Preparing analysis of one of the two case studies included in the instruction section

Case Studies In Integration Case Study #1: Brian's Story Brian Smith, Chair of hospital's Finance Committee sat recounting to a new Board Member how three years ago he had hoped that the LHIN's 3-year accountability agreement would solve the year after year reactive budget planning and allow for needs based service planning and associated operational costs. The funding formula, introduced in the 2009/10 fiscal year, had given a short term boost as a result of growth some funding for expected volumes and a little extra for the expected demographic changes, but the LHIN funding envelope was finite and the ultimately provided less than what the hospital needed. The details of the Hospital Accountability Agreement with the LHIN hadn't helped either. While the service volumes measured in the agreement had been met, it was at the expense of other “unmeasured” programs. As a result, the newly defined ‘accountability' often meant more of Government or LHIN priorities and less ability to meet actual community needs. For example, when the government emphasized reduced wait times hip and knee replacements, the hospital had no real choice but to comply even though the real need in the community was for cardiac care. That meant service cuts to comply with the Ministry/LHIN directions and less ability to meet the community's most pressing need. Complaints to the Board and administration by families whose services were curtailed or eliminated increased in frequency. Board and staff were frustrated with the constraints that came with ‘accountability and transparency' as the government and LHIN called it. The Board was also facing frequent complaints from physicians who couldn't get the OR and clinic time they needed to serve their patients. Several docs were threatening to stop taking call or more critically were considering changing hospitals. Brian noted that his hospital was not alone in this matter. He recounted that two neighbouring hospitals were also suffering the same fate. The Board was getting increasingly frustrated. Things had to change and soon. The situation demanded that the Board head down a new and different path. In 2010 Marika, the Hospital's Board Chair, called her counterparts at the other two hospitals to a private dinner to talk about possible solutions. The 3 hospital Board Chairs met and agreed to pursue a collaborative plan of action. A delegation of the Board Chairs, the CEOs and Chiefs of Staff worked diligently and devised a partnership agreement that required them to look at the big picture system picture rather than the just each hospital's own plans. Geriatric Services and Rehabilitation Services were already organized from a regional perspective with Marika's facility as the designated LHIN lead, however, acute care services was still for the most part being planned and operated by each individual hospital without the benefit of a regional framework. The partnership, Brian explained, was difficult but necessary for survival and for meeting quality standards. Clinical services had to be streamlined. This meant consolidation of some programs at only one or two sites to achieve increased clinical coherence between programs and more specialization of services on fewer sites. The partnership was not a panacea. The changes caused other complaints; for example; from the patient's perspective it meant longer travel times for select services. But at least the wait times decreased. As well, there was more coordinated care across the 3 hospitals enabled by access to a unified electronic patient record, a shared set of specialists across the 3 hospitals, standardized clinical pathways, a broader range of services provided within the region and a larger critical mass of patient which attracts funding, clinical trials, staff and physicians. The doctors were happier too. After considerable concern and uncertainty, the physicians realized they were on call less and had better access to Operating Room and clinic times. As discussed at the Finance Committee, from a financial perspective it meant increased flexibility to respond to funding inadequacies and restrictions and the LHIN's no deficit policy. It also meant a more coordinated tri-hospital response to the performance targets set in the agreement signed by the three hospitals together. From an human resource perspective it meant a more efficient approach to managing staff and physician recruitment and retention issues, more opportunities for full time work for staff and a greater ability to address workload and staffing issues. Operationally it has resulted in more efficiency in key support areas such as finance, IT, health records, food and plant maintenance through a mix of consolidation of the 3 hospital's services and bulk purchasing. He admitted that the change wasn't easy. Finding a governance structure that balanced local community control with some centralized decision-making took a lot of discussion, sometimes heated, and open and honest communication was essential. He described how they looked at several models of governance:  An amalgamation of the 3 hospitals into one single corporation  A Central Authority model in which each hospital maintained their corporate existence but above each hospital's Board there would be a Central Board, comprised of members of each Hospital Board. The nature and role of the Central Board could vary from being a decision making body to simply an advisory body. It took a while for everyone to agree to a structure and to work out the details. Since then a lot of work has gone into developing a single strategic plan, multi-year budget and detailed service plans. The strategic plan laid out the framework and accountabilities but gave flexibility to each local board to develop and implement their part of the plan. That balance of decision-making helped a lot. Most patients were happy with the changes. Bhin, a new Board member, had noted in his interview that the tri-hospital cardiac program meant he received fast and effective care. After presenting at the local emergency department with chest pains, he was admitted and then taken the next day to the cardiac centre for an angiogram. By-pass surgery followed. The whole time, his doctors could follow him from site to site and his medical record was always accessible. Later when he was ready for cardiac rehabilitation, it was back to the program available at his local campus. All in all he said that a very scary time was made a little easier by the coordination of care. Case Study #2 THE SHARMA FAMILY'S STORY As a result of a job transfer, Nirit Sharma and his wife, two kids and elderly mother had recently moved from Montreal to Uniontown. One of his children had diabetes and his mother was beginning to show signs of dementia. An early task Nirit was to find a primary care physician and some community supports to help the family cope with his mother's increasing health difficulties. Nirit asked around at work and was dismayed to find that all the family practices in Uniontown were closed to new patients. There were a few new physicians in a neighbouring area but they were mostly serving the Chinese speaking community and that would result in a language and cultural barrier. Nirit discovered that few services were available in the community for his Mother, particularly in her first language. He spoke to the local Alzheimer Association chapter but due to budget issues, they could only offer some educational help. She didn't qualify for home care services, but SeniorHelp, a non-profit community support agency, was able to provide some respite services and general assistance for a fairly reasonable price. Nirit had heard from a neighbor that the local hospital - Uniontown General Hospital – could possibly offer some of the help he was looking for. He called the Hospital and found a number of services were available to meet his family's needs. To start with, he learned that the Hospital operated a Health and Wellness Centre that included both hospital-run clinics and physician/specialist offices and a range of other health-related services. He learned that located within the Centre was a Family Health Team (FHT). The Family Health Team was run by a group of 20 primary care physicians. They also employed several nurse practitioners, social workers and other health care workers. Between the physicians and staff, the practice had the capability to converse in various languages. The FHT also had an arrangement with the hospital for the provision of nutritional counseling, health promotion services, family and children's mental health counseling and other such services within the FHT's offices. When he went over to the Health and Wellness Centre he saw that just down the hall from the FHT were many related hospital services such as a diagnostic imaging and even several operating rooms for day procedures. Also located in the Centre were child and adult diabetes programs for educational, consulting and monitoring services. Upstairs were pediatricians, surgeons, and several other specialists. Also located right within the building was a health food store, a physiotherapy clinic, an alternative medicine clinic, a pharmacy, a home health care store and the offices for the local CCAC. He further learned that all the doctors, clinics and the main hospital were electronically linked to facilitate referrals for consultations and tests, receipt of results and access by his health care providers to relevant health information. He reasoned this would result in less duplication of tests and better sharing of pertinent health information including allergies, current medications and upcoming tests. Nirit was even more excited to learn a Complex Continuing Care Hospital, physically linked to the Health and Wellness Centre, ran a regional geriatric program and that their health records were also electronically linked. The facility offered an assessment program that could do a full work up on his mother over a 3 day period and then help him locate and coordinate the help they would need including referrals to appropriate community programs, home care services and a number of long-term care services in the area. At first, his wife was a little hesitant, because when she called to make a doctor's appointment with a family physician she was told she would have to roster with the FHT, meaning agree to receive all of her primary care within the FHT. She was also told she could choose a physician but she would also receive care from the nurse practitioner when appropriate or one of the other doctors if hers wasn't available. She became more comfortable when she learned all of the staff were affiliated with the hospital and that she could call 24 hours a day for service or advice. Things were looking better. But one big problem remained. With only one family car, getting to the hospital campus was not easy and her child with diabetes would need frequent visits to the hospital to monitor his blood sugar and teach him the life skills he would need. Her mother-in-law could not be left alone for long periods of time and was a real handful to take on public transportation. So Mina was relieved when she learned that the hospital and the FHT had established a joint tele-home care program that enabled blood sugar levels to be sent via the internet to the hospital's lab and the FHT and that through the hospital's videoconferencing abilities, if necessary, the FHT or hospital could do a remote video conference with them. So the Sharma family took the plunge and joined the FHT. They were very satisfied with the care they received from the team and the easy access to and better coordination of their care, particularly for Nirit's mother. They also began take advantage of the weekend hours at the FHT. Nirit even signed up his kids for Saturday programs at the community centre that was co-located with the Health and Wellness Centre. While his daughter was in swimming class, his son would be playing hockey and Nirit could go and see the nutritional counsellor about coping with his newly diagnosed diabetes – all in the same building at the same time. Unfortunately Mina, was diagnosed with a neurological disorder which was diagnosed very expeditiously as a result of the facilitated electronic exchange of information between all members of the health care team. Unfortunately, Uniontown General Hospital did not have the specialist care to deal with her disease, so she was referred to the regional health centre. As a result, the coordination and communication Mina had become accustomed to began to break down. She had some blood work done and an MRI at Uniontown, but because the information systems weren't linked, the results didn't get to the specialist before her appointment. The tests had to be redone at the regional centre which resulted in a two month wait for another appointment. Thankfully, the problem wasn't serious and she was told she could be followed by her family doctor but when she saw her physician he had not yet received the consultation report. As a result of this experience, the Sharma family realized the advantages of being in a community where their acute care hospital/ CCC/rehab hospital, specialists, family practice group and community health care providers had come together and developed an integrated approach to providing coordinated care along the continuum. They further learned at a public meeting held by the hospital and through the local paper that the plans to expand the extent of their partnership within the community by establishing formal partnership and service arrangement with other providers in the community including other FHTs, pharmacies, public health and the CCAC. They came to truly appreciate the efforts of the hospitals and the providers to develop this integrated system. Because if the family experience, Nirit inquired about becoming a volunteer member of the Hospital Board. He learned that each organization remained autonomous with their own governance structures and separate funding, but that through voluntary agreements, money is shared and substantial collaborative efforts put towards establishing, and nurturing the relationships. Assignment Choose one of the Case studies and prepare an analysis  Submissions: - 8 pages maximum. Double spaced. (Not including title page or bibliography) ◦ Discuss the types of the integration described. ◦ What are the benefits derived and for whom? ◦ What are the key issues you see in the case study for achieiving successful implementation? ◦ Reference course readings and other literature.  Submit 2 copies in class time on or before the due date.