DTES Second Generation Strategy Evaluation Framework DRAFT – NOT FOR DISTRIBUTION

Purpose of the evaluation framework Give an overview of the strategy at a level that can be measured System performance measurement Quality improvement Demonstrates logical link: Identify gaps in measurement Prioritize activities that will most likely get us to our ultimate goal Inputs Activities Outputs Outcomes

Current state of health in DTES Poor health outcomes for DTES population High volumes of ED visits and hospitalizations of at-risk people from DTES Care is fragmented, uncoordinated, inaccessible for some Housing is unstable Access to nutritious food is challenging

Goal of DTES SGS Improving health outcomes for the population in the DTES

DTES Second Generation Strategy Theory of Change Long term outcomes Ultimate goal Intermediate outcomes Indirect result of outputs Immediate outcomes Direct results of outputs Outputs The type, volume, and quality of products and services Activities The work we are doing to produce the outputs Inputs The resources required to undertake the activities

DTES Second Generation Strategy Theory of Change Client-reported quality of life Overall health improvement Long Term Health issues/risk identified and addressed before complications occur Outcomes Intermediate Social Determinants of Health People get access to nutrition People are appropriately housed At-Risk people engaged into care Immediate Unbroken attachment to care and treatment retention Patient experience of care: Trauma-informed Culturally competent Harm reduction Recovery-orientation Coordination Outputs Appropriate housing services Nutritious food services Access & Accessibility Integrated care Capacity building: Trauma-informed care Cultural competency Best pain management practices Harm reduction Recovery-orientation Activities Strengthen relationships and partnerships New models of care: Low barrier addiction care model MH substance use drop-in model Integrated care model Strategies: Food & nutrition strategy Housing strategy Peers strategy Low Threshold Addiction Clinic New clinic sites Integrated care teams Housing contracts Inputs Embedded peers Food contracts

DTES Second Generation Strategy Theory of Change Focus of System Performance Measurement Client-reported quality of life Overall health improvement Long Term Health issues/risk identified and addressed before complications occur Outcomes Intermediate Social Determinants of Health People get access to nutrition People are appropriately housed At-Risk people engaged into care Immediate Unbroken attachment to care and treatment retention Focus of Quality Improvement Patient experience of care: Trauma-informed Culturally competent Harm reduction Recovery-orientation Coordination Outputs Appropriate housing services Nutritious food services Access & Accessibility Integrated care Capacity building: Trauma-informed care Cultural competency Best pain management practices Harm reduction Recovery-orientation Activities Strengthen relationships and partnerships New models of care: Low barrier addiction care model MH substance use drop-in model Integrated care model Strategies: Food & nutrition strategy Housing strategy Peers strategy Integrated care teams Housing contracts Inputs Low Threshold Addiction Clinic New clinic sites Embedded peers Food contracts

DTES Second Generation Strategy Theory of Change Focus of System Performance Measurement Client-reported quality of life Overall health improvement Long Term Health issues/risk identified and addressed before complications occur Outcomes Intermediate People are appropriately housed/ increased housing tenure At-Risk people engaged into care Unbroken attachment to care and treatment retention People get access to food Immediate Patient experience of care: Trauma-informed Culturally competent Harm reduction Recovery-based Coordination Outputs Appropriate housing services Food services Access & Accessibility Integrated care Training: Trauma-informed care Cultural competency Best pain management practices Harm reduction Recovery-based Activities Strengthen relationships and partnerships New models of care: Mental health & addiction care MH substance use drop-in model Integrated care model Pain management best practices Strategies: Food & nutrition strategy Housing strategy Peers strategy Low Threshold Addiction Clinic New clinic sites Integrated care teams Housing contracts Inputs Embedded Peers Food contracts

Performance Measurement Peer reviewed, validated methods, generalizability of results Give validity to the innovations of the SGS VCH is partnering with external researchers at UBC and SFU to conduct population-based analysis of key health outcomes and some outputs of the SGS

Long Term Outcome Measure Indicator definition Data source Reporting format/ Time frame SGS Innovation Overall health improvement Increase in number of clients with HONOS score in target range EMR HONOS, PARIS HONOS Integrated care teams (ICTs) and clinics, and expanded mobile care. Peer navigators Shared treatment continuums Dedicated ICT for women Enhanced partnerships with private clinics Cultural competence and trauma-informed practice Peers at drop-ins, tenant support workers linking to care teams Connect with private clinics Address service gaps for women and children Managed alcohol Strategic plan for harm reduction Best practices for pain management Overdose training Address social determinants of health: housing & food Washrooms policy Clinically significant improvement from baseline VCHRI project Oct 2017 – March 2018 Reduction in the rate of ED admissions, hospital admissions, death Improved functional assessment in 4 key areas: physical health, substance use, mental health hospitalization; adherence to medications TBD by data reference group Chronic disease indicators per guideline care EMR – TBD by data reference group Dashboard / Quarterly Client-reported quality of life Clients with a Q-LES-Q score in target range EMR HONOS, PARIS HONOS - TBD

Intermediate Outcome Measure Indicator definition Data source Reporting format / Time frame SGS Innovation Health issues/risk identified and addressed before complications occur Preventable hospitalizations: Number of in-patient acute care hospitalizations for conditions where appropriate ambulatory care may prevent or reduce the need for admission to hospital within VCH care. ED and Acute data in Decision Support Integrated care teams (ICTs) and clinics, and expanded mobile care. Peer navigators Shared treatment continuums Dedicated ICT for women Enhanced partnerships with private clinics Cultural competence and trauma-informed practice Peers at drop-ins, tenant support workers linking to care teams Connect with private clinics Address service gaps for women and children Managed alcohol Strategic plan for harm reduction Best practices for pain management Overdose training Address social determinants of health: housing & food Washrooms policy Ambulatory care sensitive condition acute admissions Acute data in DS Dashboard / Quarterly CTAS 4 and 5 level ED visits by known clients ED visit rate Hospitalization rate Acute length of stay # who stabilized on adequate methadone LTAC - TBD # who stabilized on adequate methadone/ suboxone # days reduced illicit opiate use

Immediate Outcome Measure Indicator definition Data source Reporting format / Time frame SGS Innovation At-Risk people engaged into care Counts of both total volume and unique clients VCHRI project Oct 2017 – March 2018 Peer navigation Drop-ins Trauma-informed practice Cultural competence Dedicated ICT for women Overdose training Washrooms policy Service engagement: No. of individuals known to have specified conditions I = (1,…n) who are engaged in optimal care. Service engagement: # of new patients in program who initiated on methadone or suboxone Unbroken attachment to care and treatment retention Retention / Internal attachment: Clients who in the past 14 months have had at least 4 visits to the clinic/program (regular appointments – evenly distributed) and have a Care Plan documented, especially patients with certain health conditions EMR Dashboard / Quarterly Integrated care teams Mobile health services Address gap in care for women and children Connect with private clinics People get access to nutritious food Food access/nutrition: TBD Service contracts that align with SGS food strategy Appropriate housing Appropriateness / stability of housing (tenure): To be developed Housing models designed for appropriateness Create efficient / effective system for access to housing

DTES Second Generation Strategy Theory of Change Client-reported quality of life Overall health improvement Long Term Health issues/risk identified and addressed before complications occur Outcomes Intermediate Social Determinants of Health People get access to nutrition People are appropriately housed At-Risk people engaged into care Immediate Unbroken attachment to care and treatment retention Focus of Quality Improvement Patient experience of care: Trauma-informed Culturally competent Harm reduction Recovery-orientation Coordination Outputs Appropriate housing services Nutritious food services Access & Accessibility Integrated care Capacity building: Trauma-informed care Cultural competency Best pain management practices Harm reduction Recovery-orientation Activities Strengthen relationships and partnerships New models of care: Low barrier addiction care model MH substance use drop-in model Integrated care model Strategies: Food & nutrition strategy Housing strategy Peers strategy Integrated care teams Housing contracts Inputs Low Threshold Addiction Clinic New clinic sites Embedded peers Food contracts

Quality Improvement - Output measurement Changes in outputs happen sooner than outcomes Making sure we are on track to achieve improved health outcomes Opportunity to fail fast and make course corrections

Output Measure: Quality of care Indicator Definition Data source Reporting format / time frame SGS innovation Accessibility Same day service: Clients who were referred to a certain service/team/program and were engaged in treatment/service that same day (clinical assessment, case management assessment, intervention, etc.) EMR and PARIS Dashboard Same day service at point of request Wait times to 1st contact: Clients with an open referral during the reporting period and who have been contacted by the treatment team/program Wait times from service request to first contact Cultural competence Patient experience of culturally competent care Core competencies survey Core competency training Trauma-informed care Patient experience of trauma-informed care Harm reduction Patient experience of harm reduction care Recovery-based care Patient experience of recovery-based care

Output Measure Indicator definition Data source Reporting format SGS Innovation Access Client volumes: Clients with an open referral during the reporting period EMR and PARIS Dashboard Low Threshold Addiction Clinic Integrated Care Teams Number of clients turned away TBD Care coordination Care coordination: % of clients with a new care plan or care plan update in last month EMR and PARIS - TBD Care coordinator Integration Integration: To what extent do you think that the array of services offered to DTES clients, at this time, is integrated in a way that best serves client needs? VCHRI project Data should be available Jan 2017 Peer navigators, ICTs Integration: # peers connected to drop-ins Contract deliverable Food services Food contract (Schedule A) Housing spaces Contract deliverable - TBD

Gaps Measurement of access to nutritious food Measures appropriate housing Patient experience of attachment, engagement, self-management of health Patient experience of accessibility, coordination & integration Benchmarks Program evaluation of some work streams Process evaluation of the overarching project

Balanced scorecard Area Measures System Yes! Neighbourhood No Staff Clients Some

Questions for the group Given the gaps – where would you prioritize? Appetite for program evaluation? Appetite for process evaluation? Setting benchmarks? Where do we want to be 18 months from now? What do we want to know 18 months from now? Where are our opportunities for shared monitoring and evaluation with the community?