3 Steps to Addressing Socioeconomic Barriers to Achieve Better Outcomes

Meet Sonia: she’s an 86-year-old woman born in Poland, who has outlived her husband, suffers from depression and diabetes and has just been discharged from hospital following surgery. She’s unable to afford the medication prescribed to her and has few family members or friends around to help her safely travel to a neighbourhood clinic and receive the proper follow-up care.

Sonia represents the dilemma many Ontario seniors will face in the coming years. We know that by 2030, 70 per cent of Ontario seniors will be living with two or more chronic conditions, similar to Sonia. What we don’t know is how many seniors like Sonia are being disadvantaged because of their socioeconomic living conditions. The fact that she has trouble communicating in English, that she has a small support network, and that she lives on a small income means she’s more likely to experience poorer health outcomes than individuals without these types of variables.

Addressing Socioeconomic Barriers

I believe that too few health organizations consider the added dimension of socioeconomic living conditions. Under tremendous pressures, teams work diligently to treat episodes of illness but often neglect important socioeconomic factors. When we are blind to these issues, we negatively affect the plan of care and the health outcomes patients strive to achieve.

1. Know your patients’ complete story and the neighborhood in which they live

Providing quality health care is no longer about simply shortening patients’ length of stay in hospital and getting them home as quickly as possible. Nor is it simply about caring for patients’ clinical needs. Only by tailoring care models in all care settings to specific populations, can we really meet the needs of individuals like Sonia.

The CCAC’s Community Capacity Plan, developed in collaboration with the Mississauga Halton LHIN, Central West LHIN and Central West CCAC, revealed that the care coordination we provide should be tailored to individuals based on: their diagnosis, the neighbourhood in which they live and other social determinants of health – those social and economic factors, including education level, income, race, gender, sexual orientation and place of residence, which influence health and wellbeing.

If we don’t address social determinants of health and the contributing factors in each patient’s situation, we’re putting people like Sonia at higher risk of health complications, poorer quality of life, hospital admissions and readmissions and avoidable emergency department visits.

The evidence supports this. Data from the Mississauga Halton Community Capacity Plan found that seniors from the highest-risk Socio-Economic and Cultural (SEC) group were more likely to move to institutional care, or long-term care, than those from low SEC groups. They were also 40 per cent more likely to visit hospital emergency departments than individuals with low SEC status.

These at-risk patients can’t afford to follow health care direction without the necessary resources. If their income is used to support five family members, or if they live at home with a small support network like Sonia, priorities are more likely to focus on paying rent and purchasing food than on filling prescriptions or paying for transportation to a health clinic, for example.

In fact, a Health Quality Ontario report found that one in 12 Ontarians surveyed, aged 55 years and older, didn’t fill their prescriptions or skipped a dose because of cost, while another study found that one in eight Canadians between 55 and 64 years old will occasionally skip prescription medications for the same reasons. If we know patients can’t afford their medications, we should certainly be approaching their care differently.

As I mentioned in my first post, “5 Features of a Sustainable, Integrated Health Care System,” bringing care out of institutions and closer to patients’ homes lets us tackle socioeconomic obstacles. By asking the right questions in all care settings, we can move beyond clinical diagnoses, to having meaningful conversations with patients, engaging their families, and providing more comprehensive support services at home, in the community and in hospital.

2. Identify individual and systemic barriers that create inequities

After implementing the CCAC’s Care Coordination Program of Work – a recommendation from the Community Capacity Plan – we saw the realignment of care coordination teams and service providers within the Mississauga Halton region. We identified 26 neighbourhoods of roughly 10 square kilometres each, as relevant for organizing care delivery in the community setting.

We now have teams who will really know the gaps that exist, which will allow them to better provide comprehensive care in neighbourhoods in which their patients live. For example, high utilization of certain services in a region helps us uncover the specific challenges the population in the area faces. Teams can proactively consider not only the clinical care needs but the supports required to address the SEC issues that impact a patient’s care plan.

The questions now are, how can we overcome the challenges of involving family physicians, pharmacists, nurses, hospital physicians, and others in the continuum of care, so that we can collectively wrap care around individuals more effectively and efficiently? How do we create high-performing care teams across the diversity of the independent programs and services that are available in the community?

Dr. Kwame McKenzie, Medical Director of Underserved Populations at the Centre for Addictions and Mental Health (CAMH), led an initiative to identify ways in which we can improve health equity in the country. He helped develop the following eight questions that health care professionals can ask their patients during the assessment process, which would then be shared with other health professionals:

  1. What language would you feel most comfortable speaking in with your health care provider?
  2. Were you born in Canada? (If no, what year did you arrive?)
  3. Which of the following best describes your racial or ethnic group? (list provided)
  4. Do you have any of the following disabilities? (list provided)
  5. What is your gender?
  6. What is your sexual orientation?
  7. What was your total family income before taxes last year?
  8. How many people does this income support?

These are questions that we don’t traditionally think about asking. They can be asked once by any health care professional conducting a patient’s initial assessment – either a family doctor, hospital discharge planner, nurse or care coordinator. The value of asking these questions is that health care professionals are able to have patients’ socioeconomic information at their fingertips. When they meet with patients for the first time, they will have a deeper understanding of their needs and the kinds of individualized questions to ask, to build an effective care plan that will enable patients achieve their health goals.

By acting on this data, we’re better equipped to reduce unnecessary hospital and emergency department visits and entry to long-term care. We’re also able to identify trends with patients over time, to understand risks to certain populations in the region, and to connect patients with the appropriate services in their neighbourhood.

Some organizations have begun collecting data on patients’ socioeconomic situations using these eight questions. Now we need to find a way to consolidate and share this information with everyone involved in a person’s care. As of today, we don’t have the means to share SEC scores at a patient level. Even though care providers may understand the importance of SEC status, when information isn’t shared, we see ourselves entering into the familiar cycle of asking patients to repeat their story over and over again.

The CCAC will continue using equity data collection to inform the delivery of quality care through its Care Coordination Program of Work, to ensure that care is wrapped around the patient at the neighbourhood level. Through our Client Health and Related Information System (CHRIS), we have the means to link with other systems and to share this information with those in the patient’s circle of care. Being able to share information effectively is one of the characteristics of high performing, patient-driven health systems, and leads to my third step to addressing socioeconomic barriers: effective collaboration

3. Bringing together clinical and social determinants of health through collaboration

Hospital physicians, clinicians, nurses, family physicians, care coordinators and others in the continuum of care must collaborate to help patients achieve what is most important to their wellbeing. Frankly, our patients expect this of their care team. We need to bring clinical and social determinants of health together.

By asking Sonia questions related to her socioeconomic status, we would know she feels more comfortable speaking Polish, that she is still mourning the loss of her husband, which led to her depression, that poor eating habits contributed to her type 2 diabetes and that she has a very small support system at home – issues that cannot be addressed through medication alone, but also through lifestyle changes, volunteer programs and other non-clinical supports.

Creating effective, accountable inter-professional teams through strong relationships with everybody in a patients’ circle of care is a must. As I mentioned in my previous post, “4 Ways Big Data Informs and Manages Health Care Performance,” we need an integrated system focused on system planning and patient-driven care delivery operations to ensure that individuals with the greatest needs receive comprehensive, individualized care. This includes supporting care coordination, monitoring quality, patient outcomes and their experiences and service providers’ resource use.

Standardizing clinical care pathways – management plans that display goals for patients – are a great move forward to improving clinical care outcomes for Ontario residents. Knowing SEC information, which allows us to wrap necessary supports around patients to help them achieve expected outcomes, is necessary for the individualization of care plans.

In my next post, I’ll delve a little deeper into the importance of collaboration and the ways in which it can expand health care capacity.

What do you think? Are you collecting SEC data? How is it helping you provide more effective care?  

4 Ways Big Data Informs and Manages Health Care Performance

Big data for health

computer code with images of patients and care coordinators on top. In my first post, I outlined five features of the patient-focused integrated health care system that I envisioned. The third feature is a system that: stays informed and measured by evidence from our patients and their families’ voices, as well as data drawn from assessments and social, economic and cultural (SEC) tools, among others.  This post focuses on part of this feature: the value of big data in health care performance.

Today, physicians, therapists, nurses and other clinical experts each use different tools to assess patients’ needs and record pertinent information to manage their care. The clinical expert learns about each patient, their past, current conditions and needs but once a patient  moves from one setting, like a family physician’s office, to another, like a hospital, the process usually repeats. Time is lost to redundant questions and similar assessments, while some details remain a mystery, known only to one setting’s care providers.

In the home and community care sector, we securely share our assessments, plus other data, within and across our CCACs to uncover evidence-based insights that inform and manage our patient care decisions. And when a hospital discharges a patient to a CCAC, which coordinates care with their service provider, the patient’s information follows them. But these scenarios are the exceptions. CCAC also coordinates care with other organizations in the patient’s neighborhood but the ability to appropriately  share that information in real time is currently not a standard.

For patients like Yasmin, a frail senior admitted to the emergency department with a broken leg, the clock ticks while her frantic husband recalls her medical history. Tests are run to assess her bone density, anesthetic threshold and other details her family physician already has on file. Meanwhile the backlog of aging patients with urgent needs builds.

To meet the needs of a rapidly growing older population with multiple or complex care requirements, there’s a rising imperative for more integrated systems. We need to access data from clinical experts across the continuum of care to see a complete picture of each patient, learn about the broader population’s needs and identify system opportunities to improve people’s experiences.

Organizations are working to eliminate redundancies by creating one electronic health record (EHR) for each patient, which is shared and understood across the continuum of care, but much needs to be done.

At the Canadian Home Care Association’s 2015 summit, I heard about Belgium’s work as one of the first countries to share a single assessment record per patient between multidisciplinary clinical experts and across various care settings. Dr. Anja Declercqu outlined how BelRAI, its evidence-based assessment solution, enables home care organizations, hospitals and long-term care homes to securely exchange patient data with each other. She also cited challenges, as health partners were still learning to trust each other’s assessments, but their progress was impressive.

If Yasmin lived in Belgium, all clinical experts would quickly know her history and conditions, as she moved between care settings to have her fracture set and safely return home to heal – faster and at less cost.

With a more integrated system, we will be able collaborate and coordinate our patients’ care with other members of their care team. Working together, will also deepen everybody’s understanding about the unique contributions each sector brings to the continuum of care and foster conversations about what needs to improve.

We are moving closer to this ideal in Ontario and can increasingly use big data to:

1. Address each patient’s needs –

Care coordination begins with thoroughly assessing each CCAC patient’s health care and social needs, as well as learning about their goals. Our care coordinators combine this assessment data with their clinical expertise to inform decisions around a care plan that will best meet their patients’ needs. Ontario’s CCACs are gradually adopting InterRAI, an international version of Belgium’s BelRAI assessment solution, recognized worldwide for supporting best practice patient care. It will empower our frontline teams to develop more personalized evidence-based care plans, centred on each patient’s experiences and goals.  And in a patient-focused, integrated system, a patient’s single, electronic health record will follow them, as they move between care settings, versus multiple records across the continuum of care.

2. Understand neighbourhood level needs –

Data also helps us understand the patient populations our organizations serve. It shows us people often live near those who are like them and may think, work and even approach their health care in similar ways.  Through our Community Capacity Plan study, we learned that a community care organization delivers better patient outcomes if they are familiar with the neighbourhoods where their patients live and receive their care. Our Care Coordinators need to know their local supports to an in-depth degree so they can develop a sustainable care plan aligned with their patient’s neighbourhood.

Knowing this, we developed Socioeconomic and Cultural (SEC) tools to help us understand a population or neighbourhood through data, such as income levels, average persons per dwelling and the percentage of dwellings owned, versus rented. For example, this data shows us that patients in a neighbourhood with a high SEC, are 40 per cent more likely to visit the emergency department, than those in other areas with a low SEC.

Viewed together with other population health information, these data points build a picture of a neighbourhood’s needs. These insights inform current home and community care services, including those to address a patient’s social determinants of health, as well as their clinical needs.

This data helps identify areas where services are inequitably distributed and is invaluable to long-term health system planning. When we plan neighbourhood clusters or community service hubs of services, there’s no need to arbitrarily put a pharmacy here or a chiropractor there. We can drive these decisions by evidence-based patient population needs, which we know, right down to the postal code level.

3. Coordinate care across the province –

I wonder if many realize that CCACs have an electronic health record for every patient they serve.  Our Ontario-wide Client Health and Related Information System (CHRIS) was developed by our provincial organization and CCACs. We rely on this web-based system to manage all aspects of each patient’s care, along with reporting and finances.

eHealth Ontario used CHRIS as a core part of its ConnectingGTA solution for CCACs and hospitals across the megacity to securely share electronic health information about its residents.

We’re now looking for ways to extend CHRIS access to other partners in the system. Then, it could take us beyond neighbourhoods to uncover regional trends and identify barriers that may be limiting patient outcomes.

4. Monitor and optimize resources –

Data doesn’t just inform patient care decisions, it can also manage ongoing performance. To help our teams decipher the data they need to manage all aspects of each patient’s care in real time, we developed ‘Insights.’ 

On a personal level, this interactive dashboard enables care coordinators to measure their own performance against consistent guidelines for exceptional care.

From a broader organizational perspective, clinical managers can use this tool to track resource use, patient outcomes and performance to identify issues or best practices. But why stop here? Insights can be adapted and its scope expanded to oversee performance in other care settings for an integrated people-focused system.

Our community capacity plan showed us one of our biggest opportunities lies in leveraging our current resources to build capacity, including the people, technology and processes that define how we use data.

In 2013, we looked at data across all care settings to build a comprehensive picture of our community’s needs in the next 10 to 20 years, particularly within the borders of our Health Link neighbourhoods. We saw how hospital, long-term care, community support services and CCACs currently use resources and we identified opportunities for improvement. And we used modeling to project what optimizing those resources would look like, if we had no new money to where we should invest to create the best outcomes for our patients, when resources are available.

If our health partners effectively leverage our assets, we have a shot at reaching Belgium’s ideal and optimizing our ability to care for people across Ontario.

With its Patients First legislation, the Ontario Ministry of Health and Long-term Care intends to establish sub-regions (LHIN sub-regions) within local health systems to plan performance improvement and more equitably integrate services at a community level.

Our CCAC has been moving in this direction for some time, re-aligning our care coordinators and contracted service providers around neighbourhoods that are similar to LHIN sub-regions. This model offers several benefits. Among others, these include addressing socioeconomic impacts and inequities, which I’ll discuss in my next post.

What do you think? Are there other ways we can leverage big data to improve patient outcomes and experiences?

3 Hurdles to Dodge in the Patients First Marathon

Patients First Hurdles

Runners' hurdle with Patients First report cover on top.In my last post, I discussed three goals Ontario’s Patients First legislation can potentially realize, if health care leaders effectively leverage Community Care Access Centre (CCAC) assets (people, processes and technology), as well as other organizations’ assets.

On the flipside, I believe health care leaders need to dodge the following risks when implementing Patients First:

1. Working in Silos without a Shared Understanding of Vital Design Principles

We need to work collaboratively, with a shared understanding of the design principles that are essential to a high-functioning, sustainable system.

As I outlined in my last post, we have an opportunity to build stronger connections between primary care providers and community resources. This means designing a system that enables everyone in the circle of care to easily engage with each other in the course of patient care.  For this to succeed, all parts of the system must optimize resources and work collaboratively.  It is contemplated that the LHIN sub-regions will enable this collaboration and integration.

Implementing Health Link helped many patients with complex needs but it also put us precariously close to creating parallel systems to care for those patients. Once this challenge was recognized, changes were made to streamline care and use resources in a more sustainable manner.

This time, as we think about LHIN sub-regions we have an opportunity to step back and identify the shared system design principles that need to be in place, before we move forward.

2. Paying Scant Attention to CCACs’ Proven Culture and Leadership

There’s a risk that in integrating CCACs into the LHINs, health care leaders may pay insufficient attention to proven aspects of the existing home and community care’s culture and leadership. While not perfect, we know that to deliver care in the community, enter people’s homes, work with a diverse, virtually connected workforce and their supports, a unique culture is required. This culture is led by a dual focus on system planning and care delivery operations, which include supporting care coordination, monitoring quality, patient outcomes and service providers’ resource use to ensure those with the greatest need, receive care.

Conversely, LHINs currently require a different type of culture and leadership to meet different mandates, which exclude patient care.

Effectively integrating each organization’s culture and leadership is a huge challenge. CCAC assets (people, process and technology) will be under-leveraged if this part of the expanded LHIN’s mandate receives minimal attention. Focusing on system planning at the expense of leading care delivery, could also mean that one or thousands of patients stay in hospital longer than needed, due to oversight shortfalls. This is far from ideal when systems are constrained.

Understanding the magnitude of the responsibility they are taking on, LHIN board members raised early concerns about potential conflicts for new boards as they communicate their focus after integration. Boards will need support to pay significant attention to their care delivery operations to ensure they set high standards for care quality and oversight.

3. Assuming an Easy, One-Day Transition and Disrupting Vital Processes

Some people may assume integrating two distinct organizations is an easy process with an immediate transformation point, where teams cross over to a new governance structure with new projects. In doing so, they could put the opportunity to leverage existing CCAC assets and progress in peril.

Patients First impacts the expert implementation skills and other strengths within the current CCAC system. These skills include a solid understanding of the current home and community care system and service providers’ performance, plus the leadership to ensure patients/caregivers have quality experiences. It also has the potential to disrupt the support systems developed to manage care in homes and a virtual workforce.  These systems must be adeptly integrated as part of a long-term marathon, not a sprint. This work currently underway in the CCACs includes many strategies that are planned or in motion to continuously improve home care delivery.

There is a significant risk that through integration we will disrupt current culture, process, teams and technology without understanding their value in effectively reorganizing around the LHIN sub-regions. Current initiatives need to be recognized and supported post-integration day to maintain positive traction. It’s critical how attention to that work is prioritized, pre and post-integration.

Fortunately, the MOHLTC has enabled LHIN boards to expand from nine to twelve and has been explicit in requiring directors from CCAC boards to be given consideration. Having this voice of CCAC governance engaged in LHIN planning will help mitigate this risk to patient care disruption but there is an urgency to expand these boards sooner than later.

As with a marathon, we are in the warm up phase. If LHIN boards are expected to plan now for the post-integration transformation agenda, the voice of CCAC governance and leadership at the local level should be reflected in that planning. Ideally, LHINs and CCACs should share and have a continuity plan in place for moving the collective agenda forward post-integration, with ongoing support for strategic home care work in progress.

Patients First is a marathon with a long-term agenda. Ahead of the starting line, it needs CEOs and governance to establish the culture necessary to succeed. This culture requires full engagement of primary care, home and community care, hospitals, LHINs, public health and others to propel it.

My team is ready to move forward toward the long-term goal of a more sustainable, integrated health care system that puts patients at the forefront. Are you?

What do you think? Are there points you’d like to add?  Please share your comments at the bottom of this post.

3 Aspirational Milestones in the Patients First Marathon

Patients First Marathon

Baton with Patients First written on it being passed from one runner's hand to anothers.Change is necessary for sustained and progressive success but it is rarely simple or easy. Such is the case with Patients First, new legislation that the Ontario government’s Ministry of Health and Long-Term Care (MOHLTC) first proposed on December 17, 2015 to improve the accessibility, integration and consistency of patient care across the province. This proposal has since progressed to Bill 41, the Patients First Act, which passed second reading on October 27, 2016. A key part of this legislation calls for integrating Ontario’s 14 Community Care Access Centres (CCACs) into their corresponding Local Health Integration Networks (LHINs).

Since its introduction, Patients First’s proposed design has and continues to evolve. The due diligence to advance this change is also shaping it by shining a light on high performing parts of the current system.

A noteworthy shift is the new context the MOHLTC placed around reintroduction of the legislation. Essentially, the narrative about CCACs has changed to be one about building on the strength of the current home and community care sector. Minister Eric Hoskins has said on numerous occasions: “This is not about fixing a broken system but leveraging the assets within the CCACs for the broader good.”

These assets include people, processes and technology. On the people side, initial integration talks cited the need to have CCAC care coordinators in hospitals and physicians’ offices as a key goal. Digging deeper, many learned that care coordinators have been working in hospitals and connected to physicians’ offices for years. In fact, this practice made it possible for care coordinators to help 210,000 Ontarians transition from hospital to home with a warm hand-off in 2015/16. We all know now this practice is working.

Instead, we need to focus on how to effectively optimize the relationships between care coordinators and so many parts of the system, such as primary care, acute care, working with home care providers, community resources and in patients’ homes. In my first post, Sam’s story demonstrates how our care coordinators use these relationships to help patients, even those with complex health and socioeconomic needs, to stay out of hospital.

The new system can also leverage process and technology assets. The MOHLTC is seeking a dashboard with readily accessible information to help it assess how the home and community care system is functioning, both pre and post-integration. There is now clear recognition that all CCACs use a dashboard, of various levels of sophistication, to provide oversight and inform decisions. Our care coordinators use Insights, an interactive dashboard, for multiple purposes, from planning patient visits to measuring their outcomes. The Ministry can adopt and adapt an existing CCAC dashboard.

This expanded understanding of the capacity to apply CCAC’s, as well as other’s assets, to the system’s greater transformation, opens opportunities for us to achieve several aspirational milestones or goals that put patients first. Here are three goals Patients First can realize, if health care leaders effectively leverage these assets:

Aspirational Milestones or Goals

1. More Engaged Primary Care Providers to Help Patients Achieve their Goals

A great benefit we can realize is having a system that makes it easier for primary care providers (including physicians, nurse practitioners and physician assistants) to interact with the broader community of support services that help patients achieve their goals.  This includes creating stronger connections between primary care and community resources that address a patient’s socioeconomic or cultural needs, as well as publicly funded services.

Through our care coordinators’ experiences, we know how crucially important primary care involvement is to ensure our patients have the best outcomes but it’s not easy for these providers to interact with our current, intricate community care system with its multiple access points.

Patients First legislation contemplates better understanding, planning and support for primary care and a future with expanded roles to complement their practice. These roles will involve primary care providers more closely in the planning for home and community care at the regional, neighborhood and patient level.  For example, this means that a family doctor will know that patients like Yasmin, a single, Urdu-speaking senior, who suffers from depression and diabetes, are connected with a local cultural or faith-based group, as well as home and community services.

2. Inserting the Voice of the Patient and Caregiver in Planning

The new Act sets a requirement for each LHIN to have a Patient and Family Advisory Committee to support community engagement. This offers the potential for LHINs to have and use a greater line of sight about what’s important to patients and families in their day-to-day planning.

All CCACs have experience with patient engagement strategies, and can bring that knowledge of how to involve patients and families into the LHIN’s planning work.

In 2014, we established Share Care Council – a highly structured and successful patient and caregiver advisory forum. It includes 15 patients, substitute decision-makers and family members, who volunteer their time to provide input into new programs and services. Share Care Council applies a carefully defined approach that authentically engages patients and caregivers to elicit their valuable input.

What’s eye opening is Share Care Council members’ responses to questions about how our programs can best meet their needs. We don’t hear “We need more personal support workers (PSWs) or more nursing care.” Instead, they tell us about their care experience, how it made them feel and how our system design can do better. It is less about the technical elements of care and more about the soft touches, social interaction and how these services are delivered that make the difference. For patients like Hilda, it’s having a PSW who knows how to braid her hair and set her up in the chair by the window when she leaves.

Through this requirement, the expanded LHINs can discover that when you carefully engage with patients and families on your journey of continuous quality improvement, their experience can drive development of meaningful programs and changes to care.

3. Organizing Home and Community Care around LHIN Sub-regions

A third advantage is the legislation’s shift to organizing delivery of home and community care around a LHIN sub-region, with consistent, service providers.

Our capacity plan research told us that people’s social, cultural and economic status often varies significantly between our neighbourhoods. So having care providers who are familiar with their patients’ neighborhood and its existing support resources (provincially funded and others) helps ensure successful home and community care delivery.

We also know that having a minimum number of consistent service providers who interact with our teams and patients/families builds strong relationships. Furthermore, this approach helps create high performing teams, whether virtual or in-person, in each patient’s circle of care.

With a goal of being able to identify local resources, numerous CCACs have begun reorganizing their care coordination and service provider teams around these LHIN sub-regions.

In our region, we’ve reorganized patient care around neighborhoods, so that patients, like Betty and Patty, can receive the services they need from consistent providers, who know their community and are located near their home. Organizing services around LHIN sub-regions or neighbourhoods gives service providers a greater connection with the communities where they deliver care.

I believe there’s much to be gained through LHIN sub-region planning but it’s complex work and should be viewed as part of a long-term vision or marathon.

On the flipside, implementing Patients First also poses risks, which I believe health care leaders need to dodge. I will outline three of these risks in my next post.

What do you think? Are there opportunities I’ve missed or points you’d like to add? Please share your comments at the bottom of this post.

5 Features of a Sustainable, Integrated Health Care System

Image of glass lens looking at health care team, from patient's perspective.
“We need to build an integrated health care system from the patient’s perspective outward.”

Many thoughtful leaders have taken strides toward creating a sustainable, patient-centred, integrated health care system but we’re not there yet.  Our patients, their families and evidence tell us there are opportunities for improvement. Through our front-line experience caring for 11,600 patients each day, we also know that to deliver quality home care, we need an integrated system that wraps care around the patient.

As in any sector, sustainable success is rooted in engaged teams effectively connected first through a common goal.  Health care is no different. As many leaders agree, form must follow function.

When I arrived to lead the Mississauga Halton Community Care Access Centre (CCAC) six years ago, this meant re-building a siloed organization. We fostered interdependent teams by connecting them with shared, measurable goals and a united vision. For Ontario’s health care system today, this means building an integrated system of care from the patient’s perspective outward.

If we start with structure, it is like planning a house without a location. You could well design a house that’s set to fall or flood, if you don’t know it’s going to be built on a cliff or levee. It’s also precarious to plan without full context in a fluctuating environment like ours, with its aging population and continual changes to support their rising needs, from funding reforms to new providers and evolving technologies.

To see the patient’s perspective, we need to step back and ask: ‘Why’ does the current system fall short of delivering an experience that consistently meets or exceeds expectations? Why is it not consistently responsive to patients’ and their families’ needs?

Using Home & Community Care to Overcome Obstacles

When I worked for more than 18 years in acute care, we knew that engaged and cohesive teams generated better outcomes for most patient populations.  We worked hard to involve physicians right up to the discharge door but that’s where our care ended.  To make way for those with time-sensitive, urgent needs, we discharged patients once they no longer required acute level care but sometimes before their post-discharge care was in place.

Then hospitals began to change how they delivered care and began moving alternate level care (ALC) patients to places better able to meet their needs.  Leaders saw community as an enabler to support this transformation and achieve their hospital’s goals. We also started to understand that patients and families wanted to remain at home and out of institutional care, as much as possible.

However, we had a blind spot to the role and impact of primary care physicians, nurses, allied health professionals, community service agencies and others in the continuum of care but beyond the hospital’s walls. We also had yet to realize the vital role of caregivers and families. Community was a disparate anchor. People moved back and forth between community and acute care, often multiple times a year.

Challenges in delivering consistent care experiences for our patients increased as the number of aging patients, with chronic and complex needs, rose. Without comprehensive capacity and program planning, our blind spot included socio-economic or cultural status obstacles that stopped patients from reaching their goals. It’s hard to heal when you can’t afford medication or have no means to safely travel to a clinic. Subsequently, a short hospital stay with an early discharge is detrimental when a patient returns less than 30 days later. Patients expect and deserve better outcomes.

In bringing care out of institutions and closer to patients’ homes, we shed light on these obstacles. Through meaningful conversations and assessment tools, home and community care went beyond clinical needs to identify social determinants of health that affect our patients’ care experience. We started to address these challenges through care coordination, which significantly reduces patients’ health risks, among other benefits. We also engaged families and set-up patients’ support services before they left hospital.

For Sam, a 66-year-old, frequent emergency department (ED) patient, who suffered from COPD, alcoholism, diabetes, hearing loss and depression, plus fear of eviction from a derelict apartment – healing was secondary. By the time Sam’s family physician referred him to CCAC, he was malnourished and in a desperate state. Our care coordinator had to first get him an accessible phone, re-channel his OPGT funds to pay his bills and fix his fridge. Once she addressed these necessities, she could set up medication management and coordinate his care plan.

Health care resources alone can’t meet all patient needs. Patients, like Sam, often need multiple partners at the community level, such as mental health and addiction services, volunteer or cultural groups, to play a complementary role in helping them reach their goals.  The challenge is our system’s design is incomplete. We have not intentionally designed a community care system to meet the needs of aging residents with complex needs. It doesn’t optimize the value of community-based services or integrate them to improve patient outcomes. In a more cohesive system, health care and community partners might have closely monitored Sam’s condition and alerted CCAC sooner. It might have also co-located services together, such as placing on site showers with personal support workers (PSWs) at Adult Day programs, with counselling nearby, to help patients like Sam achieve their goals.

Seeking solutions, we collaborated with the Mississauga Halton LHIN, Central West LHIN and Central West CCAC to develop a Community Capacity Plan in 2013. For this study, we contracted specialized health care consult support to assess our region’s health service needs now and the growing, future mandate. Results highlighted the importance of using patient assessments and information across the continuum of care to support population-based planning. These include Socio-Economic and Cultural (SEC) tools that can identify a neighbourhood’s needs, right down to those shared by people within the same postal code level or uncover areas where services are inequitably distributed.

The study’s findings also underscored the value that our current resources and best practices bring to our local system.

But to meet our residents’ expectations, we must resist the temptation to assess patient needs only through our lens. To design the system, we need to bring together data brought by clinical teams with patients’ and families’ expectations and goals.

That’s why our strategic plan is centred on understanding the patient’s voice. We need to listen and let it inform how we modernize the system or mobilize existing resources. By engaging our patients, through varied approaches, including our patient and caregiver advisory forum, we’re hearing about their needs.

Armed with insights from our patients and with our assets, we’ve lived a glimpse of this integrated vision through our seamless transitions: hospital to home approach. It reduced hospital readmissions in the first 30 days by 52 per cent in the pilot with Trillium Health Partners’ Medicine units and opened an opportunity to reduce ALC rates. In another example, we’re making great strides with Health Link. Through this provincial initiative, we’ve reduced the number of times patients with the highest needs visit the ED.

These programs prove that individual organizations, like our CCAC, can improve patient outcomes but not in silos.

Through this evolution of home and community care, our research and proven programs, I can envision a patient-focused, integrated health care system that:

  1. Seamlessly works with multiple partners to identify and address socioeconomic impacts on neighbourhoods and their patients.
  2. Recognizes care coordination as an essential health service for patients and supports its ongoing professional development to ensure consistent quality of care.
  3. Stays informed and measured by evidence from our patients and their families’ voices, as well as data drawn from assessments and SEC tools, among others.
  4. Collaboratively delivers care for patients at multiple levels, from patient and care coordinator partnerships to multidisciplinary partners, in acute, primary and long-term care, as well as mental health and addictions and community services.
  5. Provides ongoing monitoring and adapts to patients and their caregivers’ changing needs.

In future posts, I will discuss these features in more detail, with global examples, as well as our tools, ongoing initiatives and results.

I believe we can collaborate virtually with our multidisciplinary and community partners to deliver comprehensive, dynamic care that reflects each patient’s current goals, journey and experience. This also means making each partner individually and collectively accountable for our patients’ well-being.

I welcome your thoughts and feedback.