CLINICAL SERVICES PLANNING - CSP - updated August 2, 2011

Creating an Integrated Health Care Experience for Central East LHIN Seniors

Please visit the "Resource Documents - Planning" page on the Central East LHIN website for the latest information on the creation of a a shared governance model for specialized geriatric services in Central East.

The Central East LHIN has undertaken three important planning and integration initiatives to improve access to care and the quality of services for our communities’ seniors. These initiatives are intended to improve the patient experience, optimize health system performance and sustainability and realize the Central East LHIN’s Strategic Aims.

On May 25, 2011, reports and presentations on the three initiatives were shared with the Central East LHIN Board of Directors.  To access a presentation that provides an overview of this work, please click on the link below:

Overview Presentation 

These three projects are foundational to the near and long-term creation of an integrated health care system that will deliver a coordinated care experience for seniors in the Central East LHIN and will serve to sustain long-term improvements in seniors’ health already begun through the provincial Aging at Home Strategy, the Central East LHIN Home First initiative and Geriatric Assessment and Intervention Network, and our hospitals’ Senior Friendly Hospital Quality Improvement Plans.

Staff from the Central East LHIN are now in the process of sharing these reports with stakeholders so that the Board of the Central East LHIN, at its June 2011 Open Board Meeting, can make the appropriate decisions related to creating an integrated health care experience for Central East LHIN seniors.  If you have any feedback on these reports, please email the LHIN at

Sustainable Access (Planning for post-acute care)

The Central East LHIN recognizes that limited capacity to a continuum of post-acute care is creating access barriers for patients to appropriate care settings. These barriers are not only detrimental to population health, but hinder optimal patient flow and use of other health care services. 

The Sustainable Access initiative was a health services planning exercise that comprehensively assessed current and future access to post-acute care services, including long-term care, supportive housing/assisted living, home care, institutional rehabilitation (e.g., complex continuing care, rehabilitation/restorative care) and specialized geriatric services.

The Steering Committee's Final Report was presented to the Central East LHIN Board at its May 25, 2011 Board Meeting.  To access the report and a related powerpoint presentation, please click on the links below:

Sustainable Access Report 

Sustainable Access Presentation 

Psychogeriatric Services Coordination

In 2008, the Central East LHIN ALC Task group found dementia was the top clinical cohort of ALC patients, resulting in 9,375 ALC days. Anecdotally, all of the Central East LHIN hospitals reported complex discharge planning issues within an increasing psychogeriatric population.  There is an opportunity to provide more highly coordinated specialized care for our psychogeriatric population that will result in seniors with psychogeriatric illness or dementia being maintained at home or place of residence, decreased lengths of acute care hospitalization as well as reduced ALC numbers. An integrated approach is expected to result in better outcomes in terms of standardized approaches to population health, patient experience and fiscal effectiveness.

The Psychogeriatric Services Coordination project was a health services integration exercise, led by Ontario Shores Centre for Mental Health Sciences,  to provide a better understanding of our current landscape related to psychogeriatric services. Through an engagement of stakeholders, an environmental scan of existing services was completed, followed by exploration of more integrated approaches to psychogeriatric services. These options form an essential component to the emerging Regional Specialized Geriatric Program (see below).

This report was presented to the Central East LHIN Board at its May 25, 2011 Board Meeting.  To access the report and a related powerpoint presentation, please click on the links below:

Psychogeriatric Report 

Psychogeriatric Presentation 

Regional Specialized Geriatric Program Development

Over the last five years, the Central East LHIN and its stakeholders have recognized that the system of services must be brought closer together to better meet the needs of frail seniors living in our community. To this end, the Central East LHIN has been strategically investing in areas such as Geriatric Emergency Management (GEM) Nurses, Nurse Practitioner Outreach Teams to Long-Term Care (NPSTAT), post-acute transition and restorative care programs.  In addition, the region-wide Geriatric Assessment and Intervention Network (GAIN) now includes four geriatric urgent care clinics and Acute Care for the Elderly (ACE) in-patient units across the Central East LHIN.

The Regional Specialized Geriatrics Program Development initiative was a health services integration exercise that has provided recommendations for the establishment of a Central East LHIN Regional Specialized Geriatric Program.  Unlike the Sustainable Access initiative, this project is aimed at determining how best to coordinate current and future Specialized Geriatric Services, Senior Friendly Hospital initiatives and overall coordination with psychogeriatric services in the region.

A report titled "Regional Specialized Geriatric Services in the Central East LHIN: Options for Coordinated Delivery, Organization and Governance" was presented to the Central East LHIN Board at its May 25th Board Meeting.  As noted above, it will come back to the Board for further discussion and next steps in June 2011.  To access the report and a related powerpoint presentation, please click on the links below.

Regional Specialized Geriatrics Report 

Regional Specialized Geriatrics Report - Appendices and Attachments 

Regional Specialized Geriatrics Presentation 

Hospital Clinical Services Plan

On February 17, 2009, Dr. George Buldo, Chair of the Clinical Services Plan (CSP) Steering Committee, submitted the "Hospital Clinical Services Plan - Detailed Report"  to the Board of the Central East Local Health Integration Network.  In submitting the report, Dr. Buldo spoke about how newly formed teams came together during this project to develop proposals that will benefit patients and health care providers in the Central East LHIN. 

The report contained 28 clinical service delivery model recommendations and details on three medical leadership frameworks that were developed by over 150 stakeholders - physicians, nurses, allied health professionals, administrators.  All the recommendations and frameworks were aligned with the vision of a "One Acute Care Network" to provide quality, accessible, sustainable health care to the residents of the Central East LHIN. 

In his remarks, Dr. Buldo stated that new channels of communication had led to greater understanding and that major consensus had evolved from initial trepidation.  He acknowledged everyone who participated in the project, including the Advisory Groups and the Leadership Groups, thanking them for their thoughtful engagement.  He also thanked the members of the Steering Committee and the Executive for their diligence, dedication and support.

In receiving the report, the Board also thanked all those who participated in the project and reaffirmed their support of all continuing efforts towards the vision of a "One Acute Care Network" and their commitment to achieving results.   

Since that time, hospital leaders from across the Central East LHIN, have worked together to begin to implement the service delivery models contained in the Hospital Clinical Services Plan.  This has included the implementation of a Central East Regional Thoracic Program - click here and here for more information.  The Thoracic Program is an excellent example of how hospitals across the region are working together in an integrated way to provide the highest quality care for their patients. 

Proposals for new service delivery models that were recommended in the Hospital Clinical Services Plan are expected to come before the Central East LHIN Board in the spring of 2011. 

Clinical Services Plan - Detailed Report - pdf

Please note that a limited number of hard copies of the Detailed Report have been printed and are available by contacting the Central East LHIN, the Central East Community Care Access Centre or one of the hospitals in the Central East LHIN.   Some graphics were updated in the printed document to improve their legibility.  Files posted behind the links above reflect the printed version of the document.

Presentations - pdf