Title: An Integration Journey: Road Trips from Afar
1An Integration Journey Road Trips from Afar
- Thursday, April 3, 2008
- Sudbury, Ontario
- OHA Region 1 Conference
- Cathy Fooks
- President and CEO
- The Change Foundation
2Changed 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
3Presentation Outline
- Jurisdictional review of integration efforts
internationally and in Canada by the Foundation - Summarize common elements
- Compare to Ontarios efforts
4Jurisdictional 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
5Jurisdictional 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
6Similar 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
7Similar 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
8Similar 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
9Different 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)
10Focus 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
11Focus 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 -
12Types 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
13Common 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)
14Common 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
15Comprehensiveness
- 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)
16Comprehensiveness
- Not under the auspices of the LHINs
- Physicians
- Public health
- Ambulance services
- Labs
- Provincial networks and priority programs
17Common 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
18Patient 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
19Patient Focus of People Reporting Wait of
Six Days or More to see DoctorSource
Commonwealth Fund, 2007
20Patient Focus - Reporting Doctor Explained
Things in a Way They Could UnderstandSource
Commonwealth Fund, 2007
21Patient 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
22Patient 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
23Common 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
24Geographic 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
26Common 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
27Interprofessional Teams - Support by Group
Requiring Health Professionals to Work in
TeamsSource Health Care in Canada, 2007
28Common 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
29Standardized Care Usage of Standardized
Protocols, Hospital Group AverageSource
Hospital Report, Acute Care, 2007
30Standardized Care Usage of Standardized
Protocols, Hospital Group Range
- Teaching 13.9 81.1
- Community 1.8 69.9
- Small 0.0 74.1
31Common 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
32Common 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
33Measurement
- 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
34Common 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
35IT Hospitals Using Clinical Information
Technology, Hospital Group AverageHospital
Report, Acute Care, 2007
36IT Hospitals Using Clinical Information
Technology, Hospital Group Range
- Teaching 63.6 - 98.3
- Community 21.8 94.8
- Small 9.1 - 70.3
37Use 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
-
38Common 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
39Culture
40Common 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
41Leadership
- 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?
42Common 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
43Governance
- 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
44Governance
- Who does
- Goal setting
- Evidence based measurement and monitoring
- Allocation
- Everyone seems to have a role to play?
- Where is final authority?
45Governance 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
46Governance 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
47Common 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
48Funding
- 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?
49Not 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
50Ontario 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?
51Ontario 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.
52The 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.
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