Integrated health organizations in Canada: developing the ideal model

Building integrated care systems: a case study of Bidasoa Integrated Health Organisation

INTRODUCTION

This paper analyses the implementation of integrated care policies in the Basque Country through the deployment of an Integrated Health Organisation in Bidasoa area during the period 2011-2014. Structural, functional and clinical integration policies have been employed with the aim to deliver integrated and person-centred care for patients, especially for those living with chronic conditions.

METHODS

This organisational case study used multiple data sources and methods in a pragmatic and reflexive manner to build a picture of the organisational development over a 4-year period. In order to measure the progress of integration three concepts have been measured: (i) readiness for chronicity measured with Assessment of Readiness for Chronicity in Healthcare Organisations tool; (ii) collaboration between clinicians from different care levels measured with the D'Amour Questionnaire, and (iii) overall impact of integration through several indicators based on the Triple Aim Framework.

RESULTS

The measurement of organisational readiness for chronicity showed improvements in five of the six areas under evaluation. Similarly the collaboration between professionals of different care levels showed a steady improvement in each of the 10 items. Furthermore, the Triple Aim-based indicators showed a better experience of care in terms of patients' perceptions of care coordination; a reduction in hospital utilisation, particularly for patients with complex chronic conditions; and cost-containment in terms of per capita expenditure.

CONCLUSION

There is a significant amount of data that shows that Bidasoa Integrated Health Organisation has progressed in terms of delivering integrated care for chronic conditions with a positive impact on several Triple Aim outcomes.

Role of innovative institutional structures in integrated governance. A case study of integrating health and nutrition programs in Chhattisgarh, India

PURPOSE

The aim of this paper is to highlight the significance of integrated governance in bringing about community participation, improved service delivery, accountability of public systems and human resource rationalisation. It discusses the strategies of innovative institutional structures in translating such integration in the areas of public health and nutrition for poor communities.

DESIGN/METHODOLOGY/APPROACH

The paper draws on experience of initiating integrated governance through innovations in health and nutrition programming in the resource-poor state of Chhattisgarh, India, at different levels of governance structures--hamlets, villages, clusters, blocks, districts and at the state. The study uses mixed methods--i.e. document analysis, interviews, discussions and quantitative data from facilities surveys--to present a case study analyzing the process and outcome of integration.

FINDINGS

The data indicate that integrated governance initiatives improved convergence between health and nutrition departments of the state at all levels. Also, innovative structures are important to implement the idea of integration, especially in contexts that do not have historical experience of such partnerships. Integration also contributed towards improved participation of communities in self-governance, community monitoring of government programs, and therefore, better services.

PRACTICAL IMPLICATIONS

As governments across the world, especially in developing countries, struggle towards achieving better governance, integration can serve as a desirable process to address this. Integration can affect the decentralisation of power, inclusion, efficiency, accountability and improved service quality in government programs. The institutional structures detailed in this paper can provide models for replication in other similar contexts for translating and sustaining the idea of integrated governance.

ORIGINALITY/VALUE

This paper is one of the few to investigate innovative public institutions of a and community mobilisation to explore this important, and under-researched, topic.

A pilot with computer-assisted psychosocial risk-assessment for refugees

Background

Refugees experience multiple health and social needs. This requires an integrated approach to care in the countries of resettlement, including Canada. Perhaps, interactive eHealth tools could build bridges between medical and social care in a timely manner. The authors developed and piloted a multi-risk Computer-assisted Psychosocial Risk Assessment (CaPRA) tool for Afghan refugees visiting a community health center. The iPad based CaPRA survey was completed by the patients in their own language before seeing the medical practitioner. The computer then generated individualized feedback for the patient and provider with suggestions about available services.

Methods

A pilot randomized trial was conducted with adult Afghan refugees who could read Dari/Farsi or English language. Consenting patients were randomly assigned to the CaPRA (intervention) or usual care (control) group. All patients completed a paper-pencil exit survey. The primary outcome was patient intention to see a psychosocial counselor. The secondary outcomes were patient acceptance of the tool and visit satisfaction.

Results

Out of 199 approached patients, 64 were eligible and 50 consented and one withdrew (CaPRA = 25; usual care = 24). On average, participants were 37.6 years of age and had lived 3.4 years in Canada. Seventy-two percent of participants in CaPRA group had intention to visit a psychosocial counselor, compared to 46 % in usual care group [X² (1)=3.47, p = 0.06]. On a 5-point scale, CaPRA group participants agreed with the benefits of the tool (mean = 4) and were ‘unsure’ about possible barriers to interact with the clinicians (mean = 2.8) or to privacy of information (mean = 2.8) in CaPRA mediated visits. On a 5-point scale, the two groups were alike in patient satisfaction (mean = 4.3).

Conclusion

The studied eHealth tool offers a promising model to integrate medical and social care to address the health and settlement needs of refugees. The tool’s potential is discussed in relation to implications for healthcare practice. The study should be replicated with a larger sample to generalize the results while controlling for potential confounders.

Divergent modes of integration: the Canadian way

INTRODUCTION

The paper highlights key trajectories and outcomes of the recent policy developments toward integrated health care delivery systems in Quebec and Ontario in the primary care sector and in the development of regional networks of health and social services. It particularly explores how policy legacies, interests and cultures may be mitigated to develop and sustain different models of integrated health care that are pertinent to the local contexts.

POLICY DEVELOPMENTS

In Quebec, three decades of iterative developments in health and social services evolved in 2005 into integrated centres for health and social services at the local levels (CSSSs). Four integrated university-based health care networks provide ultra-specialised services. Family Medicine Groups and network clinics are designed to enhance access and continuity of care. Ontario's Family Health Teams (2004) constitute an innovative public funding for private delivery model that is set up to enhance the capacity of primary care and to facilitate patient-based care. Ontario's Local Health Integration Networks (LHINs) with autonomous boards of provider organisations are intended to coordinate and integrate care.

CONCLUSION

Integration strategies in Quebec and Ontario yield clinical autonomy and power to physicians while simultaneously making them key partners in change. Contextual factors combined with increased and varied forms of physician remunerations and incentives mitigated some of the challenges from policy legacies, interests and cultures. Virtual partnerships and accountability agreements between providers promise positive but gradual movement toward integrated health service systems.

Ten key principles for successful health systems integration

Integrated health systems are considered part of the solution to the challenge of sustaining Canada's healthcare system. This systematic literature review was undertaken to guide decision-makers and others to plan for and implement integrated health systems. This review identified 10 universal principles of successfully integrated healthcare systems that may be used by decision-makers to assist with integration efforts. These principles define key areas for restructuring and allow organizational flexibility and adaptation to local context. The literature does not contain a one-size-fits-all model or process for successful integration, nor is there a firm empirical foundation for specific integration strategies and processes.

Collaborative and interdisciplinary health care teams: ready or not?

Collaborative team-based practice within an interdisciplinary health service environment is an important consideration for the nursing profession. Policy directions suggest that collaborative professional skills can address complex client needs within a framework of primary health care and social accountability for health service quality, cost, and access. The pursuit of collaborative and interdisciplinary care is generally agreed to be a worthy goal. However, implementation methodologies and outcomes related to collaborative and interdisciplinary care remain elusive within a rapidly changing health care environment. This article provides a critical analysis of the multiple historical, political, economic, and social professionalization challenges associated with the achievement of collaborative team-based practice. The author argues that it is not feasible to implement broad-based team structures at the present time. Considerable effort would be required to prepare disciplines to function as a team and to address fragmented services, equitable service funding, and procurement of resources to sustain team efforts. Strategic and influential use of power and knowledge may support the efforts of nurse leaders in practice, education, research, and administration to effect change for the development of collaborative and interdisciplinary practice.