The Capital Health Region's Early Experiences: Moving Towards Integrated Healthcare
FrameworksSeveral frameworks are provided by the authors to assess health systems including those by Shortell et al. (1996), Coddington et al. (1997) and Enthoven and Vorhaus (1997). I have chosen for this commentary to use the Shortell framework to assess the progress made by the CHR.
Focuses on meeting the community's health needs
- Positive and supportive living and working conditions exist in
all our communities.
- Individuals develop and maintain the capabilities and skills
needed to thrive and meet life's challenges and to make choices to
- A diverse and sustainable physical environment with clean,
healthy and safe, air, water and land.
- An effective, efficient, innovative and respectful health
service system that provides equitable access to appropriate
- Improved health for aboriginal peoples.
- Preventable illnesses, injuries, disabilities and premature deaths are reduced.
The roles of the CHR in achieving each of these outcomes vary. For some outcomes the role is simply advocacy, while for others they include public policy development, service delivery and/or the enforcement of regulations.
Extensive work has been undertaken by the CHR to measure the health status of the Region's population and the performance of the Region's delivery systems compared to other jurisdictions. Based upon this analysis and community input, the CHR Board of Directors has established priorities to meet the population's health needs including, for example, "effective early childhood nurturing and parenting." These priorities guide the operational plans and resource allocation of the Region.
Matches service capacity to meet the community's needs
Coordinates and integrates care across the continuum
The CHR has a budget of approximately $550 million to serve its local community and Vancouver Island referrals. It provides services directly from approximately 30 sites and in people's homes, and it funds over 150 other agencies to provide direct services. Services include public health, acute care and rehabilitation, long-term care in facilities and in homes and a variety of community- based services including those for people with mental illness. Noticeably absent in this list of services, as the authors suggest, is pharmacare and non-hospital medical services.
Despite not directly providing or even funding all health services in the Region, the critical mass and breadth of services that CHR provides creates a solid platform to initiate strategies to coordinate and integrate care. In these early years of regionalization in the CHR, major strides have been made in areas such as mental health and child and youth services to better coordinate and integrate services. For example, in mental health we now have a centralized intake process that ensures clients are connected with the appropriate service, and a clinical database is now used on inpatient units as well as in outpatient and community services. In child and youth services, children in the Special Care Nursery (SCN) often require follow-up services, many of which are provided through our paediatric rehabilitation team at the Queen Alexandra Centre for Children's Health (QACCH). The SCN and QACCH staff have worked together since regionalization to ensure a seamless transition from one service to the other. In another example, children who are exhibiting severe behavioural and emotional distress are often admitted through the Victoria General Hospital (VGH) Emergency to VGH inpatient. There is no other community alternative, hence the use of Emergency. These children will often be referred to mental health services at QACCH. Through effective teamwork across both sites, this transition has been greatly improved, with reduced length of stay on the inpatient VGH unit. Other areas will follow in time as all the Region's providers gain more experience in working together in this new model.
The biggest challenge that the CHR will have with integration is to develop effective partnerships and linkages with the approximately 400 family physicians in the Region. These physicians operate in a highly autonomous manner, mostly in solo practice or small groups. Nevertheless, many of these family physicians admit patients to our four acute care hospitals. To receive admitting privileges they must participate in the Region's continuing medical education and quality improvement processes. The CHR is beginning to work on strategies to provide value-added services to these physicians to help strengthen the processes for clinical integration.
Has information systems to link consumers, providers and payers across the continuum of care
- Lack of a clear business case.
- Lack of common standards.
- Fear of loss of personal privacy.
- Inadequate incentives and training for providers to
- Poor technology solutions.
- Ineffective leadership.
In spite of these barriers, there are examples of information initiatives in the CHR that flow out of the formation of the Region. The first is a self-care, patient education initiative that combines a selfcare manual, a nurse call line and access to materials on the Internet. The evaluation of this initiative suggests that a population's behaviour can be modified positively by information strategies linking provider agencies and consumers (B.C. Health Research Foundation 1999). A second initiative is a diabetes information strategy. Using physician billing claims, the CHR has identified the people in the Region who have a confirmed diagnosis of diabetes.Working closely with approximately 30 family physicians and their diabetic patients, we are helping patients better manage their disease. The results have been remarkable,with 95% following national guidelines for diabetic management versus less than 50% for diabetics generally throughout the Region.
Provides information on costs, quality, outcomes and consumer satisfaction to multiple stakeholders
Uses financial incentives and organizational structure to align governance, management, physicians, and other providers to achieve objectives
Is able to continuously improve the care it provides
Is willing and able to work with others to ensure objectives are met
Strategies for Achieving Integrated CareIn their paper, the authors propose six strategies for achieving integrated care. I will comment on each of these strategies based upon my experience to date in the CHR.
Focus on the individual
Start with primary health care
- Physicians not wanting to have their actions controlled through
- Physicians currently working primarily in solo practice and
- Inadequate computer system support.
- Physicians questioning whether 24- hour access to primary care
service is really necessary or advisable.
- The concern about the lack of patient accountability for remaining with one primary care physician, which could lead to economic negation of the physician.
In spite of the many barriers to address primary healthcare, it deserves high priority as a strategy for achieving clinical integration. The health system will be strengthened considerably by creating a better capacity for health promotion, the management of chronic disease and coordination of care in the primary care setting.
Share information and exploit technology
Create virtual coordination networks at local level
Develop practical needs-based funding methods
I suggest that the matter of equitable funding be broken into two components: base funding and growth funding. Population growth and rates of aging vary widely by region in British Columbia, as in other provinces. I believe it would be easier in the short run to gain acceptance of funding methodologies to address demographic growth while the methodologies to address reallocation of the base funding levels by region can be further researched.
Implement mechanisms to monitor and evaluate
I agree with the authors that there is a question about who should perform the monitoring and evaluation. A recent report on hospitals in Ontario (OHA 1999) was done in partnership with the University of Toronto to ensure rigour in methodology and objectivity. There is also a national organization in Canada, the Canadian Institute for Health Information (CIHI), which has as its mandate to develop standards for data and performance indicators to enable interagency comparisons of health status and health system performance. CIHI has a major role to play in Canada-wide monitoring and evaluation.
ConclusionI believe Leatt, Pink and Guerriere are overly critical of the progress and potential of regional health authorities. The authors say that "fundamental system problems have either not been addressed or have been dealt with at the margin only, usually by throwing money at them." Major system change in healthcare services is never made quickly or easily. The CHR is less than three years old, and already significant progress is being made, including the following:
- The Regional Health Board has adopted the broad determinants of
population health in its goals.
- The Region directly operates and funds a critical mass and
breadth of services, which provides a solid platform to initiate
strategies to coordinate and integrate care.
- A program management structure has been implemented to focus
the energies of the CHR on major population healthcare needs
through strategic planning, performance measurement and resource
- Virtual coordination networks are being developed at the local
level with agencies such as municipalities, the Social Planning
Council and school boards.
- A 15-year regional service plan is being established to project
the appropriate mix of facility, community and homebased services
for the Region.
- A self-care, patient education initiative has been implemented
and evaluated to demonstrate its effectiveness.
- The Region is working closely with family physicians and their diabetic patients to help patients better manage their disease with remarkable results.
There are, of course, major opportunities to improve clinical integration in the CHR. This is particularly true in relation to primary healthcare. Health services would be strengthened considerably in the CHR by creating a better capacity for health promotion, the management of chronic disease and the coordination of care in the primary care setting.
About the Author(s)
Tom R. Closson, BASC (IND. ENG.), MBA, CHE
President and CEO, Capital Health Region, Victoria, B.C.
B.C. Health Research Foundation. 1999. Partnerships for Better Health - a Self Care Pilot Project - Interim Evaluation - Year One.
British Columbia. Ministry of Health and Ministry Responsible for Seniors. 1997. Health Goals for British Columbia.
British Columbia. Ministry of Health and Ministry Responsible for Seniors. 1999. Strategic Directions for British Columbia's Health Services System.
Canadian Institute for Health Information (CIHI). 1999. National Health Expenditure Trends, 1975-1999.
Closson, Tom. 2000. "Not Much Progress ... Really!" Healthcare Computing and Communications Canada (February). Guest Editorial.
Coddington, Dean C., Keith D. Moore and Elizabeth A. Fischer. 1997. Making Integrated Health Care Work: Second Edition. Englewood, CO: Center for Research in Ambulatory Health Care Administration.
Enthoven, Alain C. and Carol B. Vorhaus. 1997. "A Vision of Quality in Health Care Delivery." Health Affairs (May/June) 16(3): 44-57.
Hay Group. 1999. ACTH Benchmarking Comparison of Canadian Hospitals 1998 - Major Community General Hospitals.
Ontario Hospital Association (OHA). 1999. The Hospital Report '99 - A Balanced Scorecard for Ontario Acute Care Hospitals.
Shortell, Stephen M., Robin R. Gillies, D.A. Anderson, Erickson K. Morgan and J.B. Mitchell. 1996. Remaking Health Care in America: Building Organized Delivery Systems. San Francisco: Jossey- Bass.
Thomas, Roger. 1999. "Implementing Primary Care Reform and the Impact on Physicians and Their Practices." HealthcarePapers (Winter) 1(1): 72-81.
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