SNAGA Report FINAL Revised Dec 9 08 - Central LHIN/media/sites/central/... · 2015-04-06 · 42.1...
Transcript of SNAGA Report FINAL Revised Dec 9 08 - Central LHIN/media/sites/central/... · 2015-04-06 · 42.1...
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Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � � 20�© 2008 KPMG All rights reserved
Central�LHIN�Needs�and�Gaps�This�section�examines�the�health�service�needs�of�the�LHIN�and�the�LHIN-wide�gaps�that�exist�
across�the�continuum�of�care,�building�on�the�profile�of�the�LHIN�and�social�determinants�as�
described�previously.��Following�this�section,�a�more�detailed�analysis�of�the�needs�of�each�of�
the�LHIN�planning�areas�will�be�discussed,�taking�into�context�the�gaps�as�described�below.��To�
conduct�the�analysis�of�the�gaps�in�the�LHIN,�several�domains�of�interest�were�identified�and�
studied�in�detail.��These�domains�were�a�means�to�provide�insight�into�the�system-wide�gaps�
that�exist�in�the�LHIN.��The�analysis�conducted�for�these�domains�is�not�presented�here�in�its�
entirety,�but�can�be�found�in�Appendix�H�through�O.��This�section�walks�through�the�continuum�
of�care�to�describe�where�the�service�gaps�exist�in�the�LHIN�along�the�core�basket�of�services.��
Leading�into�the�discussion�across�the�continuum,�prevalence�rates�are�discussed,�laying�the�
foundation�for�demand�in�services�in�the�LHIN.���
For�the�purpose�of�this�report,�gaps�have�been�defined�in�the�following�ways:�
• Gaps�in�service�levels�to�meet�current�demand�and�variations�across�planning�areas;�
• Gaps�related�to�future�population�growth;��
• Gaps�in�the�core�basket�of�service;�and�
• Gaps�that�exist�between�the�current�service�delivery�models�and�the�vision�for�
coordinated/integrated�care.���
Throughout�this�discussion�the�frame�of�reference�will�be�the�continuum�of�care�as�shown�
below.��This�framework�will�shape�the�discussion�on�the�gaps�that�exist�across�the�LHIN.��
There�are�consistent�themes�that�have�emerged�throughout�the�domains�that�are�well�
represented�in�this�framework.��The�prevalence�rates�provide�a�baseline�of�demand�for�health�
services.��Following�this�the�continuum�will�be�discussed�including�health�promotion�and�
education,�including�activities�to�identify�and�manage�high-risk�individuals,�followed�by�primary�
care�and�community�care.��The�boxes�as�represented�below�are�not�discreet�boxes�that�are�
mutually�exclusive.��For�example�health�promotion�and�education�programs�can�be�a�part�of�any�
piece�of�the�continuum,�but�it�is�important�to�distinctly�have�a�discussion�on�these�activities�as�
they�can�impact�the�demand�for�health�services�by�reducing�or�controlling�prevalence�rates.��
Acute�care�is�the�inpatient�and�outpatient�activity�that�takes�place�in�the�LHINs’�hospitals�and�
post-acute�comprises�the�hospital�and�community�services�that�support�clients�primarily�for�
chronic�or�longer�episodes�of�care�(e.g.�Rehab,�Complex�Continuing�Care,�Palliative�Care,�Long-
term�Care�Homes).��It�is�recognized�that�the�continuum�as�represented�is�not�a�linear�function;�
in�fact�there�is�much�flow�among�the�various�pieces.��
Exhibit 11: The Core Basket of Service along the Continuum of Care
�
�
�
Health�
Promotion�
and�
Education
Primary�
Care
Community�
CareAcute�Care Post�Acute
System�Navigation,�Case�Management�and�Coordination
Prevalence
Demand Supply
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �21�© 2008 KPMG All rights reserved�
Prevalence
The�prevalence�of�disease�is�the�proportion�of�individuals�in�a�population�that�have�a�particular�
disease.��Prevalence�rates�provide�a�high�level�picture�of�need�for�health�services;�or�projected�
demand.��In�some�instances�due�to�the�data�source�prevalence�rates�may�be�understated.��
Prevalence�rates�as�measured�by�the�Canadian�Community�Health�Survey�have�been�shown�to�
be�under�reported�for�multiple�reasons,�including�the�under-reporting�of�socially�undesirable�
behaviour,�under�reporting�by�low�education�groups,�and�a�cultural�bias�including�language�
barriers�(Akhtat-Danesh�and�Landeen�(2007),�Cheung�and�Dewa�(2006),�and�Toronto�Health�
Profiles,�(2005)).��These�rates�report�the�number�of�individuals�who�have�self-identified�in�the�
LHIN�who�have�been�diagnosed�for�their�disease�or�disorder.��For�each�of�the�diseases�and�
disorders�there�may�be�individuals�that�have�the�disease�that�are�not�aware�they�have�the�
disease,�or�have�not�sought�treatment�or�diagnosis.��In�terms�of�providing�a�picture�of�demand,�
individuals�with�a�specific�disease�or�disorder�will�also�require�a�range�of�services,�with�
individuals�requiring�differing�levels�if�intensity�of�service�than�others�depending�on�their�
circumstance�or�progression�in�their�disease�trajectory.��For�this�reason,�it�is�also�difficult�to�
quickly�assign�a�specific�level�of�need�for�a�defined�prevalence�rate.��
The�demand�for�health�services�is�driven�by�many�characteristics�including�health�status�of�the�
population�and�the�accessibility�of�services�(cost,�transportation,�wait�time,�availability,�etc.).��
Age�of�the�population�may�be�the�single�most�important�factor�in�predicting�demand�for�
services�(Fos�and�Fine,�2005).��In�determining�demand�for�health�services�in�Central�LHIN,�as�
shown�in�the�previous�chapter,�when�compared�to�the�Ontario�average,�the�LHIN�is�comprised�
of�a�healthy,�wealthy,�young,�educated�population;�all�factors�contributing�to�lower�health�
service�utilization�than�the�Ontario�average�(see�table�below).��As�described�in�the�following�
chapter�although�these�characteristics�describe�the�LHIN�as�a�whole,�they�are�not�consistent�
across�each�of�the�planning�areas�
Exhibit 12: Central LHIN Population Characteristics (2008)
Source: Environics Analytics Demographics Estimates and Projections 2008
The�story�shown�above�will�start�to�shift�rapidly�over�the�next�ten�years�as�the�seniors�
population�in�the�LHIN�(aged�65�years�and�older)�is�projected�to�grow�by�40%;�the�fastest�
growing�age�cohort�in�the�LHIN.�Demand�for�health�services�in�Central�LHIN�over�the�next�ten�
years�will�be�impacted�primarily�by�growth�in�the�seniors�population.��The�table�below�
demonstrates�the�growth�in�the�population�in�the�LHIN�by�age�cohorts.��As�a�proportion�of�the�
population�seniors�will�grow�to�represent�15.3%�of�the�population�in�ten�years,�from�12.4%�
today�(204,139�seniors�today,�compared�to�285,555�in�2018).��This�compares�to�Ontario�in�
which�seniors�currently�represent�13.5%�of�the�population,�growing�to�16.2%.��Overall�the�
Central�LHIN�will�have�the�largest�absolute�number�of�seniors�in�the�province.�The�85�plus�
population�will�be�approximately�34,883 in 2018.
This�will�have�a�significant�impact�on�the�proportion�of�health�service�spending�that�will�be�
consumed�by�seniors�in�the�LHIN.��
% Population
Aged 65+
% Family Incidence
of Low Income
% Population Aged 20+ with less
than high school Education
Ontario� 13.46� 11.33� 24.60�
Central�LHIN� 12.36� 9.39� 22.36�
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �22�© 2008 KPMG All rights reserved�
Exhibit 13: Central LHIN and Ontario Projected Growth Rates
Age
Category
Central
Population
2008
Central
Population
2013
Central
Population
2018
Ontario
Population
2008
Ontario
Population
2013
Ontario
Population
2018
Central
Growth
from
2008
Ontario
Growth
from
2008
0-14� 293,977� 289,487� 293,970� 2,224,819� 2,201,531� 2,224,009� 0.00%� -0.04%�
15-44� 722,280� 747,333� 774,934� 5,467,324� 5,627,861� 5,782,242� 7.29%� 5.76%�
45-64� 431,280� 484,183� 513,008� 3,470,833� 3,783,608� 3,918,919� 18.95%� 12.91%�
65-74� 108,690� 134,075� 170,187� 908,982� 1,101,610� 1,333,476� 56.58%� 46.70%�
75-84� 71,106� 74,658� 80,485� 604,270� 614,903� 661,857� 13.19%� 9.53%�
85+� 24,343� 30,901� 34,883� 223,165� 278,956� 306,428� 43.30%� 37.31%�
Total 1,651,676 1,760,637 1,867,467 12,899,393 13,608459 14,226,930 13.06% 10.29%
Source: Environics Analytics Demographics Estimates and Projections 2008
The�population�characteristics�described�above�carry�over�into�(currently)�lower�prevalence�
rates�of�diseases�that�typically�affect�older�populations�(e.g.�chronic�conditions�such�as�cancer,�
diabetes,�and�heart�disease)�as�expected.���
Chronic Conditions
The�table�below�demonstrates�the�prevalence�rates�of�a�cross-section�of�chronic�diseases�
within�the�LHIN�including�rates�of�stroke,�depression,�asthma,�hypertension�and�heart�disease,�
arthritis�and�others.��The�prevalence�rates�for�these�conditions�are�lower�or�on�par�with�the�
Ontario�averages,�providing�less�current�demand�for�health�services�that�address�these�
conditions�in�the�LHIN.�
Exhibit 14: Chronic Disease Prevalence Rates (%), Central LHIN and Ontario 2007 (MOHLTC, 2008)
Arthritis
Hyper-
tension
Asthma
Heart
Disease
Diabetes
Depression
(i)
COPD (ii)
Cancer
Stroke
Ontario�� 17.2� 15.4� 8.0� 4.8� 4.8� 4.8� 4.1� 1.5� 1.1�
Central� 14.2� 12.4� 6.8� 4.3� 4.0� 3.1� 3.1� 1.5� 0.9�
(i) Prevalence�of�depression�is�calculated�for�those�15�and�older�
(ii) COPD�include�chronic�pulmonary�disease,�emphysema�and�bronchitis�and�is�reported�for�
the�population�aged�30+�
The�lower�prevalence�rates�are�expected�for�a�younger,�highly�educated�population.��These�
rates�are�drivers�for�lower�health�service�utilization�in�the�LHIN�as�compared�to�the�Ontario�
average.��Over�the�next�ten�years,�these�rates�are�expected�to�increase�significantly�as�the�
impact�of�an�aging�population�increases�disease�prevalence�in�the�LHIN.��As�a�demonstration�of�
this�increase,�the�projected�increase�in�the�number�of�individuals�with�Diabetes�is�shown�
below,�growing�by�50%�in�the�next�ten�years.�
This�represents�57,000�individuals�in�the�LHIN�that�currently�live�with�Diabetes�and�have�been�
diagnosed,�growing�to�85,000�individuals�by�2018,�requiring�significant�investment�in�services.��
Studies�also�demonstrate�that�43%�of�adults�with�chronic�conditions�have�more�than�one�
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �23�© 2008 KPMG All rights reserved�
condition.��The�risk�of�having�multiple�conditions�also�increases�with�age�(Wolff,�2002).��Further,�
prevalence�rates�of�diabetes�are�higher�among�people�living�with�schizophrenia;�possibly�due�to�
the�use�of�anti-psychotics�(De�Hert�et�al�2006).��
Exhibit 15: Projected Growth in Diabetes in Central LHIN and Ontario 2008-2018
�
�
�
�
�
�
�
�
Source: CCHS 2005, Environics Analytics, Infonaut
Over�the�years,�Central�LHIN�will�see�an�overall�increase�in�the�proportion�of�their�population�
with�age-related�chronic�conditions�simply�as�a�result�of�the�population’s�changing�age�
composition.��
Currently,�for�residents�in�the�Central�LHIN,�chronic�conditions�accounted�for:�
• 1�out�of�4�inpatient�separations;�
• 1�in�10�emergency�department�visits;�
• 1�in�5�visits�to�family�physicians;�and�
• 2�in�3�rehab�separations�are�related�to�chronic�disease.�
Close�to�two-thirds�of�Central�LHIN�residents�have�at�least�one�chronic�condition,�and�42%�of�
those�over�the�age�of�65�have�two�or�more.��As�described�below,�many�chronic�diseases�can�
be�prevented�or�delayed�until�the�later�stages�of�life.��Factors�that�put�people�at�risk�for�chronic�
diseases�are�for�the�most�part�modifiable.��Many�of�the�chronic�conditions�have�common�risk�
factors,�which�increases�the�risk�of�a�person�having�more�than�one�chronic�disease.��Poor�diet�
and�physical�inactivity�are�the�two�most�common�risk�factors�in�the�Central�LHIN.��Better�
management�of�chronic�conditions�can�lead�to�lower�utilization�of�health�services.�����
Mental Health and Addictions
Establishing�rates�of�individuals�living�with�mental�health�and�addictions�disorders�in�the�LHIN�
provides�a�bigger�challenge�than�establishing�prevalence�rates�for�physical�diseases�and�
disorders.��This�is�primarily�due�to�the�stigma�typically�attached�to�these�conditions,�including�
stigma�derived�from�ethno-cultural�origins�in�the�LHIN�that�may�not�recognize�depression�and�
other�mental�health�disorders.��Rates�reported�through�the�Canadian�Community�Health�Survey�
(CCHS)�are�likely�under-reported�for�this�reason.��Rates�reported�in�the�CCHS�reflect�individuals�
that�have�been�diagnosed�for�Mental�Health�conditions.��There�may�be�a�substantial�number�of�
people�living�with�mental�health�conditions�that�have�not�been�diagnosed.��There�are�several�
sources�that�help�to�define�prevalence�rates�of�mental�health�and�addictions�disorders�in�the�
LHIN.��The�rates�below�are�primarily�taken�from�the�Ontario�Health�Survey,�Mental�Health�
Projected Growth in Diabetes in Central LHIN and Ontario 2008 -
2018
0
20
40
60
80
100
2008 2013 2018
Year
Percent Change (%)
Central
Ontario
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �24�© 2008 KPMG All rights reserved�
Supplement�as�reported�in�Canadian�Journal�of�Psychiatry,�1996.��Other�sources�are�quoted�
below.���
Exhibit 16: Annual Rates of Mental Health and Addictions Disorders
Condition Male Female Total
Central LHIN
Population (Aged
15-64, 2008)
One�or�More�Disorders(i)� 17.9%� 19.4%� 18.6%� 214,562�
One�Disorder�Only(i)� 13.2%� 15.1%� 14.2%� 163,805�
Two�or�More�Disorders(i)� 4.6%� 4.3%� 4.5%� 51,910�
Serious�Mental�Illness(ii)� � � 2%-3%� 23,071�–�34,607�
Substance�Abuse(iii)� � � 7.9%� 107,258�
Alzheimer’s�and�Dementia(iv)� � � 9.0%� 18,392�
(Aged�65+)�
(i) Source:�Ontario�Health�Survey,�Mental�Health�Supplement�as�reported�in�Canadian�Journal�
of�Psychiatry,�1996�
(ii) Source:�2%�was�cited�in�the�Ontario�Health�Survey,�Mental�Health�Supplement.��Other�
sources�cite�rates�of�3%�(Kirby,�May�2006)�
(iii) Source:�World�Health�Organization,�2000�
(iv) Source:�Alzheimer’s�Society�Ontario;�April�2007.��
As�a�comparison�to�the�rates�reported�above,�the�prevalence�rates�for�mental�health�disorders�
reported�in�the�CCHS�were�5.4%�in�the�latest�survey�in�2006.��These�represent�individuals�who�
self-identified�on�the�survey�as�having�been�diagnosed�for�any�mood�disorder,�anxiety�disorder�
or�schizophrenia,�representing�73,316�individuals�in�the�LHIN.��This�compares�to�a�rate�of�8.5%�
in�Ontario.��The�rate�as�described�earlier�is�likely�an�under-reporting�of�prevalence�in�the�LHIN,�
but�represents�the�best�available�data.�
The�rate�reported�above�(18.6%)�is�the�rate�for�all�mental�health�and�addictions�disorders�
(excluding�Alzheimer’s�and�dementia).��The�disorders�included�in�this�prevalence�rate�cross�a�
range�of�severity�from�mild�and�moderate�depression,�to�major�depression,�serious�mental�
illness,�substance�abuse�and�problem�gambling.��The�majority�of�individuals�with�mild�to�
moderate�depression�and�mental�health�related�disorders�seek�care�through�their�primary�care�
provider.��Depending�on�the�severity�and�skill�level�of�the�provider�they�will�either�treat�the�
individual�or�refer�them�to�specialty�services�(e.g.�Psychiatry,�Group�Therapy�etc.).��The�range�of�
available�services�falls�inside�and�outside�the�LHIN�mandate.��The�LHIN�does�not�directly�fund�
family�physicians,�psychiatrists,�and�pharmacotherapy�outside�of�hospitals.��However�the�LHIN�
does�fund�a�broad�range�of�community�mental�health�services�for�persons�living�with�serious�
mental�illness.��
The�services�that�are�provided�by�the�LHIN�are�community�mental�health,�inpatient�and�
emergency�services�that�typically�care�for�clients�living�with�serious�mental�illness.��Prevalence�
rates�for�this�population�are�usually�in�the�two�to�three�percent�range.�Applying�these�
percentages�to�the�Central�LHIN�suggests�an�expected�number�in�need�based�on�prevalence�of�
23,071�-�34,607�individuals�living�in�the�LHIN�(See�Appendix�M�on�Mental�Health�and�Addictions�
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �25�© 2008 KPMG All rights reserved�
for�more�information).��The�LHIN�also�funds�substance�abuse�programs�and�community�
programs�for�individuals�living�with�Alzheimer’s�and�other�dementia.������
The�prevalence�rates�of�Alzheimer’s�reported�above�represent�18,392�individuals�living�in�the�
LHIN.��These�individuals�will�either�reside�at�home�receiving�services�from�the�CCAC�or�other�
community�support�agencies,�or�in�a�Long-term�Care�Home.�Among�those�aged�85�and�older,�
prevalence�for�Alzheimer’s�is�1�in�3�people.��The�population�will�grow�significantly�over�the�next�
ten�years�as�this�age�cohort�is�expected�to�grow�by�43.3%.�
Births
The�number�of�births�from�women�in�the�LHIN�has�been�steadily�increasing�over�the�past�five�
years�as�shown�below.��In�2006/2007,�almost�20%�of�expectant�women�residing�in�Central�
LHIN�gave�birth�in�a�hospital�in�Toronto�Central�LHIN�(CHN,�2008).��This�may�be�due�to�capacity�
constraints�in�the�LHIN,�clients�seeking�specialized�services�for�higher�risk�births,�or�may�be�
due�to�physician�referral�patterns�and�client�choice.��A�further�5%�of�expectant�women�in�the�
LHIN�reported�not�having�an�antenatal�care�provider�in�2006/07�and�2007/08.���
Exhibit 17: Births from Women Residing in Central LHIN (Child Health Network, 2008)
The�Central�LHIN�experienced�a�slightly�greater�level�of�low�birth�weight�babies�(less�than�
2,500�grams)�at�6.7%�than�the�Ontario�average�of�6.4%�and�is�comparable�to�the�neighbouring�
LHINs.�Low�birth-weight�is�an�important�measure�of�health�status,�as�it�is�consistently�related�
to�the�experience�of�chronic�disease�such�as�heart�disease�and�Type�II�diabetes�later�in�
adulthood.�The�low�birth-weight�rate�is�also�more�pronounced�in�lower�income�neighbourhoods�
and�according�to�a�Statistics�Canada�study�on�trends�in�infant�mortality�and�low�birth-weight,�
low�birth-weight�was�43%�higher�in�the�poorest�income�quintile�than�in�the�richest�income�
quintile�(Joseph�et.�al.�1996).�
The�youth�population�in�the�Central�LHIN�is�expected�to�match�the�Ontario�average�of�a�slightly�
negative�or�flat�growth�over�the�next�ten�years.��There�are�currently�293,977�youth�in�the�
Central�LHIN�and�in�2018�the�projection�for�the�number�of�youth�is�293,970.�Youth�in�the�
Central�LHIN�appear�to�be�slightly�healthier�than�their�counterparts�in�the�rest�of�Ontario�
(Appendix�J).�
15,500
16,000
16,500
17,000
17,500
18,000
18,500
Births
2003/04
2004/05
2005/06
2006/07
2007/08
Year
Births from Women Residing in Central LHIN
(Child Health Network, 2008)
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �26�© 2008 KPMG All rights reserved�
Health Promotion, Prevention and Education
Poor�lifestyle�habits�have�long�been�associated�with�increased�chronic�disease�prevalence�as�
demonstrated�in�the�table�below.��Health�promotion�activities�have�demonstrated�benefits�in�
reducing�health�service�utilization�by�maintaining�or�reducing�chronic�disease�prevalence�rates�
(Barr�et�al�(2003)�and�Tuomilehto�et�al�(2001)).��These�programs�typically�take�two�approaches.��
One�is�to�educate�and�promote�healthy�lifestyles�among�the�general�population,�and�the�other�
is�to�identify�and�target�high-risk�individuals�and�provide�nutritional�and�lifestyle�counselling�to�
maintain�health�and�prevent�chronic�disease�(e.g.,�individuals�with�impaired�glucose�tolerance).��
The�first�approach,�while�effective�will�not�have�an�immediate�benefit�to�reduce�health�service�
expenditures�over�the�next�ten�years�(although�early�years�and�youth�programs�could�have�an�
impact�over�the�longer�term).��The�second�approach�has�the�potential�to�have�an�impact�on�
service�utilization�across�the�chronic�diseases,�primarily,�diabetes,�cancer,�hypertension�and�
heart�disease.�
Exhibit 18: Relationship between chronic conditions and risk factors
Disease Inadequate
Fruit / Veg
Physical
Inactivity
Smoking
Alcohol
Misuse
Excess
Weight
Hyper-
tension
Lung�Cancer� XX XX
Colorectal�Cancer� XX XX X X XX
Female�Breast�Cancer� X XX XX XX
Prostate�Cancer� X X XX
Diabetes�(type�2)� X XX X XX XX
Depression� X XX X
Ischemic�Health�Disease� XX XX XX XX XX XX
Stroke� XX XX XX XX XX XX
Asthma� X X
COPD� X XX
Arthirtis� X X XX
Hypertension� XX XX XX XX
X –�Emerging�evidence�of�some�relationship�between�risk�factor�and�outcome,�but�evidence�too�limited�to�
draw�conclusions�and/or�insufficient�evidence�of�causal�relationship�
XX�–�high�likelihood�of�causal�relationship�between�risk�factor�and�outcome.�Reliable�estimates�of�relative�
risk�from�literature.�
Source: MOHLTC, 2008. Chronic Conditions in Central LHIN
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �27�© 2008 KPMG All rights reserved�
Exhibit 19: Lifestyle – Disease Prevention Rates
Source: Cancer Care Ontario
As�demonstrated�in�the�exhibit�above,�Central�LHIN�is�performing�better�than�the�Ontario�
average�on�addressing�most�chronic�disease�risk�factors,�but�is�far�from�reaching�provincial�
targets.��Throughout�the�project,�interviews�and�focus�group�participants�spoke�of�a�lack�of�
health�promotion,�prevention�and�education�programs.��While�a�large�proportion�of�these�
activities�take�place�in�primary�care�or�public�health,�there�are�options�for�the�LHIN�that�fall�
within�its�mandate.��These�include�increasing�access�to�these�services�coordinated�through�
current�and�proposed�Community�Health�Centres.��Central�LHIN�has�performed�better�than�
most�LHINs�in�children’s�preventative�care;�as�defined�by�well-baby�exams,�annual�health�
exams,�and�visits�that�included�immunizations.��This�has�had�a�marked�impact�on�reducing�
Emergency�Department�visits�as�demonstrated�in�the�table�below.��This�fact�should�help�the�
LHIN�in�launching�any�coordinated�health�promotion�activities�in�the�LHIN�involving�the�LHINs�
primary�care�providers.���
Exhibit 20: Relationship between Preventive Care and Emergency Department Visits in Children
Aged 0-17 (Source: ICES InTool).
Cancer�Care�Ontario�is�primarily�responsible�for�funding�cancer�screening�activities,�although�
Mammogram�and�Colonoscopy�volumes�need�to�be�coordinated�through�LHIN�hospitals�and�
2% 23.20%18.9%18.10%Alcohol: the percentage of adults (aged 19+) not following the Centre for Addiction and Mental Health and Mental (CAMH) low-risk drinking guidelines
90%51.10%50.9%46%Physical Activity: the percentage of adults (18+) who are active or moderately active
90%42.90%41.70%42.50%Vegetable and Fruit Intake: the percentage of adults (aged 18+) eating vegetables and fruit 5 or more times daily
5%21.80%17%20.50%Smoking: the percentage of adults (aged 20+) who are current smokers
10%15%11.6%12.80%Obesity: the percentage of adults (aged 18+) self-reporting obesity
TargetOntario (CSQI 2008)
Central(CSQI 2008)
Central (CSQI 2007)
PREVENTION
2% 23.20%18.9%18.10%Alcohol: the percentage of adults (aged 19+) not following the Centre for Addiction and Mental Health and Mental (CAMH) low-risk drinking guidelines
90%51.10%50.9%46%Physical Activity: the percentage of adults (18+) who are active or moderately active
90%42.90%41.70%42.50%Vegetable and Fruit Intake: the percentage of adults (aged 18+) eating vegetables and fruit 5 or more times daily
5%21.80%17%20.50%Smoking: the percentage of adults (aged 20+) who are current smokers
10%15%11.6%12.80%Obesity: the percentage of adults (aged 18+) self-reporting obesity
TargetOntario (CSQI 2008)
Central(CSQI 2008)
Central (CSQI 2007)
PREVENTION
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �28�© 2008 KPMG All rights reserved�
imaging�sites.��Cancer�Screening�has�the�potential�to�reduce�cancer�prevalence�through�
Cervical�and�Colorectal�screening�if�pre-cancerous�lesions�and�polyps�are�found�and�removed.��
All�cancer�screening�also�has�the�potential�to�find�cancer�in�its�early�stages,�improving�
outcomes�and�reducing�health�service�utilization�compared�to�the�discovery�of�malignancies�in�
later�stage�development�where�more�intensive�surgery�and�therapy�is�likely.���
Exhibit 21: Cancer Screening Rates for Central LHIN and Ontario (Source: Cancer Care Ontario)
�
Across�the�LHIN,�there�are�various�options�for�leveraging�existing�community�groups�and�
networks�to�increase�the�capacity�of�health�promotion�and�education.��These�community�
groups�are�eager�to�play�a�role�in�improving�the�health�of�the�population�in�the�LHIN��
Primary Care
A�recent�report�indicated�that�93%�of�LHIN�residents�have�access�to�a�primary�care�provider.��
This�indicates�that�115,600�individuals�in�the�LHIN�do�not�have�a�primary�care�provider�
(MOHLTC,�2008).��While�this�may�be�true,�as�demonstrated�in�exhibit�23,�this�is�not�uniform�
across�the�planning�areas.��Table�23�below�demonstrates�the�ratio�of�family�physicians�and�
general�practitioners�in�the�LHIN�as�compared�to�the�Ontario�average�and�across�the�planning�
areas.��The�ratio�at�71.7�physicians�is�lower�than�the�Ontario�ratio�of�75.2�per�100,000�
population.��To�bring�the�ratio�up�to�the�provincial�ratio�would�require�an�additional�sixty-nine�
physicians.��This�ratio�varies�widely�throughout�the�LHIN�with�a�high�in�North�York�Central�at�
130.2�to�a�low�of�42.1in�South�Simcoe�/�Northern�York�and�the�low�60s�across�York�Region.���
Active Family Physician Office Locations
The�following�map�illustrates�where�the�active�Family�Physicians�have�office�locations�in�and�
around�the�Central�LHIN.��There�are�limited�Family�Physicians�in�the�northern�and�central�parts�
of�the�LHIN.�
50.70%51.20%NACancer screening completeness: Percent of women who are "up-to-date" in their cancer screening tests (FOBT, cervical, and breast)
70%62.80%66.20%62.30%Breast Cancer Screening: Percent of screen-eligible women (ages
50-69) receiving a screening mammogram in the past 2 years
85%70.50%71.80%NACervical Cancer Screening: Percentage of women (aged 20-69) who reported having had a Pap test in the last three years
40%19.90%22.30%19%FOBT: Percent of men and women (ages 50-74) who received a fecal occult blood test (FOBT) in the last 2 years
TargetOntario
(CSQI 2008)
Central
(CSQI 2008)
Central
(CSQI 2007)
ACCESS
50.70%51.20%NACancer screening completeness: Percent of women who are "up-to-date" in their cancer screening tests (FOBT, cervical, and breast)
70%62.80%66.20%62.30%Breast Cancer Screening: Percent of screen-eligible women (ages
50-69) receiving a screening mammogram in the past 2 years
85%70.50%71.80%NACervical Cancer Screening: Percentage of women (aged 20-69) who reported having had a Pap test in the last three years
40%19.90%22.30%19%FOBT: Percent of men and women (ages 50-74) who received a fecal occult blood test (FOBT) in the last 2 years
TargetOntario
(CSQI 2008)
Central
(CSQI 2008)
Central
(CSQI 2007)
ACCESS
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �29�© 2008 KPMG All rights reserved�
Exhibit 22: Location of Active General Practitioners in Central LHIN
�
�
�
�
�
�
�
�
�
�
�
�
�
�
Source: Scott’s Medical Dictionary – Ontario Physician and Specialists 2008, Infonaut
The�following�table�indicates�the�number�of�active�physicians�(Psychiatry�and�Family�Medicine�/�
General�Practitioner)�per�100,000�residents�for�each�planning�area,�as�well�as�the�number�for�
Central�LHIN�and�Ontario.��The�number�of�Family�Medicine�/�General�Practitioners�ranges�from�
42.1�to�130.2�per�100,000�residents.���
Exhibit 23: Family Medicine / General Practitioner Physician Ratios
Specialty South Simcoe &
Northern York
Central York
South East York
South West York
North York West
North York
Central
North York East
Central LHIN
Ontario
Family�Medicine/�
General�Practitioners�42.1� 60.2� 56.9� 59.0� 80.8� 130.2� 60.8� 71.7� 75.2�
Source: Scott’s Medical Dictionary – Ontario Physician and Specialists 2008)
Additionally,�data�suggests�the�urban�poor,�ethno-cultural�groups,�individuals�living�with�serious�
mental�illness�and�seniors�have�increased�difficulties�accessing�primary�care.��These�high�need�
groups�will�often�seek�service�in�the�Emergency�Department�if�they�cannot�adequately�access�
primary�care.���
Similar�to�health�promotion,�the�LHIN�has�the�option�of�increasing�capacity�to�primary�care�
through�increased�access�to�Community�Health�Centres,�through�satellites�or�additionally,�
mobile�health�units�among�others.��Community�Health�Centres�are�LHIN-funded�non-profit�
organizations�that�typically�address�the�primary�care�needs�of�vulnerable�populations�with�
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �30�© 2008 KPMG All rights reserved�
specific�mandates�to�address�health�promotion�and�the�social�determinants�of�health.��
Community�Health�Centres�work�with�individuals,�families�and�communities�to�strengthen�their�
capacity�to�take�more�responsibility�for�their�health�and�well-bring�(MOHLTC,�2008).�
Across�the�domains,�the�data�suggests�a�need�for�integrated�service�delivery�which�would�take�
the�form�of�integrated/shared�care�for�mental�health�clients,�but�also�potentially�for�seniors�and�
people�living�with�chronic�diseases.��Shared�care�has�demonstrated�benefits�for�improved�
quality�and�outcomes�for�people�living�with�serious�mental�illness�(Druss�et.�al,�2001).��The�
benefits�of�shared�care�are�amplified�as�in�the�case�of�the�LHIN,�the�data�indicates�that�people�
living�with�mental�health�illness�have�difficulty�accessing�primary�care.�
Community Care
The�community�care�sector�primarily�serves�seniors,�people�living�with�mental�health�and�
addictions�conditions�and�people�living�with�disabilities.��Across�the�domains,�the�most�acute�
service�gaps�exist�among�community�mental�health�and�addictions�providers.�
Assessing�the�capacity�and�health�service�gaps�in�the�community�is�more�difficult�than�inpatient�
and�institutional�care�due�to�a�lack�of�consistent,�comparable�data,�as�well�as�the�extent�of�the�
charitable�and�non-LHIN�funded�community�resources�that�exist,�and�the�formal�and�informal�
services�they�provide�(e.g.�churches,�community�groups),�as�well�as�the�number�of�services�
provided�by�other�health�and�non-health�sectors�such�as�Ministry�of�Children�and�Youth�
Services�funded�Children’s�Treatment�Network,�Ministry�of�Community�and�Social�Services�
funded�programs,�Ministry�of�Health�promotion�funded�programs�and�even�MOHLTC�funded�
services�such�as�Public�Health�and�Health�Force�Ontario.��Data�reported�through�the�CCACs�to�
the�MOHLTC�is�fairly�reliable�due�to�consistent�data�standards�that�have�been�in�place�for�
several�years.��The�data�coming�from�community�support�services�and�community�mental�
health�providers�are�less�reliable�as�these�organizations�have�only�recently�implemented�
common�standards�and�not�all�service�agencies�have�yet�employed�them.��In�these�cases�it�
may�be�more�accurate�to�compare�total�spending�per�capita�as�these�ratios�provide�more�
reliability�than�do�activity�statistics.��As�the�reliability�of�this�data�increases�in�the�next�several�
years,�the�LHIN�will�be�able�to�more�accurately�reflect�this�data�as�comparator�for�the�activity�
taking�place�in�the�community�sector.��
Community Mental Health and Addictions
As�described�earlier�the�expected�prevalence�in�Central�LHIN�of�individuals�living�with�serious�
mental�illness�is�2%�-�3%�or�23,071�–�34,607�individuals.��This�compares�to�a�reported�number�
of�individuals�receiving�community�mental�health�services�at�19,791.��This�represents�a�
minimum�gap�of�3,280�individuals,�using�2%�prevalence�rates�(i.e.�23,071�individuals�minus�
19,971�individuals�served).��The�number�of�19,791�does�not�represent�unique�individuals,�as�
there�are�likely�individuals�receiving�multiple�services�and�the�gap�is�most�likely�much�higher.����
These�individuals�are�likely�receiving�care�in�the�Emergency�Departments,�Inpatient�Units,�
Community�Care,�Primary�Care�or�Private�Practice�Psychiatrists�or�not�at�all.���
Wait�times�as�shown�below�indicate�gaps�in�Abuse�Services,�Assertive�Community�Treatment�
(ACT)�programs,�Case�Management,�Counselling�and�Treatment,�Diversion�and�Court�Support,�
Early�Intervention�and�Social�Rehab/Recreational.��These�wait�times�indicate�waits�of�1.5�to�9�
months�for�assessment�and�1.5�to�6�months�for�service�initiation�once�assessment�has�
occurred.��This�would�indicate�that�individuals�in�the�LHIN�are�waiting�from�three�months�to�
1.5�years�for�treatment.��Unfortunately,�no�benchmarks�are�currently�available�to�assess�the�
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �31�© 2008 KPMG All rights reserved�
appropriateness�of�these�wait�times.��The�literature�does�however�indicate�that�early�
identification�and�treatment�for�mental�health�disorders�is�more�cost-effective�(Hetrick�et�al,�
2008).���
Exhibit 24: Community Mental Health Wait Times, MOHLTC Health Indicator Tool, 2007/08
Service
Average Wait For
Assessment (days)
Average Wait for Service
Initiation (days)
Abuse�Services� N/A� 57.0�
Assertive�Community�Treatment� 144.5� 119.2�
Case�Management� 111.9� 179.4�
Counselling�and�Treatment� 165.7� N/A�
Diversion�and�Court�Support� 48.5� 36.6�
Early�Intervention� 132.6� 109.0�
Social�Rehab/Recreation� 267.3� N/A�
Support�within�Housing� 89.6� 89.5�
�
Prevalence�rates�suggest�there�are�107,�258�individuals�in�the�LHIN�with�substance�abuse�
problems.��Data�is�currently�not�available�to�determine�how�or�where�these�individuals�may�
seek�care.��The�range�of�services�available�includes�a�number�of�community�and�privately�
funded�services�that�are�not�funded�by�the�LHIN�(e.g.�Alcoholics�Anonymous).�The�number�of�
individuals�served�through�LHIN-funded�substance�abuse�and�problem�gambling�community�
providers�is�3,837�for�2007/08.��While�the�data�suggests�a�gap,�it�is�unclear�the�size�of�that�gap�
and�how�many�individuals�with�a�substance�abuse�or�problem�gambling�problem�would�seek�
care�in�a�given�year.��
The�data�also�suggests�gaps�in�concurrent�disorders,�multi-lingual�services,�community�
addictions�programs�and�withdrawal�management�and�across�all�programs�the�need�to�
increased�access�to�services�for�ethno-cultural�groups.��These�gaps�are�discussed�in�more�
detail�in�Appendix�M�on�Mental�Health�and�Addictions.���
Children and Youth
Youth�under�the�age�of�17�represent�11%�of�all�Mental�Health�clients.��Females�represent�95%�
of�all�Eating�Disorder�clients�within�the�LHIN�and�51%�are�under�the�age�of�17�(MOHLTC,�
PHPDB�2008).�Close�to�one-quarter�of�Mental�Health�Crisis�Intervention�clients�and�close�to�
one-third�of�abuse�clients�are�under�the�age�of�17.�It�was�noted�in�several�sessions�that�more�
services�and�supports�for�this�population�are�needed�in�the�area�and�especially�for�youth�in�the�
transition�ages�between�childhood�and�adulthood.�Of�particular�challenge�for�this�population,�in�
addition�to�the�children’s�population�overall,�are�the�numbers�of�organizational�and�Ministerial�
boundaries�that�are�involved.���
CCAC and Community Support Services
Community�Support�Services�provide�services�primarily�to�the�Seniors�population,�providing�
activities�of�daily�living�and�instrumental�activities�of�daily�living�as�well�as�a�host�of�other�
supports�to�allow�seniors�to�age�at�home.��Over�the�past�year,�the�LHIN�has�been�making�
strategic�investments�in�this�sector�due�to�increased�funding�through�the�Aging�at�Home�
strategy.��With�a�comparably�young�population,�this�investment�is�serving�to�build�up�the�
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �32�© 2008 KPMG All rights reserved�
community�sector�to�lessen�the�current�burden�on�long-term�care�homes�and�prepare�the�LHIN�
for�a�rapidly�aging�population.���
Exhibit 25: Individuals Served by CCACs per 1,000 Population (65 Years and Older)
(Source: MOHLTC MIS Comparative Reports FY 2007/08)
A�large�proportion�of�the�CCAC’s�client�base�is�seniors�and�seniors�are�primarily�served�through�
in-home�visits.��The�table�above�shows�the�visit�rate�for�seniors�served�by�the�LHIN�per�1,000�
population�over�the�age�of�65.��The�In-home�visit�ratios�are�the�lowest�in�the�province.���
The�data�reported�below�shows�wide�variation�among�the�proportion�of�the�population�served�
by�the�CCAC�in�Central�LHIN�when�compared�to�the�provincial�average.��Since�the�Central�LHIN�
population�is�slightly�younger�and�slightly�healthier�than�the�Ontario�average,�it�is�expected�that�
the�ratio�for�Central�LHIN�would�be�somewhat�lower.��The�total�number�of�individuals�served�as�
shown�in�the�table�below�includes�placement�to�long-term�care�homes.��As�the�number�of�beds�
compared�to�the�provincial�average,�as�shown�below,�is�significantly�lower,�this�has�an�impact�
on�the�number�of�individuals�served.��As�there�is�less�availability�of�long�term�care�beds�as�a�
proportion�of�the�population,�it�is�expected�that�the�number�of�in-home�visits�by�the�CCAC�
would�be�greater�than�the�provincial�ratio.��This�may�indicate�a�significant�gap�in�serving�this�
population�as�shown�in�the�graph�above,�the�ratio�is�in�fact�below�the�provincial�and�other�LHIN�
ratios.�
The�CCAC�also�serves�paediatric�clients,�who�are�primarily�seen�through�school�and�home�
programs.�Examining�the�paediatric�and�non-paediatric�school�and�in-home�visits,�these�rates�of�
visits�were�also�lower�than�provincial�averages.���
�
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �33�© 2008 KPMG All rights reserved�
Exhibit 26: Community Care Activity Comparisons (Source: MOHLTC Health Indicator Tool,
Population: Environics Analytics)
Service Type Activity
Population
Comparator
Central LHIN
Population
Central
Number
Served per
10,000 Population
Ontario
Number
Served per
10,000 Population Differential
CCAC�
Individuals�
Served�58,240�
Total�
Population�1,651,676� 352.6� 506.2�
��25,367�
individuals�
served�
CCAC�Face-to-
Face�Visits�672,538�
Total�
Population�1,651,676� 4,072.0� 5,785.0�
283,110�
Visits�
CCAC�
Paediatric�
Visits�52,301� Age�0-14� 293,977� 1,779.0� 2,484.0�
��20,725�
Visits�
CCAC�Non-
Paediatric�In�
Home�Visits�
617,843� Adults�>�65� 204,139� 30,266.0� 38,206.0�162,098�
Visits�
As�mentioned�previously,�data�comparing�activity�for�community�mental�health�and�community�
support�providers�was�not�available�in�such�a�way�that�provided�confidence�in�the�data.��To�
compensate,�cost�comparisons�provide�a�proxy�measure�for�activity�comparisons�as�presented�
in�the�table�below.���
Exhibit 27: Community Expenditure Comparisons (Source: MOHLTC Health Indicator Tool,
Population: Environics Analytics)
Service
Type Total
Expenses
2007/08
Population
Comparator
(Service
Drivers)
Central LHIN
Population
Central
Expenditure
per
Population
Ontario
Expenditure
per
Population
Differential
CCAC� $171,450,000� All� 1,651,676� $103.80� $128.94�($25.14)�
per�person�
Community�
Support�
Providers�$��46,179,208� Adult�>�65� 204,139� $226.21� $180.71�
$45.51�
per�person�
Community�
Mental�
Health�$��59,901,500*� Adult�>�15� 1,651,676� $��36.27� $42.10**�
($5.83)�per�
person�
*Central�LHIN�Community�Mental�Health�data�is�for�2008/09�Budget�(HIT�data�was�not�reliable)�
**Ontario�Figure�provided�by�SEEI,�2007�(FY�2005�figure�adjusted�for�inflation)�
�
The�data�suggests�that�there�is�a�lower�proportion�of�Community�Mental�Health�activity�as�
compared�to�the�provincial�ratio.��This�difference�results�in�a�net�difference�of�$5.83�per�capita�
in�the�LHIN.��Central�LHIN�spends�$45�more�on�Community�Support�Providers�(primarily�for�
Seniors)�in�the�LHIN�than�the�average�LHIN�in�Ontario.��This�is�further�supported�by�examining�
the�ratio�of�community�spending�to�hospital�spending.��The�ratio�of�community-to-acute�care�
spending�in�the�LHIN�is�1:5�(CCAC,�CMHA,�CSS).��This�compares�to�1:7�for�the�rest�of�Ontario�
The�higher�ratio�of�community�to�hospital�care�may�indicate�a�gap�in�hospital�or�institutional�
care�or�else�may�be�an�indication�that�the�community�sector�has�been�built�up�in�response�to�
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �34�© 2008 KPMG All rights reserved�
the�gaps�in�hospital�services,�including�investments�made�recently�as�part�of�the�Aging�at�
Home�strategy.���
Acute Care
Acute�care�includes�all�inpatient,�outpatient,�day�surgery,�and�emergency�services.��There�is�
significantly�more�reliable�data�available�for�these�services�including�wait�times�and�service�
utilization.��This�is�not�to�indicate�the�level�of�importance�these�services�place�over�community-
based�services;�rather�it’s�a�function�of�the�availability�of�the�data.��The�availability�of�data�does�
not�make�it�any�less�challenging�to�assess�health�service�gaps.��With�acute�services,�these�
services�are�typically�more�specialized,�serving�a�wider�catchment�area�than�community-based�
services.��Due�to�this,�there�can�be�a�lot�of�inflow�and�outflow�of�patients�that�access�these�
services�across�LHIN�boundaries,�making�it�more�difficult�to�assess�true�service�gaps,�as�some�
flow�across�boundaries�is�natural�and�appropriate.��To�help�assess�the�acute�service�gaps�in�the�
LHIN,�wait�times�indicators�will�be�examined,�service�benchmarks�and�ratios�and�the�net�inflow�
and�outflow�of�individuals�across�LHIN�boundaries�seeking�care.���
Wait Times and Indicators
There�are�many�health�services�within�the�LHIN�that�either�currently�do�not�report�wait�times,�
or�that�do�track�wait�times,�but�are�not�collected�consistently�and�therefore�are�not�comparable�
across�the�LHIN.��Current�wait�times�for�the�LHIN�are�provided�in�the�table�below.�
Exhibit 28: Ministry-LHIN Accountability Indicators, Q1 2008/09
Performance Indicator
Provincial
Target
LHIN
Target
(2008/09)
LHIN
Performance
(Q1 2008/09)
90th�Percentile�Wait�Times�for�Cancer�Surgery� 84�Days� 51� 53�
90th�Percentile�Wait�Times�for�Cardiac�By-pass�Surgery� 182�Days� 60� 53�
90th�Percentile�Wait�Times�for�Cataract�Surgery� 182�Days� 110� 78�
90th�Percentile�Wait�Times�for�Hip�Replacement� 182�Days� 182� 162�
90th�Percentile�Wait�Times�for�Knee�Replacement� 182�Days� 195� 169�
90th�Percentile�Wait�Time�for�Diagnostic�MRI�Scan� 28�Days� 105� 102�
90th�Percentile�Wait�Times�for�Diagnostic�CT�Scan� 28�Days� 42� 26�
�
These�wait�times�indicate�that�for�the�procedures�they�are�tracking,�current�supply�is�meeting�
demand,�with�the�exception�of�Magnetic�Resonance�Imaging�(MRI).��The�procedures�
represented�above�track�a�limited�number�of�surgical�procedures�and�diagnostic�imaging�for�
which�the�hospitals�in�the�LHIN�have�received�dedicated�funding.��If�a�hospital�does�not�meet�
targets�for�the�number�of�procedures�performed,�the�funding�is�clawed�back,�providing�an�
incentive�for�providers�to�meet�wait�times�targets.��Current�wait�times�for�Cancer�Surgery,�
Cardiac�Bypass�Surgery,�Cataract�Surgery,�Hip�and�Knee�Replacements�indicate�that�current�
service�levels�are�meeting�demand�(as�set�by�provincial�standards)�as�wait�times�are�performing�
better�than�provincial�and�LHIN�targets.��Central�LHIN�is�also�performing�better�than�the�
provincial�target�for�CT�Scans,�but�is�far�from�the�provincial�target�for�MRI�at�102�days�versus�
the�target�of�28�days.���
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �35�© 2008 KPMG All rights reserved�
Wait�times�can�be�good�measures�to�determine�the�balance�of�supply�and�demand,�but�they�do�
not�provide�a�complete�assessment�of�service�needs.��A�gap�encountered�while�conducting�the�
needs�assessment�and�gap�analysis�was�the�availability�of�consistent,�reliable�and�comparable�
data.��As�an�ongoing�measure,�the�LHIN�should�expand�the�development�of�systematic�wait�
times�across�the�LHIN�to�provide�ongoing�data�to�inform�decision�making.��Building�on�the�wait�
times�data,�service�utilization�and�availability�ratios�are�examined�below�that�provide�an�
assessment�of�service�delivery�benchmarks�in�the�LHIN.�
Benchmarks and Service Ratios
This�section�will�examine�service�ratios�compared�to�the�Ontario�average.��This�provides�an�
assessment�of�comparable�levels�of�service�adjusted�for�population�characteristics.��Due�to�the�
nature�of�the�LHINs�and�the�permeable�boundaries�that�exist,�adherence�to�benchmarks�or�
service�ratios�do�not�provide�a�complete�picture�of�service�gaps;�they�do�however�provide�
some�insight�into�the�service�needs�of�the�population.����
To�ensure�comparability�among�service�ratios,�service�utilization�has�been�adjusted�by�age.��
Age�is�a�good�proxy�to�account�for�disease�prevalence�rates�among�the�population,�as�age�is�
the�largest�predictor�for�demand�in�health�services.�The�table�below�compares�the�bed�ratios�in�
Ontario�to�those�provided�in�Central�LHIN.��As�compared�to�the�Ontario�ratios�per�10,000�
population,�Central�LHIN�is�under-serviced�in�all�areas�on�the�basis�of�crude�age-adjusted�
population�comparisons.�
Exhibit 29: Inpatient Bed Ratios per 10,000 Population (Age-Specific) 2007/2008 (MOHLTC HIT Tool
and LHIN HAPS reporting)
Service Type Number of Beds
in Central LHIN
Hospitals
Population
Comparator
Central LHIN
Population
Central Beds per
10,000
Population
Ontario Beds per
10,000
Population
Bed Differential
(Number of Beds)
Medical�/�Surgical�
Inpatient�1,172� Population� 1,651,676� 7.1� 9.6*� 408�
Paediatric�Inpatient� 53� <�15� 293,977� 1.8� 2.6� 24.6�
Intensive�Care� 81� Adult�>14� 1,357,699� 0.6� 1.1� 66.2�
Obstetrics� 168�Females��
15-44�368,363� 4.6� 5.5� 35.3�
Paediatric�Mental�
Health�17� <�15� 293,977� 0.6� 0.6� 1.1�
Adult�Mental�Health� 170� Population� 1,651,676� 1.0� 1.1**� 17.0�
Acute�Rehab� 76� Adult�>�44� 635,419� 1.2� 1.5� 18.2�
*� Inpatient�capacity�for�the�LHIN�was�compared�to�the�Ontario�ratio�excluding�all�LHINs�with�a�high�
concentration�of�specialty�teaching/tertiary�beds�(Toronto�Central,�South�West,�Champlain�and�Hamilton�
Niagara�Haldimand�Brant)�
**Mental�Health�capacity�was�compared�to�the�Ontario�ratio�excluding�LHINs�with�a�high�concentration�of�
specialty�mental�health�beds�(Toronto�Central,�Champlain,�South�East)�
The�column�to�the�right�describes�the�number�of�beds�that�would�be�required�to�bring�the�ratio�
of�beds�up�to�the�provincial�ratio.��This�is�a�crude�comparison�that�does�not�take�into�
consideration�natural�flow�of�patients�across�LHIN�boundaries�or�concentrations�of�highly�
specialized�tertiary,�quaternary�and�mental�health�services�in�Toronto�Central�LHIN.��While�
these�numbers�reflect�bed�capacity,�there�may�be�other�non-institutional�models�of�care�that�
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �36�© 2008 KPMG All rights reserved�
would�be�appropriate�over�increasing�inpatient�capacity�(e.g.�community�mental�health�and�
addictions�and�community�support�for�Seniors).���
There�is�a�natural�flow�of�patients�across�adjacent�LHIN�boundaries�as�demonstrated�below.��
This�is�especially�true�for�tertiary�and�quaternary�services�that�require�larger,�regional�catchment�
areas�in�order�to�support�the�required�volumes�of�service�to�support�minimum�levels�of�quality.��
There�are�large�outflows�to�Toronto�Central�LHIN�for�these�services�as�demonstrated�below.��
To�account�for�the�large�number�of�specialty�hospital�beds�in�certain�LHINs�that�would�skew�
any�ratio�comparisons,�Central�LHIN’s�capacity�has�been�compared�to�that�of�LHINs�without�
specialty�Mental�Health�hospitals�(e.g.�CAMH�in�Toronto,�Whitby�Mental�Health�Centre�and�
Royal�Ottawa�Health�Care�Centre).��This�may�act�to�under-report�the�gap.��For�paediatric�beds,�
the�Ontario�ratio�also�excludes�specialty�paediatric�hospitals�such�as�the�Hospital�for�Sick�
Children�and�Children’s�Hospital�of�Eastern�Ontario�to�provide�a�more�equivalent�measure.������
There�are�some�services�listed�that�would�be�expected�to�closely�match�service�levels�in�the�
province�such�as�acute�rehabilitation,�obstetrics,�and�paediatric�mental�health.��It�would�be�
expected�that�these�service�be�provided�“close-to-home”�where�possible,�recognizing�that�
some�natural�flow�across�LHIN�boundaries�would�occur.��The�service�ratio�of�these�services�all�
indicates�gaps�in�the�level�of�service�currently�provided.���
With�respect�to�Obstetrics,�as�demonstrated�in�Exhibit�31,�the�inflow�and�outflow�of�patients�
across�LHIN�boundaries�is�approximately�equal.��This�may�indicate�that�the�differential�number�
of�beds�reported�above�(35�beds)�could�represent�close�to�a�true�gap,�as�the�number�of�beds�
required�to�serve�the�population�would�be�expected�to�closely�match�the�provincial�ratio�since�
the�balance�of�inflow�to�outflow�would�indicate�that�the�bed�capacity�should�be�meeting�the�
population�service�demand.��As�mentioned�previously,�this�gap�may�not�translate�directly�into�a�
bed�capacity�gap�as�there�may�be�options�to�increase�home�delivery�and�the�use�of�midwives.�
It�is�expected�that�the�gaps�in�bed�ratios�would�translate�into�similar�gaps�in�the�ratio�of�
physicians�working�in�the�acute�care�sector.��A�subset�of�specialized�physician�ratios�is�provided�
below�and�compared�to�the�Ontario�ratio.��The�table�demonstrates�variations�in�the�comparative�
ratios�of�specialist�physicians�in�the�LHIN.��This�data�suggests�gaps�in�service;�however�the�
true�gap�may�not�be�as�the�ratio�suggests�due�to�natural�flow�of�patients�across�the�LHIN�
boundaries.��Further�physician�data�is�available�in�the�Appendices.��
Exhibit 30: Specialist Physician Ratios (Scott’s Medical Dictionary – Ontario Physicians and
Specialists (2008)
Specialty Central LHIN Ratio per
100,000 Population
Ontario LHIN Ratio per
100,000 Population
General�Surgery� 3.3� 4.6�
Internal�Medicine� 4.3� 5.2�
Paediatrician� 6.8� 7.0�
Obstetrics�/�Gynaecology� 4.3� 5.3�
Psychiatrists� 8.2� 13.0�
�
Increasing�bed�capacity�as�cited�above,�using�Obstetrics�as�an�example,�would�require�an�
increase�in�the�number�of�Obstetricians.��Psychiatrists�also�work�in�the�community,�and�as�
demonstrated,�the�differential�number�of�these�physicians�is�proportionately�larger�than�the�
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �37�© 2008 KPMG All rights reserved�
differential�in�bed�capacity.��Since�Central�LHIN�is�situated�so�close�to�Toronto�Central�where�a�
large�concentration�of�service�is�available,�there�will�be�some�migration�towards�physicians�and�
services�in�this�LHIN.���This�flow�is�examined�below.����
Patient Inflow and Outflow
An�assessment�of�the�inflow�and�outflow�of�residents�in�the�LHIN�provides�information�on�the�
types�of�services�LHIN�residents�are�seeking�elsewhere.��This�could�be�due�to�the�service�not�
being�available�in�the�LHIN,�patient�choice�or�referral�patterns�of�the�patient’s�referring�
physician.��Various�inflow�and�outflow�rates�are�presented�in�the�table�below.��
Table 31: Inflow and Outflow of Central LHIN Resident s- Shaded Areas are those with large
Outflow Proportions
Service / Activity
Common Interventions
Visits to Central LHIN Hospitals
Inflow (%)
Visits to Other LHIN Hospital
Outflow (%)
Service Provision to Utilization Ratio*
Inpatient�
Separations�
All�Inpatient� 184,763� 31.3� 198,441� 36.1� 0.93�
Inpatient�
Neurosurgery�
Craniotomy,�extracranial�vascular�
procedures,�carpal�tunnel�release,�
and�spinal�procedures�
199� 32.2� 1,383� 90.2� 0.14�
Inpatient�
Cardio/thoracic�
Coronary�bypass�surgery,�
angioplasty,�pacemaker�implants,�
ling�or�heart�transplant,�cardiac�
valve�replacement,�resection�of�the�
lung�etc.�
5,696� 45.4� 8,212� 62.2� 0.69�
Obstetrics� Maternity� 39,030� 31.6� 39,108� 31.7� 1.0�
Primary�Level�of�
Care�(Hospital)**�
Simple�Procedures�(e.g.�Sore�
Throat)�
85,366� 25.1� 88,111� 27.4� 0.97�
Secondary�Level�of�
Care�(Hospital)�
Cases�with�more�complexity�(e.g.�
Pneumonia)�
86,015� 36.2� 86,830� 36.8� 0.99�
Tertiary�/�
Quaternary�Level�
of�Care�(Hospital)�
Highly�Complex�/�Specialized�Cases�
(e.g.�Coronary�Bypass�Surgery)�
13,382� 40.0� 22,525� 64.4� 0.59�
Unscheduled�
Emergency�Visits�
Emergency�Visits� 782,786� 22.3� 798,255� 23.8� 0.98�
Oncology�Medical�
Day�Night�
Chemotherapy�and�Radiation�
Treatment�
37,231� 27.8� 142,909� 81.2� 0.26�
Kidney�and�
Genitourinary�Tract�
Hemodialysis�and�peritoneal�
dialysis�
176,729� 26.0� 204,611� 36.0� 0.86�
Circulatory�System� Cardiac�Catheterization�and�
Angioplasty�
7,396� 55.0� 7,897� 57.8� 0.94�
*Service�Provision�to�Utilization�Ratio�is�calculated�by�dividing�the�visits�to�central�LHIN�hospitals�by�visits�to�other�LHIN�hospitals.��It�
provides�a�ratio�of�the�relative�number�of�residents�seeking�care�outside�the�LHIN�to�the�number�seeking�care�in�the�LHIN.��
**’Level�of�Care’�is�a�methodology�that�assigns�complexity�to�inpatient�cases�and�is�determined�by�age,�complexity�and�level�of�
specialization�of�the�procedure�or�diagnosis.�
Soure: MOHLTC Flow Report 2004/05 and 2005/06 data)
Central�LHIN�residents�overall�for�inpatient�care�are�seeking�care�outside�the�LHIN�slightly�more�
than�those�seeking�care�in�the�LHIN.��This�is�evident�when�looking�at�highly�specialized�
tertiary/quaternary�care�such�as�neurosurgery�and�cardio�thoracic�surgery.��These�services�are�
typically�offered�at�the�tertiary�academic�health�science�centres�in�Toronto�Central�LHIN.��
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �38�© 2008 KPMG All rights reserved�
Central�LHIN�had�second�highest�inflow�for�inpatient�services�and�emergency�department�
visits.��This�can�be�attributed�to�the�hospitals�to�the�south�of�the�LHIN,�close�to�the�LHIN�
border,�but�also�Stevenson�Memorial�Hospital�in�the�north.���
Central�LHIN�residents�are�seeking�care�in�Toronto�Central�LHIN�for�oncology�medical�day/night�
procedures�at�high�rates.��These�are�ambulatory�procedures�that�include�chemotherapy�and�
radiation�therapy�amongst�others.��With�the�construction�of�the�Southlake�Regional�Cancer�
Centre,�these�numbers�should�adjust�accordingly.��Additionally,�a�high�proportion�of�LHIN�
residents�were�seeking�care�for�hemodialysis�and�peritoneal�dialysis�outside�the�LHIN�(more�
than�were�provided�in�the�LHIN�for�LHIN�residents).��This�may�indicate�a�gap�in�hemodialysis�
and�peritoneal�dialysis.��This�is�an�outpatient�intervention�that�requires�frequent�(3�times�
weekly)�treatment�and�as�such�would�expect�to�be�provided�close�to�home.��Appendix�K�on�
Chronic�Diseases�demonstrates�growth�projections�for�dialysis�in�the�LHIN.������
It�is�expected�that�there�be�some�natural�flow�across�LHIN�boundaries�since�the�lines�are�
drawn�through�municipal�and�invisible�boundaries.��This�is�demonstrated�in�the�inflow�and�
outflow�of�patients�for�Obstetrics�where�the�net�flow�is�zero.��This�is�also�true�for�Emergency�
Services,�indicating�the�services�provided�for�these�types�of�service�should�match�the�
requirements�of�the�population.���
Emergency Services Utilization
Emergency�department�service�utilization�in�the�LHIN�is�currently�lower�when�compared�to�
other�LHINs�and�the�province�as�a�whole�as�shown�in�the�graph�below.��Flow�issues�in�the�
Emergency�Department�(ED)�can�be�caused�by�a�range�of�issues,�including�the�rate�of�arrival,�
use�of�the�ED�for�cases�that�could�be�seen�in�the�community,�complexity�and�mix�of�cases,�
staff�shortages,�and�flow�issues�into�the�hospital�(e.g.,�ICU,�Medicine�beds)�and�community�
(e.g.,�Long�Term�Care).��As�seen�previously,�family�physician�ratios�vary�across�the�planning�
areas.��Residents�having�difficulties�accessing�primary�care�is�helping�to�drive�Emergency�
Department�utilization�in�these�areas.�
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �39�© 2008 KPMG All rights reserved�
0
200
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Exhibit 32: Emergency Department Cases per 1,000 Population FY 2006/07
Source: PHPDB NACRS / Environics Analytics Population Projections 2008
In�terms�of�their�most�pressing�service�gaps,�Emergency�Departments�in�the�LHIN�cite�
difficulties�and�delays�admitting�patients�for�Critical�care,�Neurosurgery,�Vascular�Surgery�and�
Mental�Health�services.��Focus�group�participants�also�spoke�of�a�lack�of�adherence�or�
existence�of�regional�protocols�for�managing�Emergency�Department�patients�causing�delays�in�
patient�care�and�access�(e.g.�transfer�of�patients�from�smaller�centres�to�regional�centres).�
Exhibit 33: Ontario and Central LHIN % Triage CTAS Distribution FY 2006/07
Source: PHPDB NACRS)
Emergency�Department�staff�in�interviews�and�focus�groups�expressed�concern�over�
blockages�in�the�Emergency�caused�by�systemic�patient�flow�issues.��There�is�currently�an�
issue�discharging�Central�LHIN�patients�to�appropriate�levels�of�service�outside�the�hospitals�as�
described�below.��The�age-cohort�with�the�highest�proportion�of�ALC�days�is�75�years�and�older�
indicating�that�there�are�not�adequate�supports�in�rehab,�complex�continuing�care�and�long-term�
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �40�© 2008 KPMG All rights reserved�
care�and�home�supports�for�seniors.��Increasing�access�to�these�services�would�increase�flow�
through�the�system�and�help�to�alleviate�wait�times�in�the�Emergency.��Gaps�in�these�services�
are�discussed�below.���
Children and Youth Acute Care Services
Youth�in�the�Central�LHIN�generally�have�fewer�hospital�admissions,�ED�visits�and�GP/FP�visits�
for�all�chronic�diseases�then�their�peers�in�the�rest�of�Ontario.��However�it�was�noted�at�focus�
group�sessions� that�several� risk� factors� for� chronic�diseases,�such� as�obesity� are�on� the� rise�
and�many�chronic�diseases�that�were�generally�once�considered�adult�diseases�are�now�being�
seen�in�young�children.�The�following�exhibit�highlights�the�hospital�cases,�ED�visits�and�GP/FP�
visit� rates� for� those� with� diabetes� under� the� age� of� eleven� (additional� data� in� Appendix�J).�
�
Exhibit 34: Diabetes mortality, hospital separation, emergency department visit and GP/FP visit
rates by age group and gender, per 100,000 population, Central LHIN and Ontario residents
As�demonstrated,�there�are�gaps�in�acute�care�services�across�the�LHIN�as�determined�
primarily�by�comparing�service�ratios�to�provincial�or�LHINs�averages.��The�difficulty�arises�in�
accurately�quantifying�that�gap�since�there�is�a�significant�and�natural�inflow�and�outflow�of�
patients�across�the�LHIN�boundaries.��The�service�ratios�can�act�as�a�guide�to�determine�the�
maximum�gap�in�services,�but�other�factors�must�come�into�play�such�as�referral�patterns;�
access�to�tertiary�and�quaternary�care�in�academic�centres;�and,�client�choice.���
Post Acute
As�discussed�below,�the�data�suggests�health�service�gaps�in�long-term�care,�rehab,�palliative�
care,�complex�continuing�care�and�supportive�housing�for�seniors,�support�within�housing�for�
mental�health�clients�and�homes�for�special�care,�as�well�as�residential�addictions�programs.��
The�indicators�below�report�on�alternative�level�of�care�days�in�the�LHIN�and�wait�times�for�
placement�into�long�term�care.��
Long Term Care
The�indicators�below�track�wait�times�for�long-term�care�home�placement,�which�in�the�LHIN�is�
higher�than�the�provincial�target,�and,�the�ability�of�inpatient�units�in�the�LHIN�to�discharge�
patients�to�lower�levels�of�care�(e.g.�Rehab,�LTC,�Home�care�etc.)��These�indicators�provide�a�
high-level�snapshot,�and�indicate�areas�where�more�detailed�data�analysis�is�required.��The�
appendices�contain�more�detailed�analysis�on�community�services�for�Seniors.��Appendix�N�as�
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �41�© 2008 KPMG All rights reserved�
well�as�the�Appendix�on�Emergency�services�(Appendix�L)�also�provides�more�detailed�insights�
into�alternative�levels�of�care�(ALC).��
Exhibit 35: Ministry-LHIN Accountability Indicators, Q1 2008/09
Performance Indicator
Provincial
Target
LHIN
Target
(2008/09)
LHIN
Performance
(Q1 2008/09)
Median�Wait�Time�to�Long-term�Care�Placement�� 50�days� 55� 68�
Percentage�of�Alternate�Level�of�Care�Days� 9.46%� 9.60� 10.59�
In�July,�2008,�a�Central�CCAC�survey�of�all�hospital�inpatients�revealed�that�there�were�
226�clients�waiting�in-hospital�for�long�term�care.��According�to�the�MOHTLC�LTC�System�
Report�on�March�31,�2008,�this�represented�approximately�5%�of�those�waiting�for�Long-term�
Care,�as�others�were�waiting�in�the�community,�waiting�for�LTC�transfer�or�elsewhere.��This�
would�indicate�a�total�wait�list�of�approximately�4,500�people�in�the�LHIN.��The�survey�also�
examined�whether�clients�on�the�wait�list�were�eligible�to�go�home�with�additional�supports�and�
found�that�approximately�25%�of�those�waiting�in�hospital�would�qualify.��Studies�by�Lum�et�al�
(2005),�Hollander�et�al�(2001)�and�Hollander�et�al.�(2007)�indicate�that�a�proportion�of�these�
people�may�be�able�remain�in�their�homes�if�services�are�provided�by�community�providers�that�
target�a�range�of�services�including�activities�of�daily�living�and�instrumental�activities�of�daily�
living.���
The�table�below�examining�the�ratio�of�beds�per�population�85�years�and�older�suggests�a�gap�
of�824�long-term�care�beds.��While�the�data�does�suggest�a�gap,�as�the�CCAC�survey�suggests,�
there�are�opportunities�to�reduce�this�bed�gap�through�increased�supports�in�the�community.����
Exhibit 36: Inpatient, Long-term Care, Rehab and Complex Continuing Care Bed Ratios per 10,000
Population (Age-Specific) 2007/2008
Service Type
Number of
Beds in Central
LHIN Hospitals
Population
Comparator
Central LHIN
Population
Central Beds
per 10,000
Population
Ontario Beds
per 10,000
Population
Bed
Differential
(Number of
Beds)
Long-term�Care� 7,057� >�85� 24,343� 2,899� 3,238� 824�
Complex�Continuing�
Care�129� >�44� 635,419� 2.0� 11.0� 572.8�
Rehab� 280� Adult�>�44� 635,419� 4.4� 4.6� 11.5�
Source: MOHLTC HIT Tool and LHIN HAPS reporting
Complex Continuing Care and Rehabilitation
The�analysis�for�rehabilitation�above�includes�all�rehabilitation�in�rehab�designated�beds,�
including�both�specialty�and�general�rehab.��Comparing�ratios�in�the�LHIN�to�ratios�in�the�
province�suggests�a�gap�of�11.5�beds.��The�ratio�suggests�additional�capacity�in�rehab�is�
required.��Increasing�inpatient�capacity�would�also�require�investments�in�outpatient�rehab�
capacity.��Additionally,�an�OHA�Survey�in�April�2008�reported�that�23%�of�all�ALC�patients�in�
Central�LHIN�hospitals�were�waiting�for�Rehabilitation.��This�is�second�only�to�Long�term�care�
beds.���
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �42�© 2008 KPMG All rights reserved�
Additionally,�the�primary�recipients�of�rehab�services�in�the�LHIN�are�females�age�65�and�older.�
Further,�it�is�estimated�that�thirty�percent�of�rehab�patients�currently�have�comorbid�chronic�
conditions,�complicating�their�recovery.��As�the�population�ages,�the�LHIN�will�require�
investments�in�rehab�services,�likely�with�the�capacity�to�address�the�needs�of�a�more�complex�
client�base.��Currently�the�Central�LHIN�rehab�facilities�see�half�the�stroke�rehab�clients�
compared�to�the�Canadian�average.��Additional�data�collection�and�analysis�is�required�to�assess�
the�reasons�why.��Some�additional�data�can�be�found�in�Appendix�O.��A�more�fulsome�analysis�
of�Rehab�gaps�in�the�LHIN�was�beyond�the�scope�of�this�project,�but�could�be�further�explored�
in�the�future.���
Service�ratios�of�complex�continuing�care�also�suggest�service�capacity�gaps.��The�large�
differential�in�the�number�of�complex�continuing�care�beds�is�a�circumstance�of�the�large�stock�
of�beds�in�Toronto�Central�LHIN.��There�are�numerous�providers�across�the�LHIN�boundary�
each�with�more�bed�capacity�than�the�LHIN�in�its�entirety�(e.g.,�Baycrest,�West�Park,�
Sunnybrook,�Toronto�Rehab,�Bridgepoint).��Additionally,�the�OHA�Survey�reported�that�8%�of�all�
ALC�patients�in�Central�LHIN�hospitals�were�waiting�for�Complex�Continuing�Care�after�Long-
term�Care�and�Rehab.��This�may�indicate�that�that�actual�service�gap�may�not�be�an�extensive�
as�the�ratio�suggest,�likely�due�to�the�flow�of�patients�across�the�LHIN�boundary.�������
Hospice Palliative Care
There�is�currently�a�lack�of�Hospice�Palliative�care�resources�in�the�LHIN,�both�in-home�hospice�
support�and�residential�hospice.��Focus�group�participants�spoke�of�the�need�for�hospice�
palliative�care�to�support�seniors,�but�also�people�of�all�ages.��The�LHIN�was�involved�in�the�
development�of�a�single�palliative�care�network�for�the�LHIN�that�will�plan�and�coordinate�
palliative�care�across�the�LHIN.��Extensive�data�on�palliative�care�utilization�was�not�available�at�
the�time�of�writing�this�report;�however,�community�palliative�providers�are�currently�
completing�a�survey�that�will�be�available�to�the�LHIN.��Data�for�hospice�palliative�care�is�
provided�below�for�Central�LHIN,�provided�by�Alliance�Hospice�for�fiscal�year�2007/08.�
Exhibit 37: Hospice Palliative Care Clients in Central LHIN 2007/08
Referral Source Female Male Grand Total Distribution
(%)
CCAC� 176� 101� 286� 20.4%�
Nursing/OT/SW� 120� 112� 236� 16.9%�
Self/family� 133� 85� 222� 15.9%�
Hospital� 123� 97� 221� 15.8%�
Cancer�Society� 103� 59� 168� 12.0%�
not�specified� 57� 47� 110� 7.9%�
Palliative�Care�Team� 38� 24� 62� 4.4%�
Hospice� 32� 23� 55� 3.9%�
Physician� 14� 9� 23� 1.6%�
Other� 7� 7� 14� 1.0%�
unknown� �� 3� 3� 0.2%�
Grand Total 803 577 1,400 100.0%
Source: Alliance Hospice
Supportive Housing
Supportive�housing�is�an�essential�service�for�promoting�independence�in�the�community�for�
seniors�and�individuals�living�with�mental�health�and�addictions.��Supportive�housing�for�people�
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �43�© 2008 KPMG All rights reserved�
living�with�serious�mental�illness�or�addictions�helps�promote�recovery�and�independence.��
Supportive�housing�for�seniors�helps�promote�independent�living�by�providing�activities�of�daily�
living�and�instrumental�activities�of�daily�living�to�provide�an�alternative�to�Long-term�Care�
facilities.��Lack�of�supportive�housing�for�both�of�these�populations�was�identified�by�many�
stakeholders.��The�charts�below�show�the�number�of�Central�LHIN�residents�served�in�
supportive�housing�facilities�within�the�Central�LHIN�borders�for�those�with�mental�health,�
addictions,�acute�brain�injury�(ABI)�conditions�as�well�as�seniors�as�well�as�the�number�of�
homes�for�special�care�and�domiciliary�hostels�in�York�Region.��While�current�data�on�
supportive�housing�for�both�seniors�and�mental�health�and�additions�was�limited,�more�work�is�
currently�being�done�on�the�development�of�a�registry.��Data�should�be�available�to�the�LHIN�for�
future�planning.���
The�Kirby�report�on�Mental�Health�and�Addictions�reported�on�the�significant�shortfall�in�
supportive�housing,�and�the�contribution�housing�plays�to�promote�recovery.��In�Ontario,�there�
are�currently�6,750�supportive�housing�units�for�individuals�living�with�serious�mental�illness�or�
addictions�(Kirby,�2006).��The�provincial�forum�on�the�mental�health�implementation�task�force�
indicated�that�the�province�is�in�need�of�10,000�more�units.��This�would�translate�into�an�
additional�1,280�beds�for�in�Central�LHIN.��Central�LHIN�current�has�12.8%�of�the�Ontario�
population�and�10%�of�the�supportive�housing�beds.��There�are�currently�671�beds�for�support�
within�housing�for�people�living�with�mental�health�and�addictions�disorders�as�described�as�
domiciliary�hostels�in�the�table�below.����Wait�times�for�2007/2008�as�reported�by�the�MOHLTC�
Health�Indicators�Tool�indicates�clients�waited�three�months�on�average�for�placement.��To�
complement�the�core�basket�of�service�in�Mental�Health�and�Addictions,�focus�groups�
participants�also�stressed�the�need�for�residential�addictions�services�and�withdrawal�
management�programs.�
Exhibit 38: Number of Clients Served in Central LHIN in Supportive Housing (FY 07/08) Various
STRCSB�–�Short�Term�Residential�Crises�Support�Beds�
Sources: York Region, Central LHIN, Connex Database)
23 23
362
671
0
100
200
300
400
500
600
700
800
Homes�for�Special
Care
Domiciliary
Hostels
Number�of�Units
Homes
Beds
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �44�© 2008 KPMG All rights reserved�
Exhibit 39: Homes for Special Care and Domiciliary Hostels (FY 2007/08) Various
Sources: York Region, Central LHIN, Connex Database)
System Integration and Coordination
A�consistent�theme�that�emerged�across�all�service�domains�was�the�lack�of�system�integration�
and�coordination.��Interview�and�focus�group�participants�spoke�of�a�gap�in�terms�of�system�
fragmentation�and�information�sharing.��Participants�in�the�seniors’�forums�recognized�that�
Doorways�to�Care�was�a�good�start�to�share�information�on�the�services�available�in�the�
community,�but�that�knowledge�of�its�existence�was�still�not�widespread,�especially�among�
hospital�staff�and�discharge�planners.��There�was�a�reflection�that�community�mental�health�and�
addictions�services�had�also�achieved�some�work�building�a�more�coordinated�system�of�
providers,�but�more�work�was�required�to�create�an�integrated�service�delivery�model.��
As�discussed�in�the�literature�review�(Appendix�Q),�there�are�common�threads�that�emerged�
across�all�domains�that�create�the�elements�of�an�integrated�program�model.��The�lack�of�
coordinated�system�models�has�a�more�significant�impact�on�chronic�or�lifetime�conditions�
where�clients�are�continually�interacting�with�professionals�requiring�continuing�levels�of�care.��
These�would�include�Seniors�services,�Chronic�Conditions�including�Cancer�and�Mental�Health�
and�Addictions�Services.��This�is�not�to�say�that�integration�is�not�important�for�acute�services,�
but�rather�that�service�integration�is�incrementally�important�for�chronic�and�lifetime�conditions.���
The�elements�as�prescribed�in�the�literature�that�were�missing�in�the�LHIN�to�create�integrated�
program�models�included�mechanisms�to�allow�inter-professional�providers�to�collaborate�and�
work�together�towards�common�client�goals.��This�could�include�electronic�health�records�and�
other�electronic�tools�that�provide�information�sharing�and�collaboration.��The�formal�
relationship�among�inter-professional�teams�was�also�missing�in�some�instances.��This�could�be�
achieved�through�service�coordinator�/�case�management�roles�whose�responsibility�would�be�
to�bring�together�an�inter-professional�team�of�providers�from�across�organizations�to�
collaboratively�assess�clients�and�together�build�common�goals�with�the�client�and�family.���
This�would�require�the�use�of�common�program�measures�and�ongoing�evaluation�to�monitor�
and�continually�improve�team�performance.��It�would�also�require�local�or�regional�oversight�or�
590
1500
32 0
934
50
200
400
600
800
1000
1200
1400
1600
Mental�Health�Support�within�Housing
Mental�Health�STRCSB
Addictions�-�Support�within�Housing
Addictions�-�STRCSB
Seniors
ABI
Number�of�Clients�Served
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �45�© 2008 KPMG All rights reserved�
management�with�a�link�to�a�centralized�coordinator�who�would�coordinate�common�LHIN-wide�
standards,�protocols�and�supports.�
Health Human Resources
Population�growth�and�aging�will�have�a�significant�impact�on�all�health�care�providers’�ability�to�
meet�future�demand�within�the�resources�provided.��In�order�to�meet�this�demand�additional�
human�resource�capacity�will�be�required.��It�is�estimated�that�80-90%�of�all�operational�health�
spending�goes�towards�health�human�resources�(Williams,�2008).��As�discussed�above,�the�
LHIN�currently�faces�gaps�in�physicians,�both�speciality�and�family�physicians.��As�a�national�
physician�shortage�impacts�the�LHIN,�new�models�of�care�will�need�to�be�considered�to�meet�
the�health�service�needs�of�the�population.���
The�LHIN�recently�commissioned�a�report�on�the�current�and�future�Health�Human�Resource�
(HHR)�situation�in�the�Central�LHIN,�entitled�“Health�Human�Resources�Risk�Reduction�Plan”.�
The�Report�provides�valuable�information�to�start�to�address�recruitment�and�retention�
initiatives�in�the�Central�LHIN.�It�is�not�our�intent�to�duplicate�this�study�nor�its’�findings�in�this�
report.�The�report�is�however�an�important�foundation�for�developing�a�robust�health�human�
resources�strategy�for�the�future.��As�the�report�suggest,�there�is�significant�work�to�be�done,�
much�of�which�must�be�undertaken�not�only�at�the�LHIN-level,�but�also�from�the�vantage�point�
of�province-wide�planning.��The�key�findings�of�the�report�were�as�follows.�
The�greatest�supply�and�demand�issues�were�related�to�15�occupations�as�follows:�
1. Nurse:�Registered�Nurse�(RN)�
2. Personal�Support�Worker:�Diploma�
3. Nurse:�Registered�Practical�Nurse�(RPN)�
4. Personal�Support�Worker:�No�Diploma�
5. Social�Worker�
6. Occupational�Therapist�
7. Physiotherapist�
8. Technologist�—�Radiation�
9. Technician�–�Lab�
10. Dietitian/Clinical�Nutritionist�
11. Speech�Language�Pathologist�
12. Respiratory�Therapist�
13. Technologist�–�Lab�
14. Pharmacy�Assistant/Technician�
15. Pharmacist�
The�LHIN�currently�has�894�vacancies�representing�an�overall�vacancy�rate�of�approximately�
5%.��The�report�also�acknowledged�that�approximately�half�of�all�employees�in�the�Central�
LHIN�are�above�the�age�of�45.��Based�on�assumptions�about�service�level�ratios,�population�
growth,�turnover�and�retirement�the�gaps�will�widen�in�the�future.�There�is�a�significant�reality�
of�retirement�due�to�an�aging�workforce�across�the�LHIN�and�in�some�occupations.�The�
following�occupations�have�a�significant�number�of�employees�who�have�the�potential�to�retire�
(55�years�of�age�and�above):�RN,�RPN,�PSW,�Technician:�Lab�and�Technologist:�Lab.�
There�is�an�immediate�need�to�develop�sustainable�methods�to�collect�and�validate�
comprehensive�HHR�data�across�the�LHIN�on�a�consistent�and�efficient�basis.��Qualitative�
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �46�© 2008 KPMG All rights reserved�
survey�data�also�indicated�that�RNs,�Personal�Support�Workers�(PSW)�and�Registered�Practical�
Nurses�(RPN)�are�the�most�difficult�positions�for�which�to�recruit.��Methods�will�be�required�to�
overcome�these�difficulties�as�these�positions�are�likely�required�to�help�support�the�shortage�
of�physician�positions�and�work�in�the�community.���
The�report�also�found�that�the�LHIN�health�human�resource�providers�lack�an�ability�to�meet�the�
diverse�language�needs�of�the�Central�LHIN�population.��This�has�been�a�consistent�theme�
through�the�project�and�is�discussed�further�in�the�quantification�of�the�gaps.�
The�study�makes�recommendations�on�many�of�these�key�findings.�However,�with�regard�to�
the�future�state,�the�assumptions�include�a�“constant�service�level”.�That�is�“demand�was�
forecasted�to�increase�at�the�same�rate�as�the�population�growth”.�It�does�not�appear�that�the�
aging�of�the�population�was�taken�into�account�nor�was�the�fact�that�seniors�consume�a�
disproportionate�amount�of�health�care�resources.�
From�the�analysis�of�seniors,�it�has�been�projected�that�the�senior�population�(65+)�will�increase�
close�to�40%�over�the�next�ten�years.�In�the�hospital�sector�alone,�while�seniors�make�up�about�
12%�of�the�CLHIN�population,�they�account�for�a�third�of�all�acute-care�hospitalizations�and�
almost�half�of�all�hospital�days.��The�growth�in�the�general�population�coupled�with�the�growth�
in�the�seniors’�population�will�significantly�increase�the�demand�for�all�health�services.�The�
latter�has�not�been�factored�into�the�report�forecast�and�will�significantly�widen�the�anticipated�
gap.�
While�there�are�no�normative�rates�for�physicians�per�100,000�population,�the�most�recent�
Ontario�Physician�Human�Resources�Data�Centre�(OPHRDC)�has�produced�a�report�which�
identifies,�among�other�things,�the�population�per�physician�by�type�for�the�CLHIN�and�for�the�
province.�From�these�data,�it�is�clear�that�the�number�of�physicians�practicing�in�the�CLHIN�is�
well�below�the�Provincial�rate�as�demonstrated�above.��
The�rate�of�population�to�Family�Medicine�physicians�in�CLHIN�is�one�for�every�1,394�
population.�The�provincial�average�is�one�for�every�1,329�population�–�a�difference�of�4.9%.��
A�recent�study�by�the�MOHLTC�also�reported�that�7%�of�LHIN�residents�do�not�have�a�family�
physician.��For�Psychiatrists,�the�CLHIN�has�134,�which�yields�an�average�of�one�Psychiatrist�for�
every�12,325�population.�The�Provincial�average�is�one�for�every�7,600�population�–�a�difference�
of�almost�40%.�
For�all�of�Medicine,�the�CLHIN�has�over�32%�less�physicians.�Similarly,�for�all�surgeons,�the�
CLHIN�has�23�%�fewer.�For�all�specialists,�the�CLHIN�has�almost�29%�less�than�the�Provincial�
average.��Like�the�general�population,�the�impact�of�aging�will�impact�physicians�as�well.��Thirty-
seven�percent�of�the�practitioners�are�over�the�age�of�55.�According�to�the�OPHRDC�data,�the�
sharp�drop-off�occurs�around�age�65�and�these�retirements�will�put�the�CLHIN�further�behind�
Provincial�averages.�
In�terms�of�mitigating�factors,�volunteers�are�undervalued�human�resources�that�are�becoming�
increasingly�utilized�by�health�service�providers.��They�provide�many�hours�of�service�in�
hospitals,�hospices�and�community�provider�settings�and�assist�everything�from�patient�
portering�to�meals-on-wheels�to�grief�counselling.�If�volunteers�were�not�available�to�fulfil�these�
necessary�functions,�then�paid�staff�would�have�to�be�hired�to�complete�these�tasks.�In�the�
future,�as�more�energetic,�educated�seniors�become�available�with�the�anticipated�aging�
population,�new�challenges�need�to�be�found�to�provide�satisfying�and�meaningful�opportunities�
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �47�© 2008 KPMG All rights reserved�
that�might�offset�some�of�the�future�demands�for�staff.��This�will�require�an�appropriate�
investment�in�training�and�education.��
Another�mitigating�factor�that�should�be�considered�is�the�concept�of�“growing�your�own”�
staff.�Where�a�shortage�of�Registered�Practical�Nurses�(RPN)�exists,�Personal�Support�Workers�
(PSWs)�are�provided�with�incentives�and�opportunities�by�the�employer�in�return�for�a�time�
commitment,�to�train�as�RPN’s.�Where�shortages�of�Registered�Nurses�(RN’s)�exist,�employers�
provide�the�same�incentive�for�RPN’s�to�become�RN’s.�Similarly,�where�RN�(EC)’s�are�required,�
RN’s�are�provided�with�incentives�to�continue�their�education�to�fulfill�the�requirements�of�
these�positions.�
Yet�another�mitigating�factor�may�be�the�further�use�of�“extended�class�nurses”.�The�preferred�
terminology�of�the�College�of�Nurses�of�Ontario�to�describe�the�extended�practice�role�for�the�
nurse,�as�in�Nurse�Practitioner�(Extended�Class).��
Advanced�Practice�Nurse�is�seen�as�a�global�term�to�“describe�the�entire�spectrum�of�advanced�
practice�in�which�nurses�apply�maximum�nursing�knowledge�and�skill�to�meet�the�needs�of�
clients”.�Its�value�is�that�“with�appropriate�authorization�it�may�include�activities�that�fall�with�
the�traditional�scope�of�medical�practice�including�functions�such�as�diagnosing,�and�prescribing�
as�well�as�specific�procedures�or�technical�skills.”�
Advanced�Nursing�Practice�includes�roles�such�as�Clinical�Nurse�Specialist,�Primary�Health�Care�
Nurse�Practitioner,�Acute�Care�Specialty�Nurse�Practitioner�and�will�include�other�extended�
roles�such�as�Nurse�Anaesthetists�as�they�emerge.�
In�the�future,�the�RN�(EC)�has�the�potential�to�take�on�more�of�the�functions�of�medical�
practitioners.�The�RN�(EC)�is�a�common�sight�in�Primary�Care�settings�and�Long�Term�Care�
settings.�In�the�acute�care�setting,�a�proposal�currently�has�been�prepared�outlining�the�new�
scope�of�practice�for�APN’s�in�the�area�of�systemic�treatment�of�cancer.�
To�further�fulfill�the�human�resource�capacity�in�the�LHIN,�partnerships�with�Toronto�area�
Medical,�Nursing�and�Allied�Health�schools�will�be�required�to�develop�internships�in�the�LHIN�
with�incentives�if�required�to�keep�graduates�post�internship.�����
Summary of Gaps
As�evidenced�throughout�the�chapter,�several�key�service�gaps�begin�to�emerge.��These�
themes�include�Mental�Health�and�Addictions�services,�primarily�in�community�services,�but�
also�in�support�within�housing,�homes�for�special�care�and�residential�addictions�programs.�
Service�gaps�including�access�to�primary�care,�chronic�disease�prevention�and�management�
and�seniors�services�also�emerge.���
Chronic�Disease�Management�and�Prevention�consume�a�large�portion�of�health�spending,�and�
this�amount�will�likely�increase�as�the�population�ages.��As�demonstrated,�gaps�exist�in�
providing�access�to�primary�care,�but�also�self-management�and�prevention�of�chronic�diseases.��
As�the�LHIN�prepares�for�the�next�ten�years�with�an�aging�population,�it�will�be�necessary�to�
think�of�new�or�leading�practice�models�that�help�to�mitigate�the�demands�placed�on�the�health�
care�system�due�to�chronic�conditions.��Part�of�this�mitigation�strategy�will�be�innovative�ways�
to�deploy�health�human�resources,�but�will�also�require�integrated�service�delivery,�especially�
for�chronic�and�longer�term�conditions�that�require�individuals�to�interact�frequently�with�the�
healthcare�system.�
Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �48�© 2008 KPMG All rights reserved�
The�LHIN�has�been�busy�over�the�past�year�and�a�half,�implementing�the�Aging�at�Home�
strategy.��This�strategy�has�largely�led�to�increased�funding�for�community�support�services�
including�projects�that�begin�to�look�at�service�delivery�integration�(e.g.�Doorways�to�Care).��The�
gaps�related�to�seniors�services�revolve�around�service�integration�and�creating�an�integrated�
service�delivery�model.��Gaps�were�also�identified�in�services�that�would�reduce�current�strains�
on�the�emergency�and�alternate�levels�of�care�days�including�rehab,�complex�continuing�care,�
palliative�care�and�supportive�housing.���
As�demonstrated�through�the�data�and�validated�in�feedback�in�focus�groups�and�interviews,�a�
significant�service�gap�in�mental�health�and�addictions�services�exists.��The�chapter�described�
the�difficulty�identifying�the�upper�limit�on�the�estimates�of�that�gap,�but�was�able�to�estimate�a�
minimum�gap�of�3,280�individuals�living�with�serious�mental�illness.��The�services�required�to�fill�
this�gap�cross�a�range�of�community�mental�health�services.��Similarly,�while�it�is�evident�there�
exists�a�gap�in�addictions�and�problem�gambling�services,�the�limits�of�that�gap�are�more�
difficult�to�quantify.���
The�next�section�examines�the�specific�needs�within�each�of�the�planning�areas�from�a�
population�health�perspective.��As�the�gaps�described�in�this�chapter�look�across�the�LHIN,�
these�needs�are�not�uniform�across�each�of�the�planning�areas.��There�are�other�unique�needs�
that�are�also�not�described�here�as�they�are�specific�to�an�individual�planning�area.��