SNAGA Report FINAL Revised Dec 9 08 - Central LHIN/media/sites/central/... · 2015-04-06 · 42.1...

29
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 Care Acute Care Post Acute System Navigation, Case Management and Coordination Prevalence Demand Supply

Transcript of SNAGA Report FINAL Revised Dec 9 08 - Central LHIN/media/sites/central/... · 2015-04-06 · 42.1...

Page 1: SNAGA Report FINAL Revised Dec 9 08 - Central LHIN/media/sites/central/... · 2015-04-06 · 42.1 60.2 56.9 59.0 80.8 130.2 60.8 71.7 75.2 Source: Scott’s Medical Dictionary –

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

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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�

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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�

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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

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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�

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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)

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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

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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

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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

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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�

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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�

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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�

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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.���

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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�

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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.���

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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�

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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�

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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.��

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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.�

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Central�LHIN�Health�Service�Needs�Assessment�&�Gap�Analysis� � �39�© 2008 KPMG All rights reserved�

0

200

400

600

800

1000

1200

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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�

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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�

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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.���

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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�

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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

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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

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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�

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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�

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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.�

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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.��