Transcript Document

An Integration Journey: Road Trips from
Afar
Friday, January 25, 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
Presentation Outline
• Jurisdictional review of integration efforts
internationally and in Canada by the Foundation
• Summarize common elements
• Compare to Ontario’s efforts
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
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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
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
Similar Pressures in All Jurisdictions
• Documented variations in quality
• Public concerns focused on wait times – emergency
departments, specialty care – mainly surgical and
diagnostic, primary care (not in Canada)
• Demand for better information about system
management and health outcomes
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
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)
Defining Integration
• Lack of a universal definition or concept of
integration
• Almost every article reviewed started with
“there is no common definition”
• Use of multiple terms – integration, care
coordination, continuity of care
Defining Integration
• Systematic review by Suter et al. (2007) concluded that “the
definitions of integration vary as much as the terms used to
describe it.”
• Located 70 definitions
• Termed it “Tower of Babel”
• Systematic review on integration indicators by McMaster
identified similar issues regarding definition
Earlier Definitions of Integration
“Networks of organizations that provide or
arrange to provide a coordinated continuum
of services to a defined population and who
are willing to be held clinically and fiscally
accountable for the outcomes and the
health status of the population being
served.”
Shortell et al, 1993,1994
Defining Integration
“Services, providers and organizations
from across the continuum working
together so that services are complementary,
coordinated, in a seamless unified system,
with continuity for the client.”
CCHSA, 2006
Defining Integration
“An integrated health system would result in
coordinated health services that both improve
accessibility and allow people to move more
easily through the care and treatment continuum
of the health system and provide appropriate,
effective and efficient health services.”
Health Results Team for Information Management, 2006
Defining Integration
“Integration is defined broadly to encompass the
process of effectively managing the alignment of
multiple systems of independent (and
interdependent) organizations with unique goals
and objectives to achieve three important outcomes
that are central to the Ministry’s transformation
agenda:
Defining Integration
1) Ensuring that users experience service as seamless, where
boundaries between organizations are not apparent to them
2) Improving the match between single services provided and the
multiple needs of clients and families
3) Enabling effective and efficient use of system resources and
capacity by optimizing system interactions across the system
and across program silos.”
LHIN Team, MOHLTC, 2006
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
– LTC network linked to primary care practices
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
- RHA model
3) Horizontal Integration
- cooperation/collaboration between providers at same level
- 2 groups of family practices with shared care and resources
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
- SIMS model in Toronto
5) Clinical
- clinical services under one umbrella
- tends to be disease specific
- Cancer care
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 Ontario 2008
• 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 Ontario 2008
• Not under the auspices of the LHINs:
– Physicians
– Public health
– Ambulance services
– Labs
– Provincial networks and priority programs
– Drugs
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 Ontario 2008
• 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
5
Ger
20
US
20
UK
12
NZ
4
Aust
10
Canada
30
0
5
10
15
20
25
30
35
Patient Focus - % Reporting Doctor Explained Things in
a Way They Could Understand
Source: Commonwealth Fund, 2007
Neth
71
Germany
71
US
70
UK
71
NZ
80
Aust
79
Canada
75
64
66
68
70
72
74
76
78
80
82
Patient Focus - Patient Care Outside of
Usual Office Hours in Ontario
Source: National Physician Survey, 2004
% Answering Yes:
51.3% have physician available for patient care during
non office hours
19.7% provide telephone advice by a physician
associated with the practice during non office hours
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 Ontario 2008
• 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, 2006
34
Managers
10
4
Nurses
16
7
Pharamcists
5
9
36
37
13
19
Doctors
31
26
13
11
26
Public
6
0
Strongly Oppose
49
29
13
2
36
33
22
8
10
Somewhat Oppose
20
Neutral
30
40
Somewhat Support
50
Strongly Support
60
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, 2006
61
33
Managers
3
3
59
29
Nurses
11
1
54
29
Pharmacists
16
1
18
29
Doctors
33
7
13
39
37
Public
17
2
2
0
Strongly Oppose
10
20
Somewhat Oppose
30
Neutral
40
50
Somewhat Support
60
Strongly Support
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
45.8
Teaching
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 Ontario 2008
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
62
Community
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 by MDs in Main Patient Care Setting
Source: National Physician Survey, 2004
% 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
30.5%
46.6%
12.1%
5.3%
24.6%
18.8%
12.0%
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 Ontario 2008
???
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 Ontario 2008
• 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 model 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 Ontario 2008
• 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 Ontario 2008
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%
Boards are too restricted by rules
71%
70%
30%
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 Ontario 2008
• 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.
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.