Figure 1 – Population Projections for Haliburton County, Kawartha Lakes, and Peterborough

Another noteworthy characteristic of Haliburton County’s catchment area profile is the large seasonal population which places significant demands on hospital and local health services especially during the summer months. Figure 2 highlights the impact that the seasonal population has on visits to the emergency department. This data confirms anecdotal information from key stakeholders that the Haliburton County population more than doubles during the summer months.

Figure 2 – Hospital Patient Days and Emergency Department Visits at Haliburton Hospital site, 2006-2009

In terms of planning future health services, an important demographic indicator is the number and proportion of seniors. Compared to the overall demographic profiles for the Province and the CELHIN, Haliburton County’s municipalities have a much older age profile (see Table 2).

Table 2 – Number and Proportion of Seniors (65+) in Haliburton County, 2006

Given the expected numbers of individuals planning to retire to cottage country and the ongoing aging of the baby boomer cohort, this area will age rapidly over the next decade and beyond. The provincial government is forecasting that Haliburton County’s future seniors’ population will eventually exceed 35%. According to the CELHIN,

This demographic bulge expected to peak around 2020 when the leading edge of the baby boomer cohort is turning 75 is worrisome for two reasons:

1.     The prevalence of chronic diseases associated with aging is expected to increase.

2.     Many seasoned healthcare professionals will be planning to retire.

Research has also confirmed that rural residents generally have higher health needs than urban residents and less access to care. This well-documented phenomenon is called the Inverse Care Law. While there are many definitions and indicators of rural, the Ontario Ministry of Health and Long Term Care (MOHLTC) uses the Rurality Index of Ontario (RIO) which has been developed by the Ontario Medical Association. The MOHLTC’s recent review of the Underserviced Area Program (UAP) has concluded that only communities with a RIO score greater than 40 are rural enough to qualify for UAP benefits. All four Haliburton County municipalities are well above this minimum indicator of rurality (see Table 3).

Table 3 – Rurality Index of Ontario (RIO) Scores for Haliburton County Municipalities

Another important socio-demographic factor to consider for hospital and health service planning is the socio-economic profile of the catchment area. Research has shown that individuals and families living in more challenging socio-economic conditions often have higher health needs. Table 4 shows that Haliburton County residents have a lower socio-economic status compared to other areas in the CELHIN.

Table 4 – Socio-Economic Indicators for Haliburton County and Other CELHIN Municipalities, 2006

• More than 57% of lone parents with young families live in poverty.
• 23% of residents rely on welfare and other government sources of income (highest in Ontario).
• 11% of households experience food insecurity.
• Between 4-5% of families use local food banks.

Health Status Information

Consistent with the inverse care law, Table 5 confirms that the catchment area of the Haliburton Kawartha Pine Ridge (HKPR) Health Unit has a higher burden of illness and injury compared to the provincial average, as defined by age-standardized, disease-specific mortality rates.

Table 5 – Mortality Rates for HKPR area Compared to Provincial Average

Haliburton County residents already have higher prevalence rates of various chronic diseases and these prevalence rates are forecast to increase over the next decade and beyond. Recent reports from the Canadian Alzheimer Society and the Heart and Stroke Foundation are particularly noteworthy:

Health System Transformation

Since the development of HHHS’ previous strategic plan, the transformation of Ontario’s healthcare system has introduced a number of significant changes which are important contextual issues for the organization to consider in the development of its revised strategic plan.

This transformation agenda which has been widely articulated by the MOHLTC and all of the LHINs over the last few years includes:

• the creation of LHINs with the legislative mandate to plan, manage, integrate, and fund health services for 14 new geographic regions in the province of Ontario;
• increased emphasis on accountability including the requirement for all hospitals to sign hospital service accountability agreements with their LHIN;
• increased emphasis on performance measurement and reporting, with special attention to quality, patient safety, and cost-effective service delivery;
• more investments in non-hospital services, specifically primary care, community care, and home care services (for example, Aging at Home, Family Health Teams, and others);
• increased emphasis on the prevention and management of chronic diseases;
• greater focus on the determinants of health and the broad range of factors that contribute to poor health outcomes; and
• the development of a more integrated system of health services where patients experience a more coordinated and consumer friendly system.

In response to this health system transformation, hospitals need to be:

• working with other hospitals and healthcare providers on the development of more integrated models of care;
• working with local community partners on healthy community strategies;
• exploring innovative and cost-effective approaches to service delivery; and
• refining performance measurement systems for continuous quality improvement and public reporting of progress.

CELHIN Priorities

HHHS has been actively engaged with the CELHIN since its inception and has sought to incorporate the planning and integration priorities of the CELHIN into the development of this new strategic plan.

In 2009, the CELHIN released its Hospital Clinical Services Plan which focused on the following five areas:

1. Cardiac Services;
2. Maternal-Child-Youth Services (which evolved from Paediatric Services);
3. Mental Health and Addiction Services;
4. Thoracic Surgery Services; and
5. Vascular Surgery Services.

The plan was based on the following overarching principles:

• improving quality and safety by grouping together clinical or medical/surgical specialists, their teams, and appropriate physical resources;
• expanding or creating new programs that would not be viable or sustainable at multiple sites;
• creating operational and clinical efficiencies that would allow hospitals to focus on and improve their core programs; and
• create new centres of excellence to allow CELHIN residents to receive services within the CELHIN and as close to home as possible.

Of particular note to HHHS and its catchment population was the following recommendation as part of the Maternal-Child-Youth Services Model:

The CELHIN has also recently released its second Integrated Health Services Plan (IHSP) for 2010 – 2013. According to the plan, the top three priorities of the MOHLTC and the CELHIN are:

1. reducing wait times in emergency departments;
2. reducing the time patients spend in alternate levels of care (ALC) in acute hospital settings; and
3. improving access to integrated diabetes care.

In addition to these 3 priorities, all LHINs are participating in two additional provincial priorities:

1. enhancing mental health and addiction services; and
2. continuing to build an e-Health infrastructure to support other strategies (for example, electronic medical records, disease registries, telemedicine, and others).

The following are considered priority populations for the CELHIN for the next three years and build on the strategic priorities in the previous IHSP:

• seniors who are in the community at risk of hospitalization and requiring ALC;
• seniors who are in the hospital at risk of transitioning to ALC or suffering an adverse event during their stay;
• seniors requiring comprehensive community-based geriatric care, supportive housing, rehabilitation, or other services to meet their complex needs;
• individuals with a mental illness and/or substance abuse problem who require primary care and community crisis support as an alternative to emergency department visits or hospitalization;
• individuals with a mental illness and/or substance abuse problem who are in the emergency department and require supportive access to hospital in-patient care, outpatient services, peer support, and/or social services; and
• individuals who are at risk of developing a chronic disease or other complications from their mental health or addictions problems.

The new IHSP also introduced the Triple Aim framework for quality improvement in healthcare. Developed by the Institute for Healthcare Improvement (IHI), the Triple Aim methodology is designed to achieve the following three goals:

1. improve the health of the population;
2. enhance the patient’s experience; and
3. reduce (or at least control) the per capita cost of healthcare.

These goals will be achieved by focusing on the following five strategies:

1. focus on individuals and families;
2. redesign of primary care;
3. population health management;
4. cost-control platform; and
5. system integration.

The CELHIN plan has defined the following two system-wide initiatives or strategic aims consistent with the Triple Aim methodology:

Strategic Aim #1: In support of the MOHLTC’s strategic priority to improve emergency department wait times and ALC, the CELHIN will save 1,000,000 hours of time patients spend in Emergency Departments by 2013.

Strategic Aim #2: In support of the MOHLTC’s strategic priority of improving access to integrated diabetes care, and in recognition of the significant CELHIN investments in chronic disease prevention, early detection, self-management, and effective and equitable access to treatment such as stroke care, the CELHIN will reduce the impact of vascular disease by 10% by 2013.

Alignment of HHHS Strategies with MOHLTC and CELHIN

HHHS’ strategic priorities to improve access to core rural health services, enhance seniors’ care, and focus on prevention and health promotion activities will help meet the MOHLTC’s top three priorities of reducing ER wait times, reducing ALC days, and improving access to integrated diabetic care, and the CELHIN’s Strategic Aims of saving 1,000,000 hours of time patient spend in ERs and reducing the impact of vascular disease by 10%.  HHHS’ strategic priorities of sustainability, building partnerships, and employee engagement will support the three goals of the CELHIN IHSP’s Triple Aim framework to enhance the patient’s experience, reduce or control the per capita cost of healthcare, and improve the health of the population.

Opportunities for Small Rural Hospitals

While the transformation of the health system is not without its challenges for small rural hospitals, system change also represents opportunities for HHHS. Some of these potential opportunities include:

• repatriation of certain types of patients based on the principle of care closer to home  where small hospitals can support earlier discharge from larger centres and/or where the evidence indicates that small hospitals can provide the care more cost effectively than the larger referral centre;
• implementation of more satellite services from larger centres (through visiting specialist clinics and telemedicine);
• greater use of a full range of e-Health strategies (for example, telemedicine, electronic medical records, and others) to improve access and reduce travel for rural residents;
• utilization of unused capacity in small hospitals to help with provincial/CELHIN priorities (such as reducing wait times);
• creation of diagnostic centres of excellence so that rural patients do not have to have tests repeated when they are hospitalized in larger centres;
• development of innovative human resource strategies in partnership with other local healthcare providers, including training, recruitment and job-sharing;
• greater integration of acute, primary care, and LTC services; and
• development of new partnership models with the Community Care Access Centre (CCAC), community health services, and public health.

Highlights of Staff and Stakeholder Consultations

Staff Consultations

As part of HHHS strategic planning process, all staff members were provided the opportunity for input based on an online survey with the following questions:

1.     What do you believe HHHS should change or do differently in order to address the current or emerging needs of our community and the ongoing changes in our healthcare system?

2.     A Vision Statement is meant to describe our hospital’s future and provide inspiration in terms of where we’re going as an organization and the future impacts we hope to have. The current Vision Statement for HHHS is: “Excellence in all we do”. Do you think this statement is suitable for HHHS or needs to be revised?

3.     HHHS offers core Hospital, Long Term Care, and Community Programs including Supportive Housing, Mental Health, and Diabetes Education. Are there any additional services that HHHS should consider providing in the future?

4.     What do you see as future business or service opportunities for HHHS in terms of partnerships with other healthcare organizations?

Highlights from staff responses are as follows:

Change or Do Differently in Order to Meet Changing Needs

• Amalgamate emergency departments and consolidate LTC.
• Improve connection between emergency departments and mental health services.
• Reduce nursing management.
• Place additional Registered Nurses in the emergency departments.
• Increase front-line staff.
• Increase LTC beds.
• Increase use of telehealth (OTN).

Recommended Additional Services for HHHS

• Acquire CT scanner and ultrasound to reduce patient travel.
• Expand mental health program so it can provide evening and weekend coverage.
• Increase LTC capacity at both sites.
• Introduce cardiac rehabilitation and respiratory services.
• Full-time laboratory services.
• Establish local transport links to facilitate local access to health services.
• Dialysis services.
• Expand palliative program.

Future Partnership Opportunities

• Partnerships with psychiatric service providers.
• Partnership with Public Health.
• Connect better with medical schools.
• Expand partnerships north (instead of south) to leverage new opportunities (for example, Huntsville, North Bay).
• Build assisted living apartments next to LTC homes.
• Build fitness centre for staff and community.
• Contract with rehabilitation providers to reduce pressure on HHHS services.
• Victoria Order of Nurses foot care.
• Enter into buying groups (bulk purchasing) with other local healthcare partners.
• Create local drug and alcohol rehabilitation centre.

Stakeholder Consultations

As part of the HHHS strategic planning process, facilitated focus group discussions were held on October 29, 2009 with key stakeholder groups in order to get their input regarding current challenges and opportunities for the organization (see Appendix A). Highlights of feedback from stakeholders are as follows:

Community Perceptions of HHHS

• Most refer to HHHS as a hospital even though it has worked hard to develop an integrated rural health facility with a range of programs.
• Many respondents commented on high quality care and caring.
• Many felt there had been a tremendous turnaround at HHHS because of the new Chief Executive Officer (CEO).
• Community interaction and communication is improving but Board members need to play a more proactive role.

Challenges Facing HHHS

• Financial challenge of operating two sites.
• Trying to provide acute care and LTC in both communities.
• Our location is more remote than rural.
• Major socio-economic discrepancies in this area.
• Growing seniors population including retiring cottagers.
• Lack of primary care; need more doctors.
• Most emergency departments visits are non-urgent.
• No CCAC referrals from Minden site.
• No wireless capacity.
• No strategy for developing new services.

Key Opportunities for HHHS

• Partner to create additional LTC capacity.
• Show leadership in providing seniors care.
• Personalized touch is our strength.
• Better marketing of existing services.
• Small communities have the ability to work better together, especially with fewer resources.
• HHHS needs to tackle system advocacy issues.
• Time to revisit HHHS’ integrated care model - how do we build/expand upon it?
• Do we need to let go of certain community services (such as supportive housing) in order to focus on hospital services?
• It is time to consider one acute care hospital?

New Services for HHHS

• New collaborative model with midwifery for low-risk obstetrics.
• More comprehensive system of palliative (end-of-life) care.
• Day Hospital for seniors including geriatric assessment.
• Better use of telemedicine.
• More diagnostics (ultrasound).
• More timely access to laboratory results.
• Increased access to dental care – partnership with Health Unit.
• Greater use of Nurse Practitioners in LTC and emergency departments.
• Expand diabetes program.
• Create a cardiac rehabilitation unit.
• More pre-op and post-op work in collaboration with big hospitals.
• More specialist clinics (outreach and telemedicine).
• More satellite services.
• Create an information kiosk for patients.
• Better use of wireless technology – bedside documentation.

Priorities for new Strategic Plan

• Mental health for children and adults.
• Physician recruitment.
• Telemedicine.
• Ongoing involvement of community partners including Haliburton Service Provider Network.
• Greater community input to HHHS decision-making process.
• HHHS participation in more community events.
• Strengthened clinical partnerships with Public Health, Family Health Team, and CCAC.
• Clinical service agreements with Lindsay and Peterborough hospitals.
• Collaborative ventures with Foundation and other funding partners.
• Clear implementation plan with specific targets and reporting to the public.
• Establish criteria/process for evaluating new service opportunities.

Acknowledgements

1.       Strategic plan development process facilitated by Mr. Jim Whaley and HHHS CEO Mr. Paul Rosebush.

2.       Revised mission, vision, values statement facilitated by Warren Faleiro.

3.       Report prepared by Mr. Jim Whaley, HHHS CEO Mr. Paul Rosebush, and the HHHS Board of Directors.

4.       HHHS Board of Directors:

Appendix A – Stakeholder Focus Groups

Haliburton County stakeholders were invited to participate in the HHHS strategic planning process. Invitations were sent to a wide variety of groups and the following organizations responded.

HHHS also received valuable feedback from individual citizens who wrote directly to the organization. 

HHHS staff input into the development of priorities was gathered through an employee survey and through feedback gathered at staff meetings. 

Focus Group #1 - County Representation

• Eleanor Harrison, Reeve, Algonquin Highlands
• Murray Fearrey, Reeve, Dysart et al
• Peter Oyler, Councillor, Minden Hills

Focus Group #2 - Healthcare Providers

• Connie Wood, Healthy Living Program Coordinator, Family Health Team
• Fiona Kelly, Director, Family Health, HKPR District Health Unit
• Jane Rosenberg, Executive Director, Extendicare
• Pat Kennedy, Executive Director, Emergency Medical Services
• Kim Ballantyne, Regional Manager HKPR Hospitals, Central East CCAC
• Rebecca Weeks-Toth, Midwifery Services of Haliburton-Bancroft

Focus Group #3 – Physicians

• Dr. Steve Ferracuti, Chief of Staff
• Dr. Norm Bottum, President of Medical Staff
• Dr. Mike Armstrong
• Dr. Scott Coles
• Dr. Kristy Gammon
• Dr. Karl Hartwick

Focus Group #4 - Social and Community Service Providers

• Gena Robertson, Executive Director, SIRCH
• Donna MacDonald, Executive Director, Community Care
• Elena Bjelis, Director of Services, Community Living
• Terry Goodwin, Probation Services
• Terry Hartwick, Co-Chair, Mental Health Advisory Committee
• June Partridge, Mental Health Advisory Committee
• Julie Goodwin, Executive Director, Highlands Community Pregnancy Care Centre
• Andy Campbell, Manager, Haliburton County Development Corporation
• Marilyn Rydberg, Hospice
• Jane Rosenburg, Executive Director, Extendicare
• Marg Cox, Executive Director, Point in Time (Family Services)

Focus Group #5 - Fundraising Partners

• Dale Walker, Executive Director, HHHS Foundation
• Peter Oyler, HHHS Foundation Board Chair
• Lisa Tompkins, HHHS Foundation Board Vice-Chair
• Dave Coulson, HHHS Foundation Board Member
• Judy Skinner, President, Haliburton Auxiliary
• Bob McKay, Haliburton Auxiliary

Question for Key Stakeholders

1. What is the community’s perception of this healthcare corporation? What do people say about it? How would you describe HHHS’ reputation?
2. What do you see as the key challenges facing HHHS in the next few years? What do you see as future opportunities for HHHS?
3. HHHS currently offers a wide range of healthcare services (including acute care, emergency care, LTC, and community programs). What new services should HHHS consider providing in the future?
4. What do you see as future business or service opportunities for HHHS in terms of partnerships with other healthcare organizations?
5. If hospitals do not receive additional funding in the next few years, what do you think HHHS should change or do differently in order to continue to meet the emerging health needs of the community?
6. HHHS’ previous strategic plan had six priority areas. Do you think those six priorities are still important? Are there additional priorities that HHHS should consider in its new strategic plan?
7. What do you think of HHHS’ current vision statement, Excellence in all we do?
8. Overall, what would you say are the corporation’s greatest strengths and weaknesses?