in Ontario Walter Wodchis PhD Health Quality Rounds Southlake Hospital May 19 2016 Design by Walter Wodchis Luke Mondor Kevin Walker Agnes Grudniewicz Jenna Evans YuQing ID: 648822
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Slide1
Evaluating Health Links in Ontario
Walter Wodchis, PhD
Health Quality Rounds
Southlake Hospital, May 19 2016Slide2
Design by
Walter
Wodchis,
Luke
Mondor
, Kevin Walker,
Agnes
Grudniewicz
, Jenna Evans,
YuQing
(Chris
Bai
),
Seija
Kromm
, Gustavo
Mery
, Ross BakerSlide3
Objectives
3
Learn
about the successes and challenges of Health Links in
Ontario
Learn
how the Health System Performance Research Network (HSPRN) is undertaking evaluation for Health Links in the Central LHIN
Learn
about the provincial evaluation of health
links
Learn
what we know about success factors of integrated care from international experience. Slide4
HSPRN Involvement in Health Links
4
2013: What ‘value’ do Health Links add to the health system?
2015: Evaluating Health Links in the Central LHIN
2016: Palliative Indicators for Health Links
2016: Lead for Provincial Central Evaluation of Health Links Slide5
Our approach was undertaken in 3 parts: To review documents and literature to assess how ‘value’ has been recognized and measured in U.S. Accountable Care Organizations (ACOs) and to select indicators that could be applicable to Health Links.
To interview HL leaders to identify promising HL strategies and how these strategies are creating value for patients and the Ontario health system.
To conduct empirical analysis to assess the performance of HLs on measurable indicators using health administrative data held at the Institute for Clinical Evaluative Sciences.
5
2013: Assessing
V
alue in Health Links Slide6
Value of Health Links
6Slide7
Review of ACOs: ACOs have adopted a Triple-Aim focus and we identified selected domains for health measures:
7
Aim
Domain
Better care for individuals
Patient/caregive
r experience
Patient outcomes & safety
Care coordination/integration
Better health for
populations
Preventative
care
Healthy lifestyles
Health
outcomes among target populations
Lower growth in Medicare expenditure
Cost containment
Appropriate
utilization of resources
Part 1: Value of Health Links: FindingsSlide8
Interviews with 10 Health Links: Health Links are focusing on a variety of ways to add value including focusing on:
integration between organizations
c
oordination of care (care planning/information sharing)
patient engagement in planning care
patient care (clinical processes) and outcomes…with an aim to improve experience and reduce utilization of ED and acute careWe also learned about challenges, successes and approaches to improving areas of focus.
8
Part 2: Value of Health Links: FindingsSlide9
Interviews with 10 Health Links: HLs are aiming to improve value
in multiple
ways addressing many of the same domains as ACOs
:
9
Aim
Domain
Health Links’ Definitions
Better care for individuals
Patient/caregive
r experience
Timely access,
satisfaction, trust, shared decision making
Patient outcomes & safety
Quality of care & safety
Care coordination/integration
Integrated seamless care and coordination among provider organizations
Part 2: Value of Health Links: FindingsSlide10
Experience of Care: Provider & System Level Indicators
Health of the Population: System Level Indicators
System Costs
Patient perspective costs
PROMs
PREMs
Patient
Value of Health Links: BEACCON Triple AimSlide11
11
We assessed the baseline performance of health links on 21 indicators with an emphasis on 6 selected indicators
Low acuity emergency department visit rate
Hospitalization rate
Readmission rate
FP/GP Follow-up after hospital discharge within 7 days
Rostered
to a family physician
Total health system cost
Part 3: Baseline ResultsSlide12
12
Findings:
Baseline performance; early HLs; total population
by SES Quintile
High SES
Low SES
Performance
Avg
Std
Monthly Cost ($/person)
Std
Rate Acute Hospitalization (/100,000)
Std
Rate ED Visit: Low Acuity (/100,000)
Risk-adj. Estimate (%) CMG Readmission Rate
Crude Estimate (%) All Ind. PC F/U W/IN 7D Acute Discharge
Std
Proportion
Rostered
to PC Physician (%)
Health Link performance is highly related to community SES
Part 3: Baseline HL ResultsSlide13
13
There was a moderate level of agreement across indicators within Health Links. Health links with strong results tended to be strong across most indicators and those with lower scores seemed to be similarly challenged on many indicators.
Health Links performance is linked
to community
more than providers.
Health Links in Low Socioeconomic areas have poor performance while those in high Socioeconomic areas did best.
Part 3: Baseline HL ResultsSlide14
14
In 2015, we began to undertake an evaluation of the 3 Health Links in the Central LHIN
This model is now serving to support the provincial evaluation of Health Links.
2015-: Evaluating
Central LHIN
Health LinksSlide15
Evaluation Framework
How should integrated funding models be applied across the province?
Objectives
Identify
success factors and potential barriers in the
implementation
Measure utilization of health care resources and care costs across care settings (intervention vs. control groups)
Measure patient and provider experience
Inform
policy and potential provincial spread
What are the key enablers and barriers to implementation of integrated funding models?
Is care patient-
centred
and better coordinated?
Are there improved outcomes for the selected pathway and population?
Are there improved efficiencies?Slide16
Case Studies of Central LHIN Health LinksThe purpose is to understand the outcomes and the context that enables Health Links to better achieve their aims
Approach includes:
Interviews with LHINs HL Participants based on the
Context
for Integrated Care
FrameworkEmpirical Analyses of Utilization Patterns for HL enrolees Results: Summer/Fall 2016
16
Case StudiesSlide17
Goals of the Evaluation
17
Goals of the Evaluation:
Evaluate the effect of the programs on patient health service utilization
Understand the capabilities of HLs to undertake integrated care programs
Provide HLs with important, detailed data and feedbackSlide18
Understanding Impact of Health Links
18
Multi-method approach:
Qualitative Case
studies
of Health Links
North York Central
South Simcoe & Northern York Region
South West York Region
Quantitative evaluation
Comparative-effectiveness evaluation on acute care utilization and total costs of careSlide19
1
. Case Studies
Purpose:
To
identify and better understand key organizational factors that influence the performance of the
HLs
Provide each HL with detailed feedback & data
Key Organizational Factors Include:
Organizational context
Organizational capabilities Slide20
Organizational Context
Anything internal to the
organization or Health Link,
but not
only a
part of the integrated care model or interventionOrganizational CapabilitiesAbility and capacity of an organization or Health Link to carry out activities aimed at integrating care
20
1. Case S
tudiesSlide21
1
. Case Studies: CCIC FrameworkSlide22
1. Case Studies: Methods
22
Interviews
1 hour
i
nterviews with leaders/managers and providers (clinicians, care coordinators)
Follow-Up Surveys
30-40 minutes for interview participants
Short-
F
orm Surveys
10-15 minute survey for all HL members
Document Analysis
Public documents and those shared by the HLSlide23
2. Quantitative Evaluation
23
Comparative effectiveness evaluation
Patient-level (outcome) evaluation with comparator cohorts using ICES data
Measuring the effect of Health Links (HLs) on:
Acute care hospitalizations
Emergency department visits
Other health service utilization (e.g. home & primary care)
Total health system costSlide24
2. Quantitative Evaluation
24
Identify
HL
patients in a patient registry (provided by the Central CCAC)
Patient Identification (OHIP #/version code, birthdate, sex)
HL
(NYCHL, SSNYRHL, SWYRHL)
HLs Dates (
referral, CCP, transitioned/death
)
HLs referral source (family physician/outpatient care referral, hospital referral – ED, hospital referral – inpatient, EMS referral, community service referral
)
Participant Status (active, declined, transitioned, dead)Slide25
2. Quantitative Evaluation
25
Link
with
health
administrative data at the Institute
for
Clinical Evaluation Sciences (ICES
)
CIHI DAD
(inpatient
hospital
records);
NACRS (ambulatory
centre
records);
HCD (home care visits);OHIP (physician claims); and
RAI-HC (RAI
assessments for home care recipients)Slide26
2. Quantitative Evaluation
26
Identify comparator (control) patients from non-HL patients using ICES databases
Match intervention/registry with comparator patients using enrolment criteria, birth date, sex, regular physician practice type, index date, propensity score (including age, sex, comorbidity, and prior
health care
utilization,…)Slide27
27
4. Analysis comparing changes in the
outcomes
in the HL group
to those in
the
matched
comparator
group: Incremental
Effect of HL
HL Participant
Not-HL Participant
Post-enrolment Period
A
B
Pre-enrolment
Period
C
D
Pre-Post Difference
A-C
B-D
Incremental Effect
of HL
(A-C)
– (B-D)
2
. Quantitative EvaluationSlide28
28
Provincial Evaluation of Health Links
Provincial evaluation follows plan for Central HL evaluation:
Case studies
Empirical evaluation (all HLs)
and adds
Patient experience survey & interviews
Caregiver experience survey
Stakeholder dialoguesSlide29
What can we learn from others?
29Slide30
Existing programs have demonstrated micro-level integration centered on coordinated services for individuals but to different degrees Primarily service integration, with varying degrees of professional and functional integration
Few have achieved organizational integration; this takes more time
System integration has not been achieved in any country
30
What
can we learn from others?Slide31
No single ‘best approach’. Positive outcomes achieved through a wide variety of approaches.
Integrated care
is high touch
as much as high
-
tech.Patient focus enables professionals / organizations to work together, but actual engagement of patients & families varies – most could better engage patients.Primary care physicians were often not part of the core team, and care coordination is a specialized task – all could better engage primary care providers.
31
What
can we learn from others?Slide32
Integrating care:
Is a bottom-up initiative that coordinates care at the local level for shared patients.
Is enabled by system-level priorities, funding and technological supports that enable and remove barriers to sharing information and care.
Takes time, and is an ongoing process, expanding the horizons of
what
kinds of care is integrated and expanding the focus from individual to population health.
32
What
can we learn from others?Slide33
Focus on clinical integration rather than organizational or structural integration
Success appears to be related to good communication and relationships
among those
receiving care and the professionals and managers involved in delivering
care
Effective models employ multidisciplinary teams with well-defined roles and joint responsibility for care
33
Provider suggestionsSlide34
Recognize the importance of addressing the agenda of integrated care for complex populations
Provide stimulus through funding or other means to support the development of local initiatives to improve care
Avoid
a top-down policy that requires structural or organizational mergers
Remove barriers that make it more difficult for
providers to integrate care, such as differences in financing and eligibility of patients for needed care
34
Policy suggestionsSlide35
Key system characteristics for success
35
Physician engagement.
Shared health information platforms.
Population based management.
Public health initiatives and support for self-activation for healthy eating and active living.
Person-oriented performance measurement.
Stable housing / income support.Slide36
…Stay tuned
36
Follow Updates at:
http://hsprn.ca
Our Work
Evidence
Briefs
And
of course:
@
infohsprnSlide37
Questions? Comments?37Slide38
Additional slides38Slide39
39
Selected Indicators
LOWER GROWTH IN HEALTHCARE COSTS
Indicator/Metric
Source
1
Total annual government costs (age-sex standardized)
ACO Report (value
indicators)
2
Average per capita monthly costs
(age-sex standardized)
ACO Report (value
indicators)
3
Control growth in cost (age-sex standardized)
MOHLTC (evaluation based metrics)Slide40
40
Selected Indicators
BETTER CARE FOR INDIVIDUALS
Indicator/Metric
Source
4.
Emergency Department Visits (age-sex standardized):
ACO Report (value
indicators)
All ED visits
Urgent ED visits
Low acuity ED visits
5.
Avoidable ED visits for patients with conditions best managed elsewhere (age-sex standardized)
MOHLTC (results based metrics)
6.
Acute hospitalizations (age-sex standardized)
ACO Report (value
indicators)
7.
Acute hospitalization length of stay/days
(age-sex standardized)
ACO Report (value
indicators)
8.
Unnecessary acute hospitalizations (age-sex standardized)
MOHLTC (results based metrics)
9.
Mental health & addictions admissions to acute care
InterviewsSlide41
41
Selected Indicators
BETTER CARE FOR INDIVIDUALS
Indicator/Metric
Source
10.
LTC admissions (age-sex standardized)
ACO Report (value
indicators)
11.
Total ALC days (age-sex standardized)
MOHLTC (evaluation based metrics)
12.
30-day all-cause readmissions
MOHLTC (evaluation based metrics)
13.
Primary care follow-up within 7 days of acute care discharge (for all individuals)
MOHLTC (evaluation based metrics)
Primary care follow-up within 7 days of acute care discharge (for those rostered to a primary care MD)
14.
Medication reconciliation
ACO Report (quality
indicators)
15.
Proportion of individuals
rostered
to primary care physician
MOHLTC (operational metrics)
Interviews
16.
Time from referral to first home care visit
MOHLTC (results based metrics)
17.
Diabetes care indicators
ACO Report (Quality indicators )
18.
Health related quality of life (Home care and LTC clients)
ACO
Report
(
better care)Slide42
42
Selected Indicators
BETTER HEALTH
FOR POPULATIONS
Indicator/Metric
Source
TO
BE DETERMINEDSlide43
Interviews with 10 Health Links: HLs are aiming to improve value
in multiple
ways addressing
many of the same domains as
ACOs
:
43
Aim
Domain
Health Links’ Definitions
Better health for
populations
Preventative
care
Not described
Healthy lifestyles
Focus on social determinants of health
Health
outcomes among target populations
Not described
Part 1: Value of Health Links: FindingsSlide44
Interviews with 10 Health Links: HLs are aiming to improve value in multiple ways
addressing many of the same domains as ACOs
:
44
Aim
Domain
Health Links’ Definitions
Lower growth in
expenditure
Cost containment
Cost reduction, efficiency,
sustainability
Appropriate
utilization of resources
Reductions in ED visits
Reductions in hospital admissions
Part 1: Value of Health Links: FindingsSlide45
Integrated Care:
Effective
patient-centered
care focused on patient and caregiver goals, that is
well coordinated across medical and social care providers who share information about and deliver on a common plan.
45
Value
of Integrated
CareSlide46
Well Coordinated:There is a single care plan accessible by all medical and social care providers that includes: patient social condition, medical conditions and function
Providers always have all the information that they need about the patients’ known conditions, treatment goals and current treatment
Medical AND Social care providers share information about care and understand roles and responsibilities/activities of other providers
46
Value
of Integrated
CareSlide47
Patients experience high value health care when they and their providers/carers share goals of care and work together progressing toward achieving those goals with a minimum of health and social care interventions (i.e. efficiently).
47
Value of Integrated CareSlide48
Providers experience high value health care when they are able to apply their insights and knowledge to address the needs of their patients leading to improved health of their patients.
48
Value
of Integrated CareSlide49
The health care system experiences high value health care when available resources are optimally deployed to advance the health of individuals and of the population (patients in better health will use less care).
49
Value
of Integrated
Care