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THEN Very little communication and information sharing between care providers made it difficult for patients to get the right care.

HEALTH CARE IS IMPROVING We are proud of the progress that has been made to improve our health care system through the work of our health care partners and staff including many doctors, nurses, therapists, volunteers and more. This work has happened through collaboration and partnership and is guided by the valuable feedback and perspectives that were generously provided by the people in our communities who benefit from the care and support of a coordinated health system. We know there is still more work to do. As we move forward with future improvements, these positive changes remind us that change is possible and acknowledge the efforts of the people and organizations that are making it happen.


Waterloo Wellington LHIN

NOW With the use of electronic medical records growing among care providers, patients receive safer and more effective care. More than 4,000 health care staff are using electronic medical records in Waterloo Wellington.

THEN People experiencing more than one social and health issues often could not get the support they needed, which sometimes created community issues.

NOW Award winning Connectivity Tables have been introduced to bring together representatives from the police, health and social service agencies to create care strategies for people with complex health needs. Connectivity Tables have been recognized as an innovative way to help our most at risk residents get the help they need. 2

* For more information on social issues and Connectivity Tables visit

THEN There were fewer community day program options for seniors with physical, cognitive and/or mental health disabilities.

THEN People waited on average 28 hours in the emergency department to get a bed in hospital.

NOW Adult day programs in the Waterloo Wellington region have expanded with more than 1,640 seniors benefiting last year.

NOW This has reduced by almost 11 hou rs. Waterloo Wellington residents have spent over a million fewer hours waiting for care in are a emergency departments since 2008.

THEN People with complex health and social needs could have up to 15 different care providers managing their care. This made managing their entire care plan very difficult.

NOW Over 2 , now r 200 people eceive with c to ma nage support fro omplex ne the ed m Health Links ir care thro one provid s progr e r am. ugh the

THEN Children who needed an MRI had to travel outside of the Waterloo Wellington LHIN to have this done.

NOW Children can get this care locally, allowing them and th eir families to stay close to home.


IMPROVING HEALTH, TOGETHER Improving the health and well-being of everyone in Waterloo Wellington requires a plan. One that is resident focused and meets the needs of our unique local communities. This document is that plan, the Integrated Health Service Plan 2016-2019. This is your plan. We asked you – the people who live in this community, front line service providers, community stakeholders and local leaders – what is working well and what needs to be improved to help you be healthy and have a great health care experience. This is your plan, built from your experiences and understanding your needs. Over the past three years, we have heard many stories about how changes in your local health system are making a difference to your health and well-being. People now wait less time in emergency departments, more people have a primary care provider, community care has been increased and new programs have been created to improve access to mental health and addictions services. You have also told us there is still a distance to go to make this a truly integrated, high-quality health system and we agree. We will not shy away from the concerns you have expressed. The Waterloo Wellington Local Health Integration Network and all our health service providers are here to support your health and well-being and the health and well-being of all residents of Waterloo Wellington. Over the next three years, we are going to make improvements that will ensure you get the care you need, when you need it, make your health care experience better and improve the overall health of our population - because it is Your Health, Your System, Your Plan. Sincerely, Joan and Bruce

Joan Fisk, Board Chair 4

Bruce Lauckner, CEO

THEN Some people had to travel great distances to meet face-to-face with their doctor or care team to receive treatment.

“The quality of health care is improving. More people are getting ca re and have an improved quality of life.” - Resident, Cambridge/North


NOW People who have difficulty traveling to see their doctor, need specialized care or care in different languages can receive services through telemedicine (care over video conference). Last year it was used more than 34,000 times by local residents.


Health Care is Improving


Improving Health, Together


Patients First: Ontario’s Action Plan for Health Care


Our Vision


Better Health - Better Futures Means...


Our Priorities


Our Local Communities


Meeting the Needs of Our Diverse Residents 5

PATIENTS FIRST: ONTARIO’S ACTION PLAN FOR HEALTH CARE Patients First: Ontario’s Action Plan for Health Care (Patients First) is Ontario’s plan for changing and improving the health care system across Ontario. It is built on the foundation of making the needs of patients and their families the focus of our health care system.

PUTTING PATIENTS FIRST MEANS: • Supporting Ontarians to make healthier choices and help prevent disease and illness.

Providing faster access to the right care. When people are sick, injured or trying to stay healthy, they need to know where to get the right kind of help – from their family doctor, a nurse practitioner, a pharmacist or a combination of care providers. When the hospital, the family doctor, the long-term care home, community organizations and others work as a team, patients with multiple, complex conditions receive better, more coordinated care.

CONNECT Delivering better coordinated and integrated care in the community, closer to home. The foundation has been laid to enable home and community care providers to meet the needs of today’s population. Ontario has been working with patients, caregivers, providers and health care experts to transform home and community care, improve the experiences of patients and their families and ensure access to the same high-quality standard of care across the province.

• Engaging Ontarians, so we fully understand their needs and concerns.


• Focusing on people, not just their illness.

• Making decisions with patients, so patients play a major role in affecting system change.

Support people and patients – providing the education, information and transparency Ontarians need to make the right decisions about their health. For Ontarians, health is about more than the care they receive from providers. It is about living a healthier life, avoiding getting sick and learning about good ways to manage illness when it happens. Creating a culture of health and wellness will support Ontarians in making educated, informed decisions about their health.

• Being more transparent in health care, so Ontarians can make informed choices.


• Providing care that is coordinated and integrated, so a patient can get the right care from the right providers. • Helping patients understand how the system works, so they can find the care they need when and where they need it.

Patients First is a plan that is supported by research and highlights the importance of patient experiences. It demonstrates a commitment to health equity, access and universality – simply put, ensuring high quality health care for everyone. Patients First outlines four priorities to improve the health system in Ontario.



Protect our universal public health care system – making evidence based decisions on value and quality, to sustain the system for generations to come. Our universal health care system belongs to the people of Ontario. Ontarians fund it and depend on it for their health and for the health of their children. With an aging population that has a growing need for health care services, maintaining a sustainable health care system means controlling costs and focusing on preventing illness and improving results for patients.

ealth care] field “Everyone in the [h ything they do er ev at th e iz al re should ts or patients. It is affects the residen ld d their care. It cou all about them an care someday.” be you that needs – Long-Term Care

Worker, KW4

As we move forward with local system planing, our Integrated Health Service Plan (IHSP) 2016 -19 will support these provincial priorities to improve the health of Ontarians and it will also reflect the local health needs and priorities of the people who live right here, in our own communities. 7

OUR VISION BETTER HEALTH - BETTER FUTURES Our vision is better health and better futures for everyone in Waterloo Wellington. We aim to build a community where we have excellent health and where residents have a great quality of life. To achieve this, we need a strong, accessible, responsive health care system. Our vision for the health care system is one that reflects the needs and desires of local residents. Residents have told us what this looks like to them. A local health care system where Waterloo Wellington residents can confidently say...

“” 8

“We have the support we need to stay healthy and prevent us from getting sick.”

“My caregivers and I are welcomed and treated with respect when I am given care in the health care system.”

“Care is provided in my preferred language and is respectful of my cultural beliefs.”

OUR MISSION IS: To lead a high-quality integrated health system for our residents. OUR VISION IS: Better Health – Better Futures. OUR CORE VALUE IS: Acting in the best interest of our residents’ health and well-being.

lity “I can get qua en h health care w I need it.”

“I know where to get the care I need. It is easy to find services and I only have to tell my story once.”

“When my needs change the health care services I use change to match my needs. ”

“” 9

BETTER HEALTH BETTER FUTURES MEANS... AN IMPROVED PATIENT EXPERIENCE We are committed to improving the patient experience for our residents. This means creating a health care system that is good at health and good at care. It is important that you feel respected and heard when your care is delivered. This is your health system, we want you to be an active participant in your care and have the information and resources needed to make informed decisions.

BETTER POPULATION HEALTH AND HEALTH EQUITY FOR ALL RESIDENTS We want to design a health care system that improves access to health care for all. Your health is important. We will work to improve the overall health of local residents including addressing inequities some face. We expect every health service provider to review and make changes to the services they provide to ensure all of our residents have access to the right care. We will also collaborate with other organizations to address the social determinants of health with a special focus on vulnerable and underserved residents.

“[The health system] is universal, but is there really equity? Example, you might receive more services simply because you are a member of a family health team, but your neighbour has to pay for the same services because their doctor is not a member. That’s too bad.” 10

- Health care worker, Guelph

PARTNERSHIPS WITH OTHER SECTORS We need to lead, together with health care, community agencies, public health and the social service system to remove silos. Health is everyone’s job. We are fortunate to have three world class universities, one college and several research institutions in our LHIN. We need new thinking to solve old problems. The partnerships we make across the community will be instrumental in improving the health of residents.

DELIVERING INTEGRATED CARE Achieving our mission to create a high quality, integrated health care system requires a structure that reflects the needs of local residents. Health services should be accessible and close to home, but sometimes people need more complex care and equipment that isn’t available everywhere. Years ago, the Health Links model of care was introduced to provide coordinated care plans for patients with complex medical issues within their local communities. This model of care has proven to provide better health outcomes for residents and has provided more access to care in the community instead of the emergency department. To expand on this successful model of care, we have created four Sub-LHIN geographies where providers from primary care, home and community care, hospitals and public health will work in collaboration to ensure residents have optimal health and well-being. The aim is to build bridges between organizations and bring in specialized care when needed to create a system that is collaborative, efficient and provides you with the best possible care. 11

OUR PRIORITIES Waterloo Wellington residents deserve the best health outcomes possible. To ensure locally lead system improvements can support their good health, we’ve focused our objectives for 2016 -2019 on the same key priority as the Patients First plan: Access, Connect, Inform and Protect.



Your health service providers and the LHIN will: • Ensure timely, accessible, supportive primary health care for all, including enhancing access for specific populations • Provide seamless, high quality service delivery in the four integrated service delivery networks • Improve access to timely mental health and addictions services • Transform palliative and end-of-life care

“Family doctor’s offices need to “We need more coordination be open evenings, weekends and between services, doctors, holidays. We need to be able to specialists, etc. Reduce the see our family doctor the same “silo” effect.” - Caregiver in KW4 day or next day.” - Resident in KW4

“It breaks my heart to see patients with mental health needs... Care is not delivered effectively. We would not treat patients with cardiac or stroke needs in the same manner.” - Caregiver in Guelph


Only 21% of residents say access to palliative care or end-of-life care in the home is excellent or very good in Waterloo Wellington.

“I see many people who are alone and do not have someone to advocate for them, or come to appointments to help. We depend a lot on patients having a support person in their life, and if they don’t they often do not receive the care they need. For example, after surgery a patient is expected to have someone pick them up. What if they don’t have someone? People need more support in their homes, and it doesn’t seem to be there.” - Allied health staff member in Wellington



Your health service providers and the LHIN will: • Integrate hospital care to deliver consistent, evidence-based best practice as a specialized resource on the health journey • Strengthen home and community care • Modernize the provision of long-term care through infrastructure renewal and quality improvement • Support caregivers’ health and well-being

19 local long-term care homes “We need to improve the continuity of care for patients in hospital have been identified for and their transition back to their primary care physician and infrastructure renewal and community services.” - Allied health staff member in Wellington redevelopment.

23% of Canadians said that they had cared for a family member or close friend with a serious health problem in the last 12 months.




Your health service providers and the LHIN will: • Increase access to linguistically and culturally appropriate services and care that is welcoming for all • Enhance transparent access to information to support professional, patient and caregiver decision-making and transitions of care • Promote access to information to support self-management and illness prevention

“The language piece is huge. In our experience that is one of the biggest barriers across the board in terms of accessing health care.” - Service provider in KW4

20.5% of Waterloo Wellington’s population is made up of immigrants while 21.5% of residents report English is not their first language.

“We need transparency in EMR “There is a continued focus only on so that all providers for one client disease management rather than could have access to that prevention; many incidents of individual’s life time records, chronic disease could be prevented which includes visits to clinics, with continued long-term focus ERs, specialists, specialized and support.” - Nurse in Cambridge/North Dumfries services, diagnostic imaging.” - Primary care provider in Guelph




Your health service providers and the LHIN will: • Engage patients, caregivers and community stakeholders in the design and implementation of health system improvement • Reduce duplication in testing, assessment and service delivery to create a sustainable system of care • Integrate services and pursue new models of care to reduce inefficiencies and redirect funding to front-line care

“Ensure residents have a voice by engaging those with lived experience in planning.”

“I have to take family members to a family doctor who then orders blood work, refers you to someone else, then you wait months, then the patient tells the same story, then you wait longer for diagnostic - Resident in Cambridge/North Dumfries imaging.” - Caregiver in KW4

“Reduce administrative inefficiencies. There are too many layers of management.”- Resident in KW4


OUR LOCAL COMMUNITIES GROWING AND DIVERSE The Waterloo Wellington LHIN serves residents in Waterloo Region, the City of Guelph, Wellington County and south Grey County. With a population of over 778,000, we are a growing community of diverse residents. No one knows better what is needed for our community than those of us who live here, work here and receive health care here. With a Board of Directors made up of local residents, we set the direction and make decisions regarding local health care services, and integration and funding to meet your changing needs. The medical and business professionals who work at the Waterloo Wellington LHIN understand our community because they are local. Our children play sports and go to school together. We shop at the same grocery stores, we celebrate at the same local festivals, and when we need medical care, we go to the same hospitals, doctors and clinics. Most importantly, we interact regularly with you through engaging you to gather your input and feedback. This is the benefit of being local: learning your needs, seeing the system and where pieces need to be better connected, and leading local solutions that will improve your health and the health of those around you. 16


MEETING THE NEEDS OF OUR DIVERSE RESIDENTS The Waterloo Wellington LHIN and our health service providers have an obligation to support our diverse local communities with specific responsibilities related to French-speaking and Aboriginal residents.

FRANCOPHONE RESIDENTS Over the last three years, we have enhanced access to care for seniors by providing French-language seniors’ exercise programs and mental health support through counselling delivered over secure video conferencing. We hosted a successful French–language health care forum designed to ease navigation of the health care system.Over the coming three years, we will build on these successes and continue to work with our partners including the French Language Health Planning Entity (Entity2) to understand and support the health needs of our Francophone residents.

ABORIGINAL RESIDENTS Over the last three years, we have worked closely with our local Aboriginal communities to identify and address gaps in health services. For instance, an Aboriginal diabetes education program, including traditional healing practices, has been created and we now have an Aboriginal health and wellness promoter to help Aboriginal residents navigate health services. Hospice services based on the culturally specific needs of Aboriginal residents are also now available. Over the next three years, we will continue to ensure health service providers receive Aboriginal cultural sensitivity training, advance the work of the Aboriginal Homelessness and Mental Health committee and work with the Aboriginal community to continue to build local access to traditional and culturally sensitive services. For more details on our plans for supporting Francophone and Aboriginal residents and improving health equity, visit our website 17

MAPPING THE FUTURE: BUILDING THE IHSP We developed the 2016-19 IHSP based on the needs and experiences of our local residents and front-line health service providers, in alignment with the provincial plan and building on the successes and work underway. We gathered your feedback through a telephone survey, an environmental scan of factors related to health care, data analysis, multiple focus groups with often underrepresented residents and information from health service providers. We also performed an online survey of our residents and front-line service providers in both English and French. Through this survey, over 1,100 people shared their stories, hopes for the future of health care and what breaks their heart about the health care system. The quotes used throughout this plan come from that survey. You answered and we listened. This plan focuses on what matters most to you.

How would you rate your overall health? 18

YOUR HEALTH, YOUR SYSTEM, YOUR PLAN Your health, and the health of your neighbours, depends now, more than ever before on how partners in the health system work together to integrate services and resources to provide seamless, collaborative, high-quality care. When we work together we all get the care we need when we need it, we live longer, healthier lives and contribute to better patient experiences and better health outcomes across the entire system of care. This IHSP is your plan, it’s our plan, it’s everyone’s plan and it is a call to action for all of us - health service providers, community leaders and everyday residents alike - to work together to make better health for everyone possible.


THEN Many people in our communities didn’t have a family doctor.

NOW More than 96% of people in our communities report they have a primary care provider. This is the seco nd highest attachment rate in the province.

THEN A lack of cooperation between health care providers meant that patients undergoing rehab for acquired brain injuries experienced gaps in care when moving from one provider to another.


NOW Providers have partnered to create a care pathway to guide patients through a seamless system of care and support.

THEN There were few mental health supports to help youth at their schools.

d NOW h care an in lt a e h l a t Men able now avail ental is t r o p p m u s through ls o o h c s local rses. health nu

THEN Too many patients stayed in hospital, even if they were well enough to continue their recovery at home with support because home care was not available.

THEN Some people in the community with health issues struggled to get the home care support they needed to stay at home longer.

NOW Home care services hours have increased by more than 30% in Waterloo Wellington.

at the s i t s r fi tients or creating a p g n tegy f is high “Putti a r t s r that of ou center alth system stainable. su l he a loca uitable and pe we I ho y, eq qualit system that but also ne, It is a imagi .” y l n o r t can no ild, togethe ellington LHIN bu oW aterlo ,W er, CEO

kn e Lauc - Bruc

NOW Patients can recover at home because of additional home care hours. As a result, people have spent 31,000 fewer days in hospital since 2011.

Today, per challen haps more th a ged to think c n ever, we ar ensure e all ollabor the pa atively tient is plans. and to at the The on center ly way of our to imp Waterl rove he oo Wel al li a colle ctive co ngton is thro th in ug m togeth mitment to w h er for o ur resid orking health ent’s and we l l being. - Joan Fisk, B oard C hair

CONNECT WITH US Waterloo Wellington Local Health Integration Network Waterloo Wellington LHIN @WW_LHIN

Waterloo Wellington Local Health Integration Network 50 Sportsworld Crossing Road, East Building, Suite 220, Kitchener, Ontario N2P 0A4 Local: 519-650-4472 • Toll-Free: 1-866-306-LHIN (5446) • Fax: 519-650-3155 Website: • Email:

Integrated Health Service Plan 2016-2019  
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