An Integration Journey: Road Trips from Afar

1. An Integration Journey: Road Trips from Afar • Friday, January 25, 2008 • Cathy Fooks • President and CEO • The Change Foundation

2. Changed Change Foundation • Established and endowed in 1995 by the OHA • First ten years focused on grants, drivers of change and knowledge transfer • Refocused in 2007 to become a policy “think tank” • Two thematic research areas: understanding integration and quality improvement efforts in the community sector

3. Presentation Outline • Jurisdictional review of integration efforts internationally and in Canada by the Foundation • Summarize common elements • Compare to Ontario’s efforts

4. Jurisdictional Review • Purpose was to look at efforts to integrate service delivery, to extract common features or elements and to identify lessons learned. • Literature review and case studies

5. Jurisdictional Review • Managed care in the US • NHS (four different reforms) • Regional health boards/coordinated care in Australia • District health boards in New Zealand • Local health authorities in The Netherlands • Six health reforms in Germany • Regional health authorities in Canada

6. Similar Pressures in the Jurisdictions • Costs rising more quickly than productivity • Chronic disease emerging as huge cost driver • Fragmented care – particularly at transition points from one part of the system to another and particularly for those with chronic disease and comorbidities

7. Similar Pressures in All Jurisdictions • Documented variations in quality • Public concerns focused on wait times – emergency departments, specialty care – mainly surgical and diagnostic, primary care (not in Canada) • Demand for better information about system management and health outcomes

8. Similar Pressures in All Jurisdictions • Increasingly sophisticated and demanding consumers • Huge push on need for public reporting • Backdrop of public vs private financing (most delivery is private) and for-profit vs. non-profit

9. Different Responses • Different responses due to different system design • Differences include tax based vs. insurance based system, national vs. provincial vs. regional structures, funding models, nature of employment relationship with clinicians, particularly physicians • HOWEVER, the need to integrate delivery in a more organized fashion was common to all as one response to pressures (not the only response)

10. Defining Integration • Lack of a universal definition or concept of integration • Almost every article reviewed started with “there is no common definition” • Use of multiple terms – integration, care coordination, continuity of care

11. Defining Integration • Systematic review by Suter et al. (2007) concluded that “the definitions of integration vary as much as the terms used to describe it.” • Located 70 definitions • Termed it “Tower of Babel” • Systematic review on integration indicators by McMaster identified similar issues regarding definition

12. Earlier Definitions of Integration • “Networks of organizations that provide or arrange to provide a coordinated continuum of services to a defined population and who are willing to be held clinically and fiscally accountablefor the outcomes and the health status of the population being served.” • Shortell et al, 1993,1994

13. Defining Integration • “Services, providers and organizations from across the continuum working together so that services are complementary, coordinated, in a seamless unified system, with continuity for the client.” • CCHSA, 2006

14. Defining Integration • “An integrated health system would result in coordinated health services that both improve accessibility and allow people to move more easily through the care and treatment continuum of the health system and provide appropriate, effective and efficient health services.” • Health Results Team for Information Management, 2006

15. Defining Integration • “Integration is defined broadly to encompass the process of effectively managing the alignment of multiple systems of independent (and interdependent) organizations with unique goals and objectives to achieve three important outcomes that are central to the Ministry’s transformation agenda:

16. Defining Integration • Ensuring that users experience service as seamless, where boundaries between organizations are not apparent to them • Improving the match between single services provided and the multiple needs of clients and families • Enabling effective and efficient use of system resources and capacity by optimizing system interactions across the system and across program silos.” • LHIN Team, MOHLTC, 2006

17. Focus on Types of Integration(not definitions) • 1) Virtual integration • Networks of providers delivering care to common population • Separate governance and management structures • Contractual relationship • No need for co-location • LTC network linked to primary care practices

18. Focus on Types of Integration • 2) Vertical Integration • - under one governance and management structure • - shared resources • - doesn’t have to be co-located, but often is • - RHA model • 3) Horizontal Integration • - cooperation/collaboration between providers at same level • - 2 groups of family practices with shared care and resources

19. Types of Integration • 4) Functional Integration • - key support functions are coordinate across operating units • - shared or common policies and practices for the function • - does not mean centralization • - SIMS model in Toronto • 5) Clinical • - clinical services under one umbrella • - tends to be disease specific • - Cancer care

20. Common Elements • At least 11 elements were identified as success factors in all jurisdictions • One element that was not successfully implemented in all jurisdictions but was referenced by all as important (whether or not they achieved it)

21. Common Element 1 - Comprehensiveness • Comprehensiveness of services across the continuum despite multiple points of access for specific patient populations • Cited as first principle by all • Includes services from primary care through tertiary and back into the community and in some locations includes linkage to social care organizations • Some, but not all, include population health focus

22. Comprehensiveness Ontario 2008 • Under the auspices of the LHINs: • Public hospitals (2007/08) • Mental health & addictions agencies (2008/09) • Community support service agencies (2008/09) • CHCs (2008/09) • LTC Homes (2008/09) • CCACs (2009/10)

23. Comprehensiveness Ontario 2008 • Not under the auspices of the LHINs: • Physicians • Public health • Ambulance services • Labs • Provincial networks and priority programs • Drugs

24. Common Element 2 – Patient Focus • All cite the justification for integrated delivery is to meet patient need • Leads to huge focus on internal process redesign within organizations but also across transition points • Those with more of a population health focus stress the need to engage their communities in planning • Size is referenced in the literature with a view that larger integrated systems have a more difficult time retaining a patient focus

25. Patient Focus Ontario 2008 • Not a lot of systematic information on this yet • Satisfactions surveys in some sectors • Can look at whether system is organized for easy patient access • Can look at whether patients had enough information to make decisions

26. Patient Focus – % of People Reporting Wait of Six Days or More to See DoctorSource: Commonwealth Fund, 2007

27. Patient Focus - % Reporting Doctor Explained Things in a Way They Could UnderstandSource: Commonwealth Fund, 2007

28. Patient Focus - Patient Care Outside of Usual Office Hours in OntarioSource: National Physician Survey, 2004 • % Answering Yes: • 51.3% have physician available for patient care during non office hours • 19.7% provide telephone advice by a physician associated with the practice during non office hours

29. Common Element 3 - Geographic Rostering • Geographic coverage with patient rostering with or without charge back • Size is again referenced although from the opposite perspective – that is, larger numbers of clients are thought to create a more efficient integrated delivery system (generally thought to be about 1,000,000 minimum) • Much harder to get volumes in the Canadian context with our geography – density becomes important

30. Geographic Rostering Ontario 2008 • LHIN boundaries are geographic • Some rostering at the primary care level (not related to LHINs)

31. % Support by Group Requiring Patients to Register with One Primary Health Care Provider, Canada Source, Health Care in Canada, 2006

32. Common Element 4 - Interprofessional Teams • Development of interprofessional teams (assumes clinicians are in the tent either as employees or through contract) as best use of resources • A lot of barriers are cited particularly around alignment of financial incentives • Literature stresses the need for role clarity, an understanding of the decision authority for patient care (hierarchical or shared) • If not clear, can result in much slower care processes and can inhibit real integration

33. Interprofessional Teams - % Support by Group Requiring Health Professionals to Work in TeamsSource: Health Care in Canada, 2006

34. Common Element 5 – Standardized Care • Care in an integrated system ideally can be standardized to support a quality agenda • Use and acceptance of provider-developed, evidence-based clinical care guidelines and protocols are cited as important • Also links to the facilitation of interprofessional teams, as all team members are following the same protocol

35. Standardized Care – Usage of Standardized Protocols, Hospital Group AverageSource: Hospital Report, Acute Care, 2007

36. Standardized Care – Usage of Standardized Protocols, Hospital Group Range • Teaching: 13.9% – 81.1% • Community: 1.8% – 69.9% • Small: 0.0% – 74.1%

37. Common Element 6 - Measurement • Performance measurement focused on: • Process of integration • System, provider and patient outcomes • Can start as an accountability approach but usually develops quickly into a quality focus

38. Common Element 6 - Measurement • Literature contains a lot of work on indicator development but general conclusion that there is a “scarcity of literature relating to the performance of integrated health systems as whole” • May be related to definitional difficulties, number of players involved, diversity of goals, capacity to attribute effects

39. Measurement Ontario 2008 • Current Published • CCO provider survey specific to integrated cancer services • Hospitals reporting some data related to transitions (eg ALC) • Planned Published • Integration indicators in accountability agreements • Ontario Health Quality Council populating high performing system framework – integration is one component • Developing • LHINs developing series of indicators • JPPC developing indicators for home care

40. Common Element 7- IT • Heavy investment in information technology, information management and communication mechanisms • Especially key when providers are not co-located • For quality, efficiency and productivity reasons • System-wide and provider-specific information systems that relate to each other • Underpins most of the other elements • Absence cited as huge barrier

41. IT – Hospitals Using Clinical Information Technology, Hospital Group AverageHospital Report, Acute Care, 2007

42. IT – Hospitals Using Clinical Information Technology, Hospital Group Range • Teaching: 63.6% - 98.3% • Community: 21.8% – 94.8% • Small: 9.1% - 70.3%

43. Use of IT by MDs in Main Patient Care SettingSource: National Physician Survey, 2004 • % Indicating they have: • Electronic health records: 30.5% • Electronic scheduling 46.6% • Electronic reminder for pt care 12.1% • Electronic interface to external pharm 5.3% • Electronic interface to lab/diag imag 24.6% • Electronic interface to share pt info 18.8% • Electronic warning for adverse drugs 12.0%

44. Common Element 8 - Culture • Cohesive organizational culture with strong leadership and a shared vision of integration • Much harder to do under virtual or horizontal integration • Vertical integration also has its challenges but is more likely to change culture

45. Culture Ontario 2008 • ???

46. Common Element 9 - Leadership • Creating supportive environment, collegial culture, resolving conflicts requires a sophisticated leader and leadership vision • Capacity to assess effectiveness and change course if required

47. Leadership Ontario 2008 • Probably most telling element is that all others made refinements after a period of time (including Canadian RHAs) • Changed number of regions, renegotiated roles with province/state, established provincial or national health authorities to deal with high end specialty care • Will we?

48. Common Element 10 - Governance • Strong governance model with decision making authority • Whatever the mechanisms, the model must promote coordination, align financial incentives, share risk and have clear accountabilities • Seasoned board members and experienced management staff were cited as critical to success • Hindrances cited include poorly designed structure, competitive system of governance, or too many management levels

49. Governance Ontario 2008 • LHIN Boards • Local Boards • MOHLTC • Agreement between MOHLTC and LHINs • Agreements between LHINs and local Boards just beginning • Language of coordination and shared risk is in there

50. Governance Ontario 2008 • Who does: • Goal setting • Evidence based measurement and monitoring • Allocation • Everyone seems to have a role to play? • Where is final authority?