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Reading: Using segmentation and population indicators to support integrated care.


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Using segmentation and population indicators to support integrated care.


Walter Wodchis

University Of Toronto, Canada, CA
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Introduction: The Ministry of Health (MOH) in the province of Ontario in Canada has introduced Ontario Health Teams (OHTs) to advance population health and integrated care for attributed populations ranging from 35,000 to nearly 1 Million inhabitants each. OHTs must include hospital, primary care and community care providers. OHT attributed populations are based on patient attachment to primary care. The MOH is supporting OHTs with direct start-up funding and by funding research-based organizations to provide a range of coaching and evaluation activities. The Health System Performance Network (HSPN) has received funding to provide evaluation and performance information to OHTs.

Objectives: This presentation describes the data and approaches that the HSPN has taken to support the development of OHTs. Data have been collected from surveys of OHT organizational leaders based on the Context and Capabilities for Integrating Care (CCIC) Framework. Survey data were collected upon approval of OHTs and are currently being collected one and two years after approval as an OHT. Extensive health administrative data that are available for all Ontario residents are also being used to segment OHT attributed populations and to provide improvement indicators including indicators related to acute hospital, primary care, community care and transitions between sectors.

Key Highlights: Survey results highlighted strong positive results across most OHTs in Commitment to Improvement, Team Climate, Readiness for Change and Administration and Management. OHTs faced common challenges in Financial & Capital Resources, Non-financial Resources, and Clinical-Functional Integration. From the health administration data we found the greatest variation in indicators for potentially avoidable emergency department visits, unnecessary acute care hospital days, continuity of primary care and premature mortality. Specific indicators for focus populations including mental health, frail older adults and end-of-life suggest different strengths and weaknesses across OHTs. Additional indicators for population health management including cancer screening highlight additional opportunities for improvement. Segmenting the population according to different health care needs ranging from non-users to high users and end-of-life populations provides additional insights to target improvements including for example particular gaps in screening amongst relatively low users of healthcare.

Conclusions: The data being provided by the HSPN help each OHT focus on areas where they have the greatest opportunities for improvement. Using population segmentation is providing improved information to target specific populations for improvement ranging from individuals with relatively low healthcare utilization to those with high needs and high costs.

 Implications: The approach being used to support OHTs is based on evidence-informed approaches to population health management and learning health systems. This approach can and should be combined with other forms of support including coaching and local rapid-cycle evaluation to maximize improvement efforts.


How to Cite: Wodchis W. Using segmentation and population indicators to support integrated care.. International Journal of Integrated Care. 2022;22(S3):467. DOI:
Published on 04 Nov 2022.


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