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- WHO | WHO Framework on integrated people-centred health services
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The National Health Reform Agreement NHR Agreement sets out the intention of governments to work in partnership towards improving health outcomes for all Australians, and to ensure the sustainability of the Australian health system. It also supported the establishment of local governance mechanisms, such as the Local Hospital Networks and Medicare Local primary health care organisations, to improve responsiveness and accountability of health services to the community at a local level.
The NHR Agreement identified the need for the Commonwealth and States to work in partnership to develop this Framework in order to guide policy directions across priority areas in primary health care. Primary health care is a vital component of the comprehensive health care system in Australia.
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While significant reform has occurred across the health and aged care system, a nationally agreed approach on primary health care has, so far, been missing. A high quality, high performing health system needs a strong, integrated primary health care system at its centre. Health systems with strong and effective primary health care can achieve better health outcomes at a lower cost, than health systems that are more focused on acute and specialist care. Building a strong, responsive and cost-effective primary health care system is essential if we are to maintain a healthier population and ease the burden on hospitals.
By supporting health promotion and education, early diagnosis and treatment and chronic condition management, primary health care contributes to reducing the risk of conditions progressing to the point where more intensive and expensive interventions may be required. This complexity can lead to health service planning and delivery occurring in an uncoordinated and poorly integrated fashion, creating service fragmentation and gaps, and potentially less than optimal outcomes for consumers.
It is this context that makes it imperative that we turn our efforts towards improving primary health care. Responsibilities in Primary Health Care Today, all levels of government continue to make significant contributions to primary health care services. In accordance with the NHR Agreement , the Commonwealth has lead responsibility for: system management, policy and funding for primary health care; establishing Medicare Locals to promote coordinated primary health care service delivery at a regional and local level; working with each State on system-wide policy and state-wide planning for primary health care services; and promoting equitable and timely access to primary health care services.
The Commonwealth does this through the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme, through funding of Medicare Local primary health care organisations, through specific program funding to non-government organisations and private providers of health services, as well as through payments to the States. The Commonwealth also provides funding for hospital services and public health activities managed by States, including new growth funding arrangements.
The States are also responsible for funding and providing a range of community health services including prevention and health promotion services and services that help maintain community health and wellbeing 3. Traditional organizations or agencies often take pride in their identity and currently thrive in an environment with specific donations, fundraising activities, or naming rights and prestige.
Even when partnerships are established, there is still the ongoing challenge of managing the vitality, trust, and communication associated with the partnership. Providing greater funding flexibility to community hubs based on outcomes will help address these challenges by removing the program funding requirements that do not allow for service integration. The Province is currently conducting a comprehensive Program Review, Renewal and Transformation of all government programs.
This review provides an opportunity for government to review program funding with a view towards supporting greater integration and achieving better client outcomes. Each program has its own mandate, funding rules, population focus, and delivery structure. In addition, multiple provincial programs from multiple ministries with different reporting timelines, benchmarks and requirements force agencies to spend resources on complicated and time-consuming deliverables that are inconsistent. A predominant theme through our survey feedback was the strong recommendation that consistent and transparent transfer payment agreements should be established across ministries.
ONN has suggested the implementation of an integrated umbrella agreement for community hubs that receive more than one provincial funding stream. The government is undertaking a Transfer Payment Administrative Modernization project that is working with ministries to streamline business practices to help reduce administrative barriers for service providers and demonstrate better accountability for public funds.
In addition, there is no common measurement system. Therefore, even if there are measured outcomes, there is no standardized system that would allow for an analysis of what works and what does not. There is work to be done to develop outcome-focused indicators of success, taking into account the diversity of models and different objectives that apply to community hubs. As a starting point, the Province has recently undertaken work to develop a framework to support youth outcomes through its Stepping Up Framework that could be used as a model.
The Framework outlines a set of 20 outcomes that are designed to support service providers, foundations, community groups, governments, young leaders and families — to better align their work with what research and youth themselves say is important for their success. While funding in silos can be a problem in terms of community hub development, ongoing funding is also a challenge in terms of sustainability. Many groups have stated that the long-term viability and flexibility of a community hub depends on its ability to adapt and respond to evolving community needs.
Community hubs are often precluded from including commercial operations to help defray some of their capital and operating costs. Consideration should be given to allowing for commercial space that is compatible with the community hub and serves the local community, and supports the sustainability of the community hubs business model. In addition, there are potential anchor tenants that might be a good fit for a community hub and provide a consistent revenue stream.
Provincial opportunities could include Employment Ontario, community courts, Social Justice Tribunals or other provincial service providers that currently lease commercial or standalone space. We heard that the sharing of personal information among different entities in a community hub can improve services for clients.
However, navigating the different rules for protection of personal information can be challenging. We heard from the Ministry of Community Safety and Correctional Services that they are working with the Information and Privacy Commissioner on this issue. The Ontario Working Group on Collaborative, Risk-driven Community Safety has suggested an approach to improving collaboration between multiple human service entities that could be useful in a community hubs context. Organizations and agencies often experience a lack of centralized information or data sharing that would help assess community needs and outcomes.
This could serve as an important building block for establishing new community hubs. Many successful community hubs exist across the province and are models that others would like to learn from. Collecting the data and information in one open and transparent place can provide valuable resources and information to those considering a community hub model. In addition, many groups would go even further than resource sharing. They suggest that a community hubs resource package be developed and include standard template forms for internal community hub operations e.
This could also include multi-stakeholder template agreements for organizations seeking to operate community hubs as partnerships. While template forms could provide a tangible and consistent process for community hub operations, many groups have identified a need for additional training and resources. Despite the innovation and planning happening on the ground, there are challenges in local communities when it comes to space and infrastructure. In some cases there is excess, underutilized space, and in other cases, there is a lack of space.
The Province has a role to play in this issue as the owner or capital contributor to many public spaces. We have heard about schools in particular, and we know this issue is top of mind for many communities that are facing the difficult decision of whether their school should remain open. While we recognize this issue, in the context of our mandate we see underutilized schools and the community use of schools as part of a larger, systemic planning challenge that requires a multi-pronged approach. We heard from a number of groups that they had programs ready to offer, and partnerships in place, but could not find appropriate space at the right time.
These are the key barriers related to retaining and using public properties for community hubs:. They would like access to an up-to-date inventory of all public properties, including those at the municipal level. Currently the Province maintains a database at Infrastructure Ontario for surplus property, but it does not include a comprehensive inventory that can be accessed by all. Individual ministries prepare their capital plans based on their ministry needs. This means there is no overall provincial lens to review the inventory of public properties prior to decisions being made to dispose of property that might be surplus to the needs of one ministry.
It also means that there is no capital planning that looks at co-location of compatible uses, which could lead to integrated service delivery in a community hub. We also heard that ministries do not have a complete inventory of surplus properties to be used as part of the planning process. The current mandate of the provincial government is to sell surplus property at fair market value to ensure taxpayers receive the highest value for the property. Many people and organizations felt that selling public properties at market value does not properly recognize the economic and social value of the services that an asset repurposed for the public good could provide.
As it stands now, there is no systematic cost-benefit analysis of the potential value of surplus property from a socio-economic perspective, including the social, recreation, cultural, park land, affordable housing, intensification and health requirements of a community. There is no framework for a comprehensive review to determine the requirement and viability of public ownership of surplus property — either for a portion of the site or the entire site. Stakeholders told us that in the review of schools, the Province should not discourage the closure of schools altogether.
There may be other socio-economic value which is not considered in the current Fair Market Value analysis, and therefore opportunities may be missed.
WHO | WHO Framework on integrated people-centred health services
For example, one organization wanted to buy a school to leverage affordable housing funding, but could not get the financing to pay market value for the school. This planning and broader consideration of socio-economic value is a challenge that should not be borne by the Ministry of Education and school boards alone. We heard a number of issues around the circulation of property.
There is a limited circulation list and not all potential end users are consistently included e. The other issue is the limited time for review. If a school is being used by a community partner in part of its space, and students are being taught in another part and the school is therefore fully utilized by the community, only the student spaces are funded by the Ministry of Education.
We heard that it should not fall to the school boards to ensure these community services are being provided and paid for. There needs to be a way to recognize and value these partnerships. There is no mechanism to assess this space in the school that is used by the community. This does not mean that some underutilized school properties will not be sold.
It does mean that this decision could be made in a more integrated way that allows for the full consideration of the potential school use into the future. We heard from Ontario Nonprofit Network that the provincial government can support community assets by facilitating loans for the non-profit sector. Lending institutions are often reluctant to loan to non-profits. Infrastructure Ontario already provides a loans program in which organizations in certain nonprofit sectors may qualify. We heard that the provincial health capital planning process is too long and lacking the flexibility to seize local opportunities as they arise.
Once projects exceed a certain cost threshold, other requirements apply, including matching funding, that make it difficult for community hubs to obtain timely funding. We heard from the Association of Ontario Health Centres that the current rules from the Province that guide the capital process for community health care organizations can be misaligned and too rigid to achieve integrated, person-centred care.
Smaller boards, in particular, do not have large planning departments or the resources to coordinate the community development and ongoing maintenance of substantive hubs. Many groups, including municipalities and school boards, have noted challenges with forming partnerships in schools. While schools can operate as community hubs, they face significant challenges with security and liabilities associated with community use.
Although many groups talked about repurposing existing public properties, we also heard that assets for the future need to be better designed to respond to the changing needs and demographics of local communities. For example, while funding is available to integrate child care facilities into new schools, there is often no mechanism to plan for broader community partnerships that might include a multi-use, inter-generational design unless a community partner contributes to the development.
Instead, the Province tends to build or fund single-purpose facilities that may not be open in the evenings, on the weekends or during the summer. We heard clearly that the policy solutions that work for urban and rural settings are very different. Urban settings are subject to increasing density, creating a need for public space to live active, healthy lifestyles. Rural settings are experiencing a decline in population and shifting demographics, which make it more difficult to keep public spaces viable.
Access to services is also more difficult in remote, northern and rural communities. Notably, rural communities face the problem of not having access to transportation that could get them to and from the community hub. We heard that it would be helpful to explore the idea that a hub can be a "virtual entity" - a community networking group of people who ensure that all are served well, gaps are identified, and new services are incubated as needed. It is also important to recognize the specific needs of unique communities including French-language and Aboriginal communities, newcomers, as well as people with disabilities.
We heard that French-language communities need a model that is inclusive and of high quality to avoid supporting assimilation. The Aboriginal population in our province is growing at nearly five times the rate of the non-Aboriginal population. Between and , the total number of people who identify as Aboriginal in Ontario has grown by an estimated 58,, an increase of Most Aboriginal people in Ontario live off-reserve, representing This population growth has placed additional service delivery and infrastructure pressures on Friendship Centres to meet the unique needs of urban Aboriginal people.
Seniors are the fastest growing sector of the population.
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The number of people aged 65 and over is projected to more than double from about 2. In , for the first time, seniors will account for a larger share of the population than children aged 0— Many groups indicated that issues of accessibility often prevent access to integrated services in their community — both in terms of physical location as noted above, as well as through the lens of the Accessibility for Ontarians with Disabilities Act AODA , which aims to achieve accessibility for Ontarians with disabilities by through a phased approach.
The AODA requires all providers of goods and services to comply with customer service standards deigned to ensure people with disabilities can obtain, use, and benefit from them. We have learned that each community is unique, with a specific set of resources and a combination of service needs and capabilities.
Each successful community hub is therefore a unique solution to local needs. It would be a mistake to attempt to control this community-driven process from the top down. The Province needs to play a collaborative role in facilitating co-ordination and addressing barriers at the provincial level. We have therefore attempted to capture the essence of a community hub in terms of vision, principles and goals. We want these to become a touchstone that provides common ground for continuing conversations and collaboration, as well as direction and guidance to ensure community hubs evolve successfully in Ontario.
Based on consultation with community groups and the public service, I am optimistic that there are enormous opportunities available to enhance the role of community hubs in the province. This exercise was really one of exploring opportunities and laying out a plan for action. While we did hear about challenges, one thing was universal — there is overwhelming support for integrated service delivery through community hubs.
We see the opportunity to meet some of the challenge with specific fixes that we think can happen relatively quickly. A large and growing proportion of health care is provided by multisite health care delivery organizations. Those proportions are even higher today. Unfortunately, most multisite organizations are not true delivery systems, at least thus far, but loose confederations of largely stand-alone units that often duplicate services.
There are huge opportunities for improving value as providers integrate systems to eliminate the fragmentation and duplication of care and to optimize the types of care delivered in each location. To achieve true system integration, organizations must grapple with four related sets of choices: defining the scope of services, concentrating volume in fewer locations, choosing the right location for each service line, and integrating care for patients across locations.
Is relocating service lines on the table? A starting point for system integration is determining the overall scope of services a provider can effectively deliver—and reducing or eliminating service lines where they cannot realistically achieve high value.
For community providers, this may mean exiting or establishing partnerships in complex service lines, such as cardiac surgery or care for rare cancers. For academic medical centers, which have more heavily resourced facilities and staff, this may mean minimizing routine service lines and creating partnerships or affiliations with lower-cost community providers in those fields.
Although limiting the range of service lines offered has traditionally been an unnatural act in health care—where organizations strive to do everything for everyone—the move to a value-based delivery system will require those kinds of choices. Second, providers should concentrate the care for each of the conditions they do treat in fewer locations. Concentrating volume is essential if integrated practice units are to form and measurement is to improve.
Numerous studies confirm that volume in a particular medical condition matters for value. Providers with significant experience in treating a given condition have better outcomes, and costs improve as well. Patients, then, are often much better off traveling longer distance to obtain care at locations where there are teams with deep experience in their condition. That often means driving past the closest hospitals. Organizations that progress rapidly in adopting the value agenda will reap huge benefits, even if regulatory change is slow.
Concentrating volume is among the most difficult steps for many organizations, because it can threaten both prestige and physician turf. Yet the benefits of concentration can be game-changing. In , the city of London set out to improve survival and prospects for stroke patients by ensuring that patients were cared for by true IPUs—dedicated, state-of-the-art teams and facilities including neurologists who were expert in the care of stroke.
These were called hyper-acute stroke units, or HASUs. At the time, there were too many hospitals providing acute stroke care in London 32 of them to allow any to amass a high volume. UCL Partners, a delivery system comprising six well-known teaching hospitals that serve North Central London, had two hospitals providing stroke care—University College London Hospital and the Royal Free Hospital—located less than three miles apart.
University College was selected to house the new stroke unit. Neurologists at Royal Free began practicing at University College, and a Royal Free neurologist was appointed as the overall leader of the stroke program. These steps sent a strong message that UCL Partners was ready to concentrate volume to improve value.
The number of stroke cases treated at University College climbed from about in to more than 1, in All stroke patients can now undergo rapid evaluation by highly experienced neurologists and begin their recovery under the care of nurses who are expert in preventing stroke-related complications.
The third component of system integration is delivering particular services at the locations at which value is highest. Less complex conditions and routine services should be moved out of teaching hospitals into lower-cost facilities, with charges set accordingly. There are huge value improvement opportunities in matching the complexity and skills needed with the resource intensity of the location, which will not only optimize cost but also increase staff utilization and productivity.
More recently, the hospital applied the same approach to simple hypospadias repairs, a urological procedure. Relocating such services cut costs and freed up operating rooms and staff at the teaching hospital for more-complex procedures. In many cases, current reimbursement schemes still reward providers for performing services in a hospital setting, offering even higher payments if the hospital is an academic medical center—another example of how existing reimbursement models have worked against value.
But the days of charging higher fees for routine services in high-cost settings are quickly coming to an end.
The final component of health system integration is to integrate care for individual patients across locations. Care should be directed by IPUs, but recurring services need not take place in a single location. For example, patients with low back pain may receive an initial evaluation, and surgery if needed, from a centrally located spine IPU team but may continue physical therapy closer to home. Wherever the services are performed, however, the IPU manages the full care cycle.
Integrating mechanisms, such as assigning a single physician team captain for each patient and adopting common scheduling and other protocols, help ensure that well-coordinated, multidisciplinary care is delivered in a cost-effective and convenient way. Health care delivery remains heavily local, and even academic medical centers primarily serve their immediate geographic areas. If value is to be substantially increased on a large scale, however, superior providers for particular medical conditions need to serve far more patients and extend their reach through the strategic expansion of excellent IPUs.
Buying full-service hospitals or practices in new geographic areas is rarely the answer. Geographic expansion should focus on improving value, not just increasing volume. Geographic expansion takes two principle forms. The first is a hub-and-spoke model. For each IPU, satellite facilities are established and staffed at least partly by clinicians and other personnel employed by the parent organization. In the most effective models, some clinicians rotate among locations, which helps staff members across all facilities feel they are part of the team. As expansion moves to an entirely new region, a new IPU hub is built or acquired.
Patients often get their initial evaluation and development of a treatment plan at the hub, but some or much care takes place at more-convenient and cost-effective locations. Satellites deliver less complicated care, with complex cases referred to the hub. The net result is a substantial increase in the number of patients an excellent IPU can serve.
This model is becoming more common among leading cancer centers. MD Anderson, for example, has four satellite sites in the greater Houston region where patients receive chemotherapy, radiation therapy, and, more recently, low-complexity surgery, under the supervision of a hub IPU.
The cost of care at the regional facilities is estimated to be about one-third less than comparable care at the main facility. The second emerging geographic expansion model is clinical affiliation, in which an IPU partners with community providers or other local organizations, using their facilities rather than adding capacity. The IPU provides management oversight for clinical care, and some clinical staff members working at the affiliate may be employed by the parent IPU. MD Anderson uses this approach in its partnership with Banner Phoenix. Local affiliates benefit from the expertise, experience, and reputation of the parent IPU—benefits that often improve their market share locally.
The IPU broadens its regional reach and brand, and benefits from management fees, shared revenue or joint venture income, and referrals of complex cases. Successful clinical affiliations such as these are robust—not simply storefronts with new signage and marketing campaigns—and involve close oversight by physician and nurse leaders from the parent organization as well as strict adherence to its practice models and measurement systems. For example, Vanderbilt has encouraged affiliates to grow noncomplex obstetrics services that once might have taken place at the academic medical center, while affiliates have joint ventured with Vanderbilt in providing care for some complex conditions in their territories.
The preceding five components of the value agenda are powerfully enabled by a sixth: a supporting information technology platform. Historically, health care IT systems have been siloed by department, location, type of service, and type of data for instance, images.
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Often IT systems complicate rather than support integrated, multidisciplinary care. But the right kind of IT system can help the parts of an IPU work with one another, enable measurement and new reimbursement approaches, and tie the parts of a well-structured delivery system together.
The system follows patients across services, sites, and time for the full cycle of care, including hospitalization, outpatient visits, testing, physical therapy, and other interventions. Data are aggregated around patients, not departments, units, or locations. Terminology and data fields related to diagnoses, lab values, treatments, and other aspects of care are standardized so that everyone is speaking the same language, enabling data to be understood, exchanged, and queried across the whole system.
That includes referring physicians and patients themselves. The right kind of medical record also should mean that patients have to provide only one set of patient information, and that they have a centralized way to schedule appointments, refill prescriptions, and communicate with clinicians. And it should make it easy to survey patients about certain types of information relevant to their care, such as their functional status and their pain levels.
Templates make it easier and more efficient for the IPU teams to enter and find data, execute procedures, use standard order sets, and measure outcomes and costs. Expert systems help clinicians identify needed steps for example, follow-up for an abnormal test and possible risks drug interactions that may be overlooked if data are simply recorded in free text, for example. In value-enhancing systems, the data needed to measure outcomes, track patient-centered costs, and control for patient risk factors can be readily extracted using natural language processing.
Such systems also give patients the ability to report outcomes on their care, not only after their care is completed but also during care, to enable better clinical decisions. As a result, the cost of measuring outcomes and costs is unnecessarily increased. It is now moving toward giving patients full access to clinician notes—another way to improve care for patients. The six components of the value agenda are distinct but mutually reinforcing. Organizing into IPUs makes proper measurement of outcomes and costs easier.
Better measurement of outcomes and costs makes bundled payments easier to set and agree upon. A common IT platform enables effective collaboration and coordination within IPU teams, while also making the extraction, comparison, and reporting of outcomes and cost data easier. With bundled prices in place, IPUs have stronger incentives to work as teams and to improve the value of care. And so on. Implementing the value agenda is not a one-shot effort; it is an open-ended commitment.
It is a journey that providers embark on, starting with the adoption of the goal of value, a culture of patients first, and the expectation of constant, measurable improvement. The journey requires strong leadership as well as a commitment to roll out all six value agenda components. For most providers, creating IPUs and measuring outcomes and costs should take the lead. As should by now be clear, organizations that progress rapidly in adopting the value agenda will reap huge benefits, even if regulatory change is slow.
With the tools to manage and reduce costs, providers will be able to maintain economic viability even as reimbursements plateau and eventually decline. Providers that concentrate volume will drive a virtuous cycle, in which teams with more experience and better data improve value more rapidly—attracting still more volume. Superior IPUs will be sought out as partners of choice, enabling them to expand across their local regions and beyond. Maintaining market share will be difficult for providers with nonemployed physicians if their inability to work together impedes progress in improving value.
Hospitals with private-practice physicians will have to learn to function as a team to remain viable. All stakeholders in health care have essential roles to play. Their boards and senior leadership teams must have the vision and the courage to commit to the value agenda, and the discipline to progress through the inevitable resistance and disruptions that will result.
The transformation to a high-value health care delivery system must come from within, with physicians and provider organizations taking the lead. But every stakeholder in the health care system has a role to play in improving the value of care. Patients, health plans, employers, and suppliers can hasten the transformation by taking the following steps—and all will benefit greatly from doing so.
Reputations that are based on perception, not actual outcomes, will fade. Maintaining current cost structures and prices in the face of greater transparency and falling reimbursement levels will be untenable. Those organizations—large and small, community and academic—that can master the value agenda will be rewarded with financial viability and the only kind of reputation that should matter in health care—excellence in outcomes and pride in the value they deliver. Michael E. Thomas H. Lee , MD, is the chief medical officer of Press Ganey. He is a practicing internist and a professor part time of medicine at Harvard Medical School and a professor of health policy and management at the Harvard T.
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