This year has presented unexpected and extraordinary challenges across East Toronto Health Partners (ETHP), encouraging our members to work together in ways that have strengthened our partnership and forwarded our goal of co-designing and delivering an integrated system of care across our communities.
In addition to our collective efforts in slowing the spread of COVID-19 in East Toronto — both on and beyond the frontlines — we’ve made great strides in other areas in our inaugural year as an Ontario Health Team (OHT).
These accomplishments span ETHP’s three priority population working groups for Year 1 and our many work streams and committees that have come together in 2020 to address the immediate health and social needs of our communities — all while keeping an eye to the future.
Steering committee for improving care for seniors who have chronic illnesses, and their caregivers
Developed partnership with Toronto Community Housing Corporation
Organized data collection to inform and coordinate home care resources
Received support from ETHP’s Hub program for homebound seniors and their families
Steering committee for improving care for youth who need support for mental health and wellness
Over the past eight months, members of the ETHP Youth Engagement Sub-Committee have been working to develop a youth engagement model to assist in supporting the development of youth mental health initiatives within our OHT.
We were tasked with identifying a group of youth leaders whose role will be to work with and inform three ETHP working groups (steering committee, primary care and SCOPE) as they relate to youth mental health. Accomplishments to date towards this aim include:
Engaging three staff champions to work with youth in Taylor-Massey, Jones/Danforth and Thorncliffe Park/Flemingdon Park. These staff champions have each recruited two youth leaders from each of these neighborhoods. In addition, they have committed to remaining involved to help support the youth leaders’ participation within the three working groups;
Recruiting six youth leaders to be dispersed between three Youth Mental Health working groups;
Selecting a coordinator to provide essential support to the six youth leaders over the next 10 months through preparation/orientation for participation in the working groups, administration of honorariums and facilitation of monthly debrief meetings with the youth leaders and staff champions.
Steering committee for improving care for adults with needs related to substance use and addictions
Collaborated across ETHP to build beds for women at MGH’s residential withdrawal management centre, support ongoing work at the Oakridge Health and Harm Reduction Hub during the pandemic and begin work on an overarching addictions strategy
Improved hospital care for people who are pregnant and use substances through work with SRCHC’s MATCH midwives and MGH’s addictions physician lead and Maternal Newborn and Child program
Recalibrated our ETHP Strategic Priorities for 2020-2022
When we launched our OHT in December 2019, we had identified a set of priorities for our first year focused on integrating care for our three priority populations (seniors with chronic illnesses and their caregivers, adults with needs related to substance use, and youth mental health and wellness) as well as developed plans for digital health and communications. COVID-19 required us to revisit these priorities as we refocused our efforts on supporting our patients, communities and partners through the pandemic.
When the COVID-19 rates dropped during the summer months, we used that time to assess how the pandemic was impacting our partnership, our OHT priorities, our integration efforts and our new future state. With the help of our partners, patients and caregivers, we developed a revised strategy that identifies the following four key priorities for our partnership:
Accelerate integrated care across our partners
Expand our shared efforts to manage the COVID-19 pandemic and prevent/control infection
Engage our patients, caregivers and communities at every level of our work
Advance population health and reduce barriers to health equity
The new strategic plan better reflects the collective work we now need to do with our East Toronto residents and partners to address COVID-19 and to battle systemic racism and health inequities in our communities. We will also accelerate our efforts to better integrate health and social care and engage patients, caregivers and community members as partners in all of our work.
Documented our work together during COVID-19
The collective of 50-plus organizations that make up ETHP has been working together to reduce the spread of COVID-19 since the beginning of the pandemic. We were among the first regions to set up a COVID-19 assessment centre, provide on-site interprofessional support for our long-term care home partners, provide rapid access to testing for vulnerable populations in shelters and group homes, arrange for donations of masks and other PPE and share these among our partners and community residents, set up community pop-up testing sites staffed by community primary care, share our incredible infection and prevention control resource team at Michael Garron Hospital (MGH) with East Toronto, and set up a school support plan.
The incredible partnership and deep relationships in East Toronto inspired us to share the important lessons of our work together through an initial leadership essay in March 2020 as well as a longer thought leadership article published in October 2020 to help advance policy changes in Ontario.
Established a process to evaluate our work as an OHT
While we believe our partnership has tremendous capacity and potential for collective impact on healthcare in East Toronto, we also recognize that we will only know the degree to which positive change is happening by formally evaluating our efforts. We are very pleased that we have the support to do this through a partnership with the University of Toronto to establish an embedded evaluation research position.
As our evaluation lead, Dr. Sara Shearkhani will be working side-by-side with our teams to help us understand and measure the impact of our initiatives and report on our progress. In December 2020, we launched an Evaluation Steering Committee that includes patient and caregiver partners who will be working with us to design our evaluation plan.
Met the requirements to receive funding from the Ontario Ministry of Health
We were very pleased with the announcement this past summer that the Ministry of Health would be providing implementation funding to support the work of OHTs. Many of our partners have been providing in-kind resources and funding to support our work to date so the announcement of funding, particularly during the pandemic, was particularly welcome.
To receive the funding, we were required to demonstrate that we have an agreement in place among our partners that addresses important issues, such as patient, caregiver and physician engagement; shared decision-making; management of funds; commitment to quality principles; and dispute resolution.
We submitted an attestation that all of these requirements were in place as part of the ETHP Joint Venture Agreement that was signed by partners December 2019. Following this, we were asked to identify three critical metrics through which we can demonstrate accountability for making progress with the support of the Ministry’s funds. The metrics we chose align with the Quadruple Aim as follows:
Patient Experience: patient and caregiver experience with care received through our Home 2Day program. Home 2Day is a hospital-to-home integrated care pathway we have developed for our seniors and complex/chronic illnesses Year 1 priority population. It is a targeted intervention for individuals with COPD and now expanding to CHF and pneumonia.
Provider Experience: the percentage of East Toronto family physicians who are connected with the East Toronto Family Practice Network (EasT-FPN). This is a measure of our progress on family physician engagement within our OHT work through our new family practice network partner.
Population Health: the number of congregate care settings in East Toronto with integrated infection and prevention control (IPAC) support to control the spread of COVID-19, influenza and other infectious diseases. Given the extensive partnership work we are doing to expand integrated IPAC support to settings at high risk for COVID-19, this is a measure of the extent to which we have established IPAC connections and supports for shelters, long-term care (LTC) homes, group homes and retirement homes across East Toronto.
The funding received from the Ministry of Health will support the OHTs to March 2022. The ETHP will need to demonstrate our accountability for this funding by providing progress reports on our performance between now and March 2022.
Community Surge Working Group
Allocated $1.1 million to fund 13 partner projects across East Toronto with goal of ensuring patients are able to receive the right care in the right setting
Coordinated efforts including targeted flu vaccination clinics, enhanced mental health supports, expanded primary care clinics, a mobile phone equity project and a caregiver support program
Mitigated impacts of COVID-19 on ETHP services by connecting individuals in need who test positive with isolation resources and providing mobile IPAC support
Patient & Family/Caregiver Advisory Committee (PFAC)
Developed Terms of Reference
The PFAC has developed a Terms of Reference that outlines information such as the group’s mandate, membership and structure and accounting and reporting guidelines. This evolving document will help guide the PFAC’s meetings, work and role in ETHP moving forward, especially as its membership grows in the New Year.
Launched recruitment work
This year, the PFAC began work on a robust recruitment strategy that will see project manager Yordanos Woldemariam conducting community outreach and engagement in 2021 to ensure our PFAC is reflective of the diverse communities we serve. This group will continue to guide inform ETHP’s vision, guiding principles and goals while ensuring the voices of patients, caregivers and families are central in our co-design of an integrated system of care.
Engaged meaningfully throughout ETHP
Our PFAC members have had the opportunity to contribute significantly to ETHP’s work throughout the year, including at the leadership table where two representatives from our PFAC have been voting members, alongside partner CEOs, since our OHT was formally approved in December 2019. ETHP’s commitment to engaging patients, families and caregivers at every stage of care planning and delivery ensures these important voices are recognized and heard. It also ensures that our integrated system of care is co-designed with the people who will most directly benefit from it.
East Toronto Family Practice Network (EasT-FPN)
Scheduled hundreds of shifts for our family physicians to staff MGH’s COVID-19 Assessment Centre and ETHP’s nine pop-up testing sites
Supported ETHP’s Hub program’s coordinated care teams by providing home visits and virtual primary care to patients who are elderly and homebound
Conducted outreach to long-term care facilities and retirement homes to provide support during the pandemic through advanced care planning and infection control
Primary and Community Care Response Teams: Communications and Outreach Working Group
Established plan to increase awareness of and referrals to our Hubs, which have been one of the most active ETHP initiatives during COVID-19 and serves as a scaffold for other integrated service delivery models within ETHP
Recruited more than 20 organizations and generated more than 100 referrals into the program through our community outreach
Began work on a one-page flyer and partner presentation to increase our outreach and engagement efforts in 2021
Digital Steering Committee
Completed significant behind-the-scenes work
As you can imagine, creating a connected digital ecosystem for ETHP is not an easy feat. The Digital Steering Committee (DSC) has been doing some behind-the-scenes work to pull things together. In addition to creating the digital health strategy and receiving a renewed commitment from partner CEOs, we also completed a bird’s eye view assessment of back-office IT solutions being used across ETHP.
While we recognize IT changes cannot happen overnight, understanding each organization’s assets is a move in the right direction. Furthermore, with the OHT funding that was announced by the Ministry of Health in August, the DSC was able to put together a funding allocation plan which aligns with our overall strategic vision. One of these projects that was approved was the digital health micro-initiatives.
Secured funding for digital health micro-initiatives
The DSC recently launched an innovative approach to supporting primary care providers to be more digitally connected. We have made available some seed funding for East Toronto family practices and ETHP organizations with proposals for digital health micro-initiatives.
The approved projects will align with ETHP’s digital health priorities, such as connecting providers and improving patient digital access and solutions for local priority populations. These small tests of change have the potential to impact our communities. We hope to update you more about the progress in the New Year when projects are underway.
Expanded access to Hypercare
Another way we are working to create a digital ecosystem for ETHP is to improve connectivity and communication across healthcare providers in East Toronto with the expansion of Hypercare.
Initially a tool used by Michael Garron Hospital (MGH) staff to communicate securely and coordinate patient care, the secure messaging platform has been quickly expanded to over 500 healthcare professionals across East Toronto to capitalize on early successes and in response to COVID-19.
Family physicians and specialists have been able to use Hypercare to consult and coordinate patients’ ongoing care, helping to prevent unnecessary Emergency Department visits. Family physicians are also able to see who is on call at MGH and contact them directly through Hypercare. This was demonstrated when a staff member messaged the general surgeon on call via Hypercare about a G-tube that was leaking. The surgeon replied with an instructional video and offered to go to the patient’s home to fix. Home care was able to step in here, using the video to fix the G-tube and preventing the patient from being sent to the ED.
The platform has also proved valuable with discharge planning. It has connected physicians with primary care to arrange for appropriate follow-ups, especially in situations where the hospital is over capacity. One example of this is when a family doctor contacted a urologist about a shared patient via Hypercare. The urologist arranged urgent imaging and surgery, but the first surgery for the patient was cancelled because the patient had a cough.
The urologist was able to contact the family doctor via Hypercare to arrange an urgent follow-up on the patient. After surgery, the urologist contacted the family doctor to follow up on the patient’s symptoms. Two-way communication prevented ED visits for this patient and allowed the family doctor and urologist to provide more comprehensive and coordinated care while not duplicating testing.
Introduced clinical case management tool
Another project that the DSC has undertaken over the last several months is the commitment to exploring tools that can improve coordination on patient cases. The purpose of this project is to enable seamless collaboration and communication among a patient’s interdisciplinary care team.
Through piloting a digital customer relationship management (CRM) solution, we hope to create a central point of access to key patient information for providers and allow providers to communicate and collaborate effectively across ETHP partners to enhance clinical care.
This project is still in its infancy stages, but we are in the process of exploring pilot sites to implement and evaluate potential solutions that have demonstrated success in other health contexts. The pilot is expected to begin in early spring 2021.
We are extremely proud of the hard work that the DSC has put forth in 2020 and look forward to keeping you updated on our progress. If you have any questions, please contact Alistair Forsyth, chief information officer at VHA Home HealthCare, at aForsyth@vha.ca.
Updated MyChart sign-up process
One of ETHP’s digital health priorities is to improve patient access to data. The Michael Garron Hospital (MGH) Health Records department worked tirelessly to improve the patient sign-up experience throughout COVID-19.
Prior to the pandemic, patients interested in signing up for MyChart would have to physically visit the Health Records department to obtain a consent form. After completion, the team would begin the sign up process. Because of the pandemic, having patients physically request a sign-up form proved impractical. As a result, the Health Records team continuously improved the MyChart sign-up process. Several initiatives were undertaken, including the creation of a designated e-mail for the team to communicate with patients.
Since many in-hospital visits were conducted online during this time, it became mandatory to collect the patient’s e-mail address. This allowed the Health Records team to be proactive in encouraging new sign-ups. Finally, patients were also encouraged to sign up to MyChart when they visited MGH’s COVID-19 Assessment Centre. The team continues to seek new ways to reach out to patients, including updating the corporate website.
These initiatives have had a significant impact on the number of active MyChart users. We have seen an increase of almost seven times the sign-ups since summer 2019!
Best Practice Spotlight (BPSO) OHT Steering Committee
Affirmed commitment to best practices in Person- and Family-Centred Care
In late February 2020, frontline providers came together from 15 ETHP organizations, together with patient and caregiver participants, for a joint champions training in Person and Family-Centred Care (PFCC). This kicked off our work as a Best Practice Spotlight OHT and energized our frontline staff around our work as an OHT.
Launched introductory eLearning modules for PFCC
In November 2020, we launched our introductory eLearning modules for PFCC. Champions and leaders from Michael Garron Hospital (MGH) were the first group invited to complete training. Now plans are underway to extend the training to frontline staff across partners in our BPSO OHT in early 2021.
The module has been made available for online completion for anyone interested, and has been posted to the ETHP website for those wishing to download the module to import into an organization’s learning management system.
The iLearn module will help teams to have a common understanding and framework around PFCC. It also orients our frontline team members and managers to our vision and collaborative activities as ETHP.
Established infrastructure for advancing as a BPSO OHT
In our first year as a BPSO OHT we needed to establish our structures and supports for our four-year BPSO OHT partnership. We established a steering committee that meets monthly to advance our work.
Our four primary partners signed on to the NQUIRE data system where we’ll track our best practice implementation data across East Toronto. Data will be added to NQUIRE starting in early 2021, based on the data collection plans we’ve created.
Timelines for our four-year partnership have been adjusted based on the realities of the pandemic and the release date for the Registered Nurses’ Association of Ontario’s (RNAO) updated Best Practice Guideline for Care Transitions in 2022.
Launched and coordinated ETHP’s branding project
Working with Randal Boutilier, principal and creative director of 12thirteen Design, the ETHP Communications Committee embarked on a branding project for ETHP in September to determine a new visual identity that reflects our collaborative services, programs and people. We engaged more than 120 ETHP members through six branding focus groups and two online branding surveys. Through these channels, we gathered insights and feedback that were used to develop nine potential visual identity options, which were then narrowed down to three.
ETHP’s branding project presented an opportunity for our partners to come together and discuss what partnership and East Toronto mean to them. These discussions emphasized and reminded many members of ETHP’s collective goal: to create an integrated system of care across our communities that prioritizes people and collaboration. We were happy to have had this opportunity to engage members in this way and look forward to finalizing and launching ETHP’s new visual identity in the New Year.
Supporting the launch of ETHP’s website
This summer, the ETHP Communications Committee worked closely with Northwest Healthcare Properties and Magenta Health to create ETHP’s first-ever website. The website began as a place to host and share COVID-19 resources with our partners, clients and community members, but has since grown to encompass much more. It now shares information about ETHP’s journey in becoming an OHT; our guiding principles and Year 1 plans; and our patient, family and community engagement initiatives.
The ETHP website is also home to a Newsroom, which we update monthly with stories that highlight our people and the collaborative work being done across our partnership. This year, we collaborated with our partners to write more than 20 stories about our programs, services and people. The Newsroom is also a place where the Communications Committee shares positive media coverage of ETHP. More than 45 positive media stories were published about or mentioning ETHP this year.
These efforts help bolster the profile of ETHP within East Toronto, the GTA region and beyond. It illustrates, shares and documents the important work being done across our partnership and aids in keeping partners and clients informed. We look forward to building on the ETHP website with a website refresh that will reflect our new visual identity in the New Year.
Coordinating media outreach and support for ETHP’s pop-up COVID-19 testing sites
ETHP opened nine temporary COVID-19 testing sites in East Toronto this year. To help raise awareness of these sites to residents of priority neighbourhoods in East Toronto, the ETHP Communications Committee developed and executed a media outreach strategy. The temporary testing sites were covered or mentioned in a number of local, regional and national media, including the Toronto Star, the Globe and Mail and Toronto.com.
We also worked with ETHP member WoodGreen Community Services to coordinate media coverage in Omni News. WoodGreen identified Arabic- and Cantonese-speaking spokespeople who were able to speak to this initiative in their native languages. The news segments aired on Omni News’ Arabic, Cantonese and Mandarin newscasts, helping to ensure that news of ETHP’s temporary COVID-19 testing sites were able to reach our communities in the languages they speak.
We are particularly proud of this accomplishment because of what we were able to achieve within a limited timeframe. This work helped increase access to COVID-19 testing in priority neighbourhoods in East Toronto, a vital strategy for identifying COVID-19 cases and preventing community transmission. This work also helped bolster the profile of ETHP and was an example of our OHT coming together to provide care for our communities.
Collaborative Quality Improvement Plan (cQIP) Working Group
Adopted Common Quality Improvement Indicator across seven ETHP organizations
In spring 2020, we were able to formalize a Common Quality Improvement Indicator within the board-approved Quality Improvement Plans (QIPs) of seven ETHP member organizations:
Michael Garron Hospital (MGH),
VHA Home HealthCare (VHA),
South Riverdale Community Health Centre (SRCHC),
WoodGreen Community Services,
Providence Health (Unity Health Toronto),
South East Toronto Family Health Team (SETFHT), and
Bridgepoint Family Health Team.
The Collaborative QIP Indicator served as a key step in advancing a more integrated approach to quality and evaluation across the continuum of care for ETHP. In December 2020, we learned that all OHTs will be required to establish Collaborative QIPs by March 2022. We are pleased to have been able to take this step two years before it was required!
Presented maturity model for our integrated Quality Improvement journey
In summer 2020, our working group became more established as Laurie Bourne (MGH) and Kathleen Foley (SRCHC) accepted to serve as inaugural co-chairs for the ongoing work. They presented a maturity model for our integrated quality improvement journey which has proved useful to our planning and has been acknowledged and recognized by Ontario Health (Quality) as a helpful framework.
Began CQIP planning for 2021
In spite of the pandemic and many changes that took place through 2020, the work and commitment to the Collaborative QIP has remained strong. In December 2020, our seven organizations came together again to start the process for evolving our Collaborative QIP in 2021. The engagement and consultation process for next year’s QIP will continue over the next three months.
Anti-Black Racism Committee
Formed committee with ETHP partners and two community members
Developed Terms of Reference outlining group’s mandate, membership and structure, and accounting and reporting guidelines
Prepared for launch of OHT-wide survey in 2021, the responses from which will inform our workplan for ETHP