approved by the board on centretown chc october 30, 2018

CENTRETOWN CHC 2018-2020 STRATEGIC PLAN

[email protected]

www.centretownchc.org 613-233-4443

420 Cooper St, Ottawa ON

K2P 2N6

Every One Matters.

Chaque personne compte.

Approved by the Board on

October 30, 2018

Centretown CHC Strategic Plan 2018-2020

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CONTENTS

2018-2020 Strategic Plan _________________________________________ 1

About Centretown CHC ___________________________________________ 2

Our Mandate ____________________________________________________________ 2

Our History ______________________________________________________________ 3

Our Services ____________________________________________________________ 4

Our Planning Approach ___________________________________________ 5

Background _____________________________________________________________ 5

The Collaborative Strategic Planning Process __________________________________ 6

Centretown CHC’s Strategic Planning Process (2016-18) ________________________ 13

CCHC 2018-2020 Strategic Plan ___________________________________ 20

Our Vision, Mission & Values _______________________________________________ 20

Our Strategic Directions & Goals ____________________________________________ 21

Appendix I. Defining The System ___________________________________ 1

Appendix II. SWOT Analysis _______________________________________ 1

2018-2020 STRATEGIC PLAN

“Health equity for all members of our communities.”

Working as a collective to address the systemic barriers and

challenges to accessing health services Collaborative

North Star

Enhance Access

for People with Complex Needs

Demonstrate

Quality Through Impact

Leverage

Collective Capacity

Enhance

Organizational Health & Wellness

Our Strategic Directions

Our Mission We lead the way in improving health and wellbeing

for people and communities.

Our Vision Healthy caring communities where everyone matters.

Our Values Equity ▪ Empowerment ▪ Excellence ▪ Respect

By 2020, we will…

1.1. Identify hotspots of vulnerable individuals in CHC catchment areas and target health inequities in our communities ©

1.2. Improve care

coordination and health outcomes for clients with complex needs

1.3. Improve low-barrier

access to primary health care and addictions medicine for people who regularly use drugs and alcohol

3.1 Undertake a joint review of primary healthcare capacity to better understand current gaps and opportunities for improved client care ©

3.2 Be proactive in mitigating organizational risks ©

3.3 Use EMR technology to improve client care and operational efficiency

4.1 Implement an improved performance management system for staff

4.2 Assess options to improve our financial sustainability

4.3 Continuously improve the CCHC staff experience

2.1 Review our data to identify gaps in access to programs and services for priority populations ©

2.2 Identify and address inequities in the client experience and outcomes of our diverse clients

2.3 Adopt a social prescribing model to better integrate health and social services, and promote a greater sense of community belonging


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ABOUT CENTRETOWN CHC

Figure 1. Centretown CHC's Catchment Area in Ottawa, Ontario.

Our Mandate

We are a nonprofit, multi-service Community Health Centre serving the Centretown,

Glebe, and Old Ottawa South neighbourhoods. Our interdisciplinary primary

healthcare and health promotion programs support the health and wellbeing of over

13,000 Ottawa residents (including 5,300 regular primary care clients) who access our

services every year.

In a fair and just society, one’s skin colour, religion, income level, gender identity, and

sexual orientation should not predict poor health outcomes. In ours, it sadly does. To

bridge these health inequities, Centretown CHC offers a full range of healthcare

services and health promotion programs, including specialty health clinics (i.e. urban

health, newcomer health, trans health), mental health & addiction services, diabetes

programs, early year programs, and community health promotion.

Centretown

Community Health Centre


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These programs and services are delivered by a caring and diverse team of over 150

interdisciplinary health professionals, including doctors, nurse practitioners, nurses,

social workers, counsellors, dietitians, community developers, health promoters,

outreach workers, and peer workers. As a community-governed organization, we

work hard to respond to the evolving health and social needs of our community.

Our History

Centretown CHC has been playing an active role in improving its community’s health

and wellbeing since 1969. Over time, we have built a strong reputation as:

- an effective advocate for healthy policies at the municipal, provincial and

federal level;

- a committed ally to its LGBTQ+, Francophone, street-involved, vulnerable

elderly, low income, and newcomer communities;

- a high-quality provider of diabetes programs for the Champlain region.

Recent Developments at CCHC

2008 – Ontario launches Diabetes Strategy and expands CCHC’s Diabetes

Education program, later adding screening, and chiropody services.

2012 – CCHC receives its ‘Baby Friendly’ designation for its adherence to World

Health Organization (WHO) protocols that protect, promote, and support

breastfeeding.

2016 – CCHC plays a leadership role in Refugee 613, providing outreach and

low-barrier access to primary care for Syrian war refugees arriving in Ottawa.

2016 – CCHC introduces the Trans Health Clinic, providing wrap-around

services and improved access to hormone therapy for trans individuals in the

Champlain region.

2017 – CCHC receives its ‘French Language Services’ (FLS) designation from

the Ministry of Health and Long Term Care.


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Our Services

We believe in an integrated approach to care that is holistic, non-discriminatory,

caring, and innovative. Our services are delivered in a variety of ways: 1-on-1 client

care, personal development groups, and grassroots community involvement.

As a French Language Services (FLS) designated Centre, we ensure high-quality

programs and services in both official languages. In an effort to provide culturally-

safe care, cultural interpretation services are also available for all clients who walk

through our doors, and a number of groups facilitated by our diverse staff are offered

in other languages frequently spoken in our catchment, including Mandarin, Arabic,

and Somali.


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OUR PLANNING APPROACH

Background

Given that the 6 Ottawa CHCs shared similar mandates, client profiles, and pressure

points, a decision was made at the turn of the decade to formalize our partnerships

by engaging in a joint strategic planning process.

From 2012 to 2017, Carlington CHC, Centretown CHC, Pinecrest-Queensway CHC

and South-East Ottawa CHC worked towards common strategic directions, including:

i) enhancing the impact of their advocacy

ii) improving social capital among priority populations

iii) delivering high-quality programs and services, and

iv) strengthening the health of their respective organizations

The collaborative strategic plan allowed the 4 CHCs to join forces on a number of

priorities while still allowing each Centre to specify Centre-specific goals to their plan,

based on the unique needs and priorities impacting their communities.

Building on the success of this collaborative process, 2 more community health

centres (Somerset West CHC and Sandy Hill CHC) agreed to join the Ottawa CHC

collaborative strategic planning process for 2018 and beyond. A request-for-

proposals was posted in 2016 and Lansdowne Technologies Inc (LTI) was retained as

a consulting partner to the 6 CHCs, to assist with planning facilitation, strategic plan

development, and project management.


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The Collaborative Strategic Planning Process

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Phase 1: Literature Review and Environmental Scan (2016-2017)

Phase 1 of the collaborative strategic planning process involved scanning the

literature to identify best practices for planning within the context of primary

healthcare. LTI conducted a thorough literature review and presented its

recommendation that the 6 CHC Board of Directors adopt a planning framework

grounded in complexity theory (‘5-Level Framework’).

Using A Complexity-Based Approach

Understanding the domains to which managing healthcare resources in our

changing context belongs is crucial to selecting the appropriate planning and

management approach. As the Cynefin Framework tells us, complex problems are

distinct from simple or merely complicated problems (see Figure 2).


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Figure 2. Cynefin Framework (by Dan Snowden)

The decision to use a planning framework adapted to complexity was informed by

the fact that CHCs operate in a complex, unpredictable, and unknowable space. To

illustrate the point, no amount of business intelligence could reasonably have

forewarned the CHCs of the impacts of the Syrian crisis, of the OC Transpo bus strike,

or of President Trump’s election and its effect on the cross-border migration of US-

based refugees. Yet these are some of the major events, over the past 5 years, that

have called upon the Community Health Centres to respond in significant ways.

Success in such an environment requires adaptable strategies built on first principles,

timely data for sense-making, and agile collaborative structures to respond to

emerging contextual factors. Only then can a course towards defined strategic

outcomes be maintained, regardless of which way the wind blows.

Problem Domains

Simple

‘known knowns’

there are rules in place (or best

practices), the situation is stable

and the relationship between

cause and effect is clear: if you

do X, expect Y

Approach:

"sense–categorize–respond"

Complicated

‘known unknowns’

The relationship between cause

and effect requires analysis or

expertise; there are a range of

right answers

Approach:

“sense-analyze-respond”

Complex

‘unknown unknowns’

Cause and effect can only be

deduced in retrospect, and

there are no right answers (but

instructive patterns can emerge)

Approach:

“probe-sense-respond”

Chaotic

Cause and effect are unclear

Events are too confusing to wait

for a knowledge-based response

Approach:

“act-sense-respond”

“… CHCs operate in a complex, unpredictable, and unknowable space.”


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Applying a 5-Level Framework

Figure 3. 5-Level Framework

The 5-level framework was recommended by LTI and ultimately selected by the 6

Ottawa CHC boards as the framework for collaborative strategic planning. It was

also recommended that planning timeframes be shortened to no more than 3 years,

in keeping with best practices for managing organizations in complex environments.

Finally, three options were presented for the implementation of the collaborative

strategic plan at each organization:

1) Added Plan: The collaborative strategic directions and goals are added to

individual CHCs’ strategic plans as needed, based on which Centres will be

taking an active role on any given collaborative strategy.

2) Shared Plan: The CHCs’ strategic plans all share the same set of collaborative

strategic directions and goals, and may add on other strategic directions

based on their organization’s or catchment’s priorities.

3) Enabled Plan: The CHCs’ strategic plans reflect the collaborative strategic plan

as subsidiary activities in their own strategic plans. These subsidiary activities

may be reflected as a strategic goal (e.g. “strengthen CHC collaboration”)

under one of their Centre’s strategic directions. It may otherwise be reflected

as a set of enabling factors supporting all of their Centre’s strategic directions.

Multi-board discussions held in January 13, 2018 resulted in consensus that the 6 CHC

Boards wished to move forward with a Shared Plan.


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Environmental Scan

In order to assess ‘where we are now’, LTI was commissioned to produce an

environmental scan with support from CHC planners. Delivered in Fall 2017, this 80-

page document helped to define ‘the system’ (see Appendix I), describe key trends

at various levels of the system, and highlight a number of opportunities / threats

facing Ottawa CHCs (see Appendix II). Population health statistics for Ottawa and

findings by key themes are presented in Figure 4 and Table 1, respectively.

Figure 4. Population health statistics for Ottawa from the 2017 Environmental Scan.


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Table 1. Summary of Findings by Key Themes

Global

Instability and

Trauma

• Regional conflict; religious, ethnic and LGBTQ+ persecution; and adverse weather

events linked to global warming are driving increases in immigrant, refugee, and

displaced persons. Many arrive in Ottawa with significant trauma loads and face

barriers to integration.

• The integration of trauma-informed healthcare, immigrant supports, and language/job

skills development is essential to newcomer wellbeing.

Health System

Redesign

• Patients First is rationalizing health systems within LHIN boundaries and newly defined

sub-regions. CHCs will benefit from developing a shared future-state vision of sub-

regional systems and CHCs’ role within them, in order to operate from the same

playbook when negotiating at sub-regional tables.

• The risk of the current government being unseated remains high. CHCs will be well-

served by monitoring provincial party platforms, engaging with all Ottawa MPP

candidates, and planning contingencies as the June 2018 provincial election nears.

Ottawa’s Aging

Population

• On the business side, chronic disease management, dementia, and care coordination

will increase encounter volumes and case complexity.

• On the organizational side, the increasing threat of corporate memory loss will need to

be monitored and planned for as a significant wave of front-line experts, care

providers, and senior executives reach retirement age.

• Strong succession planning, alongside forecasting and advocating for needed

resources and supports (i.e. for care coordination and home care), will help mitigate

these organizational stressors.

Health Equity

• The CHCs’ community governance model leads the way in promoting health equity,

but no framework yet exists to leverage CHC data to systematically identify and

address social disparities in: the determinants of health, access to care, patient

experience, or clinical / population health outcomes.

• Adopting a health equity framework and investigating opportunities (e.g. patient

portals) to expedite the collection of complete sociodemographic data for their

centres would help CHCs maintain their status as system leaders in driving an

evidence-informed health equity agenda.

Value-For-

Money

• The 2012-2017 collaborative strategic plan demonstrated the value of collective

action, allowing CHCs to make their mark while undergoing budget freezes. In light of

recent health system funding reforms (Excellent Care for All Act), as well as the Auditor

General of Ontario (AGO) audit of LHINs/CHCs, the impetus for efficiency remains high.

• By strengthening operational partnerships (together, and with key partners, e.g.

Ottawa Public Health) and better monitoring their collective impact, Ottawa CHCs

can continue to build on best practices, align resources to do more with less, and show

value-for-money.

Big Data, GIS,

eHealth, and

QI: Building

Learning

Organizations

• Ottawa CHCs are increasingly data-rich while analytic capacity lags. Meanwhile, the

opportunity cost of not leveraging business intelligence increases yearly as software

and capabilities grow.

• CHCs are encouraged to build pockets of excellence in GIS, big data, and eHealth to

glean new insights, spur efficiencies and champion innovations that will help CHCs

meet the growing demands of an aging population. Short-term secondments could be

used as a knowledge exchange pipeline.


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The environmental scan was circulated to all 6 CHC’s board members along with

other key documents (see Table 2) to inform their efforts in Phase 2.

Table 2. Collaborative Strategic Planning – Key Inputs

Organization Key Document

CHCs 2012-2017 Collaborative Plan’s Strategic Outcomes

2017 Environmental Scan

Champlain LHIN

2016-19 Integrated Health Service Plan (IHSP)

o Community Engagement Report for IHSP 2016-19

Champlain LHIN Service Accountability Agreement (SAA) Indicators

(2017-2020)

Health Quality

Ontario (HQO) Quality Improvement Indicators (2017-18) for primary care

Association of

Ontario Health

Centres (AOHC)

Key province-wide initiatives led by AOHC

o Advocacy Priorities & Key Messaging (e.g. Elections)

o ‘Vital 8’ outcome indicators

o ‘Count Every One’ data initiative


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Phase II: Strategic Planning (2017-2018)

Phase 2 of the collaborative strategic planning process involved engaging the 6

Ottawa CHC boards in a collective visioning exercise to determine the strategic

outcomes, guidelines, and directions that would guide our organizations.

Once the strategic directions were agreed upon by the 6 CHC boards, key

stakeholders – including staff, clients, community partners at each Centre – were

consulted in order to define, validate, and refine strategies to operationalize the

collaborative strategic plan as well as inform any Centre-specific directions/priorities.

After an approval-in-principle in Spring 2018 and some further refining by the 6 CHCs’

executive directors and senior management teams over Summer 2018, three

collaborative strategic directions were approved by the CHC boards in Fall 2018.

Our Collaborative ‘North Star’

“Health Equity for All Members of Our Communities” – Working as a collective to

address the system barriers and challenges to accessing health services.

2018-2020 Collaborative Strategic Directions

1. Enhance Access for People with Complex Needs

2. Demonstrate Quality Through Impact

3. Leverage Collective Capacity


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Centretown CHC’s Strategic Planning Process (2016-18)

Throughout the Collaborative Strategic Planning process, Centretown CHC was

concurrently engaged in a series of consultations with its staff, board members,

community partners, and community members, in order to inform its input into the

collaborative strategic directions, as well as to identify needs specific to its

community members and its organization.

Client & Community Member Consultations - Summer 2016

Between July and September 2016, clients were engaged with at over 20

group classes and community events across our various locations in Ottawa

Clients / community members were asked 4 key questions:

o what needs/struggles they face

o how accessible we are

o how they hear about our programs & services

o what it is that CCHC does for them (and how we could do this even

better)

Consensus:

o CCHC is a welcoming, inclusive space that clients value being able to

access

o Clients would find it difficult to replace CCHC in their lives

o Clients typically come to the Centre for more than 1 service

o Hear about our services/events mostly via word-of-mouth, staff, and

posters


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Key Themes from 2016 Client Consultation

Challenges

Faced

• Housing, food security and employment

• Prejudice (not feeling accepted or valued as newcomers,

people with mental health and/or addiction issues, LGBTQ+,

senior citizens, etc.)

• How to access/navigate system for health & social resources

• Social isolation: “if we are not explicitly included, we are implicitly

excluded”

Areas for

Improvement

• Client orientation; health system coaching

• Shorter wait times (Primary Care, Mental Health, Trans Clinic)

• Translation supports (Arabic, Mandarin, Cantonese)

• Better educate community partners about programs & services

• More accessible (legible) posters in lobby

New Services

• Cooking classes (requested by wide range of groups)

• More health promotion information (newcomers, seniors)

• Longer term programs (>6 weeks)

• Physical activity/exercise classes (seniors (incl. LGBTQ), moms,

newcomer women)

• More outreach to social housing (seniors, other homebound)

While some of these key themes have since been addressed by Centretown CHC in

CCHC’s 2016-17 and 2017-18 Operational Plans, other areas (i.e. decreasing social

isolation, strengthening newcomer health supports, improving outreach efforts) were

in need of a strategic focus, longer timelines, and/or more resources in order to

effectively remove the barriers to health and wellbeing reported by our community

members.

These themes received due consideration by CCHC’s Board and Senior

Management during the formulation of our 2018-2020 strategic goals.


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Client Experience Survey – Spring 2018

Between February and March 2018, clients waiting in our general or clinical

reception area were asked to complete our annual Client Experience Survey

The anonymous 4-page questionnaire asks a series of demographic and

service utilization questions, also inquiring about the quality and timeliness of

the care experience, outcomes, and overall satisfaction with CCHC.

Consensus:

o CCHC clients are highly satisfied with their care (99% agree)

o Clients feel that their CCHC providers involve them in decisions about

their care (96% agree)

o Clients feel more connected with their community as a result of their

involvement with Centretown CHC (90% agree)

Key Themes from Client Surveys [ themes mentioned by x% of sampled clients in comments ]

Key Insights

• High overall satisfaction with care experience and providers

• While most individuals from marginalized groups felt welcome at our

Centre (>90%), Homeless and Trans individuals were least likely to

agree that they always felt welcome and comfortable (83% each)

• 9% of clients with a disability reported experienced some form of

difficulty or discomfort when accessing Centretown CHC’s services

Areas of

Excellence

• Friendly, helpful staff [52%]

• Quality of programs/services [14%]

• Interdisciplinary care [9%]

• Location (easy to access) [9%]

• Warm welcome at reception [9%]

Areas for

Improvement

• Wait times (in clinic and for follow-up appointments) [6%]

• Access to certain types of appointments [3%]

• Sense of physical safety in the Centre, at times [2%]

• Negative experiences at reception [2%]

• Implement eHealth / electronic communications [2%]


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These findings were shared with CCHC’s board, senior management, and staff in

Spring 2018 and received due consideration during the formulation of our 2018-2020

strategic goals.

Community Partner Consultations – Spring 2018

In April 2018, over a dozen community partners operating in our catchment

were invited to attend a facilitated discussion to share observations about

client and community trends in the Centretown neighbourhood

Facilitated discussions centred around 5 key questions:

o What factors are most affecting your clients’ quality of life?

o Which client groups is your organization struggling to serve well?

o What key health issues/concerns require the most attention?

o What is Centretown CHC’s role in the community?

o What are the key opportunities for enhanced partnerships for 2020?

Consensus:

o Poor mental health, often accompanied by addictions, is a key driver of

the health needs being felt in our community; agencies are struggling

to serve clients with mental health issues well.


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o Traumatized refugees (especially families with children) have significant

needs around trauma-informed and culturally-safe care, overcoming

language barriers, employment, and early years/afterschool programs.

o Social isolation and poverty are the hallmarks of poor quality of life in

our catchment; seniors experiencing both are especially at risk.

o Limited / segmented services available for LGBTQ+ health care and for

mental health & addictions.

o Lack of housing supports (e.g. pest control, hoarding) for vulnerable

individuals lead to poor health outcomes and evictions.

o Need to strengthen referrals for vulnerable people via ‘warm bridging’

and better awareness of each others’ services and key staff.

o Centretown CHC is a community leader well-positioned to connect

local partners, as well as a convenient place to refer people with

complex needs, knowing that these needs will be met.

Board-Staff Consultations – Spring 2018

In April 2018, two to three staff representatives from each program joined

Board members in a facilitated planning session intended to identify potential

goals under each Strategic Direction and strategies to achieve these goals.

Note: at the time, the Strategic Directions had not yet been finalized and

were still known as ‘Access Leveling’, ‘Quality Improvement’ and

‘Strengthening Key Enablers’.

Strategic Directions

Issues Proposed Solution(s)

Access

Leveling

- Lack of identified staff with

culture, skills, language to

meet needs of hard-to-

reach individuals

(Indigenous, people with

addictions, Francophone)

- Lack of awareness about

our programs among

clients and community

partners

- More Francophone (FLS) and

Indigenous staff with lived

experience (e.g. MHA, LGBTQ+,

homelessness)

- Working with partners to better

understand:

o Each other’s scopes and

any gaps remaining

o Data on who is falling

through the cracks


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- Lack of continuity of care

/ wrap-around services for

vulnerable clients

- Stigma, social isolation,

lack of mobility keep high-

need clients outside of our

doors

- Increase outreach and warm

handovers for

homeless/marginalized

populations

- More case management

resources for complex clients

- Improve sense of belonging via

programming that engages

those most at risk of social

isolation

Quality

Improvement

- Need for high-quality

Francophone primary

healthcare (Haitian

refugees + existing

Francophone population

+ FLS designation)

- Could do better at

engaging our clients

- Integration between

programs / teams could

be better

- Not enough data (or lack

of data flow) to respond

quickly to different

communities’ needs

- Offer a full continuum of

services across

CHCs/agencies instead of

patchwork and

duplication of basic

services

- More Francophone (FLS) and

Indigenous staff with lived

experience (e.g. MHA, LGBTQ+,

homelessness)

- Explore options for enhancing

client engagement (e.g. client

advisory group and/or or other

mechanisms)

- Improve awareness of our

programs and services internally

and enhance strength of cross-

program collaboration

- Collect better data on client

needs and experience with

quality our services using health

equity lens

- Review interdisciplinary primary

healthcare assets and gaps in

the community (take into

consideration hours of service,

eligibility, service type,

geographic coverage)

Key Enablers

- Need better and more

timely data

- Need to strengthen our

ability to tell our stories (i.e.

advocacy, grants, brand

reputation, influencing

system change)

- Develop approaches to

monitoring our client data over

time using an equity lens and

communicating this data to staff

- Better understand the gap

between what we are seeing at

our Centre vs the true picture of

needs in our community (e.g.

who aren’t we seeing?)


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- Need to have more agile

and collaborative

structures / resources to

respond more quickly to

emerging community

issues

- Need better technology

to make healthcare

processes more efficient

and client-centred and

reduce burden on staff

- Flow data and stories from front-

line staff / analyst /

management to

communications to better tell

our story

- Work with Communications

specialist to coach key staff on

strategy (e.g. social media)

- CHC collaborative planning:

Define core vs specialized/sub-

regional services

- Plan across programs for priority

populations (e.g. vulnerable

MHA clients; isolated seniors;

LGBTQ+)

- eFaxing, EMR, email reminders,

tablets/kiosks for client

forms/registrations


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CCHC 2018-2020 STRATEGIC PLAN

Our Vision, Mission & Values

Our Vision

Healthy, caring, inclusive communities where every one matters.

Our Mission

We lead the way in improving health and wellbeing for people and communities.

Our Values

Equity / Empowerment / Excellence / Respect

Equity. We believe in recognizing and respecting diversity among people in our

communities to provide them with appropriate services that meet their varying

needs. We strive to break down barriers so everyone can enjoy access to the services

they need to be healthy. Equity is about recognizing differences among people and

treating people differently according to their needs in order to achieve equality of

access.

Empowerment. We value participation and believe in our clients’ and communities’

right to play an active role in determining what services are offered and how they

are delivered. To achieve this, we foster open and constructive dialogue and believe

in engaging in respectful, honest and clear communications practices. We strive to

provide all the support and information required to make informed choices and

participate in meaningful ways.

Excellence. We are committed to providing excellent services and strive for constant

improvement and innovation. We focus on best practices, evidence-based

approaches and ongoing evaluation to deliver effective and comprehensive

services that best meet our clients’ and communities’ needs. We ensure

accountable, efficient and effective use of resources.

Respect. We are committed to fostering an inclusive environment where everyone is

treated in ways that are fair, courteous and compassionate. We believe in valuing

one another’s opinions and contributions and giving full considering to these views

with an open and non-judgemental mind.


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Our Strategic Directions & Goals

Individuals with 4 or more chronic conditions are defined as

medically complex individuals. If accessible, equitable and

interdisciplinary primary healthcare is not available to these

individuals, they are more likely to suffer from preventable

complications, to frequent the emergency department,

and to have poor quality of life. The CHC model of care is

ideally suited to keeping these individuals healthy and well.

GOALS

1.1. Identify hotspots of vulnerable individuals in CHC

catchment areas and target health inequities in our

communities. ©

1.2. Improve care coordination and health outcomes

for clients with complex needs.

1.3. Improve low-barrier access to primary health care

and addictions medicine for people who regularly

use drugs and alcohol.

INITIAL ACTIVITIES

1.1. Develop a community profile of complex and vulnerable individuals in the community

using a health equity lens.

1.2. Evaluate the implementation of Health Links and its impact on client outcomes.

1.3. Submit a funding proposal to Champlain LHIN for enhanced primary care and MH&A

outreach resources for street-involved clients.

By 2020 …

CHCs will ensure that clients with complex needs have

access to coordinated interdisciplinary care in Central

Ottawa via Health Links.

2020 Target: 44 Health Links

coordinated care plans (CCHC)

CCHC will reduce 30-day hospital readmissions for clients

with complex needs.

2020 Target: <9.5% 30-day hospital readmission rate for

Health Links clients

CCHC will improve client experience and continuity of

care for transient clients who use drugs and alcohol.

2020 Target: 200 more encounters/year with clients

who use drugs & alcohol due to

enhanced wrap-around services

ENHANCE ACCES FOR PEOPLE WITH COMPLEX NEEDS DIRECTION 1:


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e

Quality has many dimensions. While Centretown CHC

excels at providing effective, safe, timely, and client-

centred care to the most complex clients in our

community, we have never formally studied how equitable

the care that we provide truly is – at least not in a

systematic way. This will change in 2018-2020.

GOALS

2.1. Review our data to identify gaps in access to

programs and services for priority populations. ©

2.2. Identify and address inequities in the client

experience and outcomes of our diverse clients.

2.3. Adopt a Social Prescribing approach to better

support collaborative practice and promote a greater

sense of community belonging.

INITIAL ACTIVITIES

2.1. Develop a profile of clients served, including services accessed and client issues, using

a health equity lens.

2.2. Develop a health equity report card to monitor access, client experience, care quality

and outcomes for CCHC’s priority populations.

2.3. Develop a project plan for the implementation and evaluation of a Social Prescribing

strategy.

By 2020 …

Ottawa CHCs will have a system in place to monitor

inequities in access, client experience, and outcomes.

2020 Target: Adoption of CHC performance dashboard

with equity indicators

All Centretown CHC programs will have the information

they need to set annual equity-seeking goals.

2020 Target: 4 out of 4 CCHC programs use access maps

and the health equity report card to

set annual improvement targets

75% of clients involved in Social Prescribing pilot will report

a greater sense of community belonging.

2020 Target: 75% of monitored clients report an

improvement in their sense of

community belonging

DEMONSTRATE QUALITY THROUGH IMPACT DIRECTION 2:


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As the client journey and health outcomes of Central

Ottawans becomes an increasingly collective and

intersectoral responsibility, it is important to develop

collaborative practices that enable the sharing of best

practices, tools, and data systems so that our organizations

can collectively rise to meet the needs of the community.

GOALS

3.1. Undertake a joint review of Primary Care capacity to

better understand gaps and opportunities for improved

client care. ©

3.2. Be proactive in mitigating organizational risks. ©

3.3. Use EMR technology to improve client care and

operational efficiency.

INITIAL ACTIVITIES

3.1. Collaboratively define the scope and priority areas of the inter-CHC Primary Care

capacity review project.

3.2. Educate senior management and board members on the use of Sandy Hill CHC’s risk

management audit tool.

3.3. Undertake a cost-benefit analysis of potential EMR add-on services (e.g. eFaxing, client

kiosks).

By 2020 …

On-call providers will be able to access client records

and chart in the EMR when providing after-hours care.

2020 Target: Adoption of EMR data-sharing utility at the 6

Central Ottawa CHCs

Senior management will have adopted new tools and

processes to identify and manage organizational risks.

2020 Target: Adoption of new risk management tools and

processes captured in policies

Collection of up-to-date client socio-demographic (SD)

information will improve by +400%.

2020 Target: 50% of active clients will have up-to-

date SD information in the EMR

LEVERAGE COLLECTIVE CAPACITY DIRECTION 3:


24

Technological advancement, changes in government

priorities, and the evolving nature of our work requires us to be

constantly adapting to our context to maintain high quality,

client-centred care. In order to deliver what the community

expects of us, it is imperative that we continually look to

strengthen our funding, our infrastructure, our processes, and

our people.

GOALS

4.1. Implement an improved performance management

system for staff.

4.2. Assess options to improve our fiscal sustainability.

4.3. Improve the CCHC staff experience.

ACTIVITIES

4.1. Finalize CCHC’s staff performance management tool in our HRM system.

4.2. Identify potential efficiencies and estimate cost savings.

4.3. Conduct a survey and consultations in order to better understand staff priorities.

By 2020 …

# staff who report getting timely feedback on their job

performance will improve by +50%.

2020 Target: 75% of staff agree that they get timely

feedback

# staff who report that there is strong support for training

in their area of work will improve by +40%.

2020 Target: 70% of staff agree that there is strong

support for training

# staff who would recommend CCHC as a place to work

will improve by +8%.

2020 Target: 70% of staff agree that they would

recommend CCHC

ORGANIZATIONAL HEALTH & WELLNESS DIRECTION 4:


2

Every One Matters.

Chaque personne compte.

Follow us on Twitter: @CentretownCHC

Follow us on Facebook: @CentretownCHC

Follow us on LinkedIn: @CentretownCHC

420 Cooper St, Ottawa ON K2P 2N6 * 613-233-4443 * [email protected] * www.centretownchc.org

APPENDIX I. DEFINING THE SYSTEM

APPENDIX II. SWOT ANALYSIS Strengths

• Ottawa CHCs generally report high client satisfaction.

• Ottawa CHCs are increasingly data-rich (EMR, Be Well Survey,

Ottawa Neighbourhood Study, etc.).

• Ottawa CHCs have access to a significant number of

volunteers, many of whom have lived experience, as well as

cultural and linguistic competencies.

• Ottawa CHCs are generally becoming more efficient or

maintaining their efficiency over time.

• The practice of developing Centres of Excellence and referral

pathways among CHCs promotes service high-quality clinical

care.

Weaknesses

• Ottawa CHCs generally have limited analytical capacity and QI expertise

to make use of their client data for equity-informed quality improvement

(QI).

• Quality improvement is currently driven largely by a top-down (i.e. Health

Quality Ontario) approach rather than via client engagement.

• Low organizational maturity in program design, outcome evaluation, and

knowledge exchange make it difficult to identify, assess, and scale best

practices in group programming across CHCs.

Opportunities

• Greater use of eHealth tools like eVisits, patient portals, and

hospital eNotifications could lead CHCs to better patient

outcomes, higher client satisfaction, and significant efficiencies.

• The forthcoming integration of public health units within LHINs will

allow CHCs to better align their community development and

health promotion resources with Public Health for greater

impact.

• CHCs should explore the feasibility of becoming ‘Community

Hubs’ (and related capital funding opportunities) in order to

reduce barriers for clients needing access to social services.

• Given the recent residential school apology, TRC Calls to Action,

and growing impetus to recognize the rights of indigenous

peoples to culturally-safe care, CHCs have an opportunity to

explore partnership with Wabano to promote a shared health

equity agenda in service of indigenous communities.

Threats

• There is potential for already-high demand for newcomer health services

to be exacerbated by the recent trend of irregular crossings from US-

based asylum-seekers due to US ‘self-deportation’ policies.

• Ottawa’s aging population will significantly increase case complexity as

well as demand for chronic disease management, care coordination,

and home-based care over the next 10 years.

• The high likelihood of political turnover in the June 2018 provincial

elections casts doubt on the extent to which sub-regional healthcare

integration will proceed as planned.

• The number of individuals approaching retirement age has begun to

exceed the number entering the workforce. This trend will accelerate as

the 65+ population segment grows by 28% as a share of Ottawa’s

population by 2026. CHC loss of corporate memory and expertise poses

a significant organizational risk.

approved by the board on centretown chc october 30, 2018

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