1. Health System Funding Reform & Quality-Based Procedures
Melissa Farrell
Assistant Deputy Minister
Health System Quality & Funding Division
Ministry of Health and Long-Term Care
November 13, 2015

2. Patients First: Action Plan for Health Care
On February 2, the Minister announced Patients First, the next phase of Ontario's plan for changing and improving Ontario's health system. It exemplifies the commitment to put people and patients at the centre of the system by focusing on putting patients' needs first.
This plan focuses on four key objectives:
Open, transparent, accountable, effectively managed government that provides value for tax dollars
Health
Promise
Patients First
a caring, integrated experience for patients
faster access to quality health services
for all Ontarians at every life stage
Connect:
Providing better home and community care
Protect :
Ensuring our universal health care system is sustainable for generations to come
Inform:
Providing information to make the right decisions about your health
Access:
Providing faster access to the right care
Government Promise 2

3. Health System Funding Reform (HSFR)
Health Based Allocation Model (HBAM)
Evidence, health-based funding formula
Enables government to equitably allocate available funding for local health services
Estimates future expense based on past service levels and efficiency, as well as population and health information e.g. age, gender, population growth rates, diagnosis and procedures
Quality-Based Procedures
(QBPs)
Clusters of patients with clinically related diagnoses / treatments and functional needs identified by an evidence-based framework as providing opportunity for:
Aligning incentives to facilitate adoption of best clinical evidence- informed practices
Appropriately reducing variation in costs and practice across the province while improving outcomes
Reflect needs of the community
Equitable allocation of health care dollars
Better quality care and improved outcomes
Moderate spending growth to sustainable levels
Adopt/ learn from approaches used in other jurisdictions
Phased in over time at a managed pace
Components
Goals and Objectives
Ontario’s HSFR has two components, both using patient information:
HBAM an organizational level approach to allocating available funding to HSPs, and
QBPs which is a patient level approach to allocating appropriate funding for the delivery of high quality care to homogenous groups of patients
The QBPs will have best practices and performance indicators defined by clinical experts to facilitate this allocation of funds
40%
30% 3

4. has introduced a new HSFR governance structure
The Ministry, in collaboration with the Local Health Integration Networks (LHINs), the Ontario Hospital Association (OHA) and Cancer Care Ontario (CCO),
has introduced a new HSFR governance structure
The Hospital Advisory Committee (HAC) has been charged with providing advice and recommendations to the Ministry leadership on improvements to HSFR, including existing and planned components of HBAM and QBPs that are in alignment with the Excellent Care for All Act and Patients First: Action Plan for Health Care
Three working groups will support the work of the Hospital Advisory Committee: i) Quality & Policy ii) Formulae & Tools iii) Communication, Education & Knowledge Transfer 4

5. Quality-Based Procedures (QBPs)
QBPs will be developed across the continuum of care, using different approaches to address the varying needs of patient / client populations
Vision
QBPs are clusters of patients with clinically related diagnoses / treatments and functional needs identified by an evidence-based framework
Provide Opportunities
For aligning incentives to facilitate adoption of best clinical evidence-informed practices
For appropriately reducing variation in costs and practice across the province while improving outcomes
For ensuring we are advancing right care, at the right place, at the right time
Definition
QBPs were created with a very clinical process and quality outcomes focus. Deliberately the development of the clinical best practices are divorced at the onset from the funding of the QBP. Once the QBP has been introduced to the field the subsequent funding allocations will include pricing of the QBP.
QBP development  follows a natural transition across the care continuum.
While the QBP implementation journey had an initial inpatient focus, work is underway to develop QBPs that span beyond the hospital walls and into post-discharge and community phases of care.
Acute Inpatient
Acute-inpatient QBPs continue to be developed and rolled-out
Receive services in a hospital setting for limited time to achieve specific goals
Outpatient Clinics and Emergency Room
Expanding focus to incorporate ER care that incents appropriate and quality care; both ER and out-patient clinics serve as key transition points along the continuum of care
Transition Phase
This includes clients typically recovering from an acute exacerbation/ recurrence of existing illness or new illness/injury or maybe dying of an advance illness
Community
Care is driven by functional needs of the patients
Receive services for an indefinite period of time
As QBPs are further developed, different approaches will be required for addresses these patient/ client groups. 5

6. Current Evidence-Based Framework
Identifies QBPs that have the potential to improve patient outcomes first and foremost
Does the clinical group contribute to a significant proportion of total costs?
Is there significant variation across providers in unit costs/ volumes/ efficiency?
Is there potential for cost savings or efficiency improvement through more consistent practice?
How do we pursue quality and improve efficiency?
Is there potential areas for integration across the care continuum?
Are there clinical leaders able to champion change in this area?
Is there data and reporting infrastructure in place?
Can we leverage other initiatives or reforms related to practice change (e.g. Wait Time, Provincial Programs)?
Is this aligned with Transformation priorities?
Will this contribute directly to Transformation system re-design?
Is there variation in clinical outcomes across providers, regions and populations?
Is there a high degree of observed practice variation across providers or regions in clinical areas where a best practice or standard exists, suggesting such variation is inappropriate?
Is there a clinical evidence base for an established standard of care and/or care pathway? How strong is the evidence?
Is costing and utilization information available to inform development of reference costs and pricing?
What activities have the potential for bundled payments and integrated care? 6

7. Current QBPs Under Consideration
Agency Oversight
Status
Retinal Disease
Vision Care (UHN)
Draft Clinical Handbook submitted
Coronary Artery Disease
Cardiac Care Network
Aortic Valve Disease
Cancer Surgery – Breast
Cancer Care Ontario
Cancer Surgery – Thyroid
Corneal Transplant
Non-Emergent Spine
University Health Network
Paediatric Asthma
Provincial Council for Maternal and Child Health
Shoulder Surgery – Osteoarthritis Cuff
Health Quality Ontario
Sickle Cell Anemia
Hysterectomy
Cancer Care Ontario & Health Quality Ontario
In development
Low Risk Delivery
Mental Health: Schizophrenia
Mental Health: Dementia with Agitation
Mental Health: Major Depression
Colposcopy
Cardiac Devices
Cardiac Prevention and Rehabilitation
in the Community
Discussions are happening within the Ministry to determine whether funding implementation will follow 1 year after clinical implementation of the handbooks. 7

8. QBP Adoption Committee
The following principles have been proposed to lead the development of the Provincial Roadmap for QBP Adoption
QBPs will have a core set of tools and supports to assist adoption.
Each QBP will have a clear process at the outset to determine the adoption strategy for the QBP led by the lead agency.
The core adoption tools must be supported by a provincial strategy to drive adoption e.g. measurement and reporting, clinical team engagement and order sets.
Adoption tools and supports will be evidence-based, where possible and will capture innovation and leverage the strengths of the field. This will including considering spread and scale strategies.
All partners commit to contributing to and promoting a common on-line location for users to easily access QBP tools (i.e. QBP Connect).
QBP Adoption tools will be evaluated (ideally in a similar way).
We will celebrate success (awards and rewards).
QBPs will be defined provincially and operationalized locally using LHINs/lead agencies, existing networks and local leadership who will have a lead role in QBP Adoption.
From HQO’s presentation to HAC 8

9. QBP Adoption Committee Cont’d
The following core set of adoption tools and supports have been proposed with the vision that a minimum core set be available for each
Baseline data
Ongoing/real-time data
Data support
Audit & feedback
Clinician/care team engagement strategy
Provincial conferences/webinars
Access to provincial & regional experts (clinical/data etc.)
Community of practice
Coaching/SWAT Team
List of most important best practice recommendations
Summary QBP pathway
Standardized order set templates
Recommendations on required local & provincial infrastructure
Implementation toolkit/checklist
Goal setting/benchmarking
Evaluation
Measurement & Reporting Support
Change Management Tools
Knowledge Transfer Tools
Improvement Science
From HQO’s presentation to HAC 9

10. Spread vs Scale SPREAD SCALE Horizontal Diffusion
One team at a time
Requires champions
SCALE
System-wide structural change
Policy levers
Requires political commitment
Source: Danielle Martin, Health Quality Transformation Keynote 10

11. Clinical Leadership and Excellence
Innovators
Late Majority
Early Implementers
Early Majority
Slow Implementers
Today
Implementation
As HSFR has rolled out, different HSFps have been more or less capable and willing to adopt the changes involved. We have seen early adopters and slow adopters and others in between those extremes. The goal is to assist and encourage the early adopters and innovators to drive the bar upwards and decrease the numbers of later majority and slow adopters. This will entail a myriad of programs and processes, communication strategies, peer to peer knowledge transfer and continued dialogue.
To bridge from pockets of excellence, existing tools need to be strengthened to support greater spread:
Leverage champions from the sector
Position strong leaders at the forefront who can deliver on the vision
Develop peer-to-peer supports to accelerate clinical adoption
Scale up initiatives where investments have shown results
Effective patient engagement to optimize patient care processes
Expand quality improvement efforts across continuum of care 11

12. QBP Adoption Committee
Where to Next?
Closer review of roles, priorities and direction of HSFR (e.g. Hospital Advisory Committee)
HSFR Governance
Map roles and responsibilities (e.g. agencies, hospitals, LHINs, Ministry) for each QBP and type of activity to support adoption
Develop some standard approaches that partners support and will deliver for each QBP
Develop an action plan to start the work, particularly for some of the cross cutting strategies such as data
Regional Strategy
Following the completion of the Pan-LHIN QBP surveys, develop a more standardized regional adoption strategy for QBPs
QBP Adoption Committee 12

13. Quality foundation, guided by the Excellent Care for All Act
Where to Next Cont’d?
Evolution towards population-based frameworks for service delivery
QBPs: Evidence & standards influence average price
Single service
Health Links: Moving towards models for comprehensive care in which providers become accountable for overall outcomes
Integration of clinical care
Integrated Funding Models: Scaling up a “proof of concept” approach through an Expression of Interest
Integration of care and funding for 1 episode
Pre-requisites:
Shared governance
Shared IT, health analytics, data systems
Common service accountability agreements
Common QIP
Common understanding of patient and provider experience
This slide shows the gradual progression towards population-based frameworks for quality and funding.
QBPs are important building blocks to ensure foundation is evidence-based.
Health Links have been key to relationship building, and identifying clinical care integration techniques
Integrated funding will be an important test to challenge the current siloed funding schemes and test the impact of integrated funding for an episode of care
Moving towards an “integrated healthcare delivery system” model, where funding and governance are applied at a population level, is a logical next step.
Before getting there, there are some key foundational elements that will need to be in place.
Population-based frameworks for service delivery: Future direction, based on evaluation, policy analysis, and innovative implementation
Population-based integration of care, and funding
Quality foundation, guided by the Excellent Care for All Act 13