From the Editors.

As we consider the current pressures on healthcare, the options for where to focus our policy and leadership efforts are numerous and, at times, overwhelming. From health human resources capacity to access to mental health and preventative care to intermittent closures of emergency departments - the outlook is alarming. To help make sense of the situation, our Healthcare Quarterly (HQ) editorial team carefully considers a few areas to focus on in each edition. Over the past few issues, we have highlighted the importance of health equity and the challenges faced by different populations in gaining access to appropriate care and support. We continue to welcome submissions on this topic as we start to shift our focus toward other system priorities, including the mental health crisis in Canada. We are currently exploring a special focus edition on this long-neglected area of the health system and will be inviting submissions on this topic over the coming months.

Evaluating an Integrated Local System Response to the COVID-19 Pandemic: Case Study of East Toronto Health Partners.

Introduction: East Toronto Health Partners (ETHP) is a network of organizations that serve residents of East Toronto, Ontario, Canada. ETHP is a newly formed integrated model of care in which hospital, primary care, community providers and patients/families work together to improve population health. We describe and evaluate the evolution of this emerging integrated care system as it responded to a global health crisis. Description: This paper begins by describing ETHP's pandemic response mapping out over two years of data. To evaluate the response, semi-structured interviews were conducted with 30 decision makers, clinicians, staff, and volunteers who were part of the response. The interviews were thematically analyzed, and emergent themes mapped onto the nine pillars of integrated care. Discussion: The ETHP pandemic response evolved rapidly. Early siloed responses gave way to collaborative efforts and equity emerged as a central priority. New alliances formed, resources were shared, leaders emerged, and community members stepped forward to contribute. Interviewees identified positives as well as many opportunities for improvement post-pandemic. Conclusion: The pandemic was a catalyst for change in East Toronto that accelerated existing initiatives to achieve integrated care. The East Toronto experience may serve as a useful guide for other emerging integrated care systems.

Mobilizing a Whole Community: Policy and Strategy Implications of an Integrated Local System Response to a Global Health Crisis.

The East Toronto Health Partners (ETHP) include more than 50 organizations working collaboratively to create an integrated system of care in the east end of Toronto. This existing partnership proved invaluable as a platform for a rapid, coordinated local response to the COVID-19 pandemic. Months after the first wave of the pandemic began, with the daily numbers of COVID-19 cases finally starting to decline, leaders from ETHP provided preliminary reflections on two critical questions: (1) How were existing integration efforts leveraged to mobilize a response during the COVID-19 crisis? and (2) How can the response to the initial wave of COVID-19 be leveraged to further accelerate integration and better address subsequent waves and system improvements once the pandemic abates?

Contributing causes to adverse events in home care and potential interventions to reduce their incidence.

The increasing complexity of home care services, pressures to discharge patients quicker, and the growing vulnerabilities of home care clients all contribute to adverse events in home care. In this article, home care staff in six programs analyzed 27 fall- and medication-related events. Classification of contributing causes indicates that patient and environmental factors were common in fall events, while organization and management factors along with patient, task, team, and individual factors were common in medication-related events. Home care settings create specific challenges in identifying and mitigating risks. Some factors, such as variations in home environments, are difficult to address. However, changing care coordination structures and communication methods could ameliorate other factors, including poor communications among staff and limited team and cross-sector communication and coordination. Ensuring that medication ordering and administration processes are optimized for home environments would also contribute to safer care.

Predictors of Caregiver Distress in the Community Setting Using the Home Care Version of the Resident Assessment Instrument.

PURPOSE OF STUDY: The purpose of this study was to identify factors predictive of new onset and improved caregiver distress among informal caregivers providing assistance for clients receiving home care. PRIMARY PRACTICE SETTINGS: Home care. METHODOLOGY AND SAMPLE: The sample included 323,409 clients receiving home care from a Community Care Access Centre between March 2002 and March 2015 for whom data were available from two subsequent Resident Assessment Instrument-Home Care (RAI-HC) assessments. Separate multivariate logistic regression models were created for onset of and improvement in caregiver distress. RESULTS: Variables that increase the odds in onset of caregiver distress included primary caregiver is not satisfied with support received from family and friends; client lives with primary caregiver; 65 years and older; has Alzheimer and other related dementia; has condition or disease that makes cognition, activities of daily living, mood, or behavior patterns unstable; took sedatives in the last 7 days; Method for Assigning Priority Levels (MAPLe) score 4 or more; demonstrates persistent anger; has difficulty using the telephone; is married; requires 20 hr or more of informal help weekly; and Clinical Risk Scale score 4 or more. Variables that increased the odds of improved caregiver distress include client now lives with other persons (as compared with 90 days ago); demonstrates good prospects for recovery; treatment changes in last 30 days; surgical wound; female; one or more hospital visits in last 90 days; greater number of months between RAI-HC assessments; and two or more hours of physical activities in the last 3 days. Variables that decreased the odds of improved caregiver distress (i.e., persistent distress) include MAPLe score 4 or more; persistent anger; difficulty using telephone; Alzheimer, related dementia; requires interpreter; and lives with primary caregiver. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Informal caregivers provide essential support for home care clients. Factors predictive of new onset and improved caregiver distress can be used by case managers for comprehensive care planning that addresses the collective needs of the client-caregiver dyad.

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.

Perspectives on Advancing Bundled Payment in Ontario's Home Care System and Beyond.

Now more than ever, healthcare funders are weighing options to drive better value in care delivery, including using bundled payments to compensate healthcare providers based on expected costs to achieve specific health outcomes for patients. Ontario is currently exploring options for expanding bundled payment beyond acute care to home care, primary care, long-term care and across the continuum of care. This paper reviews the evidence, including the Ontario experience with bundled payment, and identifies opportunities for advancing bundled payment in home care as well as with other sectors. The authors consider the most promising opportunities, offer perspectives on where to start and identify the critical success factors. They conclude that is unlikely that payment reform on its own would be sufficient to drive changes in care delivery across providers. Instead, the evidence from the review points to the need to shift the conversation on bundled payment to a larger strategy for integration of care across providers and to engage providers in designing solutions, particularly for supporting chronic and complex patients who require support from multiple providers across the system.

Changing the Conversation with Home Care Clients.

Traditional home care delivery involves executing tasks for clients within a limited timeframe. Five years ago, when surveys of clients of Toronto Central Community Care Access Centre (TC CCAC) showed the lowest client experience levels across the 14 CCACs in Ontario, TC CCAC and its contracted Service Provider Organizations developed and implemented Changing the Conversation, a philosophy and framework that focuses on asking clients "what is most important" to them and then using that information as the basis for how care is delivered. Changing the Conversation has made a measurable difference to clients' experiences and has now expanded to other parts of the province and the country. It has been recognized as a Leading Practice by Accreditation Canada.