Tag Archives: LHINs

Health Links attract huge audience at HealthAchieve

There was a kind of sliding sound and then a rattle as a woman fell to the floor during Tuesday afternoon’s session of the Ontario Hospital Association’s HealthAchieve. When someone asked if there was a doctor or nurse in the house, a variety of arms shot up. We could have probably added a few allied health professionals too should the distressed conference attendee also need a lab test or an x-ray.

If you are going to pass out, this was the place to be.

Each year the OHA features a number of well-attended “candy” sessions that do more to inspire than really inform, often involving high-profile individuals. This was not one of them.

In fact the five panelists joked about whom the big crowd had come out to see.

There is great curiosity about the province’s new Health Links. As one person told me, the session attendance is in inverse proportion to how much knowledge there is about the subject. Given the crowded standing-room only audience that was driving up the room temperature, many wanted to know more.

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De-integrating home support services in Ontario

Ontario has promised three million new hours of home care personal support services over the next three years. While it sounds like a lot, keep in mind that about 32 million hours of public home care are delivered annually and another 20 million hours are paid for privately. Further, the province is leaning heavily on the sector to offload clients from Ontario’s hospitals. The province tells us that the new hours will assist 90,000 more seniors, or 30,000 more per year. In 2011/12 a total 637,727 clients were served by home care according to the Ontario Home Care Association.

Last year the province introduced a PSW Registry (Personal Support Worker), which sets qualification standards for these workers in order to be on the registry. Without the bother of creating a specific professional college for these workers, the registry was supposed to be a way of maintaining discipline among a group that is generally ill defined and whose duties can vary dramatically.

Just before the December holidays, the province quietly introduced regulatory changes to expand which agencies can provide PSWs to do this work.

The change in policy allows community support service agencies (CSS) to deliver personal support services, but will not require the PSWs hired by these agencies to be on the new registry – at least not yet.

These support agencies have traditionally carried out functions such as delivering meals on wheels, carrying out homemaking duties, running social day programs, and providing transportation services to the frail and elderly. While such services can include respite care, they are generally not the kind of agencies that would provide a bath or assistance with toileting or dressing, for example.

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PC Platform: Tim Hudak wants you to compete for the job you have

Tim Hudak is no longer the mystery man. The question is, now that his Ontario Progressive Conservative (PC) platform is out there, will it matter?

Hudak has made it clear that he intends to make public sector workers a target, including workers in health care.

“We will introduce initiatives requiring public sector unions to compete for government contracts, where appropriate,” the Tory Changebook states. “If another organization – whether a non-profit group or private business – can provide better value for money, taxpayers deserve to benefit.”

The platform goes on to suggest support services “like food preparation or laundry” in our “public institutions” are a prime example where he expects these competitions to take place.

If you are spared the competition, you may not have your next contract fairly arbitrated. Hudak plans to challenge the independence of the arbitrators, claiming recent awards have been “excessive.”

“We will require arbitrators to respect the ability of taxpayers to pay and take into account local circumstances,” the document states.

Changebook claims the Tories will “bring public sector paycheques in line with private sector standards.”

Specific to health care, Changebook makes the same promise as the McGuinty Liberals when it comes to funding – reduce increases to three per cent per year.

Hudak promises a review of all agencies and commissions, but would axe the LHINs before that even takes place. He would not replace the LHINs, which raises questions about how health care planning, local funding, and community engagement will take place. He says he will redirect the $70 million per year from closing the LHINs into front line care. At present Ontario spends $47 billion on public health care.

The Tories say they will add 5,000 new long term care beds and increase investments in home care to “give families more control over services.” That includes the ability to stay with the provider they have now, or pick a new government-funded home care provider who better meets their individual needs. Given the Tories have supported competitive bidding in home care, it is unclear whether an individual will be able to maintain their provider after they have lost the CCAC contract. While the Tories promise to increase investments in home care, they also promise to find savings at the CCACs.

Hudak says he will clamp down on fraud, but the only specific promise is to demand that people using the old red and white health cards also present another form of government-issued identification, such as a driver’s license or passport.

Unlike the Federal NDP, which promised more doctors and nurses, the Tories only claim to add to the number of doctors by increasing residency placements for medical students from Ontario who have pursued their education outside Canada. They call upon doctors, nurses, nurse practitioners, and physician assistants to work collaboratively, particularly in underserviced areas. There is no mention of the other health professions integral to the public health system.

Like the McGuinty Liberals, the Tories vow to be as obsessive about measuring health outcomes and “introducing a rigorous system of patient satisfaction.” Do we read that as even more patient satisfaction forms to fill out? And how does this square with the promise to reduce bureaucracy?

The Tories say they will make it law that the province cannot raise taxes without a clear mandate. Unfortunately, it is silent on needing the same to cut taxes, particularly for corporations.

They also promise to expand the scope of Freedom of Information, but it is not clear how.

The Tories have already come under fire for their spending commitments and tax cuts. The normally conservative Ottawa Citizen called it the “common nonsense revolution,” comparing Hudak’s plans to reckless debt run up by U.S. President George Bush. “Unlike Bush,” writes Citizen editorial board member Ken Gray, “Premier Dalton McGuinty has required Ontarians to pay for the services they receive for which his government has been dubbed ‘tax and spend’ by people who would rather spend, borrow and pay interest.”

“Hudak’s election platform is the kind of document that made Greece the model of fiscal prudence it is today,” writes Gray.

Minister asks for review of Niagara Health System plan

Niagara Health System (NHS) will get a fresh look at its controversial Hospital Improvement Plan (HIP) that closed down two ERs in Fort Erie and Port Colborne.

The Minister of Health has ordered what is called a “third party” review although members of the NHS board will be part of that review along with representatives of the municipalities and the Local Health Integration Network.

The review will only look at phases of the hospital improvement plan that have already been implemented. It will not look at phases that have yet to be implemented, including changes to pediatrics and birthing.

According to Niagara This Week, the Minister stated in her letter to Niagara Regiojnal Chair Gary Burroughs “after thoughtful deliberation and consideration, I have come to the conclusion that an independent, third-party evaluation of the implemented phases of the HIP would be valuable.”

The review is certainly welcome, although two of the three parties engaged in the review were responsible for the initial HIP that has upset residents of the Niagara Region.

While deficits at NHS have been again climbing, Matthews insists the original HIP moved the hospital in the right direction.

Further terms of the review have yet to be determined and will be left up to the LHIN.

On the eve of an election, the news opens the door a crack after years of active lobbying by the local community, including Sue Hotte and the Yellow Shirt Brigade.

The HIP was ordered by the LHIN in May 2008 and was conducted largely by executives from the Ottawa Hospital, including Dr. Jack Kitts. The report was submitted in October 2008 and approved by the LHIN in January 2009.

LHINs — It’s not so much what you put in or out

There are three issues that really coloured OPSEU’s initial relationship with the LHIN – both of them taking place long before the LHINs were even a concept in former Health Minister George Smitherman’s brain.

One is competitive bidding in home care, where contracts come and go, and so do the workers.

The second is the dramatic difference between what workers earn in the hospital and how they are remunerated in the community.

The third is the betrayal of mental health. Significant cuts to psychiatric hospitals were made and the promised alternate services were only partially re-established in the community.

In 2005 when we first learned of the LHINs, it sounded like more of the same.

The 2006 Act that brought the LHINs into being did make some adjustments to recognize the transition of health care workers between employers, but as one presenter to this week’s Central East LHIN board remarked, “often you enter in an integration and people are afraid.”

When people are afraid, they fight the change.

Long before the LHINs there was something called Hospitals In Common Labs. It is a non-profit corporation run by Ontario hospitals that does lab work for 250 health care provider clients from across Canada. HICL has generated $100 million in revenue over the last decade that has gone back into its participating hospitals. It is considered to be the gold standard for medical lab testing. It is therefore astonishing when the South East LHIN tells the media they had to make hospitals in their region play nice in the sandbox. Sorry SE LHIN, your hospitals were light years ahead of you. HICL has been around since 1967.

With a focus on transitioning work, often overlooked is the idea of keeping the work in place but cooperating as a system, as HICL has done.

To be fair, many of the integrations we are now seeing are more along these lines. At the Central East LHIN a proposal was looked at that would merge the two cardiac rehab programs in Durham with the goal of expanding the program and filling in gaps. The program – which involves weekly sessions with those at risk for heart disease, stroke and diabetes – can only be successful if they are delivered within a 30-minute radius of the patient.

Expanding the program would be a huge benefit to the region. Not only does it improve the chances of survival for a high-risk group, but it also improves quality of life, including a measureable reduction in anxiety and depression.

This week the Central East LHIN also spent time on a strategy that would bring together service providers to improve specialized geriatric services. That strategy includes a CEO-level committee to plan an entire system of care for frail seniors. By involving the CEOs, it ensures greater buy-in within the organizations. The proposal for an umbrella organization for frail seniors is timely – growth in the seniors population is expected to grow 19 per cent by 2019, at which time 47 per cent will be over the age of 85. There is desperate need for a more coherent approach to these services.

When Dr. Alex Hukowich left the board of the Central East LHIN, he made it clear that he was unsure whether the parts the LHIN was taking out of the system or putting into the system were of value.

Maybe that’s part of the problem – the need to pluck pieces out and put pieces back in is probably limited. Getting the various pieces to work as a system is likely the greater challenge.

To deal with that, the Ministry and the LHINs have to overcome a lot of history, including addressing some of our longstanding grievances prior to when the LHIN was even here.

The trouble with LHINs Part II – How do you integrate half a system?

One of the key problems with the Local Health Integration Networks was evident from the start: they were given responsibility to better integrate our health system, but couldn’t address key parts of that system.

How do you integrate health care without the ability to better coordinate primary care? Physicians have always remained outside of system planning, and it could be argued that much of our system is defined by the agreement between the Ontario Medical Association and the Ministry of Health. This is totally outside the LHINs.

Oddly, while Family Health Teams remain outside the LHINs, Community Health Centres are in.

OPSEU has argued for years that the health system would be more efficient and cost-effective if hospital medical labs also conducted community-based work. Funding for community-based volumes would allow hospitals to increase staffing in their labs, expand scope of testing, and assist in the purchase of new equipment. For community doctors, it would result in faster turnaround of medical laboratory testing and give local physicians a direct lab contact in the community. In a comparison with some of the smallest hospital labs in the province, consultants RPO discovered that these labs were performing the same testing at two-thirds the cost of private labs. Once the hospital loses community-based work (there are only a handful left that still perform community-based testing) it is totally out of the jurisdiction of the LHINs. The North Simcoe Muskoka LHIN washed its hands of this issue when we raised it at the time Bracebridge and Huntsville hospital labs were losing their community volumes.

In Owen Sound the hospital is attempting to divest speech language therapy for preschoolers to the health unit. Once it is gone, the LHIN will no longer be able to address that service given health units are out of its jurisdiction. Who will monitor outcomes once that service is transferred? What happens if it turns out the hospital was the better host for the service, or perhaps another community-based agency? Who hold the health unit to account?

Within the LHIN jurisdiction, integrations are often about moving services around rather than facilitating strong links between health providers.

Integration shouldn’t just be about moving services from provider A to provider B and C.

As the Central East LHIN recently recognized, two addictions services don’t need to merge in order to cooperate on strategic goal setting. While it has been orthodoxy to move services out of hospital, the LHIN recognized the role of Lakeridge Health in maintaining one of these two addiction services.

The LHINs have consistently drawn a line between hospitals and community-based agencies, but hospitals do exist within communities. If a hospital is to provide community-based services, would it not by its very nature integrate well with other in-hospital services?

What role does prevention play? Not only is health promotion outside the jurisdiction of the LHINs, it is completely outside the Ministry of Health and Long Term Care.

We know, for example, that a more active population would dramatically reduce diabetes costs. One estimate suggests that if we were to bring diabetes down to the same level of northern European countries Canada could save $6 billion a year in health costs.

It’s true the LHINs do have contact with health providers outside their jurisdiction. But it has no ability to evaluate the quality of the work done by these providers, or whether the services they provide might be better delivered somewhere else. Nor does a friendly contact necessarily compel these providers to work more closely with hospitals, mental health agencies, home care or long term care homes.

The idea behind the LHINs was to make our health system just that – a system.

Some say five years is not long enough to get the job done. But what significant changes have the LHINs really made to date?

How long will it take to see a system emerge from the disparate entities that presently deliver public healthcare?

Are we expecting too much from bodies appointed to manage when what we really need are signs of bold leadership? Is this even possible within a LHIN model?

And where does the accountability lie? At present everything leads to the Minister of Health. Should it not also lead back to the communities?

Everybody has a shopping list of how we could do better. While our system is in the middle of the pack with regards to cost, there is no question that we could do better from an organizational point of view.

Our LHIN discussion series continues.

The trouble with LHINs

Local Health Integration Networks (LHINs) have become lightning rods in many communities.

The Hamilton Niagara Haldimand Brant LHIN was the focus of a scathing Ontario Ombudsman report “The LHIN Spin” which suggested public engagement was no more than lip service.

The South East LHIN recently sent their local communities into a panic after it floated the idea of concentrating all surgeries in Kingston.

The Erie St. Clair LHIN generated headlines last year when it unveiled plans to bring in a Disney speaker at a cost of close to $10,000. The speaking engagement was cancelled, although not the cost.

Aside from a horrible name, the LHINs have made many blunders to turn Ontarians against them – at least among the citizens that are even aware they exist.

68 per cent of PC supporters oppose plan to kill the LHINs

In a February 2011 Vector Poll, only 22 per cent of respondents claim to have either heard or read something about LHINs. Vector has been polling this question since 2006 with barely a change in results. After a brief description of what the LHINs do, 77 per cent of Ontarians opposed shutting them down. More troublesome to PC leader Tim Hudak, 68 per cent of PC voters are opposed to his promise to kill the LHINs.

It’s like that old song, “I can’t live with you, but I can’t get along without you.”

If the LHINs are likely here to stay, how do we fix them?

For starters, it’s about time the province come up with its overall strategic plan. It was supposed to be the guide for the LHINs to develop their own regional integrated health service plans. Instead, the province has been flighty in its priorities, often changing from Minister to Minister. George Smitherman was all about aging at home. David Caplan was about mental health. Deb Matthews is focused on getting alternate level of care patients out of hospitals.

Secondly, the LHINs are likely too small and have too few professional staff to effectively carry out their work. They like to crow about how small their administrative costs are relative to funding they shell out to hospitals, long term care homes, home care and other health providers, but it may be unreasonable. The Ministry has added to the workload with additional performance indicators and a broadened scope of oversight, but it refuses to allow the LHINs to hire appropriate staff to get the job done.

This may have something to do with point three – the LHINs have been very focused on reigning in costs, mostly at hospitals. It would be political folly to add to the LHIN administration while front line health professionals are being cut. This was supposed to be an exercise about quality, but clearly the focus has been on cost. One hospital CEO showed up at a LHIN board meeting to discuss progress on his hospital’s improvement plan. Missing from his presentation was information about the hospital’s performance on the LHIN’s quality indicators. To their credit, Ontario hospitals are in a far better place financially today, but it may be at a cost in quality.

The LHINs were supposed to take their strength from the communities they served, but no community has really warmed up to them. A few years ago OPSEU was invited to participate in a panel discussion on the LHINs by the Rural Ontario Municipal Association (ROMA). When the floor opened for questions, Mayors and Councillors of small towns lined up at the microphone to vent their frustration with the LHINs. The mayors felt the LHINs were unaccountable and were carrying out a hatchet operation on their local hospitals.

When a matter of concern comes up on the LHIN board’s agenda, often communities show up in considerable numbers. The LHINs lack any mechanism for representatives of these communities to address their concerns directly to the board. Recently two LHINs opened up their board meetings to deputations, although the process at Central East may be far too onerous and controlling to ever work.

When the LHINs did hold events for public consultation, these events often involved round tables with facilitators and set question lists. Many who have attended these events found the process manipulative.

When OPSEU took the Central East LHIN before judicial review in 2008, the lawyers for the government argued the LHINs were only responsible for high-level consultation, not on specific changes. In other words, the LHINs could ask what kind of health services a community might want, not on whether 20 mental health beds should be shut down at their local hospital and moved to another community.

It’s these specific initiatives when the public is most engaged, and it is these moments when the LHIN shuts them out of the process.

There are signs the LHINs are beginning to learn from their mistakes. At a recent Central East LHIN meeting they said they looked at integration between two addiction services and realized that while cooperation between the two of them was encouraged, it didn’t make sense for them to merge. The LHIN also acknowledged that Lakeridge Health was a good place to host one of these two services – a radical departure from the LHIN’s early days when it seemed they couldn’t move services out of hospital fast enough nor convince enough providers to integrate. This is the same LHIN than asked hospitals to set aside 1 per cent of their budget to allocate to a community-based health provider while trying to maintain it was making evidence-based decision-making.

There is a value to have a process by which health care providers must justify changes in service delivery.

The Southwest LHIN recently put the breaks on a plan by Grey Bruce Health Services to jettison speech language therapy for preschoolers. The hospital made the announcement under a hope and a prayer that the Health Unit would be able to pick up the work. The LHIN has since written to the hospital asking them to submit a formal integration proposal. Such a proposal will require more than a hope and prayer in the transfer of a service — it will need a HR transition plan.

The South West also responded to complaints that the Regional Mental Health Centre in London and St. Thomas was cutting beds without providing appropriate alternate services in the community. The LHIN allocated another $2.9 million for community delivery of mental health as a result. It won’t be nearly enough, but at least there was evidence they are listening.

It is far more productive to start talking about what the LHINs or their replacement might look like rather than take an axe to it all as Tim Hudak proposes. Diablogue will write more on this in the weeks to come.