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Champlain Regional Orthopedic Program and Service Distribution Proposal

By: The Champlain Orthopedic Program Planning Initiative

June 2013

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Table of Contents Acknowledgements ...................................................................................................................................................... 3

Executive Summary ..................................................................................................................................................... 5

Introduction .................................................................................................................................................................. 9

Overview of the Champlain LHIN __________________________________________________ 10

Profile of Orthopedic Care in Champlain ____________________________________________ 11

The Platform for Change _________________________________________________________ 17

Evidence in Support of a Regional Approach ........................................................................................................ 18

Integration Literature ____________________________________________________________ 18

Principles Of Successful Integrated Health Systems ____________________________________ 20

Overview of Existing Regional Program Models ______________________________________ 22

Service Delivery Model Literature __________________________________________________ 22

Communities of Practice Literature _________________________________________________ 23

Regional Orthopedic Program Planning Process ................................................................................. ……….25

History and Planning Goals _______________________________________________________ 25

Guiding Principles for Program Development _________________________________________ 26

Champlain Regional Orthopedic Program Model .................................................................................................. 28

Primary Goal __________________________________________________________________ 28

Objectives and Opportunities ______________________________________________________ 29

Conceptual Framework __________________________________________________________ 30

Key Program Elements __________________________________________________________ 31

Clinical Elements of the Regional Orthopedic Program _________________________________ 34

Champlain Regional Orthopedic Service Delivery Model ..................................................................................... 35

Conceptual Service Delivery/Distribution model ______________________________________ 38

Considerations for Sustainability ___________________________________________________ 40

Stakeholder and Community Engagement .............................................................................................................. 40

Summary and Conclusions ....................................................................................................................................... 41

Program Recommendations ...................................................................................................................................... 42

Program Implementation Workplan ....................................................................................................................... 46

Program Budget Year One ....................................................................................................................................... 51

References ................................................................................................................................................................... 52

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Appendices Appendix A: Procedure for Acute Orthopedic Injuries Referred to CritiCall for Champlain LHIN Nov 15 2011 Appendix B: Algorithm for Acute Ortho Referrals through CritiCall in LHIN 11 – Nov 15 2011 Appendix C: Quality Based Procedures 2013-14 and 2014-15 (as of June 18 2012) Appendix D: Summary of Integration Structures (from Literature Scan) Appendix E: Review of Existing Regional Programs Appendix F: Service Delivery Model Review Eastern Counties (Deloitte, Nov 2009) Appendix G: Project Charter: Champlain Orthopedic Program Planning Initiative Appendix H: Champlain Orthopedic Program Planning Initiative – Distribution Working Group: Planning Considerations Appendix I: Regional Orthopedic Program & Distribution Model: Stakeholder Communication and Consultation Plan Appendix J: Roles/Responsibilities Champlain LHIN Orthopedic Surgeons

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Acknowledgements

Thank you to the members of the Champlain LHIN Orthopedic Program Planning Initiative for their invaluable participation in the development of the proposal:

Heather Arthur Cornwall Community Hospital Chief Clinical Officer

Holly Burns Champlain LHIN Project Manager - COPPI

Dr. P. Chang Cornwall Community Hospital Orthopedic Surgeon

Dr. Geoffrey Dervin The Ottawa Hospital Chief, Orthopedic Surgery

Nancy Desrosiers Hawkesbury General Hospital RN, Director of Perioperative Services

Paula Doering The Ottawa Hospital Senior Vice-President, Clinical Programs

Dr. Andrew Falconer* Queensway Carleton Hospital Chief of Staff

Dr. Philippe Fleuriau-Chateau Hôpital Montfort Orthopedic Surgeon

Colin Goodfellow Kemptville District Hospital CEO

Marielle Heuvelmans Hawkesbury General Hospital VP Patient Care Services

Sari Kline Champlain LHIN Lead, Emergency Departments & Wait Times

Dr Jean-Pierre Laflèche Hôpital Montfort Orthopedic Department Chief

Pierre Noel* Pembroke Regional Hospital CEO

Lucille Perreault Hôpital Montfort VP Clinical Services

Kim Peterson Community Care Access Centre Vice-President Client Services

Dr. Raj Prihar Queensway Carleton Hospital Medical Director of Peri-Operative Services

Dr. Jim Randall Queensway Carleton Hospital Orthopedic Surgeon

Dr. Chris Raynor Cornwall Community Hospital Orthopedic Surgeon

Brian Schnarch Champlain LHIN Senior Epidemiologist

Maureen Sly-Havey Reg. Hip & Knee Rplcmnt Prog Project Manager

Toni Surko Carleton Place & District Hospital CEO

Maureen Taylor-Greenly Queensway Carleton Hospital VP Patient Care and Chief Nursing Officer

Catherine Van Vliet Kemptville District Hospital Director, Pt Services & Integration

Claudine Wathier-Doucet Criticall Client Relations Manager

Helen Zipes The Ottawa Hospital Clin Dir, Rehab Ctr & TOH Academic FHT

*Co-Chairs

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Executive Summary The health care system in Ontario is facing major challenges that are impacting the system’s ability to provide the level of service residents expect and deserve. Orthopedic care is a high volume, high cost service that crosses multiple sectors – thereby providing significant opportunities for system improvement. In the Champlain LHIN:

• 17,000 surgical procedures are completed annually • Orthopaedic surgery hospitalizations utilize 7.9% of acute care beds and 8.2% of ALC days • Orthopedic patients represent 40.5% of all inpatient rehabilitation patients and 29.4% of

inpatient rehabilitation bed days • There are 42,500 hospital outpatient rehabilitation visits annually for hip and knee

replacement patients. Orthopedic patients represent over 90% of all hospital outpatient rehab.

• 39,207 emergency visits in 2011/12 were related to musculoskeletal disorders, representing 7% of all emergency visits.

• Musculoskeletal related hospital costs in Champlain in 2009-10 were estimated at $96.5 million.

The Champlain Local Health Integration Network (LHIN) recognizes that the development of a regional approach to service delivery can make a significant contribution to addressing these challenges and as such, has embarked on a regional planning exercise for the coordination and integration of orthopaedic service delivery.

What are the Issues? The evidence to support the evolution of orthopedic care in the Champlain LHIN from a complex voluntary network of organizations and institutions to a formalized collaborative program focusing equally on quality, accessibility and efficiency is strong.

Over the past five years, significant work has taken place to improve, streamline and coordinate orthopedic services in the Champlain LHIN, primarily focused on total joint replacements. It is time now to consolidate and build upon those gains. The volume and complexity of orthopedic care, recent changes to funding, provincial priorities, performance variation and the projected growth in demand all point to the need for more collaborative, better organized and more accessible orthopaedic care to address these demands.

REASONS AND RATIONALE FOR A REGIONAL ORTHOPEDIC PROGRAM

Reasons Rationale

1. To improve access to service

• Wait Times in Champlain LHIN exceed targets • Some patients wait longer than others; access is not equal • Travel time especially for emergency care is long for some patients

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• Expected 22% in demand for ortho procedures over next 10 yrs 2. To optimize distribution of Resources

• Surgeons are available; Operating rooms are available • Surgery cancellations due to bed availability/ALC • Patients want care “close to home”

3. To improve Quality and Safety

• Regional variations in quality & safety indicators not routinely monitored; emphasis has been on efficiency & access

• Best practices may not be implemented consistently 4. To enhance efficiency and sustainability

• Costs for equivalent treatment vary between sites • Some patients may not be in optimal site eg. pre & post visits • TOH seeking to decant a portion of primary & secondary services • Need to make best use of available “shrinking” funding

5. To enhance integration across the continuum of care

• Telemedicine under-utilized • Rehabilitation not standardized/integrated to patient need • Coordination of patient’s care throughout system disjointed

What is the Approach? The proposed regional orthopaedic program is a formal network of providers led by a coordinating body with the primary goal of improving the health of the orthopedic patient population in the Champlain LHIN by delivering high quality, accessible, financially sustainable care.

The building blocks to achieve the goal are integration and an organized delivery system. The three core functions of the regional program will be: planning, service delivery and performance management.

PRIMARY GOAL OF THE REGIONAL ORTHOPEDIC PROGRAM

To improve the health of the orthopedic patient population in the Champlain LHIN by delivering high quality, accessible, financially sustainable care and service in an integrated and organized manner .

Integration(def n)

“Serv ices, prov iders, and organizations f rom across the continuum working together so that serv ices are complementary, coordinated, in a seamless unif ied sy stem, with continuity f or the client” (Accreditation Canada, 2006).

Organized Delivery System(def n)

“A network of organizations thatprov ides or arranges to prov idea coordinated continuum ofserv ices to a def ined populationand is willing to be held clinicallyand f iscally accountable f or theoutcomes and health status ofthe population serv ed”(Shortell, 1996)

Core Functions:

Planning

Serv ice

Deliv ery

Perf ormance

Management

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Regional Orthopedic Program Structures

1. Leadership Structure – to provide oversight, direction and coordination, to monitor & manage issues of accountability and sustainability of the new program; and to conduct strategic planning and engagement activities.

2. Service Distribution Plan – to advise on methods to coordinate access and service delivery throughout the region.

3. Community of Practice Framework – to engage and integrate interprofessional clinicians, create a clinical advisory body, and to provide a forum for quality improvement, innovation & standardization of best practice.

What are the Recommendations?

The plan described in this proposal is framed around the following “foundational” recommendations:

• The establishment of a Regional Orthopedic Program in the Champlain LHIN to support the organization, integration and co-ordination of orthopedic care.

• The establishment of formalized partnership agreements between participating organizations to support the objectives, structures and authority of the program.

• The establishment of an oversight/leadership structure.

• Formalization of an agreement between the Regional Orthopedic Program and the LHIN which defines authority of the Regional Program, reporting structure, decision making limitations, deliverables and the responsibility of the program in advising the LHIN on distribution of orthopedic quality based funding.

• Adoption of the proposed service delivery model. The immediate priorities include: providing support to Cornwall Community Hospital to ensure that the orthopedic program is viable, sustainable and able to meet performance targets; program planning to develop a full service orthopedic program at Pembroke Regional Hospital (excludes tertiary, spinal, and other specialized services); developing the shared resource model which allows smaller centres to provide focused orthopaedic services provided by surgeons from Champlain full service hospitals.

• Adoption and establishment of a Communities of Practice Framework for orthopedic care in the Champlain LHIN.

Additional priority recommendations to support these foundational requirements are included in the proposal.

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What Needs to be Done? Over the next 12 months, the following steps need to be addressed in order to initiate a successful regional orthopedic program.

• Secure approval/endorsement from the Champlain LHIN and Health Service Providers

• Secure program funding

• Create a transitional team to manage the transition from the current state to the proposed Regional Program

• Establish a Steering Body for the Regional Program including recruitment of the Program Coordinator, Administrative Support and Lead Physician

• Initiate a Community of Practice Framework including Membership, Terms of Reference, objectives, appointment of facilitators

• Identify high priority actions for the Regional Program and begin implementation

• Initiate steps to implement the proposed Distribution/Service Delivery Model including a financial analysis of the impact of redistribution on the organizations currently providing orthopaedic services.

What Will Change? Orthopedic care is a service that plays a significant role in healthcare in the Champlain LHIN. As the population grows and as complexity in healthcare evolves and specializes, it is apparent that there is a need for coordination and integration of orthopedic services.

The benefits of a regional approach to service delivery include equal, quicker and “closer to home” access, enhanced coordination of care, seamless transition for individuals between service providers and sectors, the forum to focus on region-wide standards for quality and safety, and the opportunity to create a financially viable and sustainable orthopedic service.

The goal, broadly stated, is “the right care, at the right time, in the right place”. A regional approach to orthopedic care can satisfy this goal. As with other regional programming initiatives, there are both challenges and opportunities to be managed, however the benefits for the patient and community must be the foundation for the directions taken and the decisions made.

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Introduction The health care system in Ontario is experiencing major challenges that are having a negative impact on the system’s ability to provide the level of service residents expect and deserve. System integration changes are being implemented to address emergency room overcrowding, inappropriate utilization of acute care beds, and the looming shift in aging demographics.

The Champlain LHIN recognizes that the development of a regional approach to service delivery can make a significant contribution to addressing these challenges and as such, has focused on sectors of the system that have the potential to make the biggest impact. Orthopedic care is a high volume, high cost service that crosses multiple sectors - thereby providing significant opportunities for system improvement.

There is strong evidence to support the evolution of orthopedic care in the Champlain LHIN from a complex voluntary network of organizations and institutions to a formalized collaborative program focusing equally on quality, accessibility and efficiency of clinical care.

Over the past five years, significant effort has taken place to improve, streamline and coordinate orthopedic services in the Champlain LHIN, primarily focused on hip and knee joint replacements. It is time now to consolidate and build upon those gains. The growing volume and complexity of orthopedic care, recent changes to funding, provincial priorities, performance variation and the aging population all point to the need for strong integration and coordination.

The benefits of a regional approach to service delivery include enhanced coordination of care, seamless transition for individuals between services, equal and improved access to service including “care closer to home”, and the opportunity to create a financially viable and sustainable orthopedic service.

This proposal has been sponsored and led by a network of orthopedic care stakeholders in the Champlain LHIN. The proposal provides the following:

• An Overview of the Champlain LHIN • Profile of orthopedic care in Champlain • The platform for change • A summary of relevant literature • An overview of the planning process • A proposed regional orthopedic program model • A proposed service delivery model • Recommendations for Implementation • A proposed budget.

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Overview of the Champlain LHIN Champlain is Ontario’s easternmost LHIN. It shares a 465 km long border with Québec and, at 18,000 km2, covers an area three times the size of Prince Edward Island. There are six sub-regional planning areas: Renfrew County, Ottawa (West, Centre, and East), North Lanark/North Grenville and Eastern Counties. The 2011 Champlain population numbered 1.2 million in 2011. Two-thirds live within a 30 minute drive of the centre of Ottawa with one in five in rural areas and one in six in large towns and small cities. Figure 1: Map of Champlain, showing large towns and planning areas

In 2011-12, the Champlain LHIN allocated $2.45 billion to 158 health service providers (agencies) to manage 240 programs, with accountability attached to each. As shown in Table 1, over 70 % of the LHIN’s allocation is spent by the hospital sector. Table 1: Champlain LHIN Funding Programs and Funding Allocation by Sector ($Millions, 2011-12) Programs Sector Allocation ($M) % of total

20 Hospitals $1,749,070 71.4% 63 Long Term Care Homes $318,676 13.0%

1 Community Care Access Centre (many service locations)

$195,660 8.0%

36 Community Mental Health $64,557 2.6% 11 Community Health Centres (plus satellites) $52,831 2.2% 83 Community Support Services* $48,554 2.0% 26 Addictions and Problem Gambling Agencies $20,908 0.9%

240 $2,450,256 100% Note: There are 158 distinct agencies. Many receive funding for more than one type of program and some agencies have multiple sites. *Including acquired brain injury programs and assisted living services in supportive housing programs.

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The regional orthopedic program and recommendations outlined in this document are aligned with the Champlain LHIN’s Integrated Health Services Plan, 2013-16 (IHSP)1. The IHSPs vision, mission and strategies and several of its key result areas underpin this proposal. Vision: “healthy people and healthy communities supported by a quality, accessible health system”. Mission: “building a coordinated, integrated and accountable health system for people where and when they need it”. Strategies:

• Build a strong foundation of integrated primary, home and community care • Improve coordination and transitions of care • Increase coordination and integration of services among hospitals (organizing regional

programs is specifically identified as an action) Key Result Areas

1. More people are involved in planning their health services 2. More people receive quality, evidence based care 3. More people with mental health conditions and addictions have access to services 4. More seniors are cared for in their communities 5. More people with complex health conditions are able to manage their conditions 6. More people at end of life, families and caregivers receive palliative care supports in their

setting of choice

The proposed orthopedic program is most closely aligned with key result area #2 and to a lesser extent with #4 and #5.

Profile of Orthopedic Care in Champlain Orthopedic care is a major component of healthcare services provided in the Champlain LHIN. There are approximately 17,000 orthopedic surgeries performed annually. Almost half (49.8%) require an inpatient stay. Taken together, orthopedic surgery hospitalizations utilize 7.9% of the region’s acute care beds (based on total length of stay), and 8.2% of the alternative level of care days. Major orthopedic surgery in Champlain is concentrated at the Queensway-Carleton Hospital, The Ottawa Hospital, l’hôpital Montfort and to a lesser extent CHEO (for the pediatric population), the Cornwall Community Hospital and the Kemptville District Hospital.

1 Champlain LHIN IHSP 2013-2016

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Table 2: Orthopedic Procedures Completed by Site2 and Surgery Type (Champlain Hospitals, 2009-10, inpatient and day surgery combined)

Grouper QCH

TOH General

TOH Civic

Mont

fort

TOH

River side

CCH

CHEO

KDH CP DMH

ARH PRH AGH RVH HGH WD MH

Total

Knee, Rplc 669 703 171 453 - 124 - * - - - - - - - 2,120 HipRplc 562 667 196 222 - 105 - * - - - - - - - 1,752 Foot 331 136 191 187 355 104 82 24 5 2 6 - 6 2 - 1,431 Excprt knee 238 29 118 178 199 35 18 244 114 1 0 0 0 0 1,174 Shoulder 230 206 178 153 170 108 19 - 1 54 11 - - 1 - 1,131 Ankle Surgery 253 221 161 163 61 65 61 1 3 3 3 - 1 - 1 997 Repair Knee 66 1 31 153 130 208 0 268 127 0 0 0 0 984 Knee - Other 88 77 104 112 90 72 63 30 45 2 8 2 0 693 ACL Repair 80 16 70 140 250 13 32 38 - - - - - - - 639 Fix femur 100 138 110 85 47 23 503 Hipfract. & other 64 191 47 47 10 16 19 - 1 - - - - - - 395 pin Fus/ScolRpr - - 272 - - 6 45 - - - - - - - - 323 Fix tib & fib 50 66 93 25 1 8 18 - - - - - - - 1 262 Spine Surgery - - 231 - 15 - - - - - - - - - - 246 Fix radius & ulna

53 36 47 65 7 16 15 - - - - - - - - 239

Rpr Spin Vert - 6 201 - 9 4 2 - - - - - - - - 222 Fix humerus 12 19 26 20 - 2 64 - - - - - - - - 143 Remove devtib fib

15 10 24 15 24 5 12 5 - - - - - - - 110

Fix elbow 14 21 20 7 - 3 15 - - - - - - - - 80 Fix clavicle 17 12 18 14 1 8 4 - - - - - - - - 74 Excisinterv disc - - 59 - 7 5 - - - - - - - - - 71 Amput. femur - 2 40 - - 2 - - - - 1 - - - - 45 Red. rad, ulna 4 2 3 1 - 7 7 - - - - - 1 1 - 26 Other (659 codes)

344 606 749 233 224 140 497 7 10 33 46 64 17 17 9 2,997

Total 3190 3165 3160 2273 1553 1103 996 617 306 95 75 64 27 21 11 16657 *KDH began performing total knee and hip replacements in 2011 and 2012 Rehabilitation is typically required after major orthopedic surgery as well as for many minor procedures and non-surgical cases. In 2011-12 in Champlain, there were 1,461 orthopedic inpatients in designated rehabilitation beds for 6,186 days (equivalent to 71 beds at 90% occupancy) as shown in table 3. Orthopedic patients made up 40.5% of all inpatient rehab patients and 29.4% of all bed days.

2Excluded due to no (or very low) volume: Glengarry Memorial Hospital, St. Francis Memorial Hospital and Deep River District Hospital. Abbreviations- QCH: Queensway-Carleton Hospital, TOH: The Ottawa Hospital, General, CCH: Cornwall Community Hospital, CHEO: Children’s Hospital of Eastern Ontario, KDH: Kemptville District Hospital, CDDMH: Carleton Place and District Memorial Hospital, HGH: Hawkesbury General Hospital, ARH: Arnprior Regional Health, WDMH: Winchester District Memorial Hospital, PHR: Pembroke Regional Hospital, AGH: Almonte General Hospital, RVH: Renfrew Victoria Hospital. Procedure groupings based on grouper specially developed for the LHIN by PRH Decision Support based on CACS and CCI codes (NACRS) and CMG and CCI codes (DAD).

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Table 3: Inpatient Rehabilitation Episodes and Equivalent Beds by Site and Patient Group (Champlain Hospitals, 2011-12)

IP rehab episodes (equiv beds*)

TOH General

QCH Mont fort

Bruy ère

Pem broke

Corn wall

TOH Rehab

Total

Knee replacement 238 (6.8) 23 (0.9) 78 (2.5) 4 (0.4) 37 (1.5) 10 (0.5) 8 (0.5) 398 (13.1) Hip replacement 162 (5.4) 38 (1.4) 45 (1.9) 8 (0.6) 35 (2.0) 8 (0.5) 4 (0.2) 300 (12.0) Other orthopedics 107 (4.0) 70 (3.8) 47 (1.9) 61 (6.5) 49 (2.7) 25 (1.3) 12 (1.2) 371 (21.4) Hip fracture 76 (2.6) 116 (6.7) 51 (2.1) 93 (9.3) 30 (2.2) 23 (1.0) 3 (0.3) 392 (24.2) Total orthopedics 583 (18.8) 247 (12.8) 221 (8.3) 166 (16.8) 151 (8.4) 66 (3.3) 27 (2.2) 1,461 (70.7)

Although many patients receive hospital outpatient and community-based rehabilitation, the data is not collected and compiled in a standardized fashion. From a recent focused survey, it is known that there were 3,373 hips and knee replacement outpatient rehabilitation patients seen at 15 sites across Champlain in 2011-2012. There were also 872 clients who received rehabilitation through the Community Care Access Centre. Total joint replacement clients are estimated to represent approximately 50% of the total outpatient orthopedic rehabilitation caseload. An estimate for private physiotherapy clinics is not available although a very rough estimate based on reports from hospital outpatient departments would suggest that fewer than 5% of total hip and knee patients access private physiotherapy to meet their rehabilitation needs.

In addition to surgery and rehabilitation patients, musculoskeletal disorders accounted for 39,207 emergency visits and 1,314 non-surgical acute care hospital admissions in 2011-12. Presenting problems range from sprains, fractures, dislocations, tendon/ligament injuries, and back/pelvis injuries to chronic pain. The prevalence of these injuries supports partnerships between orthopaedic care providers and other sectors. The development of a “Falls Prevention Program” for the elderly is an excellent example of this type of collaborative effort.

In the primary care setting, musculoskeletal disorders (MSD) are also widespread. More than one in five Ontario residents (22.7%) made at least one ambulatory care physician visit for an MSD-related condition in 2006-07. Those visits made up, in turn, more than one quarter (27.3%) of all ambulatory care physician visits during the period. Injuries, arthritis and related conditions, synovitis and various bone and spine conditions were the most commonly reported problems.3

MSD-related hospital costs in Champlain in 2009-10 were estimated at $96.5 million ($62.5 M acute care, $10.0 M day surgery, $5.5 M emergency department, $18.5 M inpatient rehabilitation). The estimate includes medical and surgical patients but excludes complex continuing care hospitals, long term care homes, physician fees (for consultations and interventions), outpatient and community-based rehabilitation, diagnostic imaging, prescription

3MacKay, C., Canizares, M., Davis, A. M. and Badley, E. M. (2010). Healthcare utilization for musculoskeletal disorders. Arthritis Care Res, 62: 161–169. doi: 10.1002/acr.20064

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drugs, as well as various out-of-pocket costs such as privately engaged residential and home support services.

Orthopedic care spans the age spectrum; however, those 60-years and older are disproportionately represented. They account, for example, for 60% of the inpatient surgical patients and 73% of the related bed days but only 20% of the population in Champlain. Falls among seniors (65+) result in 5.1% of all admissions for seniors and 1.7% of admissions for all age groups combined. Based on demographic trends, it is estimated that there will be a 22% increase in orthopedic surgical needs over the next 10 years.

While elective orthopedic procedures, primarily total hip and knee joint replacements, have been the focus of attention for the Ministry of Health and Long Term Care and the LHINs for a number of years, hip and knee replacements account for only 23% of all orthopedic procedures performed (see Figure 2).

Figure 2: Orthopedic Procedures by Type (Champlain Hospitals, 2009-10, inpatient & day surgery combined)

In addition, wait time data (see figure 3) shows that there are many other elective procedures which require attention. Wait times for forefoot surgical interventions, for instance, significantly exceed hip and knee replacement wait times and the number of patients waiting for shoulder procedures is close to the number awaiting hip replacement.

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Figure 3: Elective Orthopedic Surgery 90th Percentile Wait Times (from decision-to-treat to surgery, procedures with 30+ Cases, Champlain Sites between Jan 1 & June30/12)

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The impact of emergency orthopedic (trauma) care in the Champlain LHIN is significant. There is approximately 1 emergency orthopedic surgery case for every 3 elective procedures. Emergent cases represent a challenge and burden, particularly for orthopedic healthcare providers in Ottawa and Cornwall. Four Champlain hospitals (TOH, QCH, Montfort and CCH) provide the majority of adult emergency orthopedic care while CHEO handles most pediatric emergencies.

Orthopedic Service Delivery and Distribution Full service (elective and emergency) adult orthopedic care is provided in four Champlain LHIN hospitals:

• The Ottawa Hospital (Civic Site, General Site, Riverside Site) • Queensway Carleton Hospital • Montfort Hospital • Cornwall Community Hospital

Pediatric orthopedic care is provided by the Children’s Hospital of Eastern Ontario (CHEO). In addition, referrals from outlying hospitals are accepted at CHEO for follow-up orthopedic care after emergent care (casting, for instance) is initiated. Complex adult orthopedic trauma care, and all back, neck and spinal orthopedic interventions are centralized at TOH. Minor orthopedic interventions and care are provided at a number of the smaller community and/or rural hospitals. These services typically evolved in one of two ways: 1) In relation to the specific interest/expertise of a community’s orthopedic surgeon(s), or

2) When a number of smaller community hospitals recognized a need for components of orthopedic care and recruited interested surgeons from outside their community.

For instance, Carleton Place, Arnprior, and Winchester hospitals provide minor day surgical procedures performed by surgeons from one of the full-service hospitals. A number of Champlain hospitals (e.g. Pembroke Regional Hospital) provide consultation/assessment by orthopedic surgeons affiliated with a full-service hospital, while others (e.g. Deep River) provide outpatient physiotherapy services for patients who return home after having their procedures performed in a larger, urban hospital.

A partnership between a full service hospital (The Ottawa Hospital) and a small community hospital (Kemptville District Hospital) provides low risk patients requiring total hip and knee replacements the opportunity to have their surgery in Kemptville. Surgeons travel from Ottawa to Kemptville. The arrangement was initiated as a strategy to improve access. The service is limited to a select patient population.

A Centralized intake and assessment clinic model for total knee and hip replacements is in place in the Champlain LHIN. Compliance is monitored at the local level and targets for performance have been set. Satellite total joint assessment is in place between the Queensway

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Carleton Hospital and the Pembroke Regional Hospital whereby an assessor travels to Pembroke to provide assessment “closer to home”. For this rural population, the prehabilitation component of care is provided by the Pembroke Regional Hospital, patients travel to Ottawa for surgery and then receive their rehabilitation (whether inpatient or outpatient) in Pembroke.

The development of a Falls Prevention Program which is in progress steered by the Champlain LHIN adds a prevention component to orthopaedic and geriatric care.

Emergency orthopedic care in Champlain has been organized for a number of years and is facilitated by CritiCall, a roster system and 24-hour emergency referral service for physicians across Ontario. Emergent/urgent cases are directed to accepting hospitals, based on a defined rotation. This system speeds access to urgent care for patients by averting the need to contact multiple hospitals and negotiate the patient transfer. In 2011-12, 801 orthopedic cases were referred for consultation. Of these, 608 were transferred to a receiving orthopedic hospital.4

This rotation for the distribution of trauma cases in the Champlain LHIN was collaboratively negotiated by orthopedic surgeons providing emergency care and hospital administrators (see Appendix A and B for Criticall Orthopedic Referral Procedure and Algorithm). This model has served as an example for other LHINs across the province, and typically functions very well, with some issues arising when hospitals are over capacity.

The Platform for Change From a national and provincial perspective, orthopedic care has been in the spotlight for a number of years, particularly focused on the need to improve wait times for hip and knee replacements. There are a number of reasons why orthopedic care has been targeted for healthcare reform and change:

• The discrete and boundaried nature of orthopedics makes it a prime candidate for standardization of best practices. The majority of orthopedic procedures/interventions have a distinct beginning and end, with a continuum of care that is generally predictable.5

• Orthopedics volume is high and expensive, which makes it a target for attention. As noted earlier, Champlain hospital costs related to orthopedics exceed $96 million. The direct acute care hospital costs for primary joint replacements alone are around $21 million.

• Clinical, financial and utilization data is available for orthopedics, allowing Ontario’s new funding model (Health-Based Accounting Model, including Quality Based Procedures) to be applied relatively easily. “Quality Based Procedures (QBPs) are clusters of patients with clinically related diagnoses or treatments that have been identified by an evidence-based framework as providing opportunity for process improvement, clinical re-design, improved

4 CritiCall Ontario, 2012 5 McEachern, 1996

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patient outcomes, enhanced patient experience and potential cost savings (expected because of the 40th percentile funding methodology)”.6 For a full description of HBAM and QBP Funding Changes, please click on the following link: http://www.ohima.ca/eventdocs/Presentation%20to%20OHIMA%20Michael%20October%204%202012%20vMGS%20FINAL.pdf.

In 2012-13, the first four QBPs were introduced: primary hip replacement, primary knee replacement, cataract surgery and chronic kidney disease (including dialysis). Providers will be reimbursed on a per case basis. (See Appendix C for a draft summary of Year 2 and 3 Quality Based Procedures).

• Integration is a primary focus of the Ministry of Health and Long-Term Care, and of each LHIN. Orthopedics in the Champlain LHIN is amenable to integration, coordination and organization.

• Variation in performance exists – between the Champlain LHIN and other LHINs and among providers of orthopedic care within the Champlain LHIN.7 For instance, between LHINs, only the Northeast LHIN 90th percentile wait times exceed those in the Champlain LHIN and within the Champlain LHIN itself, referrals via central intake vary significantly between surgeons practicing in different hospitals.

Evidence in Support of a Regional Approach Integration Literature A review of the literature confirms that for decades Canadian policymakers have been considering integration as a means of controlling escalating healthcare costs and improving access and effectiveness8. The majority of available literature is focused on integration rather than regional program development specifically and, as such, tends to be conceptual rather than operational. In general, health system integration is described along a continuum from informal to formal, defined by the intensity of the governance between the providers. Whatever the integration structure, it is understood that “the primary purpose of integrated care should be to improve the quality of patient care and patient experience and increase the cost-effectiveness of care.”9

The importance of integration processes are emphasized in the literature. Multiple levels of integration processes are recommended – from macro or system level (e.g. funding levels) to micro or clinical level (e.g. standardized protocols).

6 Stewart, 2012 7 Orthopedic Scorecard, 2011/12; Ontario Hip and Knee Replacement Report 2010/11 8Change Foundation, 2009; Leatt,1996; Leatt 2000; Marriot & Mable 2002 9 Curry, 2010, p3

http://www.ohima.ca/eventdocs/Presentation%20to%20OHIMA%20Michael%20October%204%202012%20vMGS%20FINAL.pdfhttp://www.ohima.ca/eventdocs/Presentation%20to%20OHIMA%20Michael%20October%204%202012%20vMGS%20FINAL.pdf

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Relationship building, collaborative planning and decision making are additional integration processes that enable success. “Integration requires an interactive, interdependent relationship to be formed among the various integrated entities. Simply aggregating a system’s operating units into a common reporting structure will not create a seamless, well-coordinated healthcare system.”10

There is no evidence to support that one type of integrated healthcare model is dominant or has a more successful outcome, perhaps because there are so many contextual factors that affect the delivery of healthcare services.11 These factors include diversity of populations, geographical issues, competition, provider resistance and funding mechanisms. As a result, “it is likely that healthcare is too complex for a one-size-fits-all solution.”12

Further, there is little evidence to support formal organizational integration as necessary when integrating care. Provided that formal agreements are in place, virtual integration through integrated provider networks can be as effective. Policy makers are encouraged to focus on clinical and service integration using multiple strategies and levels of integration to achieve best outcomes. In fact, “what matters most - is clinical and service-level integration that focuses on how care can be better provided around the needs of individuals especially where this care is being given by a number of different professionals and organizations.”13

10 Shortell, 2000 11 Armitage, 2009: Curry, 2010; Dash, 2009; Goodwin, 2011; Shotell, 2000; Suter, 2007 12Armitage, 2009, p7 13 Goodwin, 2011, p3

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Principles of Successful Integrated Health Systems

While there is no dominant integration model or strategy identified in the literature, there are a number of principles which appear consistently, and are associated with successful integration in healthcare.14 These are:

1) Comprehensive Services across the Continuum of Care: All core services along the continuum of health for the population served must be planned, provided, and co-ordinated.

2) Patient Focus: The patient is at the centre of operations, not the providers. Needs assessments must drive planning, information management and improved patient satisfaction and outcomes.

3) Geographic Coverage and Rostering: The system takes responsibility for an identified population in a geographic area.

4) Standardized Care Delivery through Inter-professional Teams: Shared protocols, such as best practice guidelines and clinical care pathways, are essential to standardized care. Inter-professional teams collaborate to ensure care is effective and efficient. Inter-professional decision-making, education, and communication are all necessary elements of collaborative, integrated care.

5) Performance Management: Performance monitoring systems, including indicators to measure outcomes at different levels, are characteristic of successful integration. Measuring care and process outcomes and using the data for service improvement are integral. Targets and rewards provide incentives.

6) Information Systems: Systems to track utilization and outcomes are necessary. Data management across systems is critical to integration. Similarly, electronic health records ensure that providers have and share clinical information, avoiding duplication or negative impacts on patients. Information systems must also enable system-wide registration, scheduling and tracking of clinical-care activities. Decision support (data analysis) is critical to planning and performance management at the provider, organization and jurisdiction levels.

7) Organizational Culture and Leadership: Implementation and operation of an integrated health system requires leadership with vision and organizational culture(s) that are congruent with the vision. Clashing cultures is one of the reasons cited for failed integration efforts. It can arise from competition conflict or professional differences. An acute-care mindset is often a cultural barrier.

8) Physician Integration: Physicians must play a key leadership role in the design, implementation and operation of an integrated health system. Their participation cannot be underestimated. Linkage between administrators and physicians is essential to successful integration.

14 Suter, 2007

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9) Governance Structure: A strong, focused governance structure is essential for successful integration. Barriers include competition, too many levels of management, and lack of a coordinated vision at the governing level. An effective governance structure can facilitate the contractual relationships or networks that promote coordination.

The governing body must be diverse enough to represent all constituencies, yet the structure should be flat to be responsive. Responsibilities include care-management mechanisms to promote quality, patient focus and appropriate use of resources. In addition, strategic planning and decision making must encompass both the financing and delivery of medical care. Lastly, physician and community representation is strongly recommended.

10) Financial Management: Cost control is usually one of the incentives for integration; however, evidence does not strongly support this claim. In fact,” integration may result in increased cost before it provides savings.”15 Funding is cited as one of the barriers to integrated service. Ontario’s new health-based allocation funding model (HBAM), with funding for different services bundled according to patient need is an attempt to address this barrier. It may be an enabler for integration of orthopedic care. Separate physician remuneration mechanisms, however, continue to be a challenge for integration.

While the principles described above must be considered when integrating a health system, “there is little evidence to demonstrate which of those principles, if any, are more relevant or if a certain combination leads to more successful integration.”16 Instead, it is perhaps more relevant for the stakeholders to seek consensus on which principles in which combinations are most important for a specific integration initiative.

15 Suter, 2007, p.32 16 Suter, 2007, p33

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Overview of Existing Regional Program Models A review of the following existing regional programs was conducted to identify successful frameworks (see Appendix E for a summary of each program):17

• Toronto Central LHIN Joint Health and Disease Management Program

• Champlain Maternal Newborn Regional Program

• Champlain Regional Cancer Program

• Champlain Hospice Palliative Care Program

• Rehabilitation Network of Champlain

In summary, while the primary focus of the model or the reason for regionalization may vary, there are a number of commonalities among all the reviewed program models which may be used to guide the implementation of a successful Regional Orthopedic Program in the Champlain LHIN.

• A combined clinical-administrative leadership • Models built on trust, collaboration and partnerships, (rather than formalized merged

organizational structures) are the norm and are showing success • All require a coordinating body to create and sustain changes • Most of the models monitor and determine service delivery structures to meet demand

and capacity balance • All function under the same guiding principles of access, quality and efficiency • All transitioned from a network type of structure to a more formalized structure

• All have mandates to integrate and coordinate.

Service Delivery Model Literature

In 2010, a review of service delivery models was completed by Deloitte Consulting, for the Champlain LHIN-sponsored Eastern Counties Clinical Service Distribution Plan exercise.18 The review highlights important considerations for the distribution of orthopedic services. Three generic service delivery models were considered: local service provision, district service provision and LHIN-wide level provision. Each option has advantages and disadvantages depending on the clinical focus. The delivery models presented focus around the types or levels of service provided or affiliated with a site (see Appendix F). Key success factors for service delivery models are identified and closely match integration principles with the following added considerations: 17 MacLeod, 2009; Champlain Regional Maternal Newborn Program, 2009; The Ottawa Regional Cancer Centre, 2012; Planning Council of the Champlain Hospice Palliative & End of Life Network, 2010; Rehab Network of Champlain, 2012 18 Champlain LHIN Eastern Counties Clinical Services Planning, 2010

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• Locate services strategically to minimize impact of distance on access • Standardize practice and clarify provider responsibilities to improve coordination across

the continuum • Designate centres of excellence to provide training, resource material and leading

practices • Define services that can be provided at each centre – Service Inventory Map

Centralization versus decentralization poses a significant distribution challenge especially in the Champlain LHIN which, geographically, is largely a rural region. The primary principle used by the National Health Service to re-organize healthcare delivery in the United Kingdom is “decentralize where possible, centralize where necessary.”19 Decentralization has advantages from the perspectives of an individual patient and a system. Decentralization results in better access, because care is closer to home. It also contributes to the goal of “one-stop shopping”, where multiple visits and duplication are reduced. Other jurisdictions are using the same approach to plan regionally, but also recognize decentralization as a strategy to shift care away from hospitals into the community by creating capacity in the community. Examples include the growth of ambulatory surgical centers in the United States as well as Alberta’s move to transfer routine services out of hospitals to community and primary care providers. Centralization, of course, must be planned when the indication is present (e.g., highly complex, low-volume procedures where specialization is required). Communities of Practice Literature

“Communities of practice are groups of people who share a concern, a set of problems, or a passion for a topic; and who deepen their knowledge and expertise in their area by interacting on an ongoing basis.”20

Community of practice is a social science concept that has been adopted successfully in industry as a tool to engage staff in organizational improvement. The basic tenet is that of knowledge management. In business arenas, “knowledge intensive organizations use the model to share “tacit” knowledge that is informal and, therefore, hard to document.”21

In the social science realm, communities of practice are viewed as social structures that support a ‘learning organization’ by “promoting individual competence, encouraging a culture of systems thinking, developing cohesive vision, supporting team learning and integrating different perspectives.”22

19 Dash, 2009, p.31 20 Fung-Kee-Fung, 2008 p.177 21 Grol, Wensing & Eccles, 2005 in Fung-Kee-Fung, 2008 22 Senge, 1999 in Fung-Kee-Fung, 2008

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The healthcare system has recently begun to examine the potential benefits of applying a community of practice model as a framework for quality improvement because of the following three trends in healthcare: 1) Focus on the patient and the needs and preferences for services 2) Shift from the focus on fragmentized subspecialty tasks to integrated evidence-based disease

management; and 3) Emphasis on efficiency of clinical practice due to economic pressures.23 Cancer surgery in the Champlain LHIN has benefited from the introduction of a community of practice framework. The formalized, collaborative learning environment between health professionals and organizations has led to innovation, professional development, engagement in quality improvement initiatives, and evidence-based decision making, based on data. The framework is easily translated to orthopedics and could serve multiple functions to support a regional approach to orthopedic care. As is the case in other jurisdictions such as Britain, the emphasis to date in Ontario has been on efficiency and access.24 The next step in the evolution of healthcare reform in Ontario is to ensure the clinical quality platform maintains status equal to access and efficiency. Communities of practice naturally create and support the quality forum by: • Providing a forum for knowledge acquisition, transfer and translation between all providers • Connecting the administrative priorities and the clinical priorities • Allowing broad clinical input into decision making • Integrating care across the continuum and among organizations • Providing a forum for clinical priority setting and strategy development • Creating an environment that builds relationships and collaboration.

23 Fung-Kee-Fung, 2008, Fung-Kee-Fung 2009, Fung-Kee-Fung 2011 24 The Change Foundation, 2009

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Regional Orthopedic Program Planning Process History and Planning Goals

In 2010, the Chief Executive Officers of hospitals in the West Ottawa Valley undertook a planning exercise to better coordinate services provided to the populations of their catchment areas. Based on an analysis of data and key opportunities for improving access, quality and sustainability, surgical services was identified as a high priority. A West Champlain Surgical Services Steering Committee was formed including CEOs of surgical hospitals in the Western part of Champlain (Almonte General Hospital, Arnprior Regional Hospital, Carleton Place Hospital, Kemptville District Hospital, Pembroke Regional Hospital, Queensway Carleton Hospital, Renfrew Victoria Hospital) and The Ottawa Hospital.

Three areas for opportunity were identified:

1) General surgery 2) Orthopedic surgery; and 3) Urology Orthopedics was identified as the first priority, but since the service of orthopedics as a major surgical service was centralized to four major hospitals primarily in the City of Ottawa (TOH, Hôpital Montfort, Queensway Carleton Hospital and Cornwall Community Hospital); it became evident that a regional approach was needed.

In part because of the emphasis placed on total joint replacement surgery by the Ministry of Health and Long-Term Care, a Regional Orthopedic Planning Committee was already in place. This committee was focused on performance management (including wait times) and some clinical management priorities such as a central intake and assessment model for total joint replacement.

As regionalization throughout the province formalized, it became evident that any re-organization of services must include the entire region, and could be facilitated with support from the LHIN. As a result, efforts to coordinate orthopedic services expanded regionally, and in early 2011, a LHIN-endorsed Champlain Orthopedic Program Planning Initiative (COPPI) was undertaken.

The Regional Orthopedic Planning Committee merged with the COPPI efforts to form a strong, engaged group of clinical experts and decision makers with the purpose of producing a plan for recommendation to the Champlain LHIN25 (see Appendix G - COPPI Project Charter). Figure 5 describes the two primary planning goals.

25 Champlain Orthopedic Program Planning Initiative Project Charter, Feb 2012

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Figure 5: Champlain Orthopedic Program Planning Initiative (COPPI) Planning Goals

Champlain Orthopedic Program Planning Initiative

Planning Goals a) Develop a Regional Program Model b) Develop a Service Delivery Distribution Model

This document is the key output of the COPPI Leadership Group. It articulates a regional orthopedic program model, including:

• Program Goals, Objectives and Rationale • Governance Structure including functions and key program elements • Service delivery distribution model and plan • Implementation Recommendations • Funding requirements • Stakeholder Engagement Plan • Year One Implementation workplan

Guiding Principles for Program Development

The planning process for the regional program and the distribution plan was guided by a set of principles which was developed and endorsed by the Orthopedic leaders in the region. These principles will be applied on an ongoing basis, and used as a tool to promote the vision of an integrated, regional orthopedic program. They will also be used as a basis for evaluation of the program:

• Optimal Patient Flow and Clinical Coherence: the organization of orthopedic services will be aligned by site to ensure optimized and efficient clinical interdependencies and patient flow.

• Appropriate Critical Mass: the organization of orthopedic services will be structured to ensure that programs/services have appropriate critical mass (i.e. volume) to allow for the provision of safe, effective, efficient and timely services while reflecting rural considerations.

• Enhanced Accessibility: the organization of orthopedic services will be structured to improve patient access to high quality programs / services (i.e. wait time, closer to home)

• Quality of Care: the organization of orthopedic services will ensure quality of care standards and practices, clinical outcomes, safety and risk management are optimized.

• Enhanced Cost Effectiveness: the organization of orthopedic services will be structured to create a more effective and efficient service cost profile and will not result in increased system funding for operations.

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• Integration and Service Coordination: the organization of orthopedic services will result in greater integration and coordination of services.

• Patient Experience: the organization of orthopedic services will be structured to enhance the patient’s experience and a focus on the patient’s needs will be maintained throughout the planning process.

• Francophone services: service distribution should be consistent with French language service designation. Any changes to distribution must take into account the impact on Francophone clients and, where possible, aim to improve access to French language services. Le Réseau des services de santé en français de l'Est de l'Ontario will be engaged as appropriate.

• Financial resources: any redistribution of orthopedic clinical services will be achieved within the existing funding allocation for the sector.

• Human resources: any changes to the organization of orthopedic services will be planned and implemented with proper consideration of human resource implications.

• Evidence-based approaches: clinical services planning will make use of best available evidence.

• Teaching and research opportunities: the configuration of orthopedic services will be structured in keeping with teaching and research needs.26

In addition to the guiding principles, a number of additional planning considerations particularly relevant to distribution of services were identified such as provincial and LHIN priorities, funding mechanisms, impact on other sectors and impact on aboriginal & immigrant populations. Appendix H provides a full description of the additional planning considerations.

26 Champlain Orthopedic Program Planning Initiative Project Charter, Feb 2012

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Champlain Regional Orthopedic Program Model Primary Goal

Figure 6 articulates the definition of the proposed regional orthopedic program – a formal network of providers led by a coordinating body with the primary goal of improving the health of the orthopedic population in the Champlain LHIN by delivering high quality, accessible, financially sustainable care and service.

The building blocks to achieve the goal are integration and an organized delivery system. The three core functions of the regional program will be: Planning, Service Delivery and Performance Management.

Figure 6: Definition and Primary Goal - Champlain Regional Orthopedic Program

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Objectives and Opportunities The rationale supporting specific objectives and opportunities are summarized in Figure 7.

Figure 7: Objectives and Opportunities of a Regional Approach27

OBJECTIVES & OPPORTUNITIES OF THE CHAMPLAIN REGIONAL ORTHOPEDIC PROGRAM

Objectives/Opportunities Rationale

1. To improve access to service

• Wait Times in Champlain LHIN exceed targets • Some patients wait longer than others; access is not equal • Travel time is long for some patients especially for

urgent/emergent orthopedic care • Demand for ortho procedures is expected to increase 22% over

next 10 years 2. To optimize distribution of Resources

• Surgeons are available • Operating rooms are available • Surgeries are cancelled due to bed availability/ALC

3. To improve Quality and Safety

• Regional Variations in performance not routinely monitored; emphasis has been on access & efficiency

• Best practices may not be planned or implemented consistently 4. To enhance efficiency and sustainability

• Costs for equivalent treatment vary between sites • Some patients may not be in optimal site eg. pre & post visits • TOH seeking to decant a portion of primary & secondary

services • Need to make best use of available funding

5. To enhance integration across the continuum of care

• Telemedicine under-utilized • Rehabilitation not standardized/ integrated to patient need • Coordination of patient’s care throughout system disjointed

(prevention/treatment)

27 COPPI Project Charter, 2012 p2

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Conceptual Framework The Regional Orthopedic Program, as conceptualized in Figure 8, will be overseen by a Steering Committee reporting to the Champlain LHIN. The committee will act in an advisory capacity to the LHIN, and will be chaired by a Champlain LHIN Orthopedic Physician Leader in conjunction with an Administrator from one of the participating orthopedic organizations.

For the first two years, while the program is maturing, it is recommended that the LHIN CEO (or delegate) participate actively. The primary mandate of the committee will be to establish the core infrastructure, implement and monitor integrative functions, ensuring service is coordinated and the program dimensions of access, efficiency and quality are addressed.

The core functions of the regional program will be planning, service delivery and performance management. An executive team will provide guidance, support, and act on behalf of the committee to liaise with and report to the LHIN. An Orthopedic Program Coordinator and the Physician Lead, along with administrative support, will make up the executive. A health service provider with orthopedic services will act as host to the executive team. Since rehabilitation plays an integral part in orthopedic care, there will be a formal link with the Rehabilitation Network of Champlain.

The accountabilities of the program will be operationalized via two subcommittees: the Clinical and Advisory Subcommittee and the Resource/Performance Management Subcommittee.

The Clinical Advisory Subcommittee will function using a Community of Practice Framework. The mandate of the subcommittee will be to focus on clinical quality improvement and provide advice to the Steering Committee regarding matters such as program requirements and clinical practice changes. There will be a core group who will be represented on the Steering Committee. The broader membership of the “community of practice” will be inter-professional and will represent the direct and indirect providers of orthopedic care. Specific details and terms of reference for the Clinical Advisory Subcommittee will be developed as a component of program implementation.

It is expected that the executive team will provide support to the Clinical Advisory Committee / Orthopedic Community of Practice to coordinate strategic priority setting, facilitate clinical changes, standardize care/processes and coordinate special projects, as identified by the subcommittee or steering committee.

The second subcommittee, which will report to the Steering Committee, will be responsible for resource and performance management. The membership will be representative of the providers of orthopedic services including rehabilitation. Specific details and terms of reference for the Resource and Performance Management Subcommittee will be developed as a component of program implementation. The committee will be accountable for recommendations to the

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Steering Committee regarding annual volume allocations, distributing/re-distributing services, human resource planning, monitoring performance indicators, and preparing an annual orthopedic capacity and quality plan.

Figure 8: Conceptual Model: Champlain Regional Orthopedic Program

Key Program Elements According to the literature review, there are a number of program elements which must be considered and incorporated when planning integration. Figure 9 identifies these elements, describes the current status, suggests how a regional model can better satisfy the elements, and suggests strategies to operationalize the model.

Figure 9: Key Program Elements of the Regional Orthopedic Model Key Program Elements of the Regional Orthopedic Model

Key Element

Current Model Proposed Model Operationalizing the Model

Comprehensive Care

Silos of care by different provider types; funding separate

Regional Program Structure which incorporates all providers. Regional Orthopedic Steering/Advisory Committee with equal

Facilitated integration through patient based funding and care pathways across the continuum

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membership from stakeholders

Standardization

Central Intake in place but processes vary between organizations Clinical Pathway – acute care pathways in place at each organization but vary in compliance

Central Intake - Standardized Processes Common Clinical Pathways (GP to surgeon referral to rehab to follow up) Clinical Practice Guidelines for common high volume orthopedic diagnoses

Revise assessment center model/processes; assessors travel to patients; surgeon/assessor clinics implemented at all sites; redistribute patients based on wait times Centralized Wait Time Coordination Adopt Communities of Practice Model

Geographic Coverage

Orthopedic Care is centralized primarily in Ottawa

Re-distribute orthopedic care to communities with capacity to provide select orthopedic services; provide support to sustain quality

Community of Practice Model Redistribution Plan Designated organizational contacts liaise with Project Manager

Patient Focus

Current Model is procedure based

Quality Based Procedures provides structures for patient centered model

Patient Satisfaction Surveys Patient participation in planning

Performance Management

Current model monitors performance indicators for TJR thru Regional Network; compliance/change is voluntary; only TJR tracked

Sub group of Regional Steering Committee responsible for performance tracking and performance improvement guided by annual Orthopedic Quality Plan; Connect funding to performance Monitoring of additional orthopedic Services including emergency services

Annual agreements for orthopedic services based on meeting targets Common clinical data measurement guided by clinical advisory sub group Quarterly/bi-annual performance teleconferences facilitated by Orthopedic Governing Body

Information Systems

Performance data for select procedures available; Shared pt. information systems not available Referral system is manual. Access to Information for clinicians and patients is limited

Regional program long term information system strategy development

Develop common e-referral system for family physicians Common tool to collect relevant/required data at the organizational level eg. use of pathways/functional status

Organizational Culture and Leadership

Regional Planning Network monitors indicators and shares information

The members of a Regional Program share region-wide vision and mission. Decision making is collaborative but not competitive.

Regional Leader supported by Advisory Committee; sponsored via Champlain LHIN. A common vision/mission is developed. Formal agreements developed

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and renewed annually Physician Integration

Orthopedic Surgeons have participated in Regional Orthopedic Planning Committee; focus is performance based

Regional Model focuses on quality and clinical improvements in addition to efficiency and access. Clinical leadership /engagement is necessary.

Communities of Practice Model Knowledge Transfer/Research Physician-Administrative Structure Annual Clinical Quality Improvement Plans

Governance Structure

The ROPC and LHIN have provided leadership for planning. There is not a formal governance structure

A Regional Model includes a formalized governance structure

Terms of Reference for Steering Committee and Working Groups Job Descriptions and Accountabilities for Program Leader(s) Strategic Plan with Annual Work Plans

Financial Management

Funding for select Orthopedic procedures – annual & incremental (Wait Time Strategy) Other orthopedic services included in base funding or organizations

Funding Reform provides a Regional Program with a funding model to match the orthopedic population

Develop funding model for all orthopedic Quality Based Procedures Case Costing Project

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Clinical Elements of the Regional Orthopedic Program The continuum of orthopedic care extends from prevention to rehabilitation. While the primary focus of attention has been on elective surgical interventions, there is a need to incorporate those clinical elements associated with emergency surgical and non-surgical orthopedic care when planning regionally. Similarly, it is important to recognize that orthopedic care relies on professionals across many health care disciplines in diverse settings. Family practitioners, surgeons, anaesthesiologists, sports medicine experts, nurses, physiotherapists and their aides, among others, are all crucial. Primary care, emergency care, acute care (including surgery), outpatient and community care all contribute. Effective and efficient orthopedic care, organized around the patient’s need, requires an understanding and collaboration across the full spectrum.

The COPPI Project Charter (Appendix G, p.6) provides a description of the services, sectors and professional disciplines which fall within the scope of regional orthopedic program planning.

It is expected that the focus of attention for the upcoming 3 years will be on the Orthopedic Quality Based Procedures as identified by the Ministry of Health and Long Term Care, however the work of the Regional Program will not be limited to these types of clinical conditions.

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Champlain Regional Orthopedic Service Delivery Model The secondary goal of the Champlain Orthopedic Program Planning Initiative was to develop a distribution model for orthopedic services throughout the LHIN. The model needs to best meet patient need and organizational capacity, while adhering to the attributes of a high-performing health system: accessible, effective, safe, patient-centred, equitable, efficient, appropriately resourced, integrated and focused on population health.28

The principles and planning considerations which underpin the Regional Framework were also used to guide the development of the distribution model. The proposed distribution or service delivery model is based on the type of orthopedic service that is provided by each organization and is focused around geographical location of acute care hospital services in the LHIN. The distribution model is focused around acute-care hospitals only as a starting point because the majority of orthopedic care involves some aspect of acute-care. Identifying where that acute-care will be provided is one means of organizing the continuum of care. As the model evolves, the complementary parts of the continuum of orthopedic care will be addressed and distributed accordingly.

While acute-care orthopedic care in the Champlain LHIN has been primarily centered in the Ottawa area, there is data to support the re-distribution of services to be provided closer to home. A detailed review of the data identified:

1. A critical mass of orthopedic patients in the Renfrew County area to support a full-service orthopedic program (defined below) at the Pembroke Regional Hospital.

2. A critical mass of orthopedic patients in the Cornwall area to maintain and strengthen Cornwall Community Hospital’s existing full-service program.

3. A critical mass of Hawkesbury-area patients (including an estimated number from adjacent areas of Quebec) to support consideration of an orthopedic “focus centre” (defined below)

The potential for program development is based only on critical mass (volumes) in relation to patient residence. Other considerations, such as readiness (human and medical resources, infrastructure etc.), quality and efficiency need to be assessed separately as part of implementation planning. Similarly, it is prudent to complete a financial analysis of the impacts to current orthopaedic hospitals if volumes are redirected to a new site.

The following Renfrew County example illustrates the critical mass ‘math’ logic:

• Patients who lived closer to Pembroke Regional Hospital or Renfrew Victoria Hospital than any other surgical hospitals underwent 1215 (874+341) non-tertiary orthopedic procedures in 2009-10 (green cells, Table 4).

28 Health Quality Ontario, 2012, p6

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• The estimated operating room time for those procedures plus the non-surgery activity (e.g. consultations), amounts to work for the equivalent of 4.7 (3.3 + 1.4) full time equivalent orthopedic surgeons (green circles, Figure 10). In other words, patients from those areas required the services of 4.7 full time orthopedic surgeons.

• The majority of that care in 2009-10 was provided at the Queensway Carleton Hospital and The Ottawa Hospital with a smaller amount at the Montfort and elsewhere (blue cells, Table 4).

Table 4: Orthopedic Procedures Completed Backyard (Patient’s Closest Surgical Hospital) and Site29 (Champlain hospitals and neighbouring areas, 2009-10, inpatient and day surgery combined, tertiary cases excluded)

Tx Site/

Backyard

QCH ARH AGH CPDMH KDH *

WDMH RVH PRH Civic Gen River side

CHEO UOHI Mont- fort

CCH HGH Other LHIN Hosp

Total

QCH 1169 4 31 103 205 . . . 424 336 274 143 3 136 1 . 77 2,906 Arnprior 130 25 5 9 12 . . . 38 43 24 14 . 24 1 . 9 334 Almonte 64 3 11 17 3 . . . 20 16 21 9 . 18 . . 11 193 Cltn Place 112 . 4 40 8 . . . 33 30 15 14 . 20 . . 13 289 Kemptville 80 2 2 3 38 1 . . 53 72 39 14 . 11 2 . 74 391 Winchest. 51 . . 2 26 11 . . 56 67 28 19 . 47 52 . 48 407 RVH 88 31 3 3 9 . 20 2 24 62 21 16 . 18 . . 44 341 Pembroke 223 30 1 8 22 . 15 62 191 113 41 31 . 65 . . 72 874 TOH/CHEO 568 . 10 66 150 . . . 705 822 456 169 4 281 13 . 65 3,309 Montfort 250 . 2 32 101 1 . . 325 591 389 146 2 1207 31 1 52 3,130 Cornwall 22 . . . 3 3 . . 46 90 42 26 . 21 754 . 40 1,047 Hawkesb. 13 . . 1 2 . . . 32 59 40 13 1 183 31 15 3 393 HGMH 9 . . . . . . . 14 19 9 14 . 34 94 . 4 197 Elsewhere 226 3 4 30 38 3 6 11 363 410 177 254 6 167 67 5 16384 18,154 Total 3005 98 73 314 617 19 41 75 2324 2730 1576 882 16 2232 1046 21 16896 31,965 *KDH volumes have increased since beginning to offer knee and hip replacement surgeries in 2011 and 2012.

29 Backyard based on closest hospital to patients by drive time. Elsewhere includes patients from outside Champlain hospital ‘backyards’, including out-of-province patients. The elsewhere group includes all patients from North East and South East LHINs even if they were not treated in Champlain. “Other LHIN hosp” includes Ontario hospitals outside Champlain. The 16,384 are North East and South East residents who were treated outside of Champlain and are not of interest here. Excluded due to very no (or very low) volume: Glengarry Memorial Hospital, St. Francis Memorial Hospital and Deep River District Hospital. Abbreviations- QCH: Queensway-Carleton Hospital, TOH: The Ottawa Hospital, General, CCH: Cornwall Community Hospital, CHEO: Children’s Hospital of Eastern Ontario, KDH: Kemptville District Hospital, CDDMH: Carleton Place and District Memorial Hospital, HGH: Hawkesbury General Hospital, ARH: Arnprior Regional Health, WDMH: Winchester District Memorial Hospital, PHR: Pembroke Regional Hospital, AGH: Almonte General Hospital, RVH: Renfrew Victoria Hospital. Procedure groupings based on grouper specially developed for the LHIN by PRH Decision Support based on CACS and CCI codes (NACRS) and CMG and CCI codes (DAD).

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Figure 10: Estimated # of Orthopedic Surgeon FTEs Required by Area of Patient Residence (2009-10)30

Preceding the development of a Regional Program and Distribution Model, the Kemptville District Hospital (KDH) embarked on an innovative partnership with The Ottawa Hospital (TOH) to open a focused orthopedic centre providing total hip and knee replacement procedures. Surgeons from TOH perform cases at KDH. The proposed distribution model incorporates this level of care but expands on the partnership to introduce the concept of a “shared resource model” for the Champlain LHIN. The concept envisions KDH as a type of satellite service site shared by and collaborating with the full service hospitals and their surgeons. The model is designed to make optimal use of available capacity, reduce costs and help meet volume and wait time targets. In addition, the concept provides an element of choice for the patient who may choose to have surgery in a smaller centre, perhaps with a shorter wait time.

While there have been challenges such as difficulty in identifying a funding methodology to account for low acuity cases, the Kemptville model sets the stage for future development of shared resource centres throughout the LHIN to provide specific types of procedures in a focused 30 Estimates for 2009-10. Areas defined by closest drive time for hospitals with surgery or endoscopy services. Patients allocated to areas based on postal code, irrespective of where they had their surgery. FTEs required based on 2000 hours/year (38.5/week * 52 weeks) and assuming 2 hours of other work for each surgery (“cutting”) hour. Hours based on number of procedures multiplied by the average time (including room turnover) per procedure type. Out-of LHIN patients were assigned to the area of the hospital where they actually received treatment. Emergency volumes based on 34.4% of IP cases (LHIN average). See LHIN Reference Document: “Champlain Surgical Volumes and Market Share Analysis” for additional information.

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manner. Minor foot and ankle interventions, for instance, are appropriate for a “focus care setting.” The Holland Centre which operates a major total joint replacement program in the absence of other full service supports in Toronto, for instance, has supported this type of arrangement very successfully for a number of years.

Conceptual Service Delivery/Distribution Model The model identifies five different levels of service according to hospital: academic/tertiary, full-service, focus centre (shared resource), partial service (shared resource), and satellite/telemedicine service (see Figure 11). The model is a hybrid type of model incorporating elements of distribution models which are of benefit to the Champlain LHIN in terms of patient need, geographic setting, and capacity. The model relies on a Regional Program structure to ensure sustainability, coordination and access.

Figure 11: Distribution Model

The proposed services to be provided at each type of site are described in Figure 12. Services and volumes at each site will be monitored by the Regional Program and recommendations for changes/expansions would be made to the LHIN by the Regional Program.

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Figure 12: Service Levels by Type of Site

Type of site Description of service

Academic / tertiary Inpatient and Day Surgery Procedures (full range; ALL neck & spine) Tertiary/Quaternary Care including Complex Trauma 24 hour Emergency on call & access to ORs Accepts rotational distribution of Orthopedic Trauma Cases Leads Research/Teaching Activities Inpatient, Outpatient & Community Physiotherapy available & accessible Orthopedic Clinic

Full service Inpatient and Day Surgery Procedures Major and Minor Procedures 24 hour Emergency on call & access to ORs Accepts rotational distribution of Orthopedic Trauma Cases Inpatient, Outpatient & Community Physiotherapy available & accessible Orthopedic Clinic

“Shared Resource” Focus centre

Major or minor

Inpatient and Day Surgery Procedures Types of procedures limited and specific Formal Affiliation Agreement with host hospital(s) as shared resource to add system capacity No 24-hour emergency orthopedic on call or access to ORs Outpatient & Community Physiotherapy available & accessible

“Shared Resource” Partial Service

Minor

Day Surgery Procedures only – limited types Open to orthopedic surgeons in the LHIN; requires formal commitment Formal Affiliation Agreement with host hospital(s) No 24-hour emergency orthopedic on call or access to after-hours ORs Outpatient & Community Physiotherapy available & accessible

Satellite/ Telemedicine

No procedures No 24-hour emergency orthopedic on call or access to after-hours ORs Pre and post assessments via TeleHealth Components of care may be offered in FHC or CHCC or Health HUB Outpatient physiotherapy may be available Community physiotherapy available & accessible

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Considerations for Sustainability While there are many benefits associated with decentralizing orthopedic care, there are a number of challenges which must be identified and managed prior to initiating any change, during the transition, and monitored on an ongoing basis. Considerations which require attention in the proposed distribution model include:

1) Cross privileging of surgeons among hospitals

2) Service agreements between organizations participating in a shared-resource or focus-centre arrangement that describes types and levels of services provided (major and minor), volume commitments, contingency plans and funding arrangements.

3) After-hours coverage plans for physicians in shared resource centres

4) Access to physiotherapy for patients close to home, regardless of where their procedure is performed (e.g. review of closed referral systems).

5) Shared information systems and scheduling systems to facilitate movement of patients and surgeons among orthopedic sites.

6) A coordinating/governing body to ensure distribution model is equitable, efficient, safe and provides the appropriate level and type of care based on evidence and demand.

7) Impact of distribution changes on organizations and physicians, if transfer of funding is required to match planned activity.

Stakeholder and Community Engagement Stakeholder engagement is an integral component of the orthopedic planning process. Community engagement is also a primary objective of the Champlain LHIN, and a legal requirement as defined in the Local Health System Integration Act, 2006.31 A Stakeholder Engagement Plan was developed to ensure the regional orthopedic program meets the needs of the patients, community, healthcare providers, and Ministry of Health and Long-Term Care (see Appendix I). The plan includes activities required, and the level of engagement required to communicate, consult and/or engage stakeholder groups.

31Jabbar, 2010

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Summary and Conclusions Orthopedic care is a service that plays a significant role in healthcare in the Champlain LHIN. Volume and complexity, changes to health care funding, provincial priorities, performance variation and the growing population need all point to the need for integration and coordination.

The evidence is strong to support the evolution of orthopedic care in the Champlain LHIN from a complex voluntary network of organizations and individuals to a formalized collaborative program focusing on quality, accessibility and efficiency of clinical care.

The benefits of a regional approach to service delivery include equal, quicker and “closer to home” access, enhanced coordination of care, seamless transition for individuals between service providers and sectors, the forum to focus on region-wide standards for quality and safety, and the opportunity to create a financially viable and sustainable orthopedic service.

The goal, broadly stated, is “right care, right time, and right place”. A regional approach to orthopedic care can help satisfy this goal. As with other regional programming initiatives, there are both challenges and opportunities to be managed, however the benefits for the patient and community must be the foundation for the directions taken and the decisions made.

The following sections of the proposal provide recommendations for implementation of a regional program and distribution model, a Year One implementation workplan, and budget requirements.

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Program Implementation Recommendations The following recommendations highlight the Champlain Orthopedic Program Planning Initiative’s project planning work which supports the development of a regional orthopedic program and distribution model. The recommendations are focused around the key elements of a successfully integrated healthcare system. The foundational recommendations for implementation are bolded.

1) Comprehensive Services across the Continuum of Care

a) Recommend that a Regional Orthopedic Program be established - to integrate and coordinate silos of care. The core functions of the program are: planning, service delivery and performance management. The program goals are to improve access, quality of care and efficiency.

b) Formalize liaison structure with Rehabilitation Network.

c) Develop an evaluation framework with tools, measures and targets to monitor the performance of the regional orthopedic program; incorporate annual program reports to the stakeholders.

d) Include all components of the continuum of orthopedic care (e.g. prevention, primary care referral, chronic disease management) in the mandate and activities of the Regional Program.

2) Patient Focus

a) Consider the implementation of a one number to call model for specialized orthopedic consultation by referring primary care providers.

b) Gain consensus on relevant key patient outcomes; develop indicators to measure successful outcomes

c) Develop a community communication tool to provide information and education to patients and caregivers regarding changes in orthopedic care as a result of a regional model.

d) Ensure Orthopedic Service is available in French Language as requested

3) Geographic Coverage

a) Recommend that the proposed service distribution model be adopted for the Champlain LHIN. The immediate priorities include: providing support to Cornwall Community Hospital to ensure that the orthopedic program is viable, sustainable and able to meet performance targets; program planning to develop a full service orthopedic program at Pembroke Regional Hospital (ex