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Changed Change Foundation. Established and endowed in 1995 by the OHAFirst ten years focused on grants, drivers of change and knowledge transferRefocused in 2007 to become a policy think tank"Two thematic research areas: understanding integration and quality improvement efforts in the communi
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1. An Integration Journey: Road Trips from Afar
Thursday, April 3, 2008
Sudbury, Ontario
OHA Region 1 Conference
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 Ontarios 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 Variations in quality
Public concerns focused on wait times emergency departments, specialty care mainly surgical, 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. 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
11. Focus on Types of Integration 2) Vertical Integration
- under one governance and management structure
- shared resources
- doesnt have to be co-located, but often is
3) Horizontal Integration
- cooperation/collaboration between providers at same level
- 2 groups of family practices with shared care and resources
12. 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
5) Clinical
- clinical services under one umbrella
- tends to be disease specific
13. 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)
14. 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
15. Comprehensiveness 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)
16. Comprehensiveness Not under the auspices of the LHINs:
Physicians
Public health
Ambulance services
Labs
Provincial networks and priority programs
17. 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
18. Patient Focus 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
19. Patient Focus % of People Reporting Wait of Six Days or More to see DoctorSource: Commonwealth Fund, 2007
20. Patient Focus - % Reporting Doctor Explained Things in a Way They Could UnderstandSource: Commonwealth Fund, 2007
21. Patient Focus - Patient Care Outside of Usual Office Hours in OntarioSource: National Physician Survey, 2007 % Answering Yes:
79.7% have physician available for patient care during non office hours
31.4% staffed clinic by physician or others in practice
12.9% medical telephone advice with access to medical record
25.8% medical telephone advice without access to medical record
22. Patient Focus MD Use of Email, Ontario Source: National Physician Survey, 2007 53.2% use to communicate with colleagues for clinical purposes
64.9% use to communicate with colleagues for other purposes
15.4% use to communicate with patients for clinical purposes
5.3% use to communicate with patients for other purposes
23. 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
24. Geographic Rostering LHIN boundaries are geographic
Some rostering at the primary care level (not related to LHINs)
25. % Support by Group Requiring Patients to Register with One Primary Health Care Provider, Canada Source, Health Care in Canada, 2007
26. 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
27. Interprofessional Teams - % Support by Group Requiring Health Professionals to Work in TeamsSource: Health Care in Canada, 2007
28. 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
29. Standardized Care Usage of Standardized Protocols, Hospital Group AverageSource: Hospital Report, Acute Care, 2007
30. Standardized Care Usage of Standardized Protocols, Hospital Group Range Teaching: 13.9% 81.1%
Community: 1.8% 69.9%
Small: 0.0% 74.1%
31. 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
32. 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
33. Measurement 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
34. 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
35. IT Hospitals Using Clinical Information Technology, Hospital Group AverageHospital Report, Acute Care, 2007
36.
Teaching: 63.6% - 98.3%
Community: 21.8% 94.8%
Small: 9.1% - 70.3% IT Hospitals Using Clinical Information Technology, Hospital Group Range
37. Use of IT in Main Patient Care Setting, OntarioSource: National Physician Survey, 2007 % Indicating they have:
Electronic health records: 31.5%
Electronic scheduling 50.7%
Electronic reminder for pt care 14.0%
Electronic interface to external pharm 4.3%
Electronic interface to lab/diag imag 26.4%
Electronic interface to share pt info 23.6%
Electronic warning for adverse drugs 13.6%
38. 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
39. Culture
???
40. 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
41. Leadership 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?
42. Common Element 10 - Governance Strong governance 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
43. Governance 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
44. Governance Who does:
Goal setting
Evidence based measurement and monitoring
Allocation
Everyone seems to have a role to play?
Where is final authority?
45. Governance Views About Canadian RHAsSource: Lewis and Kouri, Healthcare Papers, 2004 Boards CEOs Ministries
Clear division of
Authority 50% 31% 32%
Residents end run
RHA and go to the
Minister 58% 87% 96%
46. Governance Views About Canadian RHAsSource: Lewis and Kouri, Healthcare Papers, 2004 Boards CEO Ministries
Boards are legally responsible
for things over which they have
insufficient control 77% 80% 59%
Boards are too restricted by rules 71% 70% 30%
Boards have less authority than
I expected 63% 64% 33%
47. Common Element 11 - Funding Population based funding formula applied equitably with programmatic funding dedicated to specific services
The mechanisms for this vary greatly but all start with population based formula
Jurisdictions that did not align funding models found they did not promote teamwork, time spent on integrative activities or health promotion
Literature is unclear on best formula for integration purposes so at minimum age and gender have been used
48. Funding LHINs and providers are supposed to have a balanced budget
LHIN to provide providers with funding (currently based on historical allocations, service volumes, operating plans not population based)
If shortfall, parties will negotiate and revise requirements
Accountability agreement has process for recovery of funding by LHINs subject to appeal
Is this aligned with non-LHIN activity and provincial programs?
49. Not Quite So Common Element 12 Involvement of Physicians Two aspects
Engagement of clinical leadership in planning, design, and sometimes leading integration efforts. Much written about failure to do this and subsequent lack of integration success
Ways to integrate primary care providers if they are the initial point of care (often used as an integration measure)
Those that werent successful on this cite it as very important
50. Ontario 2008 Continuum will be difficult while chunks of services are not aligned with LHINs
Will need to focus on transition points across if patient focus is to be honoured
Geographic boundaries are in place but hard to see how patients will be rostered without a linkage to primary care
Increased use of interprofessional teams within facilities and in the primary care setting can we link them?
51. Ontario 2008 Increasing usage of standardized protocols more work to do but going in the right direction
A lot of discussion about measurement and a lot of indicators to be reported not a lot of actual measures of integration at present
Pockets of very exciting work on the IT front at the provider level how to achieve system level linkage?
In future, further work to clarify governance and funding arrangements will likely be required.
52. The Change Foundations Contributions Focus on the Transition Points Patient focus groups Spring 2008 to explore perceptions of system integration.
Partnership with the Ontario Association of CCACs to map the interactions and decisions patients and their caregivers must make during the transition from hospital to home.
Working with the University of Waterloo to mine the INTERAI data to understand why people who have been discharged from hospital to home are ending up back in the hospital.