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An Integration Journey: Road Trips from Afar

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Chronic disease emerging as huge cost driver ... integrate delivery in a more organized fashion was common to all as one response ... – PowerPoint PPT presentation

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

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.

53
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