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The Comprehensive Health Organization – a Practical Solution for an Integrated Health Care System
Volume 6, No. 1
Spring/Printemps 1993
Brief Report
The Comprehensive Health Organization - a Practical Solution for an Integrated Health Care System by Judith R. Meeks
This brief report takes a look at the structure and functions of a new type of health care delivery system, the comprehensive health organization (CHO).The develo nt of such a system, h or shift of focus: none of the activities of a CHO has been part of the training or Canadian health care system. The range of services a CHO would offer, whether CHO or by an outside contractor, the possible risks involved, and who the pot also discussed.
Ce rapport sommaire examine la structure et lesfonctions d’un syst2me de prestations de services de santk d’un nouveau genre, dit d’organisation de mkdecineglobale(OMG). Toutefois,sa mise en place exige de repenser lesysthe duns sa fofalifk ef de se placer duns une foute autre perspective. En efet, aucune des activitks prkconiskes par une OMG nefaif partie intkgrante de laformation ou de l‘expkrience acquise par les prestataires de santk au sein du rkgime canadien. Le rapport passe kgalement en revue la gamme de services qui pourraient hre oflerts duns le cadre de I’OMG, la prestation des services assurke en rkgie ou bien en vertu d’ententes contractuelles, les risques associks i une telle initiative et les intervenants possibles. any challenges are facing the health care system; the introduction of regional planning; reallocation of scarce resources; decentralization or devolution; re-evaluation of roles of health care professionals; case management; and the creation of an integrated health care system. Reshaping the system is vital if it is to be more effective for the next decade. One new delivery system being implemented in the province of Ontario, a Comprehensive Health Organization (CHO), presents opportunities for both its sponsors and the rest of the local health care community to address the challenges on the community’s own terms. In addition, CHOs provide opportunities for health care providers to play in a larger arena than their own organizations by becoming part of a continuum of care. On the other hand, CHOs are not for the faint-hearted. They require sponsors to assume financial risk, negotiate with other providers using real money, consider the costlbenefit of procedures and services, and involve consumers in decision making. None of these activities has been part of the training or experience of providers in the Canadian health care system up to now. By definition, a CHO is: “A non-profit corporation which assumes responsibility for the provision or
M
Gestion des soins de sante
purchase of a range of specified integrated health treatment, promotion and health-related services for a defined population of members; and for the overall quality assurance and evaluation of the health services provided.r r l (p. 1)
A new mindset Although this definition seems simple, the creation of a CHO requires a fundamental shift in mindset. As shown in Figure 1,some of these shifts involve moving from one end of a continuum to the other. Thinking about a CHO involves a reorientation in the way we think about services and, consequently, demands a shift in focus from illness to health. Since a CHO assumes full financial risk for the health care of its clients, the focus soon shifts to the determinants of health such as housing and poverty, to prevention and to the creation of strategies to keep clients on the wellness end of the continuum. Providers and clients alike usually associate organizations/services with a place and often label organizations by site. A CHO will not be a place and is likely to be ”all over town.” Some of its services may be contracted. This requires a shift in thinking from an 49
Sprinflrintemps 1993
organization as a ”place” to an organization as a collection of expertise.” Most health care services (both institutions and agencies) have existed as autonomous units or single entities. A CHO will be a large corporation with divisions. Provider units will be a part of a larger whole. This structure wiU bring new challenges in terms of corporate identity and culture, patient tracking systems, management information systems, and so on. Most health care organizations define themselves as health care providers. A CHO will need to see itself a5 a large corporation responsible for the organization of services. It will make decisions about products and trade-offs. A CHO will be a large paymaster through contract services, direct payroll, or both. Such an organization will have enormous purchasing power and will have salespeople selling equipment and supplies for use across the system. Health care providers focus on episodic care or the portion of care that relates to their expertise. A CHO will require its governors/managers to think in terms of the whole continuum of care required by patients. This will bring a strong interest in keeping the patient on the wellness end of the continuum. Once an organization is responsible for all care, it will soon get very serious about what works and what doesn’t in terms of treatment. It will also become more interested in changing the habits and lifestyles of patients (e.g., diet, exercise) because it is responsible for the financial consequences of those choices. A CHO will require a shift in focus from health care provider to case management. This is a different perspective with a different level of responsibility. A CHO will shift the focus from a medical model to one where all health care professionals are freed to participate consistent with their expertise. Legislative and financial barriers will change and provide opportunities to use all health care professionals wisely. Physicians will be freed to do what they do best and not to be tied into counselling, arranging services and reviewing medications unless this meets their interests. In a CHO, the emphasis by all parties will be on trying to keep the patient at the well end of the continuum. This will be an impetus to change the mindset from treatment to prevention and screening. Finally, there will be a shift from coping with funding barriers to flexibility in treatment modalities based on patients’ needs.
Opportunities and challenges at decision points As can be seen, the creation of a CHO involves many intricate and complex decisions. Most of the decisions required are new to health care administrators and involve a concern for costs and cost effectiveness, advertising for clients, negotiating partnerships, and so on. An understanding of the alternativessurrounding each decision point is required not only of the sponsors, but of other providers interested in becoming associated with the
50
Volume 6, No. 1
Figure 1: Shift in Focus Illness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health Collection of Expertise Place . . . . . . . . . . . . . . . . . . . . . Single Entity . . . . . . . . . . . . Large Corporation with Divisions Episodic Care . . . . . . . . . . . . . . . . . . Continuum of Care Direct Provider . . . . . . . . . . . . . . . . . . Case Management Medical . . . . . . . . . . . . . . . . . .Other Health Professionals Treatment . . . . . . . . . . . . . . . . . . PreventionlScreening Funding Barriers . . . . . . . . Flexibility Based on Patient’s Needs
CHO. The following illustrates the essential components and some of the decisions required. Since the whole health care system is in a state of flux, many of these considerations have applicability to other models of health care delivery. ‘ Range of services A CHO is responsible for providing a full range of services to its clients. What those services should be and how the CHO will organize to serve its clients is perhaps the most crucial determinant of a CHOs success. How would one decide what services should be offered to a specific population? Past records of usage are one source. The Ontario Ministry of Health would like sponsors to use morbidity and mortality data. Although these data are useful to determine treatments and what the current costs of health care have been for this population, it does not follow that this is what the population needs. Legislative, financial and other barriers have made an ideal range of treatment impractical. Some prospective CHOs have conducted a needs-based assessment, believing this area critical to the design of a new system. At a minimum, CHOs should be very knowledgeable about the most common diseases for their population and carefully examine strategies to prevent or combat these diseases at an earlier stage. The social Health Maintenance Organization (HMO) demonstration project in the United States has been in operation since 1985.Social HMOs represent a prepaid vertically integrated system of care for the elderly. They were designed to integrate community-based care and some nursing home care into a managed prepaid Health Maintenance Organization model which already contains acute care and medical services? Some of the United States’ four sites are beginning to explore what they call ”targetability,” meaning the ability to predict based on today’s symptoms what an individual’s health care needs will be four or five years later. Government expects health promotion and prevention services to be an integral part of a CHO. To be most effective,these should be targeted specifically toward prevention or delay of diseases known to have a high incidence in the prospective CHO population. Healthcare Management FORUM
Volume 6,No.1
A third important component of the range of services to be delivered is how far to go on the community-based and social services end of the continuum. Although the Ontario government believes that community-based services provide more effective and less costly care, and it intended to include this range of services as part of the CHO programs and services, it has had to discontinue this stance due to the inadequacy of its own data base. Make or buy Although CHOs are responsible for the provision of a continuum of health care services, they have the choice to ”make or buy” those services. How would a CHO decide whether to provide all services itself or to contract with other agencies? And, what questions would provide answers to help the decision-making process? One of the questions would be about identity, culture and standards of care. A CHO would want to develop its own identity in order to attract and maintain clients. It should make a conscious decision about its culture, which would be evident in attitudes toward customer service. An explicit standard of care would be essential for the CHO to ensure good care, to be cost effective and to satisfy its board and clients. How would a CHO maintain its identity, culture and standard of care if services were provided through contracts with other agencies?To date, the health care industry has not been experienced in writing standards of care and holding other agencies and providers accountable for them. A second question would be about cost effectiveness. Would it be more costly to make or buy the service? In the U.S. demonstration project, some sites chose to contract a service because prospective providers would bid against each other and drive the price down hardly a factor in the Canadian system. Some of the important factors in this country might be duplication, critical mass or variation in demand for the service. If the volume of service varies, it might be more efficient to contract the service than to deal with fluctuating numbers of full-time employees. If the service is being done well by a provider with a large volume of clients, it might be imprudent to not contract the service. On the other hand, if the CHO forms only a small portion of the other agency’s business, it would be difficult to influence it to meet conditions important to the CHO (e.g.,standard practice, standardized reporting). Another question would be about incentives the CHO might offer other agencies to undertake a contract? Some of these might be an increased volume of service, improved reporting/statistical information, a predictable volume of clients, predictable revenue or sharing surplus funds. Roles for health care professionals CHOs afford the opportunity to reassess the roles played by health care professionals. Many of the
Gestion des soins de santi2
Sprinflrintemps 1993
current roles are determined by legislative and financial incentives or barriers set down by the provincial governments. For example, in Ontario, home visits must be made by an RN, even if the function could be performed by an RNA. Within a CHO, more choices would be possible as to whether physicians or pharmacists reviewed or explained medications for office visits and whether physicians or other health care professionals provided counselling.Physicians would not have to explore and explain home care and other options, because a case manager could assume this role. Any appropriate health care worker could be used in a home setting. This flexibility would allow the CHO to redesign work patterns and roles to meet the experience and interests of its provider members and to provide care cost effectively. Utilization tied to costs Providers in the Canadian health care system seldom consider cost/benefit when developing treatment plans. Since the CHO must organize and provide the services needed by its clients within a fixed budget, cost/ benefit becomes an important component of the decision. While patients will not be abandoned once they exceed the per capita payment limit, the CHO should consider this factor in examining care options. Part of the focus of utilization review should shift from retrospective to prospective. Who would be involved in such decisions, the case manager, the physician? Are data available on the effectiveness of various treatment modalities to develop effective treatment plans? Retrospective utilization review will become an important component in developing the plan for the next year’s services. Information Information is likely to be the strength and the weakness of a CHO. The potential power of a CHO data base is formidable, and information on the health needs and usage patterns of a geographic or age-specific sector of the population will be useful. Currently, even government cannot trace the use of the health care system by an individual, but this will be possible in a CHO. Having such information would enable researchers to trace patterns of health care usage related to specific disease entities and to begin to better predict health care needs. The creation of such a data base will be challenging. Confidentiality is obviously an issue. Who should see what? How is the appropriate information transferred to each health care provider for each appointment (particularly contract services) and how is it returned in a standardized documentation format that is useful? Since the CHO is at risk financially for its operation, the timeliness of information will be essential. Workload productivity indicators will be important components so adjustments can be made to reflect shifts in
51.
Volume 6, No. 1
Sprinflrintemps 1993
workload or show changes in productivity by providers. Having productivity indicators used so directly to determine the need for continued employment will be a new experience for most health care professionals.
Case management Case management is still a new concept in Canada in any setting. In a CHO, the case manager will be required to manage a patient’s care across services that could range from acute care to grocery shopping. Will the case manager schedule all of a client’s appointments, or only receive the information later? Case management costs money. How much is practical? Where will the funding come from?
Governance The governance structure of most CHOs will be formed by partnerships. Fifty percent of the board of a CHO must be actual users of the service. This would provide an opportunity for consumers to plan services to meet local health care needs and to organize services in practical ways. It would also result in changes to the roles of providers, and place a burden on them to educate consumers so they can make informed choices. The other half of the board would be composed of health care providers that have “caught the vision” and want to be full partners in the CHO. They would be part of the normal governance structure and, in addition, they would decide what services will be offered, how such services will be organized and how any surplus funds will be used. C1i ents
Who would want to join a CHO? For the individual the cost of services would remain the same (mostly free), whether “in” or “out.” Access would also be the same, but in a CHO, there would be no need to decipher the maze of services as is the case today. CHOs will likely be attractive to two kinds of clients: those for whom a healthy lifestyle is a priority and who want an organization that emphasizes prevention and can provide an integrated range of services; and those who see themselves needing several health care services and who want an integrated network of services and a case manager to assist them in managing their care needs. Responsibility for one’s lifestyle choices has never been part of the Canadian system (except in a small way for smokers in the life insurance industry). Even in a CHO, a consumer can continue to choose to make unhealthy lifestyle choices or to not follow treatment regimes and the CHO has no option but to continue to incur the costs for this person. Education and influence are the only tools available to the CHO in such circumstances.
52
Marketing Unless the CHO involves a whole geographic community, it will need to market its services. Advertising health care services is not part of the Canadian health care system now. Do we have the expertise to do it? How will consumers react?
Incentives and risks In light of the above, why would an organization/community want to become a CHO? As mentioned earlier, the organization is at full financial risk. Some of the partners or contracted services may not make the shift to the new mindset and may hamper the process with traditional thinking. Cost must be a part of every decision. The data base must be accurate, comprehensive and provide timely information so that adjustments in service levels and staffing patterns can be ongoing. What are the incentives for individuals and organizations to become involved in CHOs? They will have the opportunity to: design and participate in a truly integrated system of care where the needs of clients are assessed and appropriately managed across the whole range of services; design a complete range of services for one’s own community that meets the needs based on its demographics and morbidity data; participate in designing and governing a system that makes sense to them; allow health care professionals to concentrate on the skills for which they were trained; use any surplus funds for additional programs that meet needs identified by consumers rather than government priorities; and work with a powerful data base that can track services required by disease progression and the efficacy of health promotion and prevention. The development of a CHO requires a new mindset, new work patterns and new partnerships. A CHO is one model for bringing an effective new health care system to reality.
References and notes 1. CHO Descriptive Document. Ontario Ministry of Health, Community Health Branch, CHO Program.
2. Leutz, Walter N., et al. 1985.Changing Health Carefor an Aging Society: Planningfor the Social Health h4aintenance Organization.Toronto: Lexington Books.
Judith R. Meeks, DBA, is President, St. Peter’s Hospital, Hamilton, Ontario. This report w a s the result of a travel award competition for study purposes sponsored by Peat M a m i c k Stevenson and Kellogg and presented under the auspices of the C.C.H.S.E. in 1990. Healthcare Management FORUM
Spring/Printemps 1993
Brief Report
The Comprehensive Health Organization - a Practical Solution for an Integrated Health Care System by Judith R. Meeks
This brief report takes a look at the structure and functions of a new type of health care delivery system, the comprehensive health organization (CHO).The develo nt of such a system, h or shift of focus: none of the activities of a CHO has been part of the training or Canadian health care system. The range of services a CHO would offer, whether CHO or by an outside contractor, the possible risks involved, and who the pot also discussed.
Ce rapport sommaire examine la structure et lesfonctions d’un syst2me de prestations de services de santk d’un nouveau genre, dit d’organisation de mkdecineglobale(OMG). Toutefois,sa mise en place exige de repenser lesysthe duns sa fofalifk ef de se placer duns une foute autre perspective. En efet, aucune des activitks prkconiskes par une OMG nefaif partie intkgrante de laformation ou de l‘expkrience acquise par les prestataires de santk au sein du rkgime canadien. Le rapport passe kgalement en revue la gamme de services qui pourraient hre oflerts duns le cadre de I’OMG, la prestation des services assurke en rkgie ou bien en vertu d’ententes contractuelles, les risques associks i une telle initiative et les intervenants possibles. any challenges are facing the health care system; the introduction of regional planning; reallocation of scarce resources; decentralization or devolution; re-evaluation of roles of health care professionals; case management; and the creation of an integrated health care system. Reshaping the system is vital if it is to be more effective for the next decade. One new delivery system being implemented in the province of Ontario, a Comprehensive Health Organization (CHO), presents opportunities for both its sponsors and the rest of the local health care community to address the challenges on the community’s own terms. In addition, CHOs provide opportunities for health care providers to play in a larger arena than their own organizations by becoming part of a continuum of care. On the other hand, CHOs are not for the faint-hearted. They require sponsors to assume financial risk, negotiate with other providers using real money, consider the costlbenefit of procedures and services, and involve consumers in decision making. None of these activities has been part of the training or experience of providers in the Canadian health care system up to now. By definition, a CHO is: “A non-profit corporation which assumes responsibility for the provision or
M
Gestion des soins de sante
purchase of a range of specified integrated health treatment, promotion and health-related services for a defined population of members; and for the overall quality assurance and evaluation of the health services provided.r r l (p. 1)
A new mindset Although this definition seems simple, the creation of a CHO requires a fundamental shift in mindset. As shown in Figure 1,some of these shifts involve moving from one end of a continuum to the other. Thinking about a CHO involves a reorientation in the way we think about services and, consequently, demands a shift in focus from illness to health. Since a CHO assumes full financial risk for the health care of its clients, the focus soon shifts to the determinants of health such as housing and poverty, to prevention and to the creation of strategies to keep clients on the wellness end of the continuum. Providers and clients alike usually associate organizations/services with a place and often label organizations by site. A CHO will not be a place and is likely to be ”all over town.” Some of its services may be contracted. This requires a shift in thinking from an 49
Sprinflrintemps 1993
organization as a ”place” to an organization as a collection of expertise.” Most health care services (both institutions and agencies) have existed as autonomous units or single entities. A CHO will be a large corporation with divisions. Provider units will be a part of a larger whole. This structure wiU bring new challenges in terms of corporate identity and culture, patient tracking systems, management information systems, and so on. Most health care organizations define themselves as health care providers. A CHO will need to see itself a5 a large corporation responsible for the organization of services. It will make decisions about products and trade-offs. A CHO will be a large paymaster through contract services, direct payroll, or both. Such an organization will have enormous purchasing power and will have salespeople selling equipment and supplies for use across the system. Health care providers focus on episodic care or the portion of care that relates to their expertise. A CHO will require its governors/managers to think in terms of the whole continuum of care required by patients. This will bring a strong interest in keeping the patient on the wellness end of the continuum. Once an organization is responsible for all care, it will soon get very serious about what works and what doesn’t in terms of treatment. It will also become more interested in changing the habits and lifestyles of patients (e.g., diet, exercise) because it is responsible for the financial consequences of those choices. A CHO will require a shift in focus from health care provider to case management. This is a different perspective with a different level of responsibility. A CHO will shift the focus from a medical model to one where all health care professionals are freed to participate consistent with their expertise. Legislative and financial barriers will change and provide opportunities to use all health care professionals wisely. Physicians will be freed to do what they do best and not to be tied into counselling, arranging services and reviewing medications unless this meets their interests. In a CHO, the emphasis by all parties will be on trying to keep the patient at the well end of the continuum. This will be an impetus to change the mindset from treatment to prevention and screening. Finally, there will be a shift from coping with funding barriers to flexibility in treatment modalities based on patients’ needs.
Opportunities and challenges at decision points As can be seen, the creation of a CHO involves many intricate and complex decisions. Most of the decisions required are new to health care administrators and involve a concern for costs and cost effectiveness, advertising for clients, negotiating partnerships, and so on. An understanding of the alternativessurrounding each decision point is required not only of the sponsors, but of other providers interested in becoming associated with the
50
Volume 6, No. 1
Figure 1: Shift in Focus Illness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health Collection of Expertise Place . . . . . . . . . . . . . . . . . . . . . Single Entity . . . . . . . . . . . . Large Corporation with Divisions Episodic Care . . . . . . . . . . . . . . . . . . Continuum of Care Direct Provider . . . . . . . . . . . . . . . . . . Case Management Medical . . . . . . . . . . . . . . . . . .Other Health Professionals Treatment . . . . . . . . . . . . . . . . . . PreventionlScreening Funding Barriers . . . . . . . . Flexibility Based on Patient’s Needs
CHO. The following illustrates the essential components and some of the decisions required. Since the whole health care system is in a state of flux, many of these considerations have applicability to other models of health care delivery. ‘ Range of services A CHO is responsible for providing a full range of services to its clients. What those services should be and how the CHO will organize to serve its clients is perhaps the most crucial determinant of a CHOs success. How would one decide what services should be offered to a specific population? Past records of usage are one source. The Ontario Ministry of Health would like sponsors to use morbidity and mortality data. Although these data are useful to determine treatments and what the current costs of health care have been for this population, it does not follow that this is what the population needs. Legislative, financial and other barriers have made an ideal range of treatment impractical. Some prospective CHOs have conducted a needs-based assessment, believing this area critical to the design of a new system. At a minimum, CHOs should be very knowledgeable about the most common diseases for their population and carefully examine strategies to prevent or combat these diseases at an earlier stage. The social Health Maintenance Organization (HMO) demonstration project in the United States has been in operation since 1985.Social HMOs represent a prepaid vertically integrated system of care for the elderly. They were designed to integrate community-based care and some nursing home care into a managed prepaid Health Maintenance Organization model which already contains acute care and medical services? Some of the United States’ four sites are beginning to explore what they call ”targetability,” meaning the ability to predict based on today’s symptoms what an individual’s health care needs will be four or five years later. Government expects health promotion and prevention services to be an integral part of a CHO. To be most effective,these should be targeted specifically toward prevention or delay of diseases known to have a high incidence in the prospective CHO population. Healthcare Management FORUM
Volume 6,No.1
A third important component of the range of services to be delivered is how far to go on the community-based and social services end of the continuum. Although the Ontario government believes that community-based services provide more effective and less costly care, and it intended to include this range of services as part of the CHO programs and services, it has had to discontinue this stance due to the inadequacy of its own data base. Make or buy Although CHOs are responsible for the provision of a continuum of health care services, they have the choice to ”make or buy” those services. How would a CHO decide whether to provide all services itself or to contract with other agencies? And, what questions would provide answers to help the decision-making process? One of the questions would be about identity, culture and standards of care. A CHO would want to develop its own identity in order to attract and maintain clients. It should make a conscious decision about its culture, which would be evident in attitudes toward customer service. An explicit standard of care would be essential for the CHO to ensure good care, to be cost effective and to satisfy its board and clients. How would a CHO maintain its identity, culture and standard of care if services were provided through contracts with other agencies?To date, the health care industry has not been experienced in writing standards of care and holding other agencies and providers accountable for them. A second question would be about cost effectiveness. Would it be more costly to make or buy the service? In the U.S. demonstration project, some sites chose to contract a service because prospective providers would bid against each other and drive the price down hardly a factor in the Canadian system. Some of the important factors in this country might be duplication, critical mass or variation in demand for the service. If the volume of service varies, it might be more efficient to contract the service than to deal with fluctuating numbers of full-time employees. If the service is being done well by a provider with a large volume of clients, it might be imprudent to not contract the service. On the other hand, if the CHO forms only a small portion of the other agency’s business, it would be difficult to influence it to meet conditions important to the CHO (e.g.,standard practice, standardized reporting). Another question would be about incentives the CHO might offer other agencies to undertake a contract? Some of these might be an increased volume of service, improved reporting/statistical information, a predictable volume of clients, predictable revenue or sharing surplus funds. Roles for health care professionals CHOs afford the opportunity to reassess the roles played by health care professionals. Many of the
Gestion des soins de santi2
Sprinflrintemps 1993
current roles are determined by legislative and financial incentives or barriers set down by the provincial governments. For example, in Ontario, home visits must be made by an RN, even if the function could be performed by an RNA. Within a CHO, more choices would be possible as to whether physicians or pharmacists reviewed or explained medications for office visits and whether physicians or other health care professionals provided counselling.Physicians would not have to explore and explain home care and other options, because a case manager could assume this role. Any appropriate health care worker could be used in a home setting. This flexibility would allow the CHO to redesign work patterns and roles to meet the experience and interests of its provider members and to provide care cost effectively. Utilization tied to costs Providers in the Canadian health care system seldom consider cost/benefit when developing treatment plans. Since the CHO must organize and provide the services needed by its clients within a fixed budget, cost/ benefit becomes an important component of the decision. While patients will not be abandoned once they exceed the per capita payment limit, the CHO should consider this factor in examining care options. Part of the focus of utilization review should shift from retrospective to prospective. Who would be involved in such decisions, the case manager, the physician? Are data available on the effectiveness of various treatment modalities to develop effective treatment plans? Retrospective utilization review will become an important component in developing the plan for the next year’s services. Information Information is likely to be the strength and the weakness of a CHO. The potential power of a CHO data base is formidable, and information on the health needs and usage patterns of a geographic or age-specific sector of the population will be useful. Currently, even government cannot trace the use of the health care system by an individual, but this will be possible in a CHO. Having such information would enable researchers to trace patterns of health care usage related to specific disease entities and to begin to better predict health care needs. The creation of such a data base will be challenging. Confidentiality is obviously an issue. Who should see what? How is the appropriate information transferred to each health care provider for each appointment (particularly contract services) and how is it returned in a standardized documentation format that is useful? Since the CHO is at risk financially for its operation, the timeliness of information will be essential. Workload productivity indicators will be important components so adjustments can be made to reflect shifts in
51.
Volume 6, No. 1
Sprinflrintemps 1993
workload or show changes in productivity by providers. Having productivity indicators used so directly to determine the need for continued employment will be a new experience for most health care professionals.
Case management Case management is still a new concept in Canada in any setting. In a CHO, the case manager will be required to manage a patient’s care across services that could range from acute care to grocery shopping. Will the case manager schedule all of a client’s appointments, or only receive the information later? Case management costs money. How much is practical? Where will the funding come from?
Governance The governance structure of most CHOs will be formed by partnerships. Fifty percent of the board of a CHO must be actual users of the service. This would provide an opportunity for consumers to plan services to meet local health care needs and to organize services in practical ways. It would also result in changes to the roles of providers, and place a burden on them to educate consumers so they can make informed choices. The other half of the board would be composed of health care providers that have “caught the vision” and want to be full partners in the CHO. They would be part of the normal governance structure and, in addition, they would decide what services will be offered, how such services will be organized and how any surplus funds will be used. C1i ents
Who would want to join a CHO? For the individual the cost of services would remain the same (mostly free), whether “in” or “out.” Access would also be the same, but in a CHO, there would be no need to decipher the maze of services as is the case today. CHOs will likely be attractive to two kinds of clients: those for whom a healthy lifestyle is a priority and who want an organization that emphasizes prevention and can provide an integrated range of services; and those who see themselves needing several health care services and who want an integrated network of services and a case manager to assist them in managing their care needs. Responsibility for one’s lifestyle choices has never been part of the Canadian system (except in a small way for smokers in the life insurance industry). Even in a CHO, a consumer can continue to choose to make unhealthy lifestyle choices or to not follow treatment regimes and the CHO has no option but to continue to incur the costs for this person. Education and influence are the only tools available to the CHO in such circumstances.
52
Marketing Unless the CHO involves a whole geographic community, it will need to market its services. Advertising health care services is not part of the Canadian health care system now. Do we have the expertise to do it? How will consumers react?
Incentives and risks In light of the above, why would an organization/community want to become a CHO? As mentioned earlier, the organization is at full financial risk. Some of the partners or contracted services may not make the shift to the new mindset and may hamper the process with traditional thinking. Cost must be a part of every decision. The data base must be accurate, comprehensive and provide timely information so that adjustments in service levels and staffing patterns can be ongoing. What are the incentives for individuals and organizations to become involved in CHOs? They will have the opportunity to: design and participate in a truly integrated system of care where the needs of clients are assessed and appropriately managed across the whole range of services; design a complete range of services for one’s own community that meets the needs based on its demographics and morbidity data; participate in designing and governing a system that makes sense to them; allow health care professionals to concentrate on the skills for which they were trained; use any surplus funds for additional programs that meet needs identified by consumers rather than government priorities; and work with a powerful data base that can track services required by disease progression and the efficacy of health promotion and prevention. The development of a CHO requires a new mindset, new work patterns and new partnerships. A CHO is one model for bringing an effective new health care system to reality.
References and notes 1. CHO Descriptive Document. Ontario Ministry of Health, Community Health Branch, CHO Program.
2. Leutz, Walter N., et al. 1985.Changing Health Carefor an Aging Society: Planningfor the Social Health h4aintenance Organization.Toronto: Lexington Books.
Judith R. Meeks, DBA, is President, St. Peter’s Hospital, Hamilton, Ontario. This report w a s the result of a travel award competition for study purposes sponsored by Peat M a m i c k Stevenson and Kellogg and presented under the auspices of the C.C.H.S.E. in 1990. Healthcare Management FORUM