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INTEGRATED CARE
PROGRAMMES IN CANADA
By: Teresa Bienkowska-Gibbs
Summary: Several Canadian provinces have implemented integrated care initiatives. Alberta and Quebec have both implemented integrated care programmes for the frail elderly population. Integration of
primary health care has also been conducted in Ontario. The main objectives of these programmes are to improve the health of the population, increase patient satisfaction, and substitute the use of institution-based services for community-based services. Where these programmes have been evaluated, results show some success in achieving the projects’ objectives but it is not clear whether this success is due to effective incentivising of stakeholders or other factors. The fragmentation of the Canadian health care system and the lack of a centralised electronic medical records database pose significant challenges to the successful integration of health care.
Keywords: Integrated Care, Primary Health Care Integration, Family Health Team Model, Canada
Teresa Bienkowska-Gibbs is an MSc student in International Health Policy at the London School of Economics and Political Science, UK. Email: T.J.Bienkowska-Gibbs@
lse.ac.uk
Background
There have been a number of initiatives to enhance the integration of care in Canada. The Comprehensive Home Option for Integrated Care of the Elderly (CHOICE) programme was piloted in Alberta in 1996 and subsequently scaled-up across the province. CHOICE is a full integration programme that integrates health and social care through the provision of transportation, day centres, health and social services, and home support. 1 Similarly, the Programme of Research on Integration of Services for the Maintenance of Autonomy (PRISMA) project in Quebec was piloted in 1997 – 1999 and was subsequently expanded across the province. The PRISMA project is a coordinated- integration model that integrates tertiary
care, long-term care, home care, and social services. The province of Quebec also piloted the SIPA (Services intégrés pour les personnes âgées en perte d’autonomie) project from 1999 – 2001. 2 This programme is a full integration model that uses community-based primary care services to integrate health and social services, acute and long-term care, and community and institutional services such as hospitals and nursing homes. 3 These three projects focus on the integration of care for the frail elderly and have benefits that include cost savings and efficiency gains for to providers, enhanced quality for clients as well as improved health outcomes.
There have also been a number of projects to improve the integration of care at the primary health care (PHC) level
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which involve the payment of financial incentives. Ontario’s Family Health Team (FHT) model is a good example. The FHT model, implemented in 2005, integrates all levels of PHC through the formation of interdisciplinary health care teams.* In contrast to the other three programmes described above, the province of Ontario has looked to improve health care integration through broader reforms to the delivery of PHC. These reforms include financial incentives to increase integration of care.
‘‘ the
goals of FHTs are far-reaching
Government support for this programme derives from its potential to improve efficiency and quality of care. Physicians in Ontario are given financial incentives to work in FHTs to improve PHC. Physicians are paid according to a blended funding model that includes capitation, some fee-for-service payments, bonuses for achieving preventive care targets, and payments for extending the range of services provided to include prenatal care, deliveries, home visits, and palliative care. 4 For example, additional annual payments are provided for patients with chronic diseases: CAN $60 (€45) per patient with diabetes or a serious mental health condition, and CAN $125 (€94) per patient with heart failure. 4
In addition, the Ministry of Health increases the incentives for physicians to work in FHTs by paying the salaries of interdisciplinary team members (such as nurses, dieticians, occupational therapists, and social workers) and providing funding for the development of electronic health records. Funding is also available for consultations with other specialists that collaborate with FHT members. FHTs allow physicians to work in cooperation with other specialists to care for patients with chronic conditions, all within one health care practice. The FHT model
* In addition to the integrated care projects mentioned in this case study there are a number of other on-going integrated care initiatives in Alberta, British Columbia, Ontario and Quebec.
also facilitates the involvement of family physicians in all stages of patient care regardless of whether the patient is in hospital, at home, or in a nursing home. 4 The incentives for patients to seek care from an FHT are the potential benefits of enhanced care and the decreased opportunity cost of using fragmented PHC.
Objective of the scheme and link to performance indicators
The objectives of the three projects are to improve the health of older people, increase patient satisfaction, and substitute institutional services for community services. 3 The goals of FHTs are far-reaching. The stated objectives that relate to improving integrated care include: provision of family health care services through an interdisciplinary team; development of community-based chronic disease management and self- care programmes; care coordination with links to other parts of the health care system; improvement of links with other community health care organisations;
and use of electronic health records that allow patient records to be accessed from different levels of the health care system. 5
Potential success and evaluation of the incentives
The CHOICE, PRISMA, and SIPA models have all demonstrated progress towards achieving their stated objectives in the pilot projects, as attested by full evaluations conducted in 1998, 2005 and 2009, respectively. 6 7 3 The FHT scheme has not yet been evaluated. The Conference Board of Canada is currently conducting a formal external evaluation of the FHT initiative to determine the extent to which it has achieved its objectives. 8 Meanwhile, the Government of Ontario reports that 200 FHTs have been created in Ontario since April 2005, serving 2.8 million patients. This suggests that the incentives for joining FHTs are sufficient for health care providers and patients to participate in the initiative.
Nevertheless, it is not yet possible to determine whether increased participation in FHTs is due to the incentives to integrate care specifically or whether it is due to the overall incentives to improve
PHC more broadly because the incentives to integrate care are embedded within the wider framework of PHC reforms.
Challenges
Health care systems in Canada are fragmented as each province is responsible for the provision of services within its territory. Although health is publicly financed, health authorities, hospitals, and primary care doctors are all financed separately. This poses an additional challenge for health care integration because each of these systems has different priorities and thus requires different incentives to integrate care. In addition, since health care is provincial, none of these programmes can be
implemented at a national level. Therefore, integrated care is geographically limited at the provincial level, as well as constrained by the programme’s ability to integrate within the respective health care system in each province. Lastly, the lack of a comprehensive centralised electronic medical records database is an impediment to health care integration on a larger scale.
References
1 Truman C. Articulating Program Impact Theory for the Comprehensive Home Option of Integrated Care for the Elderly (CHOICE). Ottawa: National Library of Canada, 2000.
2 Hebert R, Durand S, Somme D, Raiche M. PRISMA in Quebec and France: implementation and impact of a coordination-type integrated service delivery (ISD) system for frail older people. International Journal for Integrated Care 2009;9:1 – 2.
3 Beland F, Bergmen H, Lebel P, et al. Services for Frail Elders (SIPA): A Trial of a Model for Canada.
Canadian Journal on Aging 2006;25(1):25 – 42.
4 Rosser W, Colwill J, Kasperski J, Wilson L.
Progress of Ontario’s Family Health Team Model:
A Patient-Centered Medical Home. Annals of Family Medicine 2011;9(2):165 – 71.
5 Ministry of Health and Long-Term Care. Roadmap to Implementing a Family Health Team. Toronto:
Queen’s Printer for Ontario, 2009.
6 Pinnell Beaulne Associates Ltd. CHOICE Evaluation project. Evaluation summary. Final report, 26 November. Edmonton, Alta: Pinnell Beaulne Associates Ltd, 1998.
7 Hébert R, Tourigny A, Gagnon M (eds). Integrated Service Delivery to Ensure Persons’ Functional Autonomy. St-Hyacinthe: Edisem Incorporated, 2005.
8 Conference Board of Canada. Contract Research.
2012. Available at: http://www.conferenceboard.ca/
topics/health/hipe/research.aspx
