Social Policy in Ontario

Introduction

Last week, the Premier’s Council on Improving Healthcare and Ending Hallway Medicine (the “Council”) released its second Report, A Healthy Ontario: Building a Sustainable Health Care System (the “Report” – PDF). This Report was contemplated by the Council’s first report, Hallway Health Care: A System Under Strain (the “First Report” – PDF), which was released earlier this year. The key findings of the First Report were summarized by Fasken in its February 19, 2019 bulletin, Hallway Health Care: A Symptom of Broader Challenges Facing Ontario’s Healthcare System.

In the Report, the Council provides advice to the government to “[…] help the government stay on track to end hallway healthcare and build a sustainable health system”.[1] This advice is responsive to certain of the issues raised by the First Report, including the Council’s finding that Ontario’s health care system is not working to its potential. Among the advice offered by the Council through the Report is a list of 10 recommendations to improve health care (the “Recommendations”). These Recommendations are first presented in the Introduction to the Report, and are further detailed in Chapter 3.

The Recommendations are grouped into the following four categories:

A full list of the Recommendations is included at the end of this bulletin.

This bulletin will focus on the first five Recommendations, which fall into the categories of Integration and Innovation. A subsequent bulletin will focus on Recommendations 6 through 10 together with the other Chapters of the Report, namely, Chapter 1 (We Hear You, Ontario), Chapter 2 (The Vision for Health Care in Ontario), and Chapter 4 (Reporting Progress Throughout the System).

Council’s Recommendations

Chapter 3 begins by reaffirming the Council’s mandate to provide the government with strategic advice regarding the concerns that were identified through its interaction with over 1,500 patients, caregivers, families, health care professionals and organizations across Ontario regarding the future of health care in the province.

The Chapter also identifies numerous objectives of the Recommendations, including to:

• “[…] support a fundamental change in culture and organization of health care service planning and delivery”; and[2]
• “keep the many moving parts and people working together towards one common objective: a better health care system for Ontarians”. [3]

The Council has included a list of “Action Items” for the government in order to give effect to the Recommendations. While a full description of each of the Action Items is outside of the scope of this bulletin, certain of the Action Items for Recommendations 1 through 5 are summarized below.

Recommendations 1 to 3: Integration

As noted above, the Recommendations are divided into four categories, the first being “Integration”. In introducing the integration-related Recommendations, the Council emphasizes the importance of integration, stating,

“A modern, integrated and primary-care driven health care system is a fundamental shift in how the government can help patients and providers navigate the health care system, and will improve patient, provider and caregiver well-being by putting patients at the centre of their health care decisions”.[4]

This category incorporates the first three Recommendations which are said to respond to the question of how health care should be integrated around patients and among providers.

Included among the Action Items for this Recommendation is the suggestion that the government measure patient experience and engagement at each stage of the “health care journey” by gathering and utilizing “Patient Reported Experience Measures (PREMs)”[5] that are both standardized and digital. It is recommended that this measurement occur in partnership with patients and health care providers in order to achieve better results and increase engagement.  One of the benefits of these measurements identified by the Report is that the government will be able to “course-correct” in instances where the PREMs identify issues, thus increasing patient satisfaction with the health care system.

This Recommendation responds, in part, to one of the Council’s key findings set out in the First Report, specifically, that patients and families find it difficult to navigate the health care system.

The latter part of the recommendation, which suggests that electronic access to PHI be improved, is not surprising. For example, while eHealth Ontario maintains an electronic health record (EHR) of patients’ health histories, because not all care providers are connected to the EHR and some types of health information are not included in the record, the health histories of patients contained in the EHR may be incomplete. Moreover, patients are currently unable to access the EHR and must instead, request their PHI that is contained in the EHR from various organizations. For example, requests for clinical and diagnostic records must be made through eHealth, while immunization records must be requested from the patient’s local Public Health Unit.

In summary, the Action Items for this Recommendation suggest that the government:

1. Amend the Province’s health privacy legislation, the Personal Health Information Protection Act, 2004, to broaden access to PHI without compromising the privacy or security of such information.
2. Spearhead the development of a single “digital identity” for all Ontarians in order to permit care providers to access the full health histories of patients.
3. Make the health system easier to navigate through the use of current systems (e.g. Telehealth Ontario) and new innovative technologies.
4. Continue to build on systems that:

• • remove the obstacles that currently impede the sharing of PHI among care providers  and care settings (e.g. between hospitals and primary care physicians); and
  • support communications and referrals among care providers (e.g. such as eConsult or eReferral).

The First Report outlined some of the issues patients are experiencing with primary care in the Province, such as difficulty in accessing their primary care physician (including, on account of wait times) and determining where to go for the appropriate care. Like various government reports before it, the First Report emphasized the negative impact that these issues with primary care are having not only on patients, but the health care system as a whole. For example, the use of hospital emergency rooms for health care that could have been delivered more efficiently (both from a cost and patient outcome perspective) in a care setting outside of the hospital, such as a primary care setting,[6] contributes to over-capacity issues at hospitals.

Examples of the Action Items for this Recommendation include the government:

1. Facilitating communications and relationships between primary care providers and community mental health and addictions services and supports.
2. Collaborating with care providers to ensure that patients, particularly patients with complex needs, are well-connected to the range of health services in the patient’s community.

The Report suggests that integrated care at the local level may be achieved through the new Ontario Health Team model, once established.

Recommendations 4-5: Innovation

The Report indicates that the purpose of Recommendations 4 and 5 is to address:

• The need for health care innovation, in part due to the Province’s aging population and areas of low density.
• The growing demand and opportunity for health care innovation.

The Action Items for this Recommendation focus on expanding patient access to virtual care. In particular, it is suggested that the government:

1. Collaborate with care providers to broaden patient access to “virtual visits” and virtual care.
2. Utilize: (i) legislative and/or policy tools (e.g. by amending Regulation 386/99 to the Home Care and Community Services Act, 1994 to ensure that virtual care vists are caught within the definition of “visits”); and (ii) incentives, to support the growth of virtual care (e.g. delivery of care via telephone calls and internet-based psychotherapy),  both in terms of its availability and use.

Both Action Items recognize the importance of patient choice in delivering health care through innovative solutions.  The Report also emphasizes that virtual visits and technology tools are not intended to supplant the delivery of in-person health care, but rather to complement it.

This Recommendation is intended to, among other things, alleviate capacity issues at hospitals by helping patients access care in alternate settings to hospitals, including in their home and their community.

The Action Items for this Recommendation are divided into two sections:

1. action Items in respect of home care and congregate care; and
2. action Items applicable to long-term care.

Among the Action Items for the Recommendation as it relates to home care and congregate (group) care, is that the government modernize the legislation that applies to home care in the province in a manner which supports innovation in care delivery models including by:

• Relaxing current rules applicable to community care referrals to allow Ontario Health Teams and other groups of providers to more easily make such referrals if deemed appropriate.
• Enabling care coordination and navigation throughout the full continuum of care, rather than narrowly prescribing resources to a limited set of circumstances.”[7]

The Action Item presented for long-term care is for the government to modernize the placement eligibility criteria and rules that apply to access to long-term care beds, with the goal of ensuring that these beds are being appropriately occupied (i.e. by the patients who are most in need of long-term care services).

Conclusions

In terms of Fasken’s next steps, as noted in the Introduction, we will be publishing an additional bulletin on the other aspects of the Report, including the remaining Recommendations (5-10), in the near future.

As for the Council’s next steps, unlike the First Report which specified that a 2^nd report would follow, the Report does not contain any commitment from the Council to deliver any subsequent report(s). However, the Report does contemplate the Council’s continued engagement, through its:

• Provision of advice on long-term capacity planning, Ontario Health, and Ontario Health Teams.
• Search for innovative methods for health care delivery.
• Continued dialogue with the public regarding improvements to the delivery of health care in the Province.

Finally, in addition to watching for our 2^nd bulletin on this topic, your next steps may include  providing the Council with feedback on the Reports and/or the health care system more generally. The Council explicitly encourages continued participation, directing those who wish to submit feedback to email the Council at hallwayhealthcare@ontario.ca.

Complete List of Recommendations

[1] Page 6.

[2] Page 17.

[3] Page 17.

[4] Page 18.

[5] Neither this Report nor the First Report provide any additional information on PREMs. However, patient experience measures have been the topic of previous government reports, including a 2016 report by Health Quality Ontario, Ontario Patient Experience Measurement Strategy (PDF), although it is unclear as to whether PREMs would be similar to the patient experience measurements that are the subject of the foregoing report of Health Quality Ontario.

[6] The First Report refers to a 2018 “Health Care Experience Survey” which revealed that 41% of Ontarians who attended an emergency room, and 93% of Ontarians who attended a walk-in clinic, received care that could have been provided by the patient’s primary care provider. See: Ministry of Health and Long-Term Care. (2018) Health Care Experience Survey (HCES), April 2017 – March 2018 .

[7] Page 26.
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