Quality and Value in Home Care Building a Shared Vision of Value and Sustainability in Ontario s Home Care Sector CHCA Conference Presentation October 30, 2013 Jacqueline Redmond (CEO, South East CCAC) Sue VanderBent (CEO, Ontario Home Care Association) Co-Chairs of the Quality and Value in Home Care Steering Committee
Presentation Objective To showcase Ontario s Quality and Value in Home Care (QVHC) initiative as an example of a collaborative, sector-wide effort to ensure a sustainable home care sector now and in the future. 2
Overview Context National Context Ontario Context Vision What is Quality and Value in Home Care? Conceptual Framework of QVHC QVHC: Collaborative Partnership QVHC: Key Elements Outcome-Based Care and Contract Performance Framework What We are Learning: Outcome Based care Contract Performance Framework Summary 3
National Context 2003 - First Ministers Accord on Health Renewal 2004-10-Year Plan to Strengthen Health Care During the last 10 years, health funding has risen from $124 Billion to $207 Billion (including funding from Health Accords, increases in provincial and territorial spending and private spending) Funding has addressed some pressing issues including, reducing wait times (e.g. hip and knee surgery, cancer radiation therapy), primary health care reform, drug coverage and physician use of electronic records. However, are we seeing notable improvements on measures of patient care and outcomes? Better health outcomes, better quality care, and value for all, can be a framework for transforming Canada s health care system into a high performing system Source: Better Health, Better Care, Vetter Value for all: Refocusing Health care reform in Canada, Health Council of Canada, September 2013 4
Ontario Context Ontario s Action Plan for Health provided a roadmap for health system transformation to promote sustainability Fiscal context for this action plan: healthcare funding represents approximately 42% of the provincial budget Future Demographic Demands on health care system, specifically home care A key part of transformation is re-orienting to reduce the demands on the hospital system (e.g. Emergency Rooms and Alternative level of Care) while strengthening the home care system The Quality and Value in Home Care initiative is another key part of transformation with the sector leading improvements to the health outcomes of patients and the performance of home care services 5
Ontario Context: How is Home Care is Delivered There are 14 Community Care Access Centres (CCACs) funded by Ontario s Ministry of Health and Long-Term Care to co-ordinate a range of home and community care services. CCAC Care Coordinators work collaboratively with Service Provider Organizations (SPOs) to assess patient needs, develop care plans, and provide wound care services. 6
Quality and Value in Home Care Vision A patient-centred system that provides high quality, value-added, responsible home and community care for the people of Ontario now and in the future 7
What is Quality and Value in Home Care (QVHC)? A collaboratively governed, multi-faceted initiative of CCACs and Service Provider Organizations Coming together is a beginning; keeping together is progress; working together is success. Henry Ford
What is Quality and Value in Home Care (QVHC)? It involves improving our capacity to innovatively deliver care, measure value, and transparently report on performance of the home care sector We are continually learning as we plan and implement the inter-connected elements such as outcome-based care and a contract performance framework
Conceptual Framework of QVHC Michael Porter, Harvard University What is Value in Home Care? Value defined by customer and outcomes for patients/patient populations Many participants in healthcare system confound processes and outcomes or treat processes as if they were outcomes Value for patients improves when equivalent (or better) outcomes are achieved at a lower cost Equity of care can be improved by defining and measuring value, making value transparent, and rewarding value improvement Powerful lever for reducing costs is early detection and intervention for more timely care, or patient management leading to less need for care When all participants in health care system embrace value as the central goal, and work collaboratively together, the resulting improvements will be more sustainable in terms of human health and economically Source: Porter, ME, Teisberg EO. Redefining Health Care, Boston, MA: Harvard University Press, 2006 10
QVHC Partnership: Collaborative Roles Ontario has adopted a collaborative approach to governing QVHC, as represented by its membership: OACCAC, OHCA, OCSA, APACTS, CHPN, OACRS Represent the membership of their provincial associations, and consult with their respective stakeholders, as required, to ensure that they represent the collective issues and positions Working together collaboratively for system reform Service Provider Organizations (SPOs) & CCACs Champion and support change management and education delivery within their organizations Champion implementation efforts 11
QVHC Governance Structure
Quality and Value in Home Care Elements Include: Team-based approach to direct care -led by one Service Provider Organization Outcome-based pathways - evidenced-based service delivery aimed at achieving outcomes for patients with similar conditions Strengthened framework for contract performance -between CCACs and Service Provider Organizations Public reporting on the performance-based quality indicators - by Health Quality Ontario (HQO) Alternate reimbursement methods (e.g. pricing and payment) designed according to the achievement of value Health human resources strategy - to promote sustainability (e.g. supply, capacity, skills and safety) of health care workers in the sector Technology enabled communication and information sharing - amongst clinicians working in CCACs, Service Provider Organizations, Hospitals, Specialists and Primary Care 13
Quality and Value in Home Care Our Approach Priority was placed in the early phases on the development of two foundational elements: Outcome-Based Care (Pathways and Reimbursement) CCAC and Service Provider Contract Performance Framework Enablers Simultaneously supporting these priorities, the business process, technology, and health human resources are the essential enablers of these two key elements. 14
The Foundations: Outcome-Based Care and Contract Performance Framework To: From: Contracts (CCAC/SPO) for different services based on hours of care and visits (Nursing, PSW, etc.) Accountability for service delivery Payment for units of service Measuring processes Prescribed activities and processes Locking us into old practices 1 model of service delivery (one-to-one home visits) Contracts (CCAC/SPO) for different populations (wound care, unilateral hip and knee replacements) & some services Accountability for quality service delivery and patient outcomes Payment for outcomes, based on patient populations and performance Measuring quality and outcomes Greater flexibility and openness to innovation Forward looking Multiple options for service delivery
Definitions: Outcome-Based Pathways Outcome-Based Pathways (OBPs) arrange the care plan outcomes around a specific population s needs (e.g. wound care, or orthopedic populations such as individuals who have had a unilateral hip and knee replacement). The OBP identifies expected evidence-informed outcomes that are achieved as part of best practice care/treatment delivered at specific points in a patient s care journey. Enablers of Outcome-Based Pathways include: best practice guidelines, business process and patient care efficiencies, patient engagement, and innovative service delivery and technologies.
Definition and Goals: Outcome-Based Reimbursement: Traditionally, providers are paid based on a fee for service model (i.e. reconciliation of service, visit frequencies and billing code submitted). Outcome Based Reimbursement (OBR) occurs when a provider is paid based on achieving the outcomes (determined by evidence-based, best practice guidelines) or provision of best practice at certain intervals, including the final milestone. Goals of OBR: Design a reimbursement framework that incents a greater focus on producing high quality outcomes and improving cost efficiency; Create a framework in which both the CCACs and providers share in efficiency gains achieved 17
Definitions Outcome-Based Pathway Focus is outcomes Identifies indicators to measure outcomes Care Coordinator interventions detailed Less time-specific/ sensitive activities Clinical Pathway Focus is clinical goals Identifies clinical tools to measure progress Clinical interventions are detailed Tends to outline multiple timespecific sequences of activities Outcome-Based Pathways do not replace Clinical Pathways but are complementary in their use
Development Cycles Outcome Based Pathways (OBP) & Reimbursement (OBR)
Acknowledgements: OBP Proof of Concept Participants
Contract Performance Framework Background Fall of 2012: Ontario s Ministry of Health and Long- Term Care announced a policy direction that shifted CCACs from a competitive model procurement (Requests for Proposals) in combination with a revised contract management framework. Consolidated Service Contracts In addition to the changes to procurement practices, there have been delivery model changes implemented through consolidated service contracts which enable the integrated direct care teams by Service Providers
Contract Performance Framework: Purpose To guide CCACs and SPOs, through processes and tools that: Create a shared understanding of performance expectations including measurement and evaluation of performance Incent the provision of safe, high quality patient-centred care and continuous learning and quality improvement; Transparency and public accountability for quality including: the quality monitoring of contract performance the management of performance related concerns; and the consistent application of performance related consequences (rewards and remedies).
Performance Framework: Evolving Contract Management Model Elements include: Clearly articulated performance expectations for home and community care organizations Definitions for indicators and benchmarks for the satisfactory, unsatisfactory and exemplary organizational performance Provide transparent criteria and processes for Contract Performance Framework Specific rewards and remedies
Patient/Client Service Contract Performance Framework Measure Monitor Report Manage Provincial Performance Indicators and Standards Routine Contract Monitoring Performance Dashboards Performance Management (Process & Tool Kit) Indicator Weighting Contract Performance Audits Annual Report & QIP Escalating and/or Expediting the Process Provincial Targets Public Reporting by HQO Meeting/Not Meeting Contract Expectations Local Indicators and Targets Exemplary Status Related elements which are outside of the mandate of the Performance Management Working Table Rewards & Remedies
What We are Learning: Outcome- Based Care Involves Working Differently: Overview Staff work as a clinical and functional team Patients are encouraged to set goals and identify opportunities for self-management where possible The key milestones of progress are identified within the care process Requires CCACs and Service Provider organizations to have clear communication processes, including electronic information exchange
What We are Learning: Outcome-Based Care Involves Working Differently: Service Providers Have more choice about the number and timing of visits and/or method of service delivery (phone, virtual, in-person visits, team based visits) Select which health discipline provides the care to achieve outcomes Coordinate in-home clinical services, guided by the parameters or framework of a pathway Innovate on the provision of supplies, equipment, technology or other services (e.g. chiropody) Report (internal and to the CCAC) on outcome achievement, including identifying patients who may not meet the expected milestones in timelines of pathway (and patients at risk)
What We are Learning: Outcome-Based Care Involves Working Differently: CCAC Care Coordinators Comprehensive assessment and care planning Determination of eligibility and assign specific OBP Accountable for tracking patient outcomes, through review of outcome reports and focus on expectations Measure patient progress according to defined expectations Strategize with providers on outlier (or unusual) patient situations Monitor service quality Provide more emphasis on care connecting, system navigation and stronger coordination role between service provider organizations, hospitals, primary care and community support services
What We are learning: Contract Performance Patients and Caregivers will Know what care they can expect from CCACs and Service Provider Organizations, and how quality is monitored Experience more consistency in quality of care having similar experiences and achieving similar health outcomes regardless of where they live in Ontario Understand how they are essential partners in achieving health outcomes Patient experience data and satisfaction data will become more important tools for measuring organizational and system performance
What We are Learning: Contract Performance Involves Clarified expectations between Service Providers and CCACs The value of CCACs and Service Providers in having clear and consistent performance expectations Service Providers will experience greater consistency in the contract performance management process (e.g. meeting expectations/not meeting expectations, rewards, remedies) At a provincial level, the sector will have greater consistency in performance indicators and standards Taken together, these factors will increase the capacity to report publicly on home care performance
What We are Learning: Summary Broad and balanced transformation for sustainable health care is possible when: We work collaboratively (distributed leadership) The goals of improving patient health outcomes and evidence-based care are a central focus Performance is measured and reported on There is a sustained focus on the capacity enablers such as health human resources, technology, practice and business process changes Legislative, policy, funding, leadership, and shared vision are supported and sustained
Questions and Exchange