Medically Complex Patients (MCP) Webinar Advancing a System of Integrated Care November 17, 2014 Jodeme Goldhar MSW, RSW, MHSc Lead, Health System Integration

Medically Complex Patients (MCP) WebinarAdvancing a System of Integrated Care

November 17, 2014

Jodeme Goldhar MSW, RSW, MHScLead, Health System Integration for Complex Population and Primary Care – Toronto Central Community Care Access CentreAdjunct Lecturer, University of Toronto, Institute of Health Policy, Management and EvaluationPresident, University of Toronto, Institute of Health Policy, Management and Evaluation, Society of Graduates

Onil Bhattacharyya MD, PhDCo-Principal Investigator, BRIDGES Frigon Blau Chair in Family Medicine Research, Women’s College HospitalAssociate Professor, Department of Family and Community Medicine & Department of Health Policy, Management and Evaluation, University of Toronto

Objectives

• A deep dive into integration: – What is it? Can it be measured?

• How do you integrate successfully?– Barriers and facilitators; the role of leadership

• Integrating for system change:– Strategies for Inter-sectorial action

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What is Integration? Barriers and Facilitators Inter-sectoral Integration

Defining Integration

• “Human service integration is a process by which two or more entities establish linkages for the purpose of improving outcomes for people in need” Konrad,1996

• “a complex intervention where management and organizational process to support integrated care occur at many levels simultaneously” Goodwin, 2013

• “Joint working”

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Levels of Integration – Integration as a Continuum

• Information sharing and communication• Cooperation and Coordination• Collaboration• Consolidation• Integration

Konrad, 1996

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Valentijin, P., Schepman, S., Opheij, W., 7 Bruijnzeels, M.Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care. Int J Integr Care 2013; Jan–Mar

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Multidimensional Framework for Integrated Care

Why Integrate?

• Benefits of integration:– Ability to address complex needs comprehensively– Greater service accessibility and continuity– Early intervention and prevention– Reduced duplication– Reduced waste/inefficiency– Reduced costs– Greater accountability

Wingspread Conference, 1993

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Are There Drawbacks to Integration?

• Less organizational flexibility• Loss of organizational identity• Time involved• May limit client choice

Flatau, 2013

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Can Integration Be Measured?

• Proposed dimensions to examine:

– Structural inputs (e.g. extent, scope, depth, congruence within an agency, reciprocity between agencies)

– Functioning (e.g. quality of the partnership, working arrangements, range of services provided)

– Outputs (e.g. network capacity, network activities, access, outcomes)

Browne, 2007

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What type of integration activities have you undertaken?

INTEGRATING SUCCESSFULLY

Structural Reform? Layered On?

Point of Care – Functional Integration

Unwavering Focus

A Debate About Reform and Which Road is Best…Steadfast Despite Political Context

11What is Integration? Barriers and Facilitators Inter-sectoral Integration

Functional Integration at the Point-of-Care

Our Aim• Supporting populations with complex needs with better care

at home in their communities, utilizing existing resources

Our Approach• Creating One Team Through The Eyes of Clients and Families

For the Client/Family• Seamless care• One team approach

For the Providers• One team approach• Built around client and

family needs

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CCAC Working Hand-in-Hand with Primary

Care

Care Coordination

Across the Care

Continuum

Acute Care Partnership

and Protocols

Pharmacy Engagement

Emergency Medical Services

Partnership

Caregiver Support

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Functional Integration in Practice

Stop, Take Stock and Reflect

LESSONS LEARNEDHow to Enable Functional Integration


How can we work together

differently?

What do I need to do differently?

How can we understand and experience different perspectives?

How can we all work together on what is most important to the client/family?

Walk a Mile or Two…

Relationship Will Determine Success

Trust Will Determine Success

Safe Shared Accountability

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Opposing NotionsTensions

Integrated Solutions through the eyes of

Clients and their Families

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Need For Scientific Evidence and Outcomes With Quality Improvement Frameworks

For Effective Change in Complex Adaptive Systems

Balance

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Integrated Care TeamClient and Family Experience

“I meet with my ICCP care coordinator every two weeks or so… She speaks with

my doctor. This is the first time the doctor ever came to my home.” – Client

“The Coordinator works with other professionals to collect information, so I just have one person to contact. It saves

me time.” – Primary Care Physician

“The cross-sector care we now provide is improving the patient experience - as witnessed by shorter lengths of stay and improved patient satisfaction

scores within these patient groups.” – Acute Care Partner

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Do not wait for complex solutions

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There is no script…

Lead through Ambiguity……Build the bridge as you walk on it

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Leverage e-Enablers to SupportPoint-of-Care Integration

Clinical CollaborationTool (Clin-CT)

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Greater Emphasis on EMOTIONAL INTELLIGENCE

Leadership Leaderful

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Incremental Build

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Maturity Reached Over Time


Lift Up, Look out…

…and Honour the Past26

Lessons Learned from BRIDGES

• Integrate mental health with the rest of health• Build leadership and governance models that engage multiple

stakeholders• Examine the role of incentives, accountability and shared risk

in addressing barriers to integration• Consider appropriate timeframes

BRIDGES Evaluation Final Report, 2014

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What barriers to integration have you come across?

How have you addressed them?

Integrating for Systems Change


“The effort to bring local system change has required

collaboration by all key stakeholders, responsiveness to

community identified priorities, and emphasis on frontline agency

and staff empowerment and capacity building. It has fostered

relationships that involve mutual respect, equity, and

inclusiveness, recognizing the community as a resource and

aiming for shared leadership and power in health program

development”

Stergiopoulos, 2014 30


Integrating for System Change

• What is system integration?–Alignment of rules and policies within a system

Valentijin, 2013

• System integration requires a combination of structures, processes and techniques to fit the needs of individuals and populations across the continuum of care

Armitage, 2009

• It often involves coordination of key support functions such as financial management, human resources, strategic planning, information management and quality improvement

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When the Patient is the System….

Minister’s Advisory Group, Respect, Recovery, Resilience: Recommendations for Ontario’s Mental Health and Addictions Strategy

Crisis services

Housing

Legal support

Income support

Employment/ education

Front line, specialized and intensive services

Social integration

X

Hospital based care

Transitio

n of care

DISCHARGE SERVICES

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Strategies for Inter-Sectorial Action

• Establish a common ground by driving integration from the perspective of the common client and their caregivers

• Demonstrate the value of inter-sectorial work by embedding champions who have already started to do this work

• Understand the experience of local providers and engage them for joint planning and development

• Integration takes time… Stick to it!

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What sectors are you integrating or wish you could be integrating?

How have you gone about it?

Questions?

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Medically Complex Patients (MCP) Webinar Advancing a System of Integrated Care November 17, 2014 Jodeme Goldhar MSW, RSW, MHSc Lead, Health System Integration