Pan-Canadian SPOR Network in Primary and Integrated Health Care Innovations



Overview

The pan-Canadian SPOR Network in Primary and Integrated Health Care Innovations is a key CIHR initiative under the Strategy for Patient-Oriented Research and the Community-Based Primary Health Care Signature Initiative.

The pan-Canadian SPOR Network in Primary and Integrated Health Care Innovations (herein called the pan-Canadian Network) is a Network of networks that builds on regional and national assets in community-based primary and integrated health care. It will foster a new alliance between research, policy and practice to create dynamic and responsive learning systems across the country that develop, evaluate and scale up new approaches to the delivery of horizontally and vertically integrated services within and across sectors of health care (e.g., public health, home and community care, primary, secondary, and tertiary care) as well as outside the health sector (e.g., education, social services, housing). The pan-Canadian Network will initially focus on individuals with complex health needs (a relatively small subgroup of the population with high health needs that accounts for a significant amount of health care utilization and costs) where integration of care along the continuum and where upstream approaches to prevention linked to integrated care delivery systems are critical to improve patient experience and health, health equity, and health system outcomes.

The pan-Canadian Network is rooted in community-based primary health care (CBPHC), which comprises a broad range of primary care and primary prevention services horizontally integrated within the community (including public health, community pharmacy services, rehabilitation support, home care and more), and which is recognized as playing an essential role in addressing the health challenges of this century. Recognizing the importance of facilitating transitions across the care continuum, the pan-Canadian Network incorporates a focus on horizontal integration of CBPHC services; vertical system integration through primary, secondary, and tertiary care; and multi-sector integration of upstream prevention strategies and care delivery models.

The pan-Canadian SPOR Network’s overall goal is to support evidence-informed transformation and delivery of more cost-effective primary and integrated health care to improve patient experience and health, health equity, and health system outcomes for individuals with and at risk of developing complex health needs.

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. Foster the creation of learning health systems across the country that 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.

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

  • individuals with complex needs across the life course, including 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 high system use and subsequent identification and targeting of prevention strategies and interventions.

Within these priority focus areas, the pan-Canadian Network will support cross-jurisdictional research that addresses horizontally and vertically integrated care priorities shared by several member networks 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 health or health system challenges;
  • 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.

Member Network Requirements

Each jurisdictional network must fulfill ten requirements in order to be official members of the pan-Canadian Network. These requirements can be seen on the web page

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 indicatorsFootnote 1.

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 high system users are within our reach if new approaches to 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 the high system users with complex care needs (e.g., older adults with multiple chronic conditions) who are often vulnerable because of their socioeconomic status and other social and structural determinants of health. Putting a focus on the health of our children, as one key group, 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 high-system users with complex care needs (including but not limited to older adults with multiple chronic conditions and children with complex care needs) – a subgroup of the population that requires and utilizes a significant share of health care resources – and children - whose health are critical indicators of overall population health and the effectiveness of health care and public health initiatives.

High systems users with complex care needs are a relatively small subgroup of the population yet it is responsible for a significant amount of health services use and costsFootnote 2. For example, in Ontario in 2007, 5% of the population was responsible for 66% of health care expenditureFootnote 3. Their heavy use of health care services is attributable to a number of complex and interdependent system-level factors, including inadequate access to primary and preventive care, suboptimal (or entirely absent) social servicesFootnote 4, 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). High system users 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 othersFootnote 5Footnote 6Footnote 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.

Children often access health services through different routes and are often forgotten as they are generally considered a ‘healthy’ population. However, increasing lines of evidence indicate that poor health and developmental trajectories throughout childhood and youth can lead to greater health concerns throughout adulthood. It is critical that multi-sector upstream prevention strategies and care delivery models lead to optimization of clinical outcomes and overall child health, since healthy children will become healthier adults, which will decrease the burden and cost of treatment of adult diseases. The health of children can be further 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 of vulnerability must be tackled through strategies involving sectors within and outside of health (e.g., education, transportation, housing, etc.). The projections of a “tsunami” of disease burden in an aging Canadian population make the focus of healthcare improvement in our “future adults” an urgent national health priority.

The pan-Canadian Network will accelerate the pace of innovation in integrated care solutions for high system users with complex care needs (including but not limited to older adults with multiple chronic conditions), and children by enabling rapid cross-jurisdictional learning about successful and unsuccessful features of integrated health prevention and care solutions and developing capacity to implement change and scale-up successful innovations.

Guiding principles: The pan-Canadian Network will operate on the following principles:

  • Inclusivity: the pan-Canadian Network will include all stakeholders that are interested in participating
  • Co-investment: the pan-Canadian Network will maximize co-investments in integrated health care innovation occurring at provincial and territorial levels
  • Collaboration: the pan-Canadian 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 pan-Canadian 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 pan-Canadian 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 pan-Canadian 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

Network research priorities: The pan-Canadian Network will initially focus on new approaches to the delivery of integrated health care (including primary prevention and primary health care) both horizontally and vertically across the care continuum to address: high system users with complex care needs (including but not limited to older adults with multiple chronic conditions and children with complex care needs); and, multi-sector integration of upstream prevention strategies and care delivery models for children. A key element of this focus is the assessment of upstream predictors of high system use and subsequent identification and targeting of prevention strategies and interventions.

Within these priority focus areas, the pan-Canadian Network will support research that addresses horizontal 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 pan-Canadian Network 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 1.

A consultation process involving member networks and partners is currently underway to identify short and medium to long-term cross-jurisdictional priorities. Member networks that 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 pan-Canadian Network through a number of channels, including the annual pan-Canadian Network meeting.

Table 1. 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:

  • British Columbia, Ontario, Quebec, and the Atlantic region 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?
  • Alberta, Saskatchewan and Manitoba have each 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?

e-Health

  • 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

  • Ontario, Quebec and Nova Scotia 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?

Tripartite Leads

Each member network within the pan-Canadian SPOR Network in Primary and Integrated Health Care Innovations is co-led by clinical, research and policy leads that collectively cover the continuum of care (prevention, primary, secondary, tertiary, and home care). The names of the leads can be found in Table 1

Table 1: Tripartite Leads

Jurisdiction Title Lead Lead Area Lead Institution
Alberta The Alberta SPOR Primary and Integrated Health Care Innovations Network Neil Drummond Research University of Alberta
Thomas Noseworthy Policy Alberta Health Services and University of Calgary
Maeve O’Beirne Clinical University of Calgary
British Columbia BC Primary Health Care Research Network Sabrina Wong Research University of British Columbia
Anne Junker Clinical BC Children’s Hospital/University of British Columbia
Garey Mazowita Clinical Providence Health Care
Heather Davidson Policy BC Ministry of Health
Manitoba The Manitoba SPOR Primary and Integrated Health Care Innovation Network (MPN) Annette Schultz Research University of Manitoba
Tamara Buchel Clinical Manitoba College of Family Physicians
Marcia Thomson Policy Government of Manitoba
Newfoundland and Labrador Primary Healthcare Research and Integration to Improve Health System Efficiency (PRIIME) Kris Aubrey-Bassler Research Memorial University
Kevin Chan Clinical Eastern Regional Health Authority
Beverly Clarke Policy Government of NL
New Brunswick New Brunswick SPOR Network: Primary and Integrated Community Care Shelley Doucet Research University of New Brunswick
Nancy Roberts Policy New Brunswick Government
Joan Kingston Clinical University of New Brunswick
Northwest Territories Development of a Northern-Based SPOR Network in Primary and Integrated Health Care Innovations Susan Chatwood Research Institute for Circumpolar Health Research
Jim Martin Policy Tłıc̨ hǫ Government
Nathalie Nadeau Clinical Yellowknife Health and Social Services Authority
Nova Scotia Nova Scotia Primary and Integrated Health Care Innovations Network Frederick Burge Research Primary Care Research Unit, Dalhousie University
Richard Gibson Clinical Central Zone (Halifax, Eastern Shore, West Hants), Nova Scotia Health Authority
Lynn Edwards Policy Department of Health and Wellness, Province of Nova Scotia
Ontario Better Access and Care for Complex Needs (BEACCON) Geoffrey Anderson Research University of Toronto
Onil Bhattacharyya Clinical Women’s College Hospital
Patrick Dicerni Policy Ministry of Health and Long Term Care
Prince Edward Island The SPOR Network in Primary and Integrated Health Care Innovations William Montelpare Research University of Prince Edward Island
Peter MacKean Clinical Primary Health Care (Summerside)
Mark Spidel Policy Health PEI
Quebec Quebec Knowledge Network in Integrated Primary Health Care (Réseau-1 Québec) Jeannie Haggerty Research McGill University
Denis Roy Policy Institut national d'excellence en santé et en services sociaux (INESSS)
Michèle Aubin Clinical University of Laval
Saskatchewan SPOR Network in Primary and Integrated Health Care Innovations: Saskatchewan LOI Nazeem Muhajarine Research University of Saskatchewan
Cory Neudorf Clinical Saskatoon Health Region
Margaret Baker Policy Government of Saskatchewan

Dynamic Cohort

CIHR and the Canadian Institute for Health Information (CIHI) have partnered to create a dynamic cohort of complex, high system users. The cohort was developed using CIHI’s in-house datasets (e.g., hospitalizations, ER visits, and costing data) to facilitate cross-jurisdictional research. The research priorities generated for SPOR’s Primary and Integrated Health Care Innovations (PIHCI) Network were considered when building the cohort, which resulted in the development of 8 subset cohorts to encompass various definitions of “complex, high system user”, and two age groups: children (<18 years old) and adults (≥ 18 years):

  1. Highest acute care cost (eg. patients with very costly interventions and investigations): children
  2. Highest acute care cost (eg. patients with very costly interventions and investigations): adults
  3. Highest length of stay (eg. patients waiting for alternative care): children
  4. Highest length of stay (eg. patients waiting for alternative care): adults
  5. Most frequent hospitalizations (eg. patients at risk of frequent exacerbations / deterioration): children
  6. Most frequent hospitalizations (eg. patients at risk of frequent exacerbations / deterioration): adults
  7. Most frequent emergency room visits (eg. patients who lack a primary care team or patients who suffer from uncontrolled illness): children
  8. Most frequent emergency room visits (eg. patients who lack a primary care team or patients who suffer from uncontrolled illness): adults

For each subset, CIHI stratified hospitalization and ED visit records by age group (children, adults), province and year, and then identified the top 10% of patients with respect to 1) acute care cost, 2) length of stay, 3) number of hospitalizations, 4) number of ED visits. To create the control group, a 20% random sample was selected from the remaining 90% of non-high users. The cohort currently includes data from 2011-2012 to 2014-2015 and will be updated each year as data becomes available. Patients that are selected each year will be followed forward in time, updating their records each year. This will allow researchers to investigate sporadic, persistent and one-time high system users.

The dynamic cohort is available from CIHI for all research funding opportunities and we encourage those applying to use it as a way of assisting in the rapid turn-around required for many of the cross-jurisdictional research projects. A document entitled Dynamic Cohort of Complex, High System Users – 2011-2015 is available that provides more information including how to access the cohort, the methodology and descriptive statistics.

Frequently Asked Questions

This series of frequently asked questions (FAQs) is meant to provide detailed information pertaining to the Network and the phased roll out of the associated funding opportunities.

If you have any questions that are not addressed in the FAQs below, please contact us at spor-srap@cihr-irsc.gc.ca.

Contact Information

Erica Dobson, Associate, Major Initiatives
Telephone: 613-946-7656
SPOR-SRAP@cihr-irsc.gc.ca

Date modified: