SPOR Network in Primary and Integrated Health Care Innovations: Background, goals, objectives, governance and priority focus

Background: Transforming healthcare for the next generation

Although Canada is spending an increasing share of its revenue on healthcare — approximately 190 billion dollars per year — it is falling behind other industrialized nations in obtaining value for its investment. Canada ranks fifth or last in performance on safety, quality, equity and efficiency measures among six comparator nations who are making an equivalent investment in healthcare. Infant, child and youth health are critical indicators of overall population health and the effectiveness of health care and public health initiatives. Canada compares unfavorably to other G-7 countries on many of these indicators1.

The major challenges are known. Canada, similar to other nations, has an aging population, an increasing burden of chronic disease, a health care system that poses access issues for population groups with high and complex care needs. In addition, the current system is fragmented and uncoordinated which causes additional stress, confusion and potential harm to Canadians at a time when they are at their most vulnerable: in need of care. The antiquated hospital-centric care delivery model of the last century is no longer appropriate to address today's urgent health needs. Moreover, the symptoms that flag the need for transformation and integration are evident: high rates of emergency department visits for conditions and populations that are better managed through an integrated approach to community-based primary health care (CBPHC); poor access to timely first line health services; fragmented and uncoordinated care pathways lacking integration both within and across sectors of care; social, cultural, economic and environmental conditions that make unhealthy lifestyle choices the easier choices; higher rates of morbidity and mortality for vulnerable subgroups of the population (e.g. Aboriginal peoples); and compromised quality of life, particularly for those who are medically fragile and/or technology dependent such as children and adults living with complex multimorbidity typically associated with significant functional limitations. All of these symptoms point to an urgent need for transformative change towards integrated healthcare delivery models that take advantage of and build upon the foundation that provincial and territorial ministries of health have created through recent reforms and investments in CBPHC.

There is consensus that a strong foundation in CBPHC with integrated linkages to secondary and tertiary sectors of the health care system and to relevant sectors outside of health (e.g., social services, education, transportation) is required to address the challenges of health and healthcare in this century. However, a new generation of models of care is needed that extends well beyond traditional primary care medical practice, integrating the full continuum of care (including prevention, acute care, tertiary hospitals, home care, long-term care). Improved health for population groups such as children, prevention and management of chronic diseases, reduced inequities in access to health and health care for vulnerable populations, and improved access to appropriate care for individuals with complex needs across the life course are within our reach if new approaches to primary and integrated health care are developed through interdisciplinary and inter-professional collaboration, and partnerships both within and outside of the health sector.

To date, there has been limited pursuit of models of care that incorporate population and public health interventions within integrated models of health care delivery. New approaches are needed that can incorporate the assessment of upstream predictors of need and utilization with the development and implementation of corresponding preventive interventions. Such an integrated approach to prevention could have considerable effects in reducing increasingly prevalent problems such as childhood obesity, and school and work-related stress disorders which influences the public health burden of tomorrow’s adults. New approaches to primary prevention could also reduce avoidable utilization and high health care costs, particularly among individuals with complex care needs across the life course (e.g., older adults with multiple chronic conditions, children) who are often vulnerable because of their socioeconomic status and other social and structural determinants of health. For example, putting a focus on the health of our children will have long-term impacts that will enable the future adult Canadian population to have the best start in life.

Rural and remote northern populations represent a unique challenge for Canada and other circumpolar nations. In this context, community engagement is crucial to identify appropriate technologies and other innovations that can improve access to essential and culturally relevant integrated healthcare and reduce inequities in health. Meaningful citizen, patient and family engagement is also critical to ensuring that appropriate and culturally sensitive care is provided.

Building on Canada's foundations in primary health care: Provincial and territorial ministries of health have made significant investments in primary health care reform over recent years to improve access, quality, continuity, cost, satisfaction and health outcomes. Interdisciplinary team-based care, networks with streamlined care pathways, the use of health information technologies, new funding and remuneration models, patient engagement and empowerment initiatives, chronic disease prevention and management strategies, and new linkages with other key sectors are a few of the many examples of provincial and territorial reforms that have strengthened Canada’s foundations in primary health care. Recent investments by CIHR and partners in community-based primary health care innovation teams will catalyze further evidence-informed innovation. It is now time to build on this primary health care foundation to create vertically and horizontally integrated care delivery systems that foster continuity of care, smooth transitions between sectors of care, improve health system efficiency, and contribute to a better patient and family experience and health outcomes. Such transformative change will be most beneficial for individuals with complex care needs across the life course.

The SPOR network in primary and integrated health care innovations

The SPOR Network in Primary and Integrated Health Care Innovations is a network of networks that builds on provincial/ territorial/federal networks and national assets in community-based primary health care. It will foster a new alliance between research, policy and practice to create dynamic and responsive learning networks that develop, evaluate and scale up new approaches to the delivery of integrated and cost-effective services across and beyond sectors of health care, and contribute to improved clinical, population health, health equity, and health system outcomes.

Network focus: The Network will initially focus on new approaches to the delivery of primary and integrated health care (including primary prevention and primary health care) both horizontally and vertically across the care continuum to address:

  • individuals with complex care needs across the life course, showing capacity to evolve the network's scope over time to include age groups from children to older adults ; and,
  • multi-sector integration of upstream prevention strategies and care delivery models. A key element of this focus is the assessment of upstream predictors of complex needs and high system use and subsequent identification and targeting of prevention strategies and interventions.

Within this initial focus, the Network will lead a priority-setting process to identify its research priorities and questions. It is also expected that the Network will identify other priorities once it is established.

Individuals with complex needs across the life course are a relatively small subgroup of the population responsible for a significant amount of health services use and costs.2 For example, in Ontario in 2007, 5% of the population was responsible for 66% of health care expenditure.3 Their heavy use of health care services is attributable to a number of complex and interdependent health and system-level factors, including inadequate access to primary and preventive care, suboptimal (or entirely absent) social services, and fragmented service delivery4 as well as individual, social and structural determinants of health that lead to or reinforce conditions of vulnerability (e.g., stigmatization, frailty for the elderly). Individuals with complex care needs are identified in the literature as a medically and socially vulnerable population including, but not limited to, older adults with multiple chronic conditions, the frail elderly, those with mental illness, individuals with complex multimorbidity, low socio-economic status, low self-reported health status, minorities, children and youth with complex care needs, those lacking family or social support, and others.5,6,7 This subgroup of the population often use the emergency department (ED) for care that could be prevented or treated in a community setting, and are more likely to cycle in and out of hospitals and ED’s and experience gaps in transitions of care. Providing care for individuals with high and complex care needs on an emergency basis is sub-optimal and contributes to fragmented care, inappropriate utilization, high health care costs, and poor health and health equity outcomes. A critical element of successful redesign of care delivery models for this subgroup of the population is the ability to understand the multifaceted and interdependent health, social and system factors that underpin complex care needs and high utilization and to develop corresponding upstream intervention strategies focused on prevention. Experiments such as Medical Homes and Accountable Care Organizations in the United States are examples of efforts to redesign the system and care pathways to support the most effective prevention and management of complex, high needs patients.

Multi-sector integration of upstream prevention strategies and care delivery models has the potential to decrease the burden and cost of treatment and improve overall health and well-being across the life course. Moreover, the health of individuals can be threatened if they live in conditions of vulnerability influenced by individual and structural determinants of health (e.g. age, socio-economic status, sex and gender, sexuality, developmental/functional, disability, inability to communicate effectively, racial/ethnic background, geography, racial discrimination, poverty, poor housing and inadequate social assistance programs). For instance, these can include Aboriginal children and their families and others living in vulnerable circumstances. These conditions must be tackled through upstream strategies involving sectors within and outside of health (e.g. education, transportation, housing, etc.).

The SPOR Network in Primary and Integrated Health Care Innovations will accelerate the pace of innovation in integrated care solutions for individuals with complex care needs (including but not limited to older adults with multiple chronic conditions and children), including multi-sector integration of upstream prevention strategies and care delivery models for individuals across the life course from childhood to older adults. By embedding research within the health care system and linking researchers with policy makers and health professionals, the Network will enable rapid cross-jurisdictional learning about successful and unsuccessful features of integrated health care solutions and developing capacity to implement change and scale-up successful innovations.

Goal and objectives:

Goal:

  • Support evidence-informed transformation and delivery of more cost-effective and integrated health care to improve clinical, population health, health equity, and health system outcomes.

Objectives:

  1. Create cross-jurisdictional opportunities to conduct research on the comparative efficiency, cost-effectiveness and scalability of innovative and integrated models of care that build on the foundations of community-based primary health care and facilitate transitions into and along the care continuum.
  2. Accelerate the timely investigation of new interventions and approaches in primary and integrated care across multiple jurisdictions and sectors.
  3. Catalyze research on and scale-up of cost-effective and innovative approaches to primary and integrated care.
  4. Support capacity building among researchers, clinicians, decision-makers and citizens/patients/families for timely generation and use of primary and integrated health care knowledge.
  5. Foster the exchange of information and evidence on successful and unsuccessful interventions and innovative models of primary and integrated health care across jurisdictions to inform policy development.

Guiding principles: The SPOR Network in Primary and Integrated Health Care Innovations will operate on the following principles:

  • Inclusivity: the Network will include all stakeholders that are interested in participating
  • Co-investment: the Network will maximize co-investments in integrated health care innovation occurring at provincial and territorial levels
  • Collaboration: the Network will establish a research agenda that addresses issues that are relevant to some or all of the jurisdictions, and are most effectively carried out by a cross-jurisdictional network
  • Coherence: the Network will foster the conditions for provinces and territories to improve coherence in addressing priorities in the production and translation of research in integrated health care
  • Impact: the Network will evaluate the clinical, cost-effectiveness, population health, health equity and health system outcomes of its research in integrated health care
  • Continuous innovation and improvement: the Network will foster the conditions for continuous innovation and improvement in cost-effective care delivery by requiring research, practice and policy to be integrated into networks to enable continuous practice and system learning

Stakeholders

  • Clinicians and healthcare professionals
  • Policy-makers and health system managers
  • Patients/citizens, families, communities
  • Researchers
  • Health research funders
  • Professional and regulatory associations

Governance: The guiding principles, goal and objectives of the SPOR Network in Primary and Integrated Health Care Innovations will be operationalized by a governance structure, as illustrated in Figure 1. To meet the principles of co-investment and coherence, the governance
structure is conceptualized as a network of networks. Membership and core functions are defined in Table 1.

Figure 1. Network Governance

Figure 1 long description

It is expected that some provinces and territories may wish to combine their resources and maximize their respective strengths by collaborating to form a regional network (e.g., the Atlantic network).

Table 1. Network Components: Draft Membership and Core Functions

Snapshot Membership
Funders’ Consortium
Responsible for providing strategic oversight of the Network and working with the Leadership Council to jointly set research priorities.
Inclusive of all F/P/T and national organizations that invest in the Network, including public, private and not-for-profit organizations
Management and Administrative Office Housed at CIHR, it will support the Funders’ Consortium and Leadership Council, administer the budget and peer review, and make time-sensitive decisions for the Network.
  • Two Nominees from the Funders’ Consortium
  • Two Nominees from the Network Leadership Council
  • Network Program Manager
  • IHSPR, IPPH, IHDCYH, and IA Scientific Directors
Leadership Council As the innovation hub of the Network, it brings together the science, clinical and policy leads of each member network to develop science protocols and implementation
  • Science, clinical, and policy leads that collectively cover the continuum of care (prevention, primary, secondary, tertiary sectors) from each member network
  • Chaired by a scientific lead, a policy lead, and a clinical lead who are elected by the Leadership Council for two-year period that is renewable for a
    strategies for the Network’s priorities. The Leadership Council will lead a priority-setting process and make recommendations to the Funders’ Consortium to inform the Network’s research priorities.
    second term
  • A representative from the coordinating centre
  • CIHR Network Program Manager

Coordinating Centre
Harness Canada’s many national assets in integrated care to provide a coordinated approach to the Network’s communications, training, KT and engagement activities. Inclusive of interested researchers, clinicians and policy makers with pan-Canadian reach and national-level organizations, professional associations and other national assets

Network research priorities: The Network will initially focus on new approaches to the delivery of primary and integrated health care both horizontally and vertically across the care continuum to address: individuals with complex care needs across the life course, showing capacity to evolve the network's scope over time to include age groups from children to older adults ; and, multi-sector integration of upstream prevention strategies and care delivery models. A key element of this focus is the assessment of upstream predictors of complex care needs and subsequent identification and targeting of prevention strategies and interventions.

Within these priority focus areas, the Network will support research that addresses horizontal and vertical primary and integrated care priorities shared by several provinces/territories/federal jurisdictions and where there is value-added in a cross-jurisdictional approach, including:

  • Knowledge of the comparative effectiveness and efficiency of different jurisdictional approaches to the same challenge;
  • More rapid and/or generalizable response to a priority area by employing a cross-jurisdictional approach; and/or
  • A more comprehensive evaluation of a priority area through the use of expertise and resources in multiple jurisdictions.

Research priorities for the agenda of the SPOR Network in Primary and Integrated Health Care Innovations are expected to be those where several member networks share a common challenge, and where they are using different service delivery approaches, and are investing substantially in these areas, including in evaluation. This approach affords opportunities to provide a more comprehensive and informative evaluation of the particular attributes of approaches that are effective across jurisdictions, and how these are influenced by context (e.g. policy, health system delivery context). The use of common measures and outcomes will allow for more direct comparisons of promising approaches. Examples of potential priority areas and natural experiments based on variation in approaches are outlined in Table 2.

Research priorities will be identified by the Leadership Council and confirmed in collaboration with the Funders’ Consortium. Leads from each member network who are interested in the research priority will collaborate on developing a cross-jurisdictional comparative protocol that assesses the cost-effectiveness and outcomes of alternative integrated care approaches, providing a basis for decisions about their relative benefits (e.g. quality of life) and costs, and the policy changes that might be needed for implementation and scale-up. The research findings will be shared with all members of the SPOR Network in Primary and Integrated Health Care Innovations through a number of channels, including the annual Network meeting.

Table 2. Illustrative Examples of Common Challenges and Different Approaches among the Provinces and Territories

Please note: The following are hypothetical examples for illustrative purposes only.

Models of Care:

  • Four provinces have identified “new models of integrated care for older adults with multiple chronic conditions as a provincial priority. The respective provinces are implementing different policies and models of care to address this priority, with the aim of reducing avoidable hospital admissions and improving transitions of care. What are the health and economic impacts of these different approaches to integrated care for older adults with multimorbidity?
  • Three provinces have identified upstream prevention strategies to reduce the future prevalence of high-system users as a provincial priority. Each province is focusing on a different subgroup of high-system users. For each subgroup, what are the potential “savings” from both a government and societal perspective of upstream prevention strategies?

eHealth:

  • Telehealth and new payment strategies for e-consults has been implemented in some provinces to improve access to care in rural and remote areas. Is this a more cost-effective approach than transporting patients to urban/regional care facilities?

Resource allocation and disinvestment:

  • What is the impact of eliminating prescription co-payments for high needs complex patients to improve medication adherence and reduce ED visits and hospitalizations?
  • What is the impact of discontinuing glucose test strips on complication rates and hospital admissions for high needs complex patients with diabetes?

Prevention:

  • Does the implementation of a flu vaccination program for children in a particular province reduce ED visit and hospitalization rates for high needs complex patients?

Care for Children

  • Three provinces have identified integrated models of care for children with obesity as a priority, including prevention strategies. Each province is adopting a different approach and involving different sectors of care with the aim of reducing the future prevalence of childhood obesity and increasing family satisfaction with care. What are the impacts of these various strategies?

Footnotes

Footnote 1

For example, Canada ranks 40th in the world for infant mortality rate, Canada ranks 17th out of 29 “rich” countries, with below average scores for child poverty, obesity and children’s life satisfaction and ranking almost at the bottom (27) for child health and safety.

1

Footnote 2

Malone RE. (1995). Heavy users of emergency services: social construction of a policy problem. Social Science & Medicine, 40(4): 469-77

2

Footnote 3

Wodchis et al, ICES, 2012 CAHSPR Conference

3

Footnote 4

Malone RE. (1995).

4

Footnote 5

Malone RE. (1995).

5

Footnote 6

LaCalle E. Rabin E. (2010). Frequent Users of Emergency Departments: The Myths, the Data, and the Policy Implications. Annals of Emergency Medicine, 56(1): 42-8

6

Footnote 7

Khan Y. Glazier RH. Rahim M. Schull MJ. (2011). A Population-based Study of the Association between Socioeconomic Status and Emergency Department Utilization in Ontario, Canada. Academic Emergency Medicine, 18(8)

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