1. Medically Complex Patients (MCP) Webinar Advancing a System of Integrated Care November 17, 2014 Jodeme Goldhar MSW, RSW, MHSc Lead, Health System Integration for Complex Population and Primary Care – Toronto Central Community Care Access Centre Adjunct Lecturer, University of Toronto, Institute of Health Policy, Management and Evaluation President, University of Toronto, Institute of Health Policy, Management and Evaluation, Society of Graduates Onil Bhattacharyya MD, PhD Co-Principal Investigator, BRIDGES Frigon Blau Chair in Family Medicine Research, Women’s College Hospital Associate Professor, Department of Family and Community Medicine & Department of Health Policy, Management and Evaluation, University of Toronto

2. Objectives A deep dive into integration: – What is it? Can it be measured? How do you integrate successfully? – Barriers and facilitators; the role of leadership Integrating for system change: – Strategies for Inter-sectorial action 2 What is Integration? Barriers and Facilitators Inter-sectoral Integration

3. Defining Integration “Human service integration is a process by which two or more entities establish linkages for the purpose of improving outcomes for people in need” Konrad,1996 “a complex intervention where management and organizational process to support integrated care occur at many levels simultaneously” Goodwin, 2013 “Joint working” 3 What is Integration? Barriers and Facilitators Inter-sectoral Integration

4. Levels of Integration – Integration as a Continuum Information sharing and communication Cooperation and Coordination Collaboration Consolidation Integration Konrad, 1996 4 What is Integration? Barriers and Facilitators Inter-sectoral Integration

5. Valentijin, P., Schepman, S., Opheij, W., 7 Bruijnzeels, M.Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care. Int J Integr Care 2013; Jan–Mar 5 Multidimensional Framework for Integrated Care

6. Why Integrate? Benefits of integration: – Ability to address complex needs comprehensively – Greater service accessibility and continuity – Early intervention and prevention – Reduced duplication – Reduced waste/inefficiency – Reduced costs – Greater accountability Wingspread Conference, 1993 6 What is Integration? Barriers and Facilitators Inter-sectoral Integration

7. Are There Drawbacks to Integration? Less organizational flexibility Loss of organizational identity Time involved May limit client choice Flatau, 2013 7 What is Integration? Barriers and Facilitators Inter-sectoral Integration

8. Can Integration Be Measured? Proposed dimensions to examine: – Structural inputs (e.g. extent, scope, depth, congruence within an agency, reciprocity between agencies) – Functioning (e.g. quality of the partnership, working arrangements, range of services provided) – Outputs (e.g. network capacity, network activities, access, outcomes) Browne, 2007 8 What is Integration? Barriers and Facilitators Inter-sectoral Integration

9. What type of integration activities have you undertaken?

10. INTEGRATING SUCCESSFULLY

11. Structural Reform? Layered On? Point of Care – Functional Integration Unwavering Focus A Debate About Reform and Which Road is Best…Steadfast Despite Political Context 11 What is Integration? Barriers and Facilitators Inter-sectoral Integration

12. Functional Integration at the Point-of-Care Our Aim Supporting populations with complex needs with better care at home in their communities, utilizing existing resources Our Approach Creating One Team Through The Eyes of Clients and Families For the Client/Family Seamless care One team approach For the Providers One team approach Built around client and family needs 12 What is Integration? Barriers and Facilitators Inter-sectoral Integration

13. What is Integration? Barriers and Facilitators Inter-sectoral Integration CCAC Working Hand-in-Hand with Primary Care Care Coordination Across the Care Continuum Acute Care Partnership and Protocols Pharmacy Engagement Emergency Medical Services Partnership Caregiver Support 13 Functional Integration in Practice

14. Stop, Take Stock and Reflect LESSONS LEARNED How to Enable Functional Integration What is Integration? Barriers and Facilitators Inter-sectoral Integration

15. How can we work together differently? What do I need to do differently? How can we understand and experience different perspectives? How can we all work together on what is most important to the client/family? Walk a Mile or Two…

16. Relationship Will Determine Success Trust Will Determine Success Safe Shared Accountability 16 What is Integration? Barriers and Facilitators Inter-sectoral Integration

17. Opposing Notions Tensions Integrated Solutions through the eyes of Clients and their Families 17 What is Integration? Barriers and Facilitators Inter-sectoral Integration

18. Need For Scientific Evidence and Outcomes With Quality Improvement Frameworks For Effective Change in Complex Adaptive Systems Balance 18 What is Integration? Barriers and Facilitators Inter-sectoral Integration

19. Integrated Care Team Client and Family Experience “I meet with my ICCP care coordinator every two weeks or so… She speaks with my doctor. This is the first time the doctor ever came to my home.” – Client “The Coordinator works with other professionals to collect information, so I just have one person to contact. It saves me time.” – Primary Care Physician “The cross-sector care we now provide is improving the patient experience - as witnessed by shorter lengths of stay and improved patient satisfaction scores within these patient groups.” – Acute Care Partner 19 What is Integration? Barriers and Facilitators Inter-sectoral Integration

20. Do not wait for complex solutions 20 What is Integration? Barriers and Facilitators Inter-sectoral Integration

21. There is no script… Lead through Ambiguity… …Build the bridge as you walk on it 21 What is Integration? Barriers and Facilitators Inter-sectoral Integration

22. Leverage e-Enablers to Support Point-of-Care Integration 22 What is Integration? Barriers and Facilitators Inter-sectoral Integration

23. Greater Emphasis on EMOTIONAL INTELLIGENCE Leadership Leaderful 23

24. Incremental Build 24 What is Integration? Barriers and Facilitators Inter-sectoral Integration

25. Maturity Reached Over Time 25 What is Integration? Barriers and Facilitators Inter-sectoral Integration

26. Lift Up, Look out… …and Honour the Past 26

27. Lessons Learned from BRIDGES Integrate mental health with the rest of health Build leadership and governance models that engage multiple stakeholders Examine the role of incentives, accountability and shared risk in addressing barriers to integration Consider appropriate timeframes BRIDGES Evaluation Final Report, 2014 27 What is Integration? Barriers and Facilitators Inter-sectoral Integration

28. What barriers to integration have you come across? How have you addressed them?

29. Integrating for Systems Change What is Integration? Barriers and Facilitators Inter-sectoral Integration

30. “The effort to bring local system change has required collaboration by all key stakeholders, responsiveness to community identified priorities, and emphasis on frontline agency and staff empowerment and capacity building. It has fostered relationships that involve mutual respect, equity, and inclusiveness, recognizing the community as a resource and aiming for shared leadership and power in health program development” Stergiopoulos, 2014 30 What is Integration? Barriers and Facilitators Inter-sectoral Integration

31. Integrating for System Change What is system integration? – Alignment of rules and policies within a system Valentijin, 2013 System integration requires a combination of structures, processes and techniques to fit the needs of individuals and populations across the continuum of care Armitage, 2009 It often involves coordination of key support functions such as financial management, human resources, strategic planning, information management and quality improvement 31 What is Integration? Barriers and Facilitators Inter-sectoral Integration

32. When the Patient is the System…. Minister’s Advisory Group, Respect, Recovery, Resilience: Recommendations for Ontario’s Mental Health and Addictions Strategy Crisis services Housing Legal support Income support Employment/ education Front line, specialized and intensive services Social integration X Hospital based care Transition of care DISCHARGE SERVICES 32 What is Integration? Barriers and Facilitators Inter-sectoral Integration

33. Strategies for Inter-Sectorial Action Establish a common ground by driving integration from the perspective of the common client and their caregivers Demonstrate the value of inter-sectorial work by embedding champions who have already started to do this work Understand the experience of local providers and engage them for joint planning and development Integration takes time… Stick to it! 33 What is Integration? Barriers and Facilitators Inter-sectoral Integration

34. What sectors are you integrating or wish you could be integrating? How have you gone about it?

35. Questions?

36. 36 BRIDGESOMAMOHLTC www.building-bridges.cawww.oma.orghttp://www.health.gov.on.ca/en/ @BRIDGESIncubatr@OntariosDoctors@ONThealth BRIDGES@utoronto.capsc@oma.organgela.bearance@ontario.ca (416) 323-6400 x 30591-800-268-7215(613) 650-5438 Contact Us