South West LHIN

South West LHIN
A Healthier Tomorrow:
Integrated Health Service Plan
2010-2013
South West Local Health Integration Network
November 30, 2009
Table of Contents
Executive Summary 3
1. Introduction 8
What Do We Want to Build? 8
2. Summary of Provincial Priorities 9
Reducing Emergency Room (ER) Waits 9
Alternate Level of Care (ALC) 9
Diabetes Strategy 10
Mental Health and Addiction Services 10
An eHealth Framework 10
3. South West LHIN’s Vision for the Local Health Care System 12
The South West LHIN’s Vision, Mission and Values 12
South West LHIN’s System Level Goals 13
4. Overview of the Current Local Health Care System 15

What Does the Population Look Like in the South West LHIN? 15
What Does the Health Care System Look Like in the South West LHIN? 17
Profile of Health Human Resources in the South West LHIN 19
What Did We Hear from the Community? 20
5. Framework for Planning 22

Where Are We Going? The Health Services“Blueprint”Describes It! 22
How Are We Going to Get There? 26
6. Priorities & Strategic Directions for the Local Health System 29

Key Enablers 31
7. Rationale for Strategic Directions 37

Rationale for IHSP Strategic Direction: Enhance Capacity and Integration
of Primary, Specialized and Community- based Care 37
Rationale for IHSP Strategic Direction: Enhance Access and Sustainability
of Hospital-based Treatment and Care 39
8. How We Will Demonstrate/Measure Success 42
Why Do We Need to Demonstrate our Success? 42
How Will We Measure Whether or not We’ve Been Successful? 42
How Will We Know if We’ve Been Successful? 42
9. Appendices and Supporting Resources 45
10. Glossary of Key Definitions and Abbreviations 46
South West LHIN: Integrated Health Service Plan 2010-2013 2

Executive Summary
Health care in Ontario has experienced year-over-year Providers across health sectors face the following challenges:
growth. Reasons for this growth include rising demand and
use of services; an increasingly aging population; inflation • Inequitable distribution of health services across the LHIN
and new, more expensive treatments and medications; pose access challenges for residents, particularly those in
increased public expectations; new diseases; and an increase rural communities
in the prevalence of chronic diseases. • Current funding and operating models reinforce a
provider-focused versus person-centred approach to health
Even though we have experienced considerable growth, service delivery
it has not always resulted in improvements to how people • Lack of integration across sectors and of health service
experience their health care or the outcomes expected by that providers inhibits the seamless movement of individuals
care. A primary reason for this is new health care resources are and families across the continuum of care
often aligned to service structures and delivery models that • The health profile of the South West LHIN necessitates more
were created many, many years ago and no longer adequately appropriate, integrated screening and early identification
serve our population. Over time, the health care system has of health risk factors and conditions
become extremely complicated and difficult to navigate by • Lack of integrated technology platforms across the
users and providers of services. We have been continually LHIN inhibit information-sharing among health service
adding services to a foundation that is based on historical providers across sectors and geography
approaches as opposed to current needs and best practices. • Capacity limitations make it difficult to meet the
Hence, it is imperative that over the next 12 years, we increased demand for health services
address the fundamental elements that need to be • Limited availability of health human resources make it
reconstructed to ensure that we have an “Integrated difficult to meet the current and anticipated health
Health System of Care” built for 2022. service demand
Great care must be taken and effort made to ensure that These issues must be addressed to improve the health system
accessible, quality and integrated services exist and will be and ensure its sustainability in the future.
there for South West LHIN residents, their children and
their grandchildren.
r a t e d Health System of
g C
Inte ULTI-LEVEL SYSTEM OF NAVIGATION FRAMEWORK are
M
Y IN
OG TE
G
OL Local Multi- LHIN
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HN
Community Community Community

TE
TEC
DH
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• Services provided • Service delivery by • Delivery of low

EAL
TION AND CLINI
TH HU
close to home geographic clustering volume/highly complex

• Delivery of high volume/ of moderate volume/ services to manage
low complexity services complexity services specialized populations
MAN RESOU
to broader population focused on targeted • Support multi-community

• Collaboration across populations and local providers
local traditinal and non- • Seamless referral with accessibility to
RMA
traditional providers relationships with local specialized services

R
O
• Emphasis on an individual’s • May serve as a broader

CE S
and LHIN providers

INF
self-health management provincial resource

TR
G
IN
AT
BL
G E
A IES
EN
IMPL
EMEN HEALTH SYSTEMS BLUEPRINT MEWORKS
TATION AN
D ACCOUNTABILIT Y FRA

In February 2009, the South West LHIN took the bold step complement health and wellness management
of initiating the Blueprint project. The objectives of the at the more local level
Blueprint project included: • Throughout an individual’s life, he or she may
access medicine, surgical and critical care inpatient
• Provide a response to the first Integrated Health Service and ambulatory services coordinated through this
Plan (IHSP) priority to ensure access to the right services, service delivery approach
in the right place, at the right time, by the right provider
• Facilitate health care providers’and the LHIN’s planning These approaches are not mutually exclusive, but are truly
for change rather than reacting to health system trends, integrated recognizing that as an individual at various points
challenges and best practices in his or her lifetime interacts with the system, their needs
• Develop a framework for how the system should be will vary and the system must be able to respond in a
structured, across programs and geography, based on a seamless and coordinated manner.
detailed understanding of current services
• Broadly and collectively leverage our resources rather The IHSP 2010-2013, prioritizes our implementation efforts
than reacting to single issues faced by one organization, for the next three years through two strategic directions and
sector, or discipline their associated actions to work towards our Blueprint goal
of an Integrated System of Care by 2022.
The Blueprint describes in detail what we

want health service delivery to look like by IHSP Strategic Directions
2022 and the IHSP 2010-2013 identifies the
strategic directions and active steps we need 1. Enhance Capacity and Integration of Primary,
to take in the next three years to begin to Specialized and Community-based Care
make it a reality. This first IHSP strategic direction aligns with the“Population-
based Integrated Health Services”integrated service delivery
approach described by the Blueprint and is intended to move
The Blueprint describes two overarching integrated service the first three years of this approach forward. It describes
delivery approaches that detail how health services will be providing care coordination and inter-professional team
accessed and delivered by 2022: based care at the local level to focus on prevention,
identification, assessment, treatment, follow-up and
• Population-based Integrated Health Services is providing necessary supports.
tailored to the collective needs of a local population and
its health service providers. It enables local communities Local care delivery will be very important to support those
to support the health and wellness of its catchment who need assistance with their health challenges such as
population helping them to better manage their own diabetes, obesity, advanced age, mental illness or addictions
health and maintain independence. The local community issues. As care needs become increasingly complex for some
services are supported by the multi-community services individuals with conditions such as concurrent disorders,
and have access to LHIN community services as needed Alzheimer’s disease and multiple chronic illnesses, referral
• Throughout an individual’s life, he or she may access to specialist care at the multi-community and LHIN
primary care services, home and community care, levels may be required and coordinated through the
complex continuing care, long-term care, rehabilitation, inter-professional team.
chronic disease prevention and management, mental
health and addictions services and emergency services
coordinated through this service delivery approach
• Centrally Coordinated Resource Capacity optimizes
the use of targeted resources to improve access and

The South West LHIN has chosen to focus on As our population characteristics and health status show, the
the following populations: South West LHIN has a significant proportion of seniors and
people living with chronic conditions. Other data show us
• Seniors and Adults with Complex Needs that South West LHIN residents have experienced challenges
• People Living with Mental Health and accessing coordinated addictions and mental health services.
Addiction Challenges A substantial amount of work is currently taking place to
• People Living with or at Risk of Chronic Disease(s) facilitate divestment of mental health and addictions
specialty hospital services and enhance capacity in local
We will focus on these populations for a number of reasons. and multi-community settings. This is in addition to a
Since the first IHSP, we have undertaken a great deal of number of mental health and addictions’early identification,
planning and a number of initiatives have already been health promotion and disease prevention initiatives across
implemented that provide early starts to some of the our LHIN.
Blueprint implementation elements. As with all LHINs,
our actions related to seniors and adults with complex Generally, these populations tend to access and
needs have been leveraged through the provincial Aging At use a substantial portion of our health care resources.
Home initiative, Alternate Level of Care/Emergency Room But the system doesn’t always support them to use these
initiatives and quality improvement initiatives such as the resources at the right time, in the right place and by the right
FLO Collaborative. provider which often leads to crisis intervention that could
have been prevented if early identification, management
The South West LHIN also remains committed to improving and supports were in place. Currently, 58% percent of all
diabetes care by supporting the roll out of the Ontario emergency room visits in the South West LHIN are for
Diabetes Strategy. In addition to being selected as one of non-urgent patients.
the first three LHINs to implement the strategy in its first
year, we are also one of two LHINs identified as an“early 2. Enhance Access and Sustainability of
adopter”for the province’s eHealth Strategy. This puts us in Hospital-based Treatment and Care Related to:
the favourable position of fully enabling the provincial
eHealth Diabetes Registry. • Emergency Services
• Medicine, Surgical and Critical Care Services
The South West LHIN’s success with the implementation of
the Partnerships for Health program has strengthened our The Blueprint development process included undertaking
position to be effective in improving diabetes care across an assessment of the current state and future health care
the LHIN. Our involvement in the strategy, the registry and system in the South West LHIN. The information, insights
Partnerships for Health has given us real applications and strategies profiled in the Emergency Department
to test some of the Integrated Health System of Care Human Resources (EDHR) Project Final Report, May 2009
elements described by the Blueprint. In addition, our (see EDHR study), commissioned by the South West LHIN,
learnings from the experiences with diabetes will help us contributed greatly to the current state assessment. As for
to evolve systems of care for other chronic conditions. the future, the Blueprint’s“Centrally Coordinated Resource
Capacity”integrated service delivery approach heavily
influenced the IHSP action steps we will take in the next
three years.

The actions below will allow people to flow through the Recognizing that achieving an Integrated System of Care,
system equitably, minimize backlogs and optimize the use as defined by the Blueprint, requires a dedicated journey
of available resources: involving planning and implementing, the Health System
Design Steering Committee will immediately undertake the
• EMERGENCy SERVICES following key initial action steps:
Based on the recommendations of the Emergency
Department Human Resources Study and in full • Identification of leadership to guide and lead
alignment with the Blueprint’s integrated service change efforts, both at the system-wide level and
delivery approach, the LHIN will engage key local and within targeted implementation initiatives
multi-community stakeholders to initiate a process to
develop and implement strategies tailored to their • Framework for implementation planning to be
communities’emergency services needs, with completed by March 31, 2010. This framework will
a focus on: guide the development of detailed implementation
plans. As part of this process, the LHIN will work with
• Emergency services recruitment and
stakeholders within the context of the IHSP strategic
retention capability
directions to identify those opportunities that are
• Emergency services coverage with current resource pool
innovative, align to the Blueprint and can serve as
• Emergency services health care personnel capacity
“success stories”and in doing so be an example of
positive change. While we will work with health
• MEDICINE, SuRGICAL AND CRITICAL CARE SERVICES
service providers to proactively identify these groups,
Engage key local, multi-community and LHIN
we urge all stakeholders to engage in seeking out
community stakeholders to develop an action plan
opportunities as well
for creating and implementing Centrally Coordinated
Resource Capacity for medicine, surgical and critical
care services, with a focus on:
• A LHIN-wide resource capacity management system
• A centralized coordinated referral system, evidence-
based care pathways and order sets, tools and
quality guidelines

The LHIN, in collaboration with its health system partners, Acknowledging the resource limitations of today and
will also continue to provide overall direction to our health potential pressures of the future, transforming the health
system design process. More specifically, we will work to care system is even more imminent. Under the Local Health
take action on the following: System Integration Act, 2006, providers now have an
accountability to look for opportunities to integrate the
• Developing future IHSPs aligned to the vision local health system. We are a single health system and
of the Health Services Blueprint thus need to be vested in the“success of all”including
• Creating incentives for health service providers and people who deliver and receive health care, the success
partners as we are able and deemed appropriate of organizations that we have an affiliation to, in addition
• Maintaining a transparent process with open lines of to the success of other organizations and the services
communication to enable easier collaboration they deliver.
• Modifying future new accountability agreements to
include elements of the Health Services Blueprint and
IHSP. As appropriate, these agreements will reflect
transformative elements and initiatives which will prompt
health service providers towards enacting change.
These agreements will reflect the partnerships involved
across providers in making change through joint
accountability statements
IHSP IHSP IHSP IHSP

2010-2013 2013-2016 2016-2019 2019-2022
Integrated Health System of Care

INTEGRATED HEALTH SYSTEM OF CARE

1 Introduction
What do we want to build?

Building an Integrated Health System of Care by bringing
local users and providers together is vital to the work of the
South West Local Health Integration Network (South West
LHIN). We continually seek to understand how people
experience their health care and the improvements that we
must make to ensure optimum health for South West LHIN
residents. This is an enormous undertaking but one that the
South West LHIN has already begun through the creation and
implementation of its first Integrated Health Service Plan
(IHSP) 2007-2010.
Over the past three years, through substantial participation,

partnership and innovative thinking, Priority Action Teams GR E Y
completed Building the Case for Change reports for a
number of priority populations and programs. The Priority
Action Teams’comprehensive environmental scans, best BRUC
BRUCE
practice analyses and recommendations have driven a larger

and more integrated initiative nearing completion: a future
“Blueprint”for an Integrated Health System of Care for
our LHIN.
The Blueprint integrates and advances the work of the

HURO N
Priority Action Teams by developing integrated service
delivery approaches to help health service providers improve
how people experience and interact within the health care
system. That, in turn, will improve the overall health of P E RT H
residents and maximize the value of health care spending.
The Blueprint describes in detail what we want health

service delivery to look like by 2022 and why we need to OX F O RD
MI DD
DDL
L E SE X
take action today to make that vision a reality.
The IHSP continues the planning and implementation

efforts of our first IHSP and prioritizes steps towards the
achievement of our Blueprint goal of an Integrated Health
E LG
LGII N
System of Care by 2022. NO R FO
FOLLK
The South West LHIN covers an area from

Lake Erie to the Bruce Peninsula and is
home to nearly one million people.

2 Summary of Provincial Priorities
As part of the Ministry of Health and Long Term Care’s Health Human Resources Study to understand how our
(MOHLTC) stewardship role in the provision of health care, emergency departments are functioning and what changes
it has identified a number of provincial priorities that LHINs can be made to help provide the right level of service with
have been engaged in for some time now. Due to each LHIN’s current resources.
unique population needs, geography and service delivery
infrastructures, LHINs often use different strategies to A complementary opportunity that may have a greater
respond to these priorities (see Appendix A – Projects, impact is working to reduce the avoidable use of emergency
Programs and Initiatives related to Strategic Directions). services altogether. Fifty percent of ER visits are made by
The MOHLTC is currently developing a 10-year strategic patients with non-urgent or less urgent needs. Reducing
plan for Ontario’s health system but, in the interim it has the number of non-urgent cases in the ER would enable
put forward the following priorities for the health system. emergency clinicians to focus on patients with critical needs.
These priorities are: The South West LHIN, through the Blueprint’s Integrated
Health System of Care, has identified ways to help people
1. Improve Access to Emergency Department Care by
access appropriate health care services in places other than
reducing the amount of time that patients spend waiting
emergency rooms and to improve health care capacity in
in the emergency department
local communities.
2. Improve Access to Hospital Care by reducing the
amount of time that patients spend waiting for an
alternate level of care Alternate Level of Care (ALC)
3. Improve Access to Diabetes Care by supporting the roll
out of the provincial diabetes strategy Alternate Level of Care (ALC) refers to situations where
hospital patients have completed the acute care phase of
Two additional provincial priorities have also emerged: their treatment but remain in acute care beds waiting for
discharge or transfer elsewhere. Some people cannot leave
4. Enhance Mental Health and Addictions Services the hospital due to lack of access to other types of care.
5. Implement Ontario’s eHealth Strategy Other people await discharge due to inefficiency in the
system. At times in the South West LHIN, up to 12% of
hospitals’acute care beds are occupied by ALC patients.
Reducing Emergency Room (ER) Waits An ALC patient occupying an acute care bed can create a
Reducing ER wait times is one of the Ontario government’s backlog in hospitals when there are no other beds available,
top health care priorities. It recognizes that Ontarians causing people to spend a longer time in the ER. That’s why
deserve safe, reliable, appropriate and high-quality care the provincial government is investing in a variety of
when sudden injury or troubling symptoms take them to initiatives that are working to relieve the ALC pressures in
the ER. As part of its plan to improve ER performance, the Ontario hospitals. LHINs will continue to invest time and
MOHLTC has set provincial targets for ER waiting times and money to reduce the number of people who stay in hospital
is moving forward with public reporting of the time when they could be at home or in the community getting
Ontarians spend in the ER. services better suited to their needs. The South West LHIN
has a number of strategies in place that have helped people
Reducing ER waiting times is a complex issue that requires receive care in the right setting.
improvements across the entire health system. Important
work is currently underway in Ontario to achieve operational
improvements in emergency departments. In the South
West LHIN, we recently completed an Emergency Department

Diabetes Strategy That is why the Minister of Health and Long-Term Care
established a Minister’s Advisory Group on Mental Health
Ontario’s Diabetes Strategy will help tackle a growing and and Addictions to address the issue. This Advisory Group
expensive health care challenge. In 2008, about 900,000 will help create a 10-year strategy on mental health and
Ontarian – 8.8% of the province’s population – were living addictions needs and priorities.
with diabetes. The number of Ontarians with diabetes has
increased by 69% in the last 10 years and is projected to A South West LHIN environmental scan confirmed challenges
grow from 900,000 to 1.2 million by 2010. Treatment for in accessing coordinated addictions and mental health
diabetes and related conditions such as heart disease, stroke services (see Supporting Documents – South West LHIN
and kidney disease currently costs Ontario over $5 billion Consultations for Mental Health and Addiction Strategy).
each year. There is a growing awareness that mental health and
addiction integration needs to be within the whole system.
Focusing efforts on prevention programs and improving The South West LHIN’s Blueprint describes the integration
access to team-based care are central to the Diabetes needed to achieve this. In addition, a number of actions will
Strategy. The provincial Strategy includes an online registry be implemented over the next three years to assist people
that will enable better self-care by giving patients and to gain access to addiction and mental health service
providers access to information and educational tools that prevention, treatment and recovery programs.
empower them to manage their disease. The registry will
also give health care providers the ability to easily check
patient records, access diagnostic information and send An eHealth Framework
patient alerts. It will result in faster diagnoses, treatment On March 19, 2009, eHealth Ontario released Ontario’s
and improved management for Ontarians living with eHealth Strategy, 2009-2012. The eHealth strategy is about
diabetes. The South West LHIN is extremely pleased to have improved health, health care, patient safety and quality of
been chosen as one of three LHINs to be an early adopter of care for all Ontarians. It focuses on three clinical priorities
both the Diabetes Strategy and the Diabetes Registry. over the next three years. They are:
• Diabetes Management, including the Diabetes Registry
Mental Health and Addiction Services • Medication Management, including complete drug
Mental health and addiction issues and concerns exist history and dispensing information
throughout all segments of society – all ages, cultures and • Wait Times – ongoing enhancements to the Wait Times
backgrounds. Approximately one in five Ontarians will Information System and its expansion as part of the
experience a mental health and/or an addiction problem provincial Emergency Room (ER)/Alternate Level of Care
during their life. The prevalence of mental health conditions (ALC) Information Strategy
among youth is increasing. As well, given the current
economic situation, there may be a greater demand for These clinical priorities will be supported by a foundation
adult mental health services in the coming years. Almost of information systems, as identified in the eHealth
everyone knows someone who is affected. The cost to Strategy document.
individuals and society is enormous.

As the strategy evolves, with the patient’s consent, physicians,
hospitals, community health care providers, labs, pharmacies
and patients themselves, will gradually gain the ability to
access and add to a single secure electronic record. However,
this means that technology, business processes, registration,
consent and privacy protocols have to be developed,
implemented and adopted. The LHINs, the MOHLTC and
eHealth Ontario are all partners in this important initiative,
one that will enable us to transform health care delivery.
As identified earlier, the South West LHIN is very pleased to
pilot the implementation of the Diabetes Registry for the
province in addition to having a number of information and
clinical technology initiatives underway.
South West LHIN Alignment

with Provincial Priorities
The South West LHINs alignment with provincial priorities
is evident throughout the IHSP. Specifically, the LHIN has
prioritized a number of actions and performance measures
that aim to enhance capacity and integration of primary,
specialized and community-based care. There is a focus on
seniors and adults with complex needs, people experiencing
mental health and addictions challenges and people
who have or are at risk of developing chronic diseases.
In addition, the IHSP outlines actions and performance
measures related to enhancing access and sustainability
of hospital-based treatment and care with a focus on
emergency services and medicine, surgical and critical
care services.

3 South West LHIN’s Vision for the
Local Health Care System
South West LHIN’s Vision, Mission and Values
Working Together for... A Healthier Tomorrow
Our Vision
The South West LHIN shares the government’s overall direction for health care:
“A health care system that helps people stay healthy, delivers good care to them when
they get sick and will be there for their children and grandchildren.”
Our Mission
The South West LHIN brings people and organizations together to build a
health care system that balances quality, access and sustainability.
Our Values
Compassion – We appreciate all our actions have real implications
for people and communities
Courage – We will make difficult decisions and challenge the status quo when required
Evidence Informed – Our decisions will be guided by the best available information
Innovation – We will encourage and support new thinking and the
sharing of new knowledge
Integrity – We will act in a fair, consistent and unbiased manner
Trust and Respect – We believe in mutual trust and respect

South West LHIN’s System Level Goals Human resources challenges in some parts of our LHIN
have also played a role in the inability to access services
The South West LHIN strives to achieve five system level as close to home as possible.
goals. The Blueprint and IHSP 2010-13 are grounded in these
as well as the LHIN’s vision, mission and values. (see A system level goal that strives to achieve equitable access to
Appendix B – Health System Design – Blueprint Vision services takes into consideration current and future service
2022, p29). needs and the service delivery structures needed to meet
those needs. The Blueprint provides substantial detail
1. Healthier South West LHIN Community on the enhancements and modifications needed to be
The South West LHIN has not been immune to the challenges addressed to obtain equitable access to services across
related to the growing prevalence worldwide of people our LHIN. Strategies include a common system navigation
with multiple chronic conditions. Arthritis, high blood framework for service coordination; case management and
pressure, heart disease and diabetes are diseases that self-management; the creation of local integrated health
typically occur in combination with at least one other service collaboratives unique to each community;
disease. The prevalence of depression is greater among standardized tools; health human resource strategies;
individuals who have multiple conditions occurring at the and information and clinical technology.
same time. In addition, two of the major risk factors for
chronic diseases are lower income levels and educational 3. Quality of Care and Service
levels. Obesity and smoking are among two of the major The most important element in defining quality of care and
contributors to developing diabetes, lung cancer, asthma service is how South West LHIN residents individually and
and heart attacks. collectively reflect their experience of care with individual
services and the health care system overall. At an individual
Achieving a healthier South West LHIN community involves level, it is defined by person-centred care that“encompasses
increased attention on promoting healthy living, preventing respect for people’s values, preferences and their expressed
illness and injury, enhancing the availability of better self- needs; coordination and integration of care; information,
management tools, practices and information to empower communication, education; physical comfort; emotional
and support people and their care providers to manage their support and alleviation of fear and anxiety; involvement
own care. It also involves enhancing team based care to of family and friends; and transition and continuity.” 1
screen, assess and provide early intervention strategies. The
Blueprint identifies many of the strategies necessary to improve A system level goal that strives to achieve a high quality
or maintain the South West LHIN’s population health. of care involves increased attention to a person-centred
approach, improving patient safety and the use of evidence
2. Equitable Access to Services to support practice, all of which are features of the Blueprint.
Our health care system has evolved over many years and In addition, legislation requires LHINs to develop Integrated
there are many reasons why services in one area of our LHIN Health Service Plans with input from the community and
may not be as available or easily accessible to people living requires LHINs and health service providers to engage
in another part of the LHIN. Some of these reasons include their communities. This community engagement plays a
the timing, readiness and/or needs of a community that may significant role in reflecting the public’s experience with
have been evident in one part of our LHIN but not in another the health care system (see Appendix C – Community
when a funding opportunity existed. At some point, additional Engagement Summary).
communities may need the same service but the resources
needed to provide the service are no longer available.
1
Externally Informed Annual Health System Trends Report: An Input for Health System Strategy Development, Policy Development and Planning
Ministry of Health and Long-Term Care, 2009, p.6

4. Integration of Health Care Delivery 5. Sustainability of the South West Local Health System
Similar to the discussion around equitable access to care, Health care spending in Ontario currently accounts for almost
the way health care services are currently delivered has more half of the provincial budget. It is projected to increase over
to do with the fragmented way in which the system has the long term if steps are not taken to stem the year-over-
evolved over time. This has been largely influenced by year growth it has been experiencing. Reasons for this
policy, legislation, diverse funding methods and educational growth include rising demand and use of services; an
systems. With the ever-increasing demand on health care increasingly aging population; inflation and new, more
services, it has become apparent that the current system no expensive treatments and medications; increased public
longer meets the needs of the population and certainly will expectations; new diseases; and an increase in the
not meet the needs of the future population in its current prevalence of chronic diseases. Given the current pressures
design. Adding to that is the health human resource faced by the health care system, particularly human resource
shortages that challenge the system on a daily basis. pressures and an aging population, care must be taken and
effort made to ensure that services exist and will be there
Medical and technological advances, changes in scope of for South West LHIN residents, their children and
practice, increased evidence associated with the benefits their grandchildren.
of inter-professional teams and the availability of self-
management information and tools have more recently A system level goal that strives to achieve sustainability of
resulted in service delivery shifts. These, in turn call for a local health services focuses efforts on continuous quality
full re-examination of traditional structures and service improvement, improved efficiency and effectiveness of care
delivery models to ensure that integrated care is delivered and service delivery, maximizing our scarce human, financial
to individuals. and physical resources, and improved tools such as score
cards and performance indicators to measure and report on
A system level goal that strives to integrate health care productivity and quality. The Blueprint describes what
delivery involves increased focus on redesigning the health we want health service delivery to look like by 2022 and
care system, where needed, to achieve the intended the active steps we need to start taking today to make
outcomes. Integration is key to the transformative changes that happen.
required to improve population health, people’s experiences
and value for money. The Blueprint provides the framework
elements required to create an Integrated Health System of
Care for the South West LHIN.

4 Overview of the Current
Local Health Care System
To better understand the South West LHIN population’s for northern and central residents. As well, close to 30%
health care needs and the ability of the health care system of the South West LHIN population resides in rural locations,
in the South West LHIN to meet those needs, we looked at which presents unique challenges for health care delivery
a variety of data and information including: and access.
• Characteristics and health status of the
London and Middlesex County have the greatest proportion
South West LHIN population
of visible minority residents and residents with a non-
• Health service utilization and capacity in the
official language mother tongue. While the population of
South West LHIN2
Francophones in the South West LHIN is small compared to
• Extensive engagement with the public and providers3
the Francophone population in some other LHINs, the
Given the large geography of the South West LHIN, three majority of Francophones in our LHIN resides in the south
multi-community clusters have been identified to better geographic cluster (see Appendix D - Francophone Population
understand local community needs and to allow for broader Profile). Francophone and newly immigrated individuals
engagement with the public and local health providers. experience difficulty accessing health care services due
These areas are closely aligned to county boundaries and, to language and cultural barriers. The percentage of the
in many cases, are served by networks and alliances of Aboriginal population in the South West LHIN is slightly
providers. The table below shows the distribution of the lower than in the province overall (1.7% versus 2.2%)5
population across the three geographic clusters. (see Appendix J -Aboriginal Population Profile). Aboriginal
communities face greater risk factors and higher prevalence
What Does the Population Look Like rates for chronic disease and a variety of challenges
in the South West LHIN? to accessing care.
The South West LHIN health system serves approximately

944,852 residents, which is 7.4% of the provincial population.
Approximately 70% of the South West LHIN population lives
in the southern counties. The population distribution has
naturally resulted in a concentration of specialized health
services in the south, which has posed access challenges
Multi-Community Consists of Population Square Kilometres

Cluster (% of SW LHIN population)4
North Bruce County, Grey County (excluding 157,151 (17%) 8,663

parts of Southgate Township, West Grey,
and the Town of the Blue Mountains)
Central Huron and Perth Counties 138,529 (15%) 5,626
South City of London, Middlesex, Oxford and 649,172 (69%) 7,576

Elgin Counties, Norfolk County (the
southwest portions only)
Total 944,852 21,865
2
See Appendices E-I for more information on population and health services in the South West LHIN
3
See Appendix C for a summary of the community engagement process and feedback
4
Ministry of Finance, 2007
5
Indian and Northern Affairs Canada (INAC) adjusted rate

Socioeconomic Characteristics of the Prevelence of Selected Chronic Conditions*
South West LHIN Population South West Ontario
Health Indicator
Overall, the LHIN’s population reflects a similar educational 2005 2007 2005 2007
profile to the provincial average. Approximately 45.3% Asthma 7.3% 7.8% 8.0% 8.1%
of the LHIN population has completed post-secondary Arthritis & Rheumatism 18.7% 17.1% 17.1% 16.2%
Diabetes 5.2% 5.7% 4.8% 6.1%
education, 28.5% did not complete high school, and 8.8% High Blood Pressure 17.2% 17.9% 15.2% 16.4%
have less than grade 9 education.6 Obesity 18.1% 18.0% 15.1% 16.1%
Smoker 20.7% 22.7% 20.7% 20.6%
The South West LHIN unemployment rate of 5.4% is below

the provincial average.7 However, the economic downturn There has been a reported increase in mental health and
of the past year has increased this average and may have addictions prevalence across the LHIN, specifically within
adverse population health implications for some residents rural populations, among adolescent populations, in
within the LHIN. In September 2009, Statistics Canada addictions in the north and central multi-community
reported an increase in unemployment for Ontario to 8.4%, areas, and in Alzheimer-related cases within the growing
a rise of 2.0% from 2006. Current unemployment data is senior’s population.
not available for the South West LHIN as a whole although
London’s unemployment rate in September 2009 was 11.5%. Often, the rate of the population without a primary care
provider can offer an indication of the at-risk population
LHIN residents are also noted to have a lower average within our LHIN. CCHS 2007 and the Primary Care Access
household income compared to the provincial average.8 Survey11 results revealed that approximately 7% to 11% of
the population is unattached to a primary care provider.
Consultations revealed that these socioeconomic indicators Of this, Huron and London/Middlesex counties tended to
may contribute to an increased prevalence of mental illness have the highest proportion of unattached patients,
and addictions issues as well as other chronic diseases. which exceeded the provincial rate of 7%. If not managed
appropriately, the high prevalence of chronic conditions
Health Status of the South West LHIN Population could lead to increased hospitalizations in the future.
When developing a strategic plan for the health system,
it is important to understand the population’s health status,
What Will Our Population Look Like in the Future?
which is likely to influence the health care needs of the In addition to addressing the health care needs of today’s
population. The Canadian Community Health Survey population, service providers will be faced with continued
(CCHS) in 2007 revealed that, while the prevalence of chronic pressure to meet future demands for these health services,
conditions is in line with the provincial average, we have not particularly given the projected population growth.
seen any substantial improvement over the past two years.
By 2022, the population is projected to exceed 1 million
In addition, recent findings from the Canadian Institute for residents (see graph). Elgin County is projected to have the
Health Information report on Primary Health Care in Canada9 highest growth rates relative to the other counties at .98%, with
reported that 41% of the population has one or more chronic Middlesex and Grey projected at .87% and .80% respectively.12
illness. As well, historical LHIN data in 2007/200810 has
revealed that 2% of the LHIN population was dealing with a
diagnosis of cancer.
6
2006 Census of Canada
7
Ibid
8
Ibid
9
CIHI – Analysis in Brief: Experiences with Primary Health Care in Canada, July 2009
10
2007/2008 South West LHIN Oncology data
11
Primary Care Access Survey (PCAS) Results for the South West LHIN and Ontario, July 2007-June 2008
12
Ministry of Finance, 2007

South West LHIN Population Projections What Does the Health Care System
look like in the South West LHIN?
1,200,000
1,1500,00 The South West LHIN population receives services from an
1,100,000 1,054,804 array of LHIN and non-LHIN funded organizations across
1,050,000 the community, long-term care and acute health sectors.
1,000,000 944,852 Residents rely on these organizations for a variety of needs
950,000 including home/social support, episodic, chronic and
900,000 long-term care.
2007 2012 2017 2022
The following LHIN-funded organizations play a critical

As well, the senior population (age 65+) is projected to role in delivering services to its residents:
grow from 15% to 21% of the total population by 2022. • 19 public hospitals operating 33 sites and 1 private hospital
The demands of an aging population have already had a • 62 community support services
significant impact on the LHIN and will continue to grow • 2 community health centres (plus 3 under
over the next 15 years. The largest growth of this age cohort development)
will occur in the north, where it will grow from 11% to 16% • 28 mental health agencies (including 1 children’s
of the total northern population.13 mental health)
• 10 agencies providing addiction services (including
What Does This Mean for the Health of 4 which also provide problem gambling services)
the South West LHIN Population? • 75 long-term care homes
Factors such as demographics, population density, health • South West Community Care Access Centre (CCAC)
status and growth contribute to determining the health care
needs of our population and will influence delivery of health In addition, non-LHIN funded organizations, such as family
care in the South West LHIN. Challenges include: health teams, family health organizations, family health
networks, solo-physician offices and public health units,
• The large geography of the LHIN and the rural nature of play a critical role in the delivery of primary care services.
some South West LHIN communities continue to pose While these services do not fall under the LHIN’s mandate,
challenges for their residents in accessing health services understanding them is crucial to developing a plan for
• The growing unemployment rate may have an adverse integration and coordination across the health continuum.
effect on select populations, increasing the need for
mental health and addiction services beyond the Community Sector 14
current capacity
The community sector plays a pivotal role in managing
• The high prevalence of chronic disease throughout the chronic illnesses, providing services to those with mental
South West LHIN may contribute to increased health and addictions needs, and providing support services
hospitalizations if not managed appropriately that enable individuals and their personal support networks
• The demands of an aging population have already had to manage within their local communities. Examples of
a significant impact on services and will continue to these services include:
grow in the future • Homemaking, in-home personal support, meal delivery,
programs to assist the hearing and visually impaired,
If not addressed, these challenges will threaten the transportation, social and congregate dining, foot care,
sustainability of our health care system in the future. visiting hospice services, day services, assisted living/
supportive housing
13
Ibid
14
See Appendix B – A Blueprint for the Future for a list of observations,
challenges and implications for the future for each of the sectors presented.

• Crisis intervention services, psycho-geriatrics, supportive In addition to services within LTCHs, South West LHIN
housing, mental health case management, counselling, residents also benefit from an array of health services
vocational/employment support programs, social/ provided by community agencies as indicated in the
recreation/rehabilitation, consumer and family initiatives, services provided through the community sector and
peer support, addictions assessment, group sessions, non-acute services, such as Complex Continuing Care (CCC),
withdrawal management rehabilitation and transitional care units (TCU), currently
• Nursing, occupational therapy, physiotherapy, social work, located within hospitals.
speech language pathology, nutrition
In July 2009, 1,893 people in the LHIN were waiting for a
Compared to other services, a number of organizations LTCH bed, with 146 days the average wait time. Approximately
deliver community and in-home support services (such as 175 people per month are admitted to a LTCH in the LHIN.
homemaking, in-home personal support, and meal delivery) Due to the lack of appropriate supportive housing and
proportionate to the population distribution across the LHIN. wraparound services in rural areas, individuals between the
However, the service levels of others, such as day programs, ages of 18 and 65 are consistently admitted to LTCHs. For
transportation assistance and community-based mental those aged 75 and over, the need for LTCH beds is projected
health and addictions services, are reported to be inconsistent to increase across the LHIN, with the north having the
across the LHIN. Additional challenges for services in the highest increase due to the growth rate of this age cohort.
community sector include long wait lists for in-home An increase in the acuity of the population and multiple
community support services, the increasing complexity of co-morbidities, resulting in a need for homes to care for
patients discharged to the community and funding issues. specialized populations are another challenge for
the LTCH sector.
Long-term Care Home Sector
Acute and Non-acute Hospital-based
The South West LHIN has 75 long-term care homes (LTCH) Services Sector
which provide a range of services for individuals with
varying needs. These include Alzheimer secure units, Across the South West LHIN community, there are 20
ethno-cultural/religious services, short stay, convalescent, hospital organizations. These range from small rural
and psycho-geriatric beds. to large urban sites. According to The Core Service Role of
Small Hospitals in Ontario15, most sites are considered small
RATIO OF LTC BEDS TO 1000 POPULATION 75+ YEARS hospitals. South West LHIN organizations enable access to
core hospital services either through multi-site or single
South West LHIN Beds Beds per 1,000 people locations. While these organizations are mainly located in
North 1,325 106 the northern and central geographic areas within the LHIN,
Central 1.331 119 a few small hospital sites reside in pockets of the southern
South 4,163 94 (107)
geographic area.
With the pending addition of 608 beds to the southern The following are some key highlights related to
portion of the LHIN, it is expected that the relative access to hospital-based services:
these beds across the LHIN will increase the ratio of beds per
1000 population within the south to be more in line with the • The distribution of beds from designated CCC beds
north and central geographic areas of the LHIN. versus Rehabilitation beds appear to align with the
LHIN population density. Of all the CCC patients, 67%
of them were either in the clinically complex or
rehabilitation category
15
A Summary Report to the Minister of Health and Long-Term Care From the Ontario Joint Policy and Planning
Committee Multi-Site/Small Hospitals Advisory Group, December 18, 2006.

• In evaluating rehabilitation services, the largest number • Health education and promotion services which can
of admissions occurred in the southern hospitals, 65% help reduce the incidence of chronic illnesses, and
at St. Joseph’s Health Care – Parkwood. While all • Key contact for identification and early intervention
organizations offered orthopaedic and stroke in-patient for mental health and addictions challenges and
rehabilitation services, the volume of orthopaedic rehab associated risk factors
was the greatest in the central area, while stroke rehab
was utilized the most in the north DISTRIBUTION OF PRIMARY CARE RESOURCES
• The south has the highest volume of emergency
Primary All other primary care
department (ED) visits, while north and central experienced Health Community Health Centre resources (FHT, FHN,
a greater proportion of visits per population. Of the 29 Units FHO, FHG, CCM, BSM)
sites that registered ED visits, 21 sites managed greater
North 1 0 and 1 under development
than 10,000 visits in fiscal year 2007/2008, with London Central 2 0
Health Sciences Centre – Victoria as the busiest ED with South 4 2 plus 2 under development
over 100,000 visits TOTAL 7 2 plus 3 under development 87
• Although these services are widely distributed across
the LHIN, 69% of surgical and 89% of medical ambulatory
visits were captured in the south Challenges facing primary care services include inconsistency
• As well, London Health Sciences Centre received 79% of in the availability of and access to primary care resources
total chemotherapy visits, of which a portion is attributed across the LHIN. Primary care providers, although the first
to northern and central residents point of contact, often lack the tools and skill sets to
appropriately screen for mental illnesses and addictions.
Challenges for the acute and non-acute hospital-based
services sector include a lack of available specialty services in Profile of Health Human Resources
rural areas, shortage of generalists in rural communities, lack in the South West LHIN
of coordinated process to manage emergent surgical cases
and an inconsistent approach to identifying CCC patients. The delivery of health services is dependent upon regulated
and non-regulated health human resources across the LHIN.
Primary Care Services Regulated resources include disciplines such as physicians,
nurses, occupational therapists, physiotherapists, speech
A significant proportion of primary health services are language therapy, midwives, chiropodists, pharmacists,
provided through public health units, community health audiologists, dietitians, massage therapists, psychologists,
centres (CHC), family health teams (FHT), family health and respiratory therapists. Non-regulated resources such as
organizations (FHO), family health networks (FHN), family personal support workers, acupuncturists, naturopaths and
health groups (FHG), Comprehensive Care Model (CCM), chiropractors also a play a critical role in the delivery of
Blended Salary Model (BSM), and individual practitioners. health services.
While the LHIN funds two existing CHCs and one Aboriginal
Health Access Centre, there are also organizations and OVERVIEW OF ONTARIO DISTRIBUTION &
practitioners not funded by the LHIN that are pivotal in the CHARACTERISTICS OF REGISTERED PROFESSIONALS
delivery of health services to its residents. The organizations
Registered Members South West LHIN %
in the table below provide an indication of some of the first
points of access to the health system and provide an array of Chiropodists 480 n/a
educational and early intervention services including: Midwives 334 7%
Nurse Practitioners 594 5%
• System navigation for many communities Occupational Therapists 4,010 10%
Physiotherapists 6,080 10%
• Prenatal and sexual health screening services, which Registered Nurses 89,054 9%
often serve as the stepping stone to education and Registered Practical Nurses 24,482 11%
early intervention

Capturing data on health human resources is often a • Lack of integrated technology platforms across the
challenging exercise as there is no central database that LHIN inhibit information-sharing among health
exists. Professionals who are regulated are attached to service providers across sectors and geography
professional bodies so some information can be gleaned. • Capacity limitations make it difficult to meet the
There is currently a total of 1,805 physicians registered in the increased demand for health services
South West LHIN, with 79% practicing in the south. Only • Limited availability of health human resources make it
11% and 20% of them are registered in the north and central difficult to meet the current and anticipated health
geographic clusters of the LHIN, while 17% and 15% of the service demand
LHIN population live in the north and central areas of the
LHIN. Although there is a relatively even distribution of What Did We Hear from the Community?
Family Medicine physicians across the LHIN, specialist
practitioners are primarily concentrated in the south, aligned To inform and validate our priorities and to learn more about
with the academic health centres, London Health Sciences our health care system, we engaged people across the South
Centre and St. Joseph’s Health Care, London. West LHIN community through public meetings as well as
telephone and online surveys (see Appendix C - Community
One area of concern is the age distribution of regulated Engagement Summary). We received valuable feedback
health professionals across LHIN. Most are over the age of 40 regarding the development of our strategic directions.
years, with occupational therapists being the only exception.
This profile is consistent with the overall trend across Canada. Community Sessions
In July and September 2009, the South West LHIN hosted
What Does This Mean for the Health Care 17 sessions across the LHIN area to share information about
System in the South West LHIN? current health trends and issues, listen to ideas and concerns
about the health care system and get feedback on proposed
Providers across health sectors face the following challenges: priority areas for improvements. Targeted engagements
were also held with representatives of Francophone
• Inequitable distribution of health services across the communities and newly immigrated individuals.
LHIN pose access challenges for residents, particularly
those in rural communities The majority of respondents felt that our proposed priorities
• Current funding and operating models reinforce a would make a difference to them or people that they know.
provider-focused versus person-centred approach to When asked if there were other priorities that the LHIN
health service delivery should consider, respondents suggested: addressing
• Lack of integration across sectors and of health service human resource shortages, health promotion, funding,
providers inhibits the seamless movement of individuals system navigation and transportation.
and families across the continuum of care
• The health profile of the South West LHIN necessitates
more appropriate, integrated screening and early
identification of health risk factors and conditions

At the Francophone community session, the group agreed
that each of the priorities were of importance and stressed
the need for health care services to be provided in French.
They suggested additional ways to enhance access to French
language services: the establishment of a Francophone
Community Health Centre, enhancement of cultural and
linguistic competency in health care, French speaking staff
in the emergency rooms and housing supports tailored to
Francophone seniors (e.g., long-term care homes).
Those who provide services to newly immigrated

individuals in and around the London area also took part in
an engagement session. While participants agreed with the
priorities, they highlighted the lack of access to language-
and culturally appropriate health care services. It was noted
that newly immigrated individuals struggle to know how
and even when to use our health care system.
Telephone and Online Surveys

Telephone and online surveys were conducted with residents
of the South West LHIN in September 2009. Telephone
survey results showed strong support for our key priority
areas. When asked what priority may be missing, the
majority of respondents suggested the number and
availability of doctors.
Results of the online survey showed that most people felt

that all the priorities were important. When asked what
other priorities should be looked at, the desire for services
close to home and doctor shortages were cited most often.

5 Framework for Planning
Where Are We Going? The Health Services Local Community, Multi-Community and LHIN
“Blueprint” Describes It! Community are defined as follows:
Over the past year, the South West LHIN has worked to • Local Community involves the coordination and
create a health services“Blueprint”. The Blueprint included provision of services ‘close to home.’ These types of
the development of a project charter, a current and future services include primary care, some secondary care, home
state assessment and a Blueprint framework (see Appendix and community care, inter-professional clinics for chronic
B – Health System Design – Blueprint Vision 2022). The LHIN diseases and local hospital services. For these services,
has had the benefit of working on the current and future there will be many sites for service access across the
state assessment and the Blueprint framework over the past LHIN, located in communities, connected through an
several months while the IHSP for 2010 – 2013 was also inter-professional team
being developed.
• Multi-Community is the coordination and provision of
Creating the Blueprint framework now has allowed us to some specialized services that will be provided through
engage the public and health service providers about where service providers who serve both their local community,
we need to get to, based on the known practices and trends but also surrounding communities within a defined
in health today (see Appendix C - Community Engagement catchment area. Some travel to access services may be
Summary). Since the Blueprint has helped us understand our required; however services should still be accessible
health care needs 12 years into the future, the second IHSP within the Multi-Community area. Services may be
prioritizes our steps for the first three years of this journey located at two or more sites to serve several clustered
so that we can achieve our Blueprint goal of an Integrated communities. These sites will serve a large proportion of
Health System of Care by 2022 individuals who may require certain types of subspecialty
programs, yet do not need to travel to LHIN-wide sites
The Blueprint follows the important work of the Priority
Action Teams which helped define what an Integrated • LHIN Community refers to those services where the
Health System of Care should look like at a population or resources and expertise are not widely available
program level based on the priorities identified in the first throughout the LHIN. These programs will be led by one
IHSP. The Blueprint takes these directions one step further identified organization and the organization will be
by integrating common elements and creating a shared mandated to provide appropriate access and care to
approach to service delivery that can be realized across residents across our LHIN and beyond. Travel to a location
priority populations and programs at local community, may be required to access these highly specialized
multi-community and LHIN community levels. services. These organizations may also serve as a
provincial resource for certain services

at e d H ealth System o
n tegr f Car
e
I LEVEL
TI-
S Y S T E M O F N A V I G AT I O N FRAME
W ORK
MUL
GY IN
O TE
OL G
Local Multi- LHIN
RA
HN
TE
EC
DH
LT
IC A
• Services provided • Service delivery by • Delivery of low
EAL
N AND CLIN
TH HU
close to home geographic clustering volume/highly complex
• Delivery of high volume/ of moderate volume/ services to manage
low complexity services complexity services specialized populations
MAN RESOU
to broader population focused on targeted • Support multi-community
• Collaboration across
M AT I O
populations and local providers

local traditinal and non- • Seamless referral with accessibility to
traditional providers relationships with local specialized services
OR
RCE
• Emphasis on an individual’s and LHIN providers • May serve as a broader
INF
STR
self-health management provincial resource
NG
AT
I
BL
G E
A IES
EN
IMPL
EMEN HEALTH SYSTEMS BLUEPRINT MEWORKS
TATION AN
D ACCOUNTABILIT Y FRA
Service & Delivery

Approaches
Population-based integrated health services

• Home and community care, long-term care homes,
complex continuing care, rehabilitation services
• Chronic disease prevention • Surgical services
and management • Critical care services
• Emergency services • Internal medicine services
Centrally coordinated resource capacity
Local Multi- LHIN


Our Blueprint defines what our Integrated Health System Characteristics of the Two Integrated
of Care looks like through the description of two integrated Health Service Delivery Approaches
service delivery approaches:
The Population-based Integrated Health Services approach
• Population-based Integrated Health Services is exhibits the following characteristics:
tailored to the collective needs of a local population
and its health service providers. It enables local • This approach calls for health service delivery tailored
communities to support the health and wellness of its to the local needs of its catchment population and
catchment population enabling them to better manage health service providers. It builds capacity for these
their own health and maintain independence. The local communities in order to support the health and
local community services are supported by the multi- wellness of its catchment population. This approach
community services and facilitate access to LHIN will focus on total health management including
community services as needed prevention, screening, identification, assessment,
• Throughout an individual’s life journey, he or treatment, follow-up and the necessary support
she may access primary care services, home and • There is an emphasis on individual’s accountability in
community care, complex continuing care, the management of one’s own health
long-term care, rehabilitation, chronic disease • The majority of service coordination and intervention
prevention and management, mental health will be delivered through local health and social
and addictions services and emergency services service providers and coordinated through local
coordinated through this service health resources or integrated health services
delivery approach collaboratives. These collaboratives will be delivered
• Centrally Coordinated Resource Capacity optimizes through various delivery models such as co-located,
the use of targeted resources to improve access and mobile and/or virtual settings depending on the
complement the management of health and wellness health and social needs of the community and health
at the more local level service provider base
• Throughout an individual’s life journey, he or • Relies on care coordination and inter-professional
she may access medicine, surgical and critical support at the local level, including primary care,
care inpatient and ambulatory services community and public health professionals as part
coordinated through this service of the broader health care team
delivery approach • As individual needs become increasingly complex,
referral and linkage to specialist and sub-specialist
It is important to note that these approaches are not care at the multi-community and LHIN community
mutually exclusive, but are truly integrated recognizing that levels may be required and coordinated through the
as an individual at various points in their lifetime interacts inter-professional team
with the system, their needs will vary and the system must
be able to respond in a seamless and coordinated manner.

The Centrally Coordinated Resource Capacity service In short, the Blueprint offers the South West LHIN the
delivery approach does not intend shifting to a single owner direction needed to improve people’s health care experiences,
of resources, but exhibits the following characteristics: improve the health of particular populations and improve
the value that we receive for the money that we spend on
• Approach focuses on optimizing the use of targeted health care by:
resources to improve access and complement the
management of health and wellness at the more • focusing on individuals and families
local level • redesigning primary care services and structures
• This approach focuses on LHIN-wide coordination of • managing the health of particular populations
medicine, surgical and critical care inpatient and • establishing a cost-control platform
ambulatory services to maximize our resident’s access • reinforcing system integration and execution
to services. Service delivery will be coordinated across • building coalitions with other sectors
local community, multi-community and LHIN
community providers At a system level, the Blueprint:
• Local providers will play a key role in primary and
secondary identification, assessment, treatment • Emphasizes that all health programs are part of a single
and follow-up services for their local communities. health system dedicated to serving the larger South West
Providers will also focus on changing their practices LHIN population
to include the individual and their families as part • Depicts how the various component parts of the
of the care team to emphasize the individual’s health system need to adopt a shared approach to
accountability in the management of one’s service delivery
own health • Clearly communicates the roles of health providers
• Providers whose role will be to deliver services at the and professionals within the broader health system.
multi-community level will provide specialist services • Delineates the interdependencies between health
for a larger population programs which enables strategic planning and
• South West LHIN-wide providers will be responsible decision-making
for delivering highly specialized services for complex • Enables unified implementation of the IHSP.
population segments
• It should also be noted that while in some cases
tertiary hospitals will be expected to function as a
LHIN-wide resource, it is also expected that they will
also continue to function as the local care resource
for the communities in which they currently
operate today

At a service delivery level, the Blueprint: The South West LHIN, in collaboration with its health
system partners, will continue to provide overall direction
• Enables local, multi-community and LHIN-wide health to our health system design process and will work to take
service providers to critically evaluate the current state action on the following:
of their health services and identify the major issues
and opportunities that exist for them and their specific • Developing future IHSPs aligned to the vision of the
population Health Services Blueprint
• Enables health care providers and the LHIN to plan for
change by further developing and implementing a service
delivery model customized to the specific health services IHSP IHSP IHSP IHSP
and population needs at the local, multi-community and 2010-2013 2013-2016 2016-2019 2019-2022
LHIN community level
• Provides program-specific context to serve as the Integrated Health System of Care
foundation for implementation planning at the local, INTEGRATED HEALTH SYSTEM OF CARE
multi-community and LHIN community level
• Creating incentives for health service providers and
How are we going to get there? partners as able and deemed appropriate
• Maintaining a transparent process with open lines
Recognizing that achieving an Integrated System of Care, of communication to enable easy collaboration
as defined by the Blueprint, requires a dedicated journey • Modifying service accountability agreements to
involving planning and implementing, the Health System include elements of the Health Services Blueprint and
Design Steering Committee will immediately transition to IHSP. As appropriate, these agreements will reflect
undertake the following key initial action steps: transformative elements and initiatives which can
gear health service providers towards enacting change
• Identification of leadership to guide and lead change These agreements will reflect the partnerships involved
efforts, both at the system-wide level and within across providers in making change through joint
targeted implementation initiatives accountability statements
• Framework for implementation planning to be
completed by March 31, 2010. This framework will Acknowledging the resource limitations of today and
guide the development of detailed implementation plans. potential pressures of the future, our need to transform
As part of this process, we will work with stakeholders the system is even more imminent. Under the Local Health
within the context of the strategic directions identified System Integration Act, 2006, providers now have an
in the IHSP, to identify those opportunities that are accountability to look for opportunities to integrate the
innovative, align to the Blueprint and can serve as local health system. We are a single health system and thus
“success stories”and in doing so be examples of positive need to be vested in the“success of all”including people
change. While we will work with health service providers who deliver and receive health care, the success of
to proactively identify these groups, we urge providers organizations that we have an affiliation to, in addition
to engage in seeking out opportunities as well to the success of other organizations and the services
they deliver.

A Strategic Improvement Approach can Help us! system level goals. By tracking performance measurements
of these projects, the LHIN will better understand the
The Blueprint’s two integrated service delivery approaches contributions that these projects make to system level
provide the direction of where we are going but it will take results over time.
substantial planning and implementation efforts over a
number of years to move us towards experiencing health As the LHIN continues on this strategic improvement journey,
care differently in the South West LHIN. other LHINs have also recognized the concepts, methodologies
and tools that the IHI can bring to Ontario’s health care
There are many examples of health care institutions and experience. In particular, CHQI and the Change Foundation
systems that have seen vast improvements in the provision hosted a“Triple Aim”forum in September, 2009 for all 14
of health care services and outcomes over the past decade. LHINs. The LHINs have now committed to the“Triple Aim”
The MOHLTC is also interested in understanding the strategies approach in some capacity.
and learnings in other parts of the world. Over the past
couple of years, it has sponsored a number of events in Simply, Triple Aim is a framework that strives to improve
partnership with the Centre for Healthcare Quality three things at the same time:
Improvement (CHQI) and The Change Foundation (see CHQI
website) that have given LHINs and health service providers 1. People’s health care experiences
from across the province an opportunity to hear and learn 2. The health of particular populations
from areas where health care advancements have been 3. The value that we receive for the money that
made. This has led many of the LHINs to investigate the we spend on health care
Institute for Healthcare Improvement (IHI’s) compilation of
tools and strategies that reflect much of the best thinking It does so by:
and evidence associated with improving health care. The • Focusing on individuals and families
IHI is a not-for-profit organization that collaborates with • Redesigning primary care services and structures
institutions and their leaders from around the world to • Managing the health of particular populations
capture the concepts, methodologies and tools to improve • Establishing a cost-control platform
health care worldwide (see IHIs website). • Reinforcing system integration and execution
• Building coalitions with other sectors
Approximately a year and a half ago, the South West LHIN
solidified its vision, mission, values and system level goals
and embarked on a strategic improvement approach to
better align planning processes and investment strategies
to obtain system level results. The strategic improvement
approach provides a platform to support and measure the
performance of projects through a continuous loop of “Plan,
Do, Study and Act”that allows the LHIN to expand projects
that achieve the results intended and modify or terminate
projects that do not. As part of this approach, a portfolio of
projects related to priority populations and programs based
on the LHIN’s first IHSP, were mapped against the LHIN’s

TheTriple Aim framework embodies many of the core elements of the Blueprint’s integrated service delivery approaches.
To track and understand the results of our efforts, the South West LHIN has also begun to apply the Triple Aim
framework to its performance measurements. These measurements directly align with our system level goals.
Healthier South West LHIN Community

POPULATION HEALTH
Equitable Access to Services
BLUE PRINT
EXPERIENCE OF CARE Quality of Care and Services
Integration of Health Care Delivery

PER CAPITAL COST/
COST CONTAINMENT Sustainability of the South West Local Health System
The Blueprint includes a section on operationalizing the Integrated Health System of Care in addition to providing
an implementation road map (see Blueprint Supporting Documents - Appendix E: Implementation Elements).
The Blueprint’s integrated service delivery approaches will advance through planning and implementation, using a
strategic improvement approach that tests small steps. This will result in small improvements in particular areas and
then spread more broadly across the LHIN.

6 Priorities & Strategic Directions
for the Local Health System
The Blueprint describes in detail what we want health service delivery to look like by 2022 and why we need to
take active steps today to make that happen.
The IHSP for 2010-2013 continues the implementation efforts of our first IHSP. It prioritizes the steps needed to
achieve our Blueprint goal of an Integrated Health System of Care by 2022. The following chart provides a simple
sketch of how our IHSP implementation efforts over the next three years align with our Blueprint directions
and system level goals.
System Level goals
Healthier South West Equitable Access Quality of Care Integration of Health Sustainability of the
LHIN to Services and Service Care Delivery South West Local
Community Health System
Blueprint Integrated Service Delivery Approaches, 2010-2022
Population-based Integrated Health Services

Centrally Coordinated Resource Capacity
Integrated Health Service Plan Strategic Directions, 2010-2013
Enhance Capacity and Integration of Primary, Enhance Access and Sustainability of

Specialized and Community-based Care, Hospital-based Treatment and Care Related to:
with a Focus on the following Populations:
• Emergency Services
• Seniors and Adults with Complex Needs • Medicine, Surgical and Critical Care Services
• People Living with Mental Health and Addiction Challenges
• People Living with or at Risk of Chronic Disease(s)
Key Enablers
Multi-level System of Navigation

Information and Clinical Technology
Integrated Health Human Resource Strategies
Implementation and Accountability Frameworks

What does the South West LHIN plan to
implement over the next three years and why?
The South West LHIN is in a very good position to identify
the steps required over the IHSP 2010 – 2013 timeframe. The
enormous engagement and consolidation of the Blueprint
activities has set a detailed direction for what the Integrated
Health System of Care will look like and how it will function
in the South West LHIN. In general, we received public
support for the actions related to the priority populations.
This was through our community engagement process,
which included community sessions, a telephone survey
and an on-line survey (see Appendix C – Community
Engagement Summary). In addition, we have examined the
resources required and the readiness and ability of South
West LHIN’s partner to action the following initiatives:
Actions Related to Enhancing Capacity and Integration of Primary, Specialized

and Community-based Care, with a Focus on the Following Populations:
Seniors and Adults with People Living with Mental Health People Living with or at Risk
Complex Needs and Addictions Challenges of Chronic Disease(s)
• Through Aging at Home (Year 3): • Increase supportive housing for • Implement Chronic Disease
- Develop and implement an people with problematic substance Prevention and Management
integrated model of care for use and concurrent disorders strategies with an initial focus on
high-risk seniors • Implement a screening tool to the Ontario Diabetes Strategy and
- Develop and implement a screen universally for concurrent extend to other chronic illnesses
coordinated system of care for disorders where relevant
seniors with behavioural issues • Implement a training program to • Leverage success of the Partnerships
- Enhance services and supports help people to develop personal for Health project and extend
for Aboriginal seniors wellness plans to other chronic illnesses
- Enhance capacity and • Improve access to community where relevant
coordination of transportation mental health and developmental • Implement enabling technologies
services services for persons with a dual with an initial focus on the
- Create additional convalescent diagnosis provincial Diabetes Registry and
care beds in long-term • Work with partners to facilitate include other enabling technologies
care homes the movement of specialty hospital where relevant
• Define the role of and access to services (Tiers 2 and 3 divestment) • Explore the applicability of the
complex continuing care beds and • Work with partners to enhance Diabetes Registry to manage data
rehabilitation services the availability of and access to for other chronic diseases
• Monitor results of all Aging at children’s mental health beds • Continue with, and expand,
Home initiatives implementation of self-
management strategy
• Implement peritoneal dialysis
in long-term care homes to align
with Ontario Renal Network
• Continue to work with Aboriginal and Francophone communities to improve availability of and access to services

Actions related to Enhancing Access and Sustainability
of Hospital-based Treatment and Care Related to:
Emergency Services Medicine, Surgical and Critical Care Services
Based on the recommendations of the Emergency Engage key local, multi-community and LHIN community
Department Human Resources Study, engage key local stakeholders to develop an action plan for creating and
and multi-community stakeholders to initiate a process implementing Centrally Coordinated Resource Capacity for
to develop and implement strategies tailored to their medicine, surgical and critical care services, with a focus on:
communities’emergency services needs, with a focus on:
• A LHIN-wide resource capacity management system
• Emergency services recruitment and retention capability • A centralized coordinated referral system, evidence
• Emergency services coverage with current resource pool based care pathways and order sets, tools and
• Emergency services health care personnel capacity quality guidelines
Key Enablers The following is a brief description of the key enablers.
A number of key enablers have been identified to ensure Multi-level System of Navigation
successful implementation of an Integrated Health System A multi-level system of navigation underpins health
of Care. These include: care provision across all sectors. Elements of navigation
include clinical case management, self-management and
• Development, shared understanding and shared service coordination dependent on the needs of the
accountability for a multi-level system of navigation individual. The intensity of navigation varies depending
• Existence of robust information and clinical technology on needs and circumstances (including socioeconomic
• Application of integrated health human resource determinants of health) of the individual.
strategies across our LHIN
• Development of implementation and
accountability frameworks
Development of
care plan
CL
IN I
C AL
N AV I G ATI O N
C A S E M A N AG E M
Information
and
System of Referral to
appropriate
Multi-level System of Navigation education Navigation service provider
Individuals will play an active role in managing their
SELF
own health care, self-navigation, as they are able.

ENT
They will be able to navigate themselves and their family
through the integrated system of care. The system will Health/non-
empower individuals with centralized access to: health needs
post service
• Health education resources and tools
• Inventory of health services
• Access to local services for coordination and clinical case SERVICE COORDINATION
management as needed
• Assessment and development of care plans with
Service coordination will be provided by a collection of resources appropriate health/non-health resources
depending on the care setting. While this can be delivered by a • Referral to and contact with the appropriate health/non-
navigator and/or knowledge broker roles, it can also be delivered health service provider as needed
by health care professionals (primary care physicians, nurse • Management of care needs post services in order to maintain
practitioner, etc). Health care professionals will be required to continuity throughout individual’s life cycle
provide information/referral services as deemed appropriate. • Provision of education, support and consultation to the
individuals and their families
Depending on health need, clinical case management services • This person ensures that their client’s involvement in decisions
will be provided by clinical case managers and/or direct service regarding their care is maximized and that all parties are in
providers and may include: good communication and share common understandings

Modeled after the Kaiser Permanente concept, a multi-level system of navigation
is needed to capture the following catchment populations:
LEVEL 3 LEVEL 3: A strong presence of clinical case managament and service coordination for a small
High proportion of the population. This would involve a navigator and case manager that stays
complexity attuned and connected to the individual as he/she accesses health, medical and social services.
case management
LEVEL 2 LEVEL 2: A moderate presence of clinical case management and stronger need for service
High risk disease/ coordination for individuals with specicfic diseases or chronic illnesses. These case managers
care management and navigators would assist the individual through health and medical needs across health
sectors and social agencies.
LEVEL 1
Self care support/ LEVEL 1: A strong presence of service coordination as these individuals need to develop a
management (70-80%) more collaborative relationship with a navigator for educational and coordination purposes
as needed. This is roughly 70-80% of the population.
SOURCE: All Seniors and Adults with Complex Needs PAT; Prevention and management of chronic illnesses PATSource: ADAHPT Case Management Model.
http://www.health.nsw.gov.au/resources/adahps/pdf/case_mgt_model.pdf;
HRSA Clinical Case Management with Multiply Diagnosed Clients: Integrating Multiple Provider Roles,
http://hab.hrsa. gov/special/integrating.htm;
AZDHS Case Management and Clinical Team Services Plan, http://www.azdhs.gov/bhs/casemgtservplan.pdf
Enabling Information and Clinical Technology • Automated medication refills through the phone and
online pharmacist care or medication purchasing
E-health is a consumer-centred model of • Telemedicine applications that, for example, record
health care in which stakeholders can utilize people’s weight, blood pressure and glucose readings
information and communication technologies and then transmit that information to awaiting health
to manage their health care needs. E-health professionals to trigger responses, if needed
• Automated physical activity programs like the Nintendo
solutions are viewed as potential tools for
“Wii”that are accessible to people of all ages and
modernizing the health care system, by making varying abilities
care safer and more cost effective.16 • Electronic health records that contain pertinent health
information related to a particular person’s condition(s),
The internet and mobile phone technologies are not only treatment(s), medication(s) and service(s). This allows
important in people’s daily lives and in the delivery of health both providers and users to contribute to and access the
care services. They are also improving our access to health record to ensure that all the individuals involved in that
care services and health information. Some of the ways person’s care understand that person’s goals and the
they are doing so include: treatments and supports in place or that are still needed
• Web-based self-management programs that provide
disease information, strategies and tools to better
support individuals in assessing and managing their
own conditions
16
Externally Informed Annual Health System Trends Report: An Input for Health System Strategy Development,
Policy Development and Planning, Ministry of Health and Long-Term Care, 2009, p.13

Magnitude of Change
LESSER DEgREE MODERATE DEgREE gREATER DEgREE
• Health care professionals will be equipped with a centrally • A real-time, easily accessible electronic health record (EHR)
accessed repository of all South West LHIN health services needs to be available to health providers LHIN-wide, across
(e.g. thehealthline.ca, ConnexOntario.ca) which lists services the continuum of care
to enhance health education and enable care coordination
across organizations
- Enhanced functionality of real-time capacity update • A personal health portal will allow individuals to access
and electronic appointment booking their EHR and share health information as needed (e.g. with
- Accessible through online or via telephone alternative care providers). The personal health portal will
be equipped with self-assessment, management and
scheduling tools
• Enhance functionality of Criticall system
(infrastructure already available) for:
- LHIN-wide capacity management • Care coordination system will allow organizations to make
- Communicating and reporting of bed capacity status electronic appointment referrals and bookings across sectors
- Facilitating communication between physicians
and triage
- Serving as a mechanism to receive physician consult
prior to referral of individual
- Facilitating physician consults
• LHIN-wide or sub-LHIN management of capacity

as appropriate:
- Acute capacity
- Complex continuing care
- Specialized rehabilitation
- Long-term care homes
- Supportive housing service
• Telemedicine and telehealth services will enable the

provision of health services
• Specialized tele-consult services will be provided to enable
treatment and referral as needed. This will play a major role
in the LHIN’s rural areas and will assist referral process to
LHIN-wide services for higher acuity needs
The Blueprint describes the need for the above technology- When assessing potential eHealth initiatives, the South
related solutions to enable information flow, support West LHIN will consider how they tie into the Clinical or
the provision of care and facilitate communication Foundational priorities identified in Ontario’s eHealth
to achieve an integrated system of care for the South Strategy 2009-2012 (see provincial eHealth Strategy).
West LHIN. This will help ensure there is alignment with the provincial
standards and direction. (See Appendix A - Projects,
Programs and Initiatives related to Strategic Directions)

Health Human Resources
As described by the Blueprint, an Integrated

“Health human resources (HHR) are a Health System of Care requires integrated,
critical factor in health policy planning proactive HHR strategies to better equip South
across Canada and internationally. The Pan- West LHIN providers with the health human
Canadian Health Human Resource Strategy resources needed to adequately deliver
states that: appropriate planning and services. These include:
management of HHR are key to developing
a health-care workforce that has the right
number and mix of health professionals to
serve Canadians in all regions of the country”.17
Magnitude of Change
LESSER DEgREE MODERATE DEgREE gREATER DEgREE
• Developing a sustainable workforce • Create collaborative networks South • Encourage organizations to create
planning process based upon data West LHIN to leverage best practices cultures that support retention
collection and performance and drive policy changes and growth
management to be available to
health providers LHIN-wide, across
the continuum of care • Leverage recruitment programs
across South West LHIN providers
• Develop a recruitment and retention

strategy for HHR in both rural and • Set clear expectations of HHR roles
urban communities in collaboration and responsibilities within the
with South West LHIN providers future service delivery models
(e.g. interprofessional collaboration)
• Leverage current provincial and

regional initiatives to manage HHRs • Develop and implement training
programs to enhance skill sets
to include management of
specialized populations
17
Externally Informed Annual Health System Trends Report: An Input for Health System Strategy Development,
Policy Development and Planning, Ministry of Health and Long-Term Care, 2009, p.11

The need to have the right number and mix of regulated Recognizing that achieving an Integrated System of Care,
health professionals and non-regulated health care staff as defined by the Blueprint, requires a dedicated journey
and volunteers to deliver the required services has involving planning and implementing, the Health System
become a growing concern. The South West LHIN is not alone Design Steering Committee will immediately undertake
in its constant search for health care workers as the shortage the following key initial action steps:
is global. At the same time, the changing nature of practice
of health professionals complicates our ability to predict our • Identification of leadership to guide and lead
needs. Trends have shown that physician practices have change efforts, both at the system-wide level and
changed over the years with them providing fewer hours of within targeted implementation initiatives
care. Yet, an increase in the elderly population, people with • Framework for implementation planning to be
complex needs and those living with chronic diseases will completed by March 31, 2010. This framework will
most certainly require more health care resources. guide the development of detailed implementation
plans. As part of this process, the LHIN will work with
Implementation and Accountability Frameworks stakeholders within the context of the 2010-2013 IHSP
Achieving an Integrated System of Care is dependent on strategic directions to identify those opportunities that
progressively initiating a series of implementation elements are innovative, align to the Blueprint and can serve
within a defined accountability framework. This requires as“success stories”and in doing so be an example of
the establishment of a framework which enables: positive change. While we will work with health service
providers to proactively identify these groups, we urge
• Clear expectations of existing governance and leadership you to engage in seeking out opportunities as well.
structures that would facilitate and oversee change
• Stewardship through coordination of key stakeholders
and driving the agenda forward
• Improved efficiency and clarity of decision-making
• Clarity of roles and responsibilities
• Clear conflict resolution pathways
• Adoption of established standards (e.g. project
management, performance management, etc)
• Improved cross-sector, stakeholder coordination
and communication
This framework would be operationalized through agreed
upon policies and procedures around mandate, process and
information needs, and system monitoring and evaluation.

The LHIN, in collaboration with its health system partners,
will also continue to provide overall direction to our health
system design process. More specifically, we will work to
take action on the following:
• Developing future IHSPs aligned to the vision

of the Health Services Blueprint
• Creating incentives for health service providers and
partners as we are able and deemed appropriate
• Maintaining a transparent process with open lines of
communication to enable easy collaboration
• Modifying future new service accountability agreements
to include elements of the Health Services Blueprint
and IHSP. As appropriate, these agreements will reflect
transformative elements and initiatives which will
prompt health service providers towards enacting
change. These agreements will reflect the partnerships
involved across providers in making change through
joint accountability statements
The actions that have been prioritized for the next three
years, through the IHSP 2010-2013, are initiatives that
contribute to achieving an Integrated Health System of
Care. In many areas, a willingness and readiness has been
demonstrated for some time and structures and incentives
are already in place to enable a dedicated group of key
cross-sectoral stakeholders to provide their expertise and
guidance in fully planning and operationalizing the
initiatives. For other actions, a dedicated group of
stakeholders from different sectors and professions will
need to be established to oversee more detailed planning
and implementation efforts.
South West LHIN: Integrated Health Service Plan 36

7 Rationale for Strategic Directions
In February 2009, the South West LHIN took the bold step Rationale for IHSP Strategic Direction:
of initiating the Blueprint project. The objectives of the Enhance Capacity and Integration of Primary,
Blueprint project are: Specialized and Community-based Care
• Provide a response to the first IHSP priority which This first IHSP strategic direction aligns with the“Population-
was to ensure access to the right services, in the based Integrated Health Services”integrated service delivery
right place, at the right time, by the right provider approach and is intended to move the first three years of this
• Facilitate health care providers’and the LHIN’s approach forward. It describes providing care coordination
planning for change rather than reacting to health and interprofessional team based care at the local level to
system trends, challenges and best practices focus on prevention, identification, assessment, treatment,
• Develop a framework for how the system should be follow-up and providing necessary supports.
structured, across programs and geography, based
on a detailed understanding of current services Local care delivery will be very important in order to
• Broadly and collectively leverage our resources support those who need assistance with their health
rather than reacting to single issues faced by challenges such as diabetes, obesity, advanced age,
one organization, sector, or discipline mental illness or addictions issues. As care needs become
increasingly complex for some individuals with conditions
As discussed in earlier chapters, the health care system faces such as concurrent disorders, Alzheimer’s disease and
a number of current and emerging challenges. The Blueprint multiple chronic illnesses, referral to specialist care at the
addresses these challenges by describing an Integrated multi-community and LHIN levels may be required and
Health System of Care for the future where all health coordinated through the inter-professional team.
programs and services are part of a single, unified health
system of care. The Blueprint clearly communicates the The South West LHIN has chosen to focus on
roles and responsibilities of the various health services the following populations:
within this unified system and delineates the
• Seniors and Adults with Complex Needs
interdependencies between stakeholders to enable a
• People Living with Mental Health and
shared approach to service delivery. It does this through
Addiction Challenges
two integrated service delivery approaches:
• People Living with or at Risk of Chronic Disease(s)
• Population-based Integrated Health Services
We will focus on these populations for a number of reasons.
• Centrally Coordinated Resource Capacity
Since the first IHSP, we have undertaken a great deal of
planning and a number of initiatives have already been
Through these two approaches, the Blueprint describes
implemented that provide early starts to some of the
what we want health service delivery to look like by 2022.
Blueprint implementation elements. As with all other LHINs,
The IHSP identifies the strategic directions and steps that
our actions related to seniors and adults with complex needs
we need to take in the next three years to make it a reality,
have been leveraged through the provincial Aging at Home
building on the implementation efforts of our first IHSP
initiative, Alternate Level of Care/Emergency Room
and the innovative partnerships and initiatives already in
initiatives and quality improvement initiatives such as
progress or ready to be launched (see Appendix A – Projects,
the FLO Collaborative.
Programs and Initiatives related to Strategic Directions)

The South West LHIN also remains committed to improving The IHSP actions related to enhancing capacity and
diabetes care by supporting the roll-out of the Ontario integration of primary, specialized and community-based
Diabetes Strategy. In addition to being selected as one of care with a focus on seniors and adults with complex needs;
the first three LHINs to implement the strategy in its first people living with mental health and addiction challenges;
year, we are also one of two LHINs identified as an“early and people living with or at risk of chronic disease(s) will
adopter”of the province’s eHealth Strategy. This puts us in achieve the following objectives:
the favourable position of fully enabling the provincial
eHealth Diabetes Registry. • Increased availability of community care and supports
for high-risk seniors, including Alternate Level of Care
The South West LHIN’s success with the implementation patients waiting for long-term care home placement
of the Partnerships for Health program (see Partnerships • Enhanced service to clients with behavioural challenges
for Health website) has strengthened our position to be in long-term care homes
effective in improving diabetes care across the LHIN. Our • Improved hospital bed utilization by:
involvement with the strategy, the registry and Partnerships • Avoiding admission to acute care beds through
for Health has given us real applications to test some of the prevention activity, facilitated discharge from
Integrated Health System of Care elements described by the emergency department to alternative settings
Blueprint. In addition, our learnings from the experiences with supports and provision of acute care in an
with diabetes will help us to evolve systems of care for other alternative setting
chronic conditions. • Expediting discharge from acute care bed to
subsequent care destinations whether at home,
As our population characteristics and health status show, the Long-Term Care home, Complex Continuing Care
South West LHIN has a significant proportion of seniors and or Rehabilitation
people living with chronic conditions. Other data show us • Reduced emergency department demand –
that South West LHIN residents have experienced challenges reducing the number of non-urgent cases that
accessing coordinated addictions and mental health services. present at the ED will allow emergency clinicians
Generally, these populations tend to access and use a to focus on patients with emergent needs
substantial portion of our health care resources. But they • Early identification of and intervention for people
don’t always use these resources at the right time, in the living with mental illnesses and addictions
right place and by the right provider which often leads to • Improved access to and enhanced capacity of mental
crisis intervention that could have been prevented if early health and addiction services
identification, management and supports were in place. • Increased accessibility of Chronic Disease Prevention
Currently, 58% percent of all emergency room visits in the and Management team-based care close to home,
South West LHIN are for non-urgent patients. particularly for those who traditionally face barriers to
accessing care
• Strengthened capacity for self-management among
those with or at risk of, developing chronic disease(s)
and for self-management support among providers
• Improved ease of access to health education materials
• Enhanced technological supports to manage
chronic disease(s)

Rationale for IHSP Strategic Direction: resources (HR) strategies, the LHIN launched a project to
Enhance Access and Sustainability of Hospital- review the current state of physician and nursing ED
based Treatment and Care: manpower. The project focused on developing ED strategies
to be considered for implementation.
The Blueprint development process included undertaking
an assessment of the current state and future health care Seven ED HR strategies were identified as a result of key
system in the South West LHIN. The information, insights findings and current state analysis associated with the
and strategies profiled in the Emergency Department EDHR study. They are to:
Human Resources (EDHR) Project Final Report, May 2009
(see EDHR study) commissioned by the South West LHIN A. Enhance recruitment and retention capability,
contributed greatly to the current state assessment. As for activities and success at the local and LHIN levels
the future, the Blueprint’s“Centrally Coordinated Resource B. Support local physician ED leadership
Capacity”integrated service delivery approach heavily C. Support nursing and physician workplace satisfaction
influenced the IHSP action steps we will take in the next D. Support local nursing and physician capacity
three years. E. Distribute hospital resources reasonably
F. Maximize ED coverage within current resource pool
Emergency Services G. Maximize integration of nurse practitioners (NPs)
The South West LHIN has faced particular challenges in in primary care and community
accessing emergency services. Maintaining access to this
very important service has been challenged by a number It is important to note that some strategies will apply to a
of factors, including: few hospital sites, and others, to all sites. As identified in the
EDHR final report, the next step in applying these strategies
• A total of 27 emergency departments (EDs) within is to identify which strategies would be most appropriate for
different-sized hospitals with varying capacity, local and multi-community hospital sites.
volume and acuity of patients and catchment areas
• Health human resources challenges in many of Based on the recommendations of the EDHR Study and in
the 27 EDs related to consistent staffing full alignment with the Blueprint’s integrated service
• Shortages of family practitioners across the LHIN delivery approach, the LHIN intends to engage key local
in part resulting in high numbers of patients who and multi-community stakeholders to initiate a process to
do not have a primary care physician develop and implement tailored strategies to meet their
• Demand by citizens living across a broad geography communities’emergency services needs, with a focus on:
that is a mix of urban, rural and remote communities
• Emergency services recruitment and retention capability
• Emergency department catchment areas that overlap
• Emergency services coverage with current resource pool
LHIN boundaries influencing planning
• Emergency services health care personnel capacity
and coordination
As stated earlier, many health human resource challenges

currently exist and will continue to exist within the health
care system. Over the past number of years, South West LHIN
health service providers and municipalities have had variable
results through focusing on increasing or supplementing
physician and nursing resources in their communities. In an
effort to be proactive and to develop sustainable ED human

Medicine, Surgical and Critical Care Services The South West LHIN and health service providers have
The second IHSP strategic direction aligns with the already launched some initiatives that aim to achieve similar
Blueprint’s“Centrally Coordinated Resource Capacity” results. Several Hips and Knees projects, stemming from
integrated service delivery approach and is intended to the first IHSP and work of the Priority Action Team, have
move the first three years of the plan forward. It describes advanced the development and dissemination of standardized
the LHIN-wide coordination of medicine, surgical and best practices for patients who need a joint replacement
critical care inpatient and ambulatory services to maximize through creating and implementing an evidence-based
access to these services for residents of the South West joint replacement guideline in our LHIN. The current lack
LHIN and beyond. of standardization across our LHIN leads to variation in
physician referral practices and has several potential impacts
Services will be coordinated across local community, multi- on surgical wait lists, including:
community and LHIN community providers. Providers whose
role will be to deliver services at the Multi-community level • Patients being referred too early and getting lost in
will provide specialist services for a larger population and the system while they are waiting for their condition
LHIN community providers will be responsible for delivering to worsen enough for a replacement
highly specialized services for complex population segments • Patients being referred when their disease process is
from within the LHIN and beyond. so advanced that by the time they see the surgeon,
their severity has put them into the urgent priority
This integrated service delivery approach emphasizes • Patients who may not require surgery at all being seen
LHIN-wide management of resource capacity to allow people by surgeons, impacting on their wait lists
to flow through the system equitably. This will minimize
backlogs and optimize the use of available resources. It will In addition, there is no standardized referral form in use
give individual’s access to the right provider based on across the LHIN. One form based on criteria of appropriateness
complexity of need. This will help health service providers for a joint replacement would aid in ensuring that only
react to planned and unexpected events. patients who need a joint replaced are referred to an
orthopaedic surgeon. It would also aid in the triage process
The approach ensures equitable access by delivering a when referrals are received. A commonly used referral form
network of visiting specialist or physicians at the multi- that is linked to the evidence in the joint replacement
community or LHIN level based on demand and critical guideline would streamline intake processes in surgeon
mass. It is expected that enabling technologies, such as offices and help surgeons in triage patients. This also lends
telemedicine, would be used to execute best practices, itself to consistent elements of a“centralized intake”process
tools and quality guidelines across providers at all levels. recommended by the Hip and Knee Priority Action Team.
The greatest benefit to people who need a total joint

replacement will be that referrals are made at an appropriate
time, based on evidence. Patients will receive orthopaedic
care when they need it rather than too early or too late in
the disease process. With a guideline to assist primary care
physicians, patients can receive better care early on that
could potentially avert or at least delay the need for a
joint replacement.

At the other end of the continuum, research indicates that or referral of patients who need urgent or emergency
if a patient is referred too late in the disease process, surgery acute care beyond the mandate of Criticall.
cannot achieve optimal outcomes. An evidence-based
guideline that helps physicians refer at the appropriate time There is currently an initiative underway to develop and
will mean optimal surgical outcomes and quality of implement a Hospital Patient Flow Protocol in the South
life for patients. West LHIN. It will standardized patient access and flow
procedures for hospitals and physicians across the LHIN to
The benefits of physicians using an evidence-based make patient referral and transfer more transparent,
guideline in their clinical decision-making regarding care effective and efficient and understood by everyone.
and treatment of patients with osteoarthritis will: The objectives of the project include:
• Possibly avert the need for some to have • Implementing a standard LHIN-wide patient access and
a joint replacement flow protocol for acute care hospitals to support patient
• Ensure that patients are referred to orthopaedic surgeons access to specialist tertiary care and repatriation when
for a joint replacement when it is needed rather than tertiary care is no longer required
consuming surgeon time caring for patients who are • Developing LHIN-wide communication and education
not yet ready for a joint replacement tools to facilitate the implementation of the protocol
• Ensure that patients who do not need a joint • Evaluating the effectiveness of the protocol
replacement receive appropriate care
These initiatives and others demonstrate our health service
Another initiative currently underway in the South West providers’desire to enhance access to and sustainability of
LHIN is the development of a Hospital Patient Flow Protocol. hospital-based treatment and care. The South West LHIN is
Currently some hospitals in the South West LHIN are well positioned to engage key local, multi-community and
experiencing patient access challenges that stem from LHIN community stakeholders to develop an action plan for
patients requiring an Alternate Level of Care (ALC), limited the creation and implementation of Centrally Coordinated
access to long-term care home beds, human resource Resource Capacity for medicine, surgical and critical care
shortages and episodic higher emergency department services, with a focus on:
volumes. These issues may then contribute to overcrowding
in some hospital emergency departments, long lengths of • A LHIN-wide resource capacity management system
stay, service delays and cancellation of surgeries. • A centralized coordinated referral system, evidence-based
care pathways and order sets, tools and quality guidelines
Adult tertiary acute care services are largely provided in
London by the London Health Sciences Centre (LHSC) and to These actions will allow people to flow through the
a lesser extent by St. Joseph’s Health Care, London. Current system equitably, minimize backlogs and optimize the
access issues in London have led to delays transferring use of available resources.
patients to tertiary care which strains referring hospitals
and can adversely affect patient outcomes.
Similarly, capacity constraints by some hospitals outside of

London have led to challenges in repatriating patients back
to their local community hospitals when they are ready to
leave the tertiary environment. At present, the hospitals in
the South West LHIN lack a uniform protocol for the transfer

8 How will we Demonstrate/
Measure Success?
Why Do We Need to Demonstrate Our Success? process or program related and linked to specific initiatives
and projects will be reported in our Annual Business Plan.
The strategic directions in our IHSP detail how we will The broader IHSP performance measurements will be
advance our vision and system level goals, consistent with continuously tracked throughout the IHSP’s three-year
the needs of our local, multi- and LHIN-communities. timeframe and beyond.
Equally critical, the IHSP contains clear performance
measurements to enable us to assess, monitor and report As we continue to develop ways to monitor projects and
on the success of our initiatives and related actions. initiatives and improve how we evaluate information
Performance measurements and reporting are fundamental received, we are beginning to apply the Triple Aim
components of strengthened accountability. As the framework to better track and understand the results
foundation for the LHIN accountability framework with the of our efforts around:
Ministry, the LHIN reports its IHSP progress to the Ministry
of Health and Long-Term Care. The IHSP also provides • People’s health care experiences
direction to the accountability agreements with health • The health of particular populations
service providers that receive LHIN funding. Finally and • The value that we receive for the money that
most importantly, the South West LHIN is accountable we spend on health care
to engage and report to the public on our progress in
achieving our system level goals and strategic directions How Will We Know if We’ve Been Successful?
for the health care system.
We need to know if we have improved people’s health
care experiences, the health of particular populations and
How Will We Measure Whether or the value that we received for the money that we spent on
Not We’ve Been successful? health care. We have identified a number of indicators and
The South West LHIN has identified performance measurements for each of our strategic directions and related
measurements that will help us track our success in priority populations and programs that we can measure on a
achieving our strategic directions. In the following table, regular basis and for which targets have been set, or will be
we have included performance measurements for which: set before 2013. By tracking our performance against the
targets set for these measures, we will begin to understand
• We are currently accountable (e.g., through the whether or not our actions have been successful in moving
Ministry-LHIN Accountability Agreement) us closer to our strategic directions and system level
• Data are currently collected, easily retrievable and goals. Where we have achieved or surpassed our set
can be summarized or are already summarized targets, we will ensure that we continue to meet or
• Data are collected frequently enough to provide some exceed our achievements.
measurements within the IHSP timeframe of 2010-2013
• Baselines are already established or could be established
• Targets are set, or can be set, to measure our success
The three-year IHSP timeframe provides longer-term

direction for our annual business planning. Although many
of the performance measurements presented are not directly
aligned to the actions we will take to achieve our strategic
directions, the collective impact of the actions will affect the
broader outcomes being measured. Measurements that are

The measures listed below are based on those in the Ministry LHIN Accountability Agreement (MLAA),
the service accountability agreements with health services providers in the South West LHIN and
measures from the Ontario Health Quality Council.
What success will look like What we will measure What target we will try to meet
Measurements that will help us track our success in enhancing capacity and integration of primary,
specialized and community-based care, with a focus on the following populations:
Seniors and Adults with Complex Needs
• Optimize their current • Referrals from hospitals/ • Number of days from Alternate
level of health Community Care Access Centre Level of Care designation to
• Receive coordinated health services to Community Support Services discharge by discharge to
• Receive the right level of care providers/programs appropriate destination
in the most appropriate setting • Median wait time to long-term care • reduced to 35 days
• Clients placed in long-term care home placement for all placements
homes with high or very high
MAPLe* scores as a percentage of
total clients placed
People Living with Mental Health and Addiction Challenges
• People with early symptoms of • Proportion of active cases by Although this IHSP is a plan for
mental health and/or addictions admission: self-threat; threat to performance, at this time there is
challenges are equipped to better others; unable to care for self; no provincial strategic plan for mental
manage their health condition addiction problem; psychiatric health and addictions and no indicators
• People with mental health symptoms; forensic to measure improvement. All LHINs
and/or addictions challenges • Contact with community mental will work with the Ministry to develop
access coordinated services health services in the previous year the best indicators. If necessary, the
along the continuum of care • Rate of re-admission to hospital LHIN will modify its plans to reinforce
• People with mental health for people with mental health provincial mental health and
and/or addictions challenges and/or addictions challenges addictions priorities.
access the care they need where • Percentage of people with mental
and when they need it health and/or addictions challenges
that report a positive experience
with their care
• Wait time for initial assessments
• Wait time for treatment
People Living with or at Risk of Chronic Disease(s)
• Are identified, monitored and • Adjusted percentage of people • Adjusted percent of people (aged
supported (aged 66+) with diabetes for more 66+) with diabetes for more than
• Access a coordinated network than a year who had a serious a year who had a serious diabetes
of health services within their diabetes complication treated in complication treated in the hospital
community the hospital no greater than 7.5%
• Manage their condition • Hospital admission rates per • Hospital admission rates per
within targets 100,000 population for diabetes 100,000 population for diabetes
• Use of peritoneal dialysis by all no greater than 75
dialysis patients
*MAPLe – A Method of Assigning Priority Levels.

What success will look like What we will measure What target we will try to meet
Across all Three Priority Populations
Enhanced efficiency, effectiveness and • Percentage of emergency room • Number of ER unscheduled visits
integration of primary, specialized and (ER) visits for low acuity patients by quarter per 1000 population
community-based care (non-admitted CTAS** IV & V no greater than 120 visits
patients) • Alternative level of care days no
• Number of ER unscheduled visits greater than 9%
by quarter per 1000 population
• Percentage of people who are
registered with Health Care Connect
and matched to a provider
• Percentage of Alternative Level
of Care days
Measurements to help us track our success in enhancing access and sustainability

of hospital-based treatment and care related to:
Emergency Services
People move swiftly and appropriately • Proportion of admitted patients • Proportion of admitted patients
to receive the care required during treated within the length of stay treated within the length of stay
and following a visit to emergency target of ≤ 8 hours target of ≤ 8 hours greater
departments • Proportion of non-admitted high than 65%
acuity (CTAS I-III) patients treated • Proportion of non-admitted high
within their respective targets of acuity (CTAS I-III) patients treated
≤ 8 hours for CTAS I-II and ≤ 6 within their respective targets of
hours for CTAS III) ≤ 8 hours for CTAS I-II and ≤ 6
hours for CTAS III) greater than 92%
Medicine, Surgical and Critical Care Services
Improved access to medicine, surgical 90th percentile wait times for: 90th percentile wait times for:
and critical care services at the local-,
• cancer surgery • cataract surgery at 75 days
multi- and LHIN-community levels
• cardiac by-pass procedures • hip replacement at 140 days
• cataract surgery • knee replacement at 160 days
• hip replacement • diagnostic MRI scan at 100 days
• knee replacement • diagnostic CT scan at 28 days
• diagnostic CT scan
• cancer surgery at 70 days
• cardiac by-pass procedures at 50 days
*CTAS – Canadian Emergency Department Triage and Acuity Scale

9 Appendices and
Supporting Resources
• Appendix A – Projects, Programs and Initiatives

related to Strategic Directions
• Appendix B - A Blueprint for the Future
• Appendix C – Community Engagement Summary
• Appendix D – Francophone Population Profile
• Appendix E – South West LHIN Current State Profile
• Appendix F – North Current State Profile
• Appendix G – Central Current State Profile
• Appendix H – South Current State Profile
• Appendix I – Health Status of the South West
LHIN Population
• Appendix J –Aboriginal Population Profile
Supporting Resources:
• eHealth Ontario. (2009). Ontario’s eHealth Strategy:

2009-2012. Toronto.
• Institute for Healthcare Improvement. (no date.)
The Triple Aim. Retrieved November 2, 2009, from
http://www.ihi.org/IHI/Programs/StrategicInitiatives/
TripleAim.htm
• Ministry of Health and Long-Term Care. (2009.) Externally
Informed Health System Trends Report: An Input for
Health System Strategy Development, Policy Development
and Planning. Toronto.
• Morton, F., & Williams, A. P. (2009.) The South West
Balance of Care Project: Summary of Findings. Toronto:
Balance of Care Research Group, University of Toronto
• Partnerships for Health: A Chronic Disease Prevention
and Management Initiative.
http://www.partnershipsforhealth.ca
• South West Local Health Integration Network. (2009.)
Emergency Department Human Resources Project:
Final Report. London, ON.
• South West LHIN Consultations for Mental Health
and Addiction Strategy, October 2009
• Report on the Proceedings of the Aboriginal Meeting,
London, Ontario, April 23, 2009

10 Glossary of Key Definitions
and Abbreviations
Alternate Level of Care (ALC): Refers to situations where Centrally coordinated resource capacity: Service
hospital patients have completed the acute care phase of delivery approach focused on a LHIN-wide approach to the
their treatment but remain in acute care beds waiting for coordination of access and management of specialized
discharge or transfer elsewhere (e.g., Long-Term Care Home, health service resources. Throughout an individual’s life,
rehabilitation, Complex Continuing Care, home care, etc.) he or she may access medicine, surgical, and critical care
inpatient and ambulatory services coordinated through this
Community: Includes any collection of individuals that service delivery approach.
is tied together by geography, common characteristics
or a shared interest Through these approaches, local community services are
supported by multi-community services and have access to
Complex Continuing Care (CCC): Relates to designated LHIN community services as needed. This is defined as:
chronic care beds located in a hospital setting that provide
continuing, medically complex and specialized services to Local Community: Coordination of provision of
both young and old, sometimes over extended periods services provided‘close to home.’These types of services
of time include primary care, some secondary care, home and
community care, inter-professional clinics for chronic
Consumer: Includes patients, clients or user of the diseases, and local hospital services. For these services,
health care system there will be many sites for service access across the
LHIN, located in communities, and delivered through
Integrated Health System of Care: Future vision of the networks of inter-professional teams.
South West LHIN health system which unifies all health
programs and services within a single, integrated health Multi-Community: Coordination and provision of
system of care that will allow individuals/families to some specialized services that will be provided
seamlessly access and receive health services as required through service providers who serve both their local
during the course of their lifetime. This future system of community, but also surrounding communities within
care will be delivered through two integrated service a defined catchment area. Some travel may be required
delivery approaches, population-based integrated health to access services; however services should still be
services and centrally coordinated resource capacity. accessible within the Multi-Community area. Services
may be located at two or more sites to serve several
Population-based Integrated Health Services: Service communities within a defined geographic cluster/area.
delivery approach which is tailored to the collective needs of These sites will serve a large proportion of individuals
a local population and its health service providers. It enables who may require certain types of subspecialty
local communities to support the health and wellness of its programs, yet do not need to travel to LHIN
residents and surrounding communities, enabling them to Community sites.
better manage their own health and maintain their
functional independence. Throughout an individual’s life, LHIN Community: Refers to those services where
one may access primary care, home and community care, the resources and expertise are not widely available
complex continuing care, long-term care, palliative care, throughout the LHIN. These programs will be led by
rehabilitation, chronic disease prevention and management, one identified organization which will be mandated
mental health and addictions services, and emergency to provide appropriate access and care to residents
health services through this service delivery approach. across our LHIN. Travel to a location may be required
to access these highly specialized services. These
organizations may also serve as a provincial resource
for certain services.
South West LHIN: Integrated Health Service Plan 46

Integrated Health Services Collaborative: Virtual, mobile, ABBREVIATION DEFINITION
or co-located settings where inter-professional teams
BSM Blended Salary Model
(regulated and non-regulated practitioners) will deliver
CCHS Canadian Community
education, screening, assessment, treatment, navigation,
Health Survey
and the necessary support services to manage the health
CIHI Canadian Institute for
needs of individuals within a given local catchment areas.
Health Information
These teams will provide a variety of services including
CT Computerized Tomography
preventive, promotive, and lower acuity services close to
CTAS Canadian Emergency Department
home while remaining connected to multi-community and
Triage and Acuity Scale
LHIN community sites for higher acuity needs.
ED Emergency Department
EDHR Emergency Department
Local Health Integration Networks (LHIN): Not-for-profit
Human Resources
corporations that are responsible for planning, integrating
ER Emergency Room
and funding local health services in 14 different geographic
FHG Family Health Group
areas of the province. LHINs determine the health care
FHN Family Health Network
priorities and services required in their local communities,
FHO Family Health Organization
reflecting the reality that a community’s health needs and
FHT Family Health Team
priorities are best understood by those familiar with the
HHR Health Human Resources
community.
IHSP Integrated Health Service Plan
LHSC London Health Sciences Centre
Partners: Include health care providers and consumers,
LTCH Long-term Care Home
public health units, and other partners such as university
MAPLe Method of Assigning
and colleges, and other community sectors (housing,
Priority Levels
environment, education, transportation, judicial)
MI & SA Mental Illness and
Substance Abuse
Priority Action Teams (PAT): Teams of providers, consumers
MLAA Ministry-LHIN
and other partner representatives that defined what an
Accountability Agreement
integrated health system of care should look like at a
MOHLTC Ministry of Health and
population or program level based on the priorities
Long-Term Care
identified in the first IHSP
MRI Magnetic Resonance Imaging
SWCCAC South West Community
Providers: All health care organizations, professionals
and workers providing care within their communities Care Access Centre
Transitional Care Unit (TCU): Units for alternate level of
care (ALC) patients who no longer require acute care
hospitalization and who will receive a more appropriate
level of care in the TCU. In the TCU, patients are provided
with restorative care to promote independence and
maximize their potential to be cared for in retirement
homes, long-term care homes, supportive housing or
in their own homes with supports.

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4. Overview of the Current Local Health Care System 15

5. Framework for Planning 22

6. Priorities & Strategic Directions for the Local Health System 29

7. Rationale for Strategic Directions 37

9. Appendices and Supporting Resources 45

10. Glossary of Key Definitions and Abbreviations 46

South West LHIN: Integrated Health Service Plan 2010-2013 2

Community Community Community

• Services provided • Service delivery by • Delivery of low

close to home geographic clustering volume/highly complex

to broader population focused on targeted • Support multi-community

traditional providers relationships with local specialized services

• Emphasis on an individual’s • May serve as a broader

and LHIN providers

self-health management provincial resource

South West LHIN: Integrated Health Service Plan 2010-2013 3

The Blueprint describes in detail what we

South West LHIN: Integrated Health Service Plan 2010-2013 4

South West LHIN: Integrated Health Service Plan 2010-2013 5

South West LHIN: Integrated Health Service Plan 2010-2013 6

IHSP IHSP IHSP IHSP

Integrated Health System of Care

South West LHIN: Integrated Health Service Plan 2010-2013 7

What do we want to build?

Over the past three years, through substantial participation,

practice analyses and recommendations have driven a larger

The Blueprint integrates and advances the work of the

The Blueprint describes in detail what we want health

The IHSP continues the planning and implementation

The South West LHIN covers an area from

South West LHIN: Integrated Health Service Plan 2010-2013 8

South West LHIN: Integrated Health Service Plan 2010-2013 9

South West LHIN: Integrated Health Service Plan 2010-2013 10

South West LHIN Alignment

South West LHIN: Integrated Health Service Plan 2010-2013 11

South West LHIN’s Vision, Mission and Values

Working Together for... A Healthier Tomorrow

South West LHIN: Integrated Health Service Plan 2010-2013 12

South West LHIN: Integrated Health Service Plan 2010-2013 13

South West LHIN: Integrated Health Service Plan 2010-2013 14

The South West LHIN health system serves approximately

Multi-Community Consists of Population Square Kilometres

North Bruce County, Grey County (excluding 157,151 (17%) 8,663

Central Huron and Perth Counties 138,529 (15%) 5,626

South City of London, Middlesex, Oxford and 649,172 (69%) 7,576

Total 944,852 21,865

South West LHIN: Integrated Health Service Plan 2010-2013 15

The South West LHIN unemployment rate of 5.4% is below

South West LHIN: Integrated Health Service Plan 2010-2013 16

The following LHIN-funded organizations play a critical

South West LHIN: Integrated Health Service Plan 2010-2013 17

South West LHIN: Integrated Health Service Plan 2010-2013 18

South West LHIN: Integrated Health Service Plan 2010-2013 19

South West LHIN: Integrated Health Service Plan 2010-2013 20

Those who provide services to newly immigrated

Telephone and Online Surveys

Results of the online survey showed that most people felt

South West LHIN: Integrated Health Service Plan 2010-2013 21

South West LHIN: Integrated Health Service Plan 2010-2013 22

Community Community Community

• Services provided • Service delivery by • Delivery of low

populations and local providers