Expectations of the Ontario Healthcare System following the Implementation of Ontario Health Teams

Patient Experience

As denoted by the Triple Aim framework, patient experience is an important indicator of the efficacy of the integrated care model in catering to patient needs.

In German models, integrated care enterprises encompass a range of medical and non-medical services such as nursing homes, hospitals, LTCHs, general practitioners, specialists, ambulatory care etc. (Russe & Stahl, 2014). These are some of the most comprehensive and extensive integrated care teams in the world, allowing them to provide a multi-faceted approach across relevant providers. This, in-turn, focused on increasing follow-up appointments in all appropriate care providers, extended coordination in the development of care plans which was more patient-centered, leading most patients and 80% of providers to prefer an integrated care model, to previous fragmented, separate entity led medical clinics (Russe & Stahl, 2014). Aside from patient satisfaction, the enterprises also found that patients in this new integrated care system would, on average, decrease their mortality figures by 2.5 years (Russe & Stahl, 2014). A similar intervention conducted in Holland also noted similar results, with a greater emphasis on patient satisfaction and regular appointments for patients (Russe & Stahl, 2014). These results were largely driven by improved blood pressure and cholesterol levels (Russe & Stahl, 2014). On the other hand, specialist services for optical and dental departments did decrease (Russe & Stahl, 2014). A similar result was also noted in England where there were healthier levels of cholesterol (Russe & Stahl, 2014). Across England, however, patients indicated increased levels of neglect and their assertions not being valued; while emergency hospital admissions increased (Russe & Stahl, 2014).

In terms of the UK and other evidence, a highly comprehensive systematic review that covered all aspects of integration across the world, ranging from bundled payment systems, to joint healthcare teams, to shared management, to established governance structures etc. were utilised (Baxter et al., 2018). This extensive list brought upon important results that assessed levels of patient satisfaction in multiple population groups (Baxter et al., 2018). In the international literature review, these were the very patients who felt the most improved satisfaction concurrently with better accessibility and care coordination in integrated care systems (Baxter et al., 2018).

On a more remote scale, the Henan province in China also went through an integrated care intervention (Shi et al., 2015). This project was heavily needed due to barriers of fragmentation between hospitals, clinics and community health centres (Shi et al., 2015). As soon as all providers were put under a single funding envelope, with their own governance structure and healthcare management, intervention groups were noted to top all measures including service comprehensiveness, patient satisfaction on patient-centredness, patient perspectives on quality of care, as well as improved patient satisfaction for care coordination and accessibility (Shi et al., 2015). In fact, on a Likert scale of 18.0, intervention groups scored 7.6 scores higher than control groups in the patient satisfaction domain (Shi et al., 2015).

Building on from quality and coordination of care, there is typically an increased, diverse options of providers in their care services following integration (Salmon et al., 2012). Upon measures of the results of mammograms for breast cancer, serum creatinine and HbA1c tests for diabetic patients, as well as LDL cholesterol and neuropathy examinations; integration yielded mostly improved levels of evidence-based compliance and results (Salmon et al., 2012).

Growing into a diverse platform, one comprehensive assessment found the effect integrated care has on diverse patients in multi-culturally populated metropolitan communities (Shortell et al., 2017). After assessing for various healthcare models and systems such as multi-payer and single-payer systems, a broad category of chronic disease patients including diabetes and cardiovascular disease patients were identified (Shortell et al., 2017). Across social functioning and the patient activation measure instrument, which evaluates the social behaviour of patients and how they navigate through the healthcare system and interact with providers at multiple touch points (Shortell et al., 2017). It was noted that integrated care systems—across 16 accountable care organisations—were found to decrease anxiety and depression, stimulate improved social functioning in personal and professional domains of life and trigger increased rates of patient participation and engagement with their healthcare providers (Shortell et al., 2017). In-turn, as measured by the Patient Assessment of Chronic Illness Care Instrument, diabetic and cardiovascular disease patients of integrated care systems did not observe any statistically significant different blood pressure, HbA1c and LDL cholesterol levels (Shortell et al., 2017).

Diving deeper into patient experience, indicators of timely care, appointments, information management, ease of care, clinician communication and accessibility to specialists were noted to be popular indicators that patients experienced in the healthcare system (Nyweide et al., 2015). In integrated care systems, timeliness of care improved as well as communication across providers due to better communication and team-management from an administrative lens of the HSPs (Nyweide et al., 2015). In fact, by bundling services and formulating regional teams, skilled nursing and home health visits—typically limited in availability—also increased due concurrently with improved collaboration (Nyweide et al., 2015). On an outcome level, 7- and 14-day discharge rates also increased, suggesting that the care services in integrated care systems were effective in yielding better health outcomes more efficiently (Nyweide et al., 2015).

Population Health

As Canadian integrated care models are being implemented primarily to address aging and chronic disease populations, the geriatric family health team model, which mirrors integrated care models is an important resource to utilise (Moore et al., 2012). The range of integration in the geriatric family health team includes social workers, geriatricians, primary care practitioners, family practitioners, pharmacists etc. (Moore et al., 2012). In this important aspect, preventative screenings were performed, and patients found similarities in MOCA screenings, depression and nutrition tests which asserts more controlled health outcomes in terms of dementia, frailty, and mental satisfaction (Moore et al., 2012).

In Germany, an increase in patients staying with insurance pools was noted as part of the increased connectedness and satisfaction of care received (Russe & Stahl, 2014). Alternatively, in Holland—prevention was focused upon where the brunt of primary care providers were spread across clinics and the specialists were only referred when needed to (Russe & Stahl, 2014). Furthermore, in the UK, emergency department admissions increased for patient-led voluntary admissions but decreased for patients with planned admissions (Russe & Stahl, 2014).

Spanning across a greater economic diversity, integrated care has had notable impacts on population-level health when socio-economic ranges are calibrated (Blewett & Owen, 2015). It is important to note that integrated care—such as in the Minnesota Hennepin Health Model—releases a breadth of medical and non-medical services to targeted populations (Blewett & Owen, 2015). In this intervention, medical centres, public health centres, health boards and strategy development stakeholders as well as population-specific supports such as mental health and addiction support in this example, were bundled to provide care (Blewett & Owen, 2015). Structuring care relative to population-health demands—in this case extreme poverty groups who were 133% below the federal poverty line—is feasible and effective as demonstrated by this study (Blewett & Owen, 2015). Large reductions in ER admissions and in-patient ER admissions were found, being 9.1% and 3% respectively (Blewett & Owen, 2015). Subsequently, the utilisation of preventative screening boards such as public health centres increased, suggesting a utilisation paradigm shift towards prevention rather than emergency management; a more sustainable and effective alternative (Blewett & Owen, 2015).

Growing on the concept of older adults and co-morbidities, an OHT-like ACO system was found to target the older demographic with a minimum of two chronic morbidities (Ouayogodé et al., 2019). Contrasting from other projects, the performance measurement on this study compared older adults in ranges of their chronic co-morbidities (Ouayogodé et al., 2019). Across most indicators, all tertiles and ranges performed the same, with the more severe chronic co-morbidity patients experiencing longer median inpatient days (Ouayogodé et al., 2019).

Cost and Efficiency

It’s imperative to note how bundled payment systems effect total patients and provider costs. In Germany, a methodology of pre-set funding arrangements were made based on projected clinical calculations to providers through which they would be compensated (Russe & Stahl, 2014). Hence, patients did not have to pay out of pocket, resulting in a decrease of provider spending by US$203 annually per patient. Furthermore, in Holland, bundled payments were targeted towards patients of chronic diseases such as COPD, diabetes etc. (Russe & Stahl, 2014). This model noted a severe increase of US$388 annually per patient (Russe & Stahl, 2014). Researchers note, however, that this increase is largely caused by the previous in-accessibilities that patients faced towards specialists and were now using this opportunity to treat other issues as well; those out of scope of the study (Russe & Stahl, 2014). Moreover, in North England and mainland England, costs remained relatively stagnant for all integrated care groups (Russe & Stahl, 2014). This was largely due to their failure in reducing ER admissions and re admissions for their targeted population groups (Russe & Stahl, 2014).

A division of spending amounts on integrated care teams was also analysed through ACOs across the United States (Parasrampuria et al., 2018). A similar bundled payment system such as the one above was used where providers were given pre-set payments based on expected clinical usage (Parasrampuria et al., 2018). ACOs that had higher quality were noted to have an average savings of US$117 per beneficiary annually, while middle tier ACOs had average savings of US$176.42 per beneficiary annually, and lower tier ACOs had over expenditures of US$21.23 annually per beneficiary (Parasrampuria et al., 2018). The findings of this study paint initial ACO quality as large influencers of its ability in generating cost and expenditure savings (Parasrampuria et al., 2018).

Other studies noted an average decrease of geographically proximal ACOs in the central U.S area through intensive literature searches (Nyweide et al., 2015). An average of a US$35 saving per beneficiary was highlighted (Nyweide et al., 2015). Mainly, the largest drops came from in-patient hospital days (Nyweide et al., 2015). However, post-discharge follow-ups accounted for significant cost increases (Nyweide et al., 2015). The study analysed these findings to be consistent with ACOs in other areas such as Massachusetts (Nyweide et al., 2015).

Contrastingly, a literature search found that ACO size and existing patient co-morbidities to be crucial in determining expenditure rates (Herrel et al., 2017). Overall, literature supports that integrated care systems are more cost effective than traditional systems, but this study suggests that size and patient demographics must be structured to support cost-savings (Herrel et al., 2017).

Contrastingly, a socio-economic and demographic approach was also identified in integrated care teams (Hong et al., 2018). Higher spending ACOs—which are more structured and developed—are likely to have better population risk management, accounting for lower emergencies better prevention (Hong et al., 2018). Alternatively, lower spending ACOs are not as structured and developed, and are more likely to have worse preventative measures and a greater number of emergencies relative to higher spending ACO’s (Hong et al., 2018). This is why higher spending ACOs are more likely to generate savings and cut down on operating expenditures (Hong et al., 2018).

Patient Experience

It’s imperative to note that across all studies analysed in this section, patient satisfaction was profoundly bolstered with the introduction of integrated care teams. Across some countries measures such as LDL cholesterol and blood pressure improved towards normalcy (Russe & Stahl, 2014). This is largely helped by enhanced accessibility to specialists and testing services, which are often troublesome to acquire for patients experiencing fragmented healthcare systems (Shi et al., 2015). Being able to receive services from these providers helps address both administrative and time waits for the patients (Shi et al., 2015). In fact, care coordination, accessibility and timeliness were largely enhanced due to the consolidation of administrative and clinical roles, which streamlined the process of getting appointments (Nyweide et al., 2015). This was most profoundly noted in the Henan study where a revolutionary integration of a severely fragmented system led to a 7.6-points increase on an 18.0 point Likert scale (Shi et al., 2015). Furthermore, these results were more prominently noted in patients with chronic diseases and those diagnosed with multi-morbidities; commonly older adults (Baxter et al., 2018). Often times, these patients would be interacting with multiple bodies within healthcare, such as hospitals, speciality clinics or public health services on a regular basis (Finley et al., 2018). As these patients are more experienced in the system, their input is far more valuable.This effect is important for Ontario with an aging demographic and highlights the ability of integrated care teams (OHTs) in delivering more satisfying experiences for older adults and chronic disease populations. In the international literature review, these were the very patients who felt most improved satisfaction due to accessibility and care coordination with integrated care systems (Baxter et al., 2018).

Onto a more biomedical lens, it’s imperative to note that patients of integrated care systems note strong clinical improvements (Russe & Stahl, 2014). More frequent follow-up appointments, collaborated care plan development, team-oriented testing and consulting result in improved care quality for patient populations (Russe & Stahl, 2014). Again, most notably, these improvements are most explicitly observed in populations such as older adults and those with chronic multi-morbidities (Baxter et al., 2018). Across Germany, Holland and England, haemoglobin, HbA1c, BMI, LDL cholesterol and blood pressure improved towards normalcy (Russe & Stahl, 2014). Similar results were also noted in early stage accountable care organisations (Salmon et al., 2012). In fact, these outcomes were also observed in more matured accountable care organisations, which have more geographically, ethnically and socio-economically diverse patient groups (Shortell et al., 2017). This is an important testament to note as many of these measures translate into cardiovascular disease, diabetes, heart issues as well as impaired respiratory functions which have high prevalences among Canadian patient populations (Finley et al., 2018). Building on international and North American literature, it seems that integrated care teams are effective in dealing with and improving the health conditions of patients facing these issues. It is plausible to deem OHTs as being effective messengers of drumming up the health of patients with these medical concerns.

Contrastingly, patients in England and North England did highlight issues of provider neglect and a lack of patient input as barriers to positive experiences (Russe & Stahl, 2014). Drawing from this experience, it seems obligatory on the Ministry to be more proactive with patients and appropriately implement them into this new integrated system.

Population Health

As the emerging concept of population health springs into the limelight, it’s key to establish that older adults are among those with the highest co-morbidities and subsequent utilisation of the healthcare system (Moore et al., 2012). In geriatric family health team examples, older adults had their experiences immensely improved. Due to comprehensive healthcare services, multi-team interactions allowed practitioners of all specialities to devise preventative care plans for those with chronic diseases (Moore et al., 2012). Most notably, this included better screening improvements in preventative screenings such as MOCA assessments, depression tests, physical activity tests etc. (Moore et al., 2012). Increases in preventative care screenings highlight the efficacy and importance of integrated team operations in reducing the likelihood of serious diseases, translating into lower ER-admissions (Moore et al., 2012). As a Canadian example, this is effective and relatable in illustrating the preventative effect integrated care has on older and vulnerable populations (Moore et al., 2012). However, England surprisingly did have greater ER-admissions (Russe & Stahl, 2014). It’s important to note that most of those admissions were self-admissions as opposed to plan/appointment based intakes (Russe & Stahl, 2014). This could represent growing misuse of the greater accessibility to hospitals and ERs. For implications in Ontario Health Teams, it’s careful to note that effective patient education is key in limiting system mis-utilisations.

On a more socio-economic scale, the Minnesota Hennepin Health Model is an effective illustration of how integrated care can play into multiple economic streams (Blewett & Owen, 2015). This model focused on those individuals 133% below the federal poverty line (Blewett & Owen, 2015). In integrated care models, reductions in ER-admissions decreased by 9.1% and 3% respectively (Blewett & Owen, 2015). The significance of these reductions is plentiful considering the vast socioeconomic factors that hinder health in these economically marginalised communities such as crime, poor healthcare accessibility, unhealthy lifestyles etc. (Blewett & Owen, 2015). Analytically, it seems appropriate to say that lifestyle changes and the clustered targeting of vulnerable groups such as addiction patients were focused on, promoting an up-stream prevention tactic. As a lesson for Ontario Health Teams, this suggests that with a collaboration of healthcare teams, a paradigm shift towards prevention for socio-economically vulnerable populations is effective in reducing emergency situations and poor health outcomes.

Cost and Efficiency

It’s important to note how pre-set bundled payments can be used as effective tools for providers in predicting and projecting the costs for their patients’ care (Russe & Stahl, 2014). In retrospect, this can provide further guidance on structuring care services delivery within budgets to lower costs and increase value (Russe & Stahl, 2014). As seen in Germany, where US$203 savings were generated per patient annually for a group of patients with chronic diseases, pre-set budgets are far more effective in motivating providers to be more proactive in structuring their care delivery to reduce costs (Russe & Stahl, 2014). Similar results, for different reasons, were noted in the U.S. through literature searches (Nyweide et al., 2015). Lower ER utilisations and reduced in-patient stays in hospitals were strong reducers of costs. This is imperative for Ontario Health Teams which will primarily be catering to older and multi-morbid patient populations. For OHTs, delivering preventative and effective care services while streamlining clinical operations will be key in drowning costs. However, like the experiences of England, where increased access accounted for greater utilization of the ER, OHTs must be able to set-up guidelines and frameworks that restrict the excessive use of the system by patients (Russe & Stahl, 2014). Primarily, these costs are reflected in speciality services which patients often face barriers to (Russe & Stahl, 2014).

In terms of streamlining services to lower costs, it’s also important to mention how initial ACO quality and spending can affect their ability in generating savings (Parasrampuria et al., 2018). As borne out by the experience of a literature search, ACOs with higher quality were more likely to generate savings (Parasrampuria et al., 2018). This is because ACOs with higher quality have the capability available to implement clinical and fiscal structures that generate sustainable savings, which their lower-spending counterparts do not (Parasrampuria et al., 2018). Derived from this example, it must be noted that OHTs must be large enough and cater to significantly sized populations in order to spend large sums of money in order to generate effective savings. While generating savings is consistent across most ACOs and integrated care teams, it’s those with higher spending, larger patient and provider bases that create more savings.

Similar to the domain of population health, ACO spending also has an impact on integrated care expenditures and savings (Hong et al., 2018). As seen in literature, ACOs located with better spending enhanced patient populations and generates more savings as part of better preventative care and management (Hong et al., 2018). This is an important note for OHTs who will be catering to diverse populations. While spending levels do help generate savings, their impact is various. It will be an uphill battle for OHTs in Ontario to address various social circumstances and ensure confounding factors such as socio-economic status do not hinder the ability of teams in creating savings.