|System Integration in Quebec: The Prisma Project|
|Implemented in this survey?|
Canadian provinces have been improving access and quality of community-based care for seniors. A new survey of provincial Ministries of Health indicates progress in implementing best practices in integrated care for seniors such as single/coordinated entry systems, standardized, system-level assessment, system-level case management and involvement of clients and families. However, tools like shared electronic health information systems and effective decision tools are still missing.
Canadian provincial health care systems are moving toward implementing a framework of integrated care for those with chronic conditions. The framework is intended to advance health reform by improving coordinated care in the community, thereby reducing avoidable utilization of institutional services such as hospitals and long-term care homes. Hollander and Prince (2007) published a framework for coordinated care which was developed from interviews with 250 managers in provincial governments. The framework was intended to cover populations with ongoing care needs such as the elderly, children with disabilities, adults with disabilities and those with chronic mental health conditions. In 2008, provincial Ministries of Health were surveyed by the Canadian Policy Research Networks (see MacAdam, forthcoming) to ascertain to what extent progress had been made in implementing the framework.
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
Compared to the first HPM report on this issue (see "System integration in Quebec: The PRISMA project") ratings for characteristics are somewhat different. PRISMA is much more of a comprehensive system reform than the steps the provinces are currently taking, because it brings primary care, acute, rehab and community-based care together in a shared collaborative governance model. The other provinces are still building up their community care sectors within the typical silo system and there are poor linkages across the sectors. One exception is British Columbia where the Integrated Health Networks are bringing together community care and primary care. Evaluation data will become available soon and reported here in the HealthPolicyMonitor.
|Implemented in this survey?|
Home care services are not insured services under the Canada Health Act and have been provided by Canadian provincial governments out of general revenues. Although all provinces have home and community care programs, investments have been modest for two reasons: fear that demand would be high and difficult to control (the so called "woodwork effect") and weak evidence of cost effectiveness. But recent Canadian studies have indicated that home care can be a cost effective substitute for long-term care placement and perhaps could substitute for hospital use (Hollander and Chapell 2002; Hollander, 2001; Hollander et al 2009).
Slowly, stakeholder positions on the value of home and community care services for those with chronic conditions have been changing. For many years advocates of the home and community care sector and patients with disabilities have been alone in arguing for more investment in the sector. But as questions about sustainability of the current system arose, hospitals, physicians and other groups have begun to advocate for greater support for home and community care. In its 2007 pre-budget brief, the Canadian Healthcare Association, which represents a broad continuum of care, including acute care, home and community care, long-term care, public health, mental health and others, called for a $1B federal investment over three years for a home care program for people with ongoing chronic care needs (Canadian Healthcare Association 2007). At its 2008 annual meeting, the Canadian Medical Association passed a resolution advocating for "support systems to allow elderly and disabled Canadians to optimize their ability to live in the community" (Canadian Medical Association 2008). Home and community care has come to be seen as a (partial) solution to hospital issues such as overcrowded Emergency Departments and relatively high proportions of individuals who are unable to be efficiently discharged when they no longer need inpatient care. The federal goverment also changed its position regarding funding earmarked for home care; in 2004, for the first time, the federal government made new funding available to the provinces, specifically for post acute home care.
|provincial governments||very supportive||strongly opposed|
|Community providers of services||very supportive||strongly opposed|
|hospitals||very supportive||strongly opposed|
|long-term care homes||very supportive||strongly opposed|
|patients with chronic conditions||very supportive||strongly opposed|
|provincial governments||very strong||none|
|Community providers of services||very strong||none|
|long-term care homes||very strong||none|
|patients with chronic conditions||very strong||none|
Our survey of provincial Ministries of Health found that all Canadian provinces are making progress in implementing system-wide home and community care best practices. In particular, most of the provinces had made important gains in implementing clinical features such as single/coordinated entry systems, standardized, system-level assessment and care authorization, a single system-level client classification system, system-level case management and involvement with clients and families.
But provinces were far less likely to have implemented integrated information systems. The survey asked about linkages between the home and community care sector and physicians, hospitals and other social and human service sectors. Many provinces have poor linkages between home care programs and primary care physicans although some are adjusting physician remuneration to more comprehensive care for the elderly. Ontario is co-locating home care case managers in primary health centres. Most provinces have co-located home care case mangers in hospitals to assist with discharge planning but more could be done to divert elderly people who arrive at the Emergency Room.
Performance monitoring of home care and other health provider accomplishments is becoming better established. In one region of Quebec, there has been undertaken a systematic investment in monitoring and evaluating the effects of a system-wide integration and coordination of care for the elderly project (see CPRN survey "System Integration in Quebec: The PRISMA Project").
Home and community care expenditure data are difficult to obtain in Canada because of definitional, data collection and other issues. In 2007, the Canadian Institute for Health Information (CIHI) estimated that total public spending on home care was $3.4B in 2003-2004. Since 1994, expenditures per capita have increased on average by 6.1% but the number of users increased by only 1% indicating that home care users were consuming more resources than they were a decade earlier (CIHI 2007). In part, this is due to a reduction in eligibility and services covered over time. Today most Canadian home care programs are focused on serving a post acute and more disabled population. This shift would seem to support a greater investment in coordinated care mechanisms that will allow for sharing of clinical and administrative information among providers, and the development of more effective ways to support these more frail seniors in their own homes. However coordination of care across acute, primary care and home care sectors is a complex challenge and one not likely to be achieved in the near term.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
The data to date indicate that integrated care systems have strong potential for cost efficiency. However integrated systems, as opposed to demonstration projects, are complicated to implement and require, at a minimum, strong leadership, financial incentives, a commitment to interdisciplinary care management and shared information systems over a number of years. Canadian provinces are making progress but many important tools for integrated care such as shared electronic health information systems and effective decision tools remain to be implemented.
Canadian Institute for Health Information. Public-Sector Expenditures and Utilization of Home Care Services in Canada: Exploring the Data. March 2007. www.cihi.ca
Canadian Healthcare Association. A Framework for the Prosperity, Health and Well-being of Canadians. 2007. www.cha.ca
Canadian Medical Association. Health Care Transformation Resolutions. Annual Meeting. 2008. www.cma.ca
Hollander, M. Evaluation of the Maintenance and Preventive Model of Home Care. 2001. www.hollanderanalytical.com
Hollander, M. and N. Chappell. Synthesis Report: Final Report of the National Evaluation of the Cost-Effectiveness of Home Care. Hollander Analytical Services. 2002. www.hollanderanalytical.com
Hollander, M. and M. Prince. Organizing Healthcare Delivery Systems for Persons with Ongoing Care Needs and their Families: A Best Practices Framework. 2007. Healthcare Quarterly 11(1):42-52.
Hollander, M., J. Miller, M. MacAdam, N. Chappell and D. Pedlar. Increasing Value for Money in the Canadian Healthcare System: New Findings and the Case for Integrated Care for Seniors. 2009. Healthcare Quarterly 12:1:38-47.
MacAdam, M. Moving Toward Health Service Integration: Provincial Progress in System Change for Seniors. Forthcoming. www.cprn.ca/health
|System Integration in Quebec: The Prisma Project|
Process Stages: Implementation
Senior Fellow, Canadian Policy Research Network