Bridging silos: Delivering integrated care to patients with cancer in Ontario, Canada

The “silo” metaphor is one of the most pervasive in healthcare. A staple of the farming industry, silos are storage structures that tower over fields keeping crops such as corn and wheat separated, protected, and dry. These vertical structures standing side-by-side, but sealed from each other, are often compared to healthcare specialties, processes, units, organizations, and sectors that operate largely in isolation of one another. Silos of care are problematic for patients with complex healthcare needs such as those with cancer. Frequent hand-offs between professionals and transitions across care settings can lead to inconsistent patient monitoring, repeated tests, delayed diagnoses, medication errors, and dissatisfied patients.1, 2 International efforts to bridge these silos and improve quality of care abound, from Accountable Care Organizations in the United States3 and Health Links in Canada4 to Chains of Care in Sweden5 and the Pioneer Program in England.6 These initiatives are united by a common goal: to deliver care that is integrated across professionals and settings over time. Integrated care initiatives such as these have demonstrated a range of positive effects including reduced emergency department (ED) visits, lower institutional costs, higher patient satisfaction and quality of life, increased guideline adherence, and improved health outcomes.7-9 Delivering integrated care to patients involves four essential components: (1) Coordination and collaboration across professionals and organizations; (2) continuous relationships with patients and families over time and place; (3) patient- and family-centred care that is tailored to their needs and preferences; and (4) shared accountability for optimizing health among the patient, family, and care teams.10 As this definition suggests, integrated care is a complex, multi-dimensional endeavour that involves substantial changes to traditional clinical practice. Integrated care initiatives can involve the establishment of co-located or virtual inter-professional teams, care coordinators or navigators, clinical pathways, linked electronic information systems, arrangements for clinical follow-up, and/or patient self-management support.7 The literature emphasizes the importance of cultivating organizational and policy contexts that support and enable the clinical changes required for integrated care delivery.8, 11-13 Scholars also reiterate variants of the common refrain, “complex problems need complex solutions.”14, 15 So how can healthcare systems develop complex multi-level solutions to address the problem of care silos? The 5-year journey of the “Integrated Care Unit” at Cancer Care Ontario provides an illustrative case of what it takes to foster integrated care delivery at a systems level in partnership with managers, professionals, patients, and families. Cancer Care Ontario (CCO) is a government agency in Canada that funds, monitors, and improves cancer and renal services in the province of Ontario. With over 13 million residents, Ontario is Canada's most populous province, accounting for nearly 40% of the country's population.16 Cancer is the leading cause of death in Ontario, and over 90 000 new cancer diagnoses are expected this year.17 With a 1.5 billion dollar budget, CCO has a complex mandate that involves contracting for services with hospitals and providers, measuring and managing performance, deploying information systems, establishing guidelines and standards, and implementing quality improvement initiatives.18 The agency oversees the full continuum of cancer services, including screening, imaging, pathology, diagnostic assessment, systemic treatment, radiation treatment, surgical oncology, psychosocial oncology, and survivorship. CCO funds 13 Regional Cancer Programs (RCPs) across the province. RCPs are networks of hospitals and other agencies involved in cancer care delivery. RCPs are responsible for implementing provincial standards and programmes for cancer care, making sure service providers meet the requirements set out in their partnership agreements with CCO, responding to local programme issues, and working to continually improve the quality of cancer care in their region. Each RCP has a Regional Vice President with accountability to both their host hospital and to CCO. Developing and piloting an integrated model of palliative care was identified as a particular area of focus for two reasons. First, palliative care was consistently identified as a gap through consultations with regional partners. Second, both local and international evidence pointed to inadequate psychosocial support for patients with cancer, weak integration of palliative care with cancer services, and better outcomes among patients receiving palliative care early after diagnosis.2, 23-30 The INTEGRATE Project was launched to address these gaps with funding from the Canadian Partnership Against Cancer. The INTEGRATE Project was a 3-year (2014-2016) pilot project consisting of inter-professional palliative care education and an integrated care model to identify patients with palliative care needs, establish early linkages to community-based resources, and improve communication between professionals involved in patient care. The project was initiated in four cancer centres and four primary care practices in Ontario. A provincial committee comprised of clinicians, allied health practitioners, administrators, and patient and family advisors oversaw the development and implementation of the project. All participants completed Pallium Canada's “Learning Essential Approaches to Palliative and End of Life Care” (LEAP) workshops31 and a trifold decision aid was developed to support providers. Each site was assigned a community care coordinator, who was on site for one half or full day per week to support implementation of INTEGRATE, facilitate patient navigation from the cancer centres into the community, and participate in inter-professional rounding. Participating physicians at primary care practices adopted a disease-agnostic approach in which the Surprise Question was asked for all patients meeting certain criteria, such as over age 75, presence of multiple co-morbidities, and/or a diagnosis of cancer, a neurodegenerative disease, dementia, or organ failure. If the answer to the Surprise Question, “Would you be surprised if this patient were to die within 6-12 months?”, was “no,” a palliative approach to care was initiated, including patient symptom assessment and management, Advance Care Planning (ACP) and Goals of Care (GoC) conversations with the patient and family, referrals to community supportive care, and transmission of a report to patients' primary care physicians to inform them that their patient required a palliative approach to care and to share their care plan. A total of 1054 patients were ultimately identified for early initiation of palliative care using the Surprise Question, 294 in the primary care practices and 760 in the cancer centres, including 25% of all newly diagnosed patients with lung cancer and 100% of patients with glioblastoma. An evaluation of INTEGRATE was conducted using mixed methods, including site-level administrative data, pre- and post-implementation surveys, interviews, and a cost-effectiveness evaluation using a matched cohort.* The results suggest that the project was largely a success. Significant increases were observed from pre- to post-implementation in provider-reported confidence to initiate ACP conversations (29% to 63%, P < 0.001) and use of palliative care tools, such as the Palliative Performance Scale (46% to 72%, P < 0.05). Furthermore, 78% of identified patients had an ACP conversation documented in their medical chart following identification (mean time to discussion was 28 days), and 73% received home and community-based services within 14 days following identification. Among 1185 matched pairs, patients who participated in INTEGRATE received double the number of home care visits in the year following identification at a rate of 67 visits per 360 days versus 33 for the matched control group. Providers reported positive experiences with the model of care. A physician said, “When I first started using the Surprise Question, I was surprised by the power of it.” A hospice provider reflected, “Two years ago we had a lot of late referrals and it was horrible. Now people are coming to us a lot earlier and we are able to give them a better palliative experience.” Providers also identified challenges, including a lack of time to have ACP or GoC discussions, a lack of awareness of available home and community support services, and varying levels of patient readiness for the ACP conversation. Since the conclusion of the pilot, the Integrated Care Unit at CCO has been working with the participating sites to support sustainability, and sharing the results with stakeholders within and beyond Ontario to stimulate learning and spread. Over the past 5 years, CCO has learned 10 key lessons, which corroborate what we know from the literature on integrated care: Clinical leadership and engagement is needed across all elements of the change process. Implementing and managing Context matters: integrated care initiatives must be flexible and encourage tailoring to the local environment. Sustaining The INTEGRATE Project was funded by the Canadian Partnership Against Cancer (CPAC) and supported in kind by Cancer Care Ontario. We would like to thank our partner sites and all participants for contributing to the success of The INTEGRATE Project. The authors have no conflicts of interest to report.

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