Our Approach to Improving and Better Connecting Healthcare

Health Equity-Driven Quadruple Aim

We will achieve the following improvements, especially for members of our community who may be marginalized or under-served (e.g., housing situation, economic situation, language spoken):

  • Better health outcomes for people in our community
  • Better patient/client and care partner experience with care
  • Better healthcare provider experience
  • Better value per-capita

Population Health Management

Population Health Management focuses on the health needs of a population, using what we know about populations to help individual people to better design care.

The Middlesex London Ontario Health Team is focused on three key enablers to understand and support our full population:

  • A sustained care relationship between patients/clients and care partners and the Middlesex London OHT – patients/clients and care partners are supported by one team throughout their care journey
  • A shared care record – providers, patients/clients, and care partners can access their care information when they need it
  • An individualized care plan for everyone – patient/clients, care partners, and providers work together to develop a wholistic health plan that is driven by what’s most important to the patients/clients, and care partners

Initial Population of Priority

The Middlesex London OHT will initially focus on improving healthcare and supports for 2,000-3,000 people living with advanced Chronic Obstructive Pulmonary Disease (COPD) and/or Congestive Heart Failure (CHF), who need system-level care coordination or navigation and are at highest risk of hospitalization.

Eventually we will support a population of over 525,000 people with their healthcare needs.

Our Projects

The Middlesex London Ontario Health Team is laying the groundwork to develop a better connected and seamless health care experience between patients/clients, caregivers/care partners and providers. We reached out to local partners to understand the current health care system and identify opportunities to improve care.

Three priorities were established based on local input and provincial OHT priorities:

  • Access to and Awareness of Services
  • Sustained Care Relationships
  • COVID Response and Recovery
  • Health Equity

Below are some of the projects that are underway or have been implemented based on our priorities.

Why?   

The Middlesex London Ontario Health Team supports equitable access to well-connected and integrated care, therefore the OHT must have enough information about each member of our population to identify them and connect with them.

Purpose  

Leverage the provincial method for assigning people to OHTs and provincial tools to give MLOHT and SLOHT (Sarnia-Lambton Ontario Health Team) access to a full and regularly updated list of members of the population that they are accountable for.

Goals 

  • Review changes in our population over time to inform local health planning
  • Reach out to our population to share relevant health care information
  • Allow individuals to contact the OHT directly and follow-up to meet their needs

Core Project Team

  • Stewart Coppins - Project Consultant, London Health Sciences Centre
  • Dr. Matthew Meyer - Population Health Lead London Health Sciences Centre, Assistant Professor Western University
  • Amber Alpaugh-Bishop - Middlesex London Ontario Health Team Lead
  • Glen Kearns - IVP Diagnostic Services and CIO London Health Sciences Centre, St. Joseph’s Health Care London, Middlesex London Ontario Health Team Digital Health Lead
  • Dr. Sarah Jarmain, MD, FRCPC, CCPE - Middlesex London Ontario Health Team Clinical Lead
  • Steve Pancino - Sarnia-Lambton Ontario Health Team Executive Lead
  • Lyn Baluyot – Sarnia-Lambton Ontario Health Team Digital Lead
  • Mohamed Daher - Digital Health Project Manager, Middlesex London Ontario Health Team

Contact persons

Population Health Lead – Dr. Matthew Meyer matthew.meyer@lhsc.on.ca

Project Consultant – Stewart Coppins stewart.coppins@lhsc.on.ca

Digital Health Project Manager – Mohamed Daher Mohamed.daher@mloht.ca

Why?

Collaborative Quality Improvement Plans (cQIPs) are intended to drive improvements in population health outcomes by aligning efforts across Ontario Health Team (OHT) partners.

Purpose

To improve overall access to care in the most appropriate setting including community-based Mental Health and Addiction Services, and access to preventative care  in Middlesex London.

Goals

  • Establish cQIP Working Groups to oversee planning and reporting on the three cQIP key areas of focus of Mental Health and Addictions, Alternative Level of Care (ALC), and Cancer Screening
  • Develop a collaborative quality improvement plan that can result in a meaningful improvement in health care delivery in Middlesex London.
  • Use a driver diagram approach to help our partners suggest key drivers and identify change initiatives that could help the MLOHT improve specific cQIP indicators.
  • Submit the collaborative quality improvement plan to the Ministry of Health each year.
  • Evaluate progress related to each cQIP indicator in collaboration with the Quality Improvement leads at the key partners leading the change initiatives.

Core Project Team

Lists of stakeholders engaged in the cQIP process to date:

cQIP_Mental Health and Addictions

  • Centre for Addiction and Mental Health
  • CMHA Thames Valley Addiction & Mental Health Services
  • London InterCommunity Health Centre
  • London Health Sciences Centre
  • Ontario Health West
  • Middlesex London Hospital Alliance
  • PRISMA Health Care Collaborative
  • The Salvation Army Centre of Hope
  • Indwell (affordable housing)
  • St. Joseph’s Health Care
  • Thames Valley Family Health Team

cQIP_ ALC

  • SE Health
  • Cheshire Independent Living Services
  • London Health Sciences Centre
  • Middlesex London Hospital Alliance
  • Home and Community care support services
  • St. Joseph’s Health Care
  • Thames Valley Family Health Team
  • London InterCommunity Health Centre
  • PHSS Medical & Complex Care in Community
  • Middlesex London Paramedic Service

cQIP_Cancer Screening

  • London InterCommunity Health Centre
  • St. Joseph’s Health Care
  • London Health Sciences Centre
  • Ontario Health
  • South West Regional Cancer Program
  • Thames Valley Family Health Team

Contact Person

MLOHT Impact Fellow – Mulugeta Chala mulugeta.chala@mloht.ca

Why?

In the West Region, there are four self-management programs offering in-person and virtual workshops to patients, caregivers and health care providers, but they operate independently. How can we improve timely access to and awareness of self-management programs across the West Region?

Purpose

To consolidate all workshops in the four regions into one centralized website to maximize program offerings, efficiencies, and ensure equitable, timely access to these programs.

Goals

  • Empower patients and caregivers to be active partners in their care
  • Strengthen the ability for providers to enable patients/clients and caregivers to be active partners in their care
  • Maximize awareness of and access to self-management programs and course offerings across the West Region
  • Strengthen collaboration between MLOHT, West Region Self-Management Programs and neighboring OHT partners and Ontario Health West
  • Co-design the website https://selfmanagementprograms.ca, name and functionality with patients, caregivers, care partners and healthcare providers

Core Project Team

  • Sally Boyle, Business Lead, South West Self-Management
  • Hanadi Al Sadek, Project Manager, MLOHT
  • Kathlene Campbell-Conlon, MLOHT
  • JacobiElliott, MLOHT
  • Andrea Martin, South West Self-Management

Contact Person

MLOHT Project Manager – Hanadi Al Sadek –Hanadi.AlSadek@mloht.ca 

Why?

Supporting patients living with Chronic Obstructive Pulmonary Disease (COPD) and/or Congestive Heart Failure (CHF) is complex and requires collaboration across multiple health partners. Integrated care pathways can support patients/clients, caregivers/care partners, and providers by clarifying what services are available, who can provide them, and ensuring that we have enough resources to meet everyone’s care needs.

Purpose

Integrated care pathways are being developed and implemented to understand: what should be done for everyone in a population to provide good care, what resources are required to manage the health of our population, and how can we support providers to be able to deliver this level of care?

Goals

  • Create and implement integrated care pathways including clear roles and referral pathways, capacity planning to assess health human resource needs, and implement locally

Core Project Team

  • Alexander Smith, Process Design Lead (LHSC)
  • Matthew Meyer, Population Health Lead (LHSC)
  • Dr. Sarah Jarmain, Clinical Lead (MLOHT)
  • Vala Gylfadottir, Project Manager (MLOHT)
  • Care Pathways Advisory Committee

Contact Person

Process Design Lead – Alexander Smith alexander.smith@lhsc.on.ca

Why? 

Numerous barriers exist to access the COVID-19 vaccine including language barriers, lack of transportation, lack of health card, and previous healthcare experiences of newcomers, refugees and refugee claimants which can cause hesitation in accessing the vaccine through mass vaccination clinics.

Purpose

To improve access to the COVID-19 vaccine for people experiencing barriers to be vaccinated.

Goals

  • To offer cultural community clinics, where people can be vaccinated in the comfort of their community, in their language of choice, and supported by their community members
  • To offer on-demand virtual interpretation services to primary care to support patients including seasonal agricultural workers with their vaccine questions and COVID-19 care.
  • To provide free bus tickets to people needing transportation support in accessing the Covid-19 vaccine
  • Remain responsive to the needs identified by our community partners which may include supporting promotions to specific cultural communities, developing handouts, social media posts, etc.

Core Project Team

  • London Middlesex Primary Care Alliance
  • Middlesex London Ontario Health Team,
  • Middlesex London Health Unit
  • Cross Cultural Learner Centre
  • London Intercommunity Health Centre
  • Helping Hands
  • Middlesex London Parametric Services
  • Northbrae Public School
  • London Muslim Mosque
  • Hindu Cultural Centre
  • Kipps Lane Neighbourhood Centre

Contact Person

MLOHT Senior Project Manager – Vala Gylfadottir vala.gylfadottir@mloht.ca

 

Why?

Trying to find help for a patient/client, caregivers/care partners or a loved one can be a challenge. The Health Care Navigation work aims to support people looking for health care services.

Purpose

To make finding help easier and more equitable for everyone in our community

Goals

  • Provide health care navigation services 24/7 via an online platform
  • To have a live person to speak with during daytime hours
  • To bring navigation services together to better understand and share what is available to everyone

Core Project Team

  • Trudy DeVries – Health Care Navigation Planning Lead – MLOHT
  • Hanadi El Sadek – Project Manager – MLOHT
  • Charlotte Nethercott – Health Care Navigation Primary Care Lead
  • Chantel Antone – First Nations Health Care Navigation

Contact Person

Health Care Navigation Planning Lead – Trudy Devries – Trudy.DeVries@mloht.ca

Why?

Managing health care referrals is challenging for both senders and receivers. We can do better by transitioning to digital referrals to ‘axe the fax’.

Purpose

To improve referral workflows, standardize referral templates, transition to digital referrals, and improve referral status communication for patients/clients, caregivers/care partners, and providers.

Goals

  • Implement a simple, standardized digital referral template
  • Implement and evaluate eFax

Core Project Team

  • Scott Laing – Co-Physician Lead – MLOHT
  • Vineet Nair – Co-Physician Lead – LMPCA
  • Hanadi Al Sadek – Project Manager – MLOHT
  • Sarah Jarmain – MLOHT Clinical Lead – MLOHT
  • Mulugeta Chala  – MLOHT
  • Jacobi Elliot – MLOHT
  • Eric Tian – eCE
  • Beth Gerritsen – eCE

Contact person

Project Manager – Hanadi Al Sadek – Hanadi.AlSadek@mloht.ca

Why?

To support better connected care, people should have access to their health care record that is “accurate, complete, available, and accessible across the provincial health system at their request”. *This record must be available to patients/clients, caregivers/care partners, and health care providers when they need it and in a way that supports good care and positive experiences.

*From the Patient, Family, and Caregiver Declaration of Values ​

Purpose

Establish a connection between at least one Primary Care Electronic Medical Record (EMR), one Community Information System (CIS) and one Hospital Information System (HIS) to exchange health information to support better care, and Population Health Management.

Goals

  • Pre-populate data into newly created patient records or automatically update when changes are made
  • Track visits, appointments, and investigations in real time across systems, so patients/clients and providers have accurate information on care team members and care plan activities
  • Share medication information across systems so physicians can prescribe in a safe and more effective manner while remaining in their home EMR (Electronic Medical Record)
  • Share key clinical notes authored by the care team and a brief ‘About Me’ section authored by patients/clients/caregivers to improve communication during visits

Core Project Team

  • Stewart Coppins - Project Consultant, London Health Sciences Centre
  • Dr. Matthew Meyer - Population Health Lead London Health Sciences Centre, Assistant Professor Western University
  • Amber Alpaugh-Bishop - Middlesex London Ontario Health Team Lead
  • Glen Kearns - IVP Diagnostic Services and CIO London Health Sciences Centre, St. Joseph’s Health Care London, Middlesex London Ontario Health Team Digital Health Lead
  • Dr. Sarah Jarmain, MD, FRCPC, CCPE - Middlesex London Ontario Health Team Clinical Lead
  • Steve Pancino - Sarnia-Lambton Ontario Health Team Executive Lead
  • Lyn Baluyot – Sarnia-Lambton Ontario Health Team Digital Lead
  • Mohamed Daher - Digital Health Project Manager, Middlesex London Ontario Health Team

Contact persons:

Population Health Lead – Dr. Matthew Meyer matthew.meyer@lhsc.on.ca

Project Consultant – Stewart Coppins – stewart.coppins@lhsc.on.ca

Digital Health Project Manager – Mohamed Daher Mohamed.daher@mloht.ca

Why?

Requiring patients/clients to rely on family members for interpretation of sensitive, personal information is unacceptable as people have the right to have conversations with their provider to be kept confidential.

Providing service without interpretation to people experiencing language barriers poses a risk to the patient/client and may result in both negative outcomes and experiences.

Purpose

To provide dignity and equity to patients whose language of comfort is not English by offering people healthcare services and conversations in their language of comfort.

Goals:

  • Enable primary care clinics to offer people services in their language of comfort through on demand, virtual video and phone interpretation service
  • Promote the use of interpretation services across the healthcare system

Contact Person

MLOHT Senior Project Manager – Vala Gylfadottir, Vala.Gylfadottir@mloht.ca

Why?

Nearly 60,000 people in Middlesex London do not have a primary care provider. Since primary care is often the first point of contact to the health care system in Canada, having access to it is fundamental to develop a sustained care relationship between patients and their health care provider.

Purpose                                                    

To improve access to primary care in Middlesex County & London which improves the population’s overall health and reduces health care costs.

Goals

  • To establish access to primary care working group to oversee the planning, implementation, and evaluation of initiatives to improve access to primary care in Middlesex London.
  • To work and engage with relevant stakeholders to understand barriers to accessing primary care in Middlesex London.
  • To design initiatives that improve access to primary care in Middlesex London using a driver diagram approach.
  • To track progress regarding patients’ attachment to primary care and report to Ontario Health and the Ministry of health.
  • To ensure equitable access to primary care in Middlesex London.

Core Project Team

  • Vala Gylfadottir, Project Manager (MLOHT)
  • Sarah Jarmain, Clinical Lead (MLOHT)
  • Matthew Meyer, Population Health Lead (LHSC)
  • Mulugeta Bayisa Chala, OHT Impact Fellow (MLOHT)
  • Jacobi Elliott, Co-design Lead (MLOHT)
  • Rachel Labonte, Practice Facilitation Lead
  • Melissa Linseman, Primary Care Transformation Lead (LMPCA)

Contact person

Project Manager (MLOHT) – Vala Gylfadottir, Vala.Gylfadottir@mloht.ca

Why?

Effective project evaluation is the foundation for a progressive health system. The MLOHT Evaluation Framework guides the evaluation and monitoring of MLOHT-specific project initiatives.

Purpose

To guide and inform decision-making on planning, implementation, and evaluation of MLOHT initiatives. The framework also helps the MLOHT develop metrics that align with its Key Performance Indicators.

Goals

To produce a comprehensive evaluation framework that guides the evaluation process of MLOHT initiatives. Specifically, the framework;

  • Provides essential elements of project evaluation
  • Outlines the purpose, methods (e.g., qualitative, quantitative), steps, and tools needed to evaluate and monitor MLOHT projects or initiatives

Core Project Team

  • Mulugeta Bayisa Chala, PhD – MLOHT Impact Fellow
  • Matthew Meyer, PhD – Population Health Lead London Health Sciences Centre, Assistant Professor Epidemiology and Biostatistics Western University
  • Jacobi Elliott, PhD – MLOHT Co-design Lead, Evaluation, Specialized Geriatric Services, St. Joseph’s Health Care London.

Contact person

Why?

We are committed to building sustained, cooperative, mutually beneficial, and respectful relationships with local First Nations communities to create better health prospects for current and future generations.

Purpose

To seek guidance from local First Nations communities regarding priority opportunities for improving care, experience, and outcomes for community members and health service providers and to subsequently collaborate with multiple partners to implement those improvements.

Goals

  • Establish needs of local First Nation communities using a co-design approach
  • Implement improvements with partners

Core Project Team

  • Eric Hendrick, MLOHT, Elgin OHT
  • Jacobi Elliott, St. Joseph’s Health Care London (Evaluation Lead, Geriatrics)
  • Kim Fisher, Health Director Chippewa of The Thames First Nation
  • Barb Racz, Home Community Care Nurse Munsee-Delaware Nation
  • Ida Cornelius, Oneida Health Administrator
  • Beverley Williams, Oneida Indigenous Health Navigator
  • Kate Kingswell, LHSC (Support Analyst, Clinical Solutions)
  • Stephanie Johnston, LHSC (Director, Clinical Solutions)
  • Deanna Huggett – Elgin OHT Lead
  • Lauren Caruana – Elgin OHT Project and Implementation Manager
  • Amber Albaugh-Bishop, MLOHT

Why?

Despite having excellent heart failure services in our region, many are at and beyond capacity to support additional volumes, and timeliness of care remains a significant challenge.

Purpose

To develop better integration of services resulting in improved heart failure care.  The integration approach follows the Spoke (stable, low-risk patients) -Hub (moderate risk) -Node (high risk) concept developed by CorHealth.

Our focus is to better develop the Hub component of the Spoke-Hub-Node model through improved support to primary care by embedding an established community-initiated integrated disease management program (Best Care Heart Failure) in primary care practices.

Goals

To implement a Spoke-Hub-Node model of care for an integrated heart failure system, leading to improved impact on the health equity-driven quadruple aim.

This work is also expected to improve access to care, providing a more proactive approach to heart failure management.

Helping patients with heart failure at the Spoke and Hub levels will improve the use of resources and improve timely access to specialist-level disease management for more difficult-to-manage patients.

Core Team

  • Best Care
  • HCCSS-SW
  • Huron Perth and Area Ontario Health Team
  • LHSC
  • London InterCommunity Health Centre
  • London Middlesex Hospice Palliative Care Collaborative
  • London Middlesex Primary Care Alliance
  • Middlesex Hospital Alliance
  • Middlesex-London EMS
  • Ontario Health
  • Ontario Health West
  • South West Self-Management
  • St. Joseph’s Health Care
  • Thames Valley Family Health Team
  • VON

Contact

Alexander Smith; Process Design and Change Management Lead (LHSC) alexander.smith@lhsc.on.ca

Why?

Through co-design with patients/clients, care partners, and providers, we learned there is a need for more proactive identification and management of health and social determinant needs. A ‘wholistic needs screen’ has been proposed to help address the following themes:

  • Access to and awareness of services: patients/clients and care partners reported wanting earlier and consistent access to available community supports and programs for wholistic health needs
  • Early diagnosis process: patients/clients, care partners, and providers all reported wanting tools to identify people who may be at-risk for certain health conditions or who require social determinant of health needs supports
  • Promoting self-management: patients/clients and care partners reported wanting access to self-management supports for wholistic health needs

Purpose

Currently at the early stages, we envision a wholistic needs screen as a tool which:

  • Can be quickly administered to patients/clients and care partners, ideally ~10 questions or fewer, with or without provider support
  • Is inclusive of physical, spiritual, mental, emotional, environmental, social, cultural, and economic wellness of the patient/client and care partner
  • Would trigger action based on screening results including a more detailed sub-assessment, connection with a healthcare provider or service, connection to self-management supports, or a healthcare provider flag to monitor
  • Could be used to monitor and manage the health of our full attributed population

Contact

Alexander Smith; Process Design and Change Management Lead (LHSC) alexander.smith@lhsc.on.ca