An Integration Journey: Road Trips from Afar

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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

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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

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Presentation Outline

• Jurisdictional review of integration efforts
  internationally and in Canada by the Foundation
• Summarize common elements
• Compare to Ontarios efforts

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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

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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

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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

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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

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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

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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)

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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

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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

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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

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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)

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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

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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)

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Comprehensiveness

• Not under the auspices of the LHINs
• Physicians
• Public health
• Ambulance services
• Labs
• Provincial networks and priority programs

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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

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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

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Patient Focus of People Reporting Wait of
Six Days or More to see DoctorSource
Commonwealth Fund, 2007
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Patient Focus - Reporting Doctor Explained
Things in a Way They Could UnderstandSource
Commonwealth Fund, 2007
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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

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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

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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

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Geographic Rostering

• LHIN boundaries are geographic
• Some rostering at the primary care level (not
  related to LHINs)

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Support by Group Requiring Patients to Register
with One Primary Health Care Provider, Canada
Source, Health Care in Canada, 2007
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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

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Interprofessional Teams - Support by Group
Requiring Health Professionals to Work in
TeamsSource Health Care in Canada, 2007
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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

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Standardized Care Usage of Standardized
Protocols, Hospital Group AverageSource
Hospital Report, Acute Care, 2007
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Standardized Care Usage of Standardized
Protocols, Hospital Group Range

• Teaching 13.9 81.1
• Community 1.8 69.9
• Small 0.0 74.1

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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

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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

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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

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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

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IT Hospitals Using Clinical Information
Technology, Hospital Group AverageHospital
Report, Acute Care, 2007
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IT Hospitals Using Clinical Information
Technology, Hospital Group Range

• Teaching 63.6 - 98.3
• Community 21.8 94.8
• Small 9.1 - 70.3

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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

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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

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Culture

• ???

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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

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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?

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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

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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

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Governance

• Who does
• Goal setting
• Evidence based measurement and monitoring
• Allocation
• Everyone seems to have a role to play?
• Where is final authority?

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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

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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

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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

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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?

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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

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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?

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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.

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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.

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