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Toronto Central LHIN’s Health Equity Action Plan


I Introduction
II The Quality and Cost Imperative for Health Equity
III Targeted Strategies for Different Populations
IV Toronto Central LHIN’s Health Equity Action Plan
V Improving outcomes for high-needs, underserved populations

--submitted by Janine Hopkins, Senior Director, Community Engagement and Corporate Affairs, Toronto Central LHIN

I Introduction

Health professionals and providers acknowledge that health equity is an essential dimension of high quality care.  It is included in the main health quality frameworks such as the Institute for Health Care Performance’s well-established Triple Aim method.
Ontario’s health care system is beginning to systematically address equity as a core health care strategy. There is a growing appreciation that resolving disparities in health access and outcomes is not only the “right thing to do” it is also essential to improving population health, the development of healthy communities, and to health system sustainability.

For the past several years, the Toronto Central (TC) Local Health Integration Network (LHIN) has been leading initiatives to understand and address health disparities in Toronto.  

The Excellent Care for All legislation gives us a powerful platform to advance health equity and the TC LHIN has set health equity apart as a priority strategy for achieving quality health care for the population we serve.  

II The Quality and Cost Imperative for Health Equity

While the health care system works for most people, most of the time, too often it does not meet the needs of those who are at greatest risk.  The only way to achieve liveable and thriving communities is by meeting the needs of all people.  The only way to reduce disease burden and improve the health and wellbeing of communities is by reducing the disparities in health care.
Health equity is also essential to the quest for health system sustainability.  Poor quality care is costly.  Health promotion practitioners have been consistently making the case that it costs less to keep people healthy, prevent complications, and enable people to live independently for as long as possible.

In order to develop effective strategies, we need to understand the experiences and outcomes of different groups.  For example, if some 80% of people are being treated within the province’s ER wait time targets, we need to ask the question - who makes up the other 20%?

III Targeted Strategies for Different Populations

Different populations require targeted strategies. Once we identify the populations in need, we can devise more effective strategies to remove barriers to care.  

One approach taken in the TC LHIN and other jurisdictions is to target the small percentage of the population that requires the most health care resources – the 1% that accounts for 80% of health care spending.   These are the patients at the top of the Kaiser Permanente pyramid – those with multiple chronic diseases and complex needs who are at greatest risk of hospitalization and require intensive service and case management.  This group includes some of the most vulnerable individuals with the greatest unmet needs such as frail elderly, people with mental illness and addictions, and medically complex children.

The LHIN has targeted investments over the past few years at models and programs to assist frail seniors to remain at home or in a community care setting for as long as possible and to help them safely transition the right care destination after a hospital stay,
Virtual Ward is an example of an innovation designed for frail seniors. This partnership involving several hospitals, the Community Care Access Centre (CCAC) and primary care providers targets patients deemed at high risk for hospital readmission. These patients are linked with a virtual clinical team that replicates hospital care in the patient’s home including case management and 24/7 access to physicians.
Another important strategy is promoting culturally-relevant care.  Some diverse populations are not well served by mainstream health care models.  The Toronto Central LHIN recently funded Anishnawbe Health Toronto to work with the Aboriginal community to undertake community-based research to explore the needs and experiences of Aboriginal people with diabetes. The report underscored that the urban Aboriginal community is a hidden population that, for a whole host of reasons, faces barriers to appropriate care. The key takeaway is that if we are to turn the rising tide of diabetes in the Aboriginal community we need to combine western medicine with a wholistic, culture-based approach that promotes physical, mental, emotional and spiritual well-being.

Our ability to improve health equity has been hampered by a dearth of good data. We know from experience that inequities exist and have a major impact on outcomes.  However, we lack the hard evidence to understand, make choices and drive changes in policy, services and practice.

The statistics we have reveal a lot and raise important questions.  For example:

  • Low income people in Toronto access the ER more often than those with high income.
  • Diabetes incidence is twice as high in low income neighbourhoods in Toronto. Immigrant populations have higher rates of diabetes than others.
  • People with low income have a lower life expectancy.
  • Aboriginal communities have poorer health outcomes, including lower life expectancy; higher infant mortality; and higher rates of diabetes, mental illness and addictions, and HIV infections.

In the last several years the TC LHIN asked 18 hospitals to develop Hospital Health Equity Plans. These plans, signed by hospital CEOs and Board chairs, identified gaps and priorities for action to address health equity in the acute care sector.  Community Health Centres (CHCs) are also undertaking Health Equity Planning.  

The TC LHIN partnered with the Ministry of Health and Long-Term Care to develop and test a Health Equity Impact Assessment Tool (HEIA).  Now being implemented across the province, the HEIA is a systematic way to identify the impacts of policy, program and funding decisions on different populations in order to minimize unintended consequences.

IV Toronto Central LHIN’s Health Equity Action Plan

In spring 2011 the Toronto Central LHIN held stakeholder consultations to develop a Health Equity Action Plan for the local health system.

The TC LHIN Health Equity Action Plan has four priorities.

  1. Collect common sociodemographic data at the point of care and link it to health outcomes.   The process is underway with hospitals and other providers to identify the data elements to be collected.
  2. Apply an equity lens to the TC LHIN’s health system quality indicators by using the above mentioned data elements.  This will allow us to measure and set targets for improving health equity for sub-populations. Mount Sinai Hospital is leading the common equity data and indicator initiatives on behalf of the LHIN.
  3. A shared over-the-phone interpretation (OPI) service for the Toronto Central LHIN which will allow hospitals and, over time, community agencies to benefit from a high quality OPI service at reduced rates and expand non-English speaking patients’ access to interpretation services.  A request for proposals is going out in February.  Nine Toronto hospitals and the CCAC will be the first to join the service.
  4. Improve access to non-insured people.  Hospitals and CHCs – a major source of referrals for non-insured individuals to hospitals – are developing common processes for serving the non-insured. This will improve the predictability and consistency of health services to non-insured patients while alleviating the administrative demand on organizations. An expert group is conducting a comprehensive assessment of the needs and issues related to the different non-insured groups in the city.  This will enable us to prioritize the issues and develop different solutions for the different types of people who lack health insurance.

By developing relevant data about health equity we will be able to demonstrate both the impact of inequities on access and health outcomes as well as the costs to the system.  In the current challenging fiscal environment, the latter argument will be necessary to get traction with decision makers.

V Improving outcomes for high-needs, underserved populations

While we improve our knowledge about health equity, the TC LHIN is leading a number of new targeted initiatives to improve outcomes for high-needs and underserved populations.

We have a series of initiatives to support long-stay Alternate Level of Care (ALC) patients to receive care in an appropriate setting outside of hospitals.  Long-stay ALC patients no longer need acute care but have been waiting in hospital for more than 40 days because they cannot access other services such as rehabilitation, long-term care, home care or assisted living.  Long-stay patients include people who depend on ventilators, people with serious mental illness and addictions and seniors with behavioural issues caused by Alzheimer and other psychogeriatric conditions.

The TC LHIN has also just launched Health Access St. Jamestown, a collaboration among with City of Toronto, United Way, Toronto Community Housing, St. Michaels and community agencies to coordinate health services for St. Jamestown residents.  This model can eventually be adapted for other high-density and high-poverty neighbourhoods in the city.  

Health equity must be viewed as an intrinsic part of quality health care. It requires a population-based approach that develops tailor-made solutions for diverse community needs.  While there are strong social justice grounds for addressing health equity, we need good data to demonstrate the health quality and cost arguments for making this issue a health care priority. Excellent Care for All is an ideal vehicle.  As the name says, Excellent Care must be For All, not just For Some.