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An Integration Story: Challenge, Complexity and Change

Amy Boudreau,                                     
Director of Integration & Sustainability, Ottawa

The Challenge

Carefor was initially invited to participate in eleven Ontario Health Teams (OHTs) as they were storming and forming. Those early days of health system transformation in Ontario were a chaotic dance. With little time for mingling and courtship, it was more of a ‘rush to the dancefloor and grab your partner’ style dance in cities and regions across the province. 

It was a fascinating experiment put forward by the government, allowing organizations to self-partner, self-form and self-plan for their community or health team of the future. Creating a loose framework and letting people innovate and create within its walls allowed members to see what new ideas may emerge to solve age-old problems. It was an interesting proposition for change for Ontario. Thankfully, over the past two years of meetings, trust building and planning, those eleven OHTs in the Champlain Region were reduced to six with some Ministry guidance. A much more manageable number for Carefor and others with a similar regional wingspan.

The OHT’s flagship goals are improved population health, a coordinated continuum of care, 24/7 access to care coordination and system navigation, a better experience and better value for people and providers, digitally connected care and community engagement. In theory, these goals sound promising and together could bring about significant change and improvement to Ontario’s health care system. What is less understood about this ‘build your own’ community approach to health system improvement is how differently OHTs will operate from one another in future.

Those who live in the same community over time will likely learn to love this new approach, whereas those moving from one OHT to another may struggle with access and navigation of services that have been designed very differently. It will be interesting to see how the OHTs will achieve their goal of simplifying an already complicated system for Ontarians.  

At maturity, the province will have fifty or more OHTs under its umbrella. It’s too early to know how the government will help create the standardization it needs to measure success and demonstrate outcomes. In the meantime, we remain busy on the ground reimagining care and services in new and interesting ways with hopes of success and simplification.

Perhaps the greatest challenge of all for OHTs in this new era of health system organization is how funding will shift to meet a population health management approach. With a long history of hospital-based performance metrics and funding flowing to acute care, has the time finally come for a shift towards health promotion and illness prevention? With no new funding for programs and services, OHTs will be forced to reallocate funds to where they believe they should go, in the best interests of people. It would be great to see funding shift from an illness model to a wellness model, thus spending more of our limited resources in the community where people live and choose to lead their best lives.

We know this shift will not happen easily with few OHTs focusing on governance and funding allocations at these early stages. Perhaps it would be in our best interest to begin with changes to our health system metrics, which today are heavily weighted in acute care. By placing more value on person-centred care and consumer choice over health system performance, the funding could flow to meet people where they choose to live for as long as possible, in their homes and communities.       

The Complexity

We know that health system transformation is no easy ticket to change. For years the government has toyed with this idea in Ontario. For years it has remained the same, with minor tweaks here and there. This is understandable given the size of the challenge and the complexity of the existing system. However, the window of opportunity opened in 2019 and the government decided to take it.

The OHT model that evolved is an interesting one, “to provide a new way of organizing and delivering care that is more connected to patients in their local communities… and where health care providers (including hospitals, doctors and home and community care providers) work as one coordinated team, no matter where they provide care.” Encouraged to come together voluntarily around an attributed population, the first step for health care providers was to learn about the care and services delivered in their community, by their health sector partners.  

My colleagues and I often say that it takes up to two years to truly learn and understand the complexity of home and community care. In a province full of publicly and privately run home care organizations, Carefor Health & Community Services is unique in this space. It is a large regional not-for-profit charity, an organization that has 30+ programs and services, many with their own funding and accountability requirements, client/resident flows, systems, collective agreements and staffing models. The diversity of programs and services in this organization alone is nothing short of complex, making Carefor a unique health system partner offering an interesting array of bundled care under one roof.

As I quickly learned in the early days of OHTs, what’s even more interesting than the complexity of home and community care is how little it is understood by our health system partners. Those who depend heavily on the nurses, physiotherapists, occupational therapists, community-based social workers, dieticians and personal support workers to transition our patients home from acute episodes and surgeries in hospital, and who care for those with chronic illness in their homes, actually know very little about home and community care and how it works. With recent changes to legislation, specifically the Connecting People to Home and Community Care Act (2020) or Bill 175, OHTs will soon be responsible for home and community care in communities across Ontario.

With an invitation to innovate, OHTs are only now starting to unpack this historical system and its legacy processes in their quest to integrate and smooth transitions from hospital to home. Although exciting, this invitation is somewhat daunting. A blend of public and private organizations, strict procurement and contracting practices, confusing performance metrics, health human resource shortages due to wage inequities with other sectors and years of chronic underfunding leaves OHTs with more questions than answers. I look forward to seeing how the Ministry will support OHTs with this newfound responsibility.

The Change

Despite the many challenges and complexities in our path, OHTs have created a new way of working in Ontario’s health care system. Health system partners have opened their doors, are building relationships with their health colleagues in different sectors and are reimagining care and services alongside our lived experience partners in bold new ways.

Carefor has embraced this change and is enjoying this new way of working – sitting at virtual tables across the region trying our best to educate, inform and challenge our partners to do things differently. Our top priority is teaching the inner workings of the home and community care sector, while suggesting opportunities for improvement, alignment and smoothing transitions for people receiving care at home and support in the community.

If health system transformation wasn’t enough change for an organization’s lifetime, throw into the mix a global health pandemic and you’ve got the perfect storm. Navigating through the changing tides of Covid-19 over the past year and a bit has been tough for all of us, especially those working in the health care space. Our providers, volunteers and leaders have never experienced anything quite like this, and arguably never will again. Despite the challenge, Carefor has come out of this storm a stronger and more resilient organization than ever before. I believe the same is true of OHTs across the province.

Although Covid-19 was not exactly on the roadmap planned by Ontario Health in 2019, this health crisis kicked OHTs into high gear. No longer were we spending our days dreaming of transformation, the pandemic forced partners to make transformation happen in record time, helping the most vulnerable people in our communities survive. Drawing from our newly built relationships, health team partners found new ways to use technology to work together to connect with people at home. As we learned more about the impacts of Covid-19 in our more vulnerable neighbourhoods, partners got creative in their out-reach efforts, working alongside communities to increase testing and immunization rates to address those hardest hit.  

For Carefor, Safe at Home became our mantra during this time as we worked to keep people safe and supported in their homes. Fortunately for us, very few providers and clients were infected with Covid-19; a similar story was reported by other home and community service organizations across the region. The lessons to be learned from Covid-19 will be studied by researchers for decades to come and will inevitably help shape the future of health systems and their structures, processes and outcomes. From my vantage point, the power of health system partners working alongside people in our communities is the real lesson we’ve learned and is something we need much more of in our future if we want to truly transform care.

Contributing to OHTs as a home and community care leader towards a fully integrated health care system is a vision that continues to inspire and motivate us all at Carefor. Sitting at various OHT leadership tables, our goal is to encourage a shift towards health promotion, illness prevention and a greater focus on planning for home and community care. We fundamentally believe that by respecting people’s choice to stay and live well with care and supports in their homes and communities, we will truly make a difference. Our goal is to align our message across the region as a trustworthy, not-for-profit home and community care partner. 

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