Canada’s healthcare system, while committed to universal access, operates in a decentralized manner with provinces managing health service delivery. This decentralization leads to variations in healthcare services across different regions. In Ontario, Local Health Integration Networks (LHINs) were established in 2007 to oversee and coordinate health services within 14 geographical regions, aiming to break down healthcare silos and improve regional service integration. Unlike other provinces, Ontario LHINs primarily fund health service providers rather than directly providing care, fostering a managed competition environment under the strategic direction of the Ministry of Health and Long-Term Care (MoHLTC).
The Champlain LHIN, situated in southeastern Ontario, serves a diverse population of 1.2 million across 18,000 km², with a significant rural component outside of the major urban center of Ottawa. Palliative care services in this region are delivered by a range of organizations, from formally recognized Health Service Providers (HSPs) like hospitals and home care agencies to less formally integrated entities such as hospices and nursing agencies. This fragmented landscape often resulted in service provider-centric planning, hindering regional coordination and a unified approach to palliative care.
Recognizing the need for a more cohesive system, the Champlain End-of-Life (EOL) Network initiated the development of a regional program in 2009. This move was spurred by concerning indicators, such as high rates of emergency department visits (42%) and hospital deaths (52%) among cancer patients in their last two weeks of life, coupled with lengthy wait times for hospice and palliative care beds. This article delves into the strategic process employed to create the Champlain Hospice Palliative Care Program, highlighting the key steps, collaborative efforts, and foundational principles that underpinned its successful implementation. This case study provides valuable insights for regions seeking to enhance the integration and coordination of hospice palliative care services within a complex, decentralized healthcare environment.
Securing Mandate and Stakeholder Engagement
The initial phase of developing the Champlain Hospice Palliative Care Program centered on securing a formal mandate and cultivating support from key stakeholders within the Champlain LHIN. The EOL Network proactively identified individuals considered to be influential decision-makers, potential champions, and early adopters across various disciplines and sectors. This included engaging the LHIN’s Chief Executive Officer, ensuring leadership buy-in from the outset.
A series of formal and informal meetings were strategically conducted with these identified individuals to solicit their backing and gather valuable insights on the program’s overarching vision. Building upon this foundational support, the EOL Network organized a pivotal day-long retreat in April 2009, bringing together a broad spectrum of regional stakeholders. This retreat was designed to broaden input and solidify support for regionalization, initiate the development of a shared vision for palliative care, and identify immediate priority areas and subsequent action steps.
Over 70 participants attended the retreat, representing over 120 invited individuals and stakeholder organizations directly and indirectly involved in regional hospice palliative care. The diverse participant pool encompassed various settings, domains, and disciplines, including clinicians, administrators, policy makers, patients, and family members. To provide a comprehensive understanding of the existing landscape, a regional service and program survey, leveraging an Appreciative Inquiry approach, was conducted and its findings were presented at the retreat. Furthermore, a literature review on regionalization strategies and successful regional program implementations in other jurisdictions was shared, highlighting critical components and enablers for such initiatives. Key elements identified included the necessity of a common vision, robust accountability processes, performance measurement frameworks, and a unified governance structure. Notably, the concept of a single governance structure emerged during the retreat’s preparatory phase as a potential obstacle to regionalization, particularly given the operational independence of individual service providers.
Retreat participants collaboratively identified several priority areas crucial for advancing hospice palliative care in the Champlain region. These areas included:
- Increasing the availability of hospice and palliative care beds across the region.
- Enhancing consultation services within community and hospital settings.
- Strengthening the involvement of primary care providers in palliative care delivery.
- Improving patient flow and transitions between different care settings.
- Developing accessible information resources for both the public and healthcare professionals.
- Leveraging e-Health technologies to enhance palliative care services.
- Addressing the unique challenges of delivering hospice palliative care in rural and remote areas within the Champlain region.
Business Plan Development and Community Consultation
Following the retreat, the need for a structured process to propel the regional program concept forward was clearly recognized. The primary objective became the development of a comprehensive business plan that would articulate the Regional Program’s scope, operational mechanisms, functional framework, and required funding support. A detailed report summarizing the retreat outcomes, along with a funding request of $30,000, primarily for administrative and logistical support, was submitted to the LHIN. The LHIN promptly approved this request in May 2009, demonstrating their commitment to the initiative.
In May 2009, an inter-disciplinary Planning Council was established, comprising ten palliative care leaders from across the Champlain region. This council, co-chaired by two of the program’s key architects, was tasked with the critical responsibility of developing the final business plan for the formal Regional Program. To address the diverse priority areas identified at the retreat, six specialized Working Groups were formed, each dedicated to a specific area. Each group was co-chaired by two Planning Council members and included six to ten members selected for their expertise and knowledge in the respective domain. A modified Appreciative Inquiry process was employed within these working groups, encouraging them to identify existing strengths and successes, envision future improvements, and formulate recommendations for enhancing their designated areas. Nearly 100 individuals actively participated in the Planning Council and Working Group activities, reflecting the broad engagement and collaborative spirit of the initiative.
The Planning Council played a crucial role in overseeing the Working Groups’ progress, ensuring alignment with a “regional lens,” identifying areas of synergy and overlap, and highlighting overarching themes across all groups. Supporting data was meticulously collected, including referral rates to various regional services, lengths of stay in palliative care settings, wait times for hospice and palliative care unit beds, and the financial implications of acute care hospital stays for patients awaiting admission to specialized palliative care facilities. A dedicated full-time Coordinator provided essential support throughout this intricate process, from the initial stages to the eventual launch of the Regional Program.
By March 2010, the Planning Council had produced a comprehensive draft Business Plan. This plan outlined guiding principles for the program and its development process, proposed a new regional governance structure, and presented foundational recommendations for the Champlain Hospice Palliative Care Program. To ensure broad community input and validation, the draft Business Plan was widely distributed for review and feedback.
Extensive facilitated sessions, utilizing town-hall meeting formats and focus groups, were conducted from April to June 2010 to present the draft Business Plan and actively solicit input from the wider community. Beyond gathering feedback, these sessions aimed to cultivate broader support for the proposed Program. Over 320 individuals from across the Champlain region participated, representing various agencies and societies, including the Champlain chapter of the Canadian Cancer Society and the Amyotrophic Lateral Sclerosis Society. Participants included patients, family members, volunteers, representatives from Community of Care Advisory Forums, clinicians, and members of Francophone communities. Members of the Planning Council facilitated these meetings. Furthermore, an online feedback mechanism was established, generating 39 individual responses, and the draft plan was submitted to four external experts with experience in regional programs outside of Ontario for their expert insights.
This extensive feedback process informed further refinements to the Business Plan. Key elements of the finalized Business Plan are summarized in Table 1. The Plan incorporated three foundational recommendations, including the strategic dissolution of the Champlain EOL Network to pave the way for the new Regional Program. It also included a draft Accountability Agreement, termed the LHIN-Regional HPC Program Memorandum of Agreement (MOA), between the LHIN and the newly proposed Regional Hospice Palliative Care (HPC) Program [now Champlain Hospice Palliative Care Program (CHPCP)]. This MOA is a cornerstone document, delineating reporting relationships with the LHIN and outlining the roles and expectations for both the Regional HPC Program and the LHIN. Crucially, in the absence of a single regional health authority and unified service provider, the MOA provides the Regional Program with the necessary mandate and legitimacy to effectively perform its regional function. A key provision within the MOA mandates that the LHIN Board vet all palliative care and hospice proposals through the Regional Program, empowering the Regional Program to set priorities for the LHIN’s palliative and hospice-related work plans. Table 2 outlines the guiding principles and foundational recommendations embedded within the Business Plan.
Governance Structure and Inauguration
The Regional Plan received formal approval from the Champlain LHIN’s Board of Directors in May 2010. Subsequently, the LHIN tasked the Champlain EOL Network with establishing a Transitional Leadership Group to oversee the smooth transition from the EOL Network’s dissolution to the inauguration of the new Regional Board.
In June 2010, a Transitional Leadership Group was formed, comprising individuals with specific skill sets essential for managing the transition, including expertise in governance. Some members of the now-dissolved Planning Council also joined this group, ensuring continuity and institutional knowledge. The Transitional Group further benefited from input from the Champlain Regional Stroke Network and the Regional Geriatric Program of Eastern Ontario, leveraging their experiences in regional program implementation.
The Transitional Group diligently developed several key components essential for the new program’s operational framework:
- Terms of Reference for the Regional Program, its committees, and members, clearly defining roles and responsibilities.
- A protocol outlining the accountabilities of hosting agencies, addressing provincial legislative requirements for fund transfers from the LHIN to formally recognized HSPs, as the Regional Program itself would not be an HSP.
- The governance structure of the Regional Program (illustrated in Fig. 2), establishing clear lines of authority and decision-making processes.
- An annual budget of $300,000 to support the program’s initial operations.
- By-laws and governance protocols for the inaugural governing body (Board), ensuring transparent and accountable governance practices.
- A Year One Work Plan, prioritizing immediate actions based on the most pressing needs in regional palliative care.
- A competency grid outlining the skills required for the Program’s Board members, encompassing both individual member competencies and the collective competencies needed for effective Board functioning. Individual competencies included the ability to adopt a “systems thinking” approach, prioritizing patient and system needs over individual service provider interests. Collective Board competencies encompassed expertise in Systems Development, Governance and Leadership, Project Management, and Quality and Performance.
- The election process for the Regional Program’s first Board members, ensuring a transparent and merit-based selection process.
An open, region-wide nomination process was launched, attracting 30 applications, from which 11 members were elected to the inaugural Board.
The Transitional Leadership Group’s comprehensive work was approved by the Champlain LHIN in November 2010. Subsequently, the EOL Network was officially dissolved, and the new Champlain Hospice Palliative Care Program (CHPCP), referred to as the “Regional Program,” and its governing Board were inaugurated, marking a significant milestone in regional palliative care integration.
The initial organizational structure comprised the Program Board of Directors (initially termed the Regional Program’s Council of Directors, later changed to “Board” upon incorporation in 2013) and a program office staffed with an Executive Director (full-time), a Medical Lead (half-day per week), and an Administrative Assistant (full-time). The Board, consisting of 15 members (4 ex officio), reports directly to the Champlain LHIN. The Executive Director, Medical Lead, and representatives from the two host agencies serve as ex officio, non-voting members. The Medical Lead reports to the Executive Director. The Board’s composition is competency-based, with members elected based on their skills and ability to apply patient-centered, systems-based thinking, rather than representing specific organizations.
Two host agencies were strategically identified to provide essential operational support: Bruyère Continuing Care, a hospital providing office space and back-office support functions, and the CCAC, offering meeting facilities, telecommunication infrastructure, and community outreach capabilities.
The inaugural Board established three standing committees, initially termed Specialty Committees: Education and Knowledge Translation; Performance Management and Access to Services; and Standards and Best Practices. The structure retained the three Local EOL Networks, recognizing their crucial role in facilitating local program implementation and providing valuable feedback and input from local institutions and individuals. These Local EOL Networks received dedicated funds to support their activities. Task Forces or Work Groups are constituted as needed on a term-limited basis to address specific program needs. To ensure comprehensive input and diverse perspectives, the Board established three advisory bodies: a patients and families group, a health care managers group (providing insights from various care settings), and an interprofessional clinicians group. Since its inception, the committee structure has been refined and restructured to better align with evolving priorities and enhance operational efficiency. As of mid-2013, the standing committees included: Standards and Performance Indicators; Education and Information; and Quality and Best Practices, reflecting a continuous commitment to program improvement and responsiveness to regional needs.
