Predicting and testing a silo-free delivery system

Abstract

Given the scale and complexity of the challenge of addressing the aging population, increasing demand for complex and integrated care, this article sets out potential opportunities to predict a future without silos, based on international learnings. Examining another country’s health and delivery systems, it is interesting to see the similarities and differences, so we offer some reflections applicable to Canada. These models are breaking down the silos. Imagine a setting where you could collaboratively co-design scenarios, debate, refine policy, and predict future population needs. Using a transformation lab setting, governments and policy-makers, providers, patients, families, and community support groups could collaboratively take the time to learn new ways of working together in a risk-free environment before becoming accountable for delivering targeted outcomes. It is time to implement provincial transformation labs to test local strategies and operational plans to co-design scenarios, use simulation, and test the choices using evidence-based tools.

Introduction

The cost, quality, and availability of healthcare services are issues of major debate in Canada. Some say that more money is needed; others say that we are spending on the wrong things. Now is the time for decision-makers and key stakeholders to move from discussion to action in addressing the future needs of the population to understand if more money and/or new ways of working are needed.^1
–3 The challenges of eliminating structures and incentives that promote silos will continue to grow if health leaders do not put aside their silo mentalities and shift the way they work.

Calls to break down healthcare silos and provide more integrated care are not new. They were at play in 1980s, becoming more vocal in the early 1990s, and are still relevant today. The difference today is the continuous demand for more money, an aging population, and future workforce shortages. There have been successful attempts to achieve more integrated care, though they are generally limited to local examples rather than holistic, systemic change.^4
–6 Are the barriers to holistic, systematic change the result of culture, attitude (organizational and individual), geography, program design, or financial? A shift is needed to move from silos to systems and focus on implementation, scale, sustainability, and more integrated healthcare models.

Moving forward will necessitate stakeholders collaboratively agreeing on the challenges and next steps. These include:

provincial, regional, and local leadership with support from the federal government and community advocacy groups;

innovation and standardization;

setting an overall vision and detailed co-design and production;

supporting local ways of working;

managing the challenge of service delivery today; and

addressing future healthcare workforce shortages.^7

–10

Healthcare delivery is unique in its complexity

As illustrated in Figure 1, the delivery system is fragmented with many transition points for patients and families. Whether the patient is seeking services for cancer, mental health, surgery, or access to a long-term care facility, silos persist.^11,12

Figure 1.

Patients enter a delivery system of diverse provider organizations and groups. Source: E. F. Pepler, PhD Dissertation, 2004, Unpublished.

Bringing these multiple responsibilities together can be difficult and is a source of continual debate. System leaders need to facilitate discussions on how to best reach a common understanding of the unique needs and opportunities that arise from pooling efforts to manage the transformation.

The changing environment

The policy environment in Canada for healthcare is complex and slow moving, preferring analysis to actual implementation. New developments and changing priorities require attention.^9,13,14

Given this environment, how can innovation and excellence be scaled, entrepreneurialism unleased, new ways of working encouraged, and productivity increased—all while maintaining the strategic calls for integration, quality, outcomes, sustainability, and accountability? The healthcare delivery system faces many problems relating to historical boundaries of hierarchy and sectoral interests. But these, as with many other challenges within the system, are not due to money, but to a system, that fundamentally needs to shift its energies to creating the conditions for collaboration and a collective vision.¹⁵

People who try to implement innovation often fail because of poor governance, lack of information sharing, technology limitations, and clinical or geographic silos. There is no shortage of transformative ideas, pilot activities, and energetic people, but the system struggles with supporting, scaling, spreading, and sustaining this excellence.^16
-18

The challenge: Merging the new with the traditional

One of the key problems to understanding how integrated health and social care might best be deployed in practice is its complexity. To support this, we are proposing new tools to predict and test models of care and new ways of working.^11,19
–21

Simulating business systems and performance was difficult in the past, but modern methods and tools now make it practical and easy. Live, quantified business models, using scenario generation and population health simulation tools, enable organizations and groups to co-design and continuously monitor system performance.^{19,21,22

-28} Simulation modelling eliminates the need to invest time, resources, and costs on potentially unsuccessful pilot projects. Potential outcomes can be tested and changes made prior to project investment.^21,29,30

Although there is considerable variation in governance arrangements, powers, and leadership capacity, there are enough resources to improve healthcare for the population.^1,2,4,6,9

What if the silos were broken wide open to encompass all people living with chronic conditions, not just those with a single disease or in high-risk groups?

What if the silo mentality shifted to a partnership model in which patients play an active role in determining their own care and support needs?

What if the system was designed with collaborative, personalized care planning at its core?

What if a national program aimed at allocating a year of care funding for people living with multiple conditions was implemented?

What if governments, care providers, and key stakeholders were able to more effectively collaborate across current silos to deliver needed change in this complex system?

Applied research has demonstrated that we need a systems approach that acknowledges complexity and dynamism. Pairing experts from disciplines not traditionally associated with health issues, such as computer science, mathematics, and engineering, with health researchers who have access to decades of population health data, could facilitate the development of innovative care models.^{11,19,21,26,29,30}

Rethinking tradition: Creating an effective approach to predicting the future

Strategic planning and decision-making is becoming more complex. For example, provincial governments set policy and strategy for the health of their population and negotiate physician payment models and budgets¹ Currently, provincial strategies are distributed to local regions/health authorities to develop implementation plans within defined budgets. The local regions/health authorities distribute operational plans to the zones or communities to implement. With so much delegation and complexity, the ability to focus on ways to create the most value for the system and its patients is becoming even more difficult.^2,31

The strategy and execution gap is widening. Even when choices are made between service areas, programs, disease groups, or departments, trade-offs and service delivery are becoming more fragmented, resulting in duplicated operational processes and services and resource waste. Technology decisions are also more complex as organizations attempt to integrate older technologies with newer advancements and increased functionality requirements.²²

Health leaders need to think differently about how to break down the silos. They need to rethink the strategic planning process and shift the focus to outcomes, enabling people to develop scenarios with the end in mind. As illustrated in Figure 2, an outcome approach was used to build the “What if?” new way of working, aimed at addressing the needs of various population groups and communities.²¹

Figure 2.

Begin co-designing the strategic solutions with the end in mind: Population Outcomes. Source: Pepler Group, Unpublished.

As depicted in the diagram, using an outcomes-based approach versus the traditional strategic planning approach enables system-wide participants to bridge the gap between needs and outcomes, aligning the system drivers with the strategic goals. Scenario validation and simulation tools allow for testing the “model solutions” and may lead to more effective, evidence-based decisions.^{19,21,22

–27}

The successful application of simulation modelling outlined in this article, and the enthusiasm and engagement of key participants in several of our case studies, has strengthened the argument for using simulation modelling to test policy and system changes prior to implementation. As the complexity of health systems increases within an environment of constrained resources, so too does the need for evidence-based decision-making. Simulation modelling is well positioned to provide the evidence to cost-effectively analyze proposed new ways of working, structures, governance, and payment methods.^19,23,25

Learning from other jurisdictions

It has been stated that much can be learned from international jurisdictions such as Germany, the United States, the Netherlands, and especially England’s National Health Service (NHS) Long-Term Conditions (LTC) Year of Care Commissioning Program^22,23 The LTC Year of Care Program aims to transform the quality of care for people with complex care needs. People with multiple LTC need personalized care that enables them to live as well as possible. They need all their heath and care services to be coordinated.

Personalized, integrated care services can achieve better outcomes, improve patients’ quality of life, and result in more efficient use of healthcare resources. However, NHS funding systems have traditionally focused on isolated episodes of activity, rather than longer term packages of care planned proactively around the needs of the individual.²⁴

The LTC Year of Care Program, which began in 2012, has been working with early implementor sites to develop, test, and refine tools and techniques for identifying groups of patients with complex care needs and calculating the costs of their care. These sites also used simulation modelling to consider the effects of different tariffs and patient cohorts, testing new pathways of care and new datasets, and exploring workforce implications. A number of “fast followers” were selected. They implemented the shared learning to create a more effective and efficient integrated healthcare system for these patients.²⁵

In November 2015, the LTC Year of Care Program Team and the Pepler Group presented an overview of the LTC Year of Care Program to the Canadian College of Health Leaders (CCHL) Calgary Chapter. The presentation illustrated how NHS England were implementing capitated budgets within long-term conditions for people with complex needs. The presentation focused on several key messages around practical implementation, including current barriers and solutions for overcoming them.²⁷

Some of the key learnings included:

There is a perceived lack of integrated care for this population group. There needs to be a creation of narrative for the defined population. The population should be addressed holistically through partnerships between organizations, rather than the current silo approach resulting from fragmented financial flows.

Greater shared knowledge of budgets, financial flows, and the language used to describe them needs to be a core knowledge base for all stakeholders.

The system needs to work in a way that ensures the patient and their goals are the essential driver and that incentives work to ensure desired patient outcomes.

Culture and attitude were identified as a barrier on both organizational and individual levels. The culture needs a paradigm shift so that capitation budgets become the norm for financial flows, and personalized budgets are a menu option within them.

The concept of the “activated” or “informed” patient. The sooner the patient is connected to services they need—someone to help with personal care, peer groups with family members going through the same thing, not for profits, aids in daily living, and safety adaptations in the home—the better they cope with their status and the less use of emergency services.

To effectively achieve implementation, spread, and sustainability of these models, it was recognized that partnerships across and between organizations had to be developed to a high degree of maturity. Differing funding contracts and models would also need to be aligned through collaborative discussion, development, and agreement.

Collaboration with primary care physicians and General Physicians (GPs) is critical to the development of community-specific integrated models.

GPs need to be fully engaged in the process of implementation to ensure sustainability and improved system-wide outcomes.

There will potentially be an increased requirement within the workforce for individuals with care planning and coordination skills.

There potentially could be challenges with cross boundary service provision when the commissioning organization and the care delivery address are not within the same geographical location.

Learning by doing: Integrating healthcare in Canada

To achieve the provincial fiscal targets, England’s NHS LTC Year of Care Program could serve as a practical planning and system-wide change prototype for addressing the current and future challenges of the aging population and the increase in demand for complex care.

As Jacquie White, Deputy Director of the LTC Year of Care Program stated to CCHL members, …bold initiatives and health transformation simulation modelling work had to be led by a pioneering team of individuals who are prepared to take risks. It is after all unrealistic to rely solely on leaders of the system to make change happen across the board. Many barriers still exist today, and silos continue to pose challenges. Removing these barriers and the silos as the NHS moves forward to achieving their 20-year goals will require a coalition of the determined, plus the continued financial and support at the national and local levels.

It is suggested, after much work with the NHS LTC Year of Care Team, that any decision to adopt some form or portion of the NHS program must be accompanied with sufficient advanced planning, significant simulation of delivery and workforce scenarios, stakeholder consultations, and an informed reasonable transition budget. The model is achieving successful outcomes in the United Kingdom and can be adapted in its design to meet Canadian provincial needs and priorities.^22

–27

Strategic and innovative system change does not come easy. Such a foundational transformation will require province-wide vision, leadership, and political commitment. It will be essential to strengthen partnerships between all levels of government and the healthcare organizations involved in delivering care and services to people living with chronic disease, cancer, frailty, dementia, and mental health. The focus must be on building a better healthcare system for the future.

Healthcare innovation labs are not new. Organizations such as Kaiser Permanente, the Mayo Clinic, and the Cleveland Clinic have built technology innovation labs specifically to prototype and develop new solutions around healthcare delivery. What is new is an innovative transformation lab focused on developing and testing new approaches to designing new payment or service delivery models, and technology all initiatives within the strategic and operational plans—tools that support collaborative planning and enable detailed simulation modelling of federal, provincial, and local health and social service pathways, and testing of outcomes and impact of new delivery models on workforce, policy and funding investments.^21,25
-27

Users can test the likely impact of many different scenarios, whether increase in demand for services, changes to the way services are delivered, or the implementation of new policy or funding initiatives. The ability to analyze these “What if?” scenarios in a risk-free and collaborative setting helps to support more effective planning and decision-making around the design and delivery of healthcare by enabling policy-makers to assess strategic choices, priorities, and outcomes.^11,21,28

Now is the time to create the future—without any silos. The LTC Year of Care Program described in this article is a deliberate simplification of a complex delivery system. What if, provincial governments working with select communities were to explore the benefits of adopting the LTC Year of Care Program? The NHS has made substantial investments in funding, time, and people over the past decade. Capitalizing on their learning could benefit Canadians, as provinces could accelerate planning, progress, and implementation and programs could be customized to individual needs.

The challenge for Canadian health leaders is: “Are we ready to evaluate, test, and implement lessons learned since this opportunity is sizeable?”

Simulation modelling provides an opportunity to be an innovator in healthcare service delivery in Canada to the benefit of patients and families, especially if the aim is to break down the silos and implement models of care which facilitate the delivery of integrated health and care for people living with chronic conditions based on need rather than disease. Implementing a model such as the LTC Year of Care Program or any new model would challenge the system to rethink its structures, governance, and financial models.

To eliminate or reduce the silos in the healthcare system requires an understanding of how to encourage creativity, responsiveness, and innovation, while still having an integrated approach with sufficient structure to support rapid progress toward person-centred care, regardless of organizational boundaries. Can we predict the future? What if, we stay doing what we are doing? We are all aging and will need the system in the future. This will be our legacy.

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