Promoting Community Health and Wellbeing in Ontario: How LHINs can lead the way

Address by the Association of Ontario Health Centres to The Standing Committee on Social Policy concerning the review of the Local Health System Integration Act, 2006

December 9, 2013

Contact: Adrianna Tetley, Chief Executive Officer Association of Ontario Health Centres (AOHC) / Association des centres de santé de l’Ontario (ACSO) Tel: 416.236.2539

2

Good afternoon Chair and Honourable Members of the Standing Committee on Social Policy. My name is Adrianna Tetley and I am the CEO of the Association of Ontario Health Centres. A guiding vision: the best possible health and wellbeing for everyone. As Ontario’s voice for community-governed Primary Health Care, the Association of Ontario Health Centres (AOHC) is pleased to present to the Standing Committee on Social Policy as it begins its review of the Local Health System Integration Act (LHSIA). As the committee conducts the review we hope this submission will spark further, more detailed conversations with our association and our members. The Association represents 108 community-governed primary health care agencies throughout the province: 75 Community Health Centres (CHCs), 10 Aboriginal Health Access Centres (AHACs), 15 Community Family Health Teams (CFHTs), and 9 Nurse Practitioner-Led Clinics (NPLCs). These centres are distinct from Ontario’s other primary care models because they are governed by community members. And Ontario’s 75 Community Health Centres are the only primary care model in Ontario that currently fall under the jurisdiction of the Local Health Integration Networks (LHINs). CHCs are located in each of the province’s 14 LHINs; our observations and recommendations are largely informed by CHCs’ experience working with these 14 LHINs over the past seven years. AOHC’s submission is also shaped by the vision that unites our membership: the best possible health and wellbeing for everyone living in Ontario.

• A future without systemic barriers that prevent people from reaching their full health potential, a future in which everyone can make the choices that allow them to live a fulfilling life.

• A future in which individuals, families and communities are served by, and are able to actively participate in, trusted healthcare systems that respond to people’s and communities’ needs in coordinated and comprehensive ways.

• A future in which people share responsibility with their health providers for their health and wellbeing.

Our member centres are committed to a leadership role that achieves this vision of Community Health and Wellbeing. To do so they have recently adopted a new Model of Health and Wellbeing to guide our delivery of Primary Health Care at a local level (See Appendix). Our submission provides AOHC’s perspective on how the LHINs, at a regional level, can also lead the way towards Community Health and Wellbeing.

3

Key messages: This review process offers a critical opportunity to maximize the LHINs’ full potential. Going forward, the LHINs need to play a key role establishing Community Health and Wellbeing regional systems that promote the best possible health and wellbeing for everyone. To achieve this potential, we urge the Committee to consider the following directions for change:

• Require the LHINs to use a health equity approach as foundational to all its work; • Enhance the capacity of the LHINs to serve as strong planning bodies across the full

continuum of care, especially when it comes to building a more organized and effective primary health care system;

• Widen the LHINs’ scope. The Act defines the objectives of LHINs too narrowly on treating sickness and organizing health services. LHINs should be mandated to prevent more in order to treat less, with a special focus on prevention measures that address the root causes of illness and disease;

• Build strong community-based services; and • Require the LHINs to improve their processes for meaningful community engagement and

responding to the needs of the communities they serve.

These directional recommendations are based on the seven years’ experience of our member centres working with the LHINs to promote health and wellbeing. As the committee continues its review, our membership will also continue reflecting on how the potential of the LHINs can be maximized. We hope this will be the beginning of an ongoing conversation with the Standing Committee.

Retooling the LHINs to maximize their potential AOHC stands by our 2005 submission to the Standing Committee when LHSIA was first introduced: fundamentally, the establishment of the LHINs represents a major opportunity to press forward with a positive transformation for health and health care in Ontario. Ontario needs regional bodies that understand the regional perspective and unique realities of their communities and are held accountable to the regions they serve. We also need regional bodies equipped to set objectives, evaluate performance, allocate budgets, evaluate performance, and hold providers accountable for the services they deliver. However, AOHC also contends it’s time for the LHINs to be retooled. In our view, the purpose of the LHINs, as currently defined in LHSIA, doesn’t capture a big enough picture. The Act opens by stating the main purpose of the LHINs is to improve the health of people living in Ontario. But reading through the rest of the Act, and watching what’s happening on the ground, it’s clear the LHINs’ raison d’etre is health services integration – especially the structural integration of organizations that provide health services. Later in my remarks, we

4

offer our thoughts on building an optimal approach to a more integrated health system. But in our view integration – especially structural integration – should be treated as just one means to achieve a longer term goal. Integration should not be viewed as a goal, in and of itself. In our view, the LHINs’ long-term goal should be the establishment of community health and wellbeing systems across their region that promote the best possible health and wellbeing and ensure equitable health outcomes for everyone. This health system must be retooled to deal with the fact that good health is not just something you access in a medical clinic or hospital. Promoting a complete sense of health and wellbeing requires reaching objectives that are currently not listed in the Act. Overall Recommendation:

1. The Act should be enhanced with the following objectives explicitly stated as purposes for the LHINs: • Advance health equity and the reduce health disparities; • Advance upstream interventions that address the root causes of illness – in short,

prevent more in order to treat less; • Conduct comprehensive system planning that advances population health and equitable

access to services; • Develop a high performing Primary Health Care system with the capacity to fulfil its role

as the foundation of the health system; and • Develop a high performing Community-based system.

To implement this overall recommendation, the Committee must ask itself:

• If we are to achieve an integrated community health and wellbeing system that promotes the best possible health and wellbeing for everyone, ensures equitable health outcomes for all, and ensures a sustainable health care system, what are the changes required in the Act to enable the LHINs to achieve this vision and to transform the delivery of health services?

• In ten years’ time, what parts of the system will be the same? More importantly, what parts of the system will be different and how do we enable LHINs to have the tools to transform this system?

Through my remaining remarks, we will provide principles and recommendations for health system transformation, that we believe are essential to achieve this vision.

5

Principle #1: Equitable Health Outcomes Only in the preamble of the Act, do we find a commitment to equity briefly mentioned. In the main body of the Act, the need to advance health equity and reduce health disparities is not explicitly mentioned. The provincial government‘s Health Equity Impact Assessment Tool describes health equity this way. “Within the health system, equity means reducing systemic barriers in access to high quality health care for all by addressing the specific health needs of people along the social gradient, including the most health-disadvantaged populations. “ In Ontario, the need for the LHINs to reduce these systemic barriers is urgent. Consider these facts:

• Aboriginal Peoples have, on average, lower life expectancies and higher rates of serious chronic diseases such as diabetes, heart disease, cancer and asthma.

• Francophones rate their overall health lower than the rest of Ontarians. They have a higher rate of heart disease and are less likely to visit a healthcare facility.

• Many of these populations live in poverty. Research shows Canadians with the lowest incomes are twice as likely to use health care services.

• People who live in Ontario's northern regions lose more years to premature death than the national average.

• South Asians, the largest racialized group in Ontario, have diabetes rates of 11-14%, compared to 5-6% for non-racialized Ontarians.

• Immigrant women find it more difficult than Canadian-born women to access the resources they need to stay healthy.

• Lesbian, gay, bisexual and transgendered people have larger health risks, mainly because of social marginalization and the stress of coping with prejudice and discrimination.

AOHC contends both the Province and the LHINs can do much more to advance equitable health outcomes and reduce health disparities. The Ministry has developed a powerful Health Equity Impact Assessment (HEIA) tool that is specifically designed to identify and mitigate unintended impacts of any health initiative on health outcomes prior to implementation. Yet in the Minister’s Ontario’s Action Plan for Health Care, Health Links or any provincial initiative, there is no mention of HEIA or how it could be applied.

6

Principle #2: Focus upstream so we can prevent more and treat less Effective treatment of illness is critical to the health and wellbeing of all Ontarians and we continue to support the role of the LHINs to continuously improve the treatment of illness. But if we want to ensure the health and wellbeing of everyone in Ontario and sustain our health care system, the LHINs must place a stronger focus on preventing more in order to treat less. Population health and system sustainability will improve if both the Province and the LHINs apply a stronger focus on prevention, especially prevention efforts that address the broad determinants of health. As things now stand Ontario currently applies a downstream, as opposed to an upstream approach. We are not doing enough to build systems and supports to deal with the non-medical factors that affect health and wellbeing. Most LHINs currently see their mandate as “health care” and not “health”. This is clearly reflected in what LHINs are measuring and not measuring, funding and not funding.

• 14 of the 15 LHIN performance indicators apply to measures related to serious, acute, surgical or emergency situations or the excess use of emergency or alternate levels of care. One indicator is about timely access to in-home services for seniors.

• There are no indicators that measure how well LHINs are doing keeping the population they serve in good health, or that measure health equity.

• Several HSPs, including community health centres provide a wide range of upstream services, including assisting with housing, education, employment, food security, yet the LHINs are not mandated to understand or learn how these services impact the health of the most vulnerable populations. LHINs have not significantly funded these services and have shown little interest in measuring the health outcomes of this work.

Recommendations for Equitable Health Outcomes

1. The objects in the Act should be expanded to ensure equitable health outcomes and the reduction of health disparities for all people living in Ontario, with a particular focus on First Peoples, Francophone, people living in poverty, racialized, new immigrants, LGBT (lesbian, gay, bisexual, transgendered), people living with disabilities and other people experiencing barriers to equitable health outcomes.

2. The Ministry LHIN Performance Agreements (MLPA) should include the requirement that the HEIA (Health Equity Impact Assessment) be used in all regional planning and the implementation of province-wide initiatives such as Health Links.

7

• With the exception of healthy eating and active living programs, health promotion efforts are also not well funded by the LHINs. The same holds true for community development initiatives that address systemic barriers, address root causes of illness and build community capacity and resilience. These are seen to fall outside the scope of the LHINs.

Health and wellbeing indicators must be developed alongside the more clinical indicators. This will enable the LHINs to have a more fulsome understanding of how working upstream can contribute to health and wellbeing. Such indicators also ensure that service providers are recognized and accountable for this work.

Principle #3: Population health planning Planning needs to take a population needs-based planning approach. Public health’s mandate is population health and they have significant resources, especially in epidemiology. Yet in many areas LHINs and Public Health Units work in silos, duplicating and not sharing information. LHINs should be mandated to work with the Public Health Units as co-partners. The goal: to understand what trends will need to be addressed in long-term regional health system planning. LHINs must also plan specifically for the Aboriginal and First Nations and Francophone populations. Under the Act, the Minister is required to establish two Councils: an Aboriginal and First Nations health council and a French language health services advisory council. Under regulation, Francophone and Aboriginal Planning entities are to be established.

Recommendations to prevent more in order to treat less:

1. The Act must be amended to expand the LHIN’s purpose and objectives to encompass health promotion and illness prevention, with a strong focus on addressing the broad determinants of health.

2. Health and wellbeing performance indicators must be developed at the Ministry, LHIN and HSP level; the LHINs should be held accountable through the MLPA; and the Health Service Providers should be held accountable through the Multi-Sectoral Accountability Agreements (MSAAs).

3. Like HSPs, LHINs should partner with other regional partners, such as the school and justice system, to collaborate on addressing some of the upstream issues that have a direct impact on the health and wellbeing of the people in their regions.

8

There has been no progress on the Aboriginal and First Nations health council or planning entities. The French language health services advisory council meets very sporadically and the French Language Services Planning Entities are being operationalized. The French Language Services Planning Entities sign accountability agreements with the LHINs. Given that the First Peoples (First Nations, Aboriginal, Metis and Inuit) communities and the Francophone community have distinct and specific histories, and legal and constitutionally-protected rights, these advisory councils and planning entities need to be established to ensure respect, inclusiveness and equity. Given the poor health outcomes of these two populations, the Minister through the advisory councils, must make it a priority to develop a provincial First Peoples and a provincial Francophone health plan that is culturally safe, competent and appropriate. The regional planning entities then need to be empowered to work in partnership with the LHINs to implement these plans at a regional level. As such the accountability to report to the LHINs needs to be reviewed.

Principle #4: Comprehensive System Planning across the Full Continuum To create integrated community health and wellbeing, comprehensive system planning is required. LHINs should be the planners for the full continuum of the health system equipped with the authority, accountability and resources to do an effective job. Hospitals should not drive regional health planning. If they do, the system will continue to be focussed on illness and the shift to health promotion and disease prevention will not occur.

Recommendation for population health planning:

1. The Act should be amended to mandate the requirement that LHINs and the Public Health Units collaborate in the development of population needs-based plans that apply a health equity lens.

2. The Aboriginal and First Nations health council and planning entities regulation must be implemented.

3. The MOHLTC needs to work with the Aboriginal and First Nations Council and the Francophone Council to establish culturally appropriate health care plans. Primary health care should be considered a priority.

4. The reporting mechanisms of the Aboriginal and First Nations and the Francophone Planning Entities reporting through the accountability agreement to the LHIN needs to be reviewed to ensure the Planning Entities can fulfil their mandate.

9

To ensure a more seamless system, LHINs should plan for a person’s journey in and out of various parts of the health system throughout their life span. To do this they need to be responsible to plan and coordinate the entire continuum of care. This will ensure successful transitions for people moving through the health system, as well as more efficient use of resources and skills, fewer errors, and improved experience for the people accessing services and their caregivers. To enable this all remaining direct service programs at MOHLTC should be transferred to the LHINs, including HIV Aids, underserviced area, and Hep C among others.

If some part of the health system is not under the jurisdiction of the LHINs, they need to collaborate to ensure integrated and coordinated services are provided (i.e. Emergency Medical Services and Municipalities).

There is increasing agreement that Primary Care is the foundation of the health care system. It should be a key door where individuals intersect with the health system through various points in their life journeys. Yet primary care is the most fragmented, siloed, provider centric part of the health system. The LHINs have stated that they want primary care to be accountable to the LHINs. We would go further. The LHINs need to be responsible to plan for primary care, not just hold them accountable once the providers themselves, or the Ministry has decided who goes where. Gone are the days when a solo physician or nurse practitioner should be able to open an office where they please.

• In the SE LHIN, in partnership with their public health unit, the LHIN conducted a study to measure ‘deprivation’ and then mapped it against the current primary care provider supply. The results were predictable. The areas with the highest material and social deprivation (i.e. the poorest areas) had the least access to physicians and the areas with the more well-to-do areas had an oversupply of physicians.

• In another rural area, seven physicians are over the age of 65, and several are over 75 - all with large numbers of enrolled patients. What is the transition plan? Who is responsible? Should they be replaced with seven physicians or with an interprofessional team of some mix of physicians, nurse practitioners, dietitians, social workers?

In addition, like everything else in life, one size does not fit all. Primary care models need to be developed to meet the needs of the community. This means that a mix of primary care models that are designed to meet the diverse needs of the communities, and that are evidenced- based, should be implemented. Finally, primary health care planning conducted by the LHINs should build towards an ultimate goal that all Ontarians have access to an interprofessional team. This would involve developing

10

a transition strategy that is incremental and is developed taking into consideration retiring or moving physicians, new graduates, as well as (by choice) existing physicians migrating from fee-for-service into interprofessional teams.

Principle #5: High Performing Primary Health Care A strong primary health care system must serve as the foundation of the health care system to keep people healthy and out of hospitals. We believe that there are several key elements of a high performing primary health care system. We will focus on a few today as they relate to the LHIN review. As stated earlier in my remarks, we believe that interprofessional primary health care teams should be the model of the future so that all Ontarians have access to an interprofessional teams. We also believe that in an efficient and effective high performing primary health care system that all members of the team should work to their full scope of practice. This will not only ensure continuity of care with integrated and coordinated care for the people we serve, it will also be more efficient and sustainable for the health care system. As a high performing system, we believe that all primary health care organizations should provide system navigation and care coordination for the people they serve, including as they transition in and out of other parts of the health, community and social service systems, throughout their life spans.

Recommendations for Comprehensive System Planning

1. MOHLTC should transfer to the LHINs the remaining provincial programs that provide direct services.

2. The Act should be amended to include Interprofessional Primary Health Care Organizations as health service providers.

3. The objects in the Act should be amended to mandate the LHINs to plan and implement a primary health care delivery system that is population needs-based, is evidence informed and ensures an appropriate mix of models to meet the diverse needs of communities.

4. In the MLPA, the mechanisms should be outlined to develop a transition strategy to enable interprofessional primary health care organizations to be the model of the future for all people in Ontario.

11

Principle 6: Champion a culture of service integration The sustainability of Ontario’s health system depends on our ability to keep people in Ontario healthy and avoid the need for more costly care. A high performing community- based service sector is another foundational piece to achieving this goal. AOHC envisions strong community-based services that address the determinants of health and which are integrated, coordinated and efficient, working in partnership with the long-term care and acute care systems. And we endorse a health system for Ontario where every door leads to appropriate and effective services which is people-centred and coordinated at the local community level. This requires a province-wide culture of service integration across health sectors and providers, championed by the MOHLTC and the LHINs. The true test of any integration initiative is whether or not it enhances the care, improves health outcomes and results in improved quality of life for the person. AOHC, along with Addiction Mental Health Ontario (AMHO), and Ontario Community Support Agencies, (OCSA), supports integration initiatives that reflect well researched best practices, including:

• Potential benefits to the client can be clearly demonstrated; • The initiative is perceived by those involved as beneficial to the community; • The integration process is driven from the bottom up; • Relationships are voluntary, not mandated; • Implementation is collaborative; • The community is actively engaged in the integration process; • The process fosters positive working relationships and stronger linkages among services

and across sectors; • The needs and values of each community are reflected in the structures and services

that ultimately result from the integration initiative; and • The values, cultures and traditions of the not-for-profit sector are respected and

supported.

A primary role of the LHINs is to promote integration of the local health system to provide appropriate coordinated, effective and efficient health services. As we all know, the Act identifies five strategies ranging from coordination and partnering, to amalgamating services

Recommendations for High Performing Primary Care:

1. The LHINs should fund and support the interprofessional primary health care teams to be appropriately resourced to enable all members to work to their full scope of practice.

2. Interprofessional Primary Health Care Organizations should be resourced to provide system navigation and care coordination as people navigate in and out of the health care and social service system throughout their life span.

12

and cessation of operations. The LHINs’ current work on integration seems to be too focussed on structural integration – back office integration and reducing the number of health service providers. This does not necessarily lead to better service that meets community needs. In fact one health service provider recently presented a new service integration to the LHIN. There were no cost savings but there was improved and more coordinated care. The LHIN response was “that is fine for year one but by year two I expect financial savings”. In another LHIN, for the past three years, there was an attempt to merge all the mental health agencies into one LHIN wide agency. In the end, it was going to cost more and did not improve care. The initiative was aborted. AOHC believes that we need to have a strong community-based service sector, including community support agencies and mental health and addiction agencies that work together. We believe that if a people-centred approach is applied, along with strong quality improvement incentives and the requirement to meet high standards, then agencies themselves will make decisions that result in positive transformation. Health equity must also be the foundation of any integration. Merging culturally competent and culturally safe organizations with main stream organizations may not achieve equitable health outcomes. Culturally appropriate, safe and competent services must be prioritized in a strong community-based services sector.

Recommendations to champion a culture of service integration:

1. The LHINs must approach service integration from a people-centred and value basis which seeks to achieve enhanced care and improved health outcomes for people, and set high standards for quality of care and accountability.

2. Culturally appropriate, competent and safe services must be considered in any plan to integrate and coordinate community -based services. Aboriginal and First Nations and Francophone services need to be protected and enhanced.

3. The Act needs to be amended to identify the process to establish new health service providers as needed.

4. The power granted to the LHINs to order mergers, amalgamations and the dissolution of organizations must be used sparingly and with great caution.

13

Principle 7: Meaningful community engagement To transform the health system, including moving services from the hospital to the community and developing a robust primary health care and community services requires bold leadership, meaningful community engagement and strong public education. To achieve the health system transformation the community, its leaders and the public, need to support it. The LHINs have stated that community engagement is a core value. And the Act requires the LHINs to “engage with the community of persons and entities involved with the local health system in planning and setting priorities.” This includes establishing formal channels for community input and consultation, and ensuring processes to respond to people’s concerns. We are mindful community engagement is an area where LHINs face much criticism. Our assessment is that some LHINs perform better than others.

• According to our members, many of the LHINs collect information via surveys. These formal mechanisms do not reach the more vulnerable populations and many people who face barriers to access – whether through language, culture, geography or poverty.

• When the LHINs bring stakeholders together they often do not explain why they are engaging the community, the issues with which they are grappling and what the different options are to address the issues.

• The most common concern we have heard from our members is that while they do have opportunities to provide input at meetings organized by LHINs, they often have the impression this input has not been incorporated into decision making.

• There is little public discourse or public education to discuss the need to transform the system and to gauge the community readiness for change.

In a 2006 study commissioned by AOHC, a literature review revealed early evidence that suggests community engagement increases the health of communities and the effectiveness of health care. [Karen Patzer “A Review of the Trends and Benefits of Community Engagement and Local community Governance in Health Care”] This and other studies have pointed out different levels of community engagement.

• Less meaningful engagement involves decision-makers simply sharing information, or consulting to gather information.

• More meaningful types of engagement facilitate the active participation of community members in contributing to decisions that are being made.

AOHC contends that most LHINs engage at the level of sharing information or consulting to gather information. And in some LHINs there are few meaningful opportunities for members to contribute to decisions that are made. We are pleased that the need for community governance is not being questioned and that the LHINs support that community governance continue. This is one of the strengths of the ‘made in Ontario’ regional health authority and what makes the LHINs unique.

14

However, we do not believe that the LHINs have successfully harnessed the power of community governance. Community governance is the highest level in the hierarchy of community engagement and is a powerful tool to ensure effective community engagement and local volunteerism. Yet LHINs rarely meet with board members of HSPs in meaningful engagement. We also do not believe community governance should be misrepresented as one large not-for profit board of directors over a region the size of a LHIN or other large geographic areas. To us, this is not community governance. To embrace community is to tap into the core organism of a community – it may be culturally based, language based, geographically based. The size is not as important as the sense of common principles, values and sense of purpose. Community is not defined in the Act. As the Committee begins its cross province hearings, we urge you to ask your delegations what community means. We further urge you to explore this idea over the course of the year. Understanding and getting community right, is core to engaging the support required to transform the health system.

Recommendations for meaningful community engagement:

1. Community governed not-for profit health service providers must be maintained.

2. Community must be defined and the Act amended accordingly.

3. The LHINs need to build their knowledge and capacity to conduct meaningful community engagement.

4. The LHINs need to engage with the public, communities and health service providers as partners to transform the health system.

5. LHINs need to do public education on how the health system changes will improve the health and wellbeing of the person, their families and their community.

6. LHINs should be held accountable for their community engagement process, clearly outlining the process and reporting on the number of complaints per year in their MLPAs.

7. Like HSPs are required to do client satisfaction surveys, LHINs should be required to do independent community engagement satisfaction surveys of community and HSPs and report annually.

8. Community governed not-for profit health service providers must be maintained.

15

Principle # 8: Appropriate resourcing Health service providers in the community sector (Community Health Centres, community and home support services, and mental health and addictions services) need to be appropriately resourced in order to play a more effective role in Ontario’s health care system. To reflect the shift from acute care to community, the capacity and infrastructure of the community health sector must be strengthened, with investments in capital, human resources, operations, information management systems, and quality improvement. A “one way valve” funding mechanism needs to be entrenched into the Act prohibiting the flow of funding from community health organizations into acute care institutions, and should include protection of community organizations from supplementing deficits incurred in other parts of the health system. The allocation and re-allocation of resources within and across LHINs should be permitted only as a flow from acute care institutions to community-based services. There are policy inconsistencies within MOHLTC and capital which are significant barriers to the implementation of integrated community-based services:

• Community support services are not eligible for capital funding at all; • Programs funded by MOHLTC and not by the LHINs are not eligible under the

community capital process; • Systemic barriers exist to plan community hubs – even when all the agencies are LHIN

funded; and • Programs such as Early Years, immigrant services, even if it contributes to the

operations of the building, are not eligible to be considered.

The policies are so incongruous that an integrated community support and CHC organization (one HSP) is eligible for the CHC programs but not the community support services part of their one organization.

16

Principle 9: LHIN and HSP accountability Under the stewardship of MOHLTC, which sets the vision, strategy and standards for Ontario’s health care system, the LHINs must be accountable for the planning and implementation of a high performing, integrated, coordinated delivery system that ensures equitable health outcomes and the best possible health and wellbeing for everyone living in their region. In the current MLPA, the LHINs are accountable for 15 performance indicators. As stated earlier, all but one is acute care related. LHINs are not measured or held accountable for any other part of the health system. There are no indicators that relate to overall health and wellbeing or equitable health outcomes. While there are strategies for seniors, the LHINs are not measuring or being held accountable to ensure equitable outcomes for Aboriginal seniors, Francophone seniors or immigrant seniors or seniors with serious mental health challenges. This sends a signal to the other HSPs that only the acute system matters.

Recommendations for appropriate resourcing:

1. The Act should be amended to establish a “one way valve” prohibiting the flow of funding from community health organizations into acute care institutions; include protection of community organizations from supplementing deficits incurred in other parts of the health system.

2. As submitted by the LHINs, the regulation should be enacted that permit the LHINs and the Health Service Providers to receive multi-year funding and carry forward surplus.

3. MOHLTC needs to significantly invest in community-based services in order to increase the capacity and infrastructure of community support agencies and not just in programs.

4. The LHINs need to strengthen the capacity of the community health sector by prioritizing investment in human resources, operations, information management systems, and quality improvement.

5. The MOHLTC and the LHINs need to align the capital policies to support the development of integrated and coordinated community services allowing for business plans that include co-locations, creation of community hubs and ensuring all LHIN and MOHLTC funding is considered eligible for space in the capital planning.

6. HSPs need to be able to submit funding requests for urgently needed programs and services for high needs populations that often do not align with Ministry and LHIN priorities. This is essential to advance health equity and to achieve equitable health outcomes.

17

While recognizing there must be accountability of the LHINs to the MOHLTC as funder, the LHINs should also be accountable to the local community of persons and organizations for whom they are planning the local health system. There should be avenues of recourse if the community deems there has been insufficient engagement or response to the needs and priorities articulated by local people and health service providers. In addition, CHCs, community support agencies, mental health and addiction organizations are held accountable to their LHINs through a Multi-Sectoral Accountability Agreement (MSAA) which has a list of indicators and reporting requirements. Over the past seven years, the HSPs have matured, yet the LHIN does not demonstrate confidence in the governance and leadership of the HSP; effective and efficient HSPs feel very micromanaged. The accountability agreement is not designed to enhance partnership, collaboration or innovation. The accountability is one way. Only if the LHIN determines it appropriate, will a remedy process be implemented. The agreement is built on an assumption of trust and strong relationships. If that is missing, there is no recourse for the HSP. There is no appeal process if the Health Service Provider believes the LHIN has materially breached its role.

Recommendations for accountability

1. The MLPA should: • measure the health and wellbeing outcomes of the people they serve through a

health equity lens and these measures should reflect the full continuum of care; and

2. Require that the LHINs conduct community engagement satisfaction surveys and HSP satisfaction surveys

3. The Act should be amended to include an appeal or resolution process that requires MOHLTC to take action if community feedback indicates dissatisfaction with the extent and quality of community engagement undertaken by the LHIN.

4. The Act should identify an appeal process for HSPs if the LHIN has been alleged to breach their role.

5. While recognizing the fiduciary, oversight and planning responsibilities of the LHIN, the HSP accountability agreements need to be more collaborative and engage HSPs more as partners.

18

In conclusion: We have shared with you our initial thoughts and suggestions on the vital role of the LHINs in establishing the best possible health and wellbeing for everyone; a system that ensures equitable health outcomes; and results in a sustainable health system. We look forward to your questions as we explore some of these ideas more deeply.

19

Summary of recommendations Overall Recommendation:

1. The Act should be enhanced with the following objectives explicitly stated as purposes for the LHINs: • Advance health equity and the reduce health disparities; • Advance upstream interventions that address the root causes of illness – in short,

prevent more in order to treat less; • Conduct comprehensive system planning that advances population health and equitable

access to services; • Develop a high performing Primary Health Care system with the capacity to fulfil its role

as the foundation of the health system; and • Develop a high performing Community-based system.

Recommendations for Equitable Health Outcomes

1. The objects in the Act should be expanded to ensure equitable health outcomes and the reduction of health disparities for all people living in Ontario, with a particular focus on First Peoples, Francophone, people living in poverty, racialized, new immigrants, LGBT (lesbian, gay, bisexual, transgendered), people living with disabilities and other people experiencing barriers to equitable health outcomes.

2. The Ministry LHIN Performance Agreements (MLPA) should include the requirement that the HEIA (Health Equity Impact Assessment) be used in all regional planning and the implementation of province-wide initiatives such as Health Links.

Recommendations to prevent more in order to treat less:

1. The Act must be amended to expand the LHIN’s purpose and objectives to encompass health promotion and illness prevention, with a strong focus on addressing the broad determinants of health.

2. Health and wellbeing performance indicators must be developed at the Ministry, LHIN and HSP level; the LHINs should be held accountable through the MLPA; and the Health Service Providers should be held accountable through the Multi-Sectoral Accountability Agreements (MSAAs).

3. Like HSPs, LHINs should partner with other regional partners, such as the school and justice system, to collaborate on addressing some of the upstream issues that have a direct impact on the health and wellbeing of the people in their regions.

20

Recommendation for population health planning:

1. The Act should be amended to mandate the requirement that LHINs and the Public Health Units collaborate in the development of population needs-based plans that apply a health equity lens.

2. The Aboriginal and First Nations health council and planning entities regulation must be implemented.

3. The MOHLTC needs to work with the Aboriginal and First Nations Council and the Francophone Council to establish culturally appropriate health care plans. Primary health care should be considered a priority.

4. The reporting mechanisms of the Aboriginal and First Nations and the Francophone Planning Entities reporting through the accountability agreement to the LHIN needs to be reviewed to ensure the Planning Entities can fulfil their mandate.

Recommendations for Comprehensive System Planning

1. MOHLTC should transfer to the LHINs the remaining provincial programs that provide direct services.

2. The Act should be amended to include Interprofessional Primary Health Care Organizations as health service providers.

3. The objects in the Act should be amended to mandate the LHINs to plan and implement a primary health care delivery system that is population needs-based, is evidence informed and ensures an appropriate mix of models to meet the diverse needs of communities.

4. In the MLPA, the mechanisms should be outlined to develop a transition strategy to enable interprofessional primary health care organizations to be the model of the future for all people in Ontario.

Recommendations for High Performing Primary Care:

1. The LHINs should fund and support the interprofessional primary health care teams to be appropriately resourced to enable all members to work to their full scope of practice.

2. Interprofessional Primary Health Care Organizations should be resourced to provide system navigation and care coordination as people navigate in and out of the health care and social service system throughout their life span.

21

Recommendations to champion a culture of service integration:

1. The LHINs must approach service integration from a people-centred and value basis which seeks to achieve enhanced care and improved health outcomes for people, and set high standards for quality of care and accountability.

2. Culturally appropriate, competent and safe services must be considered in any plan to integrate and coordinate community -based services. Aboriginal and First Nations and Francophone services need to be protected and enhanced.

3. The Act needs to be amended to identify the process to establish new health service providers as needed.

4. The power granted to the LHINs to order mergers, amalgamations and the dissolution of organizations must be used sparingly and with great caution.

Recommendations for meaningful community engagement:

1. Community governed not-for profit health service providers must be maintained.

2. Community must be defined and the Act amended accordingly.

3. The LHINs need to build their knowledge and capacity to conduct meaningful community engagement.

4. The LHINs need to engage with the public, communities and health service providers as partners to transform the health system.

5. LHINs need to do public education on how the health system changes will improve the health and wellbeing of the person, their families and their community.

6. LHINs should be held accountable for their community engagement process, clearly outlining the process and reporting on the number of complaints per year in their MLPAs.

7. Like HSPs are required to do client satisfaction surveys, LHINs should be required to do independent community engagement satisfaction surveys of community and HSPs and report annually.

8. Community governed not-for profit health service providers must be maintained.

Recommendations for appropriate resourcing:

1. The Act should be amended to establish a “one way valve” prohibiting the flow of funding from community health organizations into acute care institutions; include protection of

22

community organizations from supplementing deficits incurred in other parts of the health system.

2. As submitted by the LHINs, the regulation should be enacted that permit the LHINs and the Health Service Providers to receive multi-year funding and carry forward surplus.

3. MOHLTC needs to significantly invest in community-based services in order to increase the capacity and infrastructure of community support agencies and not just in programs.

4. The LHINs need to strengthen the capacity of the community health sector by prioritizing investment in human resources, operations, information management systems, and quality improvement.

5. The MOHLTC and the LHINs need to align the capital policies to support the development of integrated and coordinated community services allowing for business plans that include co-locations, creation of community hubs and ensuring all LHIN and MOHLTC funding is considered eligible for space in the capital planning.

6. HSPs need to be able to submit funding requests for urgently needed programs and services for high needs populations that often do not align with Ministry and LHIN priorities. This is essential to advance health equity and to achieve equitable health outcomes.

Recommendations for accountability

1. The MLPA should: • measure the health and wellbeing outcomes of the people they serve through a

health equity lens and these measures should reflect the full continuum of care; and

2. Require that the LHINs conduct community engagement satisfaction surveys and HSP satisfaction surveys

3. The Act should be amended to include an appeal or resolution process that requires MOHLTC to take action if community feedback indicates dissatisfaction with the extent and quality of community engagement undertaken by the LHIN.

4. The Act should identify an appeal process for HSPs if the LHIN has been alleged to breach their role.

5. While recognizing the fiduciary, oversight and planning responsibilities of the LHIN, the HSP accountability agreements need to be more collaborative and engage HSPs more as partners.

23

Appendix: Model of Health and Wellbeing The Values and Principles that unite us: Highest Quality People and Community Centred Health and Wellbeing

• Everyone participates, individually and collectively, in decisions about their health and wellbeing.

• Individuals and communities receive health care that meets their needs, in a timely fashion and from the most appropriate providers, and experience the best possible results.

• Health care and other service providers work in respectful, collaborative relationships with individuals, families, and communities and each other.

• The quality of care is optimized through continuous innovation and learning to improve the experience and outcomes of those accessing care, and the efficient use of resources.

Health Equity and Social Justice

• Reduction in social inequality improves Health outcomes. • Social inequality is reduced when all people and institutions become aware of, and act

on the understanding, that inequality impacts health outcomes for the already marginalized populations.

• Equity and dignity and integrity of the person is manifest in access to nutritious food, safe and secure housing, clean water, adequate and appropriate clothing, dignified and justly-remunerated employment.

• Health care appropriate to all ages and stages of life, and mechanisms of fulsome engagement and participation in civic, social and political processes.

Community Vitality and Belonging

• Safe and caring communities improve health outcomes. • Shared values and shared vision strengthen belonging. • All members of the community have opportunities to participate in decision making

about their communities. • Public, private sectors and community organizations work together to strengthen

inclusive, caring and connected communities.

24

Attributes of the Model of Health and Wellbeing are: Anti-oppressive and Culturally Safe: AHACs and CHCs provide services in anti-racist, anti-oppressive environments that are safe for people: where there is no assault, challenge or denial of their identity, of who they are and what they need. It is about shared respect, shared meaning, shared knowledge and experience, of learning, living and working together with truth, respect, honesty, humility, wisdom, love and bravery. In practice we emphasize the presence of people from various cultural and linguistic backgrounds, resulting in their ability to control or influence the processes operating in their health services, and we believe this is one of the major ways to create a safe environment. Accessible: CHCs and AHACs are designed to improve access, participation, equity, inclusiveness, and social justice by eliminating systemic barriers to full participation. CHCs and AHACs have experience in ensuring access for people who encounter a diverse range of racial, cultural, linguistic, physical, social, economic, legal, and geographic barriers which contribute to the risk of developing health problems. Removing barriers to accessibility includes the provision of culturally appropriate programs and services, programs for the non-insured, optimal location and design of facilities in compliance with the accessibility legislation, oppression-free environments, extended hours, and on-call services. Interprofessional, integrated and coordinated: CHCs and AHACs build interprofessional teams working in collaborative practice. In these teams, salaried professionals work together to their fullest possible scope to address people’s health and wellbeing needs. CHCs and AHACs develop strong partnerships and integrations with health system and community services organizations.

25

The partnerships and integrations ensure the delivery of seamless and timely people and community-centred health, and key social determinants of health services and programs, with appropriate referrals. Referrals encompass primary care, illness prevention, and health promotion, in one to one service, personal development groups, and community level interventions. Community-governed: CHCs and AHACs are not-for-profit organizations, governed by community boards made up of members of the local community. Community boards and committees provide a mechanism for CHCs and AHACs to represent and be responsive to the needs of their local communities, and for communities to develop democratic ownership over “their” Centres. Community governance builds the health of the local communities through engaged participation contributing to social capital and community leadership. Based on the Social Determinants of Health: The health of individuals and communities is impacted by the social determinants of health including income, education, employment, working conditions, early childhood development, food insecurity, housing, social exclusion, social safety network, health services, Aboriginal status, gender, race and racism, culture and disability. CHCs and AHACs strive for improvements in social supports and conditions that affect the long-term health of people and communities, through participation in multi and cross-sector partnerships and advocacy for the development of healthy public policy, within a population health framework. Grounded in a Community Development Approach: The CHC and AHAC services and programs are driven by community initiatives and community needs. The community development approach builds on community leadership, knowledge, and the lived experiences of community members and partners to contribute to the health of their communities. CHCs and AHACs increase the capacity of local communities to address their community-wide needs and improve their community and individual health and wellbeing outcomes. Population and Needs-Based: CHCs and AHACs are continuously adapting and refining their ability to reach and to serve people and communities. CHCs and AHACs plan services and programs based on population health needs and develop best practices for serving those needs. Accountable and Efficient: CHCs and AHACs are high performing efficient Primary Health Care (PHC) organizations that are accountable to their funders and the local communities served. CHCs and AHACs strive to provide fair, equitable compensation and benefits for their staff. Capturing and measuring their work are essential parts of delivering Primary Health Care. Developing and implementing meaningful indicators based on our Model of Health and Wellbeing allows for reporting to all funders about services and programs delivered as well as the outcomes that follow.