2015-16 Annual Business Plan Outstanding care – every person, every day. Vision Outstanding care – every person, every day. Mission To deliver a seamless experience through the health system for people in our diverse communities, providing equitable access, individualized care coordination and quality health care. Values Our patients come first Learning environments are empowering Diversity is an asset We are accountable Respect is critical to all good relationships The Central West CCAC helps ensure people have the health care and support they need to remain safe and independent for as long as possible. We are privileged to help people come home from hospital, live independently, and, when appropriate, transition into long-term care. CCAC care coordinators are regulated health professionals – nurses, physiotherapists, and others – with additional, specialized training in coordinating care across the health system. Last year, we served more than 35,000 patients at home, in school, and through the three hospitals in our community. The Central West CCAC is proud to have achieved Accreditation with Exemplary Status, the highest distinction awarded by Accreditation Canada, and a score of 100%. We are passionately dedicated to our vision: Outstanding care- every person, every day. Message from the CEO I am pleased to share the Central West Community Care Access Centre’s (CCAC) inaugural Annual Business Plan (ABP) with our community. This ambitious document reflects our efforts over the past year to advance our Strategic Plan and articulates the key initiatives we will embark upon in 2015-16 as we continue to strengthen patient care in Central West. The past twelve months have been eventful and inspiring. We further developed our patient experience expertise, launched and expanded innovative programs, and conducted a highly successful pilot project that promises to transform the way we deliver care. In doing so, we began to significantly shape the delivery of local home and community care to help ensure it is responsive to the needs of those we serve today and sustainable for generations to come. We know that family doctors and nurse practitioners are often at the centre of a patient’s journey, and in 2014-15 we dramatically expanded our collaboration with them to enable more integrated, comprehensive support for people across our region. Together with our primary care partners, we also maintained our focus on supporting patients with very complex needs through Central West’s five Health Links – work that is producing results and will continue well into the coming year and beyond. Throughout 2014-15, the Central West CCAC continued to experience unprecedented demand for our services. We met this challenge head-on as we found opportunities to further invest in patient care, leveraged community resources, and strengthened partnerships to help ensure patients were safe and their needs were met. We are proud to have maintained high levels of patient satisfaction and served more people than ever before while balancing our budget. As the year progressed, our commitment to continued innovation remained strong as we began to set the stage for more dynamic, patient-centred change. In August 2014, the Central West CCAC, Headwaters Health Care Centre (Headwaters) and William Osler Health System (Osler) integrated non-clinical “back office” functions across our three organizations in the first cross-sectorial partnership of its kind in the province. We’re collaborating with these and other partners more than ever before to create an environment in which patients experience seamless, integrated care no matter where they are on the health care continuum. We will collectively improve the patient experience as we take a regional approach to best-in-class care, break down barriers and develop innovative, leading-edge services and programs that will best serve our diverse community. This collaboration will enable us to maximize resources, close gaps across the system and serve as many people as possible. There’s an energy and an optimism to this work, and it’s tremendously satisfying to see – even in these early days – the impact of our collaboration. At the same time we know we have much more to do as we pursue our Vision of outstanding care – every person, every day. As we enter into the third, and final year of our 2013-16 Strategic Plan, we will leverage the considerable skill and dedication of our staff and partners and seek further patient and caregiver input to inform our efforts. We will build upon our successes to date and embrace the opportunities ahead with purpose and determination. Together, we will build a stronger, more unified health care system in Central West. Annual Business Plan 3 Year in Review 2014-15: A Remarkable Year of Progress and Evolution In 2014-2015, the Central West CCAC made significant progress towards achievement of the three Strategic Directions at the heart of our 2013-2016 Strategic Plan. Inspired by our patients, their families, our staff and our partners, we continue to provide high quality, patient-centred care, while challenging ourselves to seek greater opportunities to engage the people we serve. Through the steadfast commitment of our staff and the partnerships we have fostered across our community, in 2014-2015 the Central West CCAC significantly advanced our three Strategic Directions: Patient engagement -- Throughout 2014-2015 we continued to actively engage and collaborate with our patients and their families to better understand and respond to their needs. We leveraged patient experience data to inform programs and initiatives, expanded our expertise related to patient and caregiver experience, and collaborated with our partners in new and exciting ways to improve the patient experience throughout our diverse region and across the health care continuum. Fabulous people – We recognize that our staff are our most valuable resources as we strive toward our Vision, and last year engaged them in bold efforts to transform the way we deliver care; aligned care teams more closely with family doctors and nurse practitioners to enable improved communication and greater collaboration; and provided innovative learning opportunities to support employees as they serve our community with expertise, purpose and passion. Culture of innovation – In 2014-2015 the Central West CCAC expanded its innovative exercise and falls prevention program to benefit more seniors across our region; continued to advance, in collaboration with our partners, Central West’s five Health Links as they provide more coordinated, comprehensive care for our most complex patients; and integrated non-clinical services with Headwaters and Osler to improve our collective ability to meet the health care needs of our community. In November the Central West CCAC was honoured to be acknowledged, along with Headwaters and Osler, with the 2014 Award in Leading Governance Excellence through the Ontario Hospital Association's (OHA) Governance Centre of Excellence. The award recognizes the organizations' Board of Directors for their work to develop a Strategic Partnership Committee to support the creation of a more unified health care system to better serve patients and families in the Central West region. The Central West CCAC was also recognized for the second consecutive year with a Gold Quality Healthcare Workplace Award through the OHA and the Ministry of Health and Long-Term Care for its efforts to create a supportive culture, in which health care professionals can learn, work and thrive. Annual Business Plan 4 Setting the Stage for 2015-16 As a publically-funded organization, the Central West CCAC recognizes the importance of being a collaborative partner in the larger health system. To inform our short and long-term planning, each year we monitor trends and changes at local, provincial and national levels to take into account the influences these environmental factors have on our operations. Our plans are aligned with the priorities of our funders, including the Ministry of Health and Long-Term Care (MOHLTC) and Central West Local Health Integration Network (LHIN). Many of these environmental factors also impact our regional partners, and aligning our collective plans will help us overcome challenges across the system. The following are some of the environmental factors we took into consideration in the development of the 2015-16 ABP. Global health care trends The continued global demand for health care creates an enormous challenge with regards to bringing health care costs under control. Promoting sustainability is a continued world-wide trend as the population ages, increasing the number of people living longer with chronic, expensive-to-treat diseases. In addition, many people choose to live, age, and, when possible, die in their own homes, rather than in a hospital or other care institution. These preferences create tremendous demand for home and community care, as well as opportunities to respond to increasingly complex patient needs through a growing range of in-home services, including home-visiting pharmacists, specialized nursing and palliative care. At the same time, technology is enabling new models of care that leverage health human resources and enable people to live in the comfort of their own homes well into their senior years. MOHLTC priorities In her 2014 mandate letter to the Minister of Health, Ontario’s Premier identified priorities including a continued expansion of home and community care, the need for more coordinated care, and reforms to ensure that Ontario’s funding system better reflects the care that people need, and in the most appropriate setting. This sustained focus on home and community care is reflected in the commitment to further investment in our sector; however, it is widely acknowledged that available resources continue to be outpaced by the magnitude of the demand, requiring continued vigilance as we seek efficiencies. Social determinants of health There is growing recognition of the need for greater cross-pollination between health and social services providers to support patients and their families in accessing the care and support they need to remain healthy and safe. This recognition is enabling new cross-sector collaborations as providers work together to address complex patient needs, which may extend beyond conventional medicine to include personal support services, mental health interventions, social programs, economic assistance and other forms of support. Annual Business Plan 5 Bold partnerships with acute care partners In 2014, the Central West CCAC, Headwaters and Osler committed to an integration of non-clinical support functions across the three organizations. This innovative partnership is putting patients and families first by strengthening the system and finding new and better ways of working together as we create formal linkages across community and acute care sectors. This first cross-sector integration of its kind in Ontario promotes further collaboration, joint investment opportunities, system-level planning and improves our combined ability to meet the health care needs of our ethnically diverse community residing in a geographically diverse region. In developing our 2015-16 ABP and operating budget, the Central West CCAC used a conservative approach to planning assumptions and did not assume any increase from current levels of base funding. The Central West CCAC is well positioned to meet the financial challenges of the year ahead, based on deliberate decisions made in 2014-15 to improve effectiveness and sustainability. Annual Business Plan 6 Our Plan for 2015-16 The Central West CCAC plays an integral role in our evolving health care system, and meeting the needs of a growing and aging population requires more than incremental change. This year, we will continue to build on the foundation established by our strategic plan as we strive to improve the patient experience, drive system transformation and advance our strategic partnerships to enable the best possible care. In 2015-2016, we will invest considerable effort and energy to make significant progress in two specific areas: engaging people and helping to lead local health care transformation. Improving patient experience to support exemplary care: Patients, caregivers, health care providers and support teams all have important perspectives and make worthy contributions to the delivery of safe, compassionate and high-quality health care. We will build on existing approaches to seek patient feedback as we deliver on our commitment to provide exemplary care. By optimizing the potential of our staff and leaders, we will focus on efforts on enhancing the care of our patients, including those with multiple chronic conditions and complex health care needs. Helping lead local health care transformation: The Central West CCAC will align with local and provincial priorities and remain mindful of emerging opportunities as we stand ready to support the evolution of health care in our region. We will work with our partners more closely than ever before to identify gaps, develop shared strategic goals, support one another to deliver what is best for patients, and measure our collective success. In 2015-16 we will also build on our non-clinical support services integration with Headwaters and Osler through increased collaboration and innovative investments, and will work with a broad range of other health and social services providers to optimize access to services in our community, so patients receive the care they need, when they need it and in the most appropriate setting. We will promote collaboration, cooperation, and improve the seamless delivery of health care through a joint Strategic Partnership Committee as we explore voluntary partnerships and integration opportunities among regional health care providers. As we enter the third year of our strategic plan, we remain confident in our Strategic Directions and energized by the possibilities. More information about the Central West CCAC’s priority initiatives for 2015-16 can be found on the following pages. Annual Business Plan 7 Strategic Direction 1: Patient Engagement 1. Develop an enhanced patient engagement framework – We will engage with patients and caregivers to better understand their expectations and experiences then infuse their perspectives into everything we do. Through our ongoing engagement efforts we will also develop a mechanism to embed patient input into program design and ensure the timely availability of robust patient data to inform our planning. 2. Enable communication and coordination amongst health care providers, including primary care providers – To support the provision of comprehensive, holistic care, we will increase to 85% the number of CCAC care coordinators connected with primary care physicians, while continuing to strive toward a 100% connection rate. 3. Improve the care of high needs patients through Health Links leadership and support – We will work with family doctors and nurse practitioners to complete more Health Links care plans to better meet the complex needs of patients throughout our region. Strategic Direction 2: Fabulous People 1. Optimize our staff’s ability to provide “value-add” service – We will create communities of practice, cultivate staff champions, and improve access to best practice information and training to strengthen the delivery of patient care across and beyond our organization. 2. Implement a leadership development program to support current and future leaders – We will implement an evidence-based leadership development program to sharpen our focus on leadership and advance organizational performance across all teams. In conjunction with our acute care partners, Headwaters and Osler, we will standardize leadership practices to inspire service excellence across the continuum of care and best equip our leaders for the roles they play to support the delivery of exemplary care across our region. 3. Use technology to make the best use of health human resources – We will improve our processes so our care coordinators have more time to directly connect with patients as they plan their care. The Central West CCAC will also leverage the skills and experience of personal support workers to implement innovative new programs that use technology to enable more efficient models of care. Annual Business Plan 8 Strategic Direction 3: Culture of Innovation 1. Take regional partnerships to the next level by identifying new opportunities for joint investment and system-level planning to strengthen our combined ability to meet the health care needs of our region – With our partners at Headwaters and Osler, we will continue to build teams that will enable a regional approach to planning to support the delivery of quality, timely health care services to those we serve and explore opportunities for clinical collaboration. 2. Transform and dramatically improve the patient experience for those living with life-limiting illnesses through a Joint Palliative Pledge – With Headwaters and Osler, we will collaborate with palliative care partners across our LHIN to determine a shared course of action that will change the way we collectively support patients and families and enhance the quality of living and dying with respect, dignity and compassion. 3. Support regional coordination of Health Links to enhance care for patients with complex care needs – Through the provision of care coordination to all five Health Links across Central West, we will continue to support increased capacity and clinical integration among health care providers in the community to better coordinate care for patients with multiple chronic conditions and complex health care needs. 4. Expand voluntary partnerships and integration opportunities among regional health care providers through our innovative Strategic Partnerships Committee – We will work with our partners at Headwaters and Osler to further develop this unique platform, which enables the exchange of ideas to improve access to health care services, promote continued efficiency of administrative functions, and align performance accountabilities among member organizations to seamlessly deliver health care services across the Central West region. 5. Facilitate clinical best practices across the continuum of care – With our partners, we will implement clinical best practice pathways for targeted populations to support safe and seamless patient transitions, including transitions from hospital to the home. Annual Business Plan 9 Measuring Success Corporate Scorecard Program Evaluation 2013-16 Patient Care Services Priorities Plan 2015-16 Quality Improvement Plan Performance Objectives for the Executive Team Annual Business Plan 10