Date: January 7, 1997

To: Interim Board of Health

From: Dr. Sheela Basrur

Acting Medical Officer of Health

Subject: Preschool Speech and Language Services System

The purpose of this report is to provide information on the current status of the Metro Toronto Preschool Speech and Language Services Initiative, more specifically, related to the selection of Toronto Public Health as the lead agency for the Toronto service system.

Funds for the direct service delivery of speech and language services will be 100 percent provincially funded and will flow through the lead agency to the speech and language program agencies in the community (approximately 3 to 4 million dollars).

Funds for the lead agency to administer the service system will include $200,000 of provincial funding for a program co-ordinator, clerk and materials and supplies. Office space, telephones, and other administrative support will be absorbed from the current public health budget and staff compliment.

It is recommended that:

(1) the Interim Board of Health approve implementation of the Health Department=s role as lead agency for the Metro Toronto Preschool Speech and Language System (pending Triministry approval of the plan)

It is currently estimated that 10 percent of young children have a disorder of language, articulation, stuttering, voice or swallowing. Unfortunately, due to a variety of barrier to service, including inadequate levels of service, lengthy waiting lists, and lack of awareness among parents, only 50 percent of children with a speech and language disorder have access to service before reaching school. In 1995, the average waiting period for speech and language service in Toronto was 9 to 27 months. Research has linked untreated speech and language disorders with learning disabilities, mental health problems, poor academic achievement, increased school dropout rate, underemployment and increased use of social services.

In its May 1996 budget, the provincial government announced the Preschool Speech and Language Initiative. This would be a $20 million annual reinvestment for children age zero to four years with speech and language disorders. The Public Health Branch of the Ministry of Health is leading the planning and implementation in collaboration with the Ministry of Community and Social Services and the Ministry of Education and Training. Planning at the local level has been lead by the Metro Toronto District Health Council.

The District Health Council has established a Preschool Speech and Language Service System Planning and Implementation Committee with representatives from health, education, social services and speech and language service agencies. This committee has been responsible for the completion of an environment scan and the development of a district service system plan. The environmental scan, which included demographic information about the 0 to 4 year old population and an inventory of provincially funded speech and language service programs in the area, was completed in early 1997. This indicated that in Metro Toronto the ratio of Speech Language Pathologists to the zero to four year population was 1:5130 (The ratio recommended by the American Speech-Language-Hearing Association is 1:1000).

Following completion of the environmental scan, the Preschool Speech and Language Service System Planing and Implementation Committee prepared a district service system plan. In accordance with Ministry of Health requirements, the district service system plan addresses eight components: early identification, assessment, a broad range of interventions, transition planning, parent support and education, simplified access, common intake, and public awareness and education. It proposes that Toronto be divided into four local service groups: Central (Toronto and East York), East (Scarborough), North (North York), and West (Etobicoke and York). Each of these local service groups will form a coalition of agencies to develop and provide the required speech and language services. Each group will designate a local co-ordinating agency.

In addition, the Ministry of Health required that each district service system plan identify from the membership of the Preschool Speech and Language Services System Committee, an agency to serve as the lead agency for the ongoing administration of the system. The lead agency will be responsible for receiving and distributing funds (according to the annual district service system plan), participating on the System Committee, developing financial reports for the System Committee and the Ministry of Health, maintaining contracts with local delivery agencies (in accordance with the annual district service system plan), and possibly providing service such as administration of a data base or provision of a common telephone service.

On September 15, 1997, in response to a call for proposals from the Metro Toronto District Health Council, the Public Health Departments of Metro Toronto submitted a joint proposal to serve as the lead agency for the Metro Toronto Preschool Speech and Language Services System (Appendix A). Our commitment to the health of young children and families, our strong experience partnering with community agencies, our administrative capacity, and our Metro-wide service delivery were cited as specific strengths. The proposal also offered a strong link with the Healthy Babies/Healthy Children program. Both of these programs share a similar goal and include the need for a parent information line, common intake, an inventory of community services, and a data base. There is considerable potential for the leveraging of resources in the development and delivery of both programs.

On November 12, 1997, we received notice from the Metro Toronto District Health Council that Toronto Public Health has been recommended by Council to act as the lead agency (Appendix B). This recommendation has been included in the Metro Toronto Preschool Speech and Language System report which has been forwarded to the Tri-Ministry Review Panel (Ministry of Health, Ministry of Community and Social Services, and Ministry of Education and Training). We are currently awaiting feedback and/or approval from the Panel which is expected imminently.

Pending any need for revisions, Toronto Public Health will be required to commence its role as the lead agency immediately upon approval. This will involve:

The Preschool Speech and Language System represents a significant financial commitment from the provincial government to address the issue of speech and language disorders among children 0 to 4 years. The Health Department=s role as lead agency further demonstrates a commitment to promoting the health and well-being of young children and families through collaboration and partnership with community agencies. The co-ordination of this program with Health Babies/Healthy Children has the potential to create a cost-effective, highly comprehensive service system from young families. Consequently, it is recommended that, once Triministry approval is received, Toronto Public Health proceed in its role as lead agency.

Susan Makin

Acting Director of Nursing, North York

Tel: (416)395-7643 Fax: (416) 395-7691

Dr. Sheela Basrur

Acting Medical Officer of Health

The Public Health Department=s mandate includes the promotion of child health through the use of a multiple strategy approach which encompasses health education, strengthening community action, advocacy, healthy public policy and social marketing. Given the significant potential for enhancing population health by focussing programs and services toward children and young families, Health Departments currently devote approximately 25% of their resources to working with this target group.

The role of staff includes the provision of health education on an individual basis and with groups, assessment for early identification, intervention and referral as appropriate and public awareness to enhance health. To achieve this Public Health Departments employ multi-disciplinary professionals and para-professional staff to work with the public, private and volunteer sectors, service providers in education, social services and health, community groups and individuals. Access to these services is facilitated through the operation of telephone information lines staffed primarily by public health nurses who provide information, consultation and facilitate referral for public health services, when appropriate, or to other services as required. The majority of service provided via the information and intake lines is to parents with infants and preschoolers 0-5 years of age. Each of these lines are linked to information systems developed to provide data which is used to plan, manage, evaluate and report on service delivery at a local and provincial level.

The Public Health Departments of Metro Toronto receive direct funding from the Ministry of Health. Currently the majority of programs are cost shared with the municipality. Although this cost sharing relationship will change in 1998, the new City of Toronto Health Department will continue to receive 100% provincial funds from the Ministry of Health for the new Healthy Babies, Healthy Children Program.

The six Public Health Departments in Metro are currently involved in amalgamating into a single Department. All facilities are located in Metro Toronto and services are delivered in communities throughout Metro.

Administrative capacity of the Health Departments is substantial and sufficient to the tasks required of the lead agency outlined in the call for proposals. Financial and legal support as well as expertise in the design, development and implementation of population based information systems, confidential data management, and data analysis at a provincial and district level currently exist in the Departments. Staff have knowledge, skills and experience with the development and operation of centralized telephone information and referral systems as well as public awareness campaigns and education. Space for staff required to support and implement the lead agency work for Preschool Speech and Language program is available.

Boards of Health are mandated to provide or ensure the provision of services. As a result, Health Departments have had experience contracting services with hospitals, community and social service agencies and community groups in Metro. These contracts have included the receipt, allocation and management of funds and the preparation of all financial reports required by the Ministry of Health as well as local decision-making boards. A few examples of the Departments= experience with contracting services include: the receipt of funds from a hospital for provision of early discharge homevisiting services; purchase of the services of staff from the Victorian Nurses of Ontario; allocation of AIDS prevention grants to over forty community agencies and groups such as Youth Link and the AIDS Committee of Toronto; financial management of funds for the Seniors Peer Counselling Program and dispensing funds at the direction of their Board.

Public Health Departments are mandated to establish and maintain collaborative and cooperative working relationships with community partners to promote health and prevent illness. Each Department has well established partnerships with their Boards of Education, social services agencies, business, hospitals, child care, and community health centres in Metro. The Departments work with local multicultural associations and groups as well as family resource centres and neighbourhood committees. Staff in the Departments facilitate and provide support to the development of intersectoral, community-based coalitions with strong consumer representation that address local health needs through enhanced communication and integration of service delivery for clients. Public Health Departments are committed to working with individuals, families, groups, aggregates, and communities in the public, private and volunteer sectors to provide timely, coordinated and cost-effective services.

Public Health Departments have a long history of provision of services to children and their families. Currently these services are directed by the Healthy Children Program Standard of the Ontario Ministry of Health Mandatory Health Programs and Services Guidelines (1989). The goal of this program is Ato enable all children (newborn to nine years of age) in the community to attain their optimal level of physical, mental, emotional and social development@. Physical development is specifically defined as including hearing and speech/language development. Health Departments for many years have been involved in hearing, vision and developmental screening and the promotion of early identification and intervention in these areas.

Health Departments have a primary prevention mandate and recognize the early formative years as critical to ensuring that everyone has the opportunity to achieve their full potential. Metro Health Departments have made a significant commitment to service planning and delivery for children (and parents) in the community. Approximately 25% of the Departments= budget is allocated to work with preschool children and their families. Our goal closely parallels the vision of the Speech and Language Service System for Preschool Children, both of which emphasize service to all children to achieve their highest potential.

More recently Public Health Departments have been mandated as the lead agency to implement the new interministerial Healthy Babies, Healthy Children program announced by the Ministry of Health in July 1997. Under this program Boards of Health are expected to work in partnership with community and social services agencies to develop a coordinated system of early identification, assessment and referral for children 0-6 years. In addition, Boards of Health are to provide assessment, referral and homevisiting services for high risk expectant parents and children to age two. In the system 100% of prenatal women and postnatally all infants born in Metro (approximately 44,000 annually) will be identified and screened by trained professionals including physicians, hospital nurses and public health nurses. Those identified at high risk of physical, cognitive, communication and/or psychosocial problems will have access to and be linked through this program to appropriate community supports including preschool speech and language services. Prenatal screening data, birth data, neonatal assessment data for all children born in Metro will be maintained on an information system. The system will also be used to track and monitor provision of services to clients in the program. The Healthy Babies, Healthy Children program goals, objectives and components are outlined in Appendix A. Currently a Metro-wide Committee is developing an implementation plan. A phased in approach has been proposed. The program will begin January 1998 and is expected to be fully operational by the end of the year.

Our focus on the broad determinants of health and commitment to promoting the health of children has required Health Departments to have an extensive knowledge of government initiatives in the health and social services sectors, education, child care, housing etc. to improve services to children at-risk. This knowledge often comes first hand as Health Departments have a pivotal role in planning, delivery and evaluation of many of these initiatives. Health Departments are actively involved in the Federal CAP-C (Brighter Futures) and Canadian Prenatal Nutrition Program (CPNP), participating in the provincial Better Beginnings program and are taking a lead in the newly funded Healthy Babies, Healthy Children interministerial initiative between Health and Social Services. At a local level, Health Departments participate on a variety of interagency committees that examine and address the issue of access to an integrated, seamless service delivery system for families in our community including participation on the Metro Toronto District Health Council Preschool Speech and Language Committee.

None of the Health Departments have been identified to serve as a Local Coordinating Agency in Metro. However, representatives of the Departments are members of the coordinating committees in each quadrant. A representative from Public Health is also a member of the Preschool Speech and Language Implementation Planning Committee.

The Public Health Departments in Metro propose that as lead agency for both the Preschool Speech and Language Services and the Healthy Babies, Healthy Children program, advantages will be created for an accessible, coordinated, and cost-effective service delivery system. The similarity in target populations, complimentary program goals and common needs for a central information line and system data bases create opportunities for simplifying access, leveraging resources, and enhancing data management capabilities.

A common centralized information line for clients that builds on the current infrastructure and experienced professional resources of Health Departments will serve to simplify and facilitate access to appropriate, cost-effective services for clients. The development of one comprehensive data base for all preschool children 0-5 years in Metro, not only those accessing primary or acute care services, will significantly reduce barriers to sharing confidential health information and enhance the data available for program planning, management, evaluation and research. Potential cost savings may be realized through the development of a single system and the leveraging of resources for system development. Efficiencies would also be gained through access to internal Health Department staff who have expertise in the development of large, population based information systems, and support for consultation on systems design, development and implementation, epidemiology and data analysis.

The following proposal is submitted by the six Metro Health Departments for your consideration and decision.

The Metro Health Department will:

• Assume responsibility for the receipt, administration and distribution of funds based on allocation directions from the Preschool Speech and Language System Committee.

• Provide quarterly financial reports, year-end settlement forms and other administrative details to the Ministry of Health.

• Dispense funds for education materials, research etc. as directed by the Preschool Speech and Language System Committee.

• Facilitate the collaborative development and implementation of Metro-wide public awareness and education initiatives and resources as appropriate with the quadrant service networks and other community partners.

• Develop and manage an electronic data base in concert with the Healthy Babies, Healthy Children data management system. Our goal is for the system to be fully operational within one year. Development of a system over the year will ensure all necessary consultation is possible and the needs of the quadrant coordinating and system planning committees and Ministry of Health for (A) monitoring and tracking of clients= movement within the system, (B) quality assurance, (C) program evaluation, (D) research and (E) reporting will be met.

• Manage the operation of a central information line which will support the work of the quadrant coordinating committees and networks. The line will be operated by qualified staff who are able to provide information, consultation, conduct brief assessments and facilitate appropriate referral based on established protocols and/or service agreements. The Preschool Speech and Language Services information line will be coordinated with the Healthy Babies, Healthy Children line serving the same population. Operation of one line will serve to simplify access for clients, facilitate the leveraging of resources, build on existing resources and ensure coordinated cost-effective service delivery. Currently the Departments operate these information lines and are investigating the electronic transfer of information between health units, hospitals and health care facilities, primary care providers and down loading of general, non-confidential information to the public.

• Undertake specific time limited tasks relating to the operation of the system, as directed by the Preschool Speech and Language Committee.

• House and provide administrative support for the staff of the Preschool Speech and Language Committee.

• Designate a Health Department representative to participate as a member of the System Committee in order to provide advice and receive direction related to the above responsibilities.

The Metro Public Health Departments propose to serve as the lead agency (banker); manage the design, development, implementation and operation of the central data base and information line in concert with the Healthy Babies, Healthy Children program to meet the needs of families, providers, system planners, and funders; facilitate the collaborative development and delivery of public awareness campaigns and educational materials with community partners for the Preschool Speech and Language System; participate as a member of the System Committee.

Budget will have to be allocated to cover administrative costs for the Preschool Speech and Language program including: (1) managing the receipt of Ministry allocated monies, (2) dispensing funds at the direction of the Preschool Speech and Language System Committee, (3) monitoring expenditures and providing all financial reports required by the System Committee and Ministry of Health, (4) managing the central data base and equipment required by program staff and (5) staff. In addition, funds for information system design, development, and implementation will be required as well as funds to cover expenses incurred for the design, development and delivery of Metro-wide public awareness campaigns and educational materials.

Metro Public Health Departments submit this comprehensive proposal for your consideration and decision. We believe that this combination of components will best meet the needs of children and their families, providers, planners and funders of the Preschool Speech and Language Services System for Metro Toronto.