South West LHIN Exchange Newsletter – January 2017

How coordinated care planning can help physicians with complex patients

Working to finalize the structures needed to support Patients First

Apply for the South West LHIN Quality Awards

Identifying and addressing barriers to primary care for vulnerable groups

#BeaBob: Connecting seniors with appropriate care in their community to remain independent

Helping people access primary care when they need it most

Thank you to our partners for your hard work over the holidays

How coordinated care planning care can help physicians with complex patients

When someone has many health care needs, they see a lot of different health care professionals for support. This makes it difficult for the patient and their families to arrange and travel to appointments. It also makes it hard to communicate the right information to their health care team.

Coordinated care planning brings all of the health care professionals together, in one meeting to develop a care plan, based on a person's unique needs and goals. To date, the South West LHIN has supported more than 500 people with Coordinated Care Planning:

 Watch physicians share their perspective on the unique way of caring for people and their families.

Working to finalize the committee and table structures needed to support Patients First

The South West LHIN is working to finalize the committee and table structures needed to support integrated planning and service delivery within the sub-regions and across the LHIN.

The creation of the committee and tables follows engagement with health service providers, primary care providers and public health leaders over the past several months to gain valuable insight and feedback for the creation of sub-region geographies and the structures needed to support integrated planning and service delivery within the sub-regions and across the LHIN. The feedback from the fall engagement sessions was themed and used to further refine the terms of reference for the LHIN’s new structures.

The goal is for the LHIN’s Board of Directors to approve three supporting structures in February 2017: the Patient Family Advisory Council; the Health System Renewal Advisory Committee; and the sub-region integration tables.

On December 7, 2016, Ontario passed thePatients First Actthat will help patients and their families obtain better access to a more local and integrated health care system, improving the patient experience and delivering higher-quality care.

The Patients First Act intends to improve access to health care services by implementing system-level changes to allow for faster and better access to care, and put patients and their families at the centre of a truly integrated system. The government is committed to the next stage of the Patients First: Action Plan for Health Care, by focusing on improving patient experience and providing more reliable and faster access to care. 

The Act is part of the government's ongoing work under the Action Plan to create a more patient-centred health care system in Ontario. The LHIN will be having ongoing dialogue with system partners as the sub-regions are established.

Apply for 2017 South West LHIN Quality Awards

Every year, the Quality Awards recognize organizations that have implemented a sustainable quality improvement initiative in the health system to achieve performance excellence. It is now time to identify award-worthy initiatives that are making a difference for the people you serve and our local health care system. The awards will be handed out at the 2017 Quality Symposium on June 1, 2017, in Stratford.

Apply by Friday, February 24, 2017

Consistent with last year, two awards will be distributed in 2017. One award will recognize a small/medium size quality improvement project, and the other award will recognize a large scale quality improvement project.

Small/Medium Quality Improvement Projects are smaller in scope (address local problems), involve fewer stakeholders and often carried out within the resources of the participating organizations.

Large Quality Improvement Initiatives are larger in scope, typically LHIN-wide initiatives with greater complexity, involving multiple stakeholders and are usually funded projects.

To be eligible for an award, the initiative must demonstrate sustainable system change and involve two or more organizations or agencies, at least one of which is LHIN-funded. Cross-continuum collaboration is encouraged.

Good luck to all those who apply and we look forward to seeing you in Stratford. For more information, please contact Rachel Stack at or Kevin De Jong at at the South West LHIN.

Identifying and addressing barriers to primary care for vulnerable groups

Not all residents in the South West LHIN have equitable access to primary care. To better understand the barriers people face in accessing health care as well as what access to primary care looks like in our geography, the South West LHIN and the West Elgin Community Health Centre conducted the Primary Health Care Capacity Report. The preliminary report was released in fall 2016 and the final report will be released in February 2017.

“Through the leadership of the Primary Health Care Capacity Steering Committee, we developed a comprehensive report with recommendations on how we can help create a stronger primary health care system in the South West,” says Dr. Gord Schacter, Primary Care Physician Lead, South West LHIN.

The result was five recommendations with 65 supporting actions to support equitable access to primary care for people most impacted by the social determinants of health in the South West LHIN:

  • Equity and health literacy;
  • Timely access;
  • Interdisciplinary care;
  • Right mix and distribution of health professionals; and
  • eHealth and information sharing.

“Our most vulnerable people and families live with the largest health and social burdens while facing the greatest challenges in accessing the care and services they need,” says Andy Kroeker, Executive Director, West Elgin Community Health Centre. “Acting on these recommendations will help us to respond and adapt to the changing needs of those facing multiple barriers to health care.”

The South West LHIN has since engaged with key partners such as hospitals and physicians to gather feedback and prioritize recommendations. The LHIN is finalizing the recommendations which will be submitted to the primary care steering committee in January.

About the report

The capacity report, prepared by the Human Environments Analysis Laboratory (HEAL), focused on five vulnerable groups (Indigenous people, ethno-cultural groups and recent immigrants, rural residents, people with low socioeconomic status and seniors) and five key barriers to care (Timeliness of care, geographical, financial, health literacy and poor relationships with health care providers). The report also identified key social determinants of health that affect an individual’s ability to access care such, as income, education, aboriginal status, gender, race and disability. 

The key questions that guided the report were:  how closely do primary care services in the South West LHIN meet the needs of the population based on the social determinants of health; what does the evidence tell us how social determinants of health affects their primary care needs; and, how do social determinants of health measures correlate with health service use.

The report contained not only LHIN-wide findings, but findings for each LHIN sub-region. For example, the report identified gaps in geographical accessibility to primary care barriers faced by vulnerable populations. 

BeaBob: Connecting seniors with appropriate care in their community to remain independent

One of the best ways to improve quality of care is to proactively screen seniors for health issues and identify areas of concern before they worsen. Assess and Restore is a proactive, best practice approach to care for older adults living in the community who are at risk of losing their independence.

Through funding from the South West LHIN, the South West Assess and Restore Project developed a tool to help health care providers screen older adults, identify areas of concern and connect them with appropriate services in their community.

Health care providers can use the Assessment Urgency Algorithm (AUA) screener to determine the level of risk of a community dwelling adult losing their independence. An AUA score is generated by answering questions. A score of 1-2 indicates a low level of risk, 3-4 a medium level, and 5-6 a high level. Different risk levels require different types of community resources and services. At each risk level, services and resources are provided to assist health care providers to connect older adults to the right care in the right place at the right time.

The resources and services are provided through collaboration with the

#BeaBob tells the story of Bob, 70, who recently retired. Bob visited his health care provider who administered the AUA and connected him to the services and resources he required to stay in community with his family. The story helps to introduce assess and restore and promote the AUA screener to health care providers. So far more than 3,000 older adults like Bob have been proactively screened with the AUA tool for risk and connected with the appropriate services. An assess and restore approach has the potential to improve the quality of care for seniors in the South West LHIN. Various assess and restore pilot projects like the AUA tool are being tested across the region. The South West Assess and Restore Project is currently pulling data from these projects for a final report to help inform and implement best practices.

Helping people access primary care when they need it most

When a doctor moves or retires, an entire community’s health care can be affected.

For these communities, it is more difficult for residents to access a family physician. To help determine those areas of high primary care need in our geography, the LHIN developed a defined, transparent, predictable approach which includes consistent criteria to support decision making.

Using information from the primary care branch at the Ministry of Health and Long-Term Care, our recent Primary Health Care Capacity report, and additional information and data from Health Force Ontario, the LHIN will first seek to understand where there is a low ratio of family medicine doctors to population.

Through this analysis, the South West LHIN can identify and prioritize those areas of high primary care physician need. Communities that scored as highest need and/or highest risk in a number of areas will be identified on our list of Communities of High Primary Care Physician Need

Communities identified as areas of high primary care need that have a Family Health Network(FHN) / Family Health Organization (FHO) model, or are appropriate to seek to develop a FHN/FHO model will be recommended to be included in the Ministry of Health and Long-Term Care Areas of High Physician Need list.

For more information on the South West LHIN’s Communities of High Primary Care Physician Need list, please contact Kristy McQueen, System Design and Integration Lead at or call 519-640-2583.

To discuss your community needs, please contact Jane Tillmann, Health Force Ontario Regional Advisor at or call 519-200-4896.

Thank you to our partners for your hard work over the holidays

The LHIN would like to thank all our health care partners who were working hard over the holidays to ensure the health system met the needs of the people in our communities.  There was a strong commitment from all partners to maintain discharge practices and service levels in our hospitals over the holiday period. Bed huddle discussions with hospitals and the CCAC took place when required during this two week period. The feedback and data collected from December 24, 2016 to January 9, 2017 will be reviewed and analyzed in March 2017.

The holiday resource page is available for all holidays year-round to share options for non-emergency medical access. It is available at