Person-Centred Care, Equity and Other Building Blocks For Excellent Care For All

Person-Centred Care, Equity and Other Building Blocks for

Excellent Care For AllBob GardnerCentral LHIN

Annual Business Plan 2013-14 CollaborativeDecember 12, 2012

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Nothing About Us, Without Us

• fundamental principle of disability rights and other consumer movements

• emphasized by Don Berwick, founder of Institute for Healthcare Improvement• key dimension of high-performing healthcare system• but really integrating PCC into how care is imagined,

planned, organized and delivered → will drive major transformation

+ equity → high-quality person-centred care that benefits all

April 12, 2023 | www.wellesleyinstitute.com

Problem to Solve: Inequitable Quality

• from a resident participating in Wellesley community-based research in St James Town

“Language is a big barrier to us whenever we use any services. When our doctor is on leave then we are unable to visit a different one due to language problem. So we may have to go to a walk-in clinic or emergency. There were no interpreter services. I do not know if they arrange them in hospitals. I couldn’t follow what the doctor said.”

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Problem to Solve: Systemic Health Inequities in Ontario

•there is a clear gradient in health in which people with lower income, education or other indicators of social inequality and exclusion tend to have poorer health + major differences between women and men•the gap between the health of the best off and most disadvantaged can be huge – and damaging•impact and severity of these inequities can be concentrated in particular populations and neighbourhoods

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Key Messages• will set out key directions and levers for improving person-centred

care (PCC)• and illustrate with ideas, examples and lessons learned from both

operationalizing equity and PCC• will highlight that reforms geared to enhancing equity and person-

centred care are not just parallel, but vitally connected• both essential to achieving excellent care for all• also essential to identified Central LHIN priorities:

• appropriate = not just right care in right places, but to support particular people and populations, the way they need it

• access to what = services matching individual and community needs and situations

• person-centred care = for all, reflecting their different needs and diverse perspectives


Building Equity Into the Health System

1. building health equity into all health care planning and delivery• doesn’t mean all programs are all about equity• but all take equity into account in planning their services and outreach

2. aligning equity with system drivers and priorities• quality improvement, chronic disease prevention and management,

wait times• none of these directions can succeed without taking equity barriers,

social determinants of health and differential risks and needs into account

• aligning with key priorities also enhances chance for success and sustainability of equity focus

3. identifying those levers that will have the greatest impact on reducing health inequities and driving system change • e.g.. enhanced primary care

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Building Equity Into the Health System: II

4. embedding equity in provider organizations’ deliverables, incentives and performance management – in the incentives and pressures that really drive the system

5. targeting some resources or programs specifically:• looking for investments and interventions that will have the highest impact on

reducing health disparities or improving the health of most disadvantaged, fastest• key access barriers – language, culture, availability• addressing disadvantaged populations – poor, isolated, racialized, homeless

6. investing up-stream in health promotion and addressing the underlying determinants of health

7. enabling equity-focused innovation• a huge range of promising and innovative programs have been developed by

Community Health Centres, hospitals, networks and other providers to address the needs of disadvantaged communities.

• we need to share lessons learned, evaluate and identify what is working, and build on the enormous amount of local imagination and innovation going on

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Where to Start?

• can’t just be ‘experts’, planners or professionals who define issues and drive system transformation• have to build diverse voices and community needs into planning• not just as occasional community engagement, but to identify fundamental

needs and priorities→ need to start from patients + through an equity lens:

• not all patients are the same – diverse cultures, backgrounds and perspectives, and unequal social and economic conditions

• how to involve all types of patients?• specifically, how to involve and empower those not normally included→ means using innovative methods – e.g. principles of inclusion research

+ thinking also about the communities in which they live and the social determinants that shape their opportunities for health


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Align Equity and PCC With System Drivers: Quality Improvement

• person-centred care is a critical component of QI• health disadvantaged populations have more complex and

greater needs for services and support • good care and provider-patient relationship means taking this

full range of people’s needs/situations into account → customizing programs and service mix to meet greater needs→ similarly, customizing transitions and follow-up to more challenging

living conditions of more health disadvantaged populations• e.g. more intensive case management, referral planning and post-

discharge follow-up for health disadvantaged • good continuity of care, navigation and transitions for the most

vulnerable = human face of system integration


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Then Effectively Use Available Levers To Drive Change

• back to patients – what does quality mean to them? and to different populations?

• key mechanism for building that in = patient-based design• innovations from around the world• one of my favourites = to help redesign a clinic in Bristol hospital, they

used an adapted taxicab parked outside as place to video patient views• at a system level, providers have to develop Quality Improvement Plans,

starting with hospitals • equity should be one of dimensions providers must report on – but

wasn’t really in hospital plans so far = missed opportunity• similarly, need objectives and indicators for excellent PCC • depending upon populations, could include interpretation, cultural

competence, community engagement


One Example: Interpretation as a Key Quality and Equity Lever

• key things that worry healthcare EDs and CEOs:• delivering high-quality care efficiently• reducing risk and enhancing safety• meeting provincial priorities – wait times, re-admissions, ALCs

• access to interpretation underlies all of these system drivers – consistent evidence that:• poor communication between provider and patient due to language or cultural

barriers is certainly poorer experience for patients• can contribute to misdiagnoses and inappropriate prescriptions• inability to read or understand instructions can lead to medication errors → safety,

cost and re-admission implications• promising indications that good interpretation helps keep people out of hospital and

gets them out sooner

• requirement that adequate interpretation be available wherever needed → improves quality and equity

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Connecting the Dots and Driving Change: Building Interpretation Into Performance Management

• for providers to meet these requirements, they will need to:• know the language needs of the communities they serve• this is far more than just the languages of those who come to them for services• also need to know who is not coming in because of language and other barriers

= unmet need• and it doesn't mean just basic demographic data on languages spoken• it means what language people are most comfortable receiving care in

→ providers assessing community needs far better, and integrating that richer knowledge into their planning

• pre-condition = need to know language preferences and other social determinants characteristics of patients• project in Toronto Central to collect such data directly• as electronic health records are being developed, ensure equity and social

determinants data is built in

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Embed Person-Centred Care in Targets, Indicators and Measurement

• innovative work underway to develop equity indicators – but don’t need to wait for perfect

• build equity into existing targets:• reducing avoidable hospitalization and/or readmissions is key prov priority – and

clearly good for patients → equity target = reduce inequitable differences in rates between different

populations or areas• and the same for person-centred care:

• satisfaction is a widely used indicator of meeting patient needs and perspectives• make sure surveys capture full diversity of population -- e.g. NRC Picker survey

has been translated into several languages+ equity target = reduce differences in satisfaction by gender, social background,

neighbourhood, etc. • and to operationalize both

• closely monitor progress against the targets and indicators• link funding and resource allocation to performance on them• disseminate the results widely

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Never Just Equitable Access, But Quality:Customize Service Delivery

• in an increasingly diverse society, high quality care = culturally competent care:• requires organizational resources, training, commitment and

embedding into routine planning and performance management• improving PCC requires identifying and addressing specific equity

barriers • e.g.. inadequate interpretation can lead to poor quality, mis-

diagnoses, people not being able to follow medication, etc. →at worst, avoidable re-admissions and complications

• health disadvantaged populations have more complex and greater needs for services and support → continuum of care especially important

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Not Just Responsive Individual Care: Build Equity-Driven Service Models

• drill down to further specify needs and barriers:• health disadvantaged populations also face greater non-healthcare

barriers – e.g.. availability/cost of transportation, childcare, language, discrimination

→ facilitated access and effective navigation/transitions that address these wider barriers is especially important

• e.g.. Community Health Centre model of care• explicitly geared to supporting people from marginalized communities • comprehensive multi-disciplinary services covering full range of needs

• CHCs, public health and many community providers have established ‘peer health ambassadors’ to provide system navigation, outreach and health promotion services to communities facing particular barriers

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Embed Person-Centred Care and Equity Into Key Initiatives

• build local needs and perspectives, and equity as driving priority, into planning key issues

• e.g. primary care reform is major priority, so:• create a patient/community advisory forum to identify priorities• build equity into planning – e.g.. to identify local service gaps and

unmet need, to prioritize immigrant and other populations -- use HEIA

→ one target = ensuring access and use of primary health care does not vary inequitably by income level, immigration status, neigbourhood, gender, race, etc.

→ idea = concentrate new FHTs or other initiatives in particular high needs regions or neighbourhoods, or in particular populations such as immigrants or uninsured


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Equity-Focused Planning: Watch for Unintended Consequences

Could this program or direction have a differential and inequitable impact on some populations or communities?

How do we need to take the specific needs of disadvantaged individuals and communities into account in service planning/delivery?

Providers should be expected to apply this type of planning lens routinely

• if needed, then apply fuller Health Equity Impact Assessment


Always plan through a Health Equity Lens:

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Watch for Unintended Consequences: Patient Self-Management

• emerging idea in quality improvement and in healthcare thinking generally

• huge potential benefits:• builds on principle of patient empowerment• can be critical means of staying healthy in general and managing chronic

conditions• when working → keeps people well and out of acute care → system sustainability

and efficiency• but

• need to enable – info and other resources, mentoring, support• given systemic inequalities in health opportunities and resources – some are

going to need more support than others• need to also recognize barriers many will face – language, literacy, living

conditions• promising idea of peer health ambassadors again


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Health Promotion: Through an Equity and PCC Lens

• programs have to take account of inequitable resources of vulnerable individuals and communities• advice to manage heart problems by exercising depends upon

affording a gym or being close to safe park• adjust programs to inequitable risks and specific barriers

• South Asian immigrants had 3X and Caribbean and Latin American 2X risk of diabetes than immigrants from Western Europe or North America (Creatore et al CMAJ Aril 19, 2010)

• deliver in languages and cultures of particular population/community• go where people are -- e.g. health promoters into malls• idea = Immigrant Women's’ Health Centre and other vans

• if not customized, generic health promotion programs can widen disparities as better off take them up disproportionately


Extending That: Health Promotion Targets Through an Equity Lens

• not enough to just measure activity -- number or % of priority pop’n that participated in program• if health promotion program is geared to enabling more exercise or healthier eating

– then we measure that initial effect• need to also measure health outcomes – even when impact only shows up in long-

term• need to differentiate those with greatest need = who programs most need to support

and keep to have an impact• need to assess reach

• who isn’t signing up that needs support the most?• who stuck with program and what impact did it have on their health – and how did

this vary within the pop’n• then adapt financial incentives and accountability drivers

• develop weighting that recognizes more complex needs and challenges of most disadvantaged, and build this into incentive system

• remember with coming quality-based funding of bundles of care

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Embedding Patient Voice and Views at System Level

• need to ensure person and community-driven planning and priority setting• can draw on innovative methods of engagement in many countries – e.g..

citizens’ juries, health councils, -- required in UK• and from beyond healthcare -- citizens’ assemblies, participatory budgeting

• also effective mechanisms at provider level:• many hospitals have community advisory panels• CHCs and many community-based providers have residents on their boards • some forms of FHTs also have community governance

• into action by embedding in provider expectations:• providers determine most appropriate mechanism/forum for their context• but all need to institutionalize some form of direct community/patient forums


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Extending Equity-Driven Service → Address Roots of Health Inequities in Communities

• look beyond vulnerable individuals to the communities in which they live• have to take SDoH into account in planning and program design• given transportation, accessibility, cost and other barriers less

advantaged face, effective transitions and continuum of care are even more important

→ meeting full range of needs means moving beyond healthcare• focus on community development as part of mandate for many

PHUs and CHCs • providing and partnering to provide related services/support

such as settlement, language, child care, literacy, employment training, youth programs, etc.


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Potential of Hub Models

hub-style multi-service centres around the world and across the country• a range of health and employment, child care, language, literacy,

training and social services are provided out of single ‘one stop' locations

• can provide more ‘wrap-around’ integrated services from person’s point of view

• based solidly in local communities and responding to local needs and priorities → can become important community ‘space’ and support community capacity building

• from provider and funder points of view = more efficient use of scarce resources

• can enable synergies among providers and better overall coordination


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Showing Real Promise in Toronto

• emerging forms:• CHC hubs of primary care, health promotion and related social services• network of neighbourhood multi-service centres• schools with health and social services acting as hubs for their local

communities • getting specific in NW Toronto – what if the old hospital site could become a hub?

• expanded Community Health Centre• Family Health Team• midwifery and birthing centre• health promotion and other public health support• settlement, social service and other community agencies• training and employment support• childcare• recreation and meeting place


Acting on Social Determinants of Health: Local Cross-Sectoral Planning

• cross-sectoral coordination and planning are key means to address wider SDoH at community level:• public health departments and LHINs are pulling together

or participating in cross-sectoral planning tables• Local Immigration Partnerships, Social Planning Councils• such broad collaborations will be particularly important to

Health Links initiative• and such collaborations are particularly important in less

advantaged communities with less resources• building on local resources and networks• idea = explicit SDoH/equity planning networks such as

SETo in Toronto• and here = NW Toronto network that put together

community health fair last month

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Look Widely for Community Innovation

MiVIA (my Way) • personal electronic health record originally developed for mostly Hispanic

seasonal farm workers in California – and then extended to other vulnerable populations

• used in networks of free clinics• supports continuity and efficiency – highlighting the potential of eHealth for

even the most marginalized• the web-based portal and records are in Spanish as well → helping to reduce

language barriers• a vital element of success has been ‘promotores’ --community/peer health

promoters – who recruit people into the program, train them on the tools and support them in their own health management

in Toronto, CAISI• integrated database for homeless people• used by hospitals, shelters, community service providers

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Pulling it All Together: Acting on Patient and Community Priorities

• build significant community participation and influence into priority setting• Health Council underway• build on insights from other countries – idea of participatory planning

• research and policy resources is provided to give participants all the information they need

• they make recommendations on promising initiatives and allocation of resources

• have also proven able to address tricky trade-off issues• make this real = allocate a % of budget to priorities or initiatives identified by

Council or other means of engagement• idea = develop sub-regional local health plans

• e.g. in NW Toronto, especially to proactively get ready for hospital moving• build on local potential – enormous provider commitment, grass-roots

innovation and strong community organizations


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Person-Centred Care, Equity and Other Building Blocks For Excellent Care For All