An Integration Journey: Road Trips from Afar

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 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 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 - doesn�t 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 weren�t 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 Foundation�s 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.