This presentation examines the building blocks for excellent care. Bob Gardner, Director of Policy www.wellesleyinstitute.com Follow us on twitter @wellesleyWI

1. Person-Centred Care, Equity and
Other Building Blocks for
Excellent Care For All
Bob Gardner
Central LHIN
Annual Business Plan 2013-14 Collaborative
December 12, 2012

2. Nothing About Us, Without Us
• fundamental principle of disability rights and
other consumer movements
• emphasized by Don Berwick, founder of
Institute for Healthcare Improvement
• key dimension of high-performing healthcare system
• but really integrating PCC into how care is
imagined, planned, organized and delivered → will
drive major transformation
+ equity → high-quality person-centred care that
benefits all
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3. Problem to Solve:
Inequitable Quality
• from a resident participating in Wellesley community-
based research in St James Town
“Language is a big barrier to us whenever we use
any services. When our doctor is on leave then
we are unable to visit a different one due to
language problem. So we may have to go to a
walk-in clinic or emergency. There were no
interpreter services. I do not know if they arrange
them in hospitals. I couldn’t follow what the
doctor said.”
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4. Problem to Solve:
Systemic Health Inequities in Ontario
•there is a clear gradient in health
in which people with lower
income, education or other
indicators of social inequality and
exclusion tend to have poorer
health
+ major differences between
women and men
•the gap between the health of
the best off and most
disadvantaged can be huge – and
damaging
•impact and severity of these
inequities can be concentrated in
particular populations and
neighbourhoods
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5. Key Messages
• will set out key directions and levers for improving person-centred
care (PCC)
• and illustrate with ideas, examples and lessons learned from both
operationalizing equity and PCC
• will highlight that reforms geared to enhancing equity and person-
centred care are not just parallel, but vitally connected
• both essential to achieving excellent care for all
• also essential to identified Central LHIN priorities:
• appropriate = not just right care in right places, but to support
particular people and populations, the way they need it
• access to what = services matching individual and community needs
and situations
• person-centred care = for all, reflecting their different needs and
diverse perspectives
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6. Building Equity Into the Health System
1. building health equity into all health care planning and delivery
• doesn’t mean all programs are all about equity
• but all take equity into account in planning their services and
outreach
2. aligning equity with system drivers and priorities
• quality improvement, chronic disease prevention and
management, wait times
• none of these directions can succeed without taking equity
barriers, social determinants of health and differential risks and
needs into account
• aligning with key priorities also enhances chance for success and
sustainability of equity focus
3. identifying those levers that will have the greatest impact on reducing
health inequities and driving system change
• e.g.. enhanced primary care
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7. Building Equity Into the Health System: II
4. embedding equity in provider organizations’ deliverables, incentives and
performance management – in the incentives and pressures that really drive the
system
5. targeting some resources or programs specifically:
• looking for investments and interventions that will have the highest impact
on reducing health disparities or improving the health of most
disadvantaged, fastest
• key access barriers – language, culture, availability
• addressing disadvantaged populations – poor, isolated, racialized, homeless
6. investing up-stream in health promotion and addressing the underlying
determinants of health
7. enabling equity-focused innovation
• a huge range of promising and innovative programs have been developed by
Community Health Centres, hospitals, networks and other providers to
address the needs of disadvantaged communities.
• we need to share lessons learned, evaluate and identify what is working, and
build on the enormous amount of local imagination and innovation going on
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8. Where to Start?
• can’t just be ‘experts’, planners or professionals who define issues
and drive system transformation
• have to build diverse voices and community needs into planning
• not just as occasional community engagement, but to identify
fundamental needs and priorities
→ need to start from patients
+ through an equity lens:
• not all patients are the same – diverse cultures, backgrounds and
perspectives, and unequal social and economic conditions
• how to involve all types of patients?
• specifically, how to involve and empower those not normally included
→ means using innovative methods – e.g. principles of inclusion research
+ thinking also about the communities in which they live and the
social determinants that shape their opportunities for health
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9. Align Equity and PCC With System Drivers:
Quality Improvement
• person-centred care is a critical component of QI
• health disadvantaged populations have more complex and
greater needs for services and support
• good care and provider-patient relationship means taking
this full range of people’s needs/situations into account
→ customizing programs and service mix to meet greater needs
→ similarly, customizing transitions and follow-up to more
challenging living conditions of more health disadvantaged
populations
• e.g. more intensive case management, referral planning and
post-discharge follow-up for health disadvantaged
• good continuity of care, navigation and transitions for the most
vulnerable = human face of system integration
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10. Then Effectively Use Available Levers To Drive
Change
• back to patients – what does quality mean to them? and to
different populations?
• key mechanism for building that in = patient-based design
• innovations from around the world
• one of my favourites = to help redesign a clinic in Bristol
hospital, they used an adapted taxicab parked outside as place
to video patient views
• at a system level, providers have to develop Quality Improvement
Plans, starting with hospitals
• equity should be one of dimensions providers must report on –
but wasn’t really in hospital plans so far = missed opportunity
• similarly, need objectives and indicators for excellent PCC
• depending upon populations, could include
interpretation, cultural competence, community engagement
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11. One Example: Interpretation as a Key Quality
and Equity Lever
• key things that worry healthcare EDs and CEOs:
• delivering high-quality care efficiently
• reducing risk and enhancing safety
• meeting provincial priorities – wait times, re-admissions, ALCs
• access to interpretation underlies all of these system drivers –
consistent evidence that:
• poor communication between provider and patient due to language or cultural
barriers is certainly poorer experience for patients
• can contribute to misdiagnoses and inappropriate prescriptions
• inability to read or understand instructions can lead to medication errors →
safety, cost and re-admission implications
• promising indications that good interpretation helps keep people out of hospital
and gets them out sooner
• requirement that adequate interpretation be available wherever
needed → improves quality and equity
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12. Connecting the Dots and Driving Change: Building
Interpretation Into Performance Management
• for providers to meet these requirements, they will need to:
• know the language needs of the communities they serve
• this is far more than just the languages of those who come to them for
services
• also need to know who is not coming in because of language and other
barriers = unmet need
• and it doesn't mean just basic demographic data on languages spoken
• it means what language people are most comfortable receiving care in
→ providers assessing community needs far better, and integrating
that richer knowledge into their planning
• pre-condition = need to know language preferences and other
social determinants characteristics of patients
• project in Toronto Central to collect such data directly
• as electronic health records are being developed, ensure equity and social
determinants data is built in
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13. Embed Person-Centred Care in
Targets, Indicators and Measurement
• innovative work underway to develop equity indicators – but don’t need to
wait for perfect
• build equity into existing targets:
• reducing avoidable hospitalization and/or readmissions is key prov
priority – and clearly good for patients
→ equity target = reduce inequitable differences in rates between different
populations or areas
• and the same for person-centred care:
• satisfaction is a widely used indicator of meeting patient needs and
perspectives
• make sure surveys capture full diversity of population -- e.g. NRC Picker
survey has been translated into several languages
+ equity target = reduce differences in satisfaction by gender, social
background, neighbourhood, etc.
• and to operationalize both
• closely monitor progress against the targets and indicators
• link funding and resource allocation to performance on them
• disseminate the results widely
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14. Never Just Equitable Access, But Quality:
Customize Service Delivery
• in an increasingly diverse society, high quality care =
culturally competent care:
• requires organizational resources, training, commitment
and embedding into routine planning and performance
management
• improving PCC requires identifying and addressing specific
equity barriers
• e.g.. inadequate interpretation can lead to poor
quality, mis-diagnoses, people not being able to follow
medication, etc. →at worst, avoidable re-admissions and
complications
• health disadvantaged populations have more complex and
greater needs for services and support
→ continuum of care especially important
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15. Not Just Responsive Individual Care: Build
Equity-Driven Service Models
• drill down to further specify needs and barriers:
• health disadvantaged populations also face greater non-
healthcare barriers – e.g.. availability/cost of
transportation, childcare, language, discrimination
→ facilitated access and effective navigation/transitions that
address these wider barriers is especially important
• e.g.. Community Health Centre model of care
• explicitly geared to supporting people from marginalized
communities
• comprehensive multi-disciplinary services covering full range of
needs
• CHCs, public health and many community providers have
established ‘peer health ambassadors’ to provide system
navigation, outreach and health promotion services to
communities facing particular barriers
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16. Embed Person-Centred Care and Equity Into
Key Initiatives
• build local needs and perspectives, and equity as driving
priority, into planning key issues
• e.g. primary care reform is major priority, so:
• create a patient/community advisory forum to identify priorities
• build equity into planning – e.g.. to identify local service gaps
and unmet need, to prioritize immigrant and other populations -
- use HEIA
→ one target = ensuring access and use of primary health care
does not vary inequitably by income level, immigration
status, neigbourhood, gender, race, etc.
→ idea = concentrate new FHTs or other initiatives in particular
high needs regions or neighbourhoods, or in particular
populations such as immigrants or uninsured
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17. Equity-Focused Planning: Watch for
Unintended Consequences
Always plan through a Could this program or direction have
a differential and inequitable impact
Health Equity Lens: on some populations or
communities?
How do we need to take the specific
needs of disadvantaged individuals
and communities into account in
service planning/delivery?
Providers should be expected to
apply this type of planning lens
routinely
• if needed, then apply fuller
Health Equity Impact
Assessment
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18. Watch for Unintended Consequences: Patient
Self-Management
• emerging idea in quality improvement and in healthcare thinking
generally
• huge potential benefits:
• builds on principle of patient empowerment
• can be critical means of staying healthy in general and managing
chronic conditions
• when working → keeps people well and out of acute care → system
sustainability and efficiency
• but
• need to enable – info and other resources, mentoring, support
• given systemic inequalities in health opportunities and resources –
some are going to need more support than others
• need to also recognize barriers many will face –
language, literacy, living conditions
• promising idea of peer health ambassadors again
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19. Health Promotion: Through an Equity and PCC
Lens
• programs have to take account of inequitable resources of
vulnerable individuals and communities
• advice to manage heart problems by exercising depends
upon affording a gym or being close to safe park
• adjust programs to inequitable risks and specific barriers
• South Asian immigrants had 3X and Caribbean and Latin
American 2X risk of diabetes than immigrants from Western
Europe or North America (Creatore et al CMAJ Aril 19, 2010)
• deliver in languages and cultures of particular
population/community
• go where people are -- e.g. health promoters into malls
• idea = Immigrant Women's’ Health Centre and other vans
• if not customized, generic health promotion programs can
widen disparities as better off take them up disproportionately
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20. Extending That: Health Promotion Targets
Through an Equity Lens
• not enough to just measure activity -- number or % of priority pop’n that
participated in program
• if health promotion program is geared to enabling more exercise or
healthier eating – then we measure that initial effect
• need to also measure health outcomes – even when impact only
shows up in long-term
• need to differentiate those with greatest need = who programs most
need to support and keep to have an impact
• need to assess reach
• who isn’t signing up that needs support the most?
• who stuck with program and what impact did it have on their health –
and how did this vary within the pop’n
• then adapt financial incentives and accountability drivers
• develop weighting that recognizes more complex needs and
challenges of most disadvantaged, and build this into incentive system
• remember with coming quality-based funding of bundles of care
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21. Embedding Patient Voice and Views at System
Level
• need to ensure person and community-driven planning
and priority setting
• can draw on innovative methods of engagement in many countries – e.g..
citizens’ juries, health councils, -- required in UK
• and from beyond healthcare -- citizens’ assemblies, participatory
budgeting
• also effective mechanisms at provider level:
• many hospitals have community advisory panels
• CHCs and many community-based providers have residents on their
boards
• some forms of FHTs also have community governance
• into action by embedding in provider expectations:
• providers determine most appropriate mechanism/forum for their context
• but all need to institutionalize some form of direct community/patient
forums
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22. Extending Equity-Driven Service → Address Roots of
Health Inequities in Communities
• look beyond vulnerable individuals to the communities in which
they live
• have to take SDoH into account in planning and program design
• given transportation, accessibility, cost and other barriers less
advantaged face, effective transitions and continuum of care are
even more important
→ meeting full range of needs means moving beyond healthcare
• focus on community development as part of mandate for many
PHUs and CHCs
• providing and partnering to provide related services/support
such as settlement, language, child care, literacy, employment
training, youth programs, etc.
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23. Potential of Hub Models
hub-style multi-service centres around the world and across
the country
• a range of health and employment, child
care, language, literacy, training and social services are provided
out of single ‘one stop' locations
• can provide more ‘wrap-around’ integrated services from
person’s point of view
• based solidly in local communities and responding to local
needs and priorities → can become important community
‘space’ and support community capacity building
• from provider and funder points of view = more efficient use of
scarce resources
• can enable synergies among providers and better overall
coordination
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24. Showing Real Promise in Toronto
• emerging forms:
• CHC hubs of primary care, health promotion and related social services
• network of neighbourhood multi-service centres
• schools with health and social services acting as hubs for their local
communities
• getting specific in NW Toronto – what if the old hospital site could become a
hub?
• expanded Community Health Centre
• Family Health Team
• midwifery and birthing centre
• health promotion and other public health support
• settlement, social service and other community agencies
• training and employment support
• childcare
• recreation and meeting place
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25. Acting on Social Determinants of Health:
Local Cross-Sectoral Planning
• cross-sectoral coordination and planning are key means to
address wider SDoH at community level:
• public health departments and LHINs are pulling together
or participating in cross-sectoral planning tables
• Local Immigration Partnerships, Social Planning Councils
• such broad collaborations will be particularly important to
Health Links initiative
• and such collaborations are particularly important in less
advantaged communities with less resources
• building on local resources and networks
• idea = explicit SDoH/equity planning networks such as SETo
in Toronto
• and here = NW Toronto network that put together
community health fair last month
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26. Look Widely for Community Innovation
MiVIA (my Way)
• personal electronic health record originally developed for mostly Hispanic
seasonal farm workers in California – and then extended to other
vulnerable populations
• used in networks of free clinics
• supports continuity and efficiency – highlighting the potential of eHealth
for even the most marginalized
• the web-based portal and records are in Spanish as well → helping to
reduce language barriers
• a vital element of success has been ‘promotores’ --community/peer
health promoters – who recruit people into the program, train them on
the tools and support them in their own health management
in Toronto, CAISI
• integrated database for homeless people
• used by hospitals, shelters, community service providers
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27. Pulling it All Together: Acting on Patient and
Community Priorities
• build significant community participation and influence into priority
setting
• Health Council underway
• build on insights from other countries – idea of participatory planning
• research and policy resources is provided to give participants all
the information they need
• they make recommendations on promising initiatives and
allocation of resources
• have also proven able to address tricky trade-off issues
• make this real = allocate a % of budget to priorities or initiatives
identified by Council or other means of engagement
• idea = develop sub-regional local health plans
• e.g. in NW Toronto, especially to proactively get ready for hospital
moving
• build on local potential – enormous provider commitment, grass-roots
innovation and strong community organizations
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