Integrated care, the pragmatic roadmap of Ontario

Marco Inzitari

I had an exceptional opportunity to be a visiting professor at the Institute of Health Policy, Evaluation and Management at the University of the Toronto School of Public Health, Canada. Before going on vacation, I would like to share some main lessons learned about integratedcare in Ontario, which is the most populous region in the country.

Upon arrival, I was invited to share the Catalan experience on integrated care in a very well-structured symposium, Essential Ingredients of Integrated Care (# IHPMEIC19, for those who want to rescue tweets), organized by prof. Walter Woodchips. The symposium ranged from "macro" aspects of public policy to teamwork; through interprofessional relationships, active patient participation, and cross-cutting facilitating aspects such as technology and recruitment tools. Besides these interesting contents, the symposium made it easier for me to land in reality and gave me a global vision of "who is who".

The path to integrated care, both within the health system and between health and social services, is not questioned concerning people with complex needs. But, against the background of the symposium, this route is itself tortuous and complex and that there is no single recipe. And this is because of different factors: problems and strategies are multi factor, the path is uncertain and could be different depending on the context, and flexibility, adaptation, unique skills and collaborative relationships based on trust are needed. What guide can tackle it all?

From a strategic and governance point of view, there is a third way between structural changes imposed from above (joint governance, the fusion of budgets, etc..) and innovation without rules and made from below. This is because changes made only from above may not change the practices and attention to people since they can be very far from reality and represent an investment without practical results. The risk of innovations from below is that they are "idiosyncratic" attempts, linked to the moment and not very exportable.

This third way is "adoption and adaptation" aimed at contextualizing and implementing existing and evaluated models (it’s unnecessary to reinvent the wheel, as they say) with the participation of patients and caregivers throughout the process. On this, I fully agreed with prof. Geoff Anderson, with whom I shared a table, and we agreed so much that we had prepared it together. And we also agree regarding patient involvement, along the lines of the National Voices of the English NHS, recently described in this same blog.

When considering the three basic ingredients to implement integrated care at the system level, we also agree that these would be:

• Select/stratify candidates for holistic care
• Put in place coordination elements
• Involve users

They also highlight these three points in the Commonwealth Fund's Decalogue, which is sprightly and recommended reading.

For organizations, the highlighted elements would be possible:

• Understand
• Promote empathy
• Accompany the change

It means all this help build strong relationships of trust between professionals and diverse institutions.

Regarding practical actions, Ontario is implementing its strategy and I think it’s very adaptable to the Catalan cause. Rather than acting only "from the top-down" or "bottom-up," you are pursuing a mixed model: With the upcoming launch of the Ontario Health Teams (OHT), experts have created a document of guiding principles and actions that they are essential to implement integrated care (available online). From here, the administration contracts the implementation of OHTs to groups of providers or institutions that have admission criteria and have presented adaptation projects to the territory, which may be different but must respect the guide points of the document bases, and will be evaluated before hiring other territories. This model seems to be able to guarantee the principles of adoption and adaptation and, therefore, the contextualization and flexibility in any environment, also in the situation of heterogeneity within Catalonia, without imposing a single model but ensuring that little "inventions" are avoided. And it’s moving forward in a non-pilot way because the first implementation projects are already assigned.

Lastly, although I agree that we must intelligently copy and adapt previous experiences, I also think we must value what we have, which is a lot (the shared clinical history of Catalonia I have not yet seen anywhere else). It should also be appreciated that each place has different structural elements and thus, in Ontario, for example, primary care is far from Catalan organization and standards, and medical care - primary and specialized - is subject to a payment or fee-for-service to the personal doctor, a system that doesn’t favour integration at all. In terms of integration with social services, it’s hardly apparent on the horizon.