Evaluating the ‘Health Links’: A Case Study of the Role of Organizational Factors in Integrating Care in Ontario, Canada

摘要

Introduction : Adults with multiple chronic illnesses account for more than 75% of health care spending. Many are considered complex due to multimorbidity, high service use, and psychosocial vulnerability. Practice Change Implemented : The Health Links (HLs) are networks of multiple health and social service organizations that voluntarily partner to deliver integrated care to complex, high-cost patients in Ontario, Canada. Aim and Theory of Change : We explored how organizational and network factors (e.g., resources, culture) influenced the implementation of the HLs. We conducted case studies of three HLs within one regional health authority. Data was analyzed using The Context and Capabilities for Integrating Care (CCIC) Framework, which stipulates that organizational and network factors (within the Basic Structures, People & Values, and Key Processes domains) influence an organizationetwork’s readiness and capacity to integrate. Targeted Population and Stakeholders : The HLs initiative is targeted at patients with four or more chronic or “high-cost” conditions, including a focus on individuals living with mental health and addictions, palliative care patients, and the frail elderly. The organizations involved vary by HL and often include hospitals, primary care practices, community support agencies, social services organizations, and emergency response. Timeline : The HLs were implemented in 2012 with 19 early adopters; there are now 82 HLs in various stages of implementation in the province. In the spring/summer of 2016, we conducted semi-structured interviews with leaders and providers working within three HLs. Interviews were supplemented with surveys and document review. Highlights : (Innovation, Impact and Outcomes) Preliminary results show that successful implementation was linked to the key organizational facilitators of leadership, patient-centredness, and team-based delivery of care. Leaders that prioritized the initiative were able to facilitate inter-organizational collaboration. Similarly, partnerships were facilitated by an explicit focus on patient-centredness and patient outcomes, rather than on formal governance and accountability structures. Comments on Sustainability : Partnering organizations will have to address several barriers going forward, including: poor awareness of HLs in the community, inefficient identification of patients, dwindling clinician engagement due to low perceived value of the initiative over and above regular care, and limitations to patient data sharing within the network. Comments on Transferability : Using the CCIC Framework, we identified organizational and network factors that supported integration of care in HLs networks. The findings are limited to three HLs networks in Ontario, however, the framework can be used across cases to support the measure of factors and the transfer of best practices to other integrated care initiatives. Conclusions : (Comprising Key Findings) Preliminary results suggest that there are common factors that most influence the implementation of integrated care initiatives, including leadership, clinician engagement, patient-centeredness, and delivery of care. Discussions : The CCIC Framework enabled a comprehensive analysis of organizational and network context. These results can be used to help prioritize key areas for discussion, measurement, and change management. Lessons Learned : Despite continued interest in partnering, we found a loss of clinician engagement and buy-in over time in HLs that did not meaningfully involve clinicians and did not demonstrate value to the patient.