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Lee Fairclough

Integrated care: Weaving a seamless web

Moving away from a fragmented and siloed health care system to one that seamlessly connects patients to the services that they need is currently driving health care reform in Ontario.
How will this look for patients?

If you’re a patient with chronic knee pain, in most cases you will be seen and assessed by a family physician. However, in some cases you may be assessed at a rapid access clinic and, if you need surgery, seeing an orthopedic surgeon in a timely manner and having knee replacement surgery. After the operation, it means that you and your family work with health care professionals, so your needs and wishes are met when being discharged from hospital. When discharged you will have a transition plan that has been developed in collaboration with you and shared with your primary care provider. You will receive post-operative rehabilitation, education and training about self-care, and you will have a clear sense of the steps needed to ensure your recovery.

If you’re a patient with the worsening of a chronic condition (s) that requires hospital admission, it means that your primary care, home care and community care professionals are properly informed through a real-time electronic notification service. While in hospital, in addition to a clinical exam, your needs are assessed to consider your overall health and any social supports that may be required. Depending on your health situation, this may include early assessment for palliative care. Once you are discharged, if you require help with bathing, meal preparation or other assistance from community services, a care coordinator arranges these services, so they are in place as soon as you return home. Everyone involved in your care is well informed of the plan throughout.

These are two broad examples of integrated care that have numerous variations based on the individual circumstances of the patient. Both scenarios are consistent with the care recommended in Health Quality Ontario’s draft quality standard on Transitions in Care, which is now available for feedback.

The need for more integrated care – where seamless transitions in care are a large component – was made clear in the First Interim Report from the Premier’s Council on Improving Healthcare and Ending Hallway Medicine. One of its key findings was “there needs to be more effective coordination at both the system level, and at the point-of-care.” Work now underway to develop Ontario Health Teams is focused on how health care professionals and organizations (including hospitals, doctors and home and community care providers) will develop and strengthen partnerships to work as one coordinated team.

At Health Quality Ontario, we’ve worked with teams over the years to improve coordination of care for patients with chronic conditions and complex needs and with teams implementing pilots of bundled care pathways and we asked over a thousand patients and caregivers about their experiences and what matters to them when they transition from hospital to home.

Here are a few things we have learned about building an integrated care team:

Imagine how care could be better - Get to the root cause of issues that could lead to poorly connected care in your locale. Involve local clinicians and patients in the process of mapping how your team’s processes could be improved. Don’t be limited in thinking of improvements to the way things were done in the past or by perceived policy or practice barriers.

Support patients proactively by:

  • Clearly defining the population to be served by the team
  • Partnering with patients from these populations in developing team plans
  • Defining what data you will collect to allow reflection on the care provided and use this data to motivate further improvement.
  • Using information technology to anticipate when a patient may need care, providing more timely access to care and ensuring timely availability of information across the care time. This might include virtual care, using electronic records to actively notify providers, or patients access to their own electronic records.

Innovate payment models - How health care providers are paid could be both a barrier and a facilitator of integrated care. Part of the new system may involve bundled care (where a single payment is made for an episode of care across multiple settings and providers) – to encourage a patient-centred team-based approach rather than payment based on individual interventions of care. This model is already being successfully applied in Ontario to acute and post-acute care for unilateral hip and knee replacement surgery and some other conditions, along with successful pilot projects in stroke, cardiac surgery and shoulder surgery.

Address broader determinants of health - For most patients with complex, chronic conditions this will be a necessity. Consider who your partners will be both within the health sector and in the community (eg. housing, justice) to achieve this. Many examples exist as to how this has been done successfully.

Ensure strong leadership and governance. Viable health teams will need strong leadership and a governance framework especially when partners need to come together and provide an integrated approach. This might require developing a shared vision among partners. Strong leadership will be required to support teams to overcome barriers as they evolve.

Build a strong team: Teams that cross traditional organizational or sector boundaries need to feel and act like a team. You need to develop trust for what will happen when patients leave your care to transition to others, and patients must have an easy mechanism to enter back into the original care team if needed.

Much is happening in Ontario to make care far more coordinated and integrated, so that care is provided that is focused on the patient’s needs across their treatment and recovery journey. As dedicated health care providers and organizations come together as a team to provide integrated care, these helpful learnings from past experiences should help enable us to effectively work as one from the get-to - amongst themselves and with patients – to weave a seamless web of care.

Join Lee Fairclough, University Health Network President and CEO Dr. Kevin Smith, patient advocate Annette McKinnon and Northern Ontario general practitioner Dr. Sarah Newbery at 8 PM on May 16 for a discussion on Twitter at #HQOchat about integrated care in Ontario. The following questions will be discussed:

1) What does integrated care mean to you?

2) What is needed to build a fully integrated health care system?

3) What are the barriers to implementing integrated care in Ontario?

4) How should we be paying providers to support integrated care?

5) Do you have examples within the current system of where care is locally well integrated or coordinated?

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