Local Collaboratives: Building Healthy Communities Informed by Population Health Planning

The Toronto Central LHIN recognizes that different areas within the LHIN have different needs. That’s why we established five sub-regions to serve as the focal point for population-based planning, service alignment and integration, and performance improvement. We also recognize that many populations, particularly high needs ones, require cross-sector partnerships in order to significantly improve their health outcomes. To foster these partnerships we have established Local Collaboratives within each sub-region, and this is where the magic happens—where we can really start to see local health care based on local needs taking shape.

During our recent winter Local Collaborative sessions, more than 300 providers, partners and members of our citizens’ panel came together as part of our ongoing efforts to develop a deeper understanding of the neighbourhoods and populations within each sub-region.

At these meetings participants were asked to assess their local sub-region on a variety of factors to determine where their sub-region was on a “maturity model” scale. The maturity model ranges from one to five, with five being an ideal state in which, for example, patients have coordinated care plans, community-based services are connected and local teams work together to provide the best possible outcomes based on clear population-based metrics and goals. Interestingly, each sub-region assessed itself as being at the same level—Level Two. Our expectation was never that each sub-region would be at Level Five already—in establishing the Local Collaboratives, our goal was to put in place the mechanism to help get us all to Level Five. Now, because of the thoughtful participation of everyone who attended, we have an even clearer sense of how to get there—and we’re making progress already.

One of the biggest undertakings of the Local Collaboratives so far has been the participation of each cross-functional teams from each sub-region in the IDEAS Advanced Learning Program.  IDEAS is a provincial program that trains health system professionals in quality improvement by supporting them through the planning and implementation of a quality improvement project. Starting last July, the five Sub-Region teams participating in IDEAS used data from the Toronto Central LHIN’s analytics team to identify areas of high population need that would be targeted for improvement. These projects all involved multiple partners and providers working together to implement improvements that meet local needs—they are the very definition of what Level Five looks like, and it’s incredibly exciting to see this work in action.

Each team developed an ambitious aim statement:

  • In the West Sub-Region: To offer arthritis chronic pain self-management psycho-educational sessions to Rockcliffe-Smythe neighborhood residents. All attendees will receive follow-up from community partner agencies to ensure connectivity and appropriate linkages to community resources.

  • In the Mid-West Sub-Region: To increase primary care attachment for young women ages 20-24 in Kensington-Chinatown by 50 individuals by June 2018 as measured by new enrollment at local CHCs and FHTs

  • In the North Sub-Region: To reduce rate of caregiver distress to seniors living alone as couples; 75 years of age and over in the Mount Pleasant West neighbourhood by 25% by June 1, 2018

  • In the Mid-East Sub-Region: To meaningfully connect 10 individuals living in Moss Park who self-identify as homeless and living with mental health and/or addictions issues to a continuing care provider to address their ongoing health and social needs by March 1, 2018

  • In the East Sub-Region: By March 31, 2018, 10% of individuals presenting with mental health and/or addictions concerns/issues to the Crisis Team in the ED at Michael Garron Hospital in the Oakridge neighbourhood will be connected to an appropriate community agency within 7 days of their visit

These projects are at varying stages of completion, but once they have all been evaluated and any refinements made based on what they’ve learned, the ultimate goal is that these solutions will be scaled and spread. We at the Toronto Central LHIN are excited to see the outcomes of these projects, but we are even more excited to see our partners working together, with each other and with our providers. 

Winter Local Collaborative