G. Ross Baker

Twenty years after the publication of the Canadian Adverse Events Study, the incidence of patient safety events remains an important challenge in Canadian healt

Integrated Care connects care providers across sectors and often from different agencies or organizations to deliver more effective, efficient and client centered care. Creating new or redesigned programs to achieve these goals typically requires new care models delivered by a range of providers who have varying experiences and mental models about what is required for effective care. Effective care designs must also consider factors such as variations in populations, available services, and resources. Thus, creating care models for integrated care can be challenging, creating conflicts that can undermine efforts to arrive at effective delivery models. Ontario Health Teams (OHTs), a new model for integrating care, launched in staged cohorts across the province in 2019, are developing new population health-focused care delivery models for specified target populations, and, eventually, for the 15 million people of Ontario, Canada. OHT leaders and staff come from a variety of agencies with varying care models, and, in some cases, limited prior collaborations with a mandate to integrate service delivery. Leaders in each OHT can design services to fit local needs, and their performance will be assessed on specified metrics. To assist in the design of new care models that meet patient needs and support providers from multiple and different agencies, a team from the ADVANCE program at the Dalla Lana School of Public Health and the Rotman School of Management at the University of Toronto have used Integrative Thinking approaches to help leaders to select and combine elements of opposing care designs to create more effective strategies for integrated care. Integrative Thinking is an innovative method developed by Roger Martin and Jennifer Riel that helps decision-makers to reframe decisions by shifting efforts away from seeking compromises among competing approaches, and, instead helps decision-makers to identify the core elements of each potential model and then reassemble these components into a new, even better design. Integrative Thinking thus helps decision makers combine seemingly competitive solutions into a stronger option through a carefully structured, facilitated process. This presentation will describe the methods used for Integrative Thinking within the context of integrated care, and home care programming specifically, to better serve local populations in different care environments.

Many health systems attempt to develop integrated and population health-oriented systems of care, but knowledge of strategies and interventions to support this effort is lacking. We aimed to identify specific redesign strategies and interventions, and to present evidence of their effectiveness. A modified scoping review process was carried out. Fifteen relevant examples of integrated care organizations that incorporated a broad population health approach in countries of the Organization for Economic Cooperation and Development described in 57 articles and reports were included in analysis. Seven key redesign strategies and multiple redesign interventions have been identified and are described. Most commonly used redesign strategies included focusing on health and wellness, embracing intersectoral action and partnerships, addressing health in vulnerable groups, and addressing a wide range of determinants of health, including making improvements in health services. Redesign interventions included creative and innovative ways of addressing clinical and non-clinical issues such as establishing housing surgeries in primary care, establlishing vast social and provider networks to support patients with complex needs and also broadening of the scope of services, workforce redesign and other. Potential reductions in the utilization of care and costs could be derived by the wider adoption of these strategies and interventions. Development of integrated and population health-oriented systems of care requires the redesign of how services are organized and delivered, and how organizations and care systems operate. Combining integration of care with the population health approach can be supported by a set of cohesive strategies and interventions aimed at preventing disease, addressing social determinants of health and improving health equity at both population- and individual-level.

The concept of “mechanism” is central to realist approaches to research, yet research teams struggle to operationalize and apply the concept in empirical research. Our large, interdisciplinary research team has also experienced challenges in making the concept useful in our study of the implementation of models of integrated community-based primary health care (ICBPHC) in three international jurisdictions (Ontario and Quebec in Canada, and in New Zealand). In this paper we summarize definitions of mechanism found in realist methodological literature, and report an empirical example of a realist analysis of the implementation ICBPHC. We use our empirical example to illustrate two points. First, the distinction between contexts and mechanisms might ultimately be arbitrary, with more distally located mechanisms becoming contexts as research teams focus their analytic attention more proximally to the outcome of interest. Second, the relationships between mechanisms, human reasoning, and human agency need to be considered in greater detail to inform realist-informed analysis; understanding these relationships is fundamental to understanding the ways in which mechanisms operate through individuals and groups to effect the outcomes of complex health interventions. We conclude our paper with reflections on human agency and outline the implications of our analysis for realist research and realist evaluation.

Patients have always played a role in research, but this role has been traditionally passive, largely limited to providing data. The active involvement of patients in research activities is more recent, and research funders in Canada, the United States, the United Kingdom and elsewhere have urged

Baker; Adaptation and standardization of integrated care practices to facilitate scale-up

The increasing complexity of home care services, pressures to discharge patients quicker, and the growing vulnerabilities of home care clients all contribute to adverse events in home care. In this article, home care staff in six programs analyzed 27 fall- and medication-related events. Classification of contributing causes indicates that patient and environmental factors were common in fall events, while organization and management factors along with patient, task, team, and individual factors were common in medication-related events. Home care settings create specific challenges in identifying and mitigating risks. Some factors, such as variations in home environments, are difficult to address. However, changing care coordination structures and communication methods could ameliorate other factors, including poor communications among staff and limited team and cross-sector communication and coordination. Ensuring that medication ordering and administration processes are optimized for home environments would also contribute to safer care.

Studying implementation of integrated models of community-based primary health care requires a "whole systems" multidisciplinary approach to capture micro, meso and macro factors. However, there is, as yet, no clear operationalization of a "whole systems" approach to guide multidisciplinary research programs. Theoretical frameworks and approaches from diverse academic traditions specify different aspects of the health system in more depth. Enabling analysis across the system, when data and ideas are captured using different taxonomies, requires that we map terms and constructs across the models. This paper uses concept mapping techniques to compare and contrast the theoretical frameworks and approaches used in the iCOACH project including: Ham's Ten Characteristics of the High-Performing Chronic Care System (capturing patient/carer and provider perspectives), the Organizational Context and Capabilities for Integrating Care framework (capturing the organizational perspective), and the Health Policy Monitor framework (capturing the policy system perspective). The aim of the paper is to link concepts across different theoretical framework to guide the iCOACH study. A concept map was developed that identifies 8 overarching concepts across the heuristic models. A preliminary analysis of one of these overarching concepts, care coordination, demonstrates how different perspectives will assign different meanings, values, and drivers of seemingly similar ideas. For patients and carers care coordination is about having a responsive team of health care providers. Building relationships in teams that exist within and across different organizations is essential for providers to achieve care coordination, where managers and policy makers see care coordination as being more about creating linkages and addressing systems gaps. This work represents a first step towards development of a fully formed conceptual framework that includes key domains, concepts, and mechanisms of implementing integrated community-based primary health care.