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Directional Plan – Vision Care Strategy Final Report December 2014 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT TABLE OF CONTENTS ACKNOWLEDGEMENTS............................................................................................... 7 EXECUTIVE SUMMARY................................................................................................ 9 1. 1.1 1.2 1.3 1.4 1.5 CONTEXT ..................................................................................................... 12 Project Overview.................................................................................................. 12 Central East LHIN Approach to Clinical Services Planning ................................... 12 Vision Care in Context .......................................................................................... 13 1.3.1 Perspectives on Comprehensive Vision Care Components .................... 13 Project Scope ....................................................................................................... 16 Approach .............................................................................................................. 16 1.5.1 Current State Assessment and Stakeholder Consultations .................... 17 1.5.2 Development and Evaluation of Future State Options ........................... 17 1.5.3 Development of Recommendations and Draft Final Report .................. 20 1.5.4 Review/Approval by Central East LHIN CEO Council and Board of Directors ................................................................................................. 20 2. KEY DEFINITIONS ......................................................................................... 20 2.1.1 Procedure Types ..................................................................................... 20 2.1.2 Facilities .................................................................................................. 22 3. 3.1 3.2 CURRENT STATE ASSESSMENT ...................................................................... 23 Description of Central East LHIN .......................................................................... 23 What are the Central East LHIN Population’s Vision Care Needs? ...................... 24 3.2.1 How Central East LHIN’s Population Will Grow in Future ...................... 24 3.2.2 How Central East LHIN’s Regional Populations Will Grow in Future...................................................................................................... 25 3.2.3 The Current Prevalence of Diabetes in Central East LHIN ...................... 26 3.2.4 How the Need for Procedures is Expected to Grow ............................... 27 Where are Central East’s Strengths and Opportunities in Vision Care? .............. 27 3.3.1 Areas of Strength .................................................................................... 27 3.3.2 Opportunities for Improvement ............................................................. 28 What is Central East LHIN’s Capacity to Meet Population Needs?...................... 29 3.4.1 Ophthalmologists/HHR ........................................................................... 29 3.4.2 Training Programs ................................................................................... 30 3.4.3 Hospital-Based Ophthalmology Equipment ........................................... 30 3.4.4 “Flow-Limiting” Factors .......................................................................... 30 How is Vision Care Currently Utilized in Central East LHIN?................................ 31 3.5.1 Procedures Volumes by Age ................................................................... 31 3.3 3.4 3.5 Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e |1 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT 3.6 3.7 4. 4.1 4.2 4.3 4.4 3.5.2 Procedures Volumes by Site ................................................................... 33 3.5.3 Procedures by Geography ...................................................................... 36 3.5.4 Current Volumes vs. Estimated Capacity ................................................ 41 3.5.5 Referral Patterns ..................................................................................... 41 3.5.6 Inflow/Outflow of Patients to/from Central East LHIN .......................... 41 3.5.7 Vision Care for Diabetics ......................................................................... 48 How Accessible is Vision Care in Central East LHIN? ........................................... 49 3.6.1 Distances Travelled by Patient................................................................ 50 3.6.2 Wait Times .............................................................................................. 52 3.6.3 Quality and Appropriateness .................................................................. 54 Current State Assessment Summary ................................................................... 55 DIRECTIONAL PLAN – VISION CARE STRATEGY .............................................. 55 Recommended Directional Plan for Vision Care in Central East LHIN ................. 55 What this Directional Plan Means for Central East LHIN ..................................... 57 4.2.1 Operations .............................................................................................. 57 4.2.2 Annual Cost Estimates ............................................................................ 57 Detailed Recommendations by Procedure and Population ................................ 58 Other Recommendations..................................................................................... 63 5. 5.1 5.2 5.3 IMPLEMENTATION PLAN .............................................................................. 65 Implementation Context...................................................................................... 65 Funding ................................................................................................................ 65 Implementation Plan ........................................................................................... 66 5.3.1 Immediate Next Steps ............................................................................ 66 5.3.2 Implementation Plan Summary .............................................................. 67 5.3.3 Description of Implementation Plan....................................................... 68 6. CONCLUSION ............................................................................................... 71 APPENDICES ............................................................................................................. 72 Appendix 1: List of Procedures by Level ........................................................................... 72 Appendix 2: Central East LHIN Decision Making Framework ........................................... 73 Appendix 3: Select Literature Scans.................................................................................. 77 A3.1 Service Delivery Models .............................................................................. 77 A3.2 Telemedicine Trends in Ophthalmic Care ................................................... 80 A3.3 Driving Referrals through Relationships ...................................................... 82 Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e |2 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT TABLE OF TABLES Table 1: Components of Comprehensive Vision Care................................................................................. 14 Table 2: Current State Assessment Components ....................................................................................... 17 Table 3: Key Procedures and Populations for the Directional Plan – Vision Care Strategy ........................ 18 Table 4: Future State Procedure/Population Dimensions .......................................................................... 18 Table 5: Procedure Levels Defined by the Provincial Vision Strategy Task Force....................................... 21 Table 6: Procedure Group Rollup Headings by Level (Provincial Vision Strategy Task Force) ................... 22 Table 7: Central East LHIN Vision Care Hospital and Site Abbreviations .................................................... 22 Table 8: Projected Population Growth for Individuals Aged 65+ by Region............................................... 26 Table 9: Number of Ophthalmologists per Hospital (Including Subspecializations)................................... 29 Table 10: Ophthalmology Procedures for Patients Under 20 (Fiscal Year 2012) ....................................... 32 Table 11: Top 10 Ontario Cataract Centres by Volume .............................................................................. 34 Table 12: Percent of Ophthalmology Procedures that are Level 2 by Hospital .......................................... 35 Table 13: Central East LHIN Inflows and Outflows ..................................................................................... 42 Table 14: Outflow Procedure Volumes ....................................................................................................... 44 Table 15: Inflow Procedure Volumes .......................................................................................................... 44 Table 16: Pediatric Outflows from Central East LHIN by Age and Destination Hospital ............................ 45 Table 17: Hospitals with Associated Health Links ....................................................................................... 46 Table 18: Inflows Entering Central East LHIN by Health Link Area ............................................................. 47 Table 19: Net Inflows and Net Outflows by Health Link Area .................................................................... 47 Table 20: Distances Travelled for Residents Receiving Services within the LHIN (Fiscal Years 2012-2013) .................................................................................................................................................................... 50 Table 21: Inflow Distances Travelled (Fiscal Year 2012) ............................................................................. 51 Table 22: Outflow Distances Travelled (Fiscal Year 2012) .......................................................................... 51 Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e |3 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Table 23: Overview of Distributed Model for Cataracts with Two Cluster Centres for Subspecialties Model .......................................................................................................................................................... 56 Table 24: Annualized Cost Estimate of Additional Subspecialists .............................................................. 58 Table 25: Description of Implementation Plan Steps ................................................................................. 68 Table 26: Central East LHIN Decision Making Framework for Vision Care ................................................. 73 Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e |4 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT TABLE OF FIGURES Figure 1: Vision Care System Continuum .................................................................................................... 15 Figure 2: Central East LHIN by Cluster ........................................................................................................ 23 Figure 3: Total Projected Population by Age Group in Central East LHIN .................................................. 24 Figure 4: Projected Population Growth by Age Group ............................................................................... 25 Figure 5: Diabetes Prevalence in Central East LHIN by Health Link Region ................................................ 26 Figure 6: Projected Number of Procedures by Volume .............................................................................. 27 Figure 7: Procedure Volumes by Age (Fiscal Year 2012)............................................................................. 31 Figure 8: Procedure Volumes by Hospital (Fiscal Years 2010-2012)........................................................... 33 Figure 9: Procedure Volume by Level ......................................................................................................... 33 Figure 10: Proportion of Procedures by Hospital (Fiscal Years 2010-2012) ............................................... 35 Figure 11: Geographical Distribution of Ophthalmology Procedure Patients for TSHB ............................. 37 Figure 12: Geographical Distribution of Ophthalmology Procedure Patients at LHB................................. 37 Figure 13: Geographical Distribution of Ophthalmology Procedure Patients for LHO ............................... 38 Figure 14: Geographical Distribution of Ophthalmology Procedure Patients for TSHB ............................. 38 Figure 15: Geographical Distribution of Ophthalmology Procedure Patients for RMH ............................. 39 Figure 16: Geographical Distribution of Ophthalmology Procedure Patients for TSHB ............................. 39 Figure 17: Geographical Distribution of Ophthalmology Procedure Patients for NHH .............................. 40 Figure 18: Ophthalmology Procedure Coverage Areas by Hospital Site..................................................... 40 Figure 19: Central East LHIN Inflow Volumes by Hospital .......................................................................... 43 Figure 20: Percentage of Hospital Procedures that are Inflows ................................................................. 43 Figure 21: Outflow Procedure Shares by Volume ....................................................................................... 44 Figure 22: Inflow Procedure Shares By Volume.......................................................................................... 44 Figure 23: Percentage of Patients Treated in Home LHIN by Procedure Level .......................................... 45 Figure 24: Adult Diabetics Receiving Retinal Eye Care ............................................................................... 48 Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e |5 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Figure 25: Rate of Ocular Procedures Per 100,000 Adults with Diabetes .................................................. 49 Figure 26: Adult Ophthalmic Surgery Wait Times by Procedure (Fiscal Year 2012) ................................... 52 Figure 27: Ophthalmology Patient Waitlist by Facility, Priority 2,3, and 4 (Fiscal 2012) ............................ 53 Figure 28: Completed Cases of Ophthalmic Surgery – Volumes and Percent Completed Within Access Target (Priority 2,3, and 4), Fiscal 2012 ...................................................................................................... 53 Figure 29: Completed Cases of Ophthalmic Surgery – Volumes and Percent Completed Within Access Target (Priority 4), Fiscal 2013 .................................................................................................................... 54 Figure 30: Proposed Implementation Plan Summary ................................................................................. 67 Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e |6 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Acknowledgements This report has been prepared on behalf of the Central East LHIN Vision Plan Working Group. The Vision Plan Working Group is acknowledged for its dedication and thoughtful direction of the process. The Group consists of the following as listed below. Vision Plan Working Group Membership James Meloche (Chair) Dr. Natalia Baziuk Dr. Navdeep Nijhawan Leslie Motz Dr. Frank Hassard Anna-Marie Sutherland Dr. Kylen McReelis Cheryl Coombes Dr. Bert Lauwers Dr. David Lane Ann Wehrstein Dr. Jordan Cheskes Rhodora Gutierrez Dr. Christroph Kranemann Dr. Jed Rabinovitch Nurallah Rahim Central East LHIN Lakeridge Health Lakeridge Health Lakeridge Health Northumberland Hills Hospital Northumberland Hills Hospital Peterborough Regional Health Centre Peterborough Regional Health Centre Ross Memorial Hospital Ross Memorial Hospital Ross Memorial Hospital Rouge Valley Health System Rogue Valley Health System The Scarborough Hospital The Scarborough Hospital The Scarborough Hospital The following individuals and group are acknowledged for their participation in the stakeholder consultation process. Additional Key Stakeholders Brad Hilker Campbellford Memorial Hospital Debbie Watson Haliburton Highlands Hospital Kevin Empey Lakeridge Health Linda Davis Northumberland Hills Hospital Helen Brenner Northumberland Hills Hospital Ken Tremblay Peterborough Regional Health Centre Brian Payne Ross Memorial Hospital Rik Ganderton Rouge Valley Health System Robert Biron The Scarborough Hospital Central East LHIN Primary Health Care Advisory Group Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e |7 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT The contributions from the Central East LHIN team are also appreciated, in particular to: Kelly Sanders, Heidi Winkelmann and Karen Poon for project, logistics and Expert Choice support respectively; and Marilee Suter and Alex Ruppert for their assistance in obtaining all of the data and providing select analyses – particularly procedures by patient geography– that have been included in this document. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e |8 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Executive Summary Context In alignment with the Ontario’s Action Plan for Health Care to improve patient care by gaining better value from Ontario’s health care system, the Ministry of Health and Long-Term Care (MOHLTC) established a Provincial Vision Strategy Task Force with respect to ophthalmology services. The Provincial Task Force developed a provincial planning framework along with 34 strategic recommendations for ophthalmology in Ontario in its May 2013 report, A Vision for Ontario: Strategic Recommendations for Ophthalmology in Ontario. Since the work of the Provincial Vision Strategy Task Force, the Central East LHIN has established a Central East LHIN Vision Plan Working Group (VPWG) to guide the development of a strategy and implementation plan that will foster a system of accountability and value for money, contributing to Ontarians’ access to high quality ophthalmology services when they need them most. This strategy has been developed under the umbrella of the Central East LHIN’s Clinical Services Plan (CSP) project, which envisions “One Acute Care Network” that will assume a collective leadership responsibility and accountability of LHIN hospitals in adopting a health system-wide approach to meet the hospital needs of Central East communities. Purpose and Scope of this Document This document presents to the Central East LHIN Board of Directors for its consideration and approval the VPWG’s “Directional Plan – Vision Care Strategy”. While a comprehensive view of the vision care system in Central East LHIN and Ontario can be construed broadly (and appropriately) to include notions of individual well-being and public health generally, this document is much more focused in scope. In particular, it is limited to inpatient and outpatient ophthalmic surgeries currently delivered by Central East LHIN hospitals and/or ophthalmic surgeries that are required by the Central East LHIN catchment area. However, it should be noted that the VPWG’s deliberations have taken into account the nuances of how people access vision care services before and after ophthalmic surgeries. This limited scope is not intended to minimize the importance of other vision care service providers, but is based on the need to manage the scope for this initial vision care project to a manageable size, with the intent on applying insights gained to future vision care planning initiatives. Process Undertaken Central East LHIN convened the VPWG in April 2014 to develop the Vision Care Directional Plan and engaged the vendor to support the work in June. The VPWG membership was selected to include one administrator and one or more ophthalmologists from the 6 hospitals (7 hospital Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e |9 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT sites) currently performing inpatient and outpatient ophthalmology surgeries in Central East LHIN. The VPWG subsequently undertook the bulk of its work from July through November 2014. The approach included and/or is expected to include the following steps: 1) Current State Assessment and Stakeholder Consultations 2) Development and Evaluation of Future State Options 3) Development of Recommendations and Draft Final Report 4) Review by Central East LHIN CEO Council and Review and Approval by the Central East LHIN Board of Directors Current State Assessment Ophthalmology services currently provided within the Central East LHIN have been recognized for the following strengths: The population in the Central East LHIN is currently well-served compared to the rest of Canada with hospitals performing well with respect to wait times for cataract surgeries Most patients can receive care close to home and in a reasonable amount of time. Access to retinal surgical procedures in most regions is perceived to be good. In certain regions, there is early screening of diabetic patients so that they could be treated with laser or less invasive procedures, potentially avoiding the need for vitrectomy; the overall vitrectomy rate for diabetes is lower in the Central East LHIN than other regions of Ontario. There exists 24/7 access to ophthalmology in most hospital Emergency Rooms. Going forward, Central East LHIN will experience the most significant population growth in the 65+ age group. The greatest increase in this age group will be found in Durham (expected population increase by 2023 is 38%). As a whole, the LHIN is a modest net exporter of procedure volumes, though most of its internal Health Link Areas are net exporters – i.e., more people leave those areas to get procedures done than come to them from others. In practice, this means that many people travel for their care, and many people travel to other LHINs for their care. To minimize travel for patients and also maximize the funds available for – and hence access to – vision care within Central East LHIN, the LHIN needs to build capacity in certain areas. Discussions with VPWG members indicate that the current service delivery is efficient and of high quality. The main concern the VPWG identified was access to subspecialty care. The focus of the Directional Plan – Vision Care Strategy is to address this concern and improve access to subspecialties. Directional Plan – Vision Care Strategy Given the above, the VPWG has developed this Directional Plan – Vision Care Strategy. This plan: reflects the “ideal state” of vision care for Central East LHIN within the next 3 years; and Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 10 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT includes an Implementation Plan that outlines how the Central East LHIN will make decisions about logistics (e.g. funding sources, specific accountabilities, and location of services or centers) going forward. During the Development and Evaluation of Future State Options phase of its work, the VPWG identified and evaluated two main options: 1) Distributive Model for Cataracts with One LHIN Centre with Subspecialties 2) Distributive Model for Cataracts with Two Cluster Centres with Subspecialties Note that for both of these options, cataract extractions will continue to be provided by the five existing hospitals in the Central East LHIN. The VPWG evaluated these two Options using the Central East LHIN Decision Making Framework and chose the Two Cluster Centres model, which creates two cluster centres and divides subspecialists across them. VPWG members judged that any economies of scale and scope associated with consolidating all subspecialties at a single existing cataract centre were not significant relative to potential access issues consolidation might create. Given the size, scale and infrastructure requirements of a cluster centre, these centers would be located at Lakeridge Health (Durham Cluster), and The Scarborough Hospital (Scarborough Cluster). Note that the specific distribution of specialists (e.g., Vitreoretinal) will be determined later through the implementation process. What the Directional Plan – Vision Care Strategy Means for Central East LHIN Briefly, this direction means that: Cataracts continue to be performed at existing sites for the foreseeable future Central East LHIN would add 4 subspecialists – vitreoretinal, glaucoma, corneal transplant, and pediatric Core capacity (i.e., cataract plus select subspecialties) will be concentrated at Lakeridge Health (Durham Cluster) and The Scarborough Hospital (Scarborough Cluster) Pediatric ophthalmology services would be situated at one of the two LHIN Cluster Centres All hospitals that provide ophthalmology services in the Central East LHIN will need to participate in one of the existing on-call coverage network in the region. This also includes a means of ensuring that the Central East LHIN captures as much as possible of the required services from its local catchment area and also ensuring that it is robust for the community. Following the development of the Vision Care Directional Plan, the Central East LHIN should establish an ongoing advisory board (similar to the existing VPWG) to oversee the implementation of the recommendations identified in the plan and make any additional Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 11 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT decisions going forward. This advisory board should also be given the mandate to support the LHIN in delivering on quality and sustainability commitments. 1. Context 1.1 Project Overview In alignment with the Ontario’s Action Plan for Health Care to improve patient care by gaining better value from Ontario’s health care system, the Ministry of Health and Long-Term Care (MOHLTC) furthered its commitment to ophthalmology patients by supporting the establishment of a Provincial Vision Strategy Task Force. The Provincial Task Force developed a provincial planning framework along with 34 strategic recommendations for ophthalmology in Ontario in its May 2013 report, A Vision for Ontario: Strategic Recommendations for Ophthalmology in Ontario. Since the work of the Provincial Vision Strategy Task Force, the Central East LHIN has taken the initiative to develop a regional strategy for ophthalmology. A Central East LHIN Vision Plan Working Group (VPWG) has been established to guide the development of a strategy and implementation plan that will foster a system of accountability and value for money, contributing to Ontarians’ access to high quality ophthalmology services when they need them most. The Central East LHIN Vision Plan Working Group (VPWG) has prepared this “Directional Plan – Vision Care Strategy” to inform future Central East LHIN decision-making with respect to resource allocation, quality improvement and access to services. In particular, it will provide direction regarding: 1) How vision care could be provided at a regional level; and 2) Where critical mass currently exists and/or needs to be developed for certain vision care services. 1.2 Central East LHIN Approach to Clinical Services Planning The Central East LHIN is one of 14 LHINs in Ontario responsible for working with local health providers and community members to manage and prioritize the health needs of its region. The mandate of the LHIN is to coordinate, integrate, and fund the local health system to achieve the intended purpose of the Local Health System Integration Act, 2006. In 2008 the Central East LHIN, launched a Clinical Services Plan (CSP) project to examine the feasibility of horizontal integration of health services in the region – specifically for hospital services. The CSP project Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 12 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT was intended to be a starting point for health services integration within the Central East LHIN, and a key stepping towards its goal of creating “One Acute Care Network”. The vision is that this single acute care network will assume a collective leadership responsibility and accountability in adopting a health system-wide approach to meet the acute care needs of its communities. With this guiding vision in place, the following overarching goals of the CSP project provided the necessary foundation upon which future clinical service delivery models for specific clinical programs: Improve quality and safety by grouping together clinical or medical/surgical specialists, their teams and appropriate physical resources Expansion or creation of new programs that would not otherwise be viable or sustainable at multiple sites Creation of operational and clinical efficiencies that would allow hospitals to focus on, and improve, their core programs Creation of new "centres of excellence" to allow Central East LHIN residents to receive services within the LHIN and as close-to-home as possible The CSP focused its initial efforts on integrating physicians and hospital based services in Thoracic Surgery, Cardiac Services, Vascular Surgery, Mental Health and Addictions and Maternal-Child-Youth-Services. Since 2009, similar regional hospital services planning has been conducted for Orthopedics, Hospital-based children psychiatry, and post-acute care (rehabilitation) services. The present document has been developed under the umbrella of the CSP, with the same vision and goals for clinical service delivery models in ophthalmology as with the others highlighted above. 1.3 Vision Care in Context Early in its deliberations, the VPWG highlighted the need to be clear about the scope of the present “Directional Plan – Vision Care Strategy” – that is, hospital inpatient/outpatient surgical procedures – and also to situate it within a larger context of what a broader network or comprehensive system of vision care should entail. Comprehensive vision care requires not only the assessment and treatment of those with visual impairment but also efforts across health system levels to provide quality care. 1.3.1 Perspectives on Comprehensive Vision Care Components The table below outlines key components of a vision care system and sample approaches to certain of these components from jurisdictions in the United States, Canada and Australia. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 13 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Table 1: Components of Comprehensive Vision Care Components Sample Perspectives on Components of Comprehensive Vision Care United States Canada Australia (Centre for Disease Control and Prevention) (Hamilton Niagara Haldimand Brant Local Health Integration Network) (Commonwealth of Australia) Engage leading organizations Engage key national partners Determine Centres of Excellence Collaborate locally Collaborate with state and local health departments Monitor and evaluate Focus care Implement surveillance and evaluation systems Monitor Eliminate health disparities and focus on at-risk populations A focus on Cataracts, Glaucoma, Retina, Cornea A focus on neuroophthalmology, pediatric ophthalmology Integrate vision care in relation to other relevant diseases Integrate vision health interventions into existing programs when appropriate System and policy change Preventative public health Include Systems and Policy changes Staffing Assure professional workforce development Establish an Applied Public Health Research Agenda Research Address behavioral changes Philosophy Maximize links across sectors and public health strategies from national and regional bases Develop and support partnerships as a means to achieving the best outcomes possible Focusing on high-risk groups who may be at higher risks for visual impairment or blindness Use life cycle approach to vision health as each age (child, youth, adult, senior) offers different needs Take a holistic approach where eye health is linked to health status and vision loss is linked to individual well-being Focusing on primary prevention to modify risk factors Research Use evidence arising from research and evaluation Consumer-oriented approach Sources: Martha Muzychka, “Environmental Scan of Vision Health and Vision Loss in the Provinces and Territories of Canada,” For the National Coalition for Vision Health, 2009, http://opto.ca/media/news-publications/Inside%20CAO/pdfsdocs/environmental-scan-of-vision-health-and-vision-loss-in-the-provinces-and-territories-of-canada.pdf; Michael Duenas and Jinan Saaddine, “Improving the Nation’s Vision Health - A Coordinated Public Health Approach” (Centre for Disease Control and Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 14 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Prevention, 2007), http://stacks.cdc.gov/view/cdc/6846; and Hamilton Niagara Haldimand Brant Local Health Integration Network, “Ophthalmology Clinical Services Plan,” April 2014. The perspectives above include some of the broadest possible views of a vision care system, characterizing comprehensive vision care as an important contributor to individual well-being and public health generally. These are useful perspectives that should be kept in mind as the Central East LHIN and province expand the scope of their vision care services. For purposes of this report, we can characterize the continuum as outlined below in Figure 1: Vision Care System Continuum. Primary Role(s) Vision Care System Element System Policy, Surveillance and Monitoring LHIN and Public Health System Prevention, Care Optometric Vision Care and Primary Care Local Collaboration Community-Based Ophthalmic Vision Care Integrated, Focused Care Hospital-Based Specialized Ophthalmic Vision Care (Surgical and Medical) Figure 1: Vision Care System Continuum At present, the scope of the work completed by the Provincial Task Force and now the Central East LHIN is deliberately limited. These scope limitations are not intended to minimize the importance of other vision care services providers, but are based on the need to manage the scope for this initial vision care integration project to a manageable size, with the intent on applying insights gained to future vision care planning initiatives. The Provincial Task Force looked at “…[improving] access to emergency and scheduled surgical, medical and diagnostic ophthalmology services for all Ontarians, including adult and pediatric populations” and specifically excluded “…routine eye care, optometrist services, optical services, and orthoptic services.”1 The work of the Central East LHIN VPWG has, like that of HNHB LHIN, identified a particular focus of care as described in the next section. At the same time, it recognizes that this indeed 1 Provincial Vision Strategy Task Force. “A Vision for Ontario - Strategic Recommendations for Ophthalmology in Ontario,” May 2013, p. 13 [italics in original] Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 15 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT requires a focus, and represents just one part of what a larger vision care system will ultimately entail. 1.4 Project Scope Recognizing that there is a continuum of vision care that links to the broader continuum of care for all of Central East LHIN’s population, the scope of this Directional Plan – Vision Care Strategy is limited on inpatient and outpatient ophthalmic surgeries currently delivered by Central East LHIN hospitals and/or ophthalmic surgeries that are required by the Central East LHIN catchment area. However, it should be noted that the VPWG’s deliberations have taken into account: a) The nuances of how people access vision care services before and after ophthalmic surgeries; and b) That ophthalmic surgeries are ophthalmic surgeons’ relationships to the hospitals at which they have privileges are not conventional – ophthalmologists maintain their own practices in the community at which many other procedures are performed. They are usually at hospitals only for specific periods of time and generally have fewer connections to hospitals, their administration, and operations than surgeons do in other disciplines. 1.5 Approach Central East LHIN convened the VPWG in April 2014 to develop the Vision Care Directional Plan and engaged the vendor to support the work in June. As detailed in the Acknowledgements section above, the VPWG membership was selected to include: one administrator; and one or more ophthalmologists from the 6 hospitals (7 hospital sites) currently performing inpatient and outpatient ophthalmology surgeries in Central East LHIN. The VPWG subsequently undertook the bulk of its work from July through November 2014. The approach included and/or is expected to include the following steps: 1) Current State Assessment and Stakeholder Consultations 2) Development and Evaluation of Future State Options 3) Development of Recommendations and Draft Final Report 4) Review by Central East LHIN CEO Council and Review and Approval by the Central East LHIN Board of Directors Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 16 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT 1.5.1 Current State Assessment and Stakeholder Consultations The first step in the VWPG’s work was the development of a Current State Assessment report; the report’s findings appear in this document in slightly modified form as the “Current State Analysis Section”. The data and information for this assessment was collected by means of stakeholder consultations (primary data collection), secondary data analysis, and a literature scan. An overview of each of the approaches is provided in the table below. Table 2: Current State Assessment Components Current State Assessment Component Stakeholder Consultations (Primary Data Collection Secondary Data Analysis Literature Scan Description Stakeholder engagement consisted of: Interviews with VPWG members A survey of VPWG members Interviews with Central East LHIN hospital CEOs A consultation with the Primary Health Care Advisory Group Note that optometrists were not consulted as part of the process. Secondary data and analyses relevant to the project’s scope and research questions were accessed and analyzed. The results from the data analysis were shared with the VPWG for feedback at the August 13th meeting. Comments from the group members are incorporated into the present report. While the scope of the project focuses on ophthalmology procedures completed in-hospital, VPWG members expressed interest at the July 15th meeting in focusing the literature review on the larger context of what a comprehensive system of vision care should entail. Accordingly, a brief literature scan was conducted with a focus on: Components of a comprehensive vision care model Service delivery models in ophthalmic care Telemedicine trends in ophthalmic care Subsequent discussion suggested that a scan for materials on building relationships between physicians/clinicians and specialists (or primary care physicians/optometrists and ophthalmologists) as well as strategies for LHINs to manage volumes in a Health System Funding Reform context would be helpful – these are included in the Literature Scan section. The findings from this Literature Scan are reflected in the “Vision Care in Context” section above as well as the VPWG’s deliberations and recommendations more generally. 1.5.2 Development and Evaluation of Future State Options Following review of the Current State Assessment, the VPWG defined 7 Key Procedures and Populations to organize deliberations for the Directional Plan – Vision Care Strategy. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 17 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Table 3: Key Procedures and Populations for the Directional Plan – Vision Care Strategy Number Procedure/Population Description 1 Cataract Extraction Surgical removal of the natural lens of the eye that has developed a cataract, followed by the implant of artificial intraocular lens to restore useful vision. 2 Surgical Retina, Surgery of the retina to treat diabetic retinopathy or Vitrectomy repair retinal detachment/to remove small portions or all of the vitreous tissue Surgery to remove blood and membranes, treat macular holes 3 Glaucoma Surgery Surgery to reduce the intraocular pressure either by laser treatment or conventional surgery 4 Corneal Surgery Surgery to treat, remove or replace diseased corneal tissue 5 Oculoplastics Surgical procedures that deal with the eye socket, eyelids, tear ducts, and the face 6 Pediatric Procedures targeted for pediatric patients, defined Ophthalmology as individuals under 20 years of age; these could include cataracts, NICU/medical retina, corneal procedures, strabismus, surgical retina, and others. 7 Urgent/Emergent Means of providing care through/for: Care Regional call system, 24/7 coverage Trauma, ruptured globes Other Urgent/Emergent requirements For each of the above procedures and populations, the VPWG defined how vision care should be delivered for each in terms of 8 dimensions outlined below in Table 4: Future State Procedure/Population Dimensions. Table 4: Future State Procedure/Population Dimensions Number Procedure/ Population 1 Service Delivery Model Description of Future State 3 Delivery models are proposed, based on Central East LHIN definitions: Local Centre: Services needed by the local population are access through a local facility. Local Centres function as part of a larger Cluster- or LHIN-oriented approach to service delivery (e.g., referral, on-call arrangements) – they do not represent the status quo and/or working on a Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 18 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Number Procedure/ Population 2 3 4 5 6 7 8 Number of Sites Proposed Volume Levels per Site Infrastructure /Equipment Requirements Health Human Resources Requirements Description of Future State standalone basis. Cluster Centre: Services are located at one institution for populations with several or many surrounding communities LHIN Centre*: Specialized services that will promote access LHIN-wide. Programs may be located at 1 or 2 sites. With respect to Vision Care, a LHIN Centre would include 2 or more sub-specialties in a “center of excellence” model Number of sites within the LHIN providing the service What volumes should be proposed per site? What infrastructure must be in place? What equipment is required (to meet the standard of care)? What is required in terms of: Administrative capacity Physician (ophthalmology, anesthesiologist) capacity Support staff (nursing) How referrals will flow/be driven through marketing and relationships to the centre Strategy for Influencing Referral Practices Quality/ Process Improvements Other Any quality or process improvements that should be made, such as: Common intake and referral Clinical Pathways Post-operative follow-up commitment As required Applicable client service/accountability/relationship requirements Over the course of two facilitated sessions on September 4th and 23rd, the VPWG developed Future State Options at the: Key Procedure and Population level (how care should be delivered for each procedure or population); and Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 19 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT LHIN-Wide level (how the vision care services for the Key Procedures and Populations should be distributed across Central East LHIN). VPWG members subsequently evaluated the Future State Options in terms of the Central East LHIN’s Decision Making Framework electronically using Expert Choice Software. Each hospital had one administrator and one ophthalmologist (or ophthalmologist delegate) submit evaluations to ensure equally weighted representation among the Central East LHIN hospitals that perform inpatient and outpatient ophthalmology surgical procedures. 1.5.3 Development of Recommendations and Draft Final Report Following the options evaluation, the Central East LHIN team and the VPWG worked together to develop final recommendations, based on discussions to date with the VPWG, Future State Options selected by the VPWG, and feedback gathered during the stakeholder consultation process. Subsequently, a Draft Final Report was developed on behalf of the VPWG for review at a working session on October 28th. Edits were subsequently made before presenting the Draft Final Report to the Central East LHIN CEO Council and the Central East LHIN Board of Directors. 1.5.4 Review/Approval by Central East LHIN CEO Council and Board of Directors This Draft Final Report will be presented to the Central East LHIN CEO Council for review, and then subsequently presented to the Central East LHIN Board of Directors for review and ultimate approval. 2. Key Definitions 2.1.1 Procedure Types While the Key Procedures and Populations have been defined as described above, this report analyzes the following procedures completed in inpatient and outpatient settings of Central East LHIN hospitals: Cataract surgery Low volume, high-risk procedures: Glaucoma Surgery Medical Retina Surgical Retina Tube Shunt Surgery Others that are defined as a “Level 4” procedures Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 20 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Procedures analyzed within this report have been grouped based on definitions established by the Provincial Vision Strategy Task Force. The Provincial Task Force divided Canadian Classification of Health Interventions (CCI) procedures into 48 procedure groupings. These groupings were then assigned to one of four levels, based on the experience required by the attending physician. These four levels are presented in the table below: Table 5: Procedure Levels Defined by the Provincial Vision Strategy Task Force2 Level Level 1 Level 2 Level 3 Level 4 Description Procedure can be completed by 2nd and 3rd year residents with supervision, or by a general ophthalmologist Procedure can be completed by 4th and 5th year residents with supervision, or by a general ophthalmologist Procedure is usually, although not exclusively, completed by a subspecialist or fellow with supervision Procedure is completed by a subspecialist using special equipment or in an operating room setting See Appendix 1 of this report for the 48 procedure groupings and associated levels. Note that the Central East LHIN VPWG does not necessarily endorse these groupings; however, they provided the working framework for analysis during the Current State Assessment phase of its work. Appendix 7 of the Task Force report contains a full list of CCI codes, their assigned Level (1 through 4), and “Procedure Group Rollup” headings. The Central East LHIN’s Decision Support Team provided data to the consulting team that had been aggregated according to the “Procedure Group Rollup” nomenclature. Data was suppressed in cases when sample sizes were smaller than 5 (in order to protect patient privacy). Procedure Group Rollup Headings are presented in the table below. 2 A Vision for Ontario: Strategic Recommendations for Ophthalmology in Ontario. The Provincial Vision Strategy Task Force (2013) Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 21 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Table 6: Procedure Group Rollup Headings by Level (Provincial Vision Strategy Task Force) 3 Level Level 1 Level 2 Level 3 Level 4 Procedure Group Rollup Heading Glaucoma Surgery Other Cataract Extraction Corneal Procedures Glaucoma Surgery Medical Retina Other Corneal Procedures Glaucoma Surgery Other Strabismus Surgical Retina Glaucoma Surgery Medical Retina Other Surgical Retina Tube Shunt Surgery 2.1.2 Facilities Surgical ophthalmology procedures are currently completed by 6 hospitals and 7 sites in the LHIN. Hospital site names and abbreviations used in this report are shown below: Table 7: Central East LHIN Vision Care Hospital and Site Abbreviations Abbr. TSHB RVC LHB LHO PRHC RMH NHH 3 Hospital The Scarborough Hospital – Birchmount Campus Rouge Valley Health System – Centenary Site Lakeridge Health – Bowmanville Site Lakeridge Health – Oshawa Peterborough Regional Health Centre Ross Memorial Hospital Northumberland Hills Hospital A Vision for Ontario: Strategic Recommendations for Ophthalmology in Ontario. The Provincial Vision Strategy Task Force (2013) Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 22 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT 3. Current State Assessment This section provides an overview of the Central East LHIN together with analyses that ask and answer key questions about the populations’ current and future needs for surgical ophthalmology services in future. 3.1 Description of Central East LHIN The Central East LHIN is a mix of urban and rural geography and is the sixth-largest LHIN in land area in Ontario (16,673 km2). As of 2011, the LHIN had a population of 1.57 million people, or 11.8% of Ontario’s population. Figure 2: Central East LHIN by Cluster Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 23 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT The LHIN’s boundaries extend from Victoria Park in Scarborough, north to Algonquin Park in Haliburton County and to Lake Ontario along the southern border. The LHIN is divided into 3 planning clusters: North East, Durham and Scarborough. 3.2 What are the Central East LHIN Population’s Vision Care Needs? Key Questions for this Section: What are the current and future vision care needs for Central East LHIN? What can we learn from current population demographics? What can we predict based on future population projections? 3.2.1 How Central East LHIN’s Population Will Grow in Future Central East LHIN’s overall population will increase for the next 25 years, with particularly rapid growth in the 65+ segment. The 0–20 population is expected to be stable over the next 5 years, after which it will begin to increase significantly. Total Projected Population by Age Group: Central East LHIN 2,500,000 2,000,000 1,500,000 1,000,000 500,000 0 2011 2013 2015 2017 2019 2021 2023 2025 2027 2029 2031 2033 2035 0-20 21-44 45-64 65+ Data Source: IntelliHealth Figure 3: Total Projected Population by Age Group in Central East LHIN Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 24 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT 3.2.2 How Central East LHIN’s Regional Populations Will Grow in Future Projected Population Growth: Ages 0-20 Projected Population Growth: Ages 21-44 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 2011 2016 2021 2026 2031 2036 2011 2016 2021 2026 2031 2036 CELHIN TORONTO CELHIN TORONTO PETERBOROUGH NORTHUMBERLAND PETERBOROUGH NORTHUMBERLAND KAWARTHA LAKES HALIBURTON KAWARTHA LAKES HALIBURTON DURHAM REG. MUN. DURHAM REG. MUN. Data Source: IntelliHealth Data Source: IntelliHealth Projected Population Growth: Ages 45-64 Projected Population Growth: Age 65+ 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 2011 2016 2021 2026 2031 2036 2011 2016 2021 2026 2031 2036 CELHIN TORONTO CELHIN TORONTO PETERBOROUGH NORTHUMBERLAND PETERBOROUGH NORTHUMBERLAND KAWARTHA LAKES HALIBURTON KAWARTHA LAKES HALIBURTON DURHAM REG. MUN. Data Source: IntelliHealth DURHAM REG. MUN. Data Source: IntelliHealth Figure 4: Projected Population Growth by Age Group The most significant population growth will be observed in the 65+ age group, as seen in the charts above, and the table below. The greatest increase in this age group will be found in Durham (expected population increase by 2023 is 38%). Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 25 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Table 8: Projected Population Growth for Individuals Aged 65+ by Region Region DURHAM REG. MUN. HALIBURTON KAWARTHA LAKES NORTHUMBERLAND PETERBOROUGH TORONTO Central East LHIN % Increase Population Size from 2013 to 2018 (magnitude of increase provided in brackets) 21.1% (+22,359) 13.2% (+7,48) 13.0% (+2,586) 15.4% (+3,554) 12.9% (+4,371) 12.3% (+12,375) 15.9% (+45,993) % Increase in Population Size from 2019 to 2023 (magnitude of increase provided in brackets) 37.8% (+50,675) 25.5% (+1,680) 26.1% (+6,120) 28.6% (+7,840) 25.5% (+10,008) 24.0% (+27,844) 30.0% (+104,239) Data Source: IntelliHealth 3.2.3 The Current Prevalence of Diabetes in Central East LHIN Based on 2012 data, diabetes prevalence within Central East LHIN is 10.9%, compared to a provincial average of 10.2%4. The map presents diabetes prevalence by Health Link. Diabetes prevalence is highest within the Northumberland Health Link. Figure 5: Diabetes Prevalence in Central East LHIN by Health Link Region 4 Key Performance Measures for the Ontario Diabetes Strategy Final Report. Health Analytics Branch (2013) Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 26 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT 3.2.4 How the Need for Procedures is Expected to Grow Projected need for procedure volume was calculated based on the number of procedures completed within the LHIN in FY 2011 and FY 2012. The calculation is based on Central East LHIN residents, and did not include inflow volumes from other LHINs. Actual future need may vary based on changes in inflow/outflow patterns. In addition, the need projection is derived from current utilization numbers, and therefore did not account for any unmet needs. Projected Number of Procedures by Volume 15,000 10,000 5,000 - DURHAM REG. MUN. KAWARTHA LAKES PETERBOROUGH HALIBURTON NORTHUMBERLAND TORONTO Figure 6: Projected Number of Procedures by Volume Data Source: IntelliHealth By 2014 the largest percentage of total volume of need will shift from Scarborough to Durham; that gap will continue to increase over time. By 2022 the projected need in Durham will be over 10,000; currently it is slightly over 7,000. 3.3 Where are Central East’s Strengths and Opportunities in Vision Care? Key Analysis Questions for this Section: What is currently working well for vision care in the Central East LHIN? What are the opportunities for improvement? Where does vision care in the Central East LHIN need to be in the next five years? 3.3.1 Areas of Strength Ophthalmology services currently provided within the Central East LHIN have been recognized for the following strengths: Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 27 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT The population in the Central East LHIN is currently well-served compared to the rest of Canada. Hospitals are performing well with respect to wait times for cataract surgeries; wait times for cataract surgeries in the Central East LHIN are shorter compared to the wait at some of the other LHINs. Most patients can receive care close to home and in a reasonable amount of time. The Scarborough cluster has shifted towards concentrated cataract centres. It is anticipated that this shift will result in economics of scale, better quality and lower costs of delivery. Access to retinal surgical procedures in most regions is perceived to be good. In certain regions, there is early screening of diabetic patients so that they could be treated with laser or less invasive procedures, thereby avoiding the need for vitrectromy. The overall vitrectomy rate for diabetes is lower in the Central East LHIN than other regions of Ontario. There exists 24/7 access to ophthalmology in most hospital Emergency Rooms. 3.3.2 Opportunities for Improvement The VPWG stakeholders have recognized the following areas as potential opportunities for improvement in the future as the Central East LHIN continues to grow its volumes and enhance the quality of its services: There is general consensus among VPWG members that there is a gap in pediatric ophthalmology. In order to repatriate some of the pediatric cases that currently leave the Central East LHIN, a possible option is hire a pediatric ophthalmologist who would service that target population. The expansion of glaucoma sub-specialty services in the Central East LHIN by recruiting a specialist in the area. Increase access to certain specialty services (e.g., retinal, oculoplastics). All hospitals that currently provide ophthalmology services in the Central East LHIN to offer 24/7 access to ophthalmology services. Integrated electronic medical records for ophthalmology to minimize the amount of paperwork involved. Create a one-stop shop experience for patients so that they could receive all necessary diagnosis and procedures on a single day without being required to visit the hospital multiple times. Ophthalmology to build greater integration with other specialties in health care (e.g., renal care for diabetes) to provide a seamless experience for patients and ensure that certain patients do not “fall through the cracks”. The possibility of consolidating all retina surgeries to a single site has been discussed as part of stakeholder consultations. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 28 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Review and promote standardized care and equipment across all hospitals in the Central East LHIN so that patients receive the same care and experience regardless of which hospital facility they go to. Increase transparency and engagement with the physician group during the allocation of volumes. 3.4 What is Central East LHIN’s Capacity to Meet Population Needs? Key Analysis Questions for this Section: What is the current capacity to deliver on community needs? How many ophthalmologists and sub-specialists work in the LHIN? How many ophthalmologists will be retiring? How available/accessible are equipment and health human resources? 3.4.1 Ophthalmologists/HHR Hospitals within Central East LHIN were asked how many ophthalmologists provide services within their hospital, and whether any were sub-specialized. Results are presented in the table below. Table 9: Number of Ophthalmologists per Hospital (Including Subspecializations) Total Ophthalmologists (general + subspecialists) with hospital privileges within the LHIN Sub Specialists Pediatric & General Ophthalmology Vitreoretinal Surgery Oculoplastics LHC 6 NHH 1 Hospital PRHC RMH 4* 2 RVHS TSHB 1 10 1 1 1 1 *PHRC has one general ophthalmology locum placement that was not counted in this table Data was also compiled on ophthalmologists’ age indicating that: At present, 8 of 26 (approximately 30%) of ophthalmologists are 60+ Holding all else equal, approximately 30% will be 65+ in 5 years Consultations with stakeholders indicated that the scope of practice for optometrists has progressively expanded to include (but not limited to) primary care, screening and prescription. In addition, financial incentives are made available to primary care providers who refer their patients to optometrists. As this trend continues, it is anticipated that service gaps that might Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 29 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT result from the retirement of ophthalmologists would likely be filled by the increasing involvement of new graduates from surgical ophthalmology training programs. 3.4.2 Training Programs At present, most hospitals in the Central East LHIN do not have formal agreements with universities to provide ophthalmology training or residency programs. The only exception is Lakeridge Health, which is one of five centres in Canada offering a fellowship/residency placement in oculoplastics and reconstructive surgeries through the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASPORS). Other hospitals have indicated that they occasionally accept students from universities to come to the hospital, observe and learn in an informal manner. For example, Peterborough Regional Health Centre indicated that in the past they have accepted 5th year residents from Queen’s University as part of their community rotations. While there was general consensus that ophthalmologist retirement will not result in an immediate resourcing issue, it was identified that partnerships with academic institutions and succession planning are potential strategies to mitigate any risks associated with decreasing access to health human resources. 3.4.3 Hospital-Based Ophthalmology Equipment Hospitals in the Central East LHIN were surveyed on the types and number of ophthalmic surgical capital equipment on site. Findings indicated that current equipment is appropriate to the services provided in the LHIN. 3.4.4 “Flow-Limiting” Factors Interviews with VPWG members indicated that potential constraints on the volume of procedures include the following, though specifics differ by procedure: Physician capacity Anesthesiology coverage and/or 24/7 anesthesiologist coverage Ability of patients to travel to facilities to receive care Skilled/dedicated nursing staff to support procedures, as well as pre- and post-op Operating room time and privileges Access to specialized equipment (for select procedures) Funding and allocated volumes VPWG members indicated that the principal constraints in practice were: Physicians with requisite subspecialty training for certain procedures Access to specialized equipment for select procedures Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 30 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Funding and allocated volumes In general, ORs were not fully utilized for all hours of the day or all weeks of the year – e.g., some operated approximately 5-8 hours per day for 30-40 weeks per year before reaching their volume allocations. 3.5 How is Vision Care Currently Utilized in Central East LHIN? Key Analysis Questions for this Section: What does current service utilization look like? Utilization by age, procedure type, level, facility and patient geography What inflow/outflow patterns exist? What is causing outflows? (referral patterns vs. access challenges) How are services being used by diabetics? 3.5.1 Procedures Volumes by Age The figure below shows that: 97% of patients who had an ophthalmologic procedure were 45+ 78% of patients who had an ophthalmologic procedure were 65+ Procedure Volumes by Age (FY 2012) 0% 1% 21% 0-20 21-44 45-64 78% 65+ Data Source: IntelliHealth Figure 7: Procedure Volumes by Age (Fiscal Year 2012) Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 31 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT The table below presents a listing of all procedures performed for individuals under 20 years of age within Central East LHIN from FY 2010-2012. Due to privacy considerations, total number of procedures was not provided for facilities that performed fewer than 5 surgeries. Table 10: Ophthalmology Procedures for Patients Under 20 (Fiscal Year 2012) Procedure Level 2 -Cataract Level 2 - Medical Retina Level 2 - other Level 3 - Corneal Procedures Level 3 – Other Level 3 – Strabismus Level 4 - Other Level 4 –Surgical Retina TSHB PRHC 5 5 RVC - Facility LHB LHO 5 7 - Total RMH - NHH - 12 17 - - - - - - - - 7 - - 8 - 13 6 5 - - - 16 15 6 6 –“ Denotes between 0- 5 procedures Findings: Approximately 80 pediatric procedures were completed over the 3 years, resulting in an average of approximately 27 procedures per year in Central East LHIN All procedures were Level 2 or greater LHB performs the majority of the LHIN’s pediatric procedures VPWG Commentary Pediatric ophthalmology services are a major gap in the LHIN; most cases under the age of 5 are being sent out of the LHIN Neo-natal ICU patients are seen at the nursery until they are deemed stable, but it is up to the pediatrician to determine how to get further follow-up for the patient. Ophthalmologists could not be sure that this follow-up care was consistently taking place. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 32 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT 3.5.2 Procedures Volumes by Site The figures below present the 3-year trend in procedure volumes by hospital and the share of procedures by Level. Procedure Volumes by Hospital from FY 2010-2012 8000 7000 6000 5000 4000 3000 2000 1000 0 2010 TSHB 2011 PRHC RVHS LHB 2012 LHO RMH NHH Figure 8: Procedure Volumes by Hospital (Fiscal Years 2010-2012) Procedure Volume by Level Level 3 1.6% Level 4 2.2% Level 1 1.8% Level 2 94.5% Data Source: IntelliHealth Figure 9: Procedure Volume by Level Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 33 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Findings: The largest procedure volume was conducted by TSHB, followed by LHB. LHO completed the fewest procedures A large majority of procedures are Level 2 The most common procedure was cataract extraction, which accounted for 92% of all procedures performed. According to the Provincial Vision Strategy Task Force Report, there are currently 67 hospitals and 1 independent facility (Kensington Eye Institute) performing cataract surgeries in hospitals. TSHB and LHB both fall within Ontario’s top 10 facilities for volume of cataract procedures. Table 11: Top 10 Ontario Cataract Centres by Volume LHIN Champlain Toronto Central Central Central East HNHB Erie St. Clair HNHB Central East Central Central West Facility The Ottawa Hospital Kensington Eye Institute Toronto North York General TSHB Niagara Health System Hotel-Dieu Grace St Joseph’s LHB Southlake Regional William Osler Volume of Cataracts 10,384 9,180 8,122 6,619 5,600 5,341 5,314 5,298 4,872 4,599 Data Source: Provincial Vision Strategy, p. 26 The chart below depicts the proportionate “market share” each hospital has for each procedure level. Note that Level 2 procedures make up 94.5% of all ophthalmology procedures completed across the LHIN. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 34 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Proportion of Procedures by Hospital (FY 2010-2012) All levels Level 4 Level 3 RVHC 8.0% TSHB 34.4% LHB 30.1% RVHC 64.0% LHO 22.2% TSHB 15.9% LHB 59.9% TSHB 35.5% Level 2 Level 1 RMH 8.8% LHB 30.5% LHB 50.0% 0% TSHB 10% RVHC NHH 5.9% RMH 8.9% LHO PRHC 0.6% 12.1% 20% 30% LHB PRHC 40.5% 40% LHO 50% PRHC 60% RMH 70% NNH 80% 90% 100% Data Source: IntelliHealth Figure 10: Proportion of Procedures by Hospital (Fiscal Years 2010-2012) TSHB and LHB complete the majority of the procedures in the LHIN RVHC completes the most Level 4 procedures (64%) TSHB and LHB perform a large proportion of the LHIN’s Level 2 procedures (Level 2 procedures are the main type of procedure completed in hospitals); see table below: Table 12: Percent of Ophthalmology Procedures that are Level 2 by Hospital Hospital TSHB RVHC** LHB LHO* PRHC RMH NHH Percent of all Ophthalmology Procedures that are Level 2 99.2% 80.6% 95.8% 8.0% 98.3% 82.6% 100.0% *Level 2 procedures are completed at LHB; the 8% observed percentage may have resulted from a data coding issue **RVHC’s cataract program has been divested in 2012; this volume of Level 2 procedures is no longer accurate Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 35 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Overall Findings for Procedure Volumes: 95% of all procedures are Level 2 Level 2 procedures account for ~80% to 90% of procedure volume ate each site, with the exception of LHO, which appears to specialize in Level 4 procedures TSHB and LHB have the highest volumes in the Central East LHIN. This consists of primarily Level 2 and Level 3 procedures. RVC and LHO have the highest volumes for Level 4 procedures with 64.0% and 22.2% respectively. LHB's volume for Level 3 procedures is ~60% which is significantly higher than the other sites in the Central East LHIN. 3.5.3 Procedures by Geography A GIS tool was used to depict where patients visiting a hospital for an ophthalmology procedure were coming from. One figure has been created for each hospital site. Note the size and shape of the single, large ellipse found on each diagram. The ellipse represents the “average” geography that patients are coming from. A smaller ellipse indicates that most patients come from within a smaller geography, while a large ellipse indicates patients are more spread out. The tilt of the ellipse indicates which direction patients are spread out in. It is also important to note the relative placement of the facility being examined, within the ellipse. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 36 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Figure 11: Geographical Distribution of Ophthalmology Procedure Patients for TSHB Figure 12: Geographical Distribution of Ophthalmology Procedure Patients at LHB TSHB and LHB These two sites represent the largest volumes in the Central East LHIN. Of note: TSHB, which has the highest inflow (patients coming from other LHINs) percentage has an ellipse very much focused in the Central East LHIN. The direction of the ellipse (North East) indicates that TSHB services the northern part of the Central East LHIN very well. LHB’s ellipse is more southwesterly, indicating that it mainly services the Durham and Scarborough area. Considering LHB’s location within the LHIN, one might expect a stronger relationship between LHB and the LHINs northern residents. There is a large degree of overlap in these ellipses. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 37 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Figure 13: Geographical Distribution of Ophthalmology Procedure Patients for LHO Figure 14: Geographical Distribution of Ophthalmology Procedure Patients for TSHB LHO and RVC LHO and RVC focus mainly on Level 4 (difficult/specialized) cases and hence have lower volumes. RVC has a very circular ellipse, which indicates is provides services equally to the Central, Toronto Central and Central East LHIN residents. LHO’s ellipse is very much east/west and focuses almost exclusively on Central East LHIN residents. Its placement within the ellipse indicates that is focuses mainly on Central East LHIN residents in the eastern section of the LHIN. There is relatively little overlap between these two ellipses. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 38 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Figure 15: Geographical Distribution of Ophthalmology Procedure Patients for RMH Figure 16: Geographical Distribution of Ophthalmology Procedure Patients for TSHB RMH and PRHC Both of these ellipses show a strong relationship between the facility and the residents closest to them. There is very little pull towards the Durham or Scarborough Health Links. RMH shows a very northerly slant to its ellipse. This indicates that its services the Central East LHIN northern residents. PRHC’s ellipse has a slight north-easterly slant. This is mainly caused by the facilities coverage in the eastern Peterborough Health Link, as well as some volume from the South East LHIN. Removing these influences would show a more north/south ellipse which would be expected based on the population in that area. PRHC also services the Central East LHIN northern residents well. There is a slight overlap in the ellipses, but overall the ellipses show a balanced coverage of the Central East LHIN northern Health Links. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 39 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Figure 17: Geographical Distribution of Ophthalmology Procedure Patients for NHH Figure 18: Ophthalmology Procedure Coverage Areas by Hospital Site NHH NHH’s ellipse shows that it provided services for the Central East LHIN almost exclusively with the Northumberland Health Link. However, there is a very strong pull to the south toward the HNHB LHIN, indicating that approximately 40% of NHH’s total patient volume is traveling from HNHB LHIN to NHH for surgery; the ophthalmologist that provides services at NHH also has an office in Hamilton. While patient travel is heavily influenced by ophthalmologists’ practice locations and referral patterns, patient choice is also factor dependent on willingness and ability to travel, wait times, and other variables. Efforts going forward should likely focus on understanding NHH’s referral patterns in more detail and working to ensure that NHH serves its catchment area and controls spending of Central East LHIN resources on residents from HNHB and other LHINs. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 40 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT 3.5.4 Current Volumes vs. Estimated Capacity Based on discussions with VPWG members and survey results, many have indicated that their hospitals have dedicated Operating Rooms or Eye Clinics (with associated equipment) for cataract surgeries and/or other ophthalmic surgeries. Since most of these Operating Rooms or Eye Clinics are not currently in operation for the entire year, there is physical capacity for hospitals to expand on the volumes and types of ophthalmic surgeries that are performed annually. The survey also indicated that all VPWG member hospitals in the Central East LHIN have 24/7 ophthalmology access to anesthesiologists. However, most hospitals also stated that while they are not limited by physical capacity/space, their ability to perform additional volumes is limited by operating funds that are needed to ensure there are appropriate health human resources available to support the surgeries. 3.5.5 Referral Patterns Based on consultations with VPWG members, it was identified that referral for inpatient and/or outpatient ophthalmic surgeries at the hospitals generally occur from the following: 5 Optometrists Primary care providers Hospital Emergency Rooms Ambulatory clinics Ophthalmologists’ clinics Key factors that are considered when making a referral include, but are not limited to: A patient’s conditions Availability of specific services and specialized equipment Wait list A patient’s preference Past experience of a family member Existing referral patterns to Ophthalmologists Quality of results 3.5.6 Inflow/Outflow of Patients to/from Central East LHIN Overall Findings: Of the 18,361 Central East resident who had an ophthalmology procedures, 4,217 opted to have the procedures performed OUTSIDE the Central East LHIN (Outflow = 23%) 5 Since this is a Directional Plan, optometrists and primary care providers were not involved for the current state report; however, primary care will be engaged by the Central East LHIN during the Future State Model Development. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 41 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT 3,797 patients from outside the Central East LHIN opted to have their ophthalmology procedure performed INSIDE the Central East LHIN (Inflow = 21.2%) As expected there was some movement of residents across LHINs that share borders with the Central East LHIN (Toronto Central, Central and South East) 2,092 Central LHIN residents had procedures performed within the Central East LHIN, while 1,669 Central East LHIN residents went to the Central LHIN. (+/- = +423) 357 South East LHIN residents had procedures performed within the Central East LHIN, while 169 Central East LHIN residents went to the South East LHIN (+/- = +188) 429 Toronto Central LHIN residents had procedures performed within the Central East LHIN, while 2,120 Central East LHIN residents went to the Toronto Central LHIN (+/- = 1,691) TSHB and NHH account for 72% of the Central East LHIN inflow (based on 3 years of data, FY 2010-2012) Outliers: 490 HNHB LHIN residents had procedures performed within the Central East LHIN. Based on numbers from other LHINs the expected number would be less than 100. Further examination of the HNHB data shows that 96% (469) of the procedures were performed at NHH, which is the most easterly Central East LHIN hospital to offer ophthalmology services. Additional examination shows that one physician has practices in both locations. Table 13: Central East LHIN Inflows and Outflows LHIN Name Central Toronto Central Central West Champlain Erie St. Clair Hamilton Niagara Haldimand Brant Mississauga Halton North Simcoe Muskoka North East North West South East South West Waterloo-Wellington Unknown Total inflows/outflows Percentage Central East LHIN Outflows Central East LHIN Inflows (# of patients leaving Central East LHIN for procedures) (# of patients entering Central East LHIN for procedures) 1669 2120 21 16 2 12 96 97 4 169 11 4,217 23.0% (Outflows) 2092 429 83 22 3 490 92 64 12 9 357 13 8 119 3,797 21.2% (Inflows) Data Source: IntelliHealth (FY 2012) Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 42 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Inflow Volumes by Hospital 3000 2500 2000 1500 1000 500 0 2010 2011 2012 TSHB PRHC RVHS LHO RMH NHH LHB Figure 19: Central East LHIN Inflow Volumes by Hospital Data Source: IntelliHealth TSHB and NHH accounted for 73% of the LHIN’s 2012 inflows, each bringing in 61% and 14% of the LHIN’s total volume, respectively. The graph below identifies the percentage of a hospital’s procedure volume that is dependent upon inflows. Percent of Hospital Procedures that are Inflows 50% 40% 30% 20% 10% 0% 2010 TSHB PRHC 2011 RVHS LHB 2012 LHO RMH NHH Figure 20: Percentage of Hospital Procedures that are Inflows The proportion of NHH’s procedure volume that comes from inflows has increased from 11% to 43% over a 3-year period RVHS’ inflow volumes have decreased from 32% to 24% over 3 years TSHB maintains a high, steady volume of inflows (~40%) Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 43 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT The following figures and tables divide out Central East LHIN’s inflows and outflows by procedure type: Outflow Procedures by Volume 3% Inflow Procedures by Volume Cataract Removal/ Lens Insertion 8% 3% 1% Cataract Removal/ Lens Insertion Vitrectomy/ Retinal Release 12% 14% 63% Other Major Eye Intervention Vitrectomy/ Retinal Release 96% Other Reconstruction/ Transplant Cornea Figure 21: Outflow Procedure Shares by Volume Figure 22: Inflow Procedure Shares By Volume Table 14: Outflow Procedure Volumes Table 15: Inflow Procedure Volumes Outflow Procedure Cataract Removal/Lens Insertion Volume Percent 2948 63.5% Vitrectomy/ Retinal Release 631 13.6% Other Major Eye Intervention Reconstruction/Transplant Cornea 557 12.0% 120 2.6% Major Eyelid Intervention Other Major Lacrimal System Intervention 76 1.6% 72 1.6% Dilation Lacrimal System 42 0.9% Minor Eyelid Intervention 39 Ophthalmology Inflow Procedure Cataract Removal/Lens Insertion Volume 3,486 Percent 94.1% Vitrectomy/ Retinal Release “Other” Procedures (3%) 94 2.5% Major Eyelid Intervention 34 0.9% Other Major Eye Intervention 24 0.6% Minor Eyelid Intervention 23 0.6% 16 11 0.4% 0.8% Other Minor Eye Intervention Other Intervention of Cornea Other Major Lacrimal System Intervention Repair Retinal Tear 37 0.8% Other Intervention of Cornea 33 0.7% Other Minor Eye Intervention 26 Repair Retinal Tear Diagnostic Intervention on the Eye Minor Laser Eye Intervention “Other” Procedures (8%) 5 0.3% 0.1% 5 0.1% Ophthalmology 4 0.1% 0.6% Reconstruction/Transplant Cornea Diagnostic Intervention on the Eye 2 1 0.1% 23 0.5% Dilation Lacrimal System 1 0.0% 21 0.5% 16 0.3% 0.0% Data Source: IntelliHealth, FY 2012 The majority of inflows (94%) are for cataract removal/lens insertion. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 44 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Outflows are divided among cataract, vitrectomy, other major eye interventions and corneal transplants Pediatric outflow rates were examined specifically for fiscal year 2010, 2011 and 2013. Outflow volumes for the LHIN overall and by age category were fairly consistent. Pediatric outflow volumes for 2012 are presented below. Table 16: Pediatric Outflows from Central East LHIN by Age and Destination Hospital Age Destination Hospital Sick Kids Toronto East General Hospital Humber River Regional Hospital Hotel-Dieu Hospital - Kingston Toronto Western Hospital Trillium Health Partners - Credit Valley Other (hospitals with fewer than 5 visits) Total 0 to 4 105 66 6 5 0 1 3 186 5 to 9 85 21 13 3 0 2 4 128 10 to 14 15 to 19 39 15 13 8 5 5 2 2 0 6 1 2 2 9 62 47 Total 244 108 29 12 6 6 18 423 The table below compares inflow and outflow rates across LHINs by procedure levels. Source: Provincial Vision Strategy, p. 30 Figure 23: Percentage of Patients Treated in Home LHIN by Procedure Level Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 45 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Level 2 procedures (largely cataract) are more likely to be completed in the patient’s home LHIN LHINs with major academic hospitals (e.g. South West, HNHB, Toronto Central, and Champlain) tend to have a higher percentage of patients treated in their home LHIN LHINs that are immediate neighbours of LHINs with academic hospitals tend to have lower percentages of procedures completed within the LHIN Drilling down further, it is useful to examine inflows and outflows to and from the Central East LHIN in terms of the LHIN’s Health Link Areas. Central East LHIN has 7 Health Link Areas: Durham North East, Durham West, Kawartha Lakes & Haliburton, Northumberland, Peterborough, Scarborough North, and Scarborough South. The table below lists each Health Link and the corresponding hospital sites within them; note that Durham West has no associated hospital performing inpatient/outpatient vision care surgeries. Table 17: Hospitals with Associated Health Links Health Link Area Durham North East Durham West Kawartha Lakes & Haliburton Northumberland Peterborough Scarborough North Scarborough South Hospital Lakeridge Health, Bowmanville Site; Lakeridge Health, Oshawa No applicable hospital for Vision Care Ross Memorial Hospital Northumberland Hills Hospital Peterborough Regional Health Centre The Scarborough Hospital, Birchmount Rouge Valley Health System, Centenary Site Abbreviation LHB, LHO N/A RMH NHH PRHC TSHB RVC The tables below show inflow and outflow figures by Health Link Area, which are then combined to identify which Health Link Areas are net “importers” or net “exporters” of procedure volume. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 46 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Table 18: Inflows Entering Central East LHIN by Health Link Area Health Link Area Durham North East (LHB, LHO) Durham West (N/A)* Kawartha Lakes & Haliburton (RMH) Northumberland (NHH) Peterborough (PRHC) Scarborough North (TSHB) Scarborough South (RVC) Central East LHIN Total 2010 2011 2012 348 381 425 167 116 57 111 199 519 96 127 189 2,515 2,775 2,316 543 496 291 3,780 4,094 3,797 Corresponding Outflows 2010 2011 2012 539 536 523 604 689 596 239 199 190 194 175 208 231 222 229 945 931 875 1,907 1,856 1,843 4,659 4,608 4,464 *Durham West Health Link does not have a hospital providing inpatient or outpatient Ophthalmology surgery. Therefore, there cannot be any inflows to this Health Link. The table below combines the inflows and outflows for each Health Link Areas to arrive at net inflows and net outflows for each Health Link (negative numbers denote net outflows). Table 19: Net Inflows and Net Outflows by Health Link Area Health Link Area Durham North East (LHB, LHO) Durham West (N/A)* Kawartha Lakes & Haliburton (RMH) Northumberland (NHH) Peterborough (PRHC) Scarborough North (TSHB) Scarborough South (RVC and TSHG) Central East LHIN Total 2010 -191 -604 -72 -83 -135 1,570 -1,364 -879 2011 -155 -689 -83 24 -95 1,844 -1,360 -514 2012 -98 -596 -133 311 -40 1,441 -1,552 -667 Legend Net Importer Net Exporter (0-499) Net Exporter (500-999) Net Exporter (1000+) The table above suggests that while the LHIN on the whole is a modest net exporter of procedure volumes, most Health Link Areas are net exporters. The dynamics within Scarborough are especially notable – the Health Link Area served by TSHB is a large net importer of volume from other LHINs while the Health Link Area serviced by RVC and TSHG is a large net exporter of volume to other LHINS. This is even more notable when one considers that TSHB and RVC are located approximately a 15-minute drive from one another and a 45-60 minute trip by public transit. However, the Scarborough South Health Link Area population does not live in such close proximity to TSHB, and may find transit to downtown (Toronto Central LHIN) locations more amenable. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 47 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT 3.5.7 Vision Care for Diabetics The figure below presents rates for retinal eye exams for patients with diabetes, according to their LHIN of residence. While the scope of this project pertains to surgical procedures, this data has been included as a possible predictor of future need for Vitrectomy. Source: Ontario Diabetes Strategy, Key performance Measures (June 2013) Figure 24: Adult Diabetics Receiving Retinal Eye Care Retinal eye exam are highest among diabetes patients in the South East LHIN (71.2%), and lowest among those in the Toronto Central LHIN (61.1%). Central East LHIN is slightly below the provincial average for retinal eye exams. These results include only retinal eye exams where a fee‐for‐service claim was submitted; some patients may have had a retinal eye exam performed by a provider who did not submit a claim or shadow billing. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 48 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT The following chart compares LHIN residents’ rates for ocular procedures (Vitrectomy and Laser Photocoagulation). These procedures may have been completed within or outside a patients’ LHIN of residence. Rate of Ocular Procedures (vitrectomy, laser photocoagulation) per 100,000 with Diabetes (18+) 8,000 7,000 6,000 5,000 09-10 4,000 10-11 3,000 11-12 ONT 2011-12 2,000 1,000 0 Source: Ontario Diabetes Strategy, Key performance Measures (June 2013) Figure 25: Rate of Ocular Procedures Per 100,000 Adults with Diabetes In 2011/12, the age‐adjusted rate of ocular procedures varied considerably by LHIN. The rate in Central West LHIN (6,696 per 100,000 persons with diabetes) was four‐times higher than the rate in the lowest LHIN (South West LHIN: 1,689 per 100,000). Central East LHIN rates are slightly below the provincial average (though it is important to note that the provincial average is skewed toward heavy outliers such as Central West and Mississauga-Halton). 3.6 How Accessible is Vision Care in Central East LHIN? Key Analysis Questions for this Section: How accessible is surgical vision care in Central East LHIN? How far are patients traveling? What wait times exist? Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 49 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT 3.6.1 Distances Travelled by Patient VPWG members discussed travel distances at length, with particular concern for patients of low socioeconomic status. Table 21 below outlines average distance travelled for Central East LHIN residents receiving treatment within the LHIN. Table 20: Distances Travelled for Residents Receiving Services within the LHIN (Fiscal Years 2012-2013) Procedure Cataract Removal/Lens Insertion Diagnostic Intervention on the Eye Dilation Lacrimal System Major Eyelid Intervention Minor Eyelid Intervention Minor Lacrimal System Intervention Ophthalmology Other Intervention of Cornea Other Major Eye Intervention Other Major Lacrimal System Intervention Other Minor Eye Intervention Reconstruction/Transplant Cornea Repair Retinal Tear Vitrectomy/Retinal Release Overall Mean (km) 16.27 28.12 28.19 28.23 21.67 14.58 21.56 15.66 27.37 35.09 16.06 19.87 19.43 13.97 16.62 90th Percentile (km) 34.98 61.18 44.70 61.81 43.07 31.71 53.44 37.26 71.87 72.40 32.91 33.53 42.20 33.62 35.61 Findings: While overall average for distance travelled appears reasonable at first glance, these figures do not capture the mode (e.g., car, transit, taxi) or direction (e.g., east or west within the LHIN) of travel; depending on the mode and direction of travel, a given distance travelled can still present a significant burden to the patient, particularly for those of low socioeconomic status The longest average distance travelled (mean: 35.09 km; 90th percentile: 72.4 km) was for “Other Major Lacrimal System Intervention” The table below presents distances travelled for patient inflows. Some inflow procedures had fewer than 5 patients and were removed from the analysis. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 50 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Table 21: Inflow Distances Travelled (Fiscal Year 2012) Procedure Cataract Removal/Lens Insertion Major Eyelid Intervention Minor Eyelid Intervention Other Intervention of Cornea Other Major Eye Intervention Other Minor Eye Intervention Reconstruction/Transplant Cornea Vitrectomy/Retinal Release Overall Mean (km) 43.54 99.72 56.88 26.99 52.51 24.50 103.06 25.53 22.86 90th Percentile (km) 178.01 213.26 133.03 38.09 102.88 44.98 137.59 60.73 137.28 Only includes >5 procedures Findings: The furthest average inflow distances travelled were for “Major Eyelid Intervention” (99.72 km), and “Reconstruction/Transplant Cornea” (103.6 km). In the 90th percentile, patients traveled furthest for “Major Eyelid Intervention” (213.26 km), and “Cataract Removal/Lens Insertion” (178.01 km) Table 22: Outflow Distances Travelled (Fiscal Year 2012) Procedure Cataract Removal/Lens Insertion Diagnostic Intervention on the Eye Dilation Lacrimal System Major Eyelid Intervention Minor Eyelid Intervention Minor Laser Eye Intervention Ophthalmology Other Intervention of Cornea Other Major Eye Intervention Other Major Lacrimal System Intervention Other Minor Eye Intervention Reconstruction/Transplant Cornea Repair Retinal Tear Vitrectomy/Retinal Release Overall Prepared by OPTIMUS | SBR © 2014 All rights reserved Mean (km) 26 66 38 51 37 57 45 27 52 90th Percentile (km) 93.38 122.18 93.22 113.69 54.23 97.88 143.98 48.83 113.03 29 57 52 81 54 35.38 62.74 111.00 123.17 136.73 144.90 110.68 P a g e | 51 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Findings: Outflow distances are considerably longer than for those within the LHIN The furthest average outflow distances travelled were for “Repair Retinal Tear” (81 km), and “Diagnostic Intervention on the Eye” (66 km). In the 90th percentile, patients travelled furthest for “Vitrectomy/Retinal Release” and “Ophthalmology”. 3.6.2 Wait Times The figure below present adult ophthalmic surgery wait times for cases performed in the Central East LHIN in days, according to procedure. 90th Percentile Wait (Days) Adult Opthalmic Surgery Wait Times by Procedure (FY 2012) 250 200 207 193 150 134 100 102 50 186 150 132 99 79 72 88 78 27 Orbital Surgery Retina Other 0 Cataract Combination Cataract and Other Procedure Cornea Other Data Source: iPort, WTIS Glaucoma - Ophthalmic Other Plastics CE LHIN 54 51 36 Retina Vitrectomy Provincial Figure 26: Adult Ophthalmic Surgery Wait Times by Procedure (Fiscal Year 2012) Relative to provincial averages, Central East LHIN hospitals have lower wait times, with the exception of “Glaucoma – Other” (79 days) The longest hospital wait times were observed for “Cornea – other” (132 days) Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 52 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Waitlist (# of Patients Waiting) Opthamology Patient Waitlist by Facility Priority 2,3,4 (FY 2012) 2000 1500 1000 500 0 RMH PRHC NHH LH RVHS TSHB Data Source: iPort, WTIS Figure 27: Ophthalmology Patient Waitlist by Facility, Priority 2, 3, and 4 (Fiscal 2012) Over FY 2012, Scarborough Hospital had the longest waitlist for priority 2, 3, and 4 procedures, followed by Lakeridge Health. As seen in the following charts, Central East LHIN is meeting 90% completion targets for waitlisted procedures 8,000 6,000 100% 100% 99% 98% 100% 95% 92% 80% 60% 4,000 40% 2,000 1,373 2,506 1,198 5,760 1,212 5,645 RMH PRHC NHH LHC RVC TSHB 0 20% 0% Completed Case Volume % Cases Completed within Access Target - Surgery Completed Case Volume Completed Cases Ophthalmic Surgery: Volume and % completed within Access Target for Priority 2,3 & 4 (FY 2012) Data Source: iPort, WTIS Figure 28: Completed Cases of Ophthalmic Surgery – Volumes and Percent Completed Within Access Target (Priority 2,3, and 4), Fiscal 2012 Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 53 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Completed Case Volume 6,000 5,000 100% 99% 100% 100% 97% 97% 1,370 2,500 1 5,066 331 4,843 RMH PRHC NHH LHC RVC TSHB 4,000 3,000 2,000 1,000 0 Completed Case Volume 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% % Cases Completed within Access Target Surgery Completed Cases Ophthalmic Surgery: Volume and % completed within Access Target for Priority 4 (FY 2013) % Cases Completed within Access Target - Surgery Data Source: iPort, WTIS Figure 29: Completed Cases of Ophthalmic Surgery – Volumes and Percent Completed Within Access Target (Priority 4), Fiscal 2013 3.6.3 Quality and Appropriateness During consultations, stakeholders were asked to describe existing activities conducted to ensure that patients have timely access to quality and appropriate vision care. The following practices have been identified as contributions to high quality and appropriate vision care while meeting the needs of patients in the Central East LHIN: Those surgeries that have traditionally been performed as an inpatient procedure are being reviewed and transitioned into an outpatient day surgery if supported by evidence-based research. Also, select surgeries are being performed with local anesthetic to reduce the amount of time that patients spend in recovery. Altogether, these practices are expected to improve the appropriateness of hospital bed utilization, reduce overall costs and improve patient experience. Some hospital facilities have established dedicated Operating Rooms or Eye Clinics with quality improvement initiatives implemented (e.g., lean process improvements) so that patients could be seen quickly and efficiently. The result is that ophthalmologists will be able to perform 20-35 cataract surgeries per day. A few hospitals have implemented or planned to implement quality indicators to measure the overall quality of the procedures and services provided. These metrics could include on-time Operating Room start and end times, costs by physicians, infection rates, patient satisfaction, etc. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 54 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT 3.7 Current State Assessment Summary In summary, data analysis and discussions with VPWG members indicate that the current service delivery is efficient and of high quality. The main concern the VPWG identified was access to subspecialty care. The focus of the Directional Plan – Vision Care Strategy is to address this concern. 4. Directional Plan – Vision Care Strategy As described earlier, this is a “Directional Plan – Vision Care Strategy” that is in keeping with the Central East LHIN’s Clinical Service Planning practices. It is also worth reiterating that the scope of this Directional Plan – Vision Care Strategy is limited to inpatient and outpatient ophthalmic surgeries currently delivered by Central East LHIN hospitals, though the VPWG’s deliberations have taken into account the nuances of how people access vision care services before and after ophthalmic surgeries. This Directional Plan – Vision Care Strategy: Reflects the “ideal state” of vision care for Central East LHIN within the next 3 years; and Includes an Implementation Plan that outlines how the Central East LHIN will make decisions about logistics (e.g. funding sources, specific accountabilities, and location of services or centers) going forward. 4.1 Recommended Directional Plan for Vision Care in Central East LHIN During the Development and Evaluation of Future State Options phase of its work, the VPWG identified and evaluated two main options: 1) Distributed Model for Cataracts with One LHIN Centre for Subspecialties 2) Distributed Model for Cataracts with Two Cluster Centres for Subspecialties Note that for both of these options, cataract extractions will continue to be provided by the five existing hospitals in the Central East LHIN. The VPWG evaluated these two Options using the Central East LHIN Decision Making Framework and Expert Choice software and chose the Two Cluster Centres model. At a broad level, the VPWG recommends that the Central East LHIN create two cluster centres and divide subspecialists across these two centres. Given the size, scale and infrastructure requirements of a cluster centre, these centers would be located at Lakeridge Health (Durham Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 55 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Cluster), and The Scarborough Hospital (Scarborough Cluster). Note that the specific distribution of specialists (e.g., vitreoretinal) will be determined later through the implementation process. Table 23: Overview of Distributed Model for Cataracts with Two Cluster Centres for Subspecialties Model Delivery Model Local Centre Changes to current volumes* Cluster Centre Changes to Health Human Resources To vary according to need 2 3 Increase volumes 2 Increase volumes 2 Increase volumes 1 LHIN Centre Population or Procedure Type Cataract No change Surgical Retina, Vitrectomy Glaucoma Surgery Corneal Transplant Oculoplastics Pediatric Ophthalmology** Urgent/ Emergent Care Add 1 Vitreoretinal subspecialist (for a LHIN-wide total of 3) Add 1 Glaucoma subspecialist (for a LHIN-wide total of 2) Add 1 Corneal subspecialist (for a LHIN-wide total of 1) No change Add 1 pediatric ophthalmologist (for a LHIN-wide total of 1) N/A Increase volumes Increase volumes N/A 1 1 N/A Description 3 Local Centres and 2 Cluster Centres (3 Local Centres + 2 Cluster Centres = 5 hospitals). One Cluster Centre will have 1 VR specialist; the other Cluster Centre will have 2 VR specialists (specific locations TBD) One subspecialist at each cluster centre To be located at one of the 2 Cluster Centres To be located at one of the 2 Cluster Centres To be located at one of the 2 Cluster Centres All hospitals providing ophthalmology services must participate in one of the existing call networks *It is assumed that volumes for all procedures will change as population size and demographics evolve, or as new technologies are implemented **Sizing and siting of pediatric ophthalmology would require further deliberation with pediatric stakeholders In general, VPWG members opted for the Distributed Model for Cataracts with Two Cluster Centres for Subspecialties model over the other model because, in terms of the Central East LHIN Decision Making Framework: Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 56 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Two Cluster Centres were viewed as providing better Access and Strategic Fit. While the Current State Analysis indicates that many patients already travel for cataract surgery, VPWG members were concerned about increased travel requirements for subspecialty procedures that would require ongoing and frequent follow-up at ophthalmologists’ nearby clinics, particularly for patients of low socioeconomic status. Two Cluster Centres were viewed as providing better Quality and Efficiency. VPWG members indicated that patients are more likely to travel to one of the two Cluster Centres (compared to the one LHIN Centre) because of the shorter distance. As a result, the two Cluster Centres would likely retain or increase their volumes and could provide better quality more efficiently. For subspecialties, VPWG members saw the Two Cluster Centre and One LHIN Centre options as roughly equivalent in terms of Innovation and Partnerships. In sum, VPWG members judged that any economies of scale and scope associated with consolidating all subspecialties at a single existing cataract centre were not significant relative to potential access issues consolidation might create. 4.2 What this Directional Plan Means for Central East LHIN 4.2.1 Operations This Directional Plan – Vision Care Strategy also includes a series of Detailed and Other Recommendations below. This section summarizes briefly what the plan means for Central East LHIN. Briefly, this direction means that: Cataracts continue to be performed at existing sites for the foreseeable future Central East LHIN would add 4 subspecialists – vitreoretinal, glaucoma, corneal transplant, and pediatric Core capacity (i.e., cataract plus select subspecialties) will be concentrated at Lakeridge Health (Durham Cluster) and The Scarborough Hospital (Scarborough Cluster) Pediatric ophthalmology services would be situated at one of the two LHIN Cluster Centres Northumberland Hills Hospital’s cataract program will need to join the broader Central East LHIN vision care call network and include a means of ensuring it captures as much as possible of the required services from its local catchment area and also ensuring that it is robust for the community. 4.2.2 Annual Cost Estimates Given data limitations and the scope of the VPWG’s work, cost estimations were beyond the scope of this Directional Plan – Vision Care Strategy. However, given the above, the VPWG offers the follow broad cost estimate ranges for consideration by the Central East LHIN Board and Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 57 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Hospitals for future consideration. The Table below outlines broad ranges of costs for the different subspecialists that would be recruited as part of the plan. Estimated costs can vary widely based on assumptions about: Volumes performed by each subspecialist (including their subspecialty and cataracts) in hospital Cost per case, and whether overhead, equipment, and staff costs are already covered by hospitals’ global budgets or allocated in some form to the cost of a procedure Note that these costs are for information purposes only and are based on limited available case costing data and industry sources; subsequent work should include detailed cost estimates and consideration of all overhead, staff, and other costs associated with bringing on additional subspecialists at the relevant centres. Subsequent cost estimates that include all relevant capital and operating costs may exceed these estimates depending on decisions made about capital investment, allocation of support, and volumes and types of volumes performed. Table 24: Annualized Cost Estimate of Additional Subspecialists Additional Subspecialist Vitreoretinal Annualized Cost Estimate Range $200,000 - $1,100,000 Glaucoma $200,000 - $800,000 Corneal transplant $100,000 - $500,000 Pediatric $200,000 - $800,000 Total $700,000 - $3,200,000 Note: These estimates represent annualized cost estimates which include charges for overhead, staff, and other costs for in-hospital surgical procedures. They do not include any up-front capital costs for equipment. 4.3 Detailed Recommendations by Procedure and Population Recommendations have been developed for each of the in-scope procedures/populations. These are aligned with findings outlined in A Vision for Ontario: Strategic Recommendations for Ophthalmology in Ontario. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 58 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Procedure/Population: Cataract Extraction Recommendation 1: The 5 hospitals that currently provide cataract extractions should continue to offer the service. Description The 5 hospitals should continue to provide cataract extractions to their respective patient populations. While no change to human health resources is anticipated, the VPWG expects they will be adequate to serve the expected increase in volumes as population size increase and demographics change, and also as new technologies are implemented. Rationale Provincial Strategy Alignment In alignment with the LHIN-wide option, cataract extractions should be delivered through the following 5 hospitals: 3 Local Centres – Northumberland Hills Hospital, Peterborough Regional Health Centre, Ross Memorial Hospital 2 Cluster Centres – Lakeridge Health and the Scarborough Hospital There was general consensus within the VPWG that the existing service delivery for cataract extractions works well in the Central East LHIN. The Central East LHIN performs well in managing the wait list for cataract extraction compared to the provincial benchmark (based on FY 2012 data). Access R1: Ministry and LHIN funding for ophthalmology services should be sustained to address wait lists for adult and pediatric eye surgery. Procedure/Population: Surgical Retina, Vitrectomy Recommendation 2: The VPWG should establish a regional approach to providing surgical retina and vitrectomy with the goal of increasing volumes and ophthalmology health human resources. Specifically, Lakeridge Health should continue to provide surgical retina and vitrectomy. Services presently provided at Rouge Valley Health System (Centenary site) should be transitioned to the other cluster centre at The Scarborough Hospital. LH and TSH should collaborate on recruiting and retaining 1 additional vitreoretinal subspecialist at one of the two hospitals (for a LHIN-wide total of 3 subspecialists) to support the volumes in the LHIN. Description Surgical retina and vitrectomy should be delivered by 3 vitreoretinal subspecialists at the 2 Cluster Centres – Lakeridge Health and the Scarborough Hospital. This recommendation will result in the transitioning of existing surgical retina and vitrectomy services from RVHS to TSH. The VPWG should plan and determine the locations of the 3rd vitreoretinal subspecialist. The hospital where the 3rd vitreoretinal subspecialist will have privileges should lead recruitment efforts. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 59 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Procedure/Population: Surgical Retina, Vitrectomy The VPWG anticipated that the 3rd vitreoretinal subspecialist will bring additional volumes into the LHIN. However, it is also assumed that volumes will change as population size and demographics evolve, or as new technologies are implemented. Rationale Provincial Strategy Alignment The new ophthalmologist will also be expected to participate in one of the existing on-call coverage networks. 24/7 coverage for the sub-specialty is not included as part of this recommendation. An additional vitreoretinal subspecialist is needed to improve access, handle the volumes and provide on-call support. N/A Procedure/Population: Glaucoma Surgery Recommendation 3: The VPWG should establish a regional approach to providing glaucoma surgery with the goal of increasing volumes and ophthalmology health human resources. The hospital that is currently providing glaucoma surgery should continue while a 2nd hospital should be identified by the VPWG to provide glaucoma surgery in the LHIN. The recruitment and retention of a 2nd glaucoma subspecialist should be completed (for a LHIN-wide total of 2 subspecialists). Description Glaucoma surgery should be delivered by 2 glaucoma subspecialists at the 2 Cluster Centres. One of the Cluster Centres will introduce glaucoma surgery as a new service that it provides to its patient population. This hospital will lead the recruitment efforts for the 2nd glaucoma subspecialist. The 2nd glaucoma subspecialist should bring additional volumes into the LHIN; however, it is also assumed that volumes will change as population size and demographics evolve or as new technologies are implemented. Rationale Provincial Strategy Alignment The 2nd glaucoma subspecialist will be expected to participate in one of the existing on-call coverage networks. 24/7 coverage for the sub-specialty is not included as part of this recommendation. An additional glaucoma subspecialist is needed to handle the volumes and provide on-call support. N/A Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 60 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Procedure/Population: Corneal Transplant Recommendation 4: The VPWG should recruit and retain 1 corneal transplant subspecialist in order to meet the needs of the patient population in the Central East LHIN (for a LHIN-wide total of 1 subspecialist). Description One of the 2 Cluster Centres should lead the recruitment efforts for 1 corneal transplant subspecialist, who will be responsible for providing corneal transplants to the patient population in the LHIN. The VPWG should plan and determine which of the Cluster Centre will be providing corneal transplant services to the LHIN. It is assumed that volumes will change as population size and demographics evolve, or as new technologies are implemented. Rationale Provincial Strategy Alignment The new ophthalmologist will also be expected to participate in one of the existing on-call coverage networks. 24/7 coverage for the sub-specialty is not included as part of this recommendation. There is a service gap in corneal transplant services in the LHIN, and adding a subspecialist would improve access. N/A Procedure/Population: Oculoplastics Recommendation 5: The LHIN should continue to provide oculoplastics with no change in ophthalmology health human resources. Description Oculoplastics should be provided at 1 of the 2 Cluster Centres, ideally close to a cancer centre. The VPWG should plan and determine which of the Cluster Centre will be providing corneal transplant services to the LHIN. Rationale Provincial Strategy Alignment It is assumed that volumes will change as population size and demographics evolve, or as new technologies are implemented. Existing access to oculoplastics is adequate and meets the need of the population; low existing and anticipated volumes do not currently justify adding another oculoplastics specialist. N/A Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 61 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Procedure/Population: Pediatric Ophthalmology Recommendation 6: The VPWG should recruit and retain 1 pediatric ophthalmologist in order to meet the needs of the patient population in the Central East LHIN (for a LHIN-wide total of 1 pediatric ophthalmologist). Description One of the 2 Cluster Centres should lead the recruitment efforts for 1 pediatric ophthalmologist, who will be responsible for providing care to pediatric patients in the LHIN. It is assumed that volumes will change as population size and demographics evolve, or as new technologies are implemented. Sizing and siting of pediatric ophthalmology will require further deliberation with pediatric stakeholders. Rationale Provincial Strategy Alignment The new ophthalmologist will also be expected to participate in one of the existing on-call coverage networks. 24/7 coverage for the sub-specialty is not included as part of this recommendation. There is a service gap in pediatric ophthalmology in the LHIN. N/A Procedure/Population: Urgent / Emergent Care Recommendation 7: All 5 hospitals providing ophthalmology services should participate in one of the existing on-call coverage networks. Description All ophthalmologists to be recruited in support of this Vision Care Directional Plan should participate in one of the existing on-call coverage networks. Rationale To improve ophthalmology coverage during the week, a regional on-call coverage network should be established. All hospitals providing ophthalmology services should participate in an existing network in order to build capacity to provide the proper coverage throughout the week. Provincial Strategy Plan R13: Planning for ambulatory models must also be contingent on Alignment maintenance of access to appropriately equipped and staffed eye suites/procedure rooms to deal with urgent and emergent cases on a 24/7 basis Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 62 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT 4.4 Other Recommendations Other recommendations to improve quality improvement are detailed in this section. Other Recommendations Recommendation 8: The Central East LHIN should establish an ongoing advisory board similar to the existing VPWG to ensure ongoing attention to vision care issues and to oversee the implementation of the recommendations identified in the Vision Care Directional Plan. Description The Central East LHIN should establish an advisory board to ensure the implementation and sustainability of the recommendations identified in the Vision Care Directional Plan. The members of the advisory board should include leaders who practice ophthalmology or related health services in the LHIN, such as ophthalmologists, optometrists, primary care providers and hospital administrators. Rationale Broaden representation to encompass more of continuum of vision care as other projects and needs arise with respect to vision care The Vision Care Directional Plan will need to be further defined, implemented and evaluated. Provincial Strategy N/A Alignment Recommendation 9: The VPWG should collaborate with the Ontario Telemedicine Network (OTN) to identify how teleophthalmology could be applied in certain scenarios to build capacity and serve the patient population living in all communities (both rural and urban) in the LHIN. Description The VPWG recognizes the limitations of tele-ophthalmology and that the technology could potentially be applicable only for certain procedures and follow-up care. In light of this, the VPWG should understand and identify the scenarios in which tele-ophthalmology is feasible, cost-effective and appropriate for the patient population. Rationale OTN is currently used to build capacity in many other health care fields; however, its use in vision care is limited at present (see “Context” section earlier in this document) Ophthalmology patients living in any communities (including rural) sometimes must travel large distances to seek care. Provincial Strategy Plan R16: Specialty centres will explore and facilitate use of teleAlignment ophthalmology to reduce travel for follow-up visits. Recommendation 10: The 5 hospitals providing ophthalmology care should improve integration with centres for diabetes care. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 63 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Other Recommendations Description The hospitals that provide ophthalmology care should establish better integration with existing centres that provide diabetes care. Diabetes care centres should be given the appropriate tools and support to assist them in referring their patients directly to a vision care provider. To support integration and seamless care coordination, vision care providers could spend more time in diabetes care centres to improve communication and access to a vision care provider for those in need. Rationale FY 2012 data indicates that diabetes prevalence in the Central East LHIN is 10.9%, higher than the provincial average of 10.2%. Patients with long-term diabetes often require retinopathy. Diabetes educators frequently refer patients to optometrists. Ophthalmology has historically been in “in-silo” with limited integration with other health services. Provincial Strategy N/A Alignment Recommendation 11: The 5 hospitals providing ophthalmology services should develop a marketing strategy to repatriate volumes back to the Central East LHIN. The strategy development and implementation should be consistent with the onboarding of the new ophthalmologists/subspecialists. Description The VPWG anticipates that the recruitment of new ophthalmologists/subspecialists will result in the increase in volumes due to the increase in capacity and new services (e.g., pediatric ophthalmology, corneal transplant). The introduction of the new ophthalmologists/subspecialists in the LHIN should be conducted in tandem with the marketing of the new services and ophthalmologists to primary care providers, optometrists, diabetes care centres and other parties that make referrals to ophthalmologists. Rationale Primary care and optometry are identified as two key stakeholder groups that make referrals to ophthalmology. Communication and marketing are needed to ensure seamless referral patterns from primary care or optometry to ophthalmology. The introduction of new ophthalmologists/subspecialists in the LHIN will need to be communicated to the stakeholder groups in a cost-effective manner. Provincial Strategy Plan R15: Patients need to cross LHIN boundaries to obtain specialty Alignment services in many instances. As such, specialty centres will develop strong referral partnerships both within and across LHINs. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 64 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Other Recommendations Recommendation 12: The 5 hospitals that provide ophthalmology services should explore potential partnerships with local community agencies in order to improve access to care for patients. Description The hospital should look at options to improving access to care for those patients who face obstacles in accessing appropriate care. Potential options to improve access to care include: Partner with local community agencies or other health service providers. Bring the care closer to where the patients live. Rationale For those patients who are older, less mobile and do not have caretakers, the lack of transportation to a hospital is one potential barrier to seek subspecialist care. Potential partnerships could reduce or eliminate any potential access issues. Similar models exist for other types of patients seeking sub-specialized care. Provincial Strategy N/A Alignment 5. Implementation Plan 5.1 Implementation Context The Directional Plan – Vision Care Strategy and its associated recommendations represent significant but incremental change for Central East LHIN. Implementation will therefore focus on largely operational concerns – determining how decisions will be made, allocating subspecialties, securing funding, recruiting subspecialists, and then taking some longer term steps to improve access and explore certain opportunities further. 5.2 Funding As described above, this plan represents an “ideal state” to be achieved over the next 3 years. Achieving that ideal state will depend on funding from a variety of potential sources, including, in no particular order: MOHLTC funding for vision care Central East LHIN funding Central East LHIN hospitals’ global budgets Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 65 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Central East LHIN hospitals’ fundraising campaigns Investments by ophthalmologists and their practices Identifying and securing funding sources for these recommendations will be part of the implementation process. 5.3 Implementation Plan 5.3.1 Immediate Next Steps The immediate next steps are: 1) Define the role of VPWG going forward: Following the development and approval of the Vision Care Directional Plan by the LHIN Board, it is anticipated that a similar advisory body will be required to continue the momentum and work completed to date. The mandate of the VPWG will transitioned from a working group to a more strategic or advisory role to support the LHIN in overseeing the implementation, championing the change and ensuring sustainability post implementation. The advisory board should include clinical and administrative leaders representing the hospitals, ophthalmologists, optometrists and primary care providers. 2) Create and execute a process to decide the locations of subspecialty care: A process is required to identify and select the location where subspecialty care. The decisionmaking criteria and process should be completed by the advisory board. A point of consideration is whether or not a particular subspecialty care needs to co-locate with another subspecialty in order to maximize quality, care-coordination, effectiveness and costs. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 66 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT 5.3.2 Implementation Plan Summary A proposed implementation plan is summarized below. FY 2014/15 Q3 FY 2015/16 Q4 Q1 Q2 Q3 FY 2017/18 FY 2016/17 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Establish an Advisory Board Select Cluster Centres & Subspecialty Care Secure Funding to Recruit Subspecialists Participate in On-Call Coverage Network Recruit Subspecialists Develop Marketing Strategy Improve Integration with Diabetes Care Centres Monitor and Evaluate Marketing Strategy Leverage OTN Technology Explore Partnership Options Figure 30: Proposed Implementation Plan Summary Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 67 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT 5.3.3 Description of Implementation Plan The steps in the proposed Implementation Plan are outlined in more detail below. Table 25: Description of Implementation Plan Steps Implementation Plan Timeline Action Q3 FY 2014/15 – Establish an Advisory Board: An Advisory Board Q1 FY 2015/16 similar to the existing VPWG should be established in order to provide strategic oversight on the implementation and post-implementation sustainability of the Vision Care Directional Plan. As part of this process, a Terms of Reference for the Advisory Board will need to be developed. The advisory board should include clinical and administrative leaders representing the hospitals, ophthalmologists, optometrists and primary care providers. Q4 2014/15 Create and execute a process to decide the locations of subspecialty care: A process is required to identify and select the location where subspecialty care. The decision-making criteria and process should be completed by the advisory board. A point of consideration is whether or not a particular subspecialty care needs to co-locate with another subspecialty in order to maximize quality, carecoordination, effectiveness and costs. Participate in On-Call Coverage Network: All hospitals that provide ophthalmology services in the Central East LHIN should participate in one of the existing oncall coverage network. Prepared by OPTIMUS | SBR © 2014 All rights reserved Owner Central East LHIN All Hospitals P a g e | 68 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Implementation Plan Timeline Action Q2 2015/16 – Detailed Costing and Secure Funding to Recruit Q3 2015/16 Subspecialists: The Cluster Centres responsible for introducing new or expanding its ophthalmology services will need to assess financial impact, develop business case (as required) to secure the resources to support the recruitment and retention of the following subspecialists: Vitreoretinal subspecialist Glaucoma subspecialist Corneal transplants subspecialist Pediatric ophthalmologist Q3 2015/16 – Recruit Subspecialists: The Cluster Centres will need Q4 2015/16 to attract, recruit and retain subspecialists to support the introduction or expansion of its ophthalmology program. The Cluster Centres may work together to define roles, responsibilities and expectations (e.g., travel, on-call coverage, volumes) of the subspecialists in exchange for privileges to practice and perform surgeries at the hospital. Q4 2015/16 Develop Marketing Strategy: The Cluster Centres will work with the newly recruited subspecialists and the Advisory Board (as appropriate) to develop and execute a strategy to introduce the newly recruited subspecialists and their provision of specialty care in the Central East LHIN. The strategy should consider the unique referral patterns for ophthalmology and incorporate insights from primary care, optometry and acute care. Prepared by OPTIMUS | SBR © 2014 All rights reserved Owner Cluster Centres (i.e., Lakeridge Health and The Scarborough Hospital), Central East LHIN Cluster Centres (i.e., Lakeridge Health and The Scarborough Hospital) Cluster Centres (i.e., Lakeridge Health and The Scarborough Hospital) P a g e | 69 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Implementation Plan Timeline Action Q1 2015/16 – Improve Integration with Diabetes Care Centres: The Q2 2015/16 5 hospitals providing ophthalmology services will identify the Diabetes Care Centres in their regions. Potential collaboration or partnership opportunities between the hospitals and the Diabetes Care Centres will need to be explored and assessed in order to improve the efficiency of the referral process for patients to see a vision care provider. For example, this may involve creating relevant vision care education materials and toolkits for clinicians who are assessing and referring patients to a vision care provider, physically integrating a vision care services directly in the Diabetes Care Centres, etc. Q1 2016/17 – Monitor and Evaluate Marketing Strategy: The Q3 2016/17 Cluster Centres will work with the Central East LHIN and the Advisory Board to assess the results of the marketing strategy and its effectiveness in repatriating some of the outflow volumes, especially for those subspecialty care that is introduced to the LHIN as part of the Vision Care Directional Plan (e.g., corneal transplant, pediatric). Q1 2016/17 – Leverage OTN Technology: The 5 hospitals providing Q2 2017/18 ophthalmology services will collaborate with the Ontario Telemedicine Network (OTN) to explore and identify opportunities to apply tele-ophthalmology in providing follow up care to patient populations living in rural communities. This would involve technology assessment, engagement of stakeholders in the rural communities, options analysis including costs and benefits. The Central East LHIN and the Advisory Board should be informed on any updates related to OTN adoption. Prepared by OPTIMUS | SBR © 2014 All rights reserved Owner All Hospitals Cluster Centres, Central East LHIN, Central East LHIN Advisory Board All Hospitals, Central East LHIN, Central East LHIN Advisory Board P a g e | 70 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Implementation Plan Timeline Action Q1 2016/17 – Explore Partnership Options: In order to reduce any Q2 2017/18 barriers to access subspecialty care for patients with transportation or other access limitations, the 5 hospitals providing ophthalmology services will work together to explore and identify options related to partnerships. Potential options: Partner with community organizations or other local health service providers Bring subspecialty care directly closer to where patients reside The potential options will need to be assessed with consideration on implementation and sustainability requirements. The Central East LHIN and the Advisory Board should be informed on progress updates. 6. Owner All Hospitals, Central East LHIN, Central East LHIN Advisory Board Conclusion The VPWG looks forward to this plan being presented for review by the Central East LHIN CEO Council and for review and approval by the Central East LHIN Board of Directors. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 71 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Appendices Appendix 1: List of Procedures by Level The 48 procedure groups below were created and assigned to 1 of 4 levels by the Provincial Vision Strategy Task Force: Vision Procedure Group Level Vision Procedure Group Level Canilicular Repair 2 Laser Coagulation 2 Cataract Extraction Cataract Extraction With Pars Plana Vitrectomy Conjunctiva 2 Lens Explantation 2 4 OCULAR TRAUMA: Corneal Excision 2 3 OCULAR TRAUMA: Extraocular. Less Complex 2 Conjunctiva 4 2 3 OCULAR TRAUMA: Intraocular. Less Complex Orbital : Evisceration, Enucleation, & Exenteration Orbital : Evisceration, Enucleation, & Exenteration Corneal Repair 3 Orbital. Major 4 Corneal Transplant : Lamellar Keratoplasty 4 Orbital. Non Major 3 Corneal Transplant : Other 4 Plaque Brachytherapy 4 Cryotherapy 4 Prosthetic Lens Insertion 2 Cyclodestruction 3 Refractive Surgery 3 DCR 4 Retinal Destruction, Except Laser Coagulation 4 Extraocular. Less Complex 3 Scleral Buckle 4 Extraocular. More Complex 4 Scleral Wound Repair 2 Extraocular. Not Complex 2 Secondary Lens Implant 2 Eyelid Lesion Excision/Reconstruction 3 Strabismus 3 Eyelid Lesion Excision/Reconstruction 4 Surgical Synechiolysis 2 Intraocular. Less Complex 2 Trabeculectomy : Laser 1 Intraocular. More Complex 3 Trabeculectomy : Surgical 3 Iridectomy/Iridotomy 2 Tube Shunt Surgery 4 Lacrimal Duct Probing 1 Vitrectomy 3 Lacrimal Repair 3 Vitrectomy 4 Laser Capsulotomy 1 Vitrectomy, Anterior 4 Corneal Excision Corneal Excision Prepared by OPTIMUS | SBR © 2014 All rights reserved 2 3 4 P a g e | 72 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Appendix 2: Central East LHIN Decision Making Framework To evaluate the Future State Options, the VPWG used a version of the Central East LHIN decision Making Framework adapted to the present Vision Care context. The criteria are summarized below in Table 26: Central East LHIN Decision Making Framework for Vision Care. Table 26: Central East LHIN Decision Making Framework for Vision Care Domain System Alignment System Performance System Values Criteria 0 Rating of Criteria - Likert Scale 1 3 5 Strategic Fit Extent to which the recommendation is in alignment with the ophthalmogical provider system role and is consistent with their mandate compared to other providers in Ontario Not aligned with the ophthalmogical provider system role and/or is not consistent with provider mandate compared to other providers in Ontario Some alignment with the ophthalmogical provider system role and/or some consistency with provider mandate compared to other providers in Ontario Moderate alignment with the ophthalmogical provider system role and/or moderate consistency with provider mandate compared to other providers in Ontario Strong alignment with the ophthalmogical provider system role and/or strong consistency with provider mandate compared to other providers in Ontario Access The extent to which the recommendation maintains or increases timely access to appropriate level of ophthalmological services No increase in timely access to appropriate level of ophthalmological services Minimal increase in timely access to appropriate level of ophthalmological services Moderate increase in timely access to appropriate level of ophthalmological services High increase in timely access to appropriate level of ophthalmological services Quality Extent to which the recommendation impacts the safety, effectiveness, and client experience of ophthalmogical services received. No impact on the safety, effectiveness, and client experience of ophthalmogical services received Minimal impact on the safety, effectiveness, and client experience of ophthalmogical services received. Moderate impact on the safety, effectiveness, and client experience of ophthalmogical services received High impact on on the safety, effectiveness, and client experience of ophthalmogical services received No efficiencies gained Minimal efficiences gained Moderate efficiencies gained High efficiencies gained No impact on generation, transfer or application of new knowledge to solve ophthalmological health or health system issues Minimal impact on generation, transfer or application of new knowledge to solve ophthalmological health or health system issues Moderate impact on generation, transfer or application of new knowledge to solve ophthalmological health or health system issues High impact on generation, transfer or application of new knowledge to solve ophthalmological health or health system issues No impact on ensuring service quality enhancement for ophthalmological services Minimal impact on ensuring service quality enhancement for ophthalmological services Moderate impact on ensuring service quality enhancement for ophthalmological services High impact on ensuring service quality enhancement for ophthalmological services Efficiency Extent to which the recommendation impacts the efficiency of ophthalmological services to optimize patient health outcomes and other benefits within the system Innovation The extent to which the recommendation impacts on generation, transfer or application of new knowledge to solve ophthalmological health or health system issues Partnerships Degree of impact on ensuring service quality enhancement for ophthalmological services including improved comprehensiveness, optimal resource use, minimal duplication, and/or increased coordination Early on in the VPWG’s deliberations, the group highlighted certain elements from the Provincial Vision Strategy Task Force’s A Vision for Ontario report as relevant for evaluating Options against the criteria. Below we break out the individual criteria and the relevant provincial considerations. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 73 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Domain System Alignment Criteria Strategic Fit Extent to which the recommendation is in alignment with the ophthalmogical provider system role and is consistent with their mandate compared to other providers in Ontario 0 Not aligned with the ophthalmogical provider system role and/or is not consistent with provider mandate compared to other providers in Ontario Rating of Criteria - Likert Scale 1 3 Some alignment with the ophthalmogical provider system role and/or some consistency with provider mandate compared to other providers in Ontario Moderate alignment with the ophthalmogical provider system role and/or moderate consistency with provider mandate compared to other providers in Ontario 5 Strong alignment with the ophthalmogical provider system role and/or strong consistency with provider mandate compared to other providers in Ontario Relevant Provincial Task Force Recommendations for consideration: Each LHIN should develop a Local Vision Plan describing how they will provide for the current state and future needs of their communities, based on the Provincial Vision Strategy Task Force Report and its findings Planning for ophthalmology services must be done in concert with planning for anesthesia to ensure that an appropriate eye surgery model is feasible, affordable, and safe. Domain Criteria Access The extent to which the recommendation maintains or System Performance increases timely access to appropriate level of ophthalmological services 0 No increase in timely access to appropriate level of ophthalmological services Rating of Criteria - Likert Scale 1 3 Minimal increase in timely access to appropriate level of ophthalmological services Moderate increase in timely access to appropriate level of ophthalmological services 5 High increase in timely access to appropriate level of ophthalmological services Relevant Provincial Task Force Recommendations for consideration: Ministry and LHIN funding for ophthalmology services should be sustained to address wait lists for adult and pediatric eye surgery Planning for ambulatory models must also be contingent on maintenance of access to appropriately equipped and staffed eye suites/procedure rooms to deal with urgent and emergent cases on a 24/7 basis Specialty centres will explore and facilitate use of tele-ophthalmology to reduce travel for follow-up visits Domain Criteria 0 Rating of Criteria - Likert Scale 1 3 Quality No impact on the Minimal impact on the Extent to which the recommendation safety, effectiveness, safety, effectiveness, System Performance impacts the safety, effectiveness, and and client experience and client experience client experience of ophthalmogical of ophthalmogical of ophthalmogical services received. services received services received. Moderate impact on the safety, effectiveness, and client experience of ophthalmogical services received 5 High impact on on the safety, effectiveness, and client experience of ophthalmogical services received Relevant Provincial Task Force Recommendations for consideration: All centres and LHINs that perform cataract surgery will report on this appropriateness measure All centres and LHINs who perform ophthalmology procedures will implement the performance management framework, including all indicators listed in Figure 38 of the report Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 74 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT New ambulatory models must be contingent on Ophthalmologists maintaining inpatient consultation and emergency coverage at local hospitals, as well as maintaining a location for outpatient consultation and follow-up services geographically situated within affiliated communities Pediatric ophthalmology procedures should remain in a hospital setting where sufficient resources to provide adequate safety and medical back-up exist. Domain Criteria System Values Efficiency Extent to which the recommendation impacts the efficiency of ophthalmological services to optimize patient health outcomes and other benefits within the system 0 No efficiencies gained Rating of Criteria - Likert Scale 1 3 Minimal efficiences gained Moderate efficiencies gained 5 High efficiencies gained Relevant Provincial Task Force Recommendations for consideration: Cataract programs must collect and trend pre- and post-operative visual acuity ideally using an automated assessment system All ophthalmology programs must adopt the same patient satisfaction measurement tool that rates patients’ ease of access to care, wait times, patient improvement, staff and facility satisfaction Ontario’s 9 Shared Services Organizations should coordinate efforts in developing a provincial sourcing model for ophthalmology supplies in order to maximize supply chain efficiencies The shifting of routine low risk ophthalmology procedure volumes to ambulatory surgery models should be developed using a LHIN-led review of Ophthalmology needs and opportunities in their local environment Considerations for consolidation of specialty ophthalmology service delivery must follow a thorough LHIN-led review of low-volume centres and a local needs assessment Domain Criteria System Values Innovation The extent to which the recommendation impacts on generation, transfer or application of new knowledge to solve ophthalmological health or health system issues 0 Rating of Criteria - Likert Scale 1 3 5 No impact on Minimal impact on Moderate impact on High impact on generation, transfer or generation, transfer or generation, transfer or generation, transfer or application of new application of new application of new application of new knowledge to solve knowledge to solve knowledge to solve knowledge to solve ophthalmological ophthalmological ophthalmological ophthalmological health or health health or health health or health health or health system issues system issues system issues system issues Relevant Provincial Task Force Recommendations for consideration: System planning must ensure that education, basic and clinical research programs in ophthalmology are sustained and enhanced Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 75 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Domain System Values Criteria 0 Partnerships Degree of impact on ensuring service No impact on quality enhancement for ensuring service ophthalmological services including quality enhancement improved comprehensiveness, optimal for ophthalmological resource use, minimal duplication, services and/or increased coordination Rating of Criteria - Likert Scale 1 3 Minimal impact on ensuring service quality enhancement for ophthalmological services Moderate impact on ensuring service quality enhancement for ophthalmological services 5 High impact on ensuring service quality enhancement for ophthalmological services Relevant Provincial Task Force Recommendations for consideration: Patients need to cross LHIN boundaries to obtain specialty services in many instances. As such, specialty centres will develop strong referral partnerships both within and across LHINs. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 76 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Appendix 3: Select Literature Scans A3.1 Service Delivery Models Service delivery, in this project’s context, is primarily focused on providing care to patients There are several service settings for providing vision care found in the literature, including: Hospital-based6 Ambulatory Care Centres7 Independent Health Facilities8 Outreach Centres9 Physician General Practitioner Offices10 Optometry Clinics11 In creating a vision care service delivery model, weightings of these components can be varied according to local system and population needs, along with additions of new services settings or providers and the elimination of less appropriate settings. To date we have not found any single model identified as a generally accepted standard for service delivery. However, the different models are driven by a common set of factors and concerns. Some factors are complementary and others must be balanced to achieve multiple health system design goals. The following list, while not exhaustive, provides necessary context for considering vision care service delivery model design. The Institute for Healthcare Improvement’s Triple Aim (Population Health, Experience of Care, Per Capita Cost) has been used to categorize the different types of factors to be considered.12 6 Thulasiraj Ravilla and Dhivya Ramasamy, “Efficient High-Volume Cataract Services: The Aravind Model,” Community Eye Health 27, no. 85 (2014): 7. 7 Ontario Ministry of Health and Long-Term Care, “A Policy Guide for Creating Community-Based Speciality Clinics,” December 2013. 8 Ibid. 9 Ravilla and Ramasamy, “Efficient High-Volume Cataract Services: The Aravind Model.” 10 T. Sharma, R. Wormald, and W. Franks, “Provision of Eye Care: Commissioning Change,” Journal of the Royal Society of Medicine 101, no. 1 (January 1, 2008): 4–5, doi:10.1258/jrsm.2007.070407. 11 Ibid. 12 Institute for Healthcare Improvement, “IHI Triple Aim Initiative,” accessed August 15, 2014, http://www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 77 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Factors in Vision Service Delivery Model Design Factor Access to Early Screening Holistic, Integrated Care Factor Type Population Health Population Health Healthcare Population Professionals Health Description Approximately 80% of the world’s visual impairments are preventable and curable.13 Yet early screening is important for timely intervention, treatment, and prevention of further disease.14 Patients must have screening that is reasonably accessible. Eye health is related to various comorbidities, and often in relation to Diabetes. To properly provide vision care, these comorbidities must also be considered and treated in a holistic and integrated care approach. In the Ontario context, this care is most often provided by the primary care physician. The WHO states that there is “ample evidence that comprehensive eye care services need to become an integral part of primary health care and health systems development”.15 The need for this type of care is related to the prevalence of chronic conditions such as Diabetes in the population being served. However, as the UK model described below highlights, there are different approaches to bringing optometry and ophthalmology expertise into primary care settings. The provision of vision care services requires several types of healthcare professionals including, but not limited to, General Practitioners, Ophthalmologists, Optometrists, and Anesthesiologists. Since each professional group is necessary, their interests must be balanced to ensure each has incentive to provide care as designed by the service delivery model. Anesthesiology is an important component in performing multiple vision related procedures. Financial incentives for anesthesiologists are higher with larger volumes of patients, when supervising anesthesiologist can oversee multiple procedures, and trained anesthesia assistants are involved.16 In some vision care delivery models, the majority of cataract procedures are performed without sedation.17 Optometrists are taking on an increased role in some service delivery models by providing care to patients in primary care physician settings, which can be beneficial where General Practitioners have only basic training in eye care.18 13 World Health Organization, “Universal Eye Health: A Global Action Plan 2014-2019,” 2013, http://www.who.int/blindness/actionplan/en/. 14 European Coalition for Vision, “Meeting with European Institutions 1st April,” April 1, 2014, http://www.epha.org/IMG/pdf/ECV_Presentation_Luxembourg_March.pdf. 15 World Health Organization, “Universal Eye Health: A Global Action Plan 2014-2019.” 16 Eye Physicians and Surgeons of Ontario, “The Current State of Cataract Anesthesia in Ontario,” July 2012, http://www.ontarioanesthesiologists.ca/wp-content/uploads/2012/09/Joint-Statement-Regarding-Current-Status.pdf. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 78 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT Factor Factor Description Type Service Experience The distance that patients must travel to receive assessment and Delivery of Care treatment impacts their personal healthcare costs as well as how Distance they view their end-to-end episode of care.19 While travel can also be a barrier to access, it affects experience of care. Economies Per Capita Increasing volumes of standardized procedures can create economies of Scale Cost of scale, with the goal of achieving per capita cost-savings. Cost Saving Per Capita While economies of scale are linked to cost-savings in service delivery Mechanisms Cost design, when the WHO outlined measures to increase cost sustainability of vision care, it did not directly link its recommendations to service delivery models. Rather, its cost-savings recommendations are relevant regardless of the model, and include: bulk purchasing; increasing productivity (salaries, overhead); and cost recovery.20 Note that several mechanisms for vision care cost-savings may lie outside of service delivery design itself. Examples of Service Delivery Models India – The Aravind Model A Hub and Spoke Model with the following Service Aspects: Outreach Clinics take screening to people in their communities, where treatment is recommended for those who require it. This increases volume and economies of scale for the “Base Hospital”. Vision Centres are set-up for walk-in appointments, and decrease travel costs for patients The “Base Hospital” provides treatment for those identified at Vision Centres and Outreach Clinics If a patient is identified as requiring surgery, they are booked immediately for same day surgery at the “Base Hospital” so that they can complete the entire cycle of care in one visit Source: Ravilla and Ramasamy, “Efficient High-Volume Cataract Services: The Aravind Model.” 17 The Provincial Vision Strategy Task Force, “A Vision for Ontario - Strategic Recommendations for Opthalmology in Ontario,” May 2013. 18 Sharma, Wormald, and Franks, “Provision of Eye Care.” 19 Ravilla and Ramasamy, “Efficient High-Volume Cataract Services: The Aravind Model.” 20 Allen Foster, “Cataract and ‘Vision 2020—the Right to Sight’ Initiative,” British Journal of Ophthalmology 85, no. 6 (2001): 635–37. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 79 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT UK – Changing Roles for General Practitioners and Optometrists Background: It is estimated that “90% of all cases of glaucoma, the second most common cause of irreversible blindness in the UK, referred to the hospital eye service are detected by optometrists.” “UK General Practitioners have little training in eye care” “Optometrists are already working in extended roles in glaucoma clinics in the hospital eye service. There is opportunity here to reconsider provision and commissioning of eye care and perhaps make cost savings.” Service Aspects: General Practitioners are the primary point of access to vision care Optometrists are looking to provide eye clinics within General Practitioner office premises in order to improve access, quality of care, and cost-efficiency. Source: Sharma, Wormald, and Franks, “Provision of Eye Care.” A3.2 Telemedicine Trends in Ophthalmic Care Telemedicine is seen as a potential means of improving productivity by “…enabling the provision of remote and cost-effective clinical or surgical eye care, enhancing diagnostic capabilities, improving continuing medical education as well as healthcare management and research.”21 Generally speaking, researchers and practitioners see practical near-term benefit arising from telemedicine care relating to screening and diagnosis for a variety of conditions and monitoring during post-operative care. These are likely to benefit populations that are the focus of the VPWG’s work – those with diabetic retinopathy, cataracts, glaucoma, age-related macular degeneration, and other retinopathies.22 Central East LHIN itself has identified telemedicine as a potential opportunity for this planning process, highlighting that it could be “…complementary to hospital sites performing cataract surgery, supporting Diabetes care (Retinal Screening) and other vision care procedures”.23 The Ontario Telemedicine Network (OTN) has been operating its Tele-ophthalmology (TOP) programs since 2009, which provides a solution to nine different tele-ophthalmology programs 21 Tang, Rosa A. and Giselle Ricur. “The benefits, challenges and future of telehealth in ophthalmic care” Expert Review of Ophthalmology, 8, No. 4 (2013): 332. 22 Ibid. 23 Thomas, Jeanne and Shelly Morris. Telemedicine in Central East LHIN – Status Report. May 2014. Access at http://www.centraleastlhin.on.ca/uploadedFiles/Home_Page/Board_of_Directors/Board_Meeting_Submenu/05.03__Presentation_OTN.pdf. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 80 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT in Ontario covering 19 urban, rural and remote sites. In January 2014, OTN issued a Request For Information to learn whether its TOP solution was comparable to others available.24 Where surgical procedures – the VPWG’s focus – are concerned, it appears to be early days for telemedicine. Telemedicine systems can be used to support surgery, but combining telemedicine with robotics to perform surgery remotely is problematic. Surgical support can come through “surgical telepresence systems [which] allow remote surgeons to conduct twoway audio-video communication and thereby observe, teach, and collaborate with local surgeons while they operate on patients.”25 Surgery itself is constrained by robotic systems that do not yet provide robust haptic feedback to surgeons.26 For the purpose of the VPWG’s work, tele-surgery does not look likely to be a development affecting the present planning. However, efforts related to screening, diagnosis, and other uses of telemedicine that affect the broader vision care system with inpatient/outpatient surgical services will continue to be relevant and represent potential opportunities for Central East LHIN. Particularly where screening for diabetic retinopathy (DR) is concerned, tele-ophthalmology has the potential to reduce barriers to screening. Two studies in the Canadian Journal of Ophthalmology suggest promise: one indicates that in Quebec, British Columbia, Alberta, Manitoba and Saskatchewan, “…mobile tele-ophthalmology imaging units efficiently lowered barriers to screening and created new screening opportunities for a large number of known diabetic individuals who were lost to the traditional health system.”27 A more recent article reviewed the diagnostic outcomes of patients assessed and managed through a teleophthalmology program. 28 It found that “Of all patients seen through the remote teleglaucoma program, most did not require an in-person consultation with an ophthalmologist and could be managed through distance collaboration. For the approximately one third who were diagnosed with glaucoma based on virtual assessment, medication was started in the majority of cases and in-person consultation was arranged.”29 Given the above, the VPWG may wish to explore further whether referral volumes can be increased through telemedicine programs for diabetic retinopathy, glaucoma and other conditions. 24 See http://www.merx.com/English/SUPPLIER_Menu.Asp?WCE=Show&TAB=1&PORTAL=MERX&State=7&id=287849&src=osr&FED_ONLY =0&ACTION=PAGE1&rowcount=28&lastpage=3&MoreResults=&PUBSORT=2&CLOSESORT=0&IS_SME=Y&hcode=JoO1OK%2FO7af2h mhIEDfccA%3D%3D. 25 Chiang, Michael F. “Telemedicine: Beyond Remote Diagnosis” 2013 Annual Meeting Syllabus, North American NeuroOphthalmology Society (2013): 408. 26 Ibid, pp. 408-409. 27 Boucher, MC, G Desroches R, Garcia-Salinas, A Kherani, D Maberley, S Olivier, M Oh, and F Stockl. “Teleophthalmology screening for diabetic retinopathy through mobile imaging units within Canada”, Canadian Journal of Ophthalmology, 43, no. 6 (2008): 658. 28 Verma, S, S Arora, F Kassam, M Edwards, and K Damji. “Northern Alberta remote teleglaucoma program: clinical outcomes and patient disposition”, Canadian Journal of Ophthalmology, 49, no. 2: 135-140. 29 Ibid: 135. Prepared by OPTIMUS | SBR © 2014 All rights reserved P a g e | 81 C E N T R AL E AS T L H I N DIRECTIONAL PLAN – VISION CARE STRATEGY: FINAL REPORT A3.3 Driving Referrals through Relationships Discussion at one VPWG meeting highlighted a potential role for improved relationships between ophthalmologists and optometrists to drive referral volume within Central East LHIN. While no models of building relationships with Ophthalmologists or Optometrists with the purpose of increasing referral rates were found in the literature scan, evidence was found relating to methods influencing referral patters in general. Cochrane Review – 2009: Interventions to improve outpatient referrals from primary care to secondary care30 Interventions seen to change referral Interventions seen not to change referral patterns: patterns: Local dissemination of information Passive dissemination of information and implementation strategies by secondary care providers Educational activities Secondary care management is responsive to changes in primary care behaviour You, Levinson and Laupacis’ article identified poor communication between primary and secondary care providers as a barrier to referrals, and that these groups may feel disdain towards the other.31 In summary, attracting referrals requires good relationships and communication, and behavior that is responsive to the needs of the physician submitting the referral. It is possible that these methods are well aligned with general business principles of increasing demand, which includes communication, building relationships, and customer satisfaction. In the United States, where increasing demand for services has long been a priority, business tools related to marketing and customer relationship management commonly help to drive referral volumes.32 While the literature scan found nothing specific relating to driving ophthalmologist and optometrist referrals through relationship building, there is no a priori reason to suggest that these vision care specialists require different approaches to relationship building. 30 A Akbari et al., “Interventions to Improve Outpatient Referrals from Primary Care to Secondary Care (Review)” (Cochrane Database of Systematic Reviews, 2009). 31 John You, Wendy Levinson, and Andreas Laupacis, “Attitudes of Family Physicians, Specialists and Radiologists about the Use of Computed Tomography and Magnetic Resonance Imaging in Ontario,” Healthcare Policy | Politiques de Santé 5, no. 1 (August 13, 2009): 54–65, doi:10.12927/hcpol.2009.21002. 32 Missy Sullivan, “The Surprising Secret Behind Doctor Referrals,” MarketWatch, April 13, 2012, http://www.smartmoney.com/plan/health-care/the-surprising-secret-behind-doctor-referrals1334332558571/; NexJ Systems, “NexJ Health | Contact for Health - Healthcare CRM,” NexJ Health, accessed August 29, 2014, http://www.nexjhealth.com/products/contact-for-health/. 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