Table 1
Integrated Care Case Study Descriptive Template.
| Program Structure (design elements) | |
|---|---|
| Segmentation | Defining and applying rules to identify and recruit patients who are likely to benefit. |
| Coordination | A process for intake to characterize needs, mechanisms for coordination across institutions and sectors like health and social care. |
| Patient and caregiver engagement | Support for shared decision-making, self-management and support for caregivers. |
| Measures | How programs defined success, their level of maturity and any evaluation work conducted. |
| Policy-related context | |
| Governance | Governance structures in place to support the model of care. Could include committees and/or boards who meet regularly and review performance data. |
| Data sharing | Data and information sharing policies and processes in place related to patient care. |
| Staffing | Staffing needed to support the model of care, including strategies on how to organize and prepare staff. |
| Financing | Financing structures put in place to support the model of care. Includes attention to payment mechanisms, presence of well-defined budgets, and sustainability of funding. |
Table 2
Sample case descriptions [for full descriptions see Appendix A].
| Case | Segmentation | Coordination | Engagement Success | measures | Policy Context | |
|---|---|---|---|---|---|---|
| SUSTAIN | ||||||
| South Holland | Target group: frail, multiple health and social care needs (but broadly defined) Entry points: self-referral (clients and families) or by professionals in the community (prevention driven with active community communication) | Intake: Conducted by any provider using a standard tool (Self-reliance matrix) filled out during a home visit (using a tablet). Patient then assigned navigator (anyone on the team, all trained for this role – likely with most experience with care needs of patient). Primary care providers: Each team includes community nurse or GP practice nurse. Direct connection to GP practice varies. Integration: At minimum social worker, community nurse and municipal social care worker. Can add: dementia case managers, physicians, social housing, etc… Transitions: All providers still linked to their parent organizations which can facilitate transition Information sharing: All providers can access a shared data platform which includes online communication tool (all teams trained on it). | Patient engagement: A strong belief of the teams, but not formalized. Also engagement is limited due to the low functional status of clients. Patient self-management: Similar to issue above, believed to be important but difficult to operationalize. Additional challenge of different characteristics of neighbourhoods. Caregiver engagement: Not yet a clear component of strategy – but family issues captured as part of the assessment process. Experimenting with digital tools to support caregiver engagement (interest in building this long term). | Maturity: Program admitted first client in 2015 and has served 5,000 since. Served approx. 300 in the past 6 months. Program started as a pilot (3 teams) and scaled up in 2016 (27 teams). Composition, objectives and aims of teams varies by neighbourhood. Measures: Better health outcomes, patient/caregiver experience and lower costs – these are not formalized in measures (not unusual). Data collection: No data on program activities are collected. Currently developing performance indicators. Evaluation: No formal evaluation conducted. | Financing for model: Both municipal (public tender and subsidized funds) and health insurer financed. Staffing model: All professionals stay employed by their mother organizations. Next to their daily work, they get extra hours for doing the multidisciplinary work/meetings. Professional training is executed by the local (applied) university and funded by the municipality. Governance structure: Shared governance model. All involved parties (health and social care providers, GPs, municipality, health insurers) are represented in a steering group. However, the two financing institutes (insurers and local government) are directing. No performance data is collected yet. Health and social care data sharing structure: To facilitate data linkage, a shared IT system has been developed. However, ‘old’ systems are still being used. Administrative burden is a risk. Care delivery innovation: Most innovative part is that a person/family has 1 contact person, and that integration takes place in all phases of the process: from intake to care delivery. | |
| ONTARIO | ||||||
| Integrated Client Care Program (ICCP) – partnership model between primary care and home care | Target group: The Integrated Client Care Program (ICCP) focuses on the top 1–5% frail older adults in need of integrated services. Patients are assessed up the RAI tool. Entry points: Patients can enter the program through multiple entry points including the Family Health Team (FHT), the Community Care Access Centre (CCAC - government agency that connects patients to home care services), and through other partners and community agencies aware of the program. | Intake: Intake depends on the RAI evaluation (see target group). The Care Coordinator from the CCAC typically takes responsibility for ICCP patients. Primary care providers: All patients on the ICCP program have sustained access to their primary care provider who is supported through a multi-disciplinary team Integration: There is a high level of professional integration with the multi-disciplinary team, as well as organizational integration between the FHT, the CCAC and hospital. Transitions: There is a formal program with the local hospital, Virtual Ward, which supports transitions for clients going from hospital to home. This is a clear process and protocol but only for patients at the local hospital – if patients end up in another hospital there is no process. Information sharing: Partnering organizations have connecting information systems (hospital and FHT), or individuals able to access multiple platforms (embedded care coordinator can see FHT and CRIS systems) | Patient engagement: Patients engagement occurs at this site and is an increasing focus. There are patient and family carer seats on committees and strategic planning groups. Patient self-management: Collaboration and patient goal-setting is a part of the culture at the FHT and embedded into the ICCP program. Caregiver engagement: Caregiver support less formalized, but providers are attentive to caregiver needs and attempt to provide supports when they can. Not a formal process. | Maturity: The ICCP program began in 2012 and is a replication from the ICCP program in palliative care run out of the CCAC. Other FHT programs like Virtual Ward and IMPACT are also established and support the integrated model. IMPACT is a replication from another site. Measures: Standard FHT measures apply to the FHT for reporting to the LHIN on performance. It is noted by decision-makers that other measures are currently missing, but they would anticipate that reduced hospitalizations and ER visits be among their key measures. Data collection: Data not available Evaluation: ICCP was not formally evaluated at the time of data collection. A different Virtual Ward program at Women’s College has had a formal evaluation, as has the IMPACT program in other settings. | Financing for model: The ICCP program is funded by the FHT and CCAC through paying for specific staff to run the program. For the FHT the staff is now part of the global budget. Staffing model: Unique staffing model which collocates the community partner (home care coordinator) in the multi-disciplinary primary care team to improve coordination and information sharing. Governance structure: The FHT, like other FHTs in Ontario has a board of directors that reviews performance metrics aligned with Ministry reporting requirements. Health and social care data sharing structure: Some innovative data sharing between the FHT and the local hospital (sharing medical records), electronic referral and information sharing with Toronto EMS (paramedics), and colocation of staff enables seeing health and social care data while in the primary care clinic. Care delivery innovation: The colocation model of ICCP, along with the virtual care and home visiting programs are innovative practices in Ontario. | |
| QUEBEC | ||||||
| Target group: Functional Autonomy Measuring System (SMAF) used to determine eligibility – need a particular score to be included. | Intake: SMAF scores guides a multidisciplinary care plan. Host organization and local organizations may have some flexibility in what is provided. Those with a SMAF >5 receive a case manager through home care services unit. | Patient engagement: Personalized care plan but shared-decision making difficult to operationalize. Culture of shared decision-making supported by government and leaders. | Maturity: CLSC’s operational since 1970s with 100,000’s since than. It is an established government run program with secure funding and spread across the province. | Financing for model: Public fund troughs taxation. In complementary, patient may directly pay for services from community agencies that are mostly not covered by the public insurance. | ||
| Entry points: Patients with 2 or more YES answers on PRIMSA-7. SMAF is managed by a specialized team at a single point of entry for defined geography. Clients can also self-refer | Primary care providers: Some regular contact but challenging to connect to primary care as they are privately owned. Case managers have primary responsibility. | Patient self-management: No clear self-management support aspects of program | Measures: Better health outcomes, patient and caregiver experience and lower costs. Related to government healthy aging policy with specific indicators: reduced wait times, reduced ED visits, # clients in the program. | Staffing model: All professionals stay employed by their mother organization. Recent initiatives are in place to “lend” allied professionals (nurses, social workers, dieticians etc.) to privately owned Grouped Medical practices – the allied professional are still employed by the mother organization but work in private physician clinics. Family physicians in the community are paid through public insurance but are autonomous workers. | ||
| Integration: Types of services offered varies by local organization but all include primary care in the community, acute and surgical, home care, nursing home, supportive housing, community day care and social supports. Some co-location but not in all sites. Transitions: Some organizations have dedicated care transitions provider (engage in pre-discharge meetings) Information sharing: Have ICT systems to facilitate integration and transitions, in particularly tools that send transfer information electronically. Government mandated (RSIPA system). Some variation in access due to location. | Caregiver engagement: Some caregiver supports offered (e.g. respite days) – no information regarding formal training. | Data collection: Performance indicators reported on regularly. Evaluation: Several formal research studies conducted to evaluate the model. Developed OSIRSIPA tool to monitor implementation and outcomes. | Governance structure: Since 2015, Almost a full integration of public establishment under the same governance (hospital, rehabilitation, home care, long care term facilities) Vertical governance structure. The HSSCs are public health and social care agencies that are mandated by the government to organize care delivery in their territories. The HSSCs have to lead in establishing local joint governance boards for various health problems with their local partners in the community (physician clinics, nursing homes, private community agencies etc.). Health and social care data sharing structure: There is a government mandated IT system (the RSIPA) that is shared between various agencies within the HSSC. However, some private agencies do not have access to this public IT system. Furthermore “older” IT systems co-exist with the public IT system. Care delivery innovation: Introduction of several initiatives. E.g. formalization of care coordination by case managers, use of multidisciplinary individualized service plans, and use of multidisciplinary health and social care evaluation tools. | |||
| NEW ZEALAND | ||||||
| NZ Network Model | Target group: The DHB serves a broad population but the CREST and care coordination programs focus on 65 and older population transitioning home from hospital. Entry points: Clients access services through Liaison Nurse who identifies eligible individuals in the hospital. Referrals for case management and care coordination programs for older adults can come through GPs, other providers or through self-referral. | Intake: Assessments used by Liaison nurses and care coordinators to assign services based on function and need (eg, interRAI) Primary care providers: GPs play an active role in NZ Network Model, referring patients as needed to programs and following up with other providers. They will engage in case conference calls with other providers as well. Integration: Involves a wide range of health as social care services some of which are tailored to older adults with complex care needs. Providers regularly speak across boundaries to deliver care. Transitions: CREST is a structured transition program from hospital to home. Care coordinators and case managers work to help integrate other services. Teams across services also work together. Information sharing: Use a few systems to share information include CCMS, SAP, Momentum, Health Conenct South and One Health Now. Providers can access patient data that sits on these systems from different settings (eg, pharma, labs, clinical care, hospitals). | Patient engagement: Goal-setting part of care delivery (particularly for CREST programs), not part of DHB training but embedded in professional training and approach. Patient self-management: Area of focus particularly for the CREST program with an emphasis on enablement and support. Caregiver engagement: Not an emphasis | Maturity: New model in DHB established in 2006/7 but gained traction in 2011 post earthquakes. An established program with ongoing funding. Measures: Emphasis on process measures (early discharge), also collect patient satisfaction and engage in peer review meetings Data collection: No regular reporting mentioned in interviews – but likely occurring particularly for funded partners Evaluation: No formal evaluation to our knowledge | Financing for model: DHB shifted to activity-based payment model for hospitals and bottom-up focused alliance contracting where maximum collective gain can only be realised if all parties support one another and agree to share any losses Staffing model: Unchanged – what has changed is how they work together Governance structure: Shift towards a Network model reliant on partnerships and governed by Alliance Support team. Health and social care data sharing structure: Not necessarily new but part of the NZ approach to data where patients have unique identifiers across health and social care data platforms to facilitate finding information. Care delivery innovation: Most notable shift is in moving clients out of hospital and into the community setting faster through partnerships with social care providers and enablement program (CREST) |