Clinical Services Roadmap (CSR)

In the South East LHIN’s Integrated Health Service Plan 2, a number of improvements were identified as necessary to streamline and improve health service delivery in the region. Through consultation with the South East hospitals and Community Care Access Centre (CCAC) seven areas of improvement were identified. These seven areas form the foundation of the Clinical Services Roadmap (CSR), with clinical working groups supporting each initiative.

Launched in July, 2010, CSR was designed to find better ways of providing improved access to care for residents across this region; to cut down on the red tape patients have to deal with in moving from one caregiver to another; and to ensure that hospitals and the CCAC can integrate their services to fill the gaps and deliver a more seamless continuum of care region-wide.

For more information view the presentation on Clinical Service Roadmap: Towards a regional system of integrated care (PDF).

About the Team

In each of these areas, cross-regional clinical teams of up to 30 or more specialists studied, discussed, debated and – after seeking and gaining input from the community through a sophisticated online engagement exercise - came up with solutions that would accomplish the objectives they had set for themselves. This community feedback came from a well-balanced and truly representative geographic cross-section of the southeast region. The feedback, both quantitative and qualitative, was provided to each of the CSR teams for consideration in the development of their final end state visions.

The CSR Staging Team (composed of hospital and CCAC senior leaders), through an iterative, interactive process, developed recommendations with respect to staging of the implementation of 32 CSR initiatives taken from the six of the seven clinical areas. All of the initiatives contribute to improved patient care within and integrated, regional system of care. The first wave of implementation includes 18 of these initiatives and the remaining initiatives will be phased in during subsequent waves. The initiatives for phase one were selected based on a variety of criteria including: contributes to the achievement of each organization's goals, builds on current activities/achievements, and/or delivers the largest value for the necessary effort.


CSR Initiatives

Click on the initiative title to view the appropriate page:

Cardiovascular

To develop a plan for regional, integrated cardiac services for the residents of the South East LHIN. The plan was informed by stakeholder input and a focus on the management of chronic underlying disease (e.g. Congestive Heart Failure) and reduction of readmission rates for post cardiac events.

Emergency Department (ED)

Wait Times To spread the focus on ED operations (process improvement and wait times reduction) throughout the LHIN.

Healthcare Acquired Infections (HAI)

To reduce the incidence and severity of HAI through the design and effective application of a regional, integrated strategy. Initial areas of focus included influencing antibiotic use in the community and hospital as well as increasing antimicrobial activity with advanced this planning process is the South Eastern Ontario Infection Control Network (SEOICN). 

To ensure leading practice is adopted regionally with respect to maternal/child services. The project was developed in conjunction with ongoing work being done in this area by the Champlain LHIN and was informed by the Perinatal Partnership Program of Eastern and Southeastern Ontario (PPPSEO).

To develop a regional, integrated plan for mental health and addictions services for the residents of the South East LHIN. The goal was to improve access to quality care, minimize/ease the patient transitions between different care providers, and ensure that residents are receiving the right care from the right provider at the right time. In addition, the plan was expected to support Tier II and III divestment in Brockville, Tier III divestment in Kingston, as well as reduce the number of repeat ED visits for patients with mental health and addictions diagnoses.

To reduce the impact of non-acute care and “avoidable” acute care in hospitals through the development of a regional, integrated plan. The intent was to improve coordination of care between sectors and providers with a focus on the provision of restorative care (including slow stream rehabilitation, activation, rehabilitation and complex continuing care).

Surgery

To develop a regional surgical services program that would, through regional collaboration and effective inter-hospital patient management, improve efficiency, patient safety, and clinical outcomes. The mandate of the work team evolved to include consideration of departmental inter dependencies which could be affected by changes made through the implementation of a regional surgical services program. Additionally, the work team will be mindful of other administrative considerations (like specialist on-call schedules) and patients access (improving wait times for consultation with surgical specialists and sub-specialists).

Other Clinical Areas 

While Cancer Care was considered and identified as a high priority, there was agreement that cancer services would be addressed through the broader based Provincial efforts and these efforts would be aligned with the CSR.
 
Similarly, Palliative Care/End of Life Care was also undergoing a concurrent planning process external to CSR that would ultimately be linked to the CSR planning process in the future.