2015/16

Constant Caring in
a Year of Change
Mississauga Halton CCAC
2015/16
Annual Report to the Community

Board of Directors’ Message
We govern in interesting times
On behalf of the Mississauga
Halton CCAC Board of
Directors, we are proud to
volunteer our skills and leadership to represent
the health needs of people across our region. We
invite you to read a summary of our role on page
30 of The Faces of Care.
Welcome to our 2015/16 Annual Report to our
Community. It was an extraordinary year for
several reasons.
1. We launched a new Strategic-Plan 2015-2020
that makes “people the point of care” and
focuses on:
• Making Meaningful experiences and
outcome for people
• Modernizing the health system
• Mobilizing professionals and technology to
make health care work for people
2. We oversaw the responsible use of funds
and achieved a balanced budget despite
an increase of 13 per cent of patients with
complex care needs; and we earned the
confidence of 95 per cent of patients who
would recommend our organization to family
and friends.
3. We received and responded to the proposal to
change health care at home, entitled, Patients
First: A Proposal to Strengthen Patientcentred
Health Care in Ontario, released by
the Ministry of Health and Long-Term Care on
December 17, 2015. That proposal calls for the
elimination of the CCAC Boards of Directors.
On behalf of patients and caregivers in this
region, we are building on our history of
collaboration with our LHIN Board colleagues
that began in 2013. Since January 2016, we’ve
re-focused our attention on the Patients First
discussion paper. If the ministry’s proposal
is implemented, we will use our governance
expertise to ensure stability in the system during
the transition for patients and for our teams of
dedicated staff.
As we continue our leadership in 2016/17, we
remain focused on governing this outstanding
organization, while educating decision-makers
to better understand what is required to care
for patients in our community today and for
the forecasted exponential growth of patients
in the future. As experienced governors of the
Mississauga Halton CCAC, we are using our vital
insight to protect patients through this significant
proposed change.
Dieter Pagani, Chair,
Mississauga Halton CCAC Board of Directors
Roshan Sapra Don Taylor
Rhonda Lawson Laurie Cabanas Rhonda Chou Kareen Hall-
Clarke
Ray Gilbert Steve Heck Frank Kelly Sona Khanna Ebere Morgan Erika Domijan
2
Community
Member

CEO’s Message
Focus on care our constant in a year of change
We learn our strength
when we are challenged
with change. I experienced
and thrived through changes in health care
throughout my career, from my beginnings as a
nurse to executive positions in acute care and to
my role as CEO of the Mississauga Halton CCAC
for the past six years.
It is with tremendous pride that we look on fiscal
year 2015/16 as a year that we enhanced our
ability to “make people the point of care.” With
our unwavering focus, we cared for a total of
48,000 patients, serving 1,369 more people in
our region than in the previous year. We were
not distracted by proposed changes to the CCAC
sector. Indeed, we realized an increase of 27 per
cent positive employee engagement, as all teams
continued to focus on caring for patients.
The past year also saw our CCAC achieve
enhanced care coordination and effective
collaboration. I am proud to highlight just four of
our accomplishments.
1. Our Care Coordination Program of Work
is the most significant change we’ve ever
undertaken to enhance the care and support
that patients and caregivers experience;
I invite you to read the overview and watch
the video featured on page 5.
2. Insights is a game-changer for helping our
care coordinators keep a crucial line of sight to
each of their patients.
Insights is
much
more
than a simple dashboard; it is an evidencebased,
real-time, customized summary of each
patient, helping us to better manage the many
aspects of each patient who is in our care.
3. In partnership with the Primary Care Network
and our LHIN, we developed a primary care
provider data base. The first of its kind in
Ontario, the data base is an accurate, single
source of primary care providers working
across our region, including up-to-date
physician profiles. This tool also enables direct
communication to physicians’ offices to
share important patient information in
real time.
4. Another innovation, DocSearch, is a medical
specialist electronic compendium that helps
primary care providers know which specialists
are in their region and available for referrals to
see their patients.
Thriving in ambiguity also means contributing
our expertise and experience to inform important
proposed changes in our health system. We
produced an organizational overview to help
leaders making changes to our health system
understand that “it takes a team to care for
patients.” We are pleased to share The Faces of
Care with you.
As we celebrate the care we provided to
patients and families in 2015/16, we continue
in 2016/17 with the next phase of our Care
Coordination Program of Work – care
coordinator and contracted service provider
neighbourhood realignment, which will provide
greater consistency and closer collaboration with
patients and families. We will also expand our
vital partnerships with health care organizations
throughout our region in pursuit of our goal
of an integrated, sustainable system of care
implemented for people in this region and
beyond.
Sincerely,
Caroline Brereton, CEO,
Mississauga Halton CCAC
3

Care Coordination Program of Work:
“Making People the Point of Care”
Through our innovative Strategic Plan 2015-2020
initiative, the Care Coordination Program of
Work, we completed an extensive, evidencebased
professional practice re-design of our
care coordination approach to better meet the
needs of all patients in the Mississauga Halton
region, including those enrolled in Health Link.
Our new rigorous, enhanced care coordination
ensures that patients receive consistent care that
integrates their services where they live, in their
own neighbourhoods.
While every patient is unique, our new approach
to care coordination removes variability; it’s
consistent for all patients. Regardless of where
patients live in our region, they will receive the
same care coordination approach, the same
quality of care and compassion.
Patient-centred Design
Share Care Council: We engaged our patient
and family advisory forum to understand how
care coordinators can provide more consistent
experiences for patients and carers. They
recommended the following.
“Support me in my journey from illness to
wellness (or illness to palliative) by becoming my
care coordinator who oversees all of my care –
my trusted advisor, advocate and coach.”
Community Capacity Plan key findings:
• Care coordination reduces health risk, but
is most effective when one person/entity
is responsible for coordinating care across
multiple providers
• Health and social programs in Mississauga
Halton region, including care coordination, need
to be targeted at specific patient populations
that take into account a patient’s socioeconomic
and cultural status, diagnosis and
place of residence
Client and Caregiver Experience Evaluation
(CCEE): A quarterly third-party, independent
survey of patients and carers revealed that
consistency in care experiences matters most.
Achievements
1. Care Coordination Enhancement
A Care Coordination Framework was implemented
for all care coordinators, including eight core
competencies and new care practices for care
planning and care conferencing. The framework
focuses on teaching, evolving and coaching care
coordinators to consistently deliver care with skill
and confidence.
“The health care system is difficult to navigate;
do more to make sure my care plan meets my
needs. I need a life plan that tells me what will
happen next.”
Community Capacity Plan: This unprecedented
study helps determine the care needs of older
adults now and in the future.
4

The skills, knowledge and behaviours
associated with each core competency
defines our expectations of how care
coordinators will interact with patients
and families to support optimal care
experiences, every time.
Training does not stop at our
doors. Care coordinators practice
this compassionate approach with
patients in their homes and they
are supported by professionals who
conduct a thorough quality practice validation
and provide real-time feedback on their patientcentred
approach.
Already, several care coordinators are
demonstrating mastery of multiple skills,
including writing care plans in a way that are
meaningful to patients and families. Owen, a
78-year old patient says, “My care coordinator
took the time to explain things to me. She was
extremely knowledgeable and very helpful. She
linked me to services I did not know were there,
and she took time to answer my questions. It
was like she really cared.”
2. More help for Patients and Families
Patients and carers told us they need a written
life plan. Our new patient package, My Story,
is a customized resource binder of important
information that patients use to track their care
at home. The foundation of My Story is a onepage
care plan, focused on patients’ personalized
life goals. Care coordinators co-develop this care
plan with patients and families and ensure all
those in the circle of care understand and follow
the plan. It also includes a section dedicated
to managing medications and equipment,
information on the roles of different community
providers, tips for falls prevention and our Patient
and Caregiver Bill of Rights.
Learn how one of our expert care coordinators, Natoya Hylton,
applied our new care coordination approach to help her
patient, Betty, recover at home.
We developed a complementary carer support
guide, A Helping Hand While Caring for Your
Loved One, with local resources to support
carers, including adult day programs, tips to
reduce stress and avoid burnout, advance
care planning tools, videos and diseasespecific
resources.
Neighbourhood Realignment
We know that to deliver the care that patients
and carers need and want, we must establish
strong, connected teams that wrap care
around patients.
To realize this goal, we realigned our care
coordination teams to neighbourhoods where
patients live. With extensive collaboration
and careful planning, starting July through to
December 2016, we are realigning our contracted
service providers to respond to patients’ demand
for consistent nursing, rehabilitation and personal
support services from people who “know them
and their unique needs.”
We’ve designed and implemented a consistent,
interdisciplinary team approach to help achieve
what’s most important to patients.
Click here on Care Coordination Program of
Work to learn how our new neighbourhood care
coordination approach benefits all patients and
families in the Mississauga Halton region.
5

Patient-Centred Care in
2015/16
91.7%
of our patients
with complex care
needs received their
first personal support
worker (PSW) visit within five days
after their assessment. *
5 Days
95.6%
of all patients
received nursing
care through
home visits
or clinics, within five days after
their assessment. *
84%
of all our patients
discharged from
hospital were not readmitted
within the first 30 days
(excluding planned admissions). **
96.2%
of all our
patients
discharged from hospital did not
visit the emergency department
within the first 30 days. **
Cared for
48,000
patients, including 13%
more patients with complex
care needs than in 2014/15.
6
95%
of patients said
they would
recommend the Mississauga
Halton CCAC to their family
and friends. ***
Notes:
* Internal data, based on
Ministry of Health and Long-term
Care indicators, average for April 1,
2015 to March 31, 2016 (Q1 - Q4
2015/16).
** Available hospital statistics, average for
July 1, 2014 to June 30, 2015 (Q2 - Q4
2014/15 & Q1 2015/16).
*** Based on independently conducted
Client & Caregiver Experience
Evaluation, average from April 1
to December 31, 2015 (Q1 - Q3
2015/16).

Fiscal Year 2015-16 Results
Overall Totals 2015-16 2014-15 % Change
Average number of patients served per month 16,421 15,898 3.3%
Total number of patients served 48,000 46,631 2.9%
Programs
Number of Palliative patients 2,053 2,010 2.1%
Number of visits to care for Palliative patients 345,211 330,640 4.4%
Number of patients on Stay at Home, Wait at
Home - LTC, and Wait at Home Enhanced programs 987 925 6.7%
Fast Facts 2015-16 2014-15 % Change
Percentage of patients and caregivers who would
recommend our services to family and friends 95.36% 96.10% -0.7%
Financial results ($ in ‘000s) 2015-16 2014-15 % Change
Fiscal Year 2015-16 Results
Revenues $166,677 $159,468 4.5%
Operating expenses
Administration 7,442 7,164 3.9%
IS, Plant, and Other 7,085 6,852 3.4%
Patient Care 151,759 145,842 4.1%
Total Operating expenses $166,286 $159,859 4.0%
Net Surplus / (Deficit) $391 $(391)
37.4%
Visits by Age
in 2015/16
23.4%
7.1%
12.0%
7.7%
12.4%
Contracted Services
in 2015/16
10.5%
8.9%
28.5%
52.1%
Operating Expenses
in 2015/16
91.3%
4.5%
4.3%
0-18
19-54
55-64
65-74
75-84
85+
Personal Support/Respite
Nursing
Medical Supplies and Equipment
Rehabilatation Services
Administration
IS, Plant, and Other
Patient Care
Notes:
Financial results are based on audited financial statement.
7

Vision
Outstanding Care – every person, every day.
Mission
To deliver a seamless experience through the health system for people in
our diverse communities, providing equitable access, individualized care
coordination and quality health care.
Etobicoke Office
401 The West Mall
Suite 1001
Etobicoke, Ontario M9C 5J5
8:30 a.m. to 4:30 p.m.
Milton Office
611 Holly Avenue
Unit 203
Milton, Ontario L9T OK4
Mississauga Office
8:30 a.m. to 4:30 p.m.
Mississauga Office
2655 North Sheridan Way
Suite 140
Mississauga, Ontario L5K 2P8
8:30 a.m. to 4:30 p.m.
Our Access Care Team is available
from 8:30 a.m. to 9:00 p.m.
We have offices and staff located in
the following hospitals. No referral is
required to contact them.
Trillium Health Partners (THP)
Mississauga Hospital, Queensway Health
Centre, Credit Valley Hospital
Halton Healthcare (HH)
Oakville Trafalgar Memorial Hospital
Georgetown Hospital, Milton District Hospital
310-2222 (CCAC)
no area code required
www.healthcareathome.ca/mh
www.mississaugahaltonhealthline.ca