An Integration Journey: Road Trips from Afar

Thursday, May 1, 2008 QHN Symposium 2008 Cathy Fooks President and CEO The Change Foundation

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

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

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

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)

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

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)

Comprehensiveness

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

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

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

Patient Focus – % of People Reporting Wait of Six Days or More to see Doctor

Source: Commonwealth Fund, 2007

Net Ger US UK NZ Aust Canada

0

4

5

5

10

10 12

15 20

20 20

25 30

30

35

Patient Focus - % Reporting Doctor Explained Things in a Way They Could

Source: Commonwealth Fund, 2007

Neth Germany US UK 70 71 71 71 NZ Aust Canada

64 66 68 70 72 74

75

76

79 80

78 80 82

Patient Focus - Patient Care Outside of Usual Office Hours in Ontario

Source: 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

Patient Focus – MD Use of Email

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

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

Geographic Rostering

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

% Support by Group Requiring Patients to Register with One Primary Health Care Provider, Canada

Source, Health Care in Canada, 2007

Managers Nurses Pharamcists Doctors Public

0

21 39 19 13 8 32 24 20 9 14 10 11 19 19 18 19 20 21 31 31 21 24 24 10 16

5 10

Strongly Oppose

15 20

Somewhat Oppose Neutral

25 30

Somewhat Support

35 40

Strongly Support

45

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

Interprofessional Teams - % Support by Group Requiring Health Professionals to Work in Teams

Source: Health Care in Canada, 2007

28 Managers 1 2 3 61 24 Nurses 1 2 11 51 30 Pharmacists 1 4 13 Doctors 10 15 20 23 32 32 38 Public 3 3

0

19

10

Strongly Oppose

20 30

Somewhat Oppose Neutral

40 50

Somewhat Support

60

Strongly Support 65

70

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

Standardized Care – Usage of Standardized Protocols, Hospital Group Average

Source: Hospital Report, Acute Care, 2007

Small 26 Provincial 38.1

40.6

Community Teaching 45.8

0 5 10 15 20 25 30 35 40 45 50

Standardized Care – Usage of Standardized Protocols, Hospital Group Range

Teaching: 13.9% – 81.1% Community: 1.8% – 69.9% Small: 0.0% – 74.1%

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

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

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

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

IT – Hospitals Using Clinical Information Technology, Hospital Group Average

Hospital Report, Acute Care, 2007

Small 40 Provincial 59 Community 62 Teaching 79

0 10 20 30 40 50 60 70 80 90

IT – Hospitals Using Clinical Information Technology, Hospital Group Range

Teaching: 63.6% - 98.3% Community: 21.8% – 94.8% Small: 9.1% - 70.3%

Use of IT in Main Patient Care Setting

Source: National Physician Survey, 2007

% Indicating they have:

Electronic health records: Electronic scheduling Electronic reminder for pt care Electronic interface to external pharm Electronic interface to lab/diag imag Electronic interface to share pt info Electronic warning for adverse drugs 31.5% 50.7% 14.0% 4.3% 26.4% 23.6% 13.6%

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

Culture

???

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

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?

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

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

Governance

Who does: • Goal setting • Evidence based measurement and monitoring • Allocation • Everyone seems to have a role to play?

• Where is final authority?

Governance Views About Canadian RHAs

Source: 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%

Governance Views About Canadian RHAs

Source: Lewis and Kouri, Healthcare Papers, 2004

Boards CEO Ministries Boards are legally responsible for things over which they have insufficient control 77% 80% 59% 71% 70% 30% Boards are too restricted by rules Boards have less authority than I expected 63% 64% 33%

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

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?

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

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?

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 report – 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.