Carole Ann Alloway’s husband, Bill, had seven ankle surgeries due to recurring infections that were eventually found to be caused by bacteria on the hardware that had been inserted 30 years ago.
Each time, Bill was sent home with an IV for his antibiotics. He was told the bag would last 24 hours, and that a home care nurse would change it – as well as attend to his wounds. The first time, the Alloways believed this.
By the fourth surgery, Carole Ann knew that it would be at least two days before a home care nurse would show up. She arranged with her local Community Care Access Centre (CCAC) – the local agencies currently tasked with managing home care services – to have the bandages and bag of medication sent directly to their home. “I would just change the bag. I had watched them do it,” she explains. Carole Ann quickly had to become good at wound care too.
Carole Ann would call the home care coordinator at the hospital and the call centre for her CCAC to try to find out why the home care nurse wasn’t arriving as expected “but that was not helpful at all.” Meanwhile, the Alloways’ primary care physician was often not notified about the hospital visits or discharges.
“Many patients encounter these same problems in the transition from hospital care to home care,” says Carole Ann, who is a patient advisor for Health Quality Ontario and founder of the advocacy group Family Caregivers Voice. “It’s not clear who’s accountable.”
The Alloways’ frustration about siloes of care in the health system – and the lack of accountability for what happens to patients who move between them – have been echoed time and time again.
It’s this lack of coordination between home, primary and hospital care that appears to have inspired the Ontario government to introduce a sweeping piece of legislation called the Patients First Act. As Doris Grinspun, CEO of the Registered Nurses Association of Ontario, sees it, “This is the largest health system restructuring that we have seen in 20 years.” In a webinar on the legislation last month, Deputy Health Minister Bob Bell explained, “What we’re anticipating is really the transformation of a system…by planning service integration between primary care and home and community care.”
In order to integrate services, the Patients First Act will give much more authority to the Local Health Integration Networks – Ontario’s 14 health care regions. LHINs will now have power to issue operational or policy directives to many health organizations at the home, community, primary and hospital level. Importantly, the Act does away with CCACs and puts the LHINs in charge of supervising, managing and funding home care providers.
The Act was slated for its second reading in the provincial legislature before Premier Kathleen Wynne prorogued parliament in September. In her recent Throne Speech, however, she promised to reintroduce it in order to “strengthen Ontario’s health care [system].”
While the Act affects many aspects of the health care system, this article will focus on the LHIN’s planned responsibilities for integrating health care. On this front, many argue the legislation won’t live up to its promises.
The vision of Patients First for integrated home, community and hospital care
David Price is a professor of family medicine at McMaster University and the co-author of a major report on primary care reform commissioned by the Ministry of Health. He describes the integrated care the LHINs would oversee like this: “When a patient is ready to be discharged from the hospital, the family physician and his or her team would be notified so they can arrange to see the patient in a timely fashion. The home care coordinator, in collaboration with the primary care team and hospital, would make a decision about whether home care services are needed.”
Currently, primary care providers are not always notified of a patient’s discharge from the hospital. As the Alloways experienced, numerous delays and communication gaps exist between home, primary and hospital care.
The LHINs technically already have a mandate to better integrate care, and physicians and nurse practitioners could take it upon themselves to better coordinate with other providers and follow up with patients.
So what would legislation change? Paul Huras, CEO of Ontario’s South East LHIN, argues that the LHINs haven’t had the authority to hold health care providers to account, which the legislation now provides them, at least to some extent. In addition, LHINs will be funded to employ primary care clinicians to help coordinate care on a part-time basis. “We’ll have doctors who are working in their communities, who can build relationships with the various organizations, and identify local needs,” says Huras. Plus, he points out, “having home and community care as part of our operations means we’re really going to be able to determine the best place for care coordinators to be placed.”
Grinspun’s understanding, based on her interactions with the Ministry, is that the overwhelming majority of home care coordinators will work at the primary care level, rather than in stand-alone agencies like CCACs, where many are now. (She adds around 10% are expected to be at the hospital). “Within interprofessional teams, the coordinators will be following patients from beginning to end. They won’t be parachuted in [when a patient leaves the hospital].”
Gail Donner, former dean of nursing at the University of Toronto and chair of an expert panel set up by the government on improving home and community care, says that integration may look very different from one LHIN to the next. But that isn’t a bad thing, she says. In a clinic that serves a large and dense population, for example, home and community care coordinators may be located right in physicians’ offices, while in a rural area, IT solutions might be used to connect patients to home and community services.
She is quick to add, however, that the Act doesn’t make health care integration inevitable. “It’s going to be up to the LHINs to figure out what they need to do to make it happen. I honestly don’t think integration, other than as a principle, can be mandated from the centre,” she explains.
Others don’t have faith the LHINs will live up to the major integration goals. Tom Closson is the former CEO of the Ontario Hospital Association. Before that, he oversaw home, hospital, and to a small extent, primary care for the Capital Health Region of BC. Pointing out that most LHINs only have around 30 employees, he doesn’t think LHIN leaders have the manpower, nor the experience, to oversee a massive transformation in how providers work together. “They don’t have the governance structures to take on hospitals, home care, community care, primary care and in their spare time, they’re supposed to have a link with public health,” he says.
While the LHINs will have added staff, with CCAC managers folded into them, these CCAC staff have experience contracting home care services, not overseeing an entire health system’s operations, Closson points out. In fact, taking on the role of the CCACs will “overwhelm the LHINs in the short term” leaving no time for integrating home care with the larger system. “There’s around 5,000 people working for CCACs and around 500 working for the LHINs. The LHINs are going to have to figure out what the CCACs do and how to integrate them.” As it is, the task of managing a diverse range of non-profit and corporate agencies that provide home care has proven notoriously difficult for the CCACs, Closson points out.
Virginia Walley, president of the Ontario Medical Association (OMA), adds that the LHINs don’t have a proven track record. A 2015 report by the Auditor General criticized the LHINs for several shortcomings, including that many LHINs hadn’t met wait time targets and didn’t sufficiently plan to meet the needs in areas like palliative and community care. “The LHINs haven’t been operating with the efficiency that most of the population hopes they would, but the ministry has continued down this path of giving the LHINs even more authority,” says Walley.
Huras points out, however, that the LHINs have been measured against “aspirational targets, not slouch targets.” Given that they were only formed 11 years ago, and the province has had leaders “who have been trained in how to be the lead of an organization rather than a system,” improvements shouldn’t be expected to be fast. Huras says his LHIN has made “great strides,” for example, in improving consistency in local mental health services. “This legislation will allow us to go further,” says Huras.
The physician question
One of the key challenges to the LHINs’ integration plans will be that the Act doesn’t give the LHINs much authority over physicians. That could be to avoid angering Ontario’s already disgruntled physicians with more reporting requirements, or because the Ministry wants to maintain more direct control over physicians’ activities, Closson points out. Under the Act, only Family Health Teams, Community Health Centres and Aboriginal Health Access Centres will fall under the LHIN’s authority. More than 80% of Ontarians see doctors who don’t work in these models, and therefore won’t be required to follow LHIN directives.
“It has been the Achilles heel of this legislation from day one,” says Kathy O’Brien, a lawyer with the Toronto-based DDO Health Law. “How can you have integrated health care when the LHINs have almost no authority over the majority of physicians?”
Still, Price thinks that the LHINs can “encourage” physicians to be more integrated – for example, by setting up interprofessional networks that oversee after-hours care for a specific region. Based on his interactions with medical trainees, Price argues that virtually all new physicians want to work in groups – such as Family Health Teams – where they can share after-hour and on-call duties and connect patients to mental health providers, nurse practitioners, dieticians, and so on. “Solo family physicians are a dying breed,” says Price. The LHINs will also have an opportunity to fund more nurse practitioner-led clinics.
In his webinar, Bell suggested voluntary integration would be the way to go for physicians. “We’re expecting that primary care providers across the province will start to organize themselves in thinking through, ‘What are the needs of their communities? How are we going to provide after-hours care within communities? How are we going to ensure that on holidays and weekends, patients understand where they are going to get access to care?’” he explains.
While the OMA questions whether this interferes with physicians’ self-regulation, the Act – as it was before the legislature was prorogued – requires physicians to report retirements, office closures, planned vacations, and so on. Huras says this will help LHINs ensure that communities aren’t without family doctors.
“We recently had two physicians retire in Smiths Falls in one month. In big communities it may not have as much of an impact, but in small communities that can have a devastating impact on the population,” explains Huras. “Having that information a year in advance would give us the opportunity to make plans ahead of time and not in crisis mode.” For example, the LHINs can direct funding to inter-professional networks, which can attract physicians to replace a retiree, Huras points out.
The creation of sub-LHINs
When it comes to the LHINs’ role in integrating care, another key aspect is that the legislation mandates the creation of sub-LHIN structures, to oversee integration at a more local level.
As Bell explained in the webinar, “Some services need to be planned on a provincial basis. Many services, however, in primary, home and community care are best planned on a local, sub-LHIN basis.”
Huras argues the sub-LHIN structure will ensure leadership is closer to the frontline, as sub-LHINs would encompass a region of, say, one or two hospitals and their surrounding communities, instead of 10 or 15.
It is hoped this will mean not only that local leaders will help to implement Ministry- and LHIN-level standards, but they will also address local problems. “In one sub-LHIN, the biggest issue might be that there aren’t enough alternative options to hospitals (like long-term care or rehabilitation facilities). In another sub-LHIN, the biggest issue may be repeat visits of people with addictions or mental health issues to the emergency department,” says Huras. “The tighter focus in these regions will lead to better performance.”
Walley meanwhile, worries that the added accountability measures will create “yet another reporting system that doesn’t improve the care for the patients that they’re concerned about.” She argues that “creating a sub-LHIN structure with all kinds of accountability, and reporting and governance requirements…will lead to a duplication of bureaucracy [between the LHINs and sub-LHINs].”
Closson, however, thinks the sub-LHINs could allow the LHINs to engage the leadership of hospitals to coordinate care at the more micro level. Hospitals have larger governance structures in place to oversee LHIN goals, he points out.
Price disagrees that hospital leaders should play the key leadership role at the sub-LHINs. “I’ve never met a hospital leader who says they want to coordinate and integrate primary care,” he says. But he recognizes system leadership that is currently concentrated at the hospital level will have to be built up at the primary care level. “There is not enough leadership capacity in primary care now,” he points out.
In short, the passing of the Patients First legislation will mean LHINs have their work cut out for them. They’ll have to take over the CCACs’ role in overseeing a slew of home care agencies, and they’ll have to improve coordination among family doctors, hospitals, community providers and home care while also holding organizations providing health care to both regional and LHIN-level standards.
The toughest part for the LHINs will be convincing primary care and hospital leaders to play along, says Closson. “When the legislation was first introduced, it created a bad feeling with the hospitals and with the doctors. It seemed very ‘command and control.’ There’s not a lot of happy people who are ready to say, ‘Let’s all get together and make this work.’”