Integrated Healthcare Organizations (IHOs) would combine responsibility for the delivery of acute care, primary care and homecare in one organization.  Additional functions could be added over time as the IHO matures, with emergency medical services (EMS) and medication management/drug programs being logical candidates.  IHOs need to be large enough to achieve economies of scale, but small enough to be manageable.  The exact number requires further analysis, but thirty to forty is likely the right range for Ontario.  System planning and funding would remain the responsibility of the Ministry, Local Health Integration Networks or whatever regional planning structure is in place.  The purpose of IHOs is to improve healthcare delivery and do it on a more cost-effective basis, not to replace current planning and funding models.

This construct was explored in two opinion pieces published by Longwoods earlier this year.  The articles elicited considerable response, including thoughtful contributions by Nan Brooks and Will Falk.  Brooks argued that “one size does not fit all” and that the IHO model would be particularly problematic in the Greater Toronto Area (GTA), given its size, complexity and diversity.  Falk felt that creating IHOs would be too disruptive and that a more evolutionary approach to system reform would be preferable. 

While disagreeing with Brooks and Falk in some respects, the approach recommended below is in fact “evolutionary” in that it builds on current structures and expands their mandates.   Falk is right that creating entirely new organizations as IHOs would be both highly disruptive and counter-productive.  However, given on-going challenges in delivering high quality healthcare, combined with the Province’s fiscal challenges, now is the time to move to more streamlined and effective care delivery models.

Implementation

The implementation of IHOs should build on current organizations and extend existing accountabilities.  The Province would need to designate a “lead” organization for each IHO.  In most instances this would likely be a hospital.  Boards of directors and management teams would stay in place and evolve over time to reflect changes in functions and the needs of the population served by the IHO.  Existing legislation and funding mechanisms are sufficiently flexible to allow implementation to proceed quickly.  If a decision was made to proceed in this direction, great progress could be made in three to six months.  Some commentators suggested that this implementation model would result in IHOs that are acute care and hospital dominated.  With the right funding, measurement and accountability mechanisms this will not occur.  The pressing system-level needs at the moment are addressing long emergency room waits and getting patients into the right care settings.  Both of these issues would be hugely aided by having primary care and homecare under the direction of one organization.

There are live examples today where integration has worked well.  However, the problem is that these examples have not been propagated and generalized and both care quality and efficiencies have suffered as a result.  Put multiple functions and organizations under common governance and leadership and real change can happen relatively quickly.  Quinte Healthcare Corporation (QHC) is a great example.

QHC is an amalgamation of four hospital corporations located in Belleville, Picton, Trenton and Bancroft.  Single governance and leadership has allowed QHC to make significant moves to create a true system of care.  Previously, limited size did not allow for the most up-to-date equipment or for the ability to attract top clinicians to smaller communities.  QHC shifted all higher acuity patients to Belleville, creating a critical mass that allows for a 7x24 Intensive Care Unit with specially trained staff.  Trenton had an excellent physical plant and became the principal centre for day surgery.  While surgeons were initially sceptical, they have embraced the new approach as it is has increased their efficiency and allowed them to provide better care in a specialized environment.  Emergency rooms and basic primary care has been retained at each of the four hospitals, as geographic distances make this important for good care.  The two primary care hospitals in Picton and Bancroft have excelled in their ability to treat patients close to home and yet have specialist care available within their own organization.  All of this would have been extraordinarily difficult if it required endless negotiation across multiple organizations, each with its own board and management team.

What about the GTA?

So what about the GTA and the argument of Ms. Brooks?  She is correct that the region is large, complex and diverse.  As a result, it should have multiple hubs – several IHOs.  Patients would be free to choose their healthcare providers, as they are able to today, but care would be much better coordinated and integrated.  Rostering of patients (with the ability on the part of patients to change IHOs) would greatly support better care management, particularly for patients with chronic diseases who require on-going monitoring, care management and the support of a variety of clinicians.  Homecare provision could start with post-acute care services being provided by the IHO and then be extended to additional services as appropriate.  There are good examples today of where excellent cooperation across organizations improve care.  Particular heart attack patients (STEMI) get top-notch care in the GTA as a result of cooperation between EMS and multiple hospitals.  And there are other examples; however, great care shouldn’t be dependent on good personal relationships between leaders and there are multiple opportunities for care improvement that we are not exploiting because our care system is so fragmented. 

Primary care needs particular attention and better integrating it into IHOs can be done relatively quickly and effectively and without coercing physicians.  Community physicians want better access to patient information and to specialist consultations and IHOs can offer them both.  This should be particularly helpful in caring for patients with one or more chronic diseases, patients who now make up the bulk of both the cost and the care requirements of the Ontario healthcare system.  Formal links to IHOs would allow the IHO to support family physicians with electronic information links and perhaps “help desk” support as well for their information systems.  Discharge summaries and other patient information would be readily available.  Work should start with some of the larger group practices and integrating them first, but then an outreach program should link to smaller practices and solo practitioners.  The Ministry could help by funding a full-time position at each IHO (likely staffed by a family physician) who would work with his or her colleagues to facilitate effective primary care integration.  The role would be similar to highly successful clinical leadership positions currently in place at Cancer Care Ontario.

Let’s use a QHC example again.  Serving Prince Edward County, the Picton hospital has a long and proud history.  It also has one of the strongest family health teams (FHTs) in the Province.  Doctors who join the team agree to provide ER coverage on a rotating basis and to follow their patients while in hospital.  Electronic health records are already linked between the hospital and the FHT.  Plans will soon be submitted to the Ministry to redevelop the current hospital site to physically link the hospital, the FHT and various community support services.  This is clearly a model for the future.

Homecare delivery

Integrated access to homecare resources is essential for the IHO model to work.  If the Ministry wants a phased approach, the responsibility for post-acute homecare could be transferred to the IHO first.  Huge system challenges exist today with patients being in the wrong care settings (so-called ALC patients).  While some of these issues have been addressed, putting all of the homecare resources under the control of an IHO would create a single point of accountability and also allow the Ministry and the public to hold a single organization responsible, rather than sit by and observe finger pointing between multiple organizations.
Congestive heart failure is a great example of a chronic disease where research evidence supports a care model that integrates primary care, acute care and homecare.  Good information links and coordinated care plans for primary care, self-care and homecare significantly reduce the likelihood that CHF patients will require in-hospital stays.

Move Quickly

In his articles, Falk provides some useful cautions that need to be taken into account in thinking about implementation.  He fears that government would insist that Board appointments be made provincially by political appointment.  This would be a major mistake.  Existing locally appointed Boards should be kept in place and they should be charged with reviewing their membership and ensuring that it is appropriately representative given the expanded mandate of the IHO.  Strong executive leaders will be needed for each IHO, and the Board should review and monitor this as appropriate.  Falk argues for an evolutionary approach to change and this makes sense.  However, the destination needs to be IHOs with integrated acute, primary and homecare and we need to move quickly.  Both quality of care and the government’s finances will suffer if we don’t.

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