Multi-Sector Service Accountability Agreement (M-SAA) Overview Presentation to Champlain LHIN community Health Service Providers Winter 2014

What is the Multi-Sector Service Accountability Agreement? The Multi-Sector Service Accountability Agreement is a core lever for Health Service Provider accountability and performance management bringing various contractual agreements between community Health Service Providers and the LHINs into one document. Required under the Local Health System Integration Act (2006) and Ministry-LHIN Performance Agreement (MLPA) A vehicle to delineate accountabilities and performance expectations A mechanism to clarify that the HSP will be responsible for performance as well as planning and integration towards the development of a health system 2

Provincial development, local execution A consistent template agreement for all community Health Service Providers was developed provincially through consultation with Health Service Provider associations and sub-sector representatives: Community Care Access Centres Community Health Centres Community Mental Health & Addictions Community Support Services 3

M-SAA Development Principles Enabling close ongoing collaboration with the Community Sector Guiding principles for development of the Agreement are to ensure the process is undertaken with a spirit of trust and collaboration among the province’s LHIN-funded community Health Service Providers, sector associations, and LHINs. The Agreement should align with provincial health system priorities and be consistent with Ministry of Health and Long-Term Care policy, legislation, and regulations. The negotiating team has sought within the Agreement to streamline processes, minimize administrative burden, and provide clarity for Health Service Providers where possible 4

Articles of the Agreement 5 Article 1 Definitions & Interpretation Clarifies terminology used throughout the document. Article 2 Term and Nature of the Agreement Defines the term of the service accountability agreement as April 1, 2014 to March 31, Article 3 Provision of Services Describes how services will be provided in accordance with legislation, applicable policies, e-health/IT compliance and the terms of this agreement. Discusses subcontracting services and conflict of interest. Article 4 Funding Outlines conditions of funding, payment and provision limitations. Procurement and disposition of goods and services are also described. Article 5 Repayment and Recovery of Funding Defines circumstances under which funding may be adjusted and/or recovered.

Articles of the Agreement continued 6 Article 6 Planning & Integration Discusses multi-year planning requirements in alignment with LHIN Integrated Health Service Plan and priorities. Article 7 Performance Discusses the need for ongoing performance improvement and the mitigating process in the event of performance factors (non-performance). Article 8 Reporting, Accounting and Review Describes the obligations of reporting and record maintenance, French language requirements, disclosure of information, transparency and reviews. Article 9 Acknowledgement of LHIN Support Health Service Provider publications are required to note LHIN support, be approved by the LHIN, and indicate views do not necessarily reflect those of the LHIN or Government. Article 10 Representations, Warranties and Covenants Confirms the Health Service Provider’s ability to enter into the agreement and carry out the funded services with the appropriate governance, personnel and documentation.

Articles of the Agreement continued 7 Article 11 Limitation of Liability, Indemnity & Insurance Outlines the limitation of liability and indemnification for the LHINs and the required insurance provisions for the Health Service Provider. Article 12 Termination of Agreement Describes the parameters for termination of the agreement by the LHIN and by the Health Service Provider. Article 13 Notice Details how notices to a party must be provided. Article 14 Additional Provisions Identifies additional provisions to the agreement. Article 15 Entire Agreement Defines the agreement as constituting the entire agreement, superseding all prior agreements.

Summary of Main Changes 8 REFERENCEDIFFERENCEREASON FOR CHANGE General UpdateMinor corrections A variety of changes were made to correct minor errors in references, use of defined terms, conformance and formatting. 1.1 DefinitionsRevised “Board” definition. The definition of “Board” was broadened to recognize that committees of management and boards of management are sometimes the ultimate authority for a Health Service Provider. This is relevant for some Long-Term Care homes that operate LHIN-funded community programs and therefore hold an Multi-Sector Service Accountability Agreement. Added “controlling shareholder” definition. Adding a definition for “controlling shareholder” and including it within the definition for Health Service Provider’s Personnel to provide clarity where a Health Service Provider has a controlling shareholder. Added “and volunteers” to definition of “Health Service Provider’s Personnel.” Volunteers and students are under the control of the Health Service Providers, no differently as regards the LHIN, than any of the Health Service Provider's paid staff or other agents. 3.2 SubcontractingChanged to enhance clarity. This provision clarifies that the Health Service Provider may hire others to provide the Services on its behalf and states the terms on which this can be undertaken. 3.4 e- Health/Information Technology Compliance Changed to conform to the LHINs’ obligations under the MLPA. The Local Health System Integration Act requires that LHINs provide their funding to Health Service Providers in accordance with the Ministry-LHIN Performance Agreement. Changes to the Agreement are therefore required to align Health Service Providers’ information technology initiatives to provincial priorities, including the requirement that the installation of e-Health systems must be “compatible or interoperable with the provincial blueprint and LHIN e-Health plan”. 4.3 AppropriationDeleted the specific actions that a LHIN may take. This provision reflects the Financial Administration Act and the change was made to eliminate any implied notion that the LHIN is limited in terms of what actions it can take in the event that there is no appropriation of funds.

Summary of Main Changes continued 9 REFERENCE DIFFERENCEREASON FOR CHANGE 4.6 Interest Adjusted language to incorporate flexibility. This section has been revised to incorporate flexibility into this requirement. It now specifies that if funding is provided by the LHIN to a Health Service Provider before it is required, it must be placed into an interest-bearing account. Interest income must be used within the same fiscal year to provide Services. 4.8 Procurement of Goods and Services Changed to enhance clarity. The Agreement requires Health Service Providers to abide by all Applicable Laws and Applicable Policies. To clarify the obligations, Section 4.8(a) has been revised by inserting the phrase “that are applicable to the Health Service Provider pursuant to the Broader Public Sector Accountability Act.” 6.1(c)(D) Multi-Year Planning Targets Changed to reflect that LHINs typically consult with an HSP on changes multi-year planning targets. Changes to multi-year planning targets should be addressed at the local LHIN level. Health Service Providers should discuss this issue with their LHIN and ask for the appropriate assumptions for planning purposes. 6.3(a)(ii) Planning and Integration Activity Pre-Proposal Changed to enhance clarity such that the obligation captures the notion of physical change. The LHINs are responsible for possible impacts to the health system of service changes and need to be made aware of changes to service delivery for health system planning purposes. In addition, this provision gives the LHIN the opportunity to review, evaluate, and provide input into the Health Service Provider's plan, rather than being limited to stopping all or part of the plan. 8.1(d) Declaration of Compliance Changed to once per year and revised due date. The frequency for Declaration of Compliance has been changed to once per year and the submission deadline has been revised to factor in time for Health Service Providers to reconcile finances and close their books before submitting the Declaration. The obligation now reads “Within 90 days of the Health Service Provider’s fiscal year-end.” 9.2(b) Acknowledgment of Funding Support Added to conform to Ontario’s Visual Identity Directives. Ontario and LHIN logos are strictly governed by Provincial policy. The provision in the Agreement reflects what is required by Ontario’s Visual Identity Directives.

Summary of Main Changes continued 10 REFERENCEDIFFERENCEREASON FOR CHANGE 10.3(b) GovernanceDefinition of “compensation award” added for clarity. The wording of the provision states that the compensation award is linked to the CEO’s performance and a definition has been added in this regard. 10.4(c) Funding, Services and Reporting Revised to reflect materiality. Language has been added to incorporate notion of materiality with respect to changes to reports and the requirement that a Health Service Provider advise the LHIN of any material changes immediately. 11 Limitation of Liability, Indemnity & Insurance The insurance provisions have been significantly amended with input from the sector. The insurance provisions have been updated to reflect sector specific risk. Health Service Providers will be required to provide to the LHIN a valid Workplace Safety and Insurance Act (1997) Clearance Certificate. 12.2(a) Termination by the HSP Revised to reflect circumstances where an HSP may require the ability to exit the Agreement on short notice. Section 12.2(a) has been revised by inserting "(or such shorter period as may be agreed by the HSP and the LHIN)". 12.4(b) Consequences of Termination Deleted to incorporate flexibilitySection 12.4(b) has been deleted to incorporate flexibility into process Terms and Conditions on Any Consent Adjusted language to reflect reasonableness. The LHINs are always obligated to act reasonably and fairly in making decisions and are committed to doing so No AssignmentAdded language to enhance clarityThis section now states “no assignment or subcontract shall relieve the Health Service Provider from its obligations under this Agreement or impose any liability upon the LHIN to any assignee or subcontractor.”

Agreement Schedules 11 ScheduleTitleDescription ADescription of ServicesDescribes the services delivered by the Health Service Provider, client populations and geography served BService PlanDescribes the financial and statistical status of the Health Service Provider CReportsIdentifies, describes and sets due dates for Health Service Provider reporting DDirectives, Guidelines, PoliciesIdentifies applicable Ministry of Health and Long-Term Care policies EPerformanceIdentifies indicators, standards and local performance requirements FTemplate for Project FundingTemplate used for funding special projects GDeclaration of ComplianceForm to be completed by the Health Service Provider’s Board of Directors to declare that the Health Service Provider has complied with the terms of the Agreement Seven schedules will be appended to the Agreement setting out the amount of LHIN funding that will be provided to the Health Service Provider, the Services for which the funding will be provided, expectations of what reports will be provided to the LHIN or Ministry of Health and Long-Term Care and when the reports must be submitted, the policies to which LHIN funding is subject, measures and targets against which the Health Service Provider’s performance will be evaluated, and necessary template forms.

Performance Indicators (Schedule E) There are two types of indicators that figure into Schedule E of the Agreement: 1. Pan-LHIN indicators are consistent between all LHINs. Some of these indicators are termed Performance Indicators and have associated targets set within the Agreement Schedules. Performance indicators are the measures to which Health Service Providers are held accountable. Other pan-LHIN indicators are termed Explanatory indicators and while they do not have targets set within the Agreement, their inclusion sets the expectation that they are measured and evaluated if additional context on performance is required. 2. Local obligations are developed by each LHIN. Effort has been made provincially to reduce the number of local obligations/indicators. 12

Performance Indicators Why Performance Standards? All performance indicators have an associated target and standard of performance. Variance outside of the standard triggers the performance management processes in Article 7 of the M-SAA. The LHIN or the HSP can identify a Performance Factor that “…could or will significantly affect a party’s ability to fulfill its obligations under the Agreement.” The identification of a Performance Factor is made formally, in writing, to the other party and will include a description of the Factor’s actual or anticipated impact and a description of any action the party is undertaking, or plans to undertake, to remedy or mitigate the Performance Factor. 13

Key Performance Indicators Performance indicators that apply to all community Health Service Providers Previous key performance indicators that will continue in : Balanced budget - Fund type 2 Proportion of budget spent on administration Variance forecast to actual expenses Percentage total margin Service activity by functional centre Variance of forecasted to actual units of service Number of individuals served New key performance indicator for : Percentage of Alternate Level of Care (ALC) days 14

Key explanatory indicators Key explanatory for all community Health Service Providers Previous key explanatory indicators that will continue in : Cost per individual serviced by program/service/functional centre Cost per unit of service by functional centre New key explanatory indicator: Client experience 15

Community Care Access Centre Indicators unique to the CCAC Performance indicators: Previous performance indicators that will continue in : Wait time from hospital discharge to service initiation (hospital clients) 90th percentile wait time from community setting to community home care services The following performance indicator will be discontinued for : Percentage people registered with Health Care Connect who are referred This indicator has been retired, as reporting obligations are already in place with the Ministry of Health and Long-Term Care 16

Community Care Access Centre Indicators unique to the CCAC Explanatory indicators: Previous explanatory indicators that will continue in : Wait time from hospital discharge to service initiation (hospital clients) by population groups (short stay, short stay rehab, long-stay complex) 90th percentile wait time from community setting to community home care services by population groups (short stay acute, short stay rehab, long-stay complex) Average monthly cost per episode (adult short stay, adult long-stay complex, end of life, children medically fragile) 17

Community Care Access Centre Indicators unique to the CCAC Explanatory indicators (cont’d): Previous performance indicators that will explanatory indicators for : Clients with MAPLe scores high and very high living in the community supported by CCAC Clients placed in LTCH with MAPLe scores high and very high as a proportion of total clients placed Indicators fit this category and provide valuable information about how the system is functioning and the opportunities for change Indicators are not a good measure for performance as targets are set locally by each LHIN 18

Community Care Access Centre Indicators unique to the CCAC Developmental indicators: There will be no developmental indicators for the CCAC for The previous developmental indicators for the CCAC have been retired for : Percentage of clients with a new or existing pressure ulcer that failed to improve Medication safety Percentage of home care clients who say they have fallen in the last 90 days Indicators have been retired, as they were not identified by HQO on the Common Quality Agenda 19

Community Support Services Indicators unique to CSS Performance indicators: There will be no unique performance indicators for CSS in Explanatory indicators: Previous explanatory indicator that will continue in : Number of persons waiting for service (by functional centre) 20

Community Support Services Indicators unique to CSS Developmental indicators: Previous performance indicator that will be developmental for : Number of days waited for first service (by functional centre) Moved from CSS performance indicator category as data is not yet available. Will become explanatory in years 2 or 3. Previous developmental indicators that will be retired for : Repeat unscheduled emergency visits within 30 days for mental health conditions Repeat unscheduled emergency visits within 30 days for substance abuse conditions These indicators will be retired as they are difficult to measure and it is not currently possible to follow clients between the hospital and the community 21

Community Health Centres Indicators unique to CHCs Performance indicators: Previous performance indicators that will continue for : Cervical cancer screening Colorectal Screening rate Inter-professional diabetes care rate Influenza vaccination rate Breast cancer screening rate Periodic health exam Vacancy Rate (for NPs and Physicians) New performance indicator for : Access to primary care clinical service 22

Community Health Centres Indicators unique to CHCs Explanatory indicators: New explanatory indicators: Emergency visits best managed elsewhere Client satisfaction – Access Clinical support staff per primary care provider Cultural interpretation Exam rooms per primary care provider New grads/new staff Number of new patients Non-Primary Care activities Number of registered clients Specialized care Supervision of students Third next available appointment Non-insured clients 23

Community Health Centres Indicators unique to CHCs Explanatory indicators (cont’d): Previous explanatory indicators that will be retired for : Repeat unscheduled emergency visits within 30 days for mental health conditions Repeat unscheduled emergency visits within 30 days for substance abuse conditions Developmental indicators: Previous developmental indicator that will continue for : CHC clients hospitalized for Ambulatory Care-sensitive conditions 24

Community Mental Health & Addictions Indicators unique to CMHA Performance indicators: There will be no unique performance indicators for CMH&A in Explanatory indicators: Previous explanatory indicators that will continue in : Number of days waited from referral/application to initial assessment complete Average number of days waited from initial assessment complete to service initiation 25

Community Mental Health & Addictions Indicators unique to CMHA Previous performance indicators that will be explanatory indicators for : Repeat unscheduled emergency visits within 30 days for mental health conditions Repeat unscheduled emergency visits within 30 days for substance abuse conditions

Community Mental Health & Addictions Indicators unique to CMHA (cont’d) Developmental indicators: Previous developmental indicator that will continue for : OCAN/GAIN Indicator 27

#Obligation Title Status for 2014/15 1 Alignment with IHSPWill be dropped (no longer needed) 2 Cultural DimensionWill continue for Home FirstWill continue for MIS ComplianceWill be dropped (no longer needed) 5 Concurrent Disorder ScreeningWill continue, but will be revised 6 Diabetes StrategyWill continue, but will be revised 7 Chronic DiseasesWill continue for M-SAA Local Obligations ( )

#Obligation Title Status for 2014/15 8 Smoking CessationWill continue for Transportation SystemWill continue, but will be revised 10 French Language ServicesWill continue, but will be revised 11 Quality Improvement PlansWill continue, but will be revised 12 Hospice Palliative Care EducationNew for Hospice Palliative Care Services and Indicators New for

M-SAA Local Obligations – New Obligations for Hospice Palliative Care Education: Applies to 6 Health Service Providers The HSP will work with the Champlain Hospice Palliative Care Regional Program to establish a regional hospice palliative care education plan. In an effort to improve hospice palliative care education in the region, the HSP agrees to provide a report to the Champlain LHIN and Champlain Hospice Palliative Care Regional Program on the use of funds provided by the LHIN for: Education for interdisciplinary service providers; Education for family physicians; Supporting and maintaining hospice volunteer visiting programs; Establishing pain and symptom management teams.

M-SAA Local Obligations – New Obligations for Hospice Palliative Care Service Adjustments and Indicator Development: Applies to 9 Health Service Providers The HSP will consult with the Champlain Hospice Palliative Care Regional Program and the Champlain LHIN prior to making any significant adjustments to hospice palliative care services, including but not limited to temporary or permanent bed closures. The HSP will work with the Champlain Hospice Palliative Care Regional Program to support the development of indicators, and their associated technical specifications and data collection processes, for planning and evaluation purposes.

32 Financial and service activity plans (CAPS) were submitted by Health Service Providers on November 15, LHIN staff are currently reviewing each submission. Where balanced budgets are not planned, services are planned to be reduced, or other issues exist, LHIN staff will discuss with the Health Service Provider Once all issues have been resolved, the plan will be presented to the Champlain LHIN Board of Directors for approval in either February or March Following the endorsement of the Champlain LHIN Board, a Multi-Sector Service Accountability Agreement with schedules containing the HSP’s financial, service activity, and performance indicator targets will be issued to the Health Service Provider for the signatures of the Executive Director and Board Chair The signed agreement is returned to the LHIN before March 31, 2014 Finalization of Multi-Sector Service Accountability Agreements

33 In the absence of definitive funding targets, CAPS will be based on a planning assumption of 0% base adjustment. CAPS should be prepared to maintain service levels within the 0% planning assumption Since the LHIN does not yet know what funding will be available in or , targets within the M-SAA will be set for only The M-SAA Schedules will be refreshed in the Fall of each year of the agreement to confirm the current year’s planning assumption and to update the agreement’s performance and explanatory indicators Finalization of Multi-Sector Service Accountability Agreements (cont’d)

Questions or comments? Please contact your Accountability Specialist at the Champlain LHIN Elan Graves Janet Jones Patrick Manhire Elizabeth Woodbury Colleen Taylor