Achieving real care co-ordination:
Lessons from Canada
MARGARET MACADAM, PH.D.
THE KING’S FUND
OCTOBER 24 2013
Integration: Why do we care?
2

 All modern health systems have similar problems:







Imbalance between care and c...
Why we care
3

 Integrated care is seen as a initiative to increase patient

satisfaction, quality of care and, possibly,...
The Canadian context
4

 Canada is a confederation with the mandate for health and

social care devolved to the 10 provin...
Canadian continuing care health policy
5

 The 2004 Health Accord between the federal government

and the provinces incre...
Policy results
6

 Since 2004, there has been a significant reduction in

home care services for those who need supportiv...
Today’s situation
7

 All provinces recognise the need to improve patient care

experience, quality and availability of s...
Integrated care in Canada
8

 There is no one definition of integrated care used by

provincial Ministries of Health.
 T...
Clinical features of integration
9

 Targeted admission criteria
 Case managed team approach

 Access to a wide range o...
Infrastructure features
10

 Shared clinical and administrative information systems
 Financial incentives to change beha...
Canada and Quebec
11
PRISMA: Program of Research to Integrate Services
for the Maintenance of Autonomy
12

PRISMA focused on integrating health...
PRISMA results
13



By year 3, the rate of implementation of all of the key
features of the model approached 80%. Physic...
Results
14

 There was no statistically significant effect on rates of

nursing home placement, consultations with health...
Patient flow in the PRISMA Model
15
Success factors
16

Unusual level of collaboration
A partnership among university researchers, the provincial
government, ...
Other success factors
17

 PRISMA was never seen as a demonstration project but

rather as a whole system change in care ...
The situation today
18

 When the PRISMA model was adopted by the Ministry of

Health, each region was granted flexibilit...
Provincial progress in implementing the model
19

Feature
Appointment of a person
responsible for
implementation
Assessmen...
Ongoing issues
20

 Physician remuneration
 Most primary care physicians in Quebec are paid on a fee-for service
basis w...
Last thoughts
21

 Because of the scope of change, especially among clinical

and organisation providers, it is very impo...
22

Thank you very much for your attention!
Margaret MacAdam, Ph.D.
m.macadam@utoronto.ca
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Margaret MacAdam: Achieving real care co-ordination - lessons from Canada

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Margaret MacAdam, Associate Professor at the University of Toronto, gives a background to integrated care in Canada, and explains how the PRISMA integrated service delivery model has helped to improve the health, empowerment, and satisfaction of frail older people in the community.

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Margaret MacAdam: Achieving real care co-ordination - lessons from Canada

  1. 1. Achieving real care co-ordination: Lessons from Canada MARGARET MACADAM, PH.D. THE KING’S FUND OCTOBER 24 2013
  2. 2. Integration: Why do we care? 2  All modern health systems have similar problems:     Imbalance between care and cure Fragmented financing, regulations and inadequate coverage of LTC Poor collaboration at organisational and provider levels, and between acute and LTC Increasing numbers of patients with complex chronic conditions
  3. 3. Why we care 3  Integrated care is seen as a initiative to increase patient satisfaction, quality of care and, possibly, to contain costs.  Promising results have been found in a small but slowly growing number of evaluated demonstration programs.
  4. 4. The Canadian context 4  Canada is a confederation with the mandate for health and social care devolved to the 10 provinces.  The Canada Health Act provides a single payer system for hospital and physician care only. There is no option for private coverage of these services.  Home, community and residential LTC care is provided by provincial funding, based on need. There is no means testing in any province.  All other health services such as pharmaceutical care, equipment and supplies etc, are funded through a mixture of public and private programs although not everyone is covered.
  5. 5. Canadian continuing care health policy 5  The 2004 Health Accord between the federal government and the provinces increased federal funding considerably and also provided federal funding for home care for the first time.  The home care funding was targeted to those needing care after a hospital admission.  Post-acute home care was supported because up to 20% of hospital beds were being used by those no longer needing inpatient care ie, ‘bed blockers’.
  6. 6. Policy results 6  Since 2004, there has been a significant reduction in home care services for those who need supportive assistance ie, housekeeping, laundry, and meal preparation  There has been an increase in nursing care and personal care such as bathing dressing and toileting  There has been an increase in average cost per client  This is the case across the country
  7. 7. Today’s situation 7  All provinces recognise the need to improve patient care experience, quality and availability of services, and contain cost increases, through improved efficiency in the system.  As a result, integrated care, especially for frequent users of hospital ERs and inpatient beds, is an important policy goal in most provinces.
  8. 8. Integrated care in Canada 8  There is no one definition of integrated care used by provincial Ministries of Health.  There is no commonly accepted set of performance measures.  But here are commonly accepted features of integration in Canada.
  9. 9. Clinical features of integration 9  Targeted admission criteria  Case managed team approach  Access to a wide range of services to meet client needs, and often  Active involvement of physicians
  10. 10. Infrastructure features 10  Shared clinical and administrative information systems  Financial incentives to change behavior  Shared vision and goals  Excellent and sustained leadership
  11. 11. Canada and Quebec 11
  12. 12. PRISMA: Program of Research to Integrate Services for the Maintenance of Autonomy 12 PRISMA focused on integrating health and social services in alignment with medical management. Features of the PRISMA Model: 1. 2. 3. 4. 5. 6. Co-ordination among services Single point of entry Case management Unique assessment tool Individualised service plan Information tool
  13. 13. PRISMA results 13  By year 3, the rate of implementation of all of the key features of the model approached 80%. Physician participation was 73%.  After four years, the PRISMA model produced significant reductions in the prevalence and incidence of functional decline, reduced ER visits, and increased client satisfaction and empowerment.
  14. 14. Results 14  There was no statistically significant effect on rates of nursing home placement, consultations with health professionals, use of home care services, or cost.  PRISMA produced improved results at no additional cost.  The PRISMA model and its features have been adopted by the Ministry of Health and Social Services in Quebec as the standard of care for older adults in all regions of the province.
  15. 15. Patient flow in the PRISMA Model 15
  16. 16. Success factors 16 Unusual level of collaboration A partnership among university researchers, the provincial government, regional health and social service planning and funding authorities, as well as managers from the home and community care service centres, was created and sustained for over 15 years. Sustained regional leadership Key leaders stayed in their positions and maintained the PRISMA vision throughout many other changes locally and provincially.
  17. 17. Other success factors 17  PRISMA was never seen as a demonstration project but rather as a whole system change in care for the frail elderly.  The model was collaborative: it did not require organisational restructuring and thus was not seen as threatening to participating organisations.
  18. 18. The situation today 18  When the PRISMA model was adopted by the Ministry of Health, each region was granted flexibility for implementing the model’s features.  But all regions are being monitored by the Ministry against a uniform set of accountability measures.
  19. 19. Provincial progress in implementing the model 19 Feature Appointment of a person responsible for implementation Assessment Availability of a specialized geriatric service Single entry point Case Management Availability of a family physician Coordination mechanism Communications system Service Plan % implemented in 2008 % implemented in 2011 77.4 84.4 54.5 36.9 67.4 67.1 36. 31.1 27.5 64.3 53.3 48.9 26.9 26.5 15.6 48.10 40.4 15.3
  20. 20. Ongoing issues 20  Physician remuneration  Most primary care physicians in Quebec are paid on a fee-for service basis which does not reimburse them for their time in care planning and service co-ordination. Though PRISMA achieved 73% participation among physicians, it is difficult to replicate that achievement throughout the province.  Ongoing training and coaching  Individual health professionals do not automatically consider the possible role of other providers, especially those at the home support/ social care level  Case managers need training in the co-ordination features of their roles  The pace of change and staff turnover can quickly result in redirection of staff away from PRISMA goals unless there is ongoing accountability
  21. 21. Last thoughts 21  Because of the scope of change, especially among clinical and organisation providers, it is very important to view integration efforts as a long time commitment.  If integration efforts are going to be evaluated, it is important to give the effort enough time to show its impacts.
  22. 22. 22 Thank you very much for your attention! Margaret MacAdam, Ph.D. m.macadam@utoronto.ca

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