Author:

Abstract

1.            Integrated Comprehensive Care 3.0 is an expansion to an alternative model of patient care. Integrated comprehensive care (ICC) is an evidence-based model of bundled care that supports patients with One Team, One Record, One Number to Call, 24/7.  ICC is enabled by integrated funding; utilizing a bundled costing model.  In partnership, St. Joseph’s Health System and Niagara Health aimed to expand ICC to all planned surgical procedures at both organizations, as well as ED Admission Avoidance at St. Josephs.

2.            A care coordination model was developed to manage new surgical pathways, with no net new resources, incorporating patients and providers input at the center. The partner hospitals completed the steps to move toward a fully integrated model with a care coordination and costing model to support the change.  We ensured alignment in strategy with our partner organizations and the local Health Integration Network.

3.            Our goals: 

•              Design the post-acute pathway and care coordination model

•              Develop a bundle price that is cost-neutral to the Ministry

•              Conduct clinical engagement, change management and facilitate culture shifts to develop the bundle recognizing unique differences at each partner organizations.

•              Development of quality reporting framework, patient experience measurement and regular reporting to the ministry

•              Improve priority outcomes such as patient and provider experience, length of stay in hospital, readmission rates and ED visits

•              Develop an integrated comprehensive care framework for admission avoidance and ALC reduction incorporating ICC elements, and thereby decreasing hallway medicine.

4.            The target population for ICC 3.0 included planned surgical patients at St. Josephs Health System and Niagara Health. The project linked hospitals, outpatient physiotherapy clinics, home and community care, primary care/ family health teams, physicians/specialists and patient advisors.

5.FY 18/19 Q1

A.. Formalize and launch working groups

B... Coordinator model developed

   FY 18/19 Q1-Q4

C.  Create and confirm pathways for surgical streams

D.. Costing Model and Bundle pricing

E. Communication Strategy planning

F. Human resource Planning

     FY 19/20 Q1

G. Sustainability Planning

H. Evaluation and Reporting

  . 

6.          Each partner organization developed adoptable care coordination models with their individual constraints, creating opportunities to see gaps and move towards a fully integrated model. This also included expansion to present virtual care in the ICC model

7, 8

           Realigning current resources to best support an integrated care model.

           Enable ongoing engagement with all stakeholders to support sustainability.

           Testing innovative ways to support further integrations.

9, 10, 11

           Funding and Care coordination models between hospital and community structures are fundamentally different. They must align for ICC success.

           There is risk to bundle holders that they must accept to enact these  changes in care coordination. 

           Stakeholders need to be accountable to the desired outcomes of the ICC model in order to have successful change.

           Ongoing transparent communication and tracking of growth at each organization was fundamental.

           A key component was the work to develop a funding costing model. This highlighted  differences in how partners are funded, potentially impacting opportunity for success.