Service Realignment

History that brought us here

We have completed several planning exercises since 2012 to provide us with the opportunity to examine what we are doing, what we expect the future of health care will look like for our community and region, and to ensure we are providing access to the right care for our patients today and tomorrow.

Our newly-defined Master Program will support, improving quality maximizing efficiencies, improved length of stays, patients receiving care in the most appropriate place, the right sizing of beds and a balanced budget.

The hospital move and transferring health care dollars into the community

Initially we were focused on the development of the new hospital and amalgamation of the former North Bay General Hospital and the Northeast Mental Health Centre. Our recent and current planning activities are critical as we move forward in response to a healthcare system challenged by the growing needs of our patients and limited by the fiscal realities of the province and an ever evolving healthcare system.

The pace of system change, the move to the new hospital along with our focus on the amalgamation caused us to fall behind from where we need to be regarding service delivery modeling and efficiency. As a result, the hospital must continue to manage major change processes while continuing with normal operations. Our work thus far is beginning to move us from a reactive approach of doing business to a proactive approach.

There is a movement by the government to invest more dollars in community-based care while acute care investment decreases. As a team, we at NBRHC have made many positive improvements over the past two years by increasing community and out-patient services, reducing the need for hospitalization through more ambulatory services, and working with community partners to improve the transition patients make from hospital discharge to community.

Operational Review conducted in 2012

In the Fall of 2012 an independent review was conducted of NBRHC operations to maximize opportunities associated with the unique operating structure and services of the amalgamated district acute and regional mental health programs established in the newly formed organization.

This Operational Review provided a solid overview of where NBRHC excels and where it falls below its peer comparator hospitals. The hospital committed to improving operations and finding efficiencies that would put NBRHC at the median of its peer comparators while ensuring quality patient care remains our number one priority. Our plan was to deal with the report’s 13 recommendations, within the following 3 themes: Performance Management, Access and Partnership.

The Operational Review identified issues associated with our length of stay and admission practices along with a number of other opportunities for improvement. It became clear that if we are to manage in an environment of zero or negative funding increases we need to consider how we can do things differently. In order to make changes in our service delivery model, we require approval from the LHIN (Local Health Integration Network) and the MOHLTC (Ministry of Health and Long term Care).

Strategic Plan developed in winter 2013

The outcomes and recommendations of the Operational Review formed the baseline for a Board led process to develop a new multi-year Strategic Plan including refreshing of the Mission, Vision and Values, Strategic Directions and Objectives. The hospital used the NE LHIN’s IHSP (Integrated Health Services Plan) for the development of the Plan. The strategic planning process involved significant input from partners, staff, volunteers and physicians.

The strategic directions and associated objectives identified by the Board in the Strategic Plan were translated into metrics and captured on a Corporate Scorecard for monitoring. These items were also used to develop 80+ departmental scorecards cascaded throughout the organization. These scorecards ensure that everyone in the organization understands their role and how their improvement work ties back to the strategic priorities of the organization.  We have incorporated the reporting of our performance on the Corporate Scorecard into the routine business of the Quality Committee and the full Board of Directors.

Master Program Development 2014

The Master Program reflects the vision and mission of the North Bay Regional Health Centre, and incorporates the current understanding of best practices in service delivery. Participation in the planning process represents a unique opportunity to mould future service provision and make major changes to the working environment to accommodate new service delivery models.

The need to complete a Master Program was first identified following the move of our 31 patients to Kirkwood Place in Sudbury. When the decision regarding the move was made in 2010 by the LHIN, we made it clear to the LHIN/MOHLTC that we had to develop a facility development process for that site. As such a plan for the development of appropriate facilities would need to be developed. The MOHLTC established the process relative to proposed Capital projects. We submitted a Pre-capital submission for Kirkwood Place in October 2011 and received approval to proceed with a Stage 1 submission in December of the same year. The completion of a Stage 1 submission necessitates having a current Master Program and Master Site Plan. These documents did not exist for the organization therefore work commenced in January 2012 to secure a consulting firm to assist with this work.

The impetus for this Master Program endeavor was originally the examination of short and long-term needs for Kirkwood Place. The project was then expanded in scope to include the organization as a whole, which allowed the hospital to think more globally and thoughtfully about its needs, opportunities and constraints going forward.

The healthcare needs of our population have changed significantly as has the way in which service is delivered. To adapt to these changes, we needed to redesign our service delivery systems. We completed an updated Master Program for the organization. This aligns directly to our strategic plan and associated mission, vision and values. This work commenced in August 2013 and was approved by the Board and LHIN in the spring of 2014.  The plan that was approved identified that a further work effort was required relative to our Regional Mental Health services.

NBRHC Service Realignment 2014

The outcome of the Master Program highlighted the need for significant service realignment. The goal of realigning our services is to improve access to care, transitions and fiscal stewardship. All decisions regarding realignment were made to provide care for our patients today and tomorrow. To ensure this continues to occur, we have implemented a continuous quality improvement system and defined quality targets. We will be closely evaluating our performance and keeping our community aware of how we are doing. NBRHC has been working to change the services it provides to meet the needs of the community. A short video entitled Reshaping Care literally draws the picture of service realignment at NBRHC.

As partners in care, we should be doing what is right for our patients – providing them with the quality care they need, where they want it – at home, in the community or in their setting of choice. Patients want to receive care in the community and at home, and only access the hospital when truly required. As a team, we at NBRHC have made many positive improvements over the past two years by increasing community and outpatient services, reducing the need for hospitalization through more ambulatory services, and working with community partners to improve the transition patients make from hospital discharge to community. Because of this improved coordination and transitions of care, we no longer require the same numbers of beds as we did in past years; demand on inpatient services is also decreasing.

Significant Improvements Already Made

• Massive reduction in ALC days
• Mental Health Transition Home – 16 new beds in Sudbury and North Bay
• Forensic Mental Health Transition Home – 4 new beds in North Bay
• Breathing Clinic – experiencing marked reduction in readmission rates
• Behaviour Supports Ontario (BSO) funding to establish NBRHC as lead Health Service Provider
• NBRHC selected as the HSP sponsor for Northeast Specialized Geriatric Services
• Physician recruitment – 28 new physicians since 2011
• Additional funding received for Forensics Services
• Review and improvement of coding practices
• 6 beds closed on  Medicine – January 2014
• 6 Beds closed on AIPU – April 2014
• 8 beds closed on Surgery – June 2014
• 8 beds closed on Medicine – September 2014
• Better utilization of Long term Care (LTC) capacity
• Investments in Quality and Performance Excellence through More Time to Care Quality Improvement Strategy
• Completed restructuring of our medical leadership team to better support the accomplishments of our strategic imperatives
• Leadership development program supporting leadership at all levels
• Development of Patient and Family partnered care approach to quality improvement and service plan
• Partnership agreements and established performance measures with organizations such as CCAC, PHARA, Phillips Lifeline, and Red Cross to achieve system improvements in the provision of care and services
• Working with community partners in the development of programs to prevent or divert admissions to the Emergency Department or hospital such as the Community Referral from Emergency Medical Services (CREMS), HUB and Mobile Crisis programs
• Collaborating with the NE LHIN and other hospitals across the region to implement Quality Based Procedures (QBPs) together through the application of the recommendations of the Clinical Services Review

Other Opportunities in Progress:

• Acquired Brain Injury Home for Nipissing District – target of 10 beds
• The Community Hospice Committee is considering space at the NBRHC to open a much needed hospice, meeting a community need. The model for palliative care delivery in the organization will be evaluated when the hospice is operational
• Alternate Funding Plan (AFP) for Hospitalists model to manage orphaned patients consistently.
• Ongoing review of coding practices
• Improvements in Long term Care (LTC) utilization and capacity by ensuring only patients with high or very high needs are admitted for care and those with lesser requirements are supported at home or in other community settings
• Continued advocacy for additional capacity in community services such as CCAC, Community Support Services and Assisted Living to divert premature admissions to LTC or hospital
• Ongoing work with our partners in care to define our respective accountabilities and ensure we are all consistently fulfilling them
• Development of a Patient Flow Navigator role and an Estimated Date of Discharge program to reduce unnecessary days in hospital
• Creating consistent practices and policies to support timely discharge of patients across the entire hospital – that is, implementing per diem rates for mental health patients as per the Public Hospitals Act (PHA)
• Submitted a proposal to the NE LHIN to host a district  Behaviour Support Unit (BSU) to fill the  current gap in the provision of specialized care for those with moderate to low-severe responsive behaviours
• Refining our role as a lead agency for Behaviour Supports Ontario (BSO) to assist our families and community partners in the care of those with mild to moderate responsive behaviours
• Strengthening our regional role in Children’s Mental Health to support the North East
• Enhance our role as a provincial leader in the  provision of treatment for women in the forensic mental health system through inpatient and community programs

Mental Health Programming Refinement Stage

The typical approach taken for Master Program development uses past performance, market share, demographic forecasts, along with comparison to peers, to forecast what services should look like in the future. This approach is flawed in terms of our Regional Mental Health programs in that we know we are not satisfied with the past performance of the system and therefore a different approach is required. As part of our analysis we are comparing ourselves to the 9 other Regional Mental Health providers.

The context for this refinement is further influenced by the Provincial budget which sees base funding for hospital corporations remaining frozen while funding for community mental health and home care is indicated to rise significantly. As a major provider of mental health services in the Region, this approach is creating the opportunity to focus our attention on supporting the community sector as we confirm our role as the Region’s specialized mental health provider. The following strategies are in progress as we continue to refine our analysis. This work effort will ensure we provide the right care in the right place at the right time, by the right provider while living within our financial capacity.

Global Strategies in Mental Health:

• New or different programming or services will open the doors to other exciting opportunities (example: Mobile Crisis Service, Youth Forensic Assessment Service, alternative residential supports for people with acquired brain injuries).
• The realignment will offer an opportunity to more closely examine how we will support patients and providers in their communities and make better use of our resources.
• We will maximize the use of technology such as telemedicine.
• We will become recognized leaders in the delivery of specialized mental health consultation, assessment and treatment.
• We will lead, create and participate in regional efforts to improve mental health care
• As partners in care we will work collaboratively with the LHIN, Ministry and Children and Youth Services (MCYS), Ministry of Community Safety and Correctional Services (MCSCS) and other government ministries and community partners to actively pursue additional funding to further enhance the mental health system of care across the region.

Mental Health and the Law:

• The expansion of Maplewood House as a co-ed facility will further improve patient flow and provide women with equitable access to transitional housing and support. It will reduce unnecessary hospital readmissions by providing appropriate supportive accommodation and care for patients living in the community when facing emergent circumstances.
• Approval of our new youth forensic assessment service will alter the trajectory of young people with mental illness who come into contact with the law – giving youth better access to prompt forensic assessments so we avoid these children even entering the adult forensic system.
• We were asked to submit a proposal for a new provincial 8 bed women’s Forensic program. We expect to receive a response before 2015 as to whether our proposal was accepted.
• We have submitted an application to the MCSCS to provide mental health consulting expertise to recommend the service delivery option that can best serve female inmates with major mental illness in Ontario’s correctional facilities.

Seniors Mental Health:

• The Ministry of Health is focusing on community programs and maintaining seniors at home as long as possible.
• The hospital has been providing ongoing custodial care for many patients whose needs could and should be met in the community through LTC or supportive housing or outreach programming.
• The Seniors Mental Health Outreach services and Behaviour Supports Ontario programs will continue to support seniors in the community to assist in meeting the Ministry of Health direction to steer more dollars from the hospital to the community.
• The hospital has been utilizing its beds to a higher degree than our peer comparators across the province.
• The Regional specialized service will focus on the assessment, treatment and transitional care back to communities, resulting in the reduction of the level of custodial care.

Psychiatric Rehabilitation and Recovery Program:

• The hospital has been providing ongoing custodial care for many patients whose needs could and should be met in the community through LTC, supportive housing or outreach programming.
• The hospital has been utilizing its beds to a higher degree than our peer comparators across the province.
• We will renew our efforts to enhance our role as a regional service provider with a focus on the assessment, treatment and transitional care back to communities, resulting in the reduction of the level of custodial care and over reliance on in patient beds.
• We are drafting a proposal for funding for a Regional Behavioural Support Team for the developmental sector comprised of Behaviour Support Technicians supervised by a Board Certified Behaviour Analyst with access to psychiatry (enhance Development Disabilities Outreach Services).
• Submitted proposals/developing partnerships for multiple housing projects with 24/7 staff support including an ABI (Acquired Brain Injury) home; a proposal for a Behavioural Group Home is currently being developed.
• We have identified the need to establish an enhanced Regional Outreach Team which would be multi-disciplinary in nature with access to Peer Support and Aboriginal Services.

Key Challenges as we move forward

While we have made tremendous gains in many areas over the past 2 years, there are key areas we are continuing to address. Recruitment of Emergency and Primary Care physicians remains a crucial issue that we must address urgently. The lack of family physicians in the community drives many residents to seek primary care at the hospital’s Emergency Department as no other alternative is available in the community. Orphaned inpatients create ongoing workload for those general practitioners who provide hospital care as they assume the role of most responsible physician in hospital. This is resulting in more physicians opting out of hospital care and thus a new model is quickly becoming critical. The implementation of Health Links for Nipissing will be key to assist in clarifying this issue and getting consensus on the work that will be required to move this forward.

In the past, the model of care in our mental health program was one of custodial care resulting in excessive lengths of stay and no capacity to support the region. In addition, poor data quality made it difficult to define the need for mental health services in our region. Fragmented and poorly resourced community supports make it extremely challenging to lead health reform. It is crucial that we clearly define our role as a provider to the Northeast region and this must be done collaboratively with key stakeholders. Access to specialized services, development of local capacity in the outlying communities and repatriation all require a concerted work effort.

Mental Health and Addiction Services Review:

Health Sciences North and the North Bay Regional Health Centre (the Partners) will be inviting formal Proposals for a review of the current adult Mental Health and Addictions Services provided throughout the region. The goal is to develop a plan of an optimal inpatient/outpatient and community service model to support people with mental health and addictions issues in the NE LHIN.

Quotes on Health Care in the Provincial Budget speech 2014

“Funding reform is particularly important in the hospital sector to help manage costs as the government is continuing to hold hospitals’ overall base operating funding to zero per cent growth in 2014-15.”

“Ontario is continuing to implement Ontario’s Action Plan for Health Care, which provides the road map for transforming health care services to create a more sustainable and high-quality health care system……increasing investments in [home and community care services] by over $750 million by 2016-17, including over $270 million in 2014-15”

“The government is providing additional funding of $300 million over 10 years to help shift care from hospitals to community settings and ensure adequate infrastructure capacity in the health care sector. This includes the creation of a dedicated Community Infrastructure Renewal Fund that would help community organizations.”

“The government is committed to balance the budget by 2017-18 in a fair and responsible way…Achieving this, however, will require some difficult choices.”

“The Province will continue a careful review of spending to determine which programs should be enhanced or reduced, while transforming public services to increase efficiencies and improve outcomes.”

“Ontario’s hospitals are highly efficient and recognize the province’s financial constraints. That is why we continue to play a leadership role in health system transformation.”

“We have been accelerating our efforts to implement health system funding reform in order to further improve quality of care for patients and drive greater value.”

“These are important initiatives and are part of a strategic effort to expand funding and capacity elsewhere in the system, particularly in the community. But at the same time that the government aims to balance its budget by 2017/18 and hospitals and other providers are implementing very large-scale change initiatives, the system is also preparing for a time of intense pressure. Service demands will continue to grow across the board at the same time that the system moves to further contain cost growth. To help manage this compression, the health system needs a long-term, province-wide capacity plan.”