ICES Mental Health & Addictions Symposium Pt 4: Panel

So thank you to all our panelists, first I'll introduce Patrick Dicerni Patrick is the assistant deputy minister of strategic policy and planning division in the Ministry of Health and Long-term Care at the Government of Ontario and I'm very fortunate to have Patrick as one of my main interlocutors at the Ministry

Just prior to his appointment Patrick worked in the deputy minister's office serving as director of policy and delivery since October 2012 He played an important role in implementing the Ministry's policy agenda and delivering on a number of key priorities during his time in the in the deputy minister's office he served two ministers and provided strategic advice and support to three deputy ministers I'm sure that he has lot of stories to tell Prior to joining the ministry Patrick held a number of increasingly senior positions at the Ministry of Children and Youth Services so he brings quite an interesting perspective from multiple positions within two ministries Next up we have Anna Greenberg

Anna is Health Quality Ontario's vice president for health system performance and she is responsible for designing and implementing a comprehensive strategy to improve performance monitoring and public reporting in Ontario Prior to joining HQO Anna was director of strategic policy at the Ministry of Health and Long-Term Care where she led a branch of policy professionals in a wide variety of areas including mental health and addictions, health care quality and safety, clinical and social service integration, and reproductive technology Prior to that she held leadership roles at Cancer Care Ontario, Princess Margaret, UHN and the Canadian Partnership Against Cancer And finally we have Judy Switson – she joined the Ministry of Children and Youth Services in January 2016 as director of the client services branch, she's a physiotherapist by profession, and following clinical practice in both pediatrics and sports medicine, Judy achieved progressive positions and management at both UHN and Sunnybrook Health Sciences Centre Most recently Judy was acting director and manager within the Ministry of Health and Long-Term Care local LHIN network liaison liaison branch

And so without further ado I'll ask Paul to come up and moderate the panel discussion So the the topic for this panel is from performance measurement to system improvement The format is that each of the panelists – and we're so grateful you came, but I just wanted to say that there are many reasons why we do what we do, but obviously we want to hear from people who are who are key consumers of the information we manage, to see, to hear from them – what is the utility of this? So we've provided them with our scorecard ahead of time, given them a chance to digest it, and posed to them two questions there up on the slide: What is the utility of performance measurement in your role? Relatedly, in what direction would you like data and performance measurement to go, to make it more relevant to your day-to-day work? And, given your respective roles as leaders in the healthcare system, what are your impressions of the results presented today? Each panel member will have five minutes to respond to these, and then we are going to be opening up for questions in the audience And we also, for the live-streaming attendees we'd ask that you type your questions into live chat and I will ask your question for you if indeed we have live chat working – have we got the thumbs up? We're going to be doing that so thank you very much Okay so I haven't chosen a particular order, but why don't we go from the audience's left to right so we'll start with Patrick Dicerni, and and then Anna and then Judy

Thank you Okay thank you all and thank you for having me To respond to the first portion of the question related to the utility of performance management – like most things in government, we like structure around – I'll give you three compelling reasons why, and two enablers or three enablers, so structure your answers accordingly I'd say this there's three plus reasons why the utility of performance measurement is important in my role and as a representative of the Ministry First and foremost, right now and for the for the last while, in terms of everything that we launched – there needs to be a strategy We need to be assuring our Treasury Board and others that we're having some way to measure the goals of what we're setting out to achieve

So in terms of the process and progress that we would look back on and understand that we are actually meeting the goals that are set out in Open |Minds and Healthy Minds With respect to a second one being, monitoring system performance and health outcomes It's more about – it's more than just monitoring what the outputs of the system are, but how are we impacting the health outcomes of Ontarians? And taking ideally a recovery-based view on people's interactions with the healthcare system, and taking a truly client-centric and timely, effective and safe provision of patient care It plays an important accountability function in terms of how the Ministry is able to account for the funds that we put into the system, and ultimately responsible to our decision makers and Ontarians in terms of that accountability function And I would extend that into public reporting – right now all the provinces and territories and the federal government are engaged in discussions related to new funding for healthcare services in the country, and not betraying any state secrets here, but a component of that would obviously be public reporting

And the federal government rightfully is going to want to be seeing the outcomes of their investments in healthcare and that's going to made clear I think some of the work that we've seen earlier, and that's been presented here today, kind of gives us a leading headstart on what that performance reporting your indicator work could and should be That's going to be important, to certainly to Ontario in our relationship with the federal government, and and I think through the work of ICES, Ontario is really positioned as a leader in this space in terms of how performance reporting underpins a lot of what we're trying to do with our mental health and addictions data strategy, their mental health and addiction strategy writ large I'd say that really does act, as it does support the foundational elements of some of the transformational activities that we're undertaking And to put a little need on that as we as we strive towards what is going to be a core set of mental health services for everyone across the province, as advised by our mental health and addictions Leadership Council, we're going to be needing to make sure that those quality – that those services are of high quality – and they're accessible to Ontarians

It also is going to help us drive some standardization and fidelity to models that we adopt and endorse and fund It's also in the last point I'll make on this is as we start looking at different ways to fund our mental health and addiction services in this province, we're going to need to really have a clear understanding of what the quality underpinnings of those services are That's the only way that we are going to responsibly adapt funding going forward so I really look at performance reporting quality as as what is the underpinning of what would be any any change or evolution of how we fund mental health and addiction services in the province With respect to the second component of the question in terms of how is how is this direction, how would you like data and performance measurement to impact and be relevant in our day to day work, let's say there's there's five things I'd highlight Some of the scorecard work that we've seen today on the on the children's side I think ideally we'd see that as a common provincial performance measurement scorecard across the entire lifespan, linking the children, adolescents and adults systems

I think that would be reflective of a recovery based approach to mental health and addictions As well the next thing I'd point to is some interesting work that's going on between the Ministries that our friends at ICES are aware of, they're involved with this concept of data linkage or breaking down data across ministry silos and and perhaps beyond ministry into into the sector of silos I think your average Ontarian would think that we do share data across our provincial institutions and our provincial ministries in at the very least the human and social services type ministries The reality is is that we don't We're in a very siloed data environment, so looking at the Ministry of Children and Youth Services or community and social services if those if those programs and services are functioning in a in a high quality and high performance type way, where are those benefits accruing, those benefits are accruing to better health outcomes better educational attainment and how do we how do we articulate that, how do we show that? And I think that the most effective way to show that would be to link our data sets across ministries and that's a capability that that our colleagues at ICES have in and have demonstrated in small areas

My firm hope and this is some work that's going on right now, is how do we scale that up across across ministries and in much larger data sets – in a de-identified and randomised way, to really track cohorts and see where where our successes and our weaknesses are? I think we need to leverage and build on some of the existing digital health and data assets, the province over the last X number of years investing a tremendous amount of money in our data and health record infrastructure, how do we turn that from investments into quality and data performance reporting? And there's a lot of opportunity ther Last point I'd make is around partnerships, and this touches back briefly to what I was talking about around data integration – I think that beyond what we have internally we can be linking our data with researchers in this room, and community and and sector representatives as well, to really bring to bear the data that you have in your various institutions and holdings and what the Ministry has The more ability to safely and under the auspices of good data sharing agreements that don't take years and years to structure, but that we could get to fairly quickly, I think there would be a lot of value and success there Thank you Okay, thank you

I'm really pleased to be here and to have seen the presentation this morning, and also to see the progress since 2015 I think it's really exciting So part of my role at Health Quality Ontario is overseeing the mandate that looks at, how do we report on how well the system is performing to the public? And I can say that we couldn't have done what we've done in mental health in this area without a partnership with the ICES mental health group and it's allowed us to have a chapter in our yearly report on mental health dedicated to mental health, it's allowed us to do a specialized report together on what community mental health and acute mental health looks like together to the best of our ability, and more recently and increasingly, it's allowed us to have sophisticated analysis that is guiding what quality care in mental health looks like, so with our new quality standards program which happily started with mental health as an area of focus, looking at major depression and schizophrenia, now looking both in the acute inpatient setting and also in the community It's this type of analysis that has allowed us to say where are the, where's the major variation that's unwarranted, and where are the gaps, and that is leading to evidence-based guidance on, what does quality care look like? And I would just say that this is the big link between data and actually understanding quality which is what does it look like what and how we know when we see it? And I think that this partnership is going to allow us to do that I also say that I'm really supportive and Health Quality Ontario is really supportive of the data strategy that's been laid out

This is building on a tremendous amount of progress that ICES has led, but what the data strategy is contemplating is that we might actually have a unique identifier across someone's lifespan so that despite different funding streams and different ministries and different data sources, we might actually be able to understand the full picture from a client centered, patient centered perspective That's a fundamental policy change that I think we'd be really supportive of that would advance our ability to understand quality The second thing, and Patrick touched on this, is leveraging more data systems not just in health and ICES has led the way in terms of having linkage with MCYS and social services, we saw today data from MCYS, and I think there's a lot more opportunity there through the mechanisms that ICES has put in place – if not break barriers in terms of care delivery and funding streams, to use data as a means of driving integration, and we're really excited about some of the advancements in data that we may see Paul talked about wait times, we at Health Quality Ontario can report on wait times now for primary care, for home care, for long-term care, for acute care, of course for a long time We're really looking forward to being able to on some routine basis talk about access and timeliness in mental health care

We're also very interested in the advancement that may happen in telepsychiatry, telemedicine, telemental health, so that when we're talking about disparities and geography with the north, that we're not just saying, we're not sure if this is even an appropriate measure for the north, we could actually look at what is virtual utilization, look like – what does community-based utilization look like? And then line that up with what we already know from existing datasets When I was invited to come and talk to the panel by coincidence I was reading an article in the current issue of the Walrus and I'm guessing some people in the room may have read this article about Tamara written by her mother, and Tamara had tragically died by suicide And as I read the Walrus story and the detailed story of a pathway that she had interacting with the mental health system, I thought about the measures that we have in place to understand the client experience, and the quality of the care that we deliver, and you know her first contact was in the ED She spent 12 hours there Her next contact with the health system was two weeks later and then there was a series of different contacts

There were several weeks out, than another two weeks, and her mother described that agony of those times in between in the sense of abandonment and not knowing how or when she would find stability And the length of time it took to actually feel like she actually had a complete diagnosis And I just find when I look at this data, there is so much that we can see, and you can see actually a reflection of Tamara's experience in the data that we see today But we also don't hear from what that experience feels like from the perspective of the clients and the caregivers, and so I think there is an opportunity, and I know there is opportunity with tools like OPOC to, in the future, understand that kind of client reported, patient reported measures Ultimately Tamara's mother ended up – not ultimately, but before the tragic passing- Tamara's mother had her daughter arrested so that she could find the care that she needed, and she found stability through medication in hospital, but then she talked about not having a robust discharge plan when she came out again

And I think the the data that we're seeing today- in terms of seven-day follow-up and your chances of getting that seven-day follow-up- really speak to that robust discharge planning that is really needed when someone might get to a point of stability What jumps out at me when I look at the findings today is that we are definitely seeing that more kids are needing care, and we see their youth not only in the acute setting be it in hospital, but also in outpatient physician visits, both rising And what's really striking to me and this was pointed out is, that where we see that increase happening and in both outpatient and in the acute setting, we don't see that seven-day follow-up changing, and we would like to see that seven-day follow-up changing, because you want to know that on the other end of those interactions with the acute care that there is some follow-up plan and that you aren't just having ED return visits or readmissions, be a kind of standard of care Of course we also know that follow-up care may not be with a physician, and so we have the beginnings of a glimpse of what is the community access look like, I will say that when I look at some of those wait times and I think about Tamara's story I think about something like a 35-day wait or a 98-day wait which may not even be- you might even have – we know we that some patients are waiting a lot longer than that But that just sounds like agony when you put it together with a personal story

I also think about the the equity dimensions that the team has thoughtfully included in the analysis, and thinking about geographic disparities, income disparities, and it does make you wonder – where is the unmet need who's not being served, and it's likely that those patients and clients do end up back in the ED and we see them in kind of the ED first contact data, but it does make you want to understand – who aren't we serving when you see this rising demand I also think that what we don't get enough of a picture of – and this is something I know we will be able to do – is the effectiveness of care and what I'm hopeful of is that if we understand, if we marry this analysis with the quality standards in mental health, taking just major depression and schizophrenia as two examples that are opportunities now, that we could we could advance the data in line with, what does quality care look like? And we could understand a better picture of what does effectiveness look like, things like the transition that should happen after an episode I also am struck by the important insights to the opioid strategy When we look at the neonatal abstinence syndrome data we've heard from prescribers the need to really understand the different types of patients and clients who need pain management and may be at risk for opioid use disorder, and I think this particular population, looking at teen moms in particular, geographies at higher risk is a really important and valuable input to what the support should look like for the opioid strategy So overall, really really interesting findings

I just want to say a big congratulations to the group because I think there's a tremendous amount of progress I think Ontario is lucky to have this kind of data infrastructure and analysis and I think we're already seeing it informing policy That's not why we invited Anna to present, but everything she said before was very meaningful Judy? Thank you I do want to speak a little bit about the journey that we've been down in MCYS with respect to data, but just before I do that, I was asked to speak to the utility of performance

In my role I'm going to speak again here to a little bit about MCYS because I think we are a bit of a unique ministry in that we have a regional office structure which has given way to LHIN structure in health and the structure in MCYS is such that our five regions report dually up to two ministries and our ministry is very new So having come over from health into MCYS I was used to a relatively rigorous and robust environment of data and I came in here sort of expecting a little bit of that but very quickly learned that the journey that MCYS has gone down and the journey that is now being part of a conversation between MCYS and health, and a very positive conversation it has been It's a journey worth telling, so I'm just going to spend a moment just walking you through that a little bit The data strategy at MCYS has been underway since about 2011 within Open Minds Healthy Minds, as the name of the strategy followed very quickly by a transformation agenda called Moving On Mental Health and the the reason or the raison d'etre for this was really based on an understanding of a tremendous need out there And a lot of the data that we've seen today represents that need

It's about consistency across the province, understanding where services are, what services are, understanding how to navigate those services, and those are understanding that there's a consistent approach to to data and to standards and to expectations on behalf of – when you go, you know that you can expect a certain standard of care from various providers So starting with an understanding of that need There was a robust exercise underway to say, it's one thing to know about need, but we need to be able to measure in some way, and that led to a consultation and collaboration that resulted in the identification of the performance indicators that you saw rolled up for you It's rolled up in as part of the report We have identified at this point 13 performance indicators of which were vigorously reporting on about 10 of them, and underpinning these 10 was a first initiative to understand- it's one thing to say that you need to measure but we needed a consistent set of what we are measuring against, so there was a, prior to the development or concurrently with the development of performance indicators, was an identification of core services

So we have a series of core services, seven core services, we have some key processes identified, we've attempted to create definitions and expectations of those, and following out from that we have gone into our performance indicators in our performance measurement So I know I'm talking a little bit lengthily but at this moment in time we have about two years worth of data that we can report on The data that's in the scorecard now is our first year's worth of data and although we're very proud of that data, obviously one year's worth of data is not a strategy by any sense of the word We have launched an exercise to start sharing that data so we've created a system of providers through our lead agencies, 31 of 33 at the moment, and we are starting to share our data and do training for our providers so that they can understand what is behind the information that they're looking at And again when you come from an environment where this is new information and it's a new approach a new lens, it's a very important part of developing the sector as we move forward very quickly upon identifying performance indicators was an identification that our indicators were not necessarily as robust, or they weren't necessarily speaking to what the providers needed in order to be able to report on their activity, and what they consider to be success in what they were doing, so we've got an exercise underway to refine those indicators and that will be an ongoing and an iterative process

We also have undertaken the implementation of a business intelligence solution and this will be a robust system to actually capture our data elements and give us that freedom and flexibility to create reports that respond to need And I think the final point that I want to say is that part of our journey, and a very critical part of the journey going forward, is the movement of our strategy into health and to include addictions And the second part of that is the working relationship that we're establishing with health and ongoing relationship with education Just in order to create that journey rather than simply looking at silos and in isolation So just in conclusion, we were asked to speak to our impression about the results today and like Anna I think mental health touches many of us in many ways and I'm not excluded, so have the experience

And in many ways I look at the information that's been presented today as a bit of a good news story because I think mental health illness is being discussed and destigmatized and I think it's wonderful that we're creating a safety network so that people feel that they can come forward and seek the help they need when they need it, that's so critically important, but I also think the statistics report to what we all know and that is that the journey is really in its infancy And I think the success factors that underpin where we're going relate to our ongoing connections across our ministries, they relate to the our commitments which I think are demonstrated here today Our lead agencies are the connect for Children and Youth Services with the other agencies with LHINS with education bodies etc and we need to, as leaders, ensure that those connections are maintained and developed And again I just want to go on to say that data is one thing, business intelligence is another thing, but it's what you do as you develop that data and how you use that data that is important So when I see these scorecards you think of the art of the possible, about where this can go in order to inform all of us as we march down this journey together, and I think about moving towards benchmarks and targets within my own ministry, and to be able to start speaking to those and looking at performance against those across the province, to allow us to continually develop the system and allow us to inform where our policy has to go in order to continue to improve the system as we go forward

I think the one final thing that I will say is and Anna and Patrick did mention this as well- it's one thing to speak about a child in their youth, it's another thing to speak about obviously a person throughout their life, and so one of the key things that I think we need to think about going forward is that ability to track the trajectory of a person as they move in and out of care in and out of sectors And not silo ourselves but make sure that we have in mind that we want to be able to look at the person and their journey not necessarily at what MCYS does, what health does, what education does, as we move forward So it's been very enlightening and I'm very happy to be part of it, so thank you very much So thanks very much to all three of you, I just want to thank you very much for agreeing to be here

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