Building a comprehensive system of services to support adults living with CMV
CCCF ePoster library. Leasa D. Oct 26, 2015; 114751; P50
Dr. David Leasa
Dr. David Leasa
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Topic: Other

Building a comprehensive system of services to support adults living with CMV

David Leasa, S. Elson

Respirology, London Health Sciences Centre, London, Canada | Regional Integration Specialist, London Health Sciences Centre, London, Canada


A fundamental tenant of a system is that the parts are defined, roles and relationships are understood and there is a shared purpose and common vision among the participants. In a multi-organization, integrated system, there also needs to be shared accountability for the overall functioning of all the services involved..

In the South West Local Health Integration Network (LHIN) in Ontario, hospitals with Level 3 ICUs, complex continuing care services, in-home community health services provided by and through the Community Care Access Centre and a specialized community support service agency Participation House Support Services have come together to design, build and operate a system to serve Adults living with Chronic Mechanical Ventilation (CMV).


The goal was to develop an integrated and coordinated approach to meeting the health and supportive care needs of adults living with CMV incorporating the full range of clinical and daily living supports needed by this population of adults.

From a population health perspective, the objectives included having an integrated and coordinated system capable of:
Adapting to the needs of each individual and responding quickly to changing needs
Optimizing the long term health of these individuals
Optimizing their ability to live a normal and meaningful a life as possible and
Making the best use of public health care resources

Methods: The project was undertaken in three phases:
Phase One: System Design, Phase Two: Implementation Planning and Phase Three: Implementation. An Oversight Committee and an Operations Management Committee currently support the system of services. There is also a metrics working group and individual person-centered transition planning and implementation task groups. The participating organizations have signed a Memorandum of Understanding as a formal commitment to their on-going involvement. Decision guides and templates have been developed and are being used to inform decision-making.

Results: There is both qualitative and quantitative evidence that a multi-organizational system of care is now operational and functioning in a way that previously did not exist. New services have been funded by the LHIN that have been critical to moving the system forward. This has included building community capacity in the form of day programs, overnight respite care, specialized residential support services and community RT services. System performance measures have been developed and are being reported on a quarterly basis. There is case-based evidence that hospital admissions are being avoided, transitions in care are being thoughtfully planned and executed collaboratively among service providers and new roles and responsibilities are being accepted within the overall system of care.

Conclusion: The work that has been undertaken reflects a shared and deep commitment among the participating individuals and organizations to improve the quality of life for adults living with CMV.

The development of a systems model of care helped to define and refine roles and responsibilities with respect to serving this population. It allowed everyone involved to see their role in the continuity of care. The model of care not only defined the component parts of the system but also how people interact and support people as they move into and participate in the system.

Implementation planning allowed specific protocols and flow maps to be developed that brought operational specificity to the relationships as defined. It provided tools to assist and support implementation.

Implementation using a three tiered approach has been successful. The Oversight Committee brings senior organizational leadership to the table. The Operational Management Committee brings operational leaders together to address operational issues. The case specific transitions groups focus on specific people and their transitional needs as transitions are planned, prepared for and implemented. While all three groups have specific roles and responsibilities they are complementary to one another and reinforce their common commitment to excellence and partnerships..


A Commitment to Excellence and Partnerships, November 2013 [Phase 1 system model]

A Systems Model to Meet the Needs of Adults Living with Chronic Mechanical Ventilation Needs – Phase 2 report [Implementation Plan]

Memorandum of Understanding (“MOU”) Re: Collaboration among Hospitals, the South West Community Care Access Centre (“CCAC”) and Participation House Support Services (“PHSS”) providing care to designated high needs, medically fragile individuals, June 2015 [Phase 3 Implementation]
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