Partnering to accelerate best care, best health, best value

Des partenariats pour offrir de meilleurs soins, être en meilleure

santé, optimiser les ressources

Taking the bestPATH

to Health System Integration

Agenda

1. Introductions

2. What is bestPATH?

3. Vision for the initiative

4. Key features and program design

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1. INTRODUCTIONS

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3

Our Panelists Today

• Kim Baker, CEO, Central Local Health Integration Network – Moderator

• Don Ford, CEO, Central East Community Care Access Centre

• Steve Vanderherberg, Senior Manager of Community & Volunteer

Engagement, WoodGreen Community Services

• Don Harterre, Physician Lead, Primary Health Care Services of

Peterborough

• Kenneth Hook, Family Physician, STAR FHT, Tavistock

• Patti Cochrane, VP Patient Services, Quality & Practice / Chief Nursing

Executive, Trillium Site, The Credit Valley Hospital and Trillium Health

Centre

2. WHAT IS bestPATH?

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Overview

• bestPATH is a broad, multi-year initiative aimed at

improving quality of care for individuals with complex

chronic illnesses

• bestPATH is:

• The consistent application of evidence-informed

effective practices – putting into practice what we

know works, all of the time

• More coordinated care delivery, with planning and

information sharing across health sectors

• Person-centred care

5

Person-Centred, Continuous Care

Person

Long Term Care

Hospitals

Primary Care

Community Care

6

3. VISION FOR THE INITIATIVE

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Vision for bestPATH Person-centred, Appropriate, Timely Healthcare

Improve health outcomes, the experience of

care, and system effectiveness through

accessible and coordinated care for Ontarians

with complex chronic illness

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best Care — Improve the care experience by making

care more accessible, and provide a smooth journey

through the system by ensuring clear communication and

strong engagement, both among providers and between

providers and care recipients

best Health — Improve outcomes for persons with

chronic conditions through the use of evidence-informed

best practices

best Value — Ensure care occurs in the most appropriate

setting, reducing the rate of unnecessary hospitalizations

and contributing to more appropriate resource utilization

Aims

bestPATH Partners

• HQO’s vision for bestPATH is partnership-based

• System partners from across many health care sectors are key to the

successful design and implementation of bestPATH including:

− Designing the key elements of bestPATH

− Identifying opportunities to align bestPATH with existing initiatives

− Developing and providing education

− Demonstrating leadership and building support for bestPATH

− Building capacity for change management

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bestPATH Partners

Health Quality Ontario has already engaged with system leaders from

across the province in the development of bestPATH and will continue to

do so as the initiative rolls out:

• LHINs

• Professional/Educational Membership Organizations

• Clinical Specialty/Safety Organizations

• System Innovators and Researchers

• Ministry of Health and Long-Term Care

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4. KEY FEATURES &

PROGRAM DESIGN

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Program Phases

• Phase I

– Focus on transitions of care

– Self-directed stream (Q and Q+)

• Future Phases

– Broaden focus to include chronic disease management,

independence and safety

– More intensive level of support

– Implementation later in 2013

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Phase I - Self-Directed Stream

Transitions of Care

• Self-Directed “Q” (for Quality) – Individual organizations from any sector register directly with

HQO

– Able to access change packages and step-by-step guides to

improvement

– Able to participate in all virtual learning activities

– No obligation to report data, but encouraged to use the

reporting system to help them track their progress

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Phase I - Self-Directed Stream

Transitions of Care

• Self-Directed “Q+” (Quality Plus) • Participating organizations benefit from all the materials offered to

Q participants, plus direct HQO QI coaching and other supports.

• Q+ organizations must:

– Undergo a readiness assessment

– Agree to become part of a QI team involving the local hospital,

CCAC and its providers, primary care, community care, and

long-term care

– Agree to basic data collection and reporting

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What Participants Receive Change Packages

• Evidence informed and vetted by an expert panel and staff in the field

• Endorsed by leaders in Canadian and Ontario health care standards

HQO Quality Framework

• Includes the best of IHI Model for Improvement, Lean and Six Sigma

approaches to quality improvement

Links to Innovative and Leading Edge Healthcare Practitioners

• Partnerships with provincial, national and international leaders

• Links to organizations who have successfully implemented best practices

and addressed barriers to adoption

Web Based Repository of Best Practices

• Evidence-informed guides to best practices and implementation tips

• Guides on quality improvement, measurement for improvement, change

management

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Targeted Focus for Maximum Impact

• Focus improvement efforts on an identified population:

– Analyze your population to determine local priority

– Consider CHF, COPD, Diabetes, CAD & Stroke

• Apply Evidence-Informed Interventions

– Implement list of best practices identified by HQO through

evidence reviews, success stories in literature

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Model for Improvement for Phase I

1. What are we trying to Accomplish?

i) Improvements in 7 & 30 day readmissions

ii) Improvements in measures of patient experience for discharge

transitions

2. How will we know that a change is an improvement?

i) Changes in measures above

ii) Process measures for adoption of best practices

3. What change can we make that will result in improvement?

i) Best practices for transitions

Transitions Best Practices for Transitions

• Assess for risk of readmission within 30 days

of discharge; plan and schedule appropriate

follow up as per readmission risk

− For individuals deemed moderate to high risk for readmission (i.e.,

LACE score ≥ 10) treat discharge as a formal transfer of care

− Timely follow-up appointments confirmed prior to discharge

− “Warm handoffs” involving discharging and receiving clinician

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Transitions Best Practices for Transitions

• Medication reconciliation at key transition points

• Conduct individualized care and discharge planning:

− Health literacy assessment at admission

− Use of “teach back” - ensure person understands care plan,

treatments, how to manage symptoms, when/who to ask for help

− Timely, written discharge documentation completed

− Written discharge instructions to patients

− Written discharge plans distributed to next care provider and

primary care

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Independence / Safety

Future Phases:

Independence and Safety

• Enable the person to take a central role in their health and

create a safe environment:

− Assess health literacy and ensure person understands how to manage

their health and care

− Support the development of goals that are meaningful and important to

the person

• Enhance the person’s ability to live independently and safely :

• Implement OHTAC “Aging in the Community’ recommendations:

− Falls prevention

− Targeted conditioning / exercise / rehabilitation

− Caregiver support

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Future Phases:

Chronic Disease Management

Chronic Disease Management

• Structured visits:

• Use chronic disease flow sheets and clinical practice guidelines

(CPGs) to guide care planning and discussion during each visit with a

patient with chronic illness

• Leverage information systems:

• Use alerts and/or electronic recall functions, flag patients who require

specific interventions, plan specialist consultations

• Coordinate care across disciplines including:

• Specialists, nurse practitioners and allied health care professionals,

creating a multidisciplinary team with shared accountability to provide

care

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What’s Next

Visit www.hqontario.ca or email

bestpath@hqontario.ca to learn more

about participating

Experiences in the

Community

Presented by: Don Ford, Central East CCAC

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Experiences in the Community

What we hear:

- “Don’t you people talk to each other?”

- “How often do I need to tell my story?”

- “Why won’t you listen to me?”

- “Don’t you already have that lab/X-ray result?”

- “Do you know who I should talk to if I need help?”

- “How can you be sure I won’t get lost in the system?”

What we surmise:

The components work, the system doesn’t … so …

We need to improve the experience, the transitions,

the hand-offs … which … Should help to improve satisfaction

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Improve Transitions - Integrated Patient Care

“Patient care that is coordinated across professionals, facilities, and support systems; continuous over time and between visits; tailored to the patients’ needs and preferences; and based on shared responsibility between patients and caregivers for optimizing health.”

To measure integrated patient care, consider seven dimensions:

• Coordination with a care team

• Coordination across care teams

• Coordination between care teams and community resources

• Continuous familiarity with the patient over time

• Continuous proactive and responsive action between visits

• Patient-centred

• Shared responsibility

“Defining and Measuring Integrated Patient Care” Sara Singer & others, 2010

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PATH

Partners Advancing Transitions in Healthcare

Change Foundation

• Provided funding for a 2 year initiative

• To a community/region committed to working differently to

understand and redesign processes to improve people’s

healthcare experience moving in to, out of and across the

continuum of care, to improve satisfaction with the care they

receive and their care outcomes

• Focused on seniors living with chronic health conditions and their

caregivers because they frequently navigate a wide range of

services

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PATH

Partners Advancing Transitions in Healthcare

Northumberland Community Partnership chosen (patients, caregivers and 12

health and social care organizations)

Northumberland Proposals Key Elements:

• To build awareness through public education supported by an Aging Well Toolkit to

guide planned aging

• To capture personal stories in print and online to empower and ensure quality

transitions in a My Health Story document to be owned by and go with the patient

• To develop training and tools for local providers based on Experience Based

Design methodology to shift the local healthcare culture to a person-centred model

of care

• To establish transition partners to direct and coach seniors towards supportive

community resources, a role to complement and not duplicate CCAC Care

Coordinators

Patients At The Heart

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A good patient experience encompasses:

• Clear, consistent reliable communication

• Access to information and exchange of information

• Coordinated and connected care

• Comprehensive care

• Engagement in decision making about care

• Respectful, empathetic and considerate interactions

• Timely and convenient care

“Winning Conditions to Improve Patient Experience”

Change Foundation, November 2011

Taking the bestPATH

to health system

integration:

South East Toronto

Presented by: Stephen Vanderherberg, WoodGreen

Community Services

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Introductions

WoodGreen Community Services: • WoodGreen Community Services is one of the largest community service agencies in

Toronto. A founding United Way of Toronto member agency, WoodGreen has grown to

span 34 locations and serves 37,000 people each year. WoodGreen helps people find

safe, affordable housing, seniors live independently, internationally-trained

professionals enter the job market, parents access childcare, children and youth

access after-school programs, newcomers settle in to Canadian life, homeless and

marginalized people get off the streets and youth find meaningful employment and

training.

Solutions Network: • A voluntary network of health care providers in East Toronto that worked together to

improve care transitions for over a decade. The network includes:

• Toronto East General Hospital, VHA Home Healthcare, South East Toronto Family

Health Team, Toronto Central CCAC, South Riverdale CHC, East End CHC,

Sherbourne CHC, Toronto EMS, Toronto Public Health, Bridgepoint Healthcare,

Providence Healthcare, WoodGreen, SPRINT, Neighbourhood Link, Gerstein Health

Centre,

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Integrated QI Initiatives

Network Successes

• Back office Solutions – shared e-learning modules

• Community Referrals by EMS (CREMS)

Member Successes

• Community Navigation and Access Program (CNAP)

• Geriatric Emergency Medicine RN Outreach to Long Term

Care

• House Calls Program

• Integrated Client Care Project (ICCP)

• Virtual Ward

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Why Experience Based Co-Design?

Solutions Network

• The needed next step for many of our integrated care

efforts

• Learning from failed QI initiatives

• Patient Centred Care: Defining the common client

WoodGreen

• The opportunity to innovate

• Bringing in unheard voices

• Focus on wrap around service approach

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Community Support Services

Perspective on Integrated Care

How might CSS agencies be involved in supporting integrated

care that aims to be patient/client centred?

– Addressing the individual complex social problems that have influence on

key health indicators

– Holistic Care: Seeing the whole picture

• Seniors Services: Variety of services to support independent living

• Housing Services: Addressing instability in housing

• Immigrant Services: Supporting ethno-cultural communities

• Mental Health Services: Individual focused supports & services

• Employment Services: Support to gain meaningful work

• Community Building Efforts: Community led problem solving

– Placed Based strategies to build healthy/supportive communities

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Outreach to Diverse & Vulnerable

Seniors Program Program: Distributes funds to small grassroots organizations to

address prominent health related issues in their own community

using their own approach

• Focus on Health Equity

• Community Empowerment

Impact

• 50% reduction in ER visits and hospital days (for those with

preventable issues)

• Improvement in self management of chronic conditions

Challenge

• How to integrate the good work of niche programs serving

specific communities into bestPATH goals and systems

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Next Steps

Solutions Network

• Starting the slow development of EBCD focused project on

a specific program in which at least 6 organizations share

clients

• Looking to other opportunities to continue our pursuit of

better integrated care through transitions by partnering

with patients and caregivers

WoodGreen

• Explore new ways to come at old problems

• Continue to build placed based strategies of intervention

• Explore how EBCD can shape our internal culture

Shared Care Optimizing Vascular Health

Presented by: Dr. Don Harterre, Peterborough Family Health Team

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Disclosure

Dr. Don Harterre, Physician Lead, Primary Health Care Services of

Peterborough

CVDPMI – Shared Care, Optimizing Vascular Health

• No conflict of interest issue has arisen.

• Free of commercial bias.

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Purpose

1. Develop a comprehensive, guidelines-based approach to

prevent, detect, and manage vascular disease by coordinating

primary and specialty care resources, providers, services and

strategies.

2. Implement and evaluate demonstrable

improvements to population health with outcomes at the patient,

provider and system levels.

3. Document and transfer model to communities interested

in adopting a similar approach.

Partner Role

Primary Care Core Steering Committee

Governance and Accountability, Lead Program Planning,

Design, Documentation, Administration, Implementation,

Evaluation Communication, Sustainability, Transferability

Business Planning, Program Design, Professional Support

(Legal, Communications, Evaluation, Strategic Alignment)

Specialty Care Core Steering Committee

Lead Clinical Model Development and Evaluation

Program Materials Contribution

Implementation in Highest Acuity Patients (VHN, PRNA)

Health System

Core Steering Committee (LHIN)

Co-Sponsor

Industry Core Steering Committee

Co-Sponsor also provided in kind Support (by invitation)

Collaboration

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Building On Strength of Community Provider Networks

Clinical Partners

Peterborough

Networked Family

Health Teams

Primary

Care

Priority Alignment

Peterborough

Regional Vascular

Health Network

Cardiology

Referral from

CVDPMI Family

Physicians or

Hospital Emergency

Department

Peterborough

Regional Nephrology

Associates

Nephrology

Outreach to First

Nations, referral

from CVDPMI Family

Physicians or

Hospital Emergency

Department

Ministry of Health Central East LHIN Vascular Aim Canadian Heart

Health Strategy

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Strategic Alignment Canadian Heart Health Strategy, C Change, Consensus

Guidelines

• CVDPMI is entirely consistent with the recommendations

and vision of the Canadian Heart Health Strategy Action

Plan.

• CVDPMI has demonstrated the ability to create a

community based model that seems to be working. No-

one has managed to get this far before. You should be

applauded.

• Overall, I am excited about this project which I certainly

hope is sustainable. I would be prepared to assist in any

way I can. Dr. Eldon Smith, Chair,

Canadian Heart Health Strategy

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This approach:

• Enables management of “at-risk, a-symptomatic” patients

• Systematic, transferable approach for population based care

• Can be implemented in variety of practice settings

• Flexible, based on practice need & team care objectives

• Measurable to demonstrate impact on patient health and

system costs

Physicians and Teams are already providing

guidelines based care for “help seeking”

Patients

Algorithms • Hypertension

– Ace/ARB Therapy

– Calcium Channel

Blocker – Diuretic

Therapy

• Lipid Therapy

• ASA Therapy

• Diabetes

Consistent

Format

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Proof of Concept

• Clinical Evaluation: Initial Findings After 3 Visits – "Based on projections from the initial screen of patients, 20 to 30 patients of

every 100 enrolled would be expected to have a cardiac event (heart attack or

stroke) within the next 10 years.

– By being entered in this program and altering their CVD risk profile, (based on

the preliminary analysis) we are able to reduce this number of people at risk for

a heart attack or stroke to from 20-30 to 10-15 out of the same hundred.

– This represents up to a 50 percent decrease, which is impressive and consistent

with what is typically seen in the clinical trial setting.

– This demonstrates that a community working together can achieve clinical trial

outcomes.

– A full outcome and economic analysis is currently underway."

• A multi-stakeholder partnership is feasible and can be used in a real world

setting as we aspire to obtain clinical study outcomes.

- Dr. Paul Oh, Medical Director, Toronto Rehabilitation Institute

Overall Analysis

• Preliminary data

on 689 men and

640 women, mean

age 59.3 (+/- 8.2)

• An average of 3.4

(+/- 1.5) visits, risk

factors improved

significantly

• All comparisons

were significant

p<0.001

Entry Exit

BMI 29.6 +/- 6.0 29.4 +/- 5.9

Waist 100.6 +/- 15.0 99.2 +/- 15.2

BP 128 (+/-17) 78 (+/- 9) 123 (+/-14) 76 (+/- 9)

TC 3.95 +/- 1.23 3.27 +/- 1.03

FRS 14.5 +/- 8.9 12.1 +/- 8.3

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High Risk

Pilot Phase

Entry Exit

LDL 3.17 1.78

BP 142/84 126/74

Pure Group

Entry Exit

LDL 2.75 2.02

BP 134/79 126/76

FRS

>20%

Entry Exit

27.0% (+/- 3.5%) 22.1% (+/- 7.3%)

In the high risk stratum the 10 year predicted event rate fell by 18.2%

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Moderate Risk

Pilot Phase

Entry Exit

LDL 3.33 1.90

BP 127/79 121/75

Pure Group

Entry Exit

LDL 3.04 2.34

BP 128/78 125/78

In the medium risk stratum the 10 year predicted event rate fell by 19.5%

FRS >10 to

<20%

Entry Exit

14.9% (+/- 2.6%) 12.0% (+/- 4.6%)

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Low Risk

Pilot Phase

Entry Exit

LDL 3.23 1.75

BP 117/77 114/74

Pure Group

Entry Exit

LDL 3.14 2.71

BP 118/75 118/75

FRS

>10%

Entry Exit

6.4% (+/- 2.3%) 5.9% (+/- 2.7%)

In the low risk stratum the 10 year predicted event rate fell by 7.8%

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Findings

• With appropriate systems in place significant change

can happen in the Primary Care setting.

• The present data is sufficient to prove the

effectiveness of the model and begin the roll-out to

other teams. The data supports the claim that the

algorithm works to improve cardiovascular risk.

• There are therapeutic and team benefits from working

collaboratively to implement the model, as evidenced

by the modification in risk factors for patients.

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For Further Information

www.cvdpmi.ca

Info@peterboroughfht.com

http://healthcouncilcanada.ca/audio/2011/P

odcasts/CVDPMI_CPedit_Sep15.mp3

BestPATH

How can we improve care for patients who are in

transition into, from, and and between our health care

institutions?

Presented by: Dr Ken Hook, STAR

Family Health Team, Tavistock

The Case of Mrs. H

• 87 years old

• Admitted from ER

• Sudden onset of loss of strength right leg

• Previous treatment for metastatic thyroid

cancer

• Co-morbidities- hypertension, hypothyroid,

anemia

• X-rays showed multiple boney metastases with

pathologic fracture of pelvis

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The Case of Mrs. H

• The patient - minimal pain, her goals

• The previous family doctor

• The specialist

• The nurse

• The physiotherapist

• The occupational therapist

• The CCAC case manager

• The family doctor of the attached LTC

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The Case of Mrs. H

• Discharged 12 days later

• Discharge summary dictated and transcribed

day of discharge, new family doctor notified

• Her new family doctor saw her at home 3 days

later

• Her radiation oncologist to call her

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The Case of Mrs. H

• Satisfactory outcome for the patient

• Satisfying for the professionals involved

• Key component was timely assessments and

communication between all the providers in the

circle of care

• Don’t you wonder if we could have done it in

fewer days?

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The Case of Mr. F

• 55 years old, schizophrenic, from LTC

• Admitted in heart failure to large urban hospital

• Stabilized and discharged

• Family doctor difficult to contact, seemed

uninterested

• Follow-up at hospital based clinic after 28 days,

no meds or meds list, visit “useless”

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Barriers to smooth transitions

• Timely discharge summaries - dictated, typed, received by follow-up provider, including LTC?

• Primary care- able to provide timely follow-up? How soon to the next available appointment?

• When a patient is in trouble can they reach their family doctor or can they access acute care only through the ER? Does the ER try to contact the family doctor for information? Ward clerk could do!

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More on barriers

• For house bound patients under care of CCAC is

their primary care physician willing to see them at

home in a crisis?

• If the family doctor is available, is she/he able to

arrange appropriate investigations and care in their

community?

• Is there any dialogue between providers at time of

transition- both admission and discharge?

• Are CCAC health reports completed by physicians in

timely manner?

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More on barriers

• Do patients admitted to hospital have timely investigations and consults and who puts it all together?

• Timely transfers to long-term care? Weekends?

• For residents in long-term care is acute care available or are residents sent to the emergency room for acute problems that could be managed there?

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Factors for improving patient transitions

• Timely responses and assessments by all

providers in the circle of care

• Effective communication between the team

members in the circle of care

• Effective bridges between key players-

primary care, hospitals, CCAC, long-term

care

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How do we improve?

• Dialogue at the local level about how we can

build the bridges help each other to improve.

• The dialogue needs to include all the key

players- primary care, hospitals, CCAC, and

long-term care

• “What needs to happen to improve transitions

for our patients?” “How can we help you with

our patients”

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How do we improve?

bestPATH can provide tools and resources to

facilitate local discussions

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Why Focus on

readmissions?

Presented by: Patti Cochrane, The Credit Valley

Hospital and Trillium Health Centre

Why focus on readmissions?

• Most “acute illnesses” are now actually exacerbations of chronic

diseases, so patients never leave the hospital in a perfect state

of health

• Hospital admissions have become shorter, so patients are sicker

at discharge

• 1% of the population consume 34% of healthcare resources

• Large “voltage drop” in the intensity of care at the time of

discharge

Source: Irfan Dhalla. University of Toronto, 2010

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Source: Irfan Dhalla. University of Toronto, 2010

66

Readm

issio

n R

ate

s

67

Readmission Rates for CHF, COPD and Pneumonia

19.3% 19.3%

15.7%

17.5%

15.1%

15.9% 18.5%

13.9% 15.7%

17.0%

9.7% 8.5%

9.3%

11.2%

7.4%

11.5% 11.6% 11.3% 11.7% 11.9%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

2008/09 2009/10 2010/11 2011/12 2012/13 Q1

Heart Failure wo Cor Angio Chronic Obstructive Pulmon Dis

Viral/Unspecified Pneumonia Grand Total

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QIP Goal: Reduce unplanned readmissions to

hospital

Quality Dimension

Integrated

Indicator

Reduce unplanned

readmissions to hospital

Corporate Target

≤ 12.5%

Target Justification

3% Improvement

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• Focus on integration activities (aligning best practices

across sites)

• Completion of an Integrated pathway for identification,

assessment and discharge planning of patients at high

risk for readmission using recommendations from

Enhancing the Continuum of Care: Report of the

Avoidable Hospitalization Advisory Panel submitted to the

Ministry of Health

• Single patient experience and plan of care across all sites

when fully implemented

Progress to date

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Integrated Pathway

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Progress to Date

Screening for

readmission risk

Aligning discharge

practices (discharge

checklist, discharge ,

bullet rounds)

Enhanced Teaching

Provision of follow

up care in

outpatient clinics

and with Primary

Care

• Automated tool at

THC-M site

• Paper based tool

at CVH site

• Application for

LHIN funding to

move automated

tool across all sites

• Collaboration with

IHI group to help

with development

protocol for those

with LACE >10

• Collaboration with QIP

ED wait time on

development

• Standardize content

provided

• Single discharge

envelope to be kept

with patients and for

patient to take to follow

up appointments

•Teach Back

Methodology

•Collaboration with

outpatient clinics to

use same content

and language

•Utilize discharge

envelope to keep

written content from

all professions

•Aligning processes

for access to

COPD/CHF clinics

•Building on current

processes to

minimize workload

on front line staff

while enhancing care

•Appointments to be

provided on

discharge

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Post Discharge

Telephone Follow up

Rapid Response

Nurse/Virtual Ward

Medication Check in

patient home after

discharge

• Application for LHIN

funding to develop set of

questions specific to the

population and protocol

for follow up to identified

concerns

•Collaboration with IHI

group to help with

development protocol for

those with LACE >10

•Collaboration with

CCAC/PCP to follow high

risk patients upon

discharge providing a link

between hospital and

community

•Pilot at Trillium M site

•December 3, 2012-

launch date

•Collaboration with CCAC,

community pharmacists

and community partner to

provide service

•Application to Ministry of

Health for funding to

implement software

needed

Progress to date

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Progress to date

Post Discharge Telephone

Follow up

Rapid Response

Nurse/Virtual Ward

Medication Check in

patient home after

discharge

• Application for LHIN

funding to develop set of

questions specific to the

population and protocol for

follow up to identified

concerns

•Collaboration with IHI

group to help with

development protocol for

those with LACE >10

•Collaboration with

CCAC/PCP to follow high

risk patients upon discharge

providing a link between

hospital and community

•Pilot at Trillium M site

•December 3, 2012- launch

date

•Collaboration with CCAC,

community pharmacists and

community partner to

provide service

•Application to Ministry of

Health for funding to

implement software needed

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Most importantly…

• Firmly in the provider’s

hand

• -- The Baton -- the care

and treatment plan

• Must be confidently and

securely grasped by the

patient,

• If change is to make a

difference

• 8,760 hours a year.

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www.hqontario.ca