Sub Plenary session at CAHSPR 2015

Sub Plenary session at CAHSPR 2015 Building Systems Level Evidence from the Mosaic of 12 Research Programs in the CIHR Signature Initiative on Community Based Primary Health Care. 1

Objectives & rationale To demonstrate the usefulness of logic models as a common tool for representing knowledge yield from heterogeneous research programs. To reveal how high level decision makers identify relevant knowledge across programs to leverage system level change Logic modelling used routinely used by decisionmakers in strategic planning and management. Common language between researchers and decisionmakers? 2

Today s speakers Luc Boileau, INESSS, Québec President and chief executive officer at INESSS (Institut national d excellence en santé et en services sociaux) Robyn Tamblyn, McGill University, Québec Professor, Department of Medicine and Department of Epidemiology and Biostatistics. Janet M. Davidson, Alberta Health Deputy Minister, Alberta Health services, Government of Alberta Alan Katz, University of Manitoba Family physician and health services researcher. Director of the Manitoba Centre for Health Policy (MCHP) Astrid Brousselle, University of Sherbrooke, Québec Professor, Department des sciences de la santé communautaire Jean Frédéric Levesque, BHI, Australia Chief executive, BHI (Bureau of health information). Conjoint Professor at the Centre for Primary Health Care and Equity of the University of New South Wales Grant Russel, Monash University, Australia Primary care clinician and health services researcher. Head of School of Primary Health Care, Director of the Southern Academic Primary Care Research Unit (SAPCRU). 3

Introduction to the CIHR Signature Initiative on Community Based Primary Health Care Dr. Robyn Tamblyn Scientific Director CIHR Institute of Health Services and Policy Research May 2015

Community Based Primary Healthcare: The Transformative Initiative (co led by IHSPR and IPPH) Goal: Transform healthcare for the next generation by supporting improved delivery of appropriate, high quality CBPHC to Canadians 1. Develop and compare innovative models for community based primary healthcare delivery within Canada and internationally 2. Build capacity by supporting interdisciplinary collaborations of researchers, decision makers, health professionals and trainees in Canada and other countries 3. Catalyze effective KT approaches to improve the delivery of CBPHC in Canada and, where appropriate, other countries

CBPHC Innovation Teams Audas Grunfeld Harris Kaczorowski Katz Haggerty LEGEND Liddy Ploeg Stewart Wodchis Wong Young Performance measurement & reporting Transforming PHC in First Nations & rural/remote communities Patient centred innovations for persons with multimorbidity Community based approaches for older adults and their caregivers Transforming Indigenous PHC delivery Communitybased cancer care along the continuum PHC for persons living with HIV/AIDs Accessing child/youth mental health services Chronic disease awareness & management Organisational innovations to improve access to PHC for vulnerable groups Transforming PHC in the remote North Improving PHC for older adults with complex care needs

CBPHC Innovation Teams CBPHC Innovation Teams Feature Highlight: Audas CBPHC Innovation Teams Grunfeld Harris Kaczorowski Katz Haggerty LEGEND Liddy Ploeg Stewart Wodchis Wong Young GREENLAND NEW ZEALAND AUSTRALIA 7

The Common Indicator Project to Measure Impact of Innovative CBPHC Models Across 12 Teams 10 teams validated on the ability to report on 7 dimensions agreed upon: Access Comprehensiveness Effectiveness Coordination Cost Equity, and Multimorbidity using the common indicators and common measures/instruments identified by consensus

Coverage by common indicator *For all teams column, data was interpreted for the 2 non validated teams. Domain Indicator Validated All teams teams Access Difficulties accessing routine or ongoing PHC 9/10 11/12 Comprehensiveness PHC support for self management of chronic 10/10 12/12 conditions Comprehensiveness Scope of PHC services 6/10 7/12 Coordination PHC team effectiveness score 9/10 11/12 Coordination Collaborative care with other healthcare 8/10 10/12 organizations Effectiveness ACSC hospitalization rate 5/10 7/12 Effectiveness PROM: Functional health 6/10 7/12 Effectiveness Self efficacy for managing chronic disease 7/10 9/12 Effectiveness Patient empowerment 5/10 5/12 Cost Direct (utilization) + indirect costs (e.g., out ofpocket) 7/10 9/12 Equity N/A 10/10 12/12 Multimorbidity N/A 4/10 4/12

Assessing Research Impact: Important Trends Increasing need for greater accountability and to demonstrate value add of research investments. Demonstration of health, health system and health policy impacts and related attribution problem High quality and relevant reporting of outputs and impacts is key Moving toward publications + Measures of impact beyond bibliometrics Challenge of publications in a relatively more nascent field of research that also requires substantial capacity development

CBPHC Signature initiative Canadian Academy of Health Sciences Performance Measurement Framework Short term (within 5 years) transformative outcomes & potential indicators BUILDING CAPACITY: Novel collaborations in CBPHC that move beyond traditional boundaries of health care Composition of CBPHC teams Composition of CBPHC collaborations % of CBPHC related publications with intersectoral and/or interdisciplinary collaborations % of CBPHC grants reporting stakeholder involvement at each stage of the research process, by stakeholder type ADVANCING KNOWLEDGE: Innovative CBPHC models identified, evaluated & tested for scale up % of identified models evaluated and tested for potential scale up % of identified models reporting improvement in health status and patient reported outecomes # of publications from CBPHC grants

CBPHC Signature initiative Canadian Academy of Health Sciences Performance Measurement Framework Long term (5+ years) transformative outcomes & potential indicators INFORMING DECISION MAKING: An evidence informed & citizen /patientcentred culture in CBPHC practice settings HEALTH SYSTEM: Scale up of evidence informed models of care that integrate population & public health interventions with CBPHC delivery HEALTH SYSTEM & ECONOMIC: Evidence informed, innovative, high quality and cost effective CBPHC practice & delivery # of Canadians as active participants in assessing benefits & advising on improvements* Description of the extent to which advice and feedback from active participants are incorporated into models of care # of citations of findings in scientific and non scientific publications (including polices and guidelines) % of Canadians involved in innovative models of care* # of successful models scaled up* Change in % of PHC organizations with arrangements with other health care organizations to manage patients together** Change in average PHC team effectiveness score** Change in % of PHC organizations that provide a range of PHC services (comprehensiveness scope of services)** # of cost effective CBPHC models of care**(placeholder for WG indicator) % of CBPHC grants reporting contribution to more effective health services HEALTH & HEALTH SYSTEM: Evidence informed models of care improve health outcomes, patient/person experience & reduce inequities in access to CBPHC Change in health related quality of life for participating Canadians* Change in disparities in access and adverse health outcomes for vulnerable groups* Change in % of population reporting difficulties accessing routing or ongoing PHC.** Change in ambulatory care sensitive conditions hospitalization rate** Change in health status and patient reported outcomes ** % of CBPHC grants reporting contributions to improved health of Canadians

Overview of the CIHR Program Logic Model for CBPHC Innovation Teams Impacts Resource Input Process/structure Outcomes Ultimate outcome Improve ment in health and social outcomes for Canadians Underperforming system access inequity, crhronic illness epidemic Crossjurisd. Interprof essional teams of investiga tors Innovative chronic disease prevention, managemen t Access for vulnerable populations Transformative change 13 health systems natural experiments 12 program logics to be developed Scale up, SPOR network External factors or underlying assumptions 13

Logic Modelling Graphic representation of the logic by which the planned activities are expected to achieve the intended outcomes inputs activities outputs outcomes Synonyms: outcomes models, theory of change, ends means models, and strategy maps Causal links supported by evidence or experience 14

Logic Model Elements: Starting conditions what is the problem to be solved What is the underlying assumption for the program Inputs /strategies/intervention the strategies and activities that are precursors to an intervention or the content of the intervention itself Processes and structures enduring characteristics of organised public social activity that result from the intervention or from the strategies. 15

Logic Model elements Impact Changes occurring in the participants of the program; essential precursors of the ultimate outcomes at a population level. Outcomes Changes in the health and well being of program participants Ultimate outcomes Changes in the health and wellbeing of a target population External factors/context/assumptions/modifiers Elements outside the planned program with an independent influence on program components or relationships between them. 16

RESEARCH PROGRAM LOGIC MODELS SOME REFLECTIONS ASTRID BROUSSELLE, PH.D. CANADA RESEARCH CHAIR IN EVALUATION AND HEALTH SYSTEM IMPROVEMENT (CRC-EASY.CA) FULL PROFESSOR, COMMUNITY HEALTH SCIENCES DEPARTEMENT RESEARCHER, CENTRE DE RECHERCHE DE L HÔPITAL CHARLES-LEMOYNE UNIVERSITÉ DE SHERBROOKE CAHSPR, 2015 BUILDING SYSTEMS-LEVEL EVIDENCE FROM THE MOSAIC OF 12 RESEARCH PROGRAMS IN THE CIHR SIGNATURE INITIATIVE ON COMMUNITY BASED PRIMARY HEALTH CARE

CIHR Program Logic Model for Transformative Change via CBPHC Innovation Teams Resources Strategy, inputs Process, structure Impacts Crossjurisd. Interprofe ssional teams of investigat ors Improvement in health and social outcomes for Canadians Underperforming system access inequity, chronic illness epidemic Innovative chronic disease prevention, management Access for vulnerable populations Transformative change 13 health system natural experiments 12 program logics to be developed Scale-up, SPOR network External factors or underlying assumptions

Resources Strategy, inputs Process, structure Impacts Crossjurisd. Interprofe ssional teams of investigat ors Improvement in health and social outcomes for Canadians Underperforming system access inequity, chronic illness epidemic Program of research = intervention Innovative chronic disease prevention, management Access for vulnerable populations Transformative change 13 health system natural experiments 12 program logics to be developed Scale-up, SPOR network External factors or underlying assumptions

. Passive transport TV Stay seated at CAHSPR conf. others Causes Sedentarity Older population Genetics Late diagnosis and intervention Problems targeted Chronic diseases more prevalent with major invalidating health consequences Persistent problems of access for vulnerable populations Resources Strategy, inputs Process, structure Impacts Other causes Small influence of research in health system organization Crossjurisd. Interprofe ssional teams of investigat ors Improvement in health and social outcomes for Canadians Underperforming system access inequity, chronic illness epidemic Program of research = intervention Innovative chronic disease prevention, management Access for vulnerable populations Transformative change

Sedentarity Sedentarity Sedentarity Passive transport TV Causal Model Passive work Why? others Causes Sedentarity Older population Genetics Late diagnosis and intervention Problems targeted Chronic diseases more prevalent with major invalidating health consequences Persistent problems of access for vulnerable populations Resources Strategy, inputs Process, structure Impacts Other causes Small influence of research in health system organization Crossjurisd. Interprofe ssional teams of investigat ors Improvement in health and social outcomes for Canadians Underperforming system access inequity, chronic illness epidemic Program of research = intervention Innovative chronic disease prevention, management Access for vulnerable populations Transformative change

Passive transport TV Causal Model Passive work Why? others Causes Sedentarity Older population Genetics Late diagnosis and intervention Problems targeted Chronic diseases more prevalent with major invalidating health consequences Persistent problems of access for vulnerable populations Resources Strategy, inputs Process, structure Impacts Other causes Small influence of research in health system organization Crossjurisd. Interprofe ssional teams of investigat ors Improvement in health and social outcomes for Canadians Underperforming system access inequity, chronic illness epidemic Program of research Logic model = How? intervention Innovative chronic disease prevention, management Access for vulnerable populations Transformative change

Passive transport TV Causal Model Passive work Why? others Causes Sedentarity Older population Genetics Late diagnosis and intervention Problems targeted Chronic diseases more prevalent with major invalidating health consequences Persistent problems of access for vulnerable populations Resources Strategy, inputs Process, structure Impacts Other causes Small influence of research in health system organization Crossjurisd. Interprofe ssional teams of investigat ors Improvement in health and social outcomes for Canadians Underperforming system access inequity, chronic illness epidemic Program of research Logic model = How? intervention Innovative chronic disease prevention, management Access for vulnerable populations Transformative change

Passive transport TV Causal Model Passive work Why? others Causes Sedentarity Older population Genetics Late diagnosis and intervention Problems targeted Chronic diseases more prevalent with major invalidating health consequences Persistent problems of access for vulnerable populations Resources Strategy, inputs Process, structure Impacts Other causes Small influence of research in health system organization Crossjurisd. Interprofe ssional teams of investigat ors Improvement in health and social outcomes for Canadians Underperforming system access inequity, chronic illness epidemic Program Operational of research model = intervention Innovative chronic disease prevention, management Change model Access for vulnerable populations Transformative change

MATH Problem: You have a funding agency that finances 12 different packages of resources, and 12 research teams that will find 12 different ways of using resources. Three problems are targeted, but programs won t necessarily target the same problems and not always the same causes for the same problem. How many models do you draw? Solution: 12 operational models 12 change models? 3 causal models

POTENTIAL USES OF RESEARCH PROGRAM LOGIC MODELS (1/3) 1- Associated with the process of building the logic models: Shared understanding of resources, activities and intended outcomes, among researchers and other participants (stakeholders, policy-makers, etc.) Improved, enriched activities for other research programs Better understanding of the complementarity of the different programs in terms of knowledge-building (2 programmatic questions) (scale-up phase?)

POTENTIAL USES OF RESEARCH PROGRAM LOGIC MODELS (2/3) 2- Associated with analysis of the change model (logic analysis) Are we there yet? : - Two programmatic questions (prevention and management of chronic disease, access for vulnerable population) - One political question (influence of science on policies) How will knowledge derived from science impact the causes of the targeted problems? What are or what would be the best ways to get to the expected effects? Should we put in place other activities to foster the expected impact of science? What are the contextual conditions for success? Can we influence the context to facilitate achieving the objectives?

POTENTIAL USES OF RESEARCH PROGRAM LOGIC MODELS (3/3) 3- Associated with analysis of the targeted problems, their causes and determinants (strategic analysis) If we really want to improve prevention and management of chronic diseases, to improve access to primary care for vulnerable population, and to influence health policies and health 3 care organization, what are the main causes (by importance and feasibility) that should be targeted? Are we targeting the right causes? What other actors should be mobilized to solve such problems? Who should invite them to participate?

Slide 28 3 Suggestion: "...what are the main causes (by priority and feasibility) that should be targeted?" Patrick Riley, 5/21/2015

4 NOT JUST A DRAWING Astrid.brousselle@usherbrooke.ca crc-easy.ca

Slide 29 4 Note on the slide notes: "finalité" in French = "purpose" in English, generally speaking. "Finality" has a a quite different meaning. Patrick Riley, 5/21/2015

CIHR Program Logic Model for Transformative Change via CBPHC Innovation Teams Resource Input Process/structure Impacts Outcomes Ultimate outcome Improve ment in health and social outcomes for Canadians Underperforming system access inequity, crhronic illness epidemic Crossjurisd. Interprof essional teams of investiga tors Innovative chronic disease prevention, managemen t Access for vulnerable populations Transformative change 13 health systems natural experiments Scale up, SPOR network External factors or underlying assumptions

Innovative Models Promoting Access to care Transformation (IMPACT) Improving PHC access for vulnerable populations Grant Russel Primary care clinician and health services researcher. Head of School of Primary Health Care, Director of the Southern Academic Primary Care Research Unit (SAPCRU). Jean Frédéric Levesque Chief executive, BHI (Bureau of health information). Conjoint Professor at the Centre for Primary Health Care and Equity of the University of New South Wales

Innovative Models Promoting Access to care Transformation (IMPACT) Improving PHC access for vulnerable populations Situation Statement Strategies / Inputs / Intervention Processes / Structures Impacts / Intermediate Outcomes Persisting inequalities in access Health reforms may accentuate access gap for vulnerable groups Assess access related need Identify promising innovations that fit Scope organisational access innovations Form local network Realist reviews Multi stakeholders partnerships Engage local champions Mobilise resources for and plan innovation Trial vulnerability focused organisational innovations Uptake by vulnerable groups Outreach to vulnerable groups Sensitivity to evidence in local decision making for vulnerability Linkages between PHC and community organisations Consolidation of vulnerability focused organisational innovations Appropriate, effective and efficient service use Enhanced ability to perceive, to reach and to engage with PHC Pro vulnerability innovations required Modifying Political factors: Health reforms impacting partnerships Modifier: No funding or appetite for innovation Modifier: awareness and acceptance for the intervention from stakeholders Political factors: Budget cut backs; health reforms (user fees, mandated mergers); autonomous physician practice.

Starting Conditions & Underlying assumption Persisting inequalities in access to comprehensive and appropriate PHC for socially vulnerable groups (inverse care law) Health reforms may accentuate gap Face of vulnerability differs between regions and health system context Assumption: Vulnerability sensitive interventions required to redress gap

Strategies, Inputs, Intervention Assess access related need Form local network Identify promising innovations that fit Scope organisational access innovations Realist reviews Development of Local Innovation Partnerships in each region Local knowledge Deliberative dialogue Assembly of evidence base by the research team Identify local access related needs and vulnerable population Identify range of potential interventions Realist reviews to support the selection and adaptation of the intervention for local implementation

Processes & Structures Multi stakeholders partnerships Engage local champions Mobilise resources for and plan innovation Trial vulnerability focused organisational innovations Uptake by vulnerable groups Strength of local partnerships critical to moblize local resources Research evidence base and coordination support Intensive interaction leading to trialing of intervention Outreach to vulnerable groups

Impacts, Intermediate outcomes Sensitivity to evidence in local decision making for vulnerability Linkages between PHC and community organisations Consolidation of vulnerability focused organisational innovations Appropriate, effective and efficient service use Enhanced ability to perceive, to reach and to engage with PHC Local partnerships give decisionmakers privileged access to evidence base and vulnerable populations New organisational routines and behaviors are established Socially vulnerable groups become aware of new services

Innovation in Community Based Primary Healthcare: Supporting Transformation in the Health of First Nations and Rural/remote Manitoba Communities (iphit) Alan Katz University of Manitoba Family physician and health services researcher. Director of the Manitoba Centre for Health Policy (MCHP)

Innovation in Community Based Primary Healthcare: Supporting Transformation in the Health of First Nations and Rural/remote Manitoba Communities (iphit) Poor health outcomes in First Nations. PHC can mediate but locally adapted models needed based on identifying what works; what doesn t Strategy, inputs, intervention Interviews, focus groups, workshops; analyze evolving health in different communities Understand PHC in communities; limitations imposed by funding and Jurisdictional barriers Visits to FN communities, present and co interpret findings. Meetings LRA, local advisory committee. Processes and structures Creating awareness, providing evidence, and identifying gaps in health service provision Platform for community dialogue; understand existing PHC model; empowerment to consider alternatives Established connections and trust relationship between academic & FN communities. Impacts, intermediate outcomes Open and collaborative approach to improving PHC in FN communities (activism) Generating quality data, co creation of solutions and possible implementation of innovative PHC models. Respecting community research ethics & protocols. Input at every stage (OCAP) Written agreements adhering to university and community research ethics & protocols. Innovative PHC systems with local ownership Culturally sensitive and locally controled health systems lead to improved health outcomes Researchers, communities and decision makers collaboration Appropriate funding Factors affecting PHC in First Nations communities in Manitoba: continuing colonization, jurisdictional barriers, tension between academia and FN communities, lack of & pockets of funding,

Luc Boileau Janet Davidson THINK OUT LOUD!

Thank you!