Essays

Essays April 2019
Opinion

A Cure for Chaos? Ontario’s Health System Transformation from Street Level

Andrew J. Bond

tent city 

The Opportunity

The 12,000 Ontarians experiencing homelessness each day face life expectancies below 50 and a disproportionate prevalence and complexity of physical illnesses, mental health challenges and substance use disorders (Hwang et. al. 2009). The additional chaos foisted upon them by the deeply disconnected and barrier-rich health sector appears at street level to be purpose-built to fail. Ultimately, the human, system performance and economic costs of the status quo for people experiencing homelessness, a subset of who have been identified as health system 'super-utilizers' (Blumenthal et. al. 2016), are profound (Hwang et. al. 2011) (McCormick and White, 2016) (Hwang et. al. 2013). While there are notable pockets of exception across the province, these beacons of hope remain significant outliers.

Given this dismal state of affairs, the announcement by the Minister of Health and Long-term Care on February 26th that ‘the people of Ontario deserve peace of mind that this system is sustainable and accessible for all patients and their families, regardless of where you live, how much you make, or the kind of care you require’ (ON Goverment, 2019) was received with eager anticipation and hope. That these goals are to be achieved through a health-system transformation driven by the imperatives of person-centered care and performance-accountable integration into Ontario Health Teams (OHTs) aligns very well with the tools that we know work for people experiencing homelessness – targeted, specialized outreach medical services thoroughly integrated with hospital, shelter, social supports and the wider primary care system (McCarthy et al. 2015). Not only has this approach been successfully pioneered in some of the largest public health systems in the US (O’Toole et. al. 2016) and the UK (Wyatt, 2017), it has also been picked up by UnitedHealth in the private sector in the US, a clear signal of the cost-efficiency of these models of care. 

The Challenges

Integration has always been touted as the strategic ideal to ‘fix’ healthcare (Porter and Lee, 2013). The challenge of going beyond simple ‘joined-up’ (Hawkes, 2009) care to real integration, however, is difficult to overstate, especially in the community sector. There one finds hundreds of small- to medium-sized agencies working in widely variable geographies from the hyper-local to the widely dispersed. Bringing them together into geographically distinct integrated wholes is a herculean aspiration – but a worthy one.

Despite the sheer number and range of organizations, the vast majority are highly motivated to do the best for the people they serve and are used to working collaboratively. The community health sector lives by relationships, and learning how to cultivate and empower these relationships in deeper ways will be a significant determining factor in the success or failure of the current transformation. The openness and voluntariness of the current OHT process may be complicated and confusing at times, but its importance as an enabling approach is unquestionable.

Another major challenge ahead will be developing the relationships required between the community health and hospital sectors. Much important work has been done by both sectors in previous years, but it would be a mistake to assume that there do not remain major obstacles ahead in designing governance and accountability systems for OHTs that balance the goals of community health agencies and hospitals for the long-term benefit of the people they collectively serve. While the power and budget imbalances will be substantial, with adequately designed performance measures and accountability mechanisms, highly constructive partnerships can form that are able to deliver meaningful value-driven health system improvements. 

A complex irony facing the community health sector serving vulnerable and marginalized populations, in Toronto at least, is that many organizations doing this difficult work may be too integrated for the Ministry’s plan. As OHTs have been almost entirely described as being geographical entities, and Toronto will certainly require the formation of several OHTs, there is a fundamental problem for those organizations which are organized and operate across the whole city and thus across what will predictably become multiple OHT geographies. It is not at all clear how such organizations are to engage with the OHT formation process and there is an urgent need for a strategic policy solution to this problem. As the leading edge of integration, they should be the guides to the future rather than the collateral damage of a system struggling to catch up.

The Responsibility

Despite the significant challenges ahead, the promise of integration is both real and enormous for all Ontarians. For those experiencing homelessness, the prospect of a cure for chaos – at least that of the healthcare system – portends marked improvements in health, quality of life and service experiences. Such opportunities demand deep responsibility on behalf of all those involved to approach the health system transformation as a civic process of collective value creation – human value, economic value, and societal value.  These lofty goals need to sink deep into the architecture of organizational restructuring and governance, the choice and balance of performance metrics and ultimately the way budgets are set, divided and held publicly accountable. As we move into this open future, let’s not forget that serving people as whole individuals and communities goes well beyond integration within the healthcare sector and keep alive the prospect for integration across sectors including shelter, housing and social services; it is there that the greatest value can be realized and we are already heading off in that direction together.  

About the Author

Andrew J. Bond, BScH, MD, CCFP, FCFP

Medical Director, Inner City Health Associates

Lecturer, Department of Family and Community Medicine, University of Toronto

Chair, Canadian Network for the Health and Housing of the Homeless (CNH3)

References

Blumenthal, D., B. Chernhof, T. Fulmer, J. Lumpkin, and J. Selberg. 2016. Caring for high-need, high-cost patients: An urgent priority. New England Journal of Medicine 375(10): 909-911; Gawande, A. 2011. The Hot-Spotters: Can we lower medical costs by giving the neediest patients better care? The New Yorker January: 40-51.

Hawkes, N. 2009. Joined-up Thinking. British Medical Journal 338: 1238-1239

Hwang, S., C. Chambers, S. Chiu, M. Katic, A. Kiss, D. Redelmeier, and W. Levinson. 2013. A comprehensive assessment of health care utilization among homeless adults under a system of universal health insurance. American Journal of Public Health 103(S2): S294-301.

Hwang, S., J. Waver, T. Aubry, and J. Hoch. 2011. Hospital costs and length of stay among homeless patients admitted to medical, surgical, and psychiatric services. Medical Care 49(4): 350-354.

Hwang, S., R. Wilkins, M. Tjepkema, P. O’Campo, and J. Dunn. 2009. Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study. British Medical Journal, 339(7729): 1068-1070.

McCarthy, D., Ryan, J., and S. Klein. 2015. Models of care for high-need, high cost patients: An evidence synthesis. New York: The Commonwealth Fund.

McCormick, B. and J. White. 2016. Hospital care and costs for homeless people. Clinical Medicine 16(6): 506-510;

Ontario Government News Release. 2019. Ontario's Government for the People to Break Down Barriers to Better Patient Care.  https://news.ontario.ca/mohltc/en/2019/02/ontarios-government-for-the-people-to-break-down-barriers-to-better-patient-care.html

O’Toole, T., E. Johnson, R. Aiello, V. Kane, and L. Pape. 2016. Tailoring care to vulnerable populations by incorporating social determinants of health: The Veteran’s Health Administration’s ‘Homeless Patient Aligned Care Team’ Program. Preventing Chronic Disease 13(E44) 150567 DOI: http://dx.doi.org/10.588/pcd13.150567

Porter, M. and T. Lee. 2013. The strategy that will fix healthcare. Harvard Business Review 91(10): 50-70.

Wyatt, L. 2017. Positive outcomes for homeless patients in UCLH Pathway program. British Journal of Healthcare Management 23(8): 367-371

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