Health System Funding Reform & Quality-Based Procedures

Melissa FarrellAssistant Deputy MinisterHealth System Quality & Funding DivisionMinistry of Health and Long-Term Care

November 13, 2015

On February 2, the Minister announced Patients First, the next phase of Ontario's plan for changing and improving Ontario's health system. It exemplifies the commitment to put

people and patients at the centre of the system by focusing on putting patients' needs first.

This plan focuses on four key objectives:

Open, transparent, accountable, effectively managed government that provides value for tax dollars

Health Promise

Patients First• a caring, integrated experience for patients• faster access to quality health services • for all Ontarians at every life stage

Connect:• Providing better

home and community care

Protect :• Ensuring our

universal health care system is sustainable for generations to come

Inform:• Providing

information to make the right decisions about your health

Access:• Providing faster

access to the right care

Government Promise

Patients First: Action Plan for Health Care

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Health Based Allocation Model (HBAM)

• Evidence, health-based funding formula• Enables government to equitably allocate

available funding for local health services• Estimates future expense based on past

service levels and efficiency, as well as population and health information e.g. age, gender, population growth rates, diagnosis and procedures

Quality-Based Procedures (QBPs)

• Clusters of patients with clinically related diagnoses / treatments and functional needs identified by an evidence-based framework as providing opportunity for:

− Aligning incentives to facilitate adoption of best clinical evidence-informed practices

− Appropriately reducing variation in costs and practice across the province while improving outcomes

• Reflect needs of the community• Equitable allocation of health care dollars• Better quality care and improved outcomes• Moderate spending growth to sustainable levels• Adopt/ learn from approaches used in other jurisdictions• Phased in over time at a managed pace

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Health System Funding Reform (HSFR)

40% 30%

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New HSFR Governance

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The Hospital Advisory Committee (HAC) has been charged with providing advice and recommendations to the Ministry leadership on improvements to HSFR, including existing and planned components of HBAM and QBPs that are in alignment with the Excellent Care for All Act and Patients First: Action Plan for Health Care

Three working groups will support the work of the Hospital Advisory Committee: i) Quality & Policy ii) Formulae & Tools iii) Communication, Education & Knowledge Transfer

The Ministry, in collaboration with the Local Health Integration Networks (LHINs), the Ontario Hospital Association (OHA) and Cancer Care Ontario (CCO),

has introduced a new HSFR governance structure

Quality-Based Procedures (QBPs)

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• QBPs will be developed across the continuum of care, using different approaches to address the varying needs of patient / client populationsVision

• QBPs are clusters of patients with clinically related diagnoses / treatments and functional needs identified by an evidence-based framework

Provide Opportunities

• For aligning incentives to facilitate adoption of best clinical evidence-informed practices

• For appropriately reducing variation in costs and practice across the province while improving outcomes

• For ensuring we are advancing right care, at the right place, at the right time

Definition

• Does the clinical group contribute to a significant proportion of total costs?• Is there significant variation across providers in unit costs/ volumes/ efficiency?• Is there potential for cost savings or efficiency improvement through more consistent practice?• How do we pursue quality and improve efficiency? • Is there potential areas for integration across the care continuum?

• Are there clinical leaders able to champion change in this area?• Is there data and reporting infrastructure in place?• Can we leverage other initiatives or reforms related to practice change

(e.g. Wait Time, Provincial Programs)?

• Is this aligned with Transformation priorities?• Will this contribute directly to Transformation system re-design?

• Is there variation in clinical outcomes across providers, regions and populations?

• Is there a high degree of observed practice variation across providers or regions in clinical areas where a best practice or standard exists, suggesting such variation is inappropriate?

• Is there a clinical evidence base for an established standard of care and/or care pathway? How strong is the evidence?

• Is costing and utilization information available to inform development of reference costs and pricing?

• What activities have the potential for bundled payments and integrated care?

Current Evidence-Based Framework

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Identifies QBPs that have the potential to improve patient outcomes first and foremost

Current QBPs Under Consideration

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QBP Agency Oversight Status

Retinal Disease Vision Care (UHN) Draft Clinical Handbook submitted

Coronary Artery Disease Cardiac Care Network Draft Clinical Handbook submitted

Aortic Valve Disease Cardiac Care Network Draft Clinical Handbook submitted

Cancer Surgery – Breast Cancer Care Ontario Draft Clinical Handbook submitted

Cancer Surgery – Thyroid Cancer Care Ontario Draft Clinical Handbook submitted

Corneal Transplant Vision Care (UHN) Draft Clinical Handbook submitted

Non-Emergent Spine University Health Network Draft Clinical Handbook submitted

Paediatric Asthma Provincial Council for Maternal and Child Health Draft Clinical Handbook submitted

Shoulder Surgery – Osteoarthritis Cuff Health Quality Ontario Draft Clinical Handbook submitted

Sickle Cell Anemia Provincial Council for Maternal and Child Health Draft Clinical Handbook submitted

Hysterectomy Cancer Care Ontario & Health Quality Ontario In development

Low Risk Delivery Provincial Council for Maternal and Child Health In development

Mental Health: Schizophrenia Health Quality Ontario In developmentMental Health: Dementia with Agitation Health Quality Ontario In developmentMental Health: Major Depression Health Quality Ontario In developmentColposcopy Cancer Care Ontario In developmentCardiac Devices Cardiac Care Network In development

Cardiac Prevention and Rehabilitationin the Community Cardiac Care Network In development

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QBP Adoption Committee

1. QBPs will have a core set of tools and supports to assist adoption.

2. Each QBP will have a clear process at the outset to determine the adoption strategy for the QBP led by the lead agency.

3. The core adoption tools must be supported by a provincial strategy to drive adoption e.g. measurement and reporting, clinical team engagement and order sets.

4. Adoption tools and supports will be evidence-based, where possible and will capture innovation and leverage the strengths of the field. This will including considering spread and scale strategies.

5. All partners commit to contributing to and promoting a common on-line location for users to easily access QBP tools (i.e. QBP Connect).

6. QBP Adoption tools will be evaluated (ideally in a similar way).

7. We will celebrate success (awards and rewards).

8. QBPs will be defined provincially and operationalized locally using LHINs/lead agencies, existing networks and local leadership who will have a lead role in QBP Adoption.

The following principles have been proposed to lead the development of the Provincial Roadmap for QBP Adoption

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QBP Adoption Committee Cont’d

• Baseline data• Ongoing/real-time data• Data support• Audit & feedback

• Clinician/care team engagement strategy

• Provincial conferences/webinars• Access to provincial & regional experts

(clinical/data etc.)• Community of practice• Coaching/SWAT Team

• List of most important best practice recommendations

• Summary QBP pathway• Standardized order set templates• Recommendations on required local &

provincial infrastructure• Implementation toolkit/checklist

• Goal setting/benchmarking• Evaluation

Measurement & Reporting Support

Change Management Tools

Knowledge Transfer Tools

Improvement Science

The following core set of adoption tools and supports have been proposed with the vision that a minimum core set be available for each

www.HQOntario.ca

Source: Danielle Martin, Health Quality Transformation Keynote

Policy levers

Requires political commitment

SPREAD

Horizontal Diffusion

One team at a time

Requires champions

SCALE

System-wide structural change

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Spread vs Scale

Implementation

To bridge from pockets of excellence, existing tools need to be strengthened to support greater spread:• Leverage champions from the sector• Position strong leaders at the forefront who can deliver on the vision• Develop peer-to-peer supports to accelerate clinical adoption• Scale up initiatives where investments have shown results• Effective patient engagement to optimize patient care processes• Expand quality improvement efforts across continuum of care

Today

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Clinical Leadership and Excellence

Early Implementers

Innovators Slow Implementers

Early Majority Late Majority

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Where to Next?

• Closer review of roles, priorities and direction of HSFR (e.g. Hospital Advisory Committee)HSFR Governance

• Map roles and responsibilities (e.g. agencies, hospitals, LHINs, Ministry) for each QBP and type of activity to support adoption

• Develop some standard approaches that partners support and will deliver for each QBP• Develop an action plan to start the work, particularly for some of the cross cutting

strategies such as data

Regional Strategy

• Following the completion of the Pan-LHIN QBP surveys, develop a more standardized regional adoption strategy for QBPs

QBP Adoption Committee

Single service

Integration of clinical care

Integration of care and funding for 1 episode

Population-based integration of care, and funding

Population-based frameworks for service delivery: Future direction, based on evaluation, policy analysis, and innovative implementation

Integrated Funding Models: Scaling up a “proof of concept” approach through an Expression of Interest

Health Links: Moving towards models for comprehensive care in which providers become accountable for overall outcomes

QBPs: Evidence & standards influence average price

Quality foundation, guided by the Excellent Care for All Act

Pre-requisites:• Shared governance • Shared IT, health analytics, data systems• Common service accountability agreements

• Common QIP• Common understanding of patient and provider

experience

Where to Next Cont’d?Evolution towards population-based frameworks for service delivery

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