Health Link Alberta is a model of successful regional integration. Launched as a single-region service in 2000, Health Link Alberta was rolled out as a province-wide service in 2003, operating as one service from two sites (Calgary and Edmonton). Provincial integration of Health Link Alberta was successful because it took the time to establish collaborative governance structures, build relationships with regional and provincial stakeholders, recognize and accommodate regional and local needs, and develop the processes and tools that it needed to deliver a quality, consistent and accessible service for all Albertans. Within three years, Health Link Alberta achieved 63% awareness and 46% utilization among all Alberta households.

Background

There has always been a public need for health advice that is reliable, trustworthy and easy to access. For many people – and for many years – this meant a visit to the family doctor or a call to the emergency department at the nearest hospital. As the health system became more complex, people also needed help navigating it and finding their way to the most appropriate service. Over time, a variety of telephone advice lines and recorded information services were developed across Alberta to meet the growing demand for health advice, information and system navigation – but these services were fragmented and it was difficult for the public to know whom to call for what information. With the advent of sophisticated telephone systems and computer software in the 1990s, the vision of a "one-stop" multi-channel health information contact centre could finally be realized.

Health Link Alberta (HLA) is a health advice and information service available to all Albertans, 24 hours a day, seven days a week, through telephone and Internet. The province-wide service is delivered from contact centres in Edmonton and Calgary and serves a provincial population of 3.5 million residents. Calls are answered by Registered Nurses and non-clinical information and referral agents, using a range of software and Internet supports. Health Link Alberta was launched as a province-wide service in June 2003 as a cornerstone of the Government of Alberta's Primary Care Transition Strategy. The province-wide service leveraged expertise in Capital and Calgary health regions in the delivery of teletriage services.

In addition to meeting the public need for consistent and reliable health advice and information from a legitimate source, HLA supports primary healthcare reform by:

• Ensuring healthcare services are accessed appropriately;
• Reducing pressure on doctors' offices and emergency departments; and
• Increasing emphasis on self-care, health promotion and prevention, and chronic disease management.

Today, HLA is a successful example of health system integration, but it took creativity, patience, commitment and time to create a single provincial service that is the same whether you access it from a farm in northern Alberta or an inner-city hostel in downtown Calgary. The purpose of this case study is to describe the principles, process and change strategies that were used to create this widely utilized provincial service.

Project/Intervention

Alberta Health and Wellness identified that implementation of a province-wide health information and triage line would meet a number of the primary healthcare reform objectives, including increasing access, increasing emphasis on health promotion and prevention, and facilitating improved coordination and integration with other health services (Shelley Ewart-Johnson, personal communication to Sheila Weatherill, May 6, 2001). In addition, the need for a province-wide health advice and information service was strongly supported by Alberta's 17 health regions in a letter to the Minister of Health in June 2001 (Calgary Health Region and Capital Health 2002). The project had executive support, but the challenge was to ensure the service was understood and supported by the front-line providers in these regions, who would contribute significantly to the success (or failure) of the service. An effective working relationship between the Edmonton and Calgary sites was critical to ensure one service from two locations. Although both were metropolitan health regions, the former Calgary Health Region and Capital Health had very different corporate cultures, organizational structures, operational processes and support services. A memorandum of understanding (MOU) was reached between the two health regions to establish the context for the relationship and to ensure each region was a contributor to the development of HLA. The one-page MOU outlined the parameters of the service and set the expectation that the two regions would work together toward a common goal.

The two regions developed an implementation plan to guide the planning and rollout of HLA. A key element of the plan was the creation of a governance structure that would facilitate a partnership between HLA, the non-metropolitan health regions and other provincial stakeholders. The framework established a planning committee with representatives from key stakeholder groups, including the former health regions, the Alberta Cancer Board, and the Alberta Mental Health Board. (As of April 1, 2009, all public healthcare entities in the province of Alberta have been amalgamated into one organization – Alberta Health Services.) This committee, called the Provincial Collaborative Council (PCC), provided a forum for initial implementation planning, ongoing strategic planning, web development and oversight for evaluation of the HLA service. A provincial operations committee, comprising managers from both the Calgary and Edmonton sites, was created to oversee day-to-day planning and operations of the service. According to a comprehensive, three-year evaluation of HLA conducted by an independent evaluator, the governance framework "provided an effective means of facilitating the initial coordination and integration of HLA with regional health services" and "was instrumental in the expansion of HLA to all Albertans" (Alberta Health and Wellness 2006: 36).

With these formal structures in place, the task of ensuring local regional program providers understood the relationship of their service delivery to that of HLA began in earnest. The provincial director of Health Link Alberta and the Calgary manager hit the road and, over a five-month period, met with senior executives, managers, front-line staff and physicians across Alberta. The "road show" was part of a community development approach to engage regional providers in articulating their issues and identifying opportunities to integrate HLA with regional programs and services. Some of the key opportunities they identified included:

• Collapsing existing hotline and recorded-information services;
• Identifying and customizing "hand-offs" to local health providers to ensure continuity of care for the caller;
• Enhancing and standardizing evidence-based practice;
• Creating an inventory of all regional health services;
• Reducing the on-call function, particularly in rural regions;
• Managing the risk of telephone advice provided by busy emergency department staff; and
• Responding quickly to health emergencies.

Most of these opportunities dovetailed with the HLA mandate and were integrated into the rollout process. The time and effort expended on the road show was well spent. Rather than seeing HLA as something imposed on them by the province and external to their service delivery, regional stakeholders saw themselves as HLA partners with an equal share in its success. As such, they had confidence in the service and played a pivotal role in marketing it in their regions.

Once region front-line staff were oriented, the work of integrating HLA with regional programs and services began on a number of fronts. Clinical content used by HLA was reviewed by experts in each region to confirm congruence with local practices. Detailed service information – including description, location, hours of operation, referral process and more – was collected for all regional health services and entered into InformAlberta, an online, searchable directory of health and human services in the province. Process flowcharts were developed for each region to manage seamless hand-offs from HLA to regional services, such as emergency departments, community/public health, home care and environmental health. Before the launch, all regional staff were oriented to the HLA service to enable them to accurately describe it to their patients and clients. Health Link Alberta provided common marketing materials, including refrigerator magnets and brochures that were distributed in each region through established distribution systems. Posters were placed in all healthcare facilities and clinics and other common meeting places identified by each region. At launch, a "no health advice in the emergency department" policy was implemented by each region to mitigate the known risk to busy emergency staff. Public health centre reception staff were provided with scripts and instructions to refer calls for health advice to HLA. Health Link Alberta was rolled out one region at a time. By June 2003, all regions were "live" – just seven months after the implementation process began.

Regional integration was a significant undertaking but was not the only way in which HLA was becoming a fully integrated provincial health advice and information service. In April 2003, the Alberta Mental Health Helpline was integrated into the HLA delivery model. People could still call the mental health line, but it was now answered by HLA nurses. The HLA infrastructure was also used to provide three additional health-related telephone-based services on a contract basis from the Edmonton site. These services include an addiction information and referral service, for people impacted by alcohol, drugs and gambling addictions; a smokers' helpline that provides tobacco cessation counselling; and a child disability resource link that assists families of children with disabilities.

Change Process/Methodology/Results

Alberta Health Services identified four change strategies that are central to the process of integrating services and achieving best practices. Each of these strategies, and how they contributed to the integration of HLA services across Alberta, is described below.

1. Providing People-Centred Care

Health Link Alberta is successful because it never loses sight of the people it serves. Providing people-centred care is about making it easier for patients, families and providers to participate in and better understand the care journey. Health Link Alberta makes the care journey easier by being the first – and, in some cases, the only – point of access that people require for the health system; over half (54%) of callers with symptoms are given self-care advice. Customer focus is an integral part of all staff orientation; service is focused on the need the caller identifies, and choices are given for follow-up care where required. Caller satisfaction surveys are conducted daily.

Success in focusing on the caller is evident in the results of the Alberta Health and Wellness evaluation report (Alberta Health and Wellness 2006), as well as in annual satisfaction surveys conducted by HLA in 2008 and 2009. Caller survey results consistently show callers are able to get the information needed (95% agree/strongly agree); could handle a similar concern in the future (80%); and are highly satisfied with the service overall (>90% rate as very good/excellent). In comparison, 80% of Canadians rank the quality of telephone advice lines as good or excellent (College and Association of Registered Nurses of Alberta 2008).

Customer focus is evident in other ways as well. Regional healthcare providers noted the ability of HLA to service hard-to-reach populations – those with limited mobility, those requiring translation and those wishing to remain anonymous (Alberta Health and Wellness 2006). Alberta Health and Wellness (2006) physician survey results found 67% thought their patients with symptoms benefited by using HLA. In fact, many of the challenges presented by regional integration were overcome by focusing on "people-centred care" as a key touchstone. Many barriers were broken down by focusing on the needs of patients and clients, rather than on protecting any regional or provider "turf."

2. Reducing Clinical Variance

Health Link Alberta is a single service delivered from two sites to people throughout the province. While this model offers many benefits, including a larger pool for recruitment and back-up capacity when needed, multiple sites present significant challenges to providing a standardized service. One of the key ways in which HLA reduces clinical variance is through electronic evidence-based protocols that are used as decision-support tools by all nurses, whether in Edmonton, Calgary or working from home. The protocols include guided assessment questions that provide a standard approach to assessing patient symptoms and making appropriate dispositions. Clinical content in the protocols is reviewed regularly by content experts and updated simultaneously by one site to reflect new standards and/or best practices. Healthcare providers around the province routinely consult the clinical practice team to ensure front-line advice is congruent with that provided by HLA or to find the most current best practice for a particular intervention.

Regional integration presented a different challenge to reducing variance. Although regions offered similar services, the way in which those services were delivered varied from one region to the next and, in some cases, from one site to the next within a region. Business and clinical processes used to refer people to regional services had to be identified, documented and, where possible, standardized to ensure HLA agents were providing reliable and practical information.

Other tools and processes used to standardize practice include common orientation to practice, common staff appraisal tools and standards, common discussion of practice innovation and operational issues, and standardized monthly and annual reporting to all stakeholders.

3. Organizing the Care Continuum

Health Link Alberta is experienced as part of a seamless continuum of care in which the teletriage nurse hands off the patient to the next care provider, along with relevant clinical episode information. Integration across this care continuum is supported by improved information-sharing processes and single-point-of-access solutions. Tools like electronic client records make it easy for HLA to share information with other care providers. Nurses securely fax caller clinical information from their desktop to other providers anywhere in the province when follow-up is required by another healthcare provider. Front-line staff indicate that the information faxed provides an understanding of the nature of the problem and helps them prepare to call back the client; provides a baseline to determine…if symptoms have changed significantly; reduces the need for the client to repeat their story and provides for continuity of care (Alberta Health and Wellness 2006: 57).

A shared plan of care between the primary healthcare provider and HLA for individuals with chronic mental health concerns is another example of continuity of care. The shared plan, part of the client electronic record at HLA, promotes a consistent approach to the patient.

In 2005, results of the physician survey indicated 40% of physicians felt HLA reduced the number of patients seen after regular daytime hours (Alberta Health and Wellness 2006). Developing relationships with the primary care networks have HLA staff booking next-day appointments in physician offices, faxing referrals and scheduling appointments in after-hours clinics.

Other examples of organizing the continuum of care include hand-offs from the generalist nurse at HLA to more specialized providers – those with particular areas of expertise in chronic disease management and providers with other scope of practice, such as pharmacists and dietitians. Health Link Alberta callers can immediately access both pharmacist and dietitian services through call transfer by the HLA nurse. A pilot with virtual-team community-based pharmacists at the Edmonton site has these health professionals documenting on the same electronic caller record as the HLA nurse. Findings include increased access to pharmacist services after hours and increased volume and richness of adverse reaction reporting.

Health Link Alberta also assists with management of public health emergencies or outbreaks across the continuum of care by providing the public with access to timely, accurate information on what has occurred and on how to access any services they require. Examples include boil-water advisories, hepatitis and salmonella outbreaks, and the Wabamun oil spill, where bunker oil from a train derailment contaminated a popular recreational lake, with subsequent health- and water-quality issues affecting hundreds of people. Health Link Alberta's response can be tailored from a provincial scope to a local hamlet. Intranet tools allow management of the information the HLA staff need to respond to caller concerns.

In addition, HLA, through the Edmonton site, has developed central access for specialist appointment scheduling and wellness and chronic disease management class registration. Central access is used by the public, primary care physicians and other health providers across the province as a single point-of-contact to a growing number of programs and services provided in Edmonton (16 at time of writing). Central access not only improves continuity of care as the HLA nurse can, for example, directly connect pregnant women with prenatal class registration, but also helps to maximize the use of program resources by managing a single wait list for multiple program sites. In 2007/2008, central access received 29,623 calls and booked appointments for 16,070 registrants.

InformAlberta is another important strategy for organizing and integrating the care continuum. InformAlberta was developed by HLA in collaboration with the City of Calgary as a comprehensive online database of all health and human services offered in Alberta. HLA staff use the database to assist callers in navigating the health system. Public users can also access it online to conduct their own searches. During the planning and implementation of HLA, the implementation team worked with "data stewards" in each region to collect, review and enter program and service data. Ownership of service content is decentralized to the program level, with regionally-based stewards having responsibility for the regular review and update of service information in their regions.

4. Improving Process Management

Process management and improvement have been central to HLA's operations since its inception. Two supports are key to efficient and effective process management – electronic tools such as the Internet and clear and concise process maps or flowcharts. Flowcharts are used in all areas of the contact centre to clearly and concisely document business processes so that staff can use them to standardize the work of the centre. Expectations and standards of practice for such things as call management, call length and number of calls managed per shift are presented at orientation and regularly reinforced. All calls are recorded and randomly selected by managers for review with each agent every month – another tool to assist with standardized service quality and process management. Health Link Alberta agents receive extensive orientation, including three weeks in the classroom and "buddy shifts" until they transition to independence. In addition to daily reminders, "tips" and coaching from managers, staff receive periodic updates and inservices to ensure their knowledge and skills remain sharp.

A standardized, system-wide issues management process enables all HLA staff, callers, regional stakeholders and other health providers to flag potential problems or issues for resolution as they arise. This process was particularly important during implementation, as it allowed regional stakeholders to provide immediate feedback if things were not working as planned, and to see those issues addressed in a timely manner. Feedback on the outcome of the issue investigation is provided to both the regional contact for HLA and the initiator of the issue. This two-way flow of information through the regional HLA contact was key to ensuring that a regional representative was aware of any issues with HLA service delivery and was key to issues resolution as the regional representatives were informants on local culture, standards and service delivery. During implementation in 2003, health region senior managers and medical directors, as well as community and emergency department physicians identified several protocols where they felt advice provided was too cautious, with too many callers being referred for immediate medical attention. Based on this feedback, a revision was made to a number of protocols, with positive feedback from stakeholders (Alberta Health and Wellness 2006).

Conclusion

Within just three years of being launched as a province-wide service, HLA had achieved 63% awareness among all Alberta households. That number was even higher among females (70%), families (74%) and adults aged 25–44 years (76%). These high awareness levels are directly attributable to marketing of the service by front-line providers, and awareness has continued to increase. By 2005, 46% of Alberta households had used the service at least once, and almost 100% said they would use it again. In 2005/2006, HLA broke the one million plateau, receiving 1,037,415 calls – a 16% increase since its launch in 2003. Call volume has remained over one million calls per annum. The majority of calls to HLA are for health advice and information. Over half (54%) of health advice callers are advised to provide self-care, 31% are advised to see a physician or other healthcare provider and between 10% and 19% are sent to an emergency department (varies by region, depending on the availability of other services). Compliance is very high, with 74% of those advised to go to an emergency department doing so in less than 24 hours and 72% of those given self-care advice acting on that advice (Alberta Health and Wellness 2006).

A key indicator of the success of integration strategies has been the positive response from region health providers and physicians. In addition, HLA has monthly requests for consultation with other national and international jurisdictions inquiring about HLA success factors in integration and marketing.

Integration is about building stronger connections between health services, people and providers to better support people in the care journey. Health Link Alberta is a successful example of health system integration because it took the time to establish collaborative governance structures, build relationships with regional and provincial stakeholders, recognize and accommodate regional and local needs, and develop the processes and tools that it needed to deliver a quality, consistent and accessible service for all Albertans. It has established an effective service delivery infrastructure by which it meets the following key objectives of health system integration:

• Increasing coordination and integration among regional healthcare services and providers;
• Providing staff, physicians and partners with the tools they need to deliver care more effectively;
• Increasing emphasis on health promotion and disease/illness prevention; and
• Encouraging more appropriate use of Alberta's healthcare resources.

As Alberta moves toward a fully integrated provincial health system, HLA is recognized as a model of successful integration.

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