1. An Integration Journey: Road Trips from Afar Friday, January 25, 2008 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 Ontario’s 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 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

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. 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

11. 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

12. 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

13. 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

14. 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

15. 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:

16. 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

17. 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

18. 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

19. 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

20. 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)

21. 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

22. 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)

23. Comprehensiveness Ontario 2008 Not under the auspices of the LHINs: –Physicians –Public health –Ambulance services –Labs –Provincial networks and priority programs –Drugs

24. 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

25. 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

26. Patient Focus – % of People Reporting Wait of Six Days or More to See Doctor Source: Commonwealth Fund, 2007

27. Patient Focus - % Reporting Doctor Explained Things in a Way They Could Understand Source: Commonwealth Fund, 2007

28. 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

29. 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

30. Geographic Rostering Ontario 2008 LHIN boundaries are geographic Some rostering at the primary care level (not related to LHINs)

31. % Support by Group Requiring Patients to Register with One Primary Health Care Provider, Canada Source, Health Care in Canada, 2006

32. 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

33. Interprofessional Teams - % Support by Group Requiring Health Professionals to Work in Teams Source: Health Care in Canada, 2006

34. 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

35. Standardized Care – Usage of Standardized Protocols, Hospital Group Average Source: Hospital Report, Acute Care, 2007

36. Standardized Care – Usage of Standardized Protocols, Hospital Group Range Teaching:13.9% – 81.1% Community: 1.8% – 69.9% Small: 0.0% – 74.1%

37. 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

38. 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

39. 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

40. 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

41. IT – Hospitals Using Clinical Information Technology, Hospital Group Average Hospital Report, Acute Care, 2007

42. Teaching: 63.6% - 98.3% Community:21.8% – 94.8% Small: 9.1% - 70.3% IT – Hospitals Using Clinical Information Technology, Hospital Group Range

43. Use of IT by MDs in Main Patient Care Setting Source: National Physician Survey, 2004 % Indicating they have: Electronic health records:30.5% Electronic scheduling46.6% Electronic reminder for pt care12.1% Electronic interface to external pharm 5.3% Electronic interface to lab/diag imag24.6% Electronic interface to share pt info18.8% Electronic warning for adverse drugs12.0%

44. 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

45. Culture Ontario 2008 ???

46. 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

47. 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?

48. 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

49. 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

50. 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?

51. Governance Views About Canadian RHAs Source: Lewis and Kouri, Healthcare Papers, 2004 BoardsCEOsMinistries Clear division of Authority50%31%32% Residents end run RHA and go to the Minister58%87%96%

52. 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 control77%80%59% Boards are too restricted by rules71%70%30% Boards have less authority than I expected63%64%33%

53. 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

54. 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?

55. 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

56. 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?

57. 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.

58. 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.