How to Deliver Integrated Care Models: Lessons from Ontario

By: Kevin Smith and Adalsteinn Brown

It is clear that better integrated care (also known as bundled care, integrated health, seamless care and a number of other names) will be part of our upcoming system reforms in Ontario. In this blog post, we highlight research from The Milbank Quarterly that provides support for such reforms through the evaluation of six provincial bundled care pilots and draw out two important themes.

In a recent issue of The Milbank Quarterly[1], a team of Ontario-based researchers evaluated six bundled care pilots funded by the Ministry of Health and Long-term Care.[2] These pilots involved collaboration by at least two separate organizations to implement care that was more seamlessly organized around the patient. These programs covered a range of different causes of hospital admission, ranging from acute events (Stroke, Cardiac Surgery, Urinary Tract Infections, and Cellulitis) to chronic disease (Chronic Obstructive Pulmonary Disease and Congestive Heart Failure) and covered time periods ranging from 30 days following hospital discharge (Cardiac Surgery) to 104 days afterwards (Stroke).

The researchers took a novel approach to their analysis that allowed them to explore and describe how the context preceding the pilots and the efforts they made during the pilots each contributed to perceived improvements in the integration of care. Although a new course for the Ontario health system has yet to be charted, it is clear from both statements by the Chair of the Premier’s Council on Improving Healthcare and Ending Hallway Medicine and global trends in health reform that better integration of care will be part of upcoming system reforms.

This paper provides valuable support for such reforms. One of its most important conclusions is that context, or what existed prior to the pilots, was important but not necessary to improving integration. The researchers described six key areas where efforts during the pilots helped increase the participants’ sense of integration.  These key areas were:

  1. Building off of structural elements; although differences in size between collaborating organizations could be problematic.
  2. Leveraging existing partnerships.
  3. Building trust.
  4. Developing thoughtful models.
  5. Engaging clinicians.
  6. Sharing information.

All of these key areas are important in the design of integrated care, but we want to draw out two themes that resonate across the reported research. The first is the importance of context. In each case, the way that organizations could build on their existing assets, relationships and culture was critical. There was nothing in the research that said indicated one best way to integrate care. This means that models should be built based on the community in which they will be deployed. Evidence from this and other studies is valuable in their design but there is no single best practice that should be slavishly followed.

The second is the importance of trust. Building trust was a key area but the importance of trust, and the factors that contribute to trust like engagement of clinicians, well-developed communications plans (both formal and informal), and the leveraging of relationships all speak as well to the importance of trust. In other work, one of us has argued that repeated interactions can build trusted relationships in knowledge transfer.[3] It is likely true here as well. This means that integration efforts should either build on those areas where partners have regular and genuine opportunities to work together or the creation of these opportunities must be a part of the change management strategy supporting integration.

A final, somewhat poignant note from this paper is the importance of who is included in the development of these models. The researchers interviewed those people that the pilot projects identified as important. At one pilot, there was no physician champion included in the interview list and only one pilot included a patient advocate. They note that this is “an indication of what was valued.”

If we fail to include clinicians, particularly physicians, in the design, implementation and leadership of integrated care, we increase the likelihood of failure. Indeed meaningful engagement of clinicians was identified in this study as one of the six key factors. But it is also a key element to any sort of successful health system transformation[4] and emerging evidence from Accountable Care Organizations (an advanced model of integrated care) in the U.S. suggests that provider-led ACOs perform better than others.[5] The researchers neatly captured the problems that can emerge when providers are excluded.

[W]e’ve got some really good clinical champions… [but] the clinicians are frustrated… I think that we, the steering committee, have failed the clinicians because we’ve insisted on perhaps having too much say in what they were looking at and what they were doing.

[W]e’ve got some really good clinical champions… [but] the clinicians are frustrated… I think that we, the steering committee, have failed the clinicians because we’ve insisted on perhaps having too much say in what they were looking at and what they were doing.

But an even more important exclusion from these models is the voice of the patient. A recent special edition of the CMAJ showed that there are multiple effective ways we can engage patients in the design and evaluation of health system changes.[6] So we cannot plead ignorance of the importance of engagement nor the lack of models to do so. Without strong patient engagement, new integrated care models may end up both pursuing the wrong goals and pursuing them the wrong way.

Adalsteinn Brown is Dean and Professor at the Dalla Lana School of Public Health. Kevin Smith is President & CEO of University Health Network.


[1] Gayathri Embuldeniya, Maritt Kirst, Kevin Walker, and Walter Wodchis. The generation of integration: The early experience of implementing bundled care in Ontario, Canada. Milbank Quarterly, 2018;96(4):782-813

[2] One of us (KS) led one of the initial pilots at St. Joseph’s Healthcare Hamilton.

[3] https://journals.sagepub.com/doi/abs/10.1177/1355819615602030?journalCode=hsrb

[4] https://www.ncbi.nlm.nih.gov/pubmed/24863106

[5] https://www.nejm.org/doi/full/10.1056/NEJMsa1803388

[6] http://www.cmaj.ca/content/190/supplement

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