Author – Paul Sulkers, Healthcare Consultant
The COVID crisis is placing huge demands on the Ontario health system, with a heavy reliance on acute care, perhaps our last line of defense. COVID has also brought in to focus the need for strong primary care and population health management, as we seek better ways to assess and manage COVID patients, many with other health or social challenges. To achieve population health, we need a health system that is integrated from a consumer perspective, understanding their needs and tailoring strategies to improve the health status of the entire population.
We understand that population health management must be enabled by primary care and consumer engagement, and we understand the policies needed for integration[↓1][↓3]. However, we have launched an OHT strategy that integrates around hospitals, fragmenting primary care into regions, and challenging consumers affiliated with multiple OHTs [↓4]. Our OHT approach also lacks the ability to scale investments, such as Toronto’s SCOPE, [↓5] or Sunnybrook’s “One-Team” [↓6] which could be classified as the ‘right idea’ in the ‘wrong place’, trapped within OHTs. Under the pressures of COVID, there is a natural tendency to fall back on OHTs as the ‘right path’, reinforcing acute-centric culture [↓18] rather than building capacity with primary care and consumer engagement to manage population at the front lines.
We can learn from others. Leading jurisdictions have invested in primary capacity, scaled across entire populations, and are now reaping the benefits of a seismic shift in the way that health is managed, funded and measured [↓7][↓13]. Spain established a population health strategy for Catalonia, segmenting their population into 320 risk categories [↓10]. Denmark reduced the number of acute hospitals from 98 to 36, shifting funds from acute to primary care [↓11]. The NHS uses community outreach and partnerships with the post office, re-defining health as a “team sport” to better manage the elderly closer to home [↓13]. In the US, Kaiser Permanente has created an integrated care delivery model that emphasizes preventive care and management of chronic disease [↓12]. Geisinger utilized centralized clinical leadership across enterprise-scale primary care, reducing costs per patient by 11% over five years, and reducing avoidable readmission rates by over 35% [↓8][↓9].
In all cases, enterprise-scale primary care was key, recognizing primary care’s critical role to be consumer-facing and leader of population health management. Enterprise-scale means moving from individual practices to integrated primary care governance, including standard care models, shared resources including virus surveillance capacity, paediatrics and palliative care, and partnerships with home care to manage care closer to home. Enterprise data enables central physician leadership to develop new funding models, addressing cohorts with similar risks, co- morbidities, and social determinants. Consumers view an enterprise or integrated system, including their care plan, educational content, health reminders, appointments and referrals.
A critical enabler of their enterprise primary care was a shared EMR, with the ability to scale care models and process, enable jurisdiction-wide view of population data, and a single digital view for consumers regardless of their residence [↓14]. Clearly, Ontario is not going to move to a single EMR any time soon! However, we can learn from other industries who have used digital process automation to integrate the ‘front’ end of the enterprise across a variety of disparate IT systems. Digital process automation will allow the fragmented Ontario health IT landscape to ‘appear’ integrated, shifting from variable and open loop process (using fax, phone and pagers) to digital processes that are patient-centred, closed loop, and measured, evidenced by Toronto’s ConsultLoop [↓14] [↓15].
Digital process automation across our primary care practices will enable enterprise status, including the ability to scale innovation across the entire population. Supported by outcome measures and innovative funding models, primary care will leverage shared resources and partnerships with home care and community services to better manage complex patients closer to home. Enterprise primary care will engage consumers via ‘extended reach’, moving knowledge to the patient, and reducing patient administration costs via the ‘healthcare manager’ in each household [↓14]. Social distancing has exacerbated the importance of communication and extended reach, not only with providers, but also among families, split apart by COVID.
Enterprise primary care will also achieve increased productivity by leveraging healthcare AI, including virtual care, predictive early warning, digital assistants, as well as digitally supported case managers [↓16] [↓17]. Increased productivity will free-up clinical resources to focus on in-person care, critical to manage patients drifting towards high cost cohorts.
However, digital is not the core competency of our health system. We must leverage the Canadian private sector to invest in enterprise primary care, pulling Ontario in to the 21st century. Private sector has the know-how gained from other industries successfully addressing similar integration challenges. Importantly, Ontario’s health digital expenditures must become an investment to build a new digital health & health AI economy in Ontario [↓14].
Together with private sector, we must start with enterprise primary care to integrate the ‘front-end’, ensuring consumers see a seamless view of Ontario healthcare, regardless of any OHT-defined relationship. COVID-19 presents a watershed moment to either continue acute-centric models or invest in enterprise primary care, at scale – rapidly!
1. World Economic Forum; Value in Healthcare Project
2. Peggy Leatt, George H Pink, Michael Guierre, Towards a Canadian Model of Integrated Healthcare, March 2000
3. Dr Robert Bell, August 2019
7. Primary Care Patient Centred Collaborative
8. D Maeng et al. “Can Telemonitoring Reduce Hospitalization and Cost of Care? Geisinger’s Experience in Managing Patients with Heart Failure”. Journal of Population Health May 2014
11. Denmark: Australian Financial Review
12. Kaiser Permanente Integrated Care Models
13. Jersey Post – Call and Check Program
14. Sulkers, P. “Integrating Ontario Healthcare: A POV”
16. Case Management: Mobiheatlh News, David Muoio, January 4, 2018
17. Productivity of Case Management: AHIP blog, Darcy Lewis, January 25, 2018
18. COVID-19 Assessment Centre