1. Noushon Farmanara & Catherine Labasi-Sammartino, MOHSSR
Clinical Integration Through Centralisation and Merger: Promises and Potential Pitfalls
Amélie Quesnel-Vallée Canada Research Chair in Policies and Health Inequalities Director, McGill Observatory on Health and Social Services Reforms
Noushon Farmanara & Catherine Labasi-Sammartino, MOHSSR

2. Bill 10: The Promise Improve the accessibility of services
Improve the quality and safety of services
Increase efficiency
Through
Merger of establishments
Centralisation of administrative structures
Founded on assumptions of a hierarchical, mechanical views of organisations. Health care organisations, which are complex, and ideally learning/adapting systems, do not conform well to that model
Sources:: Contandriopoulos D, Perroux M, Brousselle A, Breton Mylaine. Analyse logique des effets prévisibles du projet de loi n°10 et des avenues d'intervention souhaitables. Montréal: Institut de recherche en santé publique Université de Montréal; p.
Mémoire à la commission de la santé et des services sociaux sur le projet de loi 10. Montréal: Département d’administration de la santé, École de Santé Publique Université de Montréal; p.

3. Mergers: Evidence from England
Non-linear inverse relationship between size of merger and cost savings
Optimal below 200 beds
Plateau at 400 beds (~3,000 employees; 100,000 population)
600+ beds more costly
Improvement in quality only for low volume services
Cultural differences between establishments an unforeseen barrier to integration
Alberta: A similar approach to Bill 10
- Regional structure abolished and centralized governance responsibilities to the Alberta Health Services
Did not improve the efficiency that had been promised
Patients have difficulty navigating the structure
Civic organizations have difficulty identifying local service managers
AHS more concerned about corporate functions and responsibilities
Far from clinicians and patients
Staff work to push problems under the carpet [items out the door]
Consequences:
Elimination of regional structure led to the creation of new structures
To integrate local concerns and implement local innovations at the provincial level
Sources: Nuffield Institute for Health, University of Leeds, & NHS Centre for Reviews and Dissemination, University of York (1996). Hospital volume and health care outcomes. Costs and patients access. Effective Health Care, 2 (8),1-16.; Fulop N. et al. (2002). Process and impact of mergers of NHS trusts: multicentre case study and management cost analysis. British Medical Journal, 325, ; Contandriopoulos D, Perroux M, Brousselle A, Breton Mylaine. Analyse logique des effets prévisibles du projet de loi n°10 et des avenues d'intervention souhaitables. Montréal: Institut de recherche en santé publique Université de Montréal; p.
Mémoire à la commission de la santé et des services sociaux sur le projet de loi 10. Montréal: Département d’administration de la santé, École de Santé Publique Université de Montréal; p.

4. Clinical integration: Intermountain
Focus: Care delivery process management and standardization
Lessons learned
Initiatives and changes were led largely by physicians
Focus on clinical processes and outcomes rather than location of care
Developed and adopted measurement standards and indicators for guideline adherence
Unique clinical management structure: part-time physician leaders teamed with full-time nurse administrators (within geographic regions)
OF COURSE: MONEY FOLLOWS THE PATIENT IN THIS SYSTEM
Intermountain Healthcare
Not-for-profit integrated healthcare delivery system providing medical services in Utah and Idaho; also offers integrated managed care under ‘SelectHealth’.
Intermountain’s Clinical Integration program, which was designed to improve value system-wide, focused on integrating HIT (health information technology), clinical and operations management, and incentives.
Eleven clinical improvement projects yielded $20 million in savings.
Beginning in the mid-1980’s Intermountain launched an effort to assess variation in the provision of certain medical services across providers.
Found large variation in treatment practices across physicians for patients with similar complexity and severity of disease.
This variation corresponded to an up to two-fold difference in the hospital’s costs per case.
Rather than focusing on individual physicians, they focused on improvement of process management that aimed to standardize processes of care delivery for a variety of treatments.
Resulted in both declines in variation while maintaining high clinical outcomes for patients. Decreased variation in care delivery also contributed to lower costs.
1991 initiative by Intermountain that introduced evidence-based clinical practice guidelines for use of mechanical ventilators for treatment of serious pulmonary illnesses (i.e. acute respiratory distress syndrome).
Guidelines were integrated into clinical work (e.g. through checklists, order sets).
Among those who were seriously ill, this method reduced variation in the implementation of evidence-based guidelines from 59% to 6%; furthermore, patient survival went from 9.5% to 44%.
Recognized that process measures and quality improvement interventions largely being applied within isolated practices.
In 1995, leaders at Intermountain began development of strategy to extend quality interventions and standards across the entire Intermountain system.
Four key components to the initiative:
Identify key processes (interventions, care delivery).
Relatively small subset of services that make up the bulk of care delivered by a clinical organization.
Example: 11% of the systems care delivery costs were related to pregnancy, labour, and delivery – thus, initial clinical process interventions focused in this area.
Create information systems for parallel clinical and financial management.
Adapt organizational structure so that resulting data could be used to encourage accountability and change.
Align financial incentives so that clinicians would not suffer financial harm.
Mental Health Integration (MHI) – another initiative of Intermountain health to better integrate mental health care into primary care, beginning in the late 1990s.
Address challenges faced by primary care physicians when encountering patients with mental health concerns and their families (e.g. time constraints, lack of training, etc.).
Address underuse of evidence-based treatments for patients with mental health issues; particularly those with co-morbidities such as other chronic conditions.
Key considerations:
Initiatives and changes were led largely by physicians.
Focus on clinical processes rather than location of care; meant that the systems business model was catered towards population-level health and shifting focus towards factors that cause disease rather than solely responding to health issues (preventive vs. reactive care).
Developed and adopted measurement standards and indicators for guideline adherence (requiring significant time and resources).
Data available for 60 of 104 key clinical processes, which make up ~80% of clinical activities.
Unique clinical management structure: built around part-time physician leaders teamed with full-time nurse administrators (within geographic regions)
Leader-teams meet with physicians and nurses practicing within their health region to review process and outcome measures (e.g. clinical, cost, services) and to address improvement opportunities
Sources: James BC, Savitz LA. How Intermountain trimmed health care costs through robust quality improvement efforts. Health Affairs Jun 1;30(6):
Reiss-Brennan B, Briot PC, Savitz LA, Cannon W, Staheli R. Cost and quality impact of Intermountain's mental health integration program. J Healthc Manag Mar 1;55(2):
Enthoven AC. Integrated delivery systems: the cure for fragmentation. Am J Manag Care Dec;15(12):S284.

5. Clinical Integration: VA Health System
Focus: Transition from a hospital system to a health care system requiring coordination between facilities, variety of resources and provision of care in various environments
Lessons learned:
Ongoing measurement and public reporting of key health care process and outcome indicators.
Links between senior management compensation and indicator-based performance.
Centralized and computerized patient record system.
Integrated evidence-based clinical guidelines and automated tools to support standard and quality care among physicians and health care providers.
Veterans Affairs Health System
In response to criticisms of poor quality of care within the Veterans Health Administration, VA launched reorganization of health system in 1995 to include:
Better use of information technology.
Improved measurement and reporting of performance.
Integration of service and realigned payment policies.
Up until 1990s, VA operated largely as a hospital system focused on provision of general medical care, surgical services, etc.
Medical centers/facilities operated largely independently; delivery of duplicative services common.
Veterans Health Care Eligibility Reform Act (1996) – transition from hospital system to health care system; underlying assumption that the effective provision of care required coordination between facilities, variety of resources and provision of care in various environments (not just hospitals).
Largest integrated health care delivery system in the United States.
VA organized around regional networks (Veteran Integrated Service Networks – VISNs).
Approximately 23 VISNs across the US – with 152 inpatient medical centers and 1500 outpatient clinics.
Resources now allocated to each network, rather than individual facilities – helped create financial incentives for coordination of care and resources between facilities.
Veterans Health Administration ‘Quality Enhancement Research Initiative’
Integration of health services research, policy, and care delivery to improve quality, outcomes and efficiency of VHA.
Goal of implementing evidence-based practices in routine care settings.
Comparisons between similar patient groups using various quality indicators found quality of care to be higher in the VA system as compared to Medicare in the five years following the reorganization process (Jha et al. 2003).
Key considerations:
Ongoing measurement and public reporting of key health care process and outcome indicators.
Links between senior management compensation and indicator-based performance.
Centralized and computerized patient record system.
Integrated evidence-based clinical guidelines and automated tools to support use among physicians and health care providers.
Sources: Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N Engl J Med May 29;348(22):
Perlin JB, Kolodner RM, Roswell RH. The Veterans Health Administration: quality, value, accountability, and information as transforming strategies for patient-centered care. Am J Manag Care Nov 1;10(11):

6. Bill 10: Promise and Potential Pitfalls
Principles for successful integration (Armitage 2009)
Comprehensive services across the continuum of care
Patient Focus
Geographic coverage and rostering
Standardized care delivery through interprofessional teams
Performance management
Information Systems
Organizational culture and leadership
Physician integration
Governance structure
Financial management   
OVERVIEW OF PRINCIPLES FOR BEST PRACTICE OF CLINICAL INTEGRATION
Example of best practices taken from Armitage (2009) based on systematic review of current evidence domestically and internationally on clinical integration models.
Identified 10 key characteristics that were consistently demonstrated across these models.
Principles for successful integration
Key points
Bill 10: Contextualizing SWOT
Comprehensive services across the continuum of care:
Assume the responsibility to purchase/provide all core services for the population served.
Requires clear understanding of similar goals, vision, and mission.
Strengths and opportunities
Administrative mergers can support service corridors and facilitate patient navigation of health and social services system.
Potential to facilitate access and continuity of care.
Challenges and threats (Bill 10)
Reduced focus on population of health due to creation of large regions with different service needs; challenging to develop clear goals or mission.
Lack of representation from different institutional sectors (particularly social services) threatens the provision of a continuum of services and may lead to misallocation of resources.
Patient Focus
Patients at the centre of integration efforts.
Population needs assessment to drive service planning and integration; must be responsive to changing needs of the population
Importance of involving/being representative of the community served.
Challenges (Bill 10)
Patient engagement and participation is imperative.
Challenging for large integrated systems to maintain a patient-centred focus/mission.
Smaller systems may have better chances of improved patient outcomes and success (Linenkugel 2001).
Bill 10: Institutions perceived as mechanical entities, not as complex/dynamic institutions with community roots.
Reduced focus on population health due to large service regions created.
Geographic coverage and rostering
Small, widely dispersed populations as a barrier to implementation of successful integrated systems.
Standardized care delivery through interprofessional teams
Clearly defined roles and responsibilities of all professionals in teams.
Shared protocols of best practices, clinical care pathways, decision-making tools.
Confusion/lack of role clarity, competing ideologies, self-interest etc. all common challenges to necessary collaborative processes.
Linked to effective communication across organizations – use of electronic information systems to facilitate effective communication.
All providers employ the same current concepts of best practice and the same evidence-based practice guidelines to minimize quality shortfalls and variations in care.
Strengths (Bill 10)
Potential to facilitate access to continuity of care by dissolving service delivery silos.
Performance management
Well-developed performance monitoring systems and indicators.
Standardized protocols and procedures to measure care processes and outcomes for the purpose of service improvement.
Information Systems
Use of computerized information systems to track and measure utilization and outcomes.
Enhances communication across networks – improves efficiency and continuity of care across providers.
Issues of poor design and implementation; lack of incentive for providers to participate in these systems is a common barrier.
Organization culture and leadership
Goal of having cohesive vision across the integrated network.
Issues: clashing cultures (e.g. differing priorities across services and providers).
Placing acute care (i.e. the hospital) as the centre of the integration process as another barrier; rather the focus should be on population-based health-care delivery.
Physician integration
Integration of physicians at all levels; key leadership role in design, implementation, and operation of integrated system.
Necessity for physician engagement and leadership in the integration process (Dye and Sokolov 2013).
Challenges and threats
Professional networks overlooked as critical components of a functioning institution.
Democratic processes for electing institutional boards removed; replaced with government-appointed boards.
Beyond the governance structure – what has been the physician role thus far in the integration process?
Governance structure
Must be diverse – ensure representation from all relevant stakeholder groups including physicians and the community.
Mechanisms for accountability and decision-making necessary (standardized methods/procedures).
Removes democratic processes for electing institutional boards of directors (replaced by government appointed boards).
One board to oversee diverse health and social service mandates – professional and community networks overlooked as a critical component to promoting a united vision.
Financial management
Cost control as one of the major incentive for systems integration in US.
Economic benefits from economies of scale and cost reduction in administrative/clinical areas.
Major barrier: differentiated service funding across care.
Financing mechanisms that allow pooling of funds across services is ideal (e.g. global capitation).
General challenges
Remuneration of physicians in Canada one of the major challenges to integration; threatens potential cost-savings. 
Sources: Armitage GD, Suter E, Oelke ND, Adair CE. Health systems integration: state of the evidence. Int J Integr Care Jun 17;9(2).
Suter E, Oelke ND, Adair CE, Armitage GD. Ten key principles for successful health systems integration. Healthc Q Oct;13:16-23.