One Client, One Team: Health system integration for leaders.

This article examines the implementation of the strategy and Integrated Client Care Program, a multi-level health system strategy to break down the barriers in a solid health system and a program to integrate care for populations with the most complex needs. Specific reference is made to two specialized programs, older adults with complex care needs and a palliative care program whose goal is to meet the needs of patients and their families in a community setting.

Leading Integrated Health and Social Care Systems: Perspectives from Research and Practice.

As the research evidence on integrated care has evolved over the past two decades, so too has the critical role leaders have for the implementation, effectiveness and sustainability of integrated care. This paper explores what it means to be an effective leader of integrated care initiatives by drawing from the experiences of a leadership team in implementing an award-winning integrated care program in Toronto, Canada. Lessons learned are described and assessed against existing theory and research to identify which skills and behaviours facilitate effective leadership of integrated care initiatives.

Effect of a postdischarge virtual ward on readmission or death for high-risk patients: a randomized clinical trial.

IMPORTANCE: Hospital readmissions are common and costly, and no single intervention or bundle of interventions has reliably reduced readmissions. Virtual wards, which use elements of hospital care in the community, have the potential to reduce readmissions, but have not yet been rigorously evaluated. OBJECTIVE: To determine whether a virtual ward-a model of care that uses some of the systems of a hospital ward to provide interprofessional care for community-dwelling patients-can reduce the risk of readmission in patients at high risk of readmission or death when being discharged from hospital. DESIGN, SETTING, AND PATIENTS: High-risk adult hospital discharge patients in Toronto were randomly assigned to either the virtual ward or usual care. A total of 1923 patients were randomized during the course of the study: 960 to the usual care group and 963 to the virtual ward group. The first patient was enrolled on June 29, 2010, and follow-up was completed on June 2, 2014. INTERVENTIONS: Patients assigned to the virtual ward received care coordination plus direct care provision (via a combination of telephone, home visits, or clinic visits) from an interprofessional team for several weeks after hospital discharge. The interprofessional team met daily at a central site to design and implement individualized management plans. Patients assigned to usual care typically received a typed, structured discharge summary, prescription for new medications if indicated, counseling from the resident physician, arrangements for home care as needed, and recommendations, appointments, or both for follow-up care with physicians as indicated. MAIN OUTCOMES AND MEASURES: The primary outcome was a composite of hospital readmission or death within 30 days of discharge. Secondary outcomes included nursing home admission and emergency department visits, each of the components of the primary outcome at 30 days, as well as each of the outcomes (including the composite primary outcome) at 90 days, 6 months, and 1 year. RESULTS: There were no statistically significant between-group differences in the primary or secondary outcomes at 30 or 90 days, 6 months, or 1 year. The primary outcome occurred in 203 of 959 (21.2%) of the virtual ward patients and 235 of 956 (24.6%) of the usual care patients (absolute difference, 3.4%; 95% CI, -0.3% to 7.2%; P = .09). There were no statistically significant interactions to indicate that the virtual ward model of care was more or less effective in any of the prespecified subgroups. CONCLUSIONS AND RELEVANCE: In a diverse group of high-risk patients being discharged from the hospital, we found no statistically significant effect of a virtual ward model of care on readmissions or death at either 30 days or 90 days, 6 months, or 1 year after hospital discharge. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01108172.

Integrated client care for frail older adults in the community: preliminary report on a system-wide approach.

The Toronto Central Community Care Access Centre is leading a collaborative local health integration network systemic change initiative to implement and evaluate a practical model of integrated care for older adults with complex needs. The approach is embedded in the community where older adults and their families live and is designed to first and foremost improve the quality of care while ultimately bending the cost curve. The model is leveraging and aligning existing system resources by bringing together sectors from across the health system to create ways of working that build capacity in the system to be more responsive to this population. Outcomes to date will be discussed and next steps described. The secondary goal was to understand the key elements of this integration that can be scaled locally and across the province.

Interprofessional stroke rehabilitation for stroke survivors using home care.

OBJECTIVE: To compare a specialized interprofessional team approach to community-based stroke rehabilitation with usual home care for stroke survivors using home care services. METHODS: Randomized controlled trial of 101 community-living stroke survivors (<18 months post-stroke) using home care services. Subjects were randomized to intervention (n=52) or control (n=49) groups. The intervention was a 12-month specialized, evidence-based rehabilitation strategy involving an interprofessional team. The primary outcome was change in health-related quality of life and functioning (SF-36) from baseline to 12 months. Secondary outcomes were number of strokes during the 12-month follow-up, and changes in community reintegration (RNLI), perceived social support (PRQ85-Part 2), anxiety and depressive symptoms (Kessler-10), cognitive function (SPMSQ), and costs of use of health services from baseline to 12 months. RESULTS: A total of 82 subjects completed the 12-month follow-up. Compared with the usual care group, stroke survivors in the intervention group showed clinically important (although not statistically significant) greater improvements from baseline in mean SF-36 physical functioning score (5.87, 95% CI -3.98 to 15.7; p=0.24) and social functioning score (9.03, CI-7.50 to 25.6; p=0.28). The groups did not differ for any of the secondary effectiveness outcomes. There was a higher total per-person costs of use of health services in the intervention group compared to usual home care although the difference was not statistically significant (p=0.76). CONCLUSIONS: A 12-month specialized, interprofessional team is a feasible and acceptable approach to community-based stroke rehabilitation that produced greater improvements in quality of life compared to usual home care. Clinicaltrials.gov identifier: NCT00463229.

Integrated complex care model: lessons learned from inter-organizational partnership.

Providing integrated care for children with medical complexity in Canada is challenging as these children are, by definition, in need of coordinated care from disparate providers, organizations and funders across the continuum in order to optimize health outcomes. We describe the development of an inter-organizational team constructed as a unique tripartite partnership of an acute care hospital, a children's rehabilitation hospital and a home/community health organization focused on children who frequently use services across these three organizations. Model building and operationalization within the Canadian healthcare system is emphasized. Key challenges identified to date include communication and policy barriers as well as optimizing interactions with families; critical enablers have been alignment with policy trends in healthcare and inter-organizational commitment to integrate at the point of care. Considerations for policy developments supporting full integration across service sectors are raised. Early indicators of success include the enrolment of 34 clients and patients and the securing of funds to evaluate and expand the model to serve more children.

Balancing institutional and community-based care: why some older persons can age successfully at home while others require residential long-term care.

Why can many older persons with relatively high needs age successfully at home, while others with similar needs require residential long-term care (LTC)? How can healthcare investments best be balanced to ensure that older persons have access to the most appropriate, cost-effective care?

Care, Attention and Making Tough Choices: Learning from Failure Means Weeding the Garden.

Like ecosystems in nature, healthcare systems are complex, interdependent systems. Does that mean they should be left to the forces of slower, evolutionary transformation? Given the pressures and expectations on public healthcare, the more deliberate hand of a gardener may be needed to "weed out" programs that are no longer fruitful in solving current issues. Taking such a discerning view of health system programs would mean re-examining attitudes about failure. Just as harvested plants provide compost that feeds the garden, knowledge gained from failure can strengthen healthcare. A public environment that favours "success stories" means other system participants don't get the benefit of the knowledge that can be gleaned from failure. Scientific disciplines advance knowledge by studying failed experiments. Health leaders must do the same. Even programs deemed "success stories" have likely failed in some ways, experience that should be shared as transparently and widely as the successes. Both notable successes and valiant failures can be equally valuable in designing health system programs that meet the needs of all patients.

Home chemotherapy for children with cancer: perspectives from health care professionals.

The goal of this study was to determine the perspectives of healthcare professionals (HPs) from community and hospital settings involved in a paediatric home chemotherapy programme. Using a prospective descriptive study design, HPs including paediatricians, community nurses, hospital clinic nurses, administrators and pharmacists were interviewed using a moderately structured open-ended approach. Through inductive content analysis, data were categorised under three themes reflecting HPs' perspectives on the programme: (1) perceived family benefits, (2) human resources and service delivery considerations and (3) impact on the role of the HP. All HPs reported that home chemotherapy helped reduce both disruption to family life and psychological stress. Community-based HPs reported increased job satisfaction, increased workload and increased frustration related to scheduling challenges. Hospital-based HPs reported decreased patient interaction and discrepancies in workload changes. Both groups emphasised the need for consistency in care and for specific chemotherapy training. Service delivery issues included the need for more clarity in the programme process, improved eligibility criteria, a focus on community laboratory coordination and development of centralised communications.

Development of a checklist of safe discharge practices for hospital patients.

BACKGROUND: Discharge from hospital can be a vulnerable period for patients. Multifaceted "discharge bundles" facilitate care transitions and possibly decrease adverse outcomes. We describe a structured approach to discharge planning, starting from admission and proceeding through discharge, using a standardized checklist of tasks to be performed for each hospitalization day. OBJECTIVE: To create an evidence-based checklist of safe discharge practices for hospital patients. METHODS: In the province of Ontario, the Ministry of Health and Long-Term Care convened a panel of expert members from multiple disciplines and across several healthcare sectors. The panel conducted a systematic search of the literature and used a structured approach to review evidence-based practices that ensure efficient, effective, safe, and patient-centered care transitions. A discharge-checklist tool was created to facilitate safe discharge from hospital. RESULTS: The final checklist describes the processes necessary for a safe and optimal discharge and recommended timeline of when to complete each step, starting from the first day of admission. The checklist domains include (1) indication for hospitalization, (2) primary care, (3) medication safety, (4) follow-up plans, (5) home-care referral, (6) communication with outpatient providers, and (7) patient education. CONCLUSIONS: The Checklist of Safe Discharge Practices for Hospital Patients summarizes the sequence of events that need to be completed throughout a typical hospitalization. Standardizing discharge planning and initiating processes early on in a patient's hospital stay may ensure a safe transition home.

Hospital and home chemotherapy for children with leukemia: a randomized cross-over study.

BACKGROUND: The study objective was to compare a hospital-based and a home-based chemotherapy program for children with acute lymphoblastic leukemia (ALL) in relation to Quality of Life (QOL), safety, caregiver burden, and costs. PROCEDURE: A randomized cross-over trial (RCT) design with repeated measures was conducted with 23 children with ALL who attended the oncology outpatient clinic of a metropolitan university affiliated tertiary level pediatric hospital and who also received home visits from a community health services care provider in central Canada. RESULTS: During the home-treatment phase, children were more capable of maintaining their usual routines than when receiving hospital chemotherapy (Wilcoxon statistic = 80, P = 0.023), but they appeared to experience greater emotional distress (Wilcoxon sign rank statistic S = 66, P = 0.043) according to parental report. Treatment location had no effect on caregiver burden and adverse effects. No significant differences between groups existed with respect to societal costs of care. As the child's age increased, QOL improved relative to younger children (t(20) = -2.37, P = 0.02), the time burden related to child care tasks was reduced (t(21) = -3.56, P = 0.002), caregiver effort/difficulty in physical and behavioral support decreased (t(21) = -2.09, P = 0.049) and the odds of experiencing one or more adverse events decreased (OR = 0.79, CI = (0.63-1.00), chi(1) (2) = 4.01, P = 0.045). CONCLUSIONS: With few differences noted between groups, these results indicate preliminary support for administrating some or all of a child's chemotherapy at home. Home chemotherapy was associated with specific improvements and decrements in parent reported QOL. No effects were seen on burden of care, adverse events, or cost. Overall, young age adversely affected QOL, burden of care, and adverse events. These data provide important information to families and caregivers as they consider home or hospital-based therapy in childhood ALL.

Children receiving chemotherapy at home: perceptions of children and parents.

The aim of this descriptive exploratory study was to determine the perspectives of parents and children with cancer on a home chemotherapy program. Qualitative analyses were used to organize data from 24 parents and 14 children into emerging themes. Themes included (1) financial and time costs, (2) disruption to daily routines, (3) psychological and physical effects, (4) recommendations and caveats, and (5) preference for home chemotherapy. When home chemotherapy was compared with hospital clinic-based chemotherapy, parents reported fewer financial and time costs and less disruption to their work and family schedules, and children reported more time to play/study, improved school attendance, and engagement in normal activities. Although some parents felt more secure with hospital chemotherapy, most found it more exhausting and stressful. At home, children selected places for their treatment and some experienced fewer side effects. Although some coordination/communication problems existed, the majority of parents and children preferred home chemo-therapy. Home chemotherapy treatment is a viable, acceptable, and positive health care delivery alternative from the perspective of parents and children with cancer.