On May 16, 2019, Health Quality Ontario hosted a lively and informative tweet chat (#HQOchat) on integrated care.
The chat featured a panel of moderators: Health Quality Ontario VP of Quality Improvement Lee Fairclough (@lfairclo), patient advocate Annette McKinnon (@anetto), University Health Network (UHN) President and CEO Dr. Kevin Smith (@KevinSmithUHN) and Marathon, ON family physician Dr. Sarah Newbery (@snewbery1).
@lfairclo provided the background for the discussion in a blog post which referenced Health Quality Ontario’s draft quality standard on transitions in care as well as detailing lessons learned from the work Health Quality Ontario has done working with teams to improve the coordination of care for patients with chronic conditions and complex needs. The blog closed by posing the five questions that framed the tweet chat discussion.
While the chat formally only lasted one hour, comments continued to be tweeted overnight and during the succeeding days, showing the strong interest in this topic. To date, more than 150 people have posted more than 700 tweets.
The overwhelming theme expressed in the comments was the importance of an integrated health care delivery system to improve care for patients. Asked to define integrated care, @anetto stated: “access to all of the services I require would be easy. Integrated care makes me think of team-based care”
“To me it means care that is seamless for patients - telling their story one time - and coordination amongst involved health care providers to ensure smooth care transitions,” @snewbery1 tweeted. Others expressed similar views.
Asked what is needed to build such an integrated system, @KevinSmithUHN listed the following: “Culture of customer service! Clinical leadership and followership. Patient engagement. Standards and standardization. Care navigators. Ease of data entry and retrieval. Simple tech support. Real time evaluation.”
Another physician tweeted his own list: “Patients and caregivers at the center. Support from primary care. Technology to allow seamless regular communication. Hospitals that integrate with primary care. Patients and families must co create this vision with primary care.” And Health Quality Ontario Interim President and CEO tweeted her own list: “System co-design with patients. Patient and caregiver access to their own records. EHR. Virtual care. Bundled funding.”
Another participant tweeted: “To completely be a fully integrated healthcare system you need a team of specialists to address the SDOH (social determinants of health). Our current system is fragmented due to how it is funded and figuring out what needs to be funded.”
Having a comprehensive and accessible electronic record of patient information was mentioned by many as a key building block for an integrated system and another blog post has dealt with that part of the discussion. A strong primary care network was also identified by many as a core component of integrated care.
On the issue of barriers, @KevinSmithUHN supplied another comprehensive list: “Turf. Compensation models. Scope of practice. Silos. Fragmented IT. Perceptions re Privacy legislation. Risk aversion. Waiting to get it 100% right before launch. Perceived legislative barriers.”
@snewbery1’s comment on this was well-received by many: “There are barriers created by the way that we value (or undervalue) physician and provider time spent on the communication pieces. There is little time in the day for the conversations & meaningful communications that matter.”
@LFairclo’s list of barriers “perceived or real” read: “silos between organization, different cultures among teams, ensuring patients integral part of team, incentives need to be aligned, inability to easily access common source of information, defaulting to the 'traditional way' of doing things.”
In response to comments about siloed care, one participant noted: “we need to invest time/energy/resources into building up the stuff between silos. (The bricks in the wall are important, but the mortar holds it together.)”
Turning to the issue of funding an integrated system, @snewbery1 commented “(I) don't know as much as I should about accountable care organizations, but moving from a transaction based payment system to an outcomes based system would support providers to do the things that matter for care outcomes.”
Another physician recommended a salaried model because “people with multimorbidity, disability and other complex health and social needs require more time than fee for service models.”
“How about designing from the outcomes we want and then figuring out what payment model works best? I’m really not sure what payment model works best but for me, as a complex patient, the current model doesn’t work,” one participant tweeted.
Others talked about moving from a transaction to an outcome-based model of compensation.
The chat finished by asking participants to identify integrated care models already working well in Ontario.
Examples referenced included rural communities in general, Community Health Centres , the St. Joseph Health System, and Trillium Health Partners. “As low tech as this sounds, my best examples are in poorly resourced systems where people still reach out to their colleagues personally to do warm hand offs, inform about admission etc. & follow up with patient when transitions happen. Hospice care is an example,” was another comment made.
“I think as of 5pm yesterday there’s an email inbox at the Ministry that is likely flooded with outstanding examples of integrated care from every region of the province!” one participant tweeted as the day before had been the initial deadline for groups interested in becoming Ontario Health teams to submit their applications.