DRAFT. Incorporating The. Within A Regional Chronic Disease System. South West Regional Cancer Program

Transcription

1 A Cancer Ontario Partner Incorporating The Within A Regional Chronic Disease System Draft - March, 2009 Brian Orr Regional Vice President Cancer Program

2 1 Chronic Disease Management Delivery System Purpose This document presents the work to date to describe how the could be incorporated within a possible regional Chronic Disease Management Delivery System ( CDMDS ) architecture for the LHIN. The document is a working draft as many aspects of the architecture have yet to be developed. It is being circulated to describe the work to date as well as solicit input from stakeholders. Situation The LHIN report, Preventing and Managing Chronic Illness 1, identifies that in Ontario almost 80% of Ontarians over the age of 45 have a chronic condition, and of those, about 70% suffer from two or more chronic conditions. Increasingly cancer is becoming recognized as a chronic disease with 44% of men and 39% of women are expected to personally face cancer sometime in their lifetime 2. Like other chronic disease management systems, the scope of the cancer systems ranges from health promotion and prevention through to end-of-life care. Initial work identified that the components of a comprehensive regional cancer program are the same as those that exist within a generic regional chronic disease management system. Hence it makes sense to align/merge the within a broader LHIN Chronic Disease Management Delivery System. Addressing cancer care as an integral part of chronic disease management provides several benefits including: Adoption of terminology used to describe the regional cancer program with that used in other chronic disease programs. Sources: 1. LHIN, Integration Priority & Action Plan Report: Preventing and Managing Chronic Illness, October 31, Cancer Ontario, Ontario Cancer Plan , It provides a consistent approach across all chronic disease management programs which is of significant benefit to most hospitals and other healthcare organizations in the LHIN who are small and cannot afford to have separate approaches for managing each type of chronic disease. It will help to promote integrated patient/family centred care by encouraging healthcare providers to work together to effectively manage each patient s combination of chronic conditions. Concepts The development of a CDMDS architecture is founded on previous work undertaken by the LHIN as well as other related developments. Ontario s Chronic Disease Prevention and Management ( CDPM ) framework {figure 1, page 2} presents the overall model applicable to all chronic care conditions. The CDMDS architecture focuses on developing one aspect of this framework, namely, the Delivery System Design, and the link to Informed, activated Individuals and Families. The Continuum of model {figure 2, page 3} identifies the types of care required. All of the components of this model need to be incorporated into a CDMDS architecture. Triple Aim Framework {figure 3, page 4} introduces the emerging concept of population health based approach that provides a useful approach for improving region-wide healthcare system. This draft is an early attempt to link the Triple Aim Framework into a regional CDMDS architecture. Cancer Ontario s Cancer System Model {figure 4, page 5} introduces components, related to aspects of the Continuum of Model that are also incorporated into this architecture.

3 Figure 1: Ontario s CDPM Framework 2 Source: LHIN, Integration Priority & Action Plan Report: Preventing and Managing Chronic Illness, October 31, 2006, page 4.

4 Figure 2: Continuum of Model Promotive Preventive Curative Rehabilitative Supportive Primary Health Education, Research & Knowledge Sharing Evidence-Informed Practices System Navigation 3 Communication Source: LHIN, Integration Priority & Action Plan Report: Building Linkages Across the Continuum All Seniors, and Adults with Complex eeds, October 31, 2006, page 3.

5 Figure 3: Triple Aim Framework The Triple Aim Framework, developed by the Institute for Healthcare Improvement, is intended to guide the optimization of a health system along three dimensions: the experience of the individual; the health of a defined population; and the per capita cost for the population Below are short summaries of the underlying components of the Triple Aim Health System design. 1. Individuals and Families Provide coordinated services among multiple care provides, in order to engage and improve healthcare for all individuals and families. 2. Redesign of Primary Services and Structures A coordinated primary care system that can deliver basic services to at least 70% of the necessary medical and health-related social services to the population, including flexibility to provide customized health care for the needs of patients, families, and providers. Coordination with other specialties, hospitals, and community services related to health. 3. Population Health Management Efficiently serve all segments of the population. Includes prevention and health promotion, and strategic initiatives related to providing equitable outcomes and minimizing undesirable variation in practice. 4. (System) Cost Control Platform Achieve < 3% annual inflation per capita cost by reducing overuse of unnecessary health care and optimizing the contribution of all components of the healthcare system including patients and families. Includes rewarding health care providers and health care organizations for their contribution to producing better health for the population. 5. System Integration Includes matching capacity and demand for health care and social services, coordinated planning and execution based on the needs of the population, and a system for ongoing learning and improvement. 4 Source: Institute for Health Improvement, Triple Aim Concept Design, April 4, Components 1. Individuals and Families 2. Redesign of Primary Services and Structures 3. Population Health Management 4. (System) Cost Control Platform 5. System Integration

6 Cancer System Model Cancer Ontario Model Figure 4 presents the Cancer Ontario s Cancer System Model that was included in the Cancer Plan. This model presents the core components in the cancer delivery system from prevention through to end-of-life care. Although not identified in this model, the cancer system includes many of the components included in Figures 1 and 2. The strengths of the current focus of Cancer Ontario is on following components. Community and hospital-based screening services and screening program management, particularly with the Ontario Breast Screening and Colon Cancer Check programs. System design for the hospital-based components, particularly diagnosis, treatment, palliative and end-of-life care. Hospital-based supportive environments and multi-disciplinary care teams.. System-based clinical information and decision support systems Education, research and evidence-informed practices, and knowledge sharing mechanisms. Establishing operational and performance standards. Although the CCO Cancer System Model has many strengths, the work to date has put less emphasis in areas that are more developed in the management of other chronic disease management programs. These include the following components of a comprehensive chronic disease system. Helping individuals and families to live with one or more chronic diseases and conditions for the rest of their lives. Engaging primary care providers and community-based health services in the continuum of care for individuals with chronic diseases. Figure 4: Cancer Model Long-Term Survival Risk Factors & Prevention Screening Diagnosis Treatment QUALITY, ACCOUNTABILITY, INNOVATION Palliative & End-of-Life 5 Source: 1. Cancer Ontario, Ontario Cancer Plan , 2008.

7 Regional Chronic Disease Mgt. Delivery System Comprehensive Model Combining components of these frameworks and system models provides an approach to developing a comprehensive regional CDMDS functional model, presented in figure 5 {page 7}. The core of this model is the combination of the care components of the Continuum Of Model {figure 2}, with the Cancer Ontario Model {figure 4}. This is reflected in the components from Promotive & Preventive through to End-of-Life. Other components of the Continuum of Model are reflected in the green double-ended arrows. Aspects of the Triple Aim Framework {figure 3}, not already implied in the other models, are reflected in the blue double-ended arrows. As noted above, this regional chronic disease system model fits within the CDPM Framework {figure 1}, which reflects a more holistic perspective of all aspects of chronic disease management. A fundamental requirement of this model is the ability to adapt to describe other chronic disease delivery systems, including the opportunity to identify common or shared components that would strengthen service delivery capacities of various healthcare organizations across the LHIN. Defining System Components The proposed regional CDMDS model identifies the functional components of a comprehensive delivery system. Definitions or descriptions of the various components are scattered through the various references and other documents. Further work is needed to incorporate a common set of definitions and descriptions within one reference document, which would make the model more useable in its potential application to specific chronic diseases. 6 It is anticipated that the definitions may have some variation depending of the particular characteristics of various chronic diseases. For example the various care components will be different in their characteristics for each chronic disease, as well as the specific evidence-informed practices that are applicable to each disease. Other Architecture Elements The regional CDMDS model is one element of the overall CDMS architecture. Other elements will likely include: Primary/Community Distributed Service model Defines how aspects of primary care / community care services should be distributed across the region for each chronic disease. Hospital-Based Distributed Service model Defines how aspects of hospital-base services should be distributed across the region for each chronic disease. CDMS infrastructure model Provides a model of the infrastructure and support services that are required to have an operationally efficient chronic disease management system. CDMS resourcing and accountability model Provides a model of how a regional system should be resourced and be accountable for specific components as well as overall outcomes. The remainder of this document presents some initial work on developing a hospital-based distributed service model based on experiences from the regional cancer program.

8 Figure 5: Chronic Disease Mgt. Delivery System Model LHIN Chronic Disease Prevention and Management Framework Informed, activated individuals & families Primary Services Promotive & Preventive Screening & Detection Assessment & Diagnosis Curative & Rehabilitative Continual & Monitoring End-of-Life 7 Supportive (Psychosocial & Palliative) Education, Research & Knowledge Sharing Evidence-Informed Practices System Navigation Communication System Integration & Cost Control Population Health Management Provincial Chronic Disease Requirements

9 Distributed Service Challenge Distributing Chronic Disease Services As noted earlier the proposed regional CDMDS model {figure 5}identifies the components of a comprehensive system, but it does not address the challenge of determining where various components need to be located across the LHIN in order to deliver care as close to home as practical while maintaining quality of care and sustainable operational capacity. Generally services can range from highly centralized to highly distributed taking into account population distribution and wide range in capacity of healthcare organizations and providers across the LHIN. It is anticipated that at least two distributed service models are needed, particularly given that the LHIN is predominantly rural and is served by relatively small healthcare organizations outside of London/Middlesex. The challenge with delivering chronic disease services in rural areas, is distances between communities as well as the small size of most healthcare organizations who may lack the necessary infrastructure and complement of specialized healthcare professionals needed to provide a full range of care. A comprehensive primary/community-based care distributed service model is vital to providing the continuum of care needed for anyone with one or more chronic diseases. However the initial work to date has been limited to developing a hospital-based distributed service, based on experiences gained in developing a regional cancer system for the LHIN. Regional Hospital-Based Distributed Services Some preliminary work has been started to develop a Hospital-Based Distributed Services Model for cancer services. It is recognized the different distribution models may be needed for other chronic diseases. Note that this model is an early and incomplete model. The expectation is that this work will evolve and eventually result in an approved model for the LHIN. Current State There is no overall strategy that defines what types of cancer services should be located in hospitals, or criteria that can be used to determine whether a hospital should host a range of cancer services, or how various geographic areas, within the LHIN can be served. The only work on a distributed delivery model is found in the Cancer Ontario ( CCO ) regional systemic therapy standard, which includes a framework that has been used as the starting point for this initial development work.. With respect to hospital-based cancer services, any hospital providing these services must have the clinical expertise and infrastructure needed to comply with a growing set of cancer related evidence-based clinical practices, guidelines and standards; performance targets and operational requirements. The goal is have cancer services delivered as close to patients communities as practical provided that standards of related to operational capacity and quality of care can be maintained. Because of the size of the LHIN s community hospitals, there needs to be careful consideration to developing and sustaining the needed clinical expertise and infrastructure in selected sites across the LHIN. 8

10 Hospital-Based Distributed Service Model Distribution Model s Components To date the distribution model incorporates three components that are summarized below. 1. Hospital Categories. Because of the range of clinical and operational capacity, across the region s hospitals, a schema for categorizing hospitals has been drafted to define criteria for differentiating the services provided. The proposed hospital categories are defined on the right hand side of this page. 2. Service Distribution by Category This component provides a means of categorizing how chronic disease patient care services are distributed across the hospital categories. 3. Program Elements by Category This component provides a means of categorizing the clinical, operational and administrative capacity needed by hospital category. 4. etwork Map The network map presents the geographic distribution of the hospitals participating in the regional cancer system along with their category designation and primary patient flows. Service Distribution by Category The draft cancer service distribution by hospital category is illustrated in Table 1 {page 10} which describes how hospital-based cancer services may be distributed across the range of hospital categories. The generic pattern is that the breadth of care services, scope of cancer disease types, and sophistication of care provided vary across the hospital categories. Program Elements by Category The program elements, required to be present for each category, are illustrated in Table 2 {pages 11,12}. This provides a framework for defining the range and sophistication of the clinical, operational and administrative capability required for each hospital category. 9 Hospital Categories The concept of hospital categories has arisen from the recognition that not every hospital can be expected to provided a full range of specialized hospital-based services for any specific chronic disease, especially outside a large urban centre. Note that a site could be formed through a partnership of two or more hospitals. Level 1: Regional Centre A hospital that functions as the regional centre and is home for the largest group of specialists (for a specific chronic disease) within the region. For the South West LHIN this is usually the London Hospitals. Level 2: Area Centre A community hospital that has sufficient hospital capacity and healthcare professional expertise on staff, to be able to provide a wide range of healthcare services associated with a specific chronic disease. Such a hospital may act as an area centre, and would have a close working relation with the Level 1 Centre. Level 3: Affiliate Site A community hospital which has the capacity and healthcare professional expertise to offer a defined set of healthcare services associated with a specific chronic disease. The range of services may be more limited than for a Level 2 Area Centre, and would work in partnership its closest Level 2 Centre as well as with the Level 1 Regional Centre to ensure patients have access to a broad range of hospital-based healthcare services. Level 4: Satellite Site A community hospital which offers a limited range of services associated with a specific chronic disease. The purpose is to ensure that routine and frequently used services are available a close to home as possible. It would be partnered with the closest Level 2 Area Centre and/or Level 1 Regional Centre. Level 5: Basic Site A community hospital that provides little if any specialized care with respect to a specific chronic disease. The role is to provide basic care and support (particularly urgent/emergent care) to patients who have chronic diseases.

11 Table 1: Hospital-Based Service Distribution by Category Cancer Service Components Level 1: Regional Centre Level 2: Area Centre Level 3: Affiliate Site Level 4: Satellite Site Level 5: Basic Site Screening Services Manages and participates in all screening services. Participates in all screening services. Participating in screening programs is desired, but optional. Participating in screening programs optional. Participating in screening programs optional. Assessment & Diagnostic Services Full range of cancer assessment & diagnostic services Provides selected range of cancer assessment and diagnostic services. Refers to Level 1 when appropriate. May have limited set of basic assessment and diagnostic services. Likely to refer to Level 2 or 1as appropriate. Basic cancer assessment & diagnostic services are optional. Expected to refer to Level 2 or 1as appropriate. No cancer assessment & diagnostic service necessary. Expected to refer to Level 2 or 1as appropriate. Treatment Services Full range of cancer treatment services across broad range of cancer types. May refer to another Level 1. Cancer surgery and systemic therapy for defined set of cancer types. Has a CCO Cancer Surgery Agreement. Provides pre & post treatment care. Cancer surgery and may provide systemic therapy for limited set of cancer types. Has a CCO Cancer Surgery Agreement. Provides pre & post treatment care. Provides limited systemic therapy. No formal cancer surgery program. Provides pre & post treatment care. May provide pre & post treatment care. Pre/Post Treatment, Supportive, Symptom Management & Palliative Services Full range of specialized services available to all cancer patients. Includes complex pre & post treatment care, symptom management & palliative care. Full range of services, for patients available in the hospital or local community. Can provide pre/post treatment care for most patients treated at Level 1. Core range of services available in hospital or local community. Able to provide routine pre/post treatment care. Essential range of services available in hospital or local community to be able to provide routine pre/post treatment care as well as basic supportive & palliative care. Services not required to be available within the hospital other than for emergent/urgent care. Cancer Specialization Provides a full range of cancer services across all of the recognized cancer disease sites. Provides full range of services for the high volume and less complex cancer types. Patients go to Level 1 for radiation therapy and for complex treatment. Provides specified set of services for the high volume and less complex cancer types. Provides pre and post treatment care for patients from catchment area. Provides specific screening and systemic therapy treatment along with selected pre and post treatment care for patients from catchment area. Unscheduled urgent / emergent pain and symptom management care for patients from catchment area. Limited pre & post treatment care. 10

12 Table 2: Program Elements Program Elements Level 1: Regional Centre Level 2: Area Centre Level 3: Affiliate Site Level 4: Satellite Site Level 5: Basic Site 1. Health Providers Sub-specialized medical, radiation and surgical oncologists who are primarily academic oncologists who also teach and/or conduct research. Oncology nursing & pharmacy expertise and teaching. Advanced oncology nurses. May have medical and/or surgical oncologists on site. Physicians, nurses & pharmacists, caring for cancer patients, have oncology training. Specialized oncologist support available remotely. Physicians, nurses & pharmacists, caring for cancer patients, have some oncology training. Oncologist support available remotely. General surgeons perform cancer surgeries regularly (part-time basis). If applicable, systemic therapy supervised onsite by MD (nononcologist) with some cancer training, Staffed by nurses with appropriate cancer care training. Remote medical, radiation and surgical oncologist consults. Staff capable of handling pain and symptom management, for cancer patients, on an emergent/ urgent care basis. Access to specialists as needed. 2. Education of Health Providers Ongoing cancer related professional education for all providers. Participation in regional Multi-Disciplinary Case Conferences (MCCs). Ongoing cancer related professional education for appropriate staff. Participation in MCCs. Periodic cancer related professional education for appropriate staff. Participation in MCCs. Periodic cancer related professional education for appropriate staff. Participation in MCCs. Periodic professional development for emergent / urgent care staff. 3. Service Type and Complexity Investigational new drugs (phase I/II) Highly developed clinical trials infrastructure Complex concurrent chemotherapy and radiotherapy Full range of cancer services. First dose high risk drugs, and moderate to high risk systemic therapy. Treatment Planning onsite. Surgical oncology for commonly occurring cancers. Pre and post care services. Low to medium risk systemic therapy under remote supervision by medical oncologist. Specific cancer surgery services. Specific pre and post care services. Drugs in formulary needed for systemic therapy and urgent/ emergent care. Low risk systemic therapy if applicable. Limited pre and post care services. Drugs in formulary needed for systemic therapy and urgent/ emergent care. Limited screening service. Limited pre and post treatment care. Drugs in formulary needed for urgent/ emergent care. 11

13 Table 2: Program Elements (Continued) Program Elements Level 1: Regional Centre Level 2: Area Centre Level 3: Affiliate Site Level 4: Satellite Site Level 5: Basic Site 4. Quality Assurance and Safety Full cancer patient safety & QA programs. Documented protocols for all diagnostic and treatment practices. Lead & contribute cases to all MCCs. Cancer patient safety program & QA program. Documented protocols for all diagnostic and treatment practices. Participate in and submit cases to appropriate MCCs. Same as Level 2. Same as Level 2. Participation in appropriate MCCs is optional. 5. Facility Requirements Ambulatory and inpatient hospital services needed to support complex and high risk cases. Radiation therapy services on site. Diagnostic & pathology services onsite. Dedicated clinical trials infrastructure onsite. Ambulatory and inpatient hospital services needed to support assigned types of cancer cases treated or cared for on site. Access to diagnostic & pathology services. 24 hr. Emergency Services equipped to support cancer patients. Ambulatory and inpatient hospital services needed to support assigned types of cancer cases treated or cared for on site. Access to diagnostic & pathology services. Emergent/Urgent Services equipped to support cancer patients. Ambulatory hospital services needed to support assigned types of cancer cases treated on site. Access to diagnostic & pathology services. Emergent/ Urgent Services equipped to support cancer patients. Emergent / Urgent Services equipped to support cancer patients 6. Administration and Organizational Responsibilities Fully equipped with Cancer related clinical information systems needed by all services. Regional cancer program administrative centre. Admin leads for regional cancer program Uses CPOE system for systemic therapy & clinical information systems. Have a designated site MD and an administrative lead for cancer services. Same as Level 2. Same as Level 2. Designated cancer services contact. 12

14 Regional Distributed Service Hospital Network Developing a Hospital Network The final component is to develop a hospital network map that identifies the participating hospitals, their level designation and the major working relationships among the participating hospitals. An initial, incomplete draft of such a Regional Hospital Network is presented in Figure 6 {page 14}). This model presents a conceptual network. A complete network would identify the specific hospital sites and the associated level. Identification of the most likely hospital candidates, for each level, has not been done to date. Designating Hospital Sites The expectation is that a regional cancer services hospital network map would be developed through the application of the proposed Hospital Categories and Program Elements as criteria for selecting suitable sites. In addition consideration needs to be given to the geographic distribution of site locations with the goal of distributing services across the entire LHIN in a way that meets quality standards, is practical and minimizes travel time for patients. A site could be selected in part, because of its location and ability to provide services along the boundary of a neighbouring LHIN. A key factor is expected to be the ability to develop the capability, at designated sites, to bundle the provision of two or more chronic disease care programs in order to achieve a sustainable number of medical and other healthcare specialists at a given location. Observations The experience to date, with the, leads to the following set of initial observations. 13 The Northern Area {Grey, Bruce} is sufficiently far away from London, to justify the development of a strong Northern Area Network that can meet the routine and some specialized needs of patients with one or more chronic disease. It is assumed that this would include at least one Level 2 Area Centre as well as a mix of Level 3, 4 and 5 sites. The Central Area (Huron, Perth) would probably benefit from the development of at least one Level 2 Area Centre plus a mix of Level 3, 4 and 5 sites. In the Southern Area, London would serve as the Level 1 Regional Centre. However, at least one Level 2 Centre may be needed given: a) the concentration of population in this area, b) the breadth of LHIN2 in the south, and c) the limited healthcare capacity along the LHIN 1& 2 boundary as well as the LHIN 2 & 4 boundary. In addition there should be a mix of Level 3, 4/5 sites. Note that the St. Joseph s Hospital and the University Hospital are currently de-facto level 3 cancer sites based on the current range of cancer services provided. In both cases there is some screening and diagnostic services along with cancer surgery. Next Step It is evident from the various frameworks and models that a significant amount of work is required to develop a comprehensive regional chronic disease management system architecture. The next step will be to continue to develop how cancer services should fit within a broader regional chronic disease management framework.

15 Figure 6: Preliminary Regional Cancer Network Map Northern Area Level 3, 4, 5 Sites Northern Area Level 2 Centre(s) Central Area Level 3, 4, 5 Sites Central Area Level 2 Centre(s) Level 1 Regional Centre Southern Area Level 3, 4, 5 Sites Southern Area Level 2 Centre(s) 14 The double ended solid arrows portray the likely flow of many patients within each area of the LHIN. The dotted arrows portray the alternative patient flow pattern directly between Level 3/4/5 sites and the Level 1 Centre which occur depending on disease type and type of care required.