Integrated care is founded on the principle of inter-organizational teamwork and collaboration, where groups of people are designing and implementing a set of interrelated initiatives to shift the health system towards a shared purpose. That is, ensuring that there are the necessary elements in place to eventually allow the AOHT to operate under a single clinical and fiscal accountability framework to meet all the care needs for its attributed population.
Leadership, Accountability, and Governance
Work in leadership, accountability, and governance ensures organizational alignment with the AOHT at the highest level of each partner organization – enabling and supporting change. This is being accomplished by the creation of the Leadership Council, which is facilitated by the AOHT Transformation Office, and works across all AOHT partners to develop a strategy and mobilize resources to operationalize the plan. By the end of the first year of operations, the AOHT is responsible for establishing its first Strategic Plan starting in 2022 that leverages its integrated leadership and governance structure.
Digital health initiatives are primarily about providing better information and access for patients through digital tools – and they underpin the patient experience. Objectives of this working group include growing virtual care options, online appointment booking, and digital access for patients, as well as finding connection tools, data integration, and predictive analytics for providers. As part of the first year of operations, the AOHT will be undertaking a Harmonized Information Management Plan and identifying the initial areas of focus for digital health, whether that’s managing community referrals or supporting scheduling and workflow across organizations.
Performance Measurement, Quality Improvement, and Continuous Learning
Quality improvement is all about delivering the best possible care and achieving the best possible outcomes for people every time they deal with the health system or use its services. The AOHT has created a Quality Improvement Committee that is providing active expert guidance on design, execution, measurement, monitoring, sustainability, and spread of initiatives. The Committee is responsible for establishing a Community of Practice to help provide a forum for rapid improvement and laying the foundation for a joint Collaborative Quality Improvement Plan (cQIP) across partners.
An important component of integrated care is performance measurement – setting goals and measuring what matters to support rapid improvement and learning. As part of our first year of operations, we’ll be putting in place a performance measurement dashboard to support improvement both at the project level and across the AOHT.
We've chosen three overarching indicators to guide our work:
Proportion of patients who are contacted by their primary care provider within 7 days of discharge from the hospital
Number of visits to the Emergency Department with a main problem that is “better served in the community”
Median wait time for community care
Increasing this measure will ensure that patients are receiving well-rounded and continuous care from providers.
Improving and shifting care for chronic conditions into the community will reduce the number of visits to the Emergency Department, both improving the patient experience and reducing traffic at the hospital.
Improving efficiency and health system infrastructure will reduce the wait time for community care options.