One Client, One Team - Health Care Integration for Populations with Complex Care Needs: Driving Redesign in a Complex System for Those Who Need It Most

摘要

Introduction : Working in a provincial environment where the health care system is fragmented, across 60,000 primary care physicians, 155 hospitals, 162 home care providers, and over 1,000 community support service organization, presents a compelling need to integrate care and services to make the system less confusing for clients (patients), particularly those clients and their families with complex care needs, who frequently have to access services from multiple parts of the health care system. Our aim was to start with the largest jurisdiction in Ontario to improve client experience, outcomes, and value with the goal of clients and families to experience multiple providers across different systems of care as one team. Description : The Toronto Central CCAC, a publicly funded home and community health care delivering health care to approximately 74,000 clients annually, began its integration journey in 2010, positioning the home and community care sector at the center of driving system change and integration across the care continuum. For five years, the Toronto Central CCAC has been driving integration for populations with complex needs and building integrated care teams within a quality improvement and evidence-based framework built on and aligned with leading global practices in integration. This integration strategy, entitled One Client, One Team, has been implemented in one large jurisdiction with the goal of developing a scalable model for the province of Ontario. The strategy is marked by using existing resources and creating partnerships across many sectors – primary care, acute care, paramedic services, and community services to deliver wrap-around care services to complex populations. In 2014, the organization partnered with The Evaluation Centre for Complex Health Interventions to perform a more comprehensive, mixed-methods evaluation that is informed by a theory-driven framework. The evaluation provides a deeper understanding around what is working well and helps to inform opportunities to advance implementation, drive scalability and build a shared vision for integrated care across the province. Key Findings : The impact of Toronto Central CCAC’s integration strategy has been felt at the system and leadership level across the care continuum, at the point of care across care teams and providers, and at the experience level of clients and families. Four kinds of findings will be shared at the conference: - Learnings about the mechanisms by which integrated care can impact person centered care; - Learnings from the trajectories of outcomes of clients with complex conditions and how the evaluation can help develop learnings about how such trajectories can be modified; - Video and qualitative evidence on how person centered care can make a difference to health outcomes. - Successes and barriers in enabling integrated care and leveraging lessons learned to inform scale and spread The discussion of the results will highlight the contexts and mechanisms by which integrated care can impact person centered care and inform implementation and scalability—all of the discussion on mechanisms will be supported by both qualitative and quantitative evidence. The concept of an ‘ecology of evidence’ – the types of evidence that are needed to support implementation of a complex coordinated care system will inform the presentation of the findings. Highlights : Throughout its integration journey, the Toronto Central CCAC has learned that sustainable, system level change can be driven locally, by any organization, with key foundations in place, including strong leadership competencies, trusting relationships across stakeholders and a common commitment across all partners to putting the client’s and family’s care experience at the center of the change. Health care organizations have an accountability to evolve the way they work and waiting for a complex solution to a complex problem is often not the most effective path to change. Conclusion: This approach to integration leverages practicality, innovation, and partnership to improve the client experience. The strategy is highly relevant for integrated care delivery and development internationally is as it highlights the need for fundamental shifts in the conceptualization of integrated care, program implementation, and the role of evaluation within integration efforts to inform improvement, scale, spread and sustainability.