be empowered to co-

create the new entity

8. From your perspective, are there any barriers or challenges that commonly impede the

success of voluntary integrations?


Funding

1. Funding to ensure that we have consistent people to commit to the project

2. The levels of administration within the funding model may impede the willingness to

integrate voluntarily

3. The cost of service inequities may prohibit joint planning or full integration

Communication

1. Lack of early involvement of service users in the process leading to a disconnect

between service provider perspective and that of end users

2. Lack of media (incl. social media) engagement in building momentum in favor of the

integration

3. No comprehensive communication strategy

Resource Availability

1. Lack of support for senior staff in the due diligence and planning stages

2. Many Staff, CEOs and EDs tend to be overworked, overwhelmed and strained by the

rigors of integration, with no guarantee of employment in the integrated organization

3. Some resources may not be committed to the process and could sabotage the

integration efforts

a. Staff who do the same work but are paid differently

Change Management

1. The issue of job security is one often at the forefront of stakeholders’ minds, and one

we haven’t done a good job of addressing

a. Union staff may presume that layoffs are afoot

2. Lack of incentives, vision, and goals

a. A plan that does not include service access, high quality care, staff expertise and

appropriate compensation will be unsuccessful

3. Management and staff do not understand change management

a. It takes a significant amount of time to integrate, and a lack of understanding of

the change management process often leads to pitfalls

b. Unrealistic expectations for integration (timelines and resourcing)

Organizational Culture

1. No consensus on key values

a. Different organizational cultures are a common barrier to integration




b. Organizations need to move to a model of transparency with access rules,

practices and barriers to access

c. This may foster a competitive atmosphere rather than a collaborative one

2. Organizational territoriality – there may be a tendency to hold on to each organization’s

identity and not embrace a new ‘integrated’ identity

a. Potential dedication to the organization as opposed to the client/patient’s well

being

b. Potential for smaller organizations to fear being “swallowed up”

c. Some organizations may believe that certain programs have an important place

in their identity, and may be reluctant to give them up

3. Trust building

a. Some integration efforts can be seen as a takeover of one agency by another

Facilitated Integration in the Toronto Central LHIN

9. Please list and briefly describe the essential criteria that need to be followed to help ensure a

successful integration of services led by Toronto Central LHIN (a Facilitated Integration).


Communication

1. Clear articulation of benefit to stakeholders a. Issue report(s) to the community to show benefits of integration, and progress

towards integration

2. All parties (staff, clients/patients, unions, community members) need to be consulted, involved in decision-making, and fully supportive of the need for integration

a. Engage in a robust consultation process within the sub-populations by catchment

b. Have experienced facilitators lead integration workshops

3. A well-developed planning process and communication strategy with clearly articulated goals and outcomes for projects

a. Identify and share clear communication expectations for all parties involved in each integration initiative

b. Active and consistent follow-through on commitments from all parties

Transparency

1. A well planned, highly consultative process that allow all parties, including the LHIN, to share decision making and power

a. Early meaningful involvement of service users in the process b. Provide a clear outline of how challenges/impasses will be handled

2. Well-developed roadmap that outlines principles, risks, goals, process, desired future state / outcomes, measures of success




a. A clear, evaluative plan to show how services will be better and savings made b. Underscore the risks associated with both integration and the status quo c. Present a risk mitigation / contingency plan for all identified integration risks

3. Success needs to be clearly defined and performance measures be evidence based a. Process change plans ought to be comprehensive

Resource Support

1. Sufficient financial resources/assistance to do the planning and integration implementation work

a. Service integration may be more efficient and optimal if collaborating organizations receive additional financial support

2. Ensuring resources are in place to sustain the integration a. Provide adequate people resources/capacity to support the integration effort

3. Adequate time and other resources

Stakeholder Buy-in

1. Board and Senior Leadership need agreement that there will be an overall benefit to the community or clients/patients

a. Ensure that the right organizations are coming together

2. All parties involved, especially staff, need to believe in the need for the integration a. Work with community leaders, and allow solutions to come from the bottom-up b. All sectors and providers will need to have responsibility/accountability for

change c. Understand what the resistance from involved parties may be, listen

3. Good relations between top executives and natural fit of the organizations

Clear/compelling Rationale

1. A rationale for change that is clear to everyone a. Non-viability of one or more of the potential organizations over time b. Integration driven by the needs of clients/patients and their families

2. There needs to be some benefit or at least no harm to client/patient access and care a. Have clear strategic vision, objectives and outcomes b. Quantify what will change and how it will be positive for the sub-LHIN regions

and population needs c. Provide an indication of the Return on Investment (ROI) to be measured against

3. Must be very apparent from start what the benefits of the integration would be a. Identify the type of integration (e.g. structural, process, merger etc.) b. Would integration be necessary if we were to tweak some aspect of the current

operation/organization?




c. Avoid having ‘winners’ and ‘losers’ in an integration, where possible

10. Please list and briefly describe the barriers that would limit or hamper a successful

integration that was led by Toronto Central LHIN (a Facilitated Integration).


Unintended Consequences of Integration

1. Standardization could inhibit ability to respond to unique local needs

a. Standardization may decrease an organization’s ability to be nimble

2. No clear/compelling evidence that integration is suitable and appropriate

a. Any pressure to integrate without a solid business case may meet with

resistance

3. Facilitation may create a competitive rather than cooperative environment

a. Competitive atmosphere arising from perceived threat rather than voluntary

collaboration

b. Agencies may start jockeying for a perceived advantage

c. A high functioning, cost effective agency may be weakened by an unnecessary

merger

Lack of Adequate Resources

1. Difficulties in managing staff across multiple locations

a. Lack of personnel to sustain the integrated operations

b. Staff with valuable experience tend to be the first to leave in times of

uncertainty

2. Financial support (so that costs aren’t borne by other programs)

a. It is possible that integration would proceed more efficiently if LHIN were to

fund the bridging elements (management/coordinating staff, etc.)

3. Too much time spent on planning and not enough on integration

a. Sufficient time is not provided for implementation

b. Service providers will need time to go through the stages of change, and some

will need more time than others to get it right

Lack of Trust/Understanding

1. Differences in compensation across similar positions

a. Could lead to an environment where people may stop sharing learnings that

lead to improved outcomes

2. Lack of trust between/among organizations

a. Confusion about why integration is required could lead to demoralized staff

b. Potential for a lack of board buy-in into the integration




c. Potential lack of buy-in with senior level staff and volunteers could foster

unwilling participants

3. Lack of consensus on or adoption of shared/key values

a. Those who value social determinants of health working with those who don’t

b. Merging organizations where one has a union and the other does not

c. There is a potential that the focus could be solely on cost reduction, and not

benefits to clients/patients, communities, and patient pathways

d. Some organizations may be wedded to the notion that they exist to “further

their organization” and are averse to cultural change

Lack of Communication

1. There is a perceived tendency to keep such initiatives “private” until completed,

operating under the notion of “sensitivity”

a. A lack of transparency may lead to a fear of the unknown and resistance to

change

b. Many may assume that integration is really about saving money and not

improving care

2. Failure to heed advice garnered through consultation with the broader stakeholder

community

a. Not addressing stakeholder concerns could destabilize various agencies

3. Fundamental misalignment with vision and mission of integration

a. There may be a disconnect in perspectives between service providers and end

users, and an ensuing unwillingness to even consider integration

b. A lack of effective communication of expectations – including the role of LHIN vs

providers may hamper integration efforts

c. The ability to be clear on what aspect of integration is required will be

paramount

Opportunities for Integration in the Toronto Central LHIN

11. Considering your experiences and observations within the Toronto Central LHIN, which

sectors, populations, programs or services have the most potential to benefit from integrations

and why? Please be specific.





Mental Health and Addictions (MH&A)

1. There are approximately 29 supportive housing providers serving this population, and

many are relatively close to another

2. These programs may be more accessible in community settings as opposed to in

hospitals

3. There are too many separate organizations and some integration would help service

delivery (e.g. CSS, Post-Acute, Primary Care and Hospitals all serve MHA, Seniors and

disabilities)

Community Support Services (CSS)

1. There are too many separate organizations and some integration would help service

delivery (e.g. CSS, Post-Acute, Primary Care and Hospitals all serve MHA, Seniors and

disabilities)

2. Very interested in an integration across the suite of services, including case

management/intervention and assistance/social work

3. The opportunity to create one home and community care team underpins a population

based service delivery model. One home care team can provide the full continuum of

care (PC, Acute Care, Specialty care, etc.)

Small / Medium Sized Organizations

1. Organizations with budgets less than $3 Million may have difficulty maintaining a solid

infrastructure and may become unviable (e.g. small community mental health and

community service organizations)

2. They would benefit from planning and evaluation, as well as the back office capabilities

of a larger organization (relieving the need to use costly external resources for day to

day operations – HR, IT, Finance)

3. Organizations with similar mandates and visions and very distinct centres of excellence

may benefit from integration (e.g. one with a Centre of Excellence (COE) in working with

homeless populations and one that focuses on mental health and equity issues)

Community Health Centers (CHC)

1. Something needs to be done through the integration model to reduce barriers within

CHC where divisions between community and clinical programs are an issue

2. Few CHCs serve an appropriate number of clients/patients today. CSS can link seniors or

individuals with diabetes to health service providers on a CHC team; CHCs could

integrate their mental health services and harm reduction programs (the benefit of

which could be reduced wait times, and broader knowledge base for resources under a

coordinated supervision structure)

3. Catchment at the LHIN level is being redesigned to hold 4-5 territories (sub-LHINs)




Vulnerable Populations

1. The primary access point for some of the most marginalized people are grossly

underfunded and understaffed

a. A number of CSS agencies are not funded to provide services around mental

health issues and do not have access to mental health care practitioners –

leading to community members of all ages living with issues of mental illness,

and addiction, and often, doing so in poverty

2. Seniors experiencing abuse cannot be systematically surfaced to the LHIN since there is

no funding envelope within the CSS sector to work with such clients/patients. Some

organizations do this work and it would be beneficial to coordinate/integrate the effort

a. Outreach services can be integrated with Supported Housing – having the ability

to place residents directly from a retirement/supportive housing facility into a

long term care home (or at the very least, applying the CCAC reunification policy

to spouses in a multi-purpose complex)

3. Youth mental health would benefit with a integration into community health centres

4. Bringing SickKids and Bloorview together is a natural clinical integration that would drive

synergies and cost reduction

12. Please describe what past integrations in the Toronto Central LHIN and elsewhere have had

the most impact on client/patient services and operations in your opinion, and why.


Health Links in Owen Sound: Talked to an end user who found the experience highly positive

because services were personalized and customized for her full range of needs. Workers LISTENED

to her.

The partnership between community mental health and addiction agencies with Toronto

Community Housing: It has allowed very marginalized and vulnerable tenancies and community

to access important resources that improve both health and housing outcomes at both an

individual and building level.

CASH: Led to massive increases in waitlists because it formalized a system whereby less ill people

can access the waitlist easily and stay in the supportive housing (no process to eliminate

inappropriate referral pathways). The integrations focused on the wrong thing (i.e. common wait

list) rather than the right thing (i.e. improving access and making more transparent).

Toronto Ride: Standardization of transport services and delivery as well as back-office integration

has increased service to clients/patients. It has also addressed, but not totally solved resource

inequities across the Toronto Central LHIN’s jurisdiction.




CNAP: Central access and referral for clients/patients (directly and indirectly) has promoted

standardization of client/patient information and assessment tools.

UHN and TRI; Sinai and Bridgepoint: Greatly improved service delivery.

Sunnybrook and Women's College: Created years of acrimony.

UHN and Michener Institute: Created the possibility of new models of care, enhancement of the

labour force and better health human resources planning.

March of Dimes and Cheshire Foundation (Bloor St): Ensured the continuity of care despite

economic short falls and the employment of qualified staff.

PACE, Clarendon, March of Dimes: Ensured third party standards to guide the process and again

allowed continuity of care/employment.

Family Health Teams and CHCs: Made positive impact on providing multidisciplinary services to

clients/patients in one “stop.”

WoodGreen, Dixon Hall, CNH: This is a good model that goes beyond back-office integration to

include holistic and wrap-around services for populations and an integration of isolated

populations into a community of services and engagement.

CCAC and LHIN: CCAC developed its integrated care for populations with complex care needs and

along with the LHIN brought together leaders from all sectors to discuss where we were failing

clients/patients and their families and discussed how best to address – leading to the

development of integration projects (ICCP, SCOPE, Virtual Ward, Impact Clinics, etc.).

OLIS: Has been tremendously useful, and has likely reduced the number of tests ordered, and the

efficiency with which client/patient problems are managed.

TEGH: Has been fantastic in getting consult notes, imaging notes and diagnostic notes re. our

clients/patients to our EMRs in a prompt way.

WoodGreen Community Services/Community Care East York: Integration was very successful -

enhanced services to seniors, more clients/patients served, better funded and sustainable back-

office and modest net cost savings.

The Toronto Central LHIN Patient’s First Engagement Consultations

Overview

In December 2015, the Ministry of Health and Long Term Care released Patients First: A

Proposal to Strengthen Patient-Centred Health Care in Ontario




While the Ministry held separate consultations across Ontario, each LHIN was invited to

consult with providers and residents within the communities they serve, and share this

feedback with the Ministry

The Toronto Central LHIN held or participated in over 20 consultations over the last

several weeks, and posted an online survey for public input

Feedback from consultation sessions were collected and key themes identified for a

report back to the Ministry

Key Findings

Effective Integration of Services and Greater Equity

Make LHINs responsible for all health service planning and performance.

Identify sub-LHIN regions as the focal point for integrated service planning and delivery

(note that these regions would not be an additional layer of bureaucracy).

Align LHIN boundary to City of Toronto

Co-design with clients/patients and caregivers

Bring all HSPs to planning table and define role of Boards

Collaborate with non-health partners to account for social determinants of

health, specifically housing

Establish a shared vision and change map

Establish patient-based outcomes

Let providers innovate

Plan and fund to address health equity

Timely Access to, and Better Integration of Primary Care

LHINs would take on responsibility for primary care planning and performance

improvement, in partnership with local clinical leaders.

Identified need for a primary care network

Identified need for better coordination and access

Recommend health equity goals for primary care to achieve.

Shift to a sub-LHIN rostered model over time

Questions of whether LHINs can succeed without holding funding for primary

care.

More Consistent and Accessible Home & Community Care

Direct responsibility for service management and delivery would be transferred from

CCACs to the LHINs.

Create a new model of integrated community care that includes home care,

community supports, and community mental health.

Build on the successes realized by the Toronto Central CCAC.




Define opportunity for hospitals in home and community care delivery such as

post-surgical care.

Expand mandate of Care Coordinators

Support seamless sharing of clients/patient information between home and

community care, primary care and acute care (through technology).

Standardize connection between sub-LHIN teams and regional / specialized care.

Review LTCH role to reduce ALC

Stronger Links to Population & Public Health

Linkages between LHINs and public health units would be formalized

Expand focus on prevention and health promotion.

Create partnerships with municipalities and public housing.

Enhance communication between primary care and public health




4.3 Summary of Data Analysis Activities

One of the goals in the Toronto Central LHIN’s Strategic Plan is to maintain a sustainable system.

In the current tight fiscal environment, efficient use of resources allows for more care to be

provided with the resources we do have. Data is one starting point from which to receive direction

for finding areas where improvement might yield the greatest benefit. The data is best paired with

an understanding of local factors so that we can properly interpret what the numbers suggest. An

evidence-based data approach will highlight opportunities, some of which may be revealed on

further examination as false opportunities while others will identify true areas for improvement.

To provide direction for further discussion and examination two sets of data were analyzed. The

first set focused on indicators that affect clients/patients directly, while the second set focused

on administration and resource efficiencies.

To understand the impact on the clients/patients, indicators related to readmissions, wait times,

and appropriate locations of care were examined.

For the administration and resource efficiency data set, high-level HSP performance measures

were analyzed including overall margin, the percentage of the organization’s budget spent on

administrative costs, and two measures of efficiency, cost per unit of service and individuals

served per full time equivalent. The output from this analysis follows.

As this analysis is meant to be directional, organizations have been numbered in the graphs rather

than identified by name (organization numbers purposely do not correspond across different

analyses).

4.3.1 Wait Times for Mental Health and Addiction Services

Wait times are long for MH&A services, especially for supportive housing. Long wait times mean

clients and patients are not able to access the right services at the right time, which can lead to

further health complications. The median wait time for closed requests in four programs were

analyzed for 3 quarters. Acronyms for these four programs are:

Assertive Community Treatment (ACT)

Coordinated Access to Supportive Housing (CASH)

Supportive Housing for People with Problematic Substance Use (SHPPSU)

Intensive Case Management (ICM)

Clients/patients waited for over 1.5 months for ACT and over 4 months for ICM. Waits for

supportive housing could be over 1 year.

Figure 2: MH&A Median Wait Times for Closed Requests




Clients/patients are waiting approximately 1 month for community mental health

clinics/programs and day/night care, and over 2 months for mental health or addictions

residential programs.

Table 1: Wait Times for Community Mental Health Services

Wait Times (days) for Community Mental Health Services

Case Management

Clinics/ Programs

Day/Night Care Residential - Mental Health

Residential - Addictions

Count of HSPs Included in Data

17 34 7 8 12

Max 365 549 120 365 294

Median 34 39 29 69 69

4.3.2 Care Best Managed Elsewhere

In relation to primary care provided at CHCs, integration between acute and primary care may be

an opportunity. While the Emergency Department is an important component of our health

system, many health concerns can be dealt with by a primary care provider rather than in an

76

334 332

119 118

324

34

393 409

138 123

647

98

236

304

161 154

335

69

321348

139 132

435

0

100

200

300

400

500

600

700

ACT CASH CASH, SHPPSU ICM ICM, ACT SHPPSU

Media

n W

ait T

ime (

days)

MH&A Median Wait Times for Closed Requests, by Program

13/14 Q3 13/14 Q4 14/15 Q1 Average




Emergency Department, where the physician is less likely to know the client/patient and their

history. A set of health conditions, which are low acuity and can be managed in primary care, is

tracked to see if people are going to the Emergency Department for these conditions rather than

their CHC. On average, 10% of the emergency department visits provided to clients/patients of a

CHC are “best managed elsewhere” and could have been provided in primary care. This

percentage ranges from 2.9-19.3% across different CHCs, and measures the rate of Emergency

Department visits by CHC active clients with a CTAS score of 4 or 5. This may represent an

opportunity for improvement so that care that is best provided in primary care is provided there

as often as possible.

A better link with primary care may also improve care for people living in Long-Term Care Homes

(LTCHs). The potentially avoidable Emergency Department visits for LTCHs ranges from 10-50%

per 100 visits. These are Emergency Department visits which may have otherwise been avoided if

the person had better access to other health services.

Figure 3: Percentage of Emergency Department Visits Best Managed Elsewhere

2.94.3 4.9 5.2 5.6 5.8

7.2 7.38.2

9 9.3 9.7 1011.6 11.7

12.6 13.1

19.3

11.4

0

5

10

15

20

25

% o

f ED

Vis

its

Be

st M

anag

ed

Els

ew

he

re

CHCs

Percentage of Emergency Department Visits of Rostered CHC Clients that are Best Managed Elsewhere

(April 2012 - March 2014; Source: NACRS/CHC-EMR)




Figure 4: Potentially Avoidable Emergency Department Visits Among LTCH Residents

4.3.3 Total Margin

Multiple years of spending beyond budget may represent a financial risk to the organization and

as such, a risk to the sustainability of services that the organization provides to clients/patients.

Total margins of health service providers were analyzed for fiscal year (FY) 2013/2014 and

2014/2015. A negative margin means that spending was greater than revenues and represents

risk.

Findings from this analysis identified that 10 CMHA and 10 CSS organizations in the Toronto

Central LHIN had a negative margin for both years, while 5 and 6 respectively had a negative

margin that was greater than -3%. No CHCs or hospitals had negative margins for both years.

CHCs: 3 CHCs had a negative margin for one fiscal year, while none had a negative margin for both

years analyzed

0%

10%

20%

30%

40%

50%

60%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

% a

void

able

ED

vis

its,

per

10

0

LTC Home in Toronto

Potentially Avoidable ED Visits Among LTCH Residents(October 1, 2014- September 30, 2015; per 100; Source: CCRS-LTC,

NACRS)




Figure 5: Community Health Centre Total Margins

CMHAs: 10 had a negative margin for both fiscal years; 5 were lower than a negative 3% negative

margin in 2014/2015 Figure 6:Community Mental Health and Addiction Agencies Total Margins

-5.0%

0.0%

5.0%

10.0%P

erce

nta

ge T

ota

l Mar

gin

CHC

CHC Percentage Total Margin

FY 13/14 FY 14/15

-5.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

1 3 5 7 9

11

13

15

17

19

21

23

25

27

29

31

33

35

37

39

41

43

45

47

49

51

53

55

57

59

61

63

65

67

69

71

Ave

rage

Per

cen

tage

To

tal M

argi

n

CMHA

CMHA Percentage Total Margin

FY 13/14 FY 14/15




CSSs: 10 had a negative margin for both fiscal years; 6 were lower than 3% negative margin in

2014/15 Figure 7: Community Support Services Total Margins

(note: the above graph has been capped at -20% and 20%)

Hospitals: No hospitals had negative margins in both years examined Figure 8: Hospital Total Margins

Methodological notes:

This analysis is limited in that it only examined Q4 FY 2014/2015. Identifying trends over

time would strengthen the findings from this analysis.

-20.0%

-15.0%

-10.0%

-5.0%

0.0%

5.0%

10.0%

15.0%

20.0%

Per

cen

tage

To

tal M

argi

n

CSS

CSS Percentage Total Margin

FY 13/14 FY 14/15

-1.0%

1.0%

3.0%

5.0%

7.0%

9.0%

11.0%

Per

cen

tage

To

tal M

argi

n

Hospital

Hospital Percentage Total Margin

FY 13/14 FY 14/15




4.3.4 Percentage of Budget Spent on Administration

Administrative costs associated with client/patients services are necessary, yet balance is needed

since when more resources go to administrative costs fewer can go to direct client/patient service.

The following graphs present the percentage of costs from each service provider that go to

administration.

Findings from this analysis identified that administrative costs range greatly, and as such there

may be opportunity to improve administrative efficiency. CMHAs and CHCs had the greatest

ranges of administrative costs (0-44% and 0-100% respectively in 2014/15) and likely represent

the greater opportunity for identifying administrative efficiencies.

CMHAs: There appear to be CMHAs that are outliers in regards to the percentage of budget spent

on administrative costs with 5 organizations spending twice the average in FY 2014/15. These

costs ranged from 0-44% of the organization’s budget in FY 2014/15.

Figure 9: CMHAs Percentage Budget Spent on Administration

(note: the above graph has been capped at 50%)

CSSs: There appear to be CSSs that are outliers in regards to the percentage of budget spent on

administrative costs with 4 organizations spending twice the average in FY 2014/15. These costs

ranged from 0-100% of the organization’s budget in FY 2014/15. Confirmation about what the

data suggests should be done with the organization, as 100% spending of budget on

administrative costs is likely due to other reasons. Excluding administrative costs of 100% of the

organization’s budget, the range in FY 2014/15 is 0-57%.

0%

10%

20%

30%

40%

50%

1 4 7

10

13

16

19

22

25

28

31

34

37

40

43

46

49

52

55

58

61

64

67

70

Ave

rage

Bu

dge

t Sp

ent

on

Ad

min

CMHA

CMHA Percentage of Budget Spent on Administration

FY 13/14 FY 14/15




Figure 10: CSSs Percentage Budget Spent on Administration

CHCs: There is a smaller amount of variation in the administrative costs of CHCs compared with

CMHAs and CSSs, with these costs ranging from 0-21% in FY 2014/15.

Figure 11: CHCs Percentage Budget Spent on Administration

Methodological notes:

1 CHC was not included in the analysis since it reported zero administrative costs; 16 CHCs

were included in the analysis.

0%

20%

40%

60%

80%

100%1 3 5 7 9

11

13

15

17

19

21

23

25

27

29

31

33

35

37

39

41

43

45

47

49

51

53

55

57

59

61

63

65

Bu

dge

t Sp

ent

on

Ad

min

CSS

CSS Percentage of Budget Spent on Administration

FY 13/14 FY 14/15

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

Bu

dge

t Sp

ent

on

Ad

min

CHC

CHC Percentage of Budget Spent on Administration

FY 13/14 FY 14/15




11 CMHAs were not included in the analysis since they each reported zero administrative

costs, many of which were larger organizations that provided services in addition to

community mental health services, 61 CMHAs were included in the analysis. A number of

organizations reported very low administrative costs and it could not be confirmed

whether these costs are true or due to data reporting issues. Unless the organization

reported zero administrative costs, it was included in the analysis.

12 CSSs were not included in the analysis since 10 reported zero administrative costs and

2 reported 100% administrative costs, and both of these situations were assumed to be

unrealistic, 53 CSSs were included in the analysis. A number of organizations reported

very low administrative costs and it could not be confirmed whether these costs are true

or due to data reporting issues. Unless the organization reported zero administrative

costs, it was included in the analysis.

4.3.5 Cost per Unit of Service and Individuals Served per FTE

As a directional measure of efficiency the total cost of common functional centres was examined

in relation to the cost per unit of service provided and individuals served per full-time equivalent

(FTE). Two functional centres were analyzed from each sector. The functional centres chosen for

analysis had a higher sample size of HSPs with the same functional centre and a higher total cost

for the functional centre at the sector level.

There are high levels of variation in cost per unit of service, suggesting that there are opportunities

for increased efficiency. This is especially pronounced for CMHAs where the maximum costs per

unit for case management and residential mental health were 198 and 88 times greater than the

minimum costs respectively. These differences may or may not be due to differences in the

activities performed by these organizations.

Analyzing the number of individuals served per full-time staff equivalent (FTE) revealed that each

sector had a functional centre with low variation and another functional centre with high

variation. For the high variation functional centres, the maximum number of individuals served

per FTE was over 60 times greater than the minimum number of individuals served per FTE in

each case.

Further investigation may reveal whether differences are due to variation in activities, reporting,

or efficiency.

The following functional centres were analyzed:

CHCs

Clinics/Programs - General Clinic (code: 72 5 10 20) (17 HSPs included in analysis)

Health Promotion/Education – Personal Health and Wellness (code: 72 5 50 45)

(15 HSPs included in analysis)




CMHA

Case Management/Supportive Counselling & Services - Mental Health (code: 72

5 09 76) (22 HSPs included in analysis)

Residential Mental Health - Support within Housing (code: 72 5 40 76 30) (20 HSPs

included in analysis)

CSS

CSS In-Home – Assisted Living Services (code: 72 5 82 45) (30 HSPs included in

analysis)

CSS In-Home – Day Services (code: 72 5 82 20) (19 HSPs included in analysis)

The analysis focused on levels of variation as an indication that there may be opportunity for

improvement. For the cost per unit of service analysis, the greatest variation was seen in the

CMHA sector where the maximum cost was 197.6 and 88.0 times greater than the minimum cost

for the two functional centres respectively.

Table 2: Cost per Unit of Service for HSPs in the Toronto Central LHIN

Metric Cost per Unit of Service

Sector CHC CMHA CSS

Functional Centre Clinics/Programs - General Clinic

Health Prom/Educ& Com. Dev – Personal Health and Wellness

Case Management/Supportive Counselling & Services - Mental Health

Residential Mental Health - Support within Housing

CSS IH - Assisted Living Services

CSS IH - Day Services

Minimum Value $77 $216 $6 $3 $13 $60

Median Value $148 $1,198 $70 $27 $48 $98

Maximum Value $243 $1,700 $1,148 $247 $386 $170

Number of times that max value is greater than min value

2.1 6.9 197.6 88.0 27.9 1.9




In analyzing individuals served per full time staff equivalent (FTE), significant variation is seen in

all sectors with the maximum number of individuals served were up to 99.6 times greater than

the minimum number of individuals served for each of the functional centres.

Table 3: Individuals Served for HSPs in the Toronto Central LHIN

In analyzing two functional centres from each sector, each sector had a functional centre with low

variation and another functional centre with high variation, with the maximum number of

individuals served per FTE being over 60 times greater than the minimum number of individuals

served per FTE in each case.

Methodological Notes:

Functional centres were chosen based on the sample size of HSPs that have the specific

functional centre as well as the total cost of that functional centre to the LHIN. The top

two sample sizes were analyzed for each sector, with the exception of CSS organizations.

In CSS organizations for which the 1st and 3rd largest sample sizes were analyzed as the

functional centre with the 2nd largest sample size had a cost impact of approximately 25%

of the functional centre with the 3rd largest sample size.

Metric Individuals Served/FTE

Sector CHC CMHA CSS

Functional Centre Clinics/Programs - General Clinic

Health Prom/Educ.& Com. Dev – Personal Health and Wellness

Case Management/Supportive Counselling & Services - Mental Health

Res. Mental Health - Support within Housing

CSS IH - Assisted Living Services

CSS IH - Day Services

Minimum Value 71 122 9 2 1 3

Median Value 178 1,339 32 11 7 15

Maximum Value 434 9,605 188 200 42 36

Number of times that max value is greater than min value

5.1 77.8 19.8 99.6 64.2 11.9




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Esther Suter, N. D. O. Carol E. Adair and Gail D. Armitage. (2009). Ten Key Principles for Successful Health Systems Integration. Healthcare Quarterly, 13(Sp), 16–23.

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Linda Smyth. (2009). Making Integration Work Requires More than Goodwill. Healthcare Quarterly, 13(Sp), 43–48.

Lurie, S. (2009). Getting to Integration: Command and Control or Emergent Process. The Innovation Journal, 14(1). Retrieved from http://www.innovation.cc/scholarly-style/lurie4.pdf

Lyngsø, A. M., Godtfredsen, N. S., Høst, D., & Frølich, A. (2014). Instruments to assess integrated care: A systematic review. International Journal of Integrated Care; Vol 14, July-September 2014. Retrieved from http://www.ijic.org/index.php/ijic/article/view/1184

Ontario Government. (2016). Local Health System Integration Act, 2006. Retrieved January 14, 2016, from http://www.ontario.ca/laws/view

Ontario Ministry of Health and Long-Term Care. (2015). Patients First: A Proposal to Strengthen Patient-Centred Health Care in Ontario. Discussion Paper. Retrieved from http://www.health.gov.on.ca/en/news/bulletin/2015/docs/discussion_paper_20151217.pdf

Sirotich, F., Durbin, A., et al. (2016). Supportive Housing and ICM-ACT Indicators: Fiscal Years 2013/14-2015/16.

Suter, E., Oelke, N. D., Adair, C. E., Waddell, C., Armitage, G. D., & Huebner, L. (2007, October). Health




Systems Integration: Definitions, Processes & Impact: A Research Synthesis. Alberta Health Services. Retrieved from http://www.albertahealthservices.ca/assets/info/res/if-res-hswru-hs-integration-report-2007.pdf

Toronto Central LHIN. (n.d.). Toronto Central LHIN Patient First Engagement Feedback.

Toronto Central LHIN. (n.d.). Toronto Central LHIN Strategic Plan 2015-2018. Retrieved from http://www.torontocentrallhin.on.ca/goalsandachievements.aspx

WoodGreen. (2012). From Strategy to Implementation: An integration toolkit for community-based health service providers. Retrieved March 25, 2016, from https://dl.dropboxusercontent.com/u/86669743/From%20Strategy%20to%20Implementation%20%20An%20integration%20toolkit%20for%20community%20based%20health%20service%20providers.pdf

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Documents

Integration Review Project - Reference Document