Goals and Key Accomplishments

Working together from Lake Erie to the Bruce Peninsula

After listening to and hearing from those who use the health system, health service provider leaders and governors, networks, municipal leaders and the public, we designed a plan that reflects the current needs and directions of the health system. We are pleased to continue building a system that better understands and meet the needs of our patients. Patients, clients and residents belong at the heart of the health care system. And through a shared commitment, we can improve the health of our communities. It is now up to the LHIN and health system partners to focus on achieving the outcomes we know are needed. Please join us in developing a healthier tomorrow. 

How will we know we have been successful?

Stronger primary health care that is linked with the broader health care system
  • Faster access to primary care when you are sick.
  • Fewer visits to the Emergency Department for conditions that are better managed in primary care.
  • More people see their primary care provider following discharge from hospital.
Optimized health for people and caregivers living at home, in long-term care and in other community settings
  • Faster access to care provided by personal support workers and nursing in the community.
  • Fewer people waiting in the hospital for care in the community.
Supporting people in preventing and managing chronic conditions
  • Improved transitions of care following a hospital stay.
  • Fewer people need to be hospitalized for chronic conditions.
Stronger mental health and addiction services and relationships with other partners
  • Fewer people returning to the Emergency Department due to better connections to community supports.
  • Fewer people needing to be hospitalized for mental health conditions.
  • Fast access to mental health care in the community.
Timely access to hospital-based care at the LHIN-wide, multi-community, and local level
  • Faster access to care in Emergency Departments.
  • Faster access to surgical and diagnostic procedures.
  • Improved cost alignment to provincial standard.
A rehabilitative approach across the care continuum
  • More people able to access rehabilitative services to maximize recovery.
People with life-limiting illnesses and their families at the centre of hospice palliative care
  • More people with palliative care needs being supported at home.

Key accomplishments

A variety of methods are used within the South West LHIN to understand our achievements. The LHIN values hearing the real life stories about the experiences of people interacting with the health system and seeks to understand how those experiences are improved as a result of changes that are being made. The LHIN also measures improvements made as a result of projects or initiatives happening within the LHIN. Ultimately, we strive to measure impact at an overall system level by focusing on key performance measures and “big dot” outcomes over time.

Highlights

  • Better coordinated access to home, hospital and community services for high-risk seniors and special populations.
    • Adult day programs, supportive housing, complex continuing care and rehabilitation beds, Diabetes Education Centres, mental health and additions services.
  • More community resources.
    • CCAC intensive home care team, adult day programs, respite programs, supportive housing, mental health crisis and case management services.
  • Sectors are pulling together to support the needs of people in our communities.
    • Hospice palliative care, wound care, mental health and addictions, those working with people who have responsive behaviours
    • Access to Care is changing care for seniors and adults with complex needs in order to support them in their homes for as long as possible
  • More capacity through system-wide training efforts.
    • More training in experience based design, quality improvement, French Language Services toolkit, Indigenous Cultural Competency training, critical care training, participating in the provincial IDEAS program.
    • More training for those working with people who have responsive behaviours. 
  • Developing coordinated care plans to support people at risk.
    • Health Links.
  • Responding to the needs of specific populations.
    • Priority population planning groups such as the South West LHIN Aboriginal Health Advisory Committee.
    • Engages and collaborates through the Erie St. Clair/South West French Language Health Planning Entity to ensure the best possible health outcomes for the Francophone population.
  • Using innovative care models and redesigning how services are delivered.
    • Diabetes foot care, stroke, hospice palliative care, wound care, helping those with responsive behaviours.
  • Better oversight to improve experiences of care and value for money across the system.
    • Clinical services planning for stroke, cataracts and endoscopy, hospice palliative care, wound management, how we support those with responsive behaviours, Health Links, falls prevention, primary care network.
  • Adopting new technology.
    • CritiCall Ontario Repatriation Tool, Telemedicine, e-Referral /eNotification/ eDischarge, ClinicalConnect, Diagnostic Imaging, Regional Integration Decision Support, Integrated Assessment Record.
  • Offering collaborative learning opportunities.
    • Emergency Department Pay-for-Results and Knowledge Transfer, Responsive Behavioural Virtual Team Networks, Health Links.
  • Planning services together and organizations amalgamating.
    • Oxford hospitals joint services planning, three mental health and addictions providers amalgamated in London, Mental Health Tier 2 Divestment, Huron Perth Healthcare Alliance Vision 2013, two HIV/AIDS organizations amalgamated.

Our aim for April 2013 to March 2016 included three Big Dot outcomes:
 

1. Increase availability and access to 
community supports for
people: our goal is to reduce
17,000 days spent in hospital.
Patients have spent 22,968 more
days at home instead of in the
hospital because they received more
appropriate care in other settings to
better meet their needs.

2. Fewer emergency room visits:
our goal is to save 15,000
re-visits to the emergency
department within 7 days.
There have been 2,779 fewer revisits
to the Emergency Department
within 7 days.

3. Increase availability of family
health care: our goal is that 745
more clients see their family
health care provider within 7
days of discharge from hospital.*
Although measuring this outcome
continues to be a challenge, since
2013, 79.6 per cent more discharge
summaries are sent to family
healthcare providers within 2 days of
patients leaving the hospital.

*For selected conditions such as cardiac conditions, chronic obstructive pulmonary disease, stroke, diabetes, gastrointestinal disorder, and pneumonia. 

Areas where progress has been limited include:

  • Patients visiting their family health care provider within 7 days of leaving the hospital.
  • Patients returning to the hospital within 30 days of leaving.
  • Wait times for diagnostic services (e.g. MRI and CT scans).
  • Wait times for certain surgical procedures including hip and knee replacements.
  • Pressure ulcer-related hospital visits.
  • Hospital acquired infection rates (e.g. C. difficile).
  • Actual costs more in line with expected costs for hospitals.
  • Emergency department visits due to falls in adults aged 65 plus.