Integrated comprehensive care- bundled care and funding: transition from hospital to home

Abstract

Introduction: Integrated Comprehensive Care (ICC) program, developed in 2012 by St. Joseph’s Health System(SJHS) in Ontario, Canada targeted several conditions including Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF). Designed with extensive consultation with patients, the program significantly improves transition from hospital to home. In 2015, the program was expanded to all acute hospitals in region. Practice change implemented: a single collaborative team whose care coordinators are accountable to hospital with responsibility for planning and overseeing all care delivered in community; single integrated care path from hospital to home with one point of contact for patient and caregivers; single shared medical record accessible to all team members; simple technology; and bundled funding. Aim: Improving patient outcomes, experience, and system efficiency are main aims of ICC. Central to development of ICC is integrating care and bundling payment. Care integration programs brings together expertise and skills across sectors while bundled payment models offer providers financial incentives for such collaboration. By bringing integrated care and bundled funding together,ICC program is set to facilitate pursuit of Triple Aim. Populatin& stakeholders: Community dwelling residents admitted with COPD or CHF and require home care post discharge. Program developed and implemented in collaboration: Home&Community care, community health centers,existing COPD/CHF programs;specialty clinics and physicians,primary care teams;patients and caregivers;hospitals. Timeline: ICC is ongoing operational program (no longer a pilot project). Governance and committee structures, and leads (Executive, Medical, Operations) for each organization were confirmed in the first quarter of the program in 2015. Finance model and cost sharing, care pathways for integrated care and bundle wer finalized in the second quarter. Hiring and training of staff, as well as confirming electronic medical records were aslo part of the tasks completed during the second quarter. Patient recruitment, patient engagement, execution of the communication plan, data monitoring and reconciliation, evaluation and reporting, and sustainability planning are ongoing. Highlights: Impactful innovations are implementation of bundled funding improving outcomes and experiences without new funding. ICC team empowered to make decisions in the best interests of the patients and have complete flexibility in care planning decisions; all care team members access single patient record. ICC resulted in statistically significant reduction in Length of stay,ED visits,readmissions,and increased system capacity. Sustainability &transferability: ICC was successfully spread across 9 hospitals. Robust governance structure enabled ongoing engagement with all stakeholders to support sustainability, testing innovative ways to support further integrations. ICC directly informed provinces bundled funding policy. Regular formal and informal touchpoints of integrated team enables real time problem resolution and ongoing Quality Improvement. Conclusion, discussion, lessons learned: ICC increased quality and reduced unwarranted variation for eligible patients. ICC maximized efficiency of healthcare resource utilization, increased patient-centred care, increased patient, caregiver, and provider satisfaction, and continues to inform policy development. Main lessons learned; targeted patient and provider engagement is essential to success in efforts to spread and scale; bundle holder needs to be organization with greatest risk; care coordinators must be accountable to hospital; single lead homecare agency key success factor in supporting integrated team.

Keywords

• bundled care
• bundled funding
• transition from hospital to home
• care coordination