Onil Bhattacharyya, MD, PhDFrigon Blau Chair in Family Medicine Research

Women’s College HospitalUniversity of Toronto

Overview

Acknowledgements– Dr. Wendy Levinson– Dr. Lynn Wilson– Dr. Fiona Webster– Dr. Kaveh Shojania

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Key Partners:Ontario Ministry of Health and Long-Term Care – Health Quality Branch

Executive Committee– Dr. Vicky Stergiopoulos– Dr. Gary Naglie– Dr. Onil Bhattacharyya

Schedule

8:15 Overview of BRIDGES Onil Bhattacharyya 9:00 Keynote Ed Wagner 10:00 Integrated Home-based Primary Care Tia Pham10:20 BREAK 10:40 Coordinated Access to Care from Hospital ED Vicky11:00 BRIDGES meta-analysis Dr. Fiona Webster 11:30 Lunch and Poster viewing12:30 Leveraging Lessons Learned Jodeme Goldhar 1:00 Closing Remarks Dr. Wendy Levinson

What is the most important problem in health care?

What is the most difficult problem in health care?

What is the solution?

Objective• Create a platform for development of new

models of integrated care for complex patients.

Family Medicine

Medicine Psychiatry

Across Disciplines Across the Continuum

Community Services

Primary Care

Hospital

Incubating Models of Integrated Care

Bridging Different Worlds

Health Service

Providers

Pragmatic Decision-Making

Data-Driven Decision-Making

Academics

HSR Clinical Sciences

Basic Sciences

Rigorous QI Methodology

Shared Space for Innovation

High Quality Health Services

Research

The BRIDGES Process

• 61 proposals, 9 funded• From Barrie to South Lake

Reviewed on• Scientific rigour• System relevance

• Study design, data coordination and analysis• Qualitative evaluation• Economic evaluation

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Hypothesis Testing Framework

PROBLEM MODEL OBJECTIVE OUTCOME

VALUE HYPOTHESIS

To Patients

To Providers

GROWTH HYPOTHESIS Patient and Provider

Recruitment Strategy

POTENTIAL PROBLEMS

• Work with HQO and CAHO• Many potential partners• No firm results yet

Project

Collaborative

System

Collective Impact

Project Population Model

IMPACT Plus Complex patients Multidisciplinary team consultation

IHBPC Homebound elder Multidisciplinary homecare team

Innovate AFib Atrial Fibrillation Nurse coordinator

PIC COPD COPD Nurse-led self-management

CATCH-ED Frequent ED users in Mental Health

Transitional case management

SCOPE GPs with high user patients

Phone consultation + coordination

H-SOAP Addictions Rapid consultation + care

RAPT Mental Health Rapid consultation

ICCT GPs w/ complex older patients

Shared or assumed care

The BRIDGES Collaborative

BRIDGES in Brief

• 9 projects• 28 lead investigators• 23 Institutions• 2,300+ patients• 30 providers + their patients

Communication between

institutions

Joint care delivery

Joint management across institutions

SCOPE IHBPCPIC COPD

TEAMCATCH ED

ICCT

Integration Across the Continuum

Building BRIDGES

• Continuous testing and improvement• Co-leadership w/ psychiatry• Characterizing key elements of QI• Building trust and sharing

Impacts

• Tested model for incubating pilot projects– Adapted for provincial pilot initiative

• Strong collaboration b/w departments and CCAC

• All models sustained after funding• Synergy w/ Health Links

Key Deliverables

• Increase likelihood of project success in terms of effectiveness and learning

• Assess impact of overall initiative and potential of models

• Project results by 2015

What have we learned?

It’s Hard

• Recruitment• Targeting• Making the intervention work• Management across institution• Outreach to primary care

It’s Easy to get it Wrong

Be ready to change• Zoom in/out• User segment pivot• User need pivot• Business architecture pivot• Channel pivot

It’s Worth It

• Patients appreciate the comprehensiveness• Providers appreciate being connected• Managers appreciate connection to other

institutions• Policymakers like the coherence

There’s Much More to Do

• No magic bullets• No clear answers yet• More people are in the game• Growing potential for cumulative learning

Thanks!