1

PrimeronCitizenandCommunityWell-beingLiteratureandEvidenceSummary

PreparedfortheWindsor-EssexCollectiveImpactCitizens’TableFebruary2015KeyFindings:• Thehealthofindividualscannotbeunderstoodorimprovedwithoutrecognizingthathumansare

socialbeingsthathaveevolvedtoliveinfamilies,socialgroups,andcommunities.“Community”isthecrucibleformostimportantdeterminantsofhealth,aswellasformanyoftheimportantsocialrelationshipsthataffectwell-beingandmakelifeworthliving.

• Awealthofframeworksandmodelshasbeendevelopedtoexplainhealthsystems.Ourworkinghypothesis:likeprogramsandservices,nomatterhowprofoundasinglemodelis,adherencetoitinisolationwillachieveanisolatedimpact.However,thereiscommongroundwheremultiplemodelsconvergeandcanproductivelycomplimentandfeedintoeachother.

• Ecologicalmodelofhealthandwell-being:Anindividual’sbehavioraffectstheirhealthandwell-beingandisshapedbydynamicinteractionwiththeirsocialandnaturalenvironment,includinginterpersonal,organizational,community,andpolicylevelinfluences.Acommunity’scultureandwell-beingissimilarlyshapedbyitsbroadersocialenvironment.Individualandcommunitybehaviorcannotbealteredwithoutalsochangingprevailingsocialnorms.

• Integratedcommunity-basedhumandevelopmentandhealthpolicyprovidesanimportantnewtheoreticalparadigmthatemphasizestheecological,nested,andinteractiverelationshipbetweenhealth,socialandeconomicenvironmentofcommunities,alongwithintegratedtheoriesofcommunityhealthchangetoguidethedevelopmentofmultilevelprogrammodels.

Selectedliteraturesynthesis

PART1:CAREMODELS

I PersonalizedorPerson-CentredModelsAtulGawande,BeingMortal:MedicineandWhatMattersintheEnd• “We’vebeenwrongaboutwhatourjobisinmedicine.Wethinkourjobistoensurehealthand

survival.Butreallyitislargerthanthat.Itistoenablewell-being.Andwell-beingisaboutthereasonsonewishestobealive.Thosereasonsmatternotjustattheendoflife,orwhendebilitycomes,butallalongtheway.

• Wheneverserioussicknessorinjurystrikesandyourbodyormindbreaksdown,thevitalquestionsarethesame:Whatisyourunderstandingofthesituationanditspotentialoutcomes?Whatareyourfearsandwhatareyourhopes?Whatarethetrade-offsyouarewillingtomakeandnotwillingtomake?Andwhatisthecourseofactionthatbestservesthisunderstanding?”

AnneSnowdonIt’s All About Me: The Personalization of Health Systems (Feb 2014) • Strongtheoreticalbasisfordefiningpersonalization.Salutogenesis(Antonovsky,1980s),defines

healthrelativetowhatmatterstopeople,wheretheultimategoalofhealthcareistoenablehealth

2

asakeydeterminantofqualityoflife.LindstromandEriksson(2011)usetheanalogyof“riveroflife”asapotentialvisionforpersonalizedhealthsystems.Downstream,healthsystemsofferdiseasemanagement,whichislikesavingonefromdrowning.Upstream,healthcareismorecloselyalignedwithpeople’svaluesofhealthandwellnesstoachievequalityoflife.

• 10stepshealthsystemscantaketopersonalizetheirstructures,servicesandcaredeliverymodelstoachieveapersonalizedsystemthatachievesvalueforthepopulationstheyserve:1.Reframetheconversation.2.Redefinesuccessintermsofwhatmatters.3.Putthepersoninchargeofdecisions,nottheprovider.4.Shiftcareprocessesto“OneSizeFitsOne”5.Stopcompetingandstartcollaborating.6.Jointhe21stCenturyandgetconnected.7.Democratizeinformationtoempowerpeopletotakechargeoftheirhealthwellness.8.Learnfromindustryandcustomizehealthcaretotheneeds,expectationsandvaluesofthepopulation.9.Putthepopulationinchargeofdefiningvalue.10.Measurewhatmatters.

Canadian Association for People-Centred Health • Fourkeyprinciplesofpeoplecentredhealthcare:responsibility,autonomy,informedhealth

management,andpartnership.• Apeople-centredhealthsystemdiffersfromtheillness-centredsystemwehaveinplacetoday.Itis

basedonfourprinciplesandthefundamentalbeliefthateachpersonmanagesandisresponsiblefortheirownhealthandwellness.Thepurposeofapeople-centredsupportsystemistoinform,assist,andencourageeachpersonontheirwellnessjourney.People-centredcareiscommittedtosupportingallaspectsofhealth–notjustillnessandemergencycare,butalsoprevention,holisticcare,andwellness.People-centredcaretakeseachpieceofthehealthsystempuzzleandensuresthattheneedsoftheuserscomebeforetheneedsofthesystem.

P4MEDICINEINSTITUTE(LeeHood)http://www.p4mi.org/p4medicine• Theconvergenceofsystemsbiology,thedigitalrevolutionandconsumer-drivenhealthcareis

transformingmedicinefromitscurrentreactivemode,whichisfocusedontreatingdisease,toaP4Medicinemode,whichismedicinethatispredictive,preventive,personalizedandparticipatory.

• P4Medicineistheconvergenceofsystemsmedicine,bigdataandpatient(consumer)drivenhealthcareandsocialnetworks.

3

Anderson’sBehavioralModelofHealthServicesUtilization(1995)• Threecategoriesofpopulationcharacteristicsactasdeterminantsofhealthcareuse,including

personalpredisposingcharacteristicssuchasage,socialstructureandbeliefsystems;enablingfactorssuchasfamilyeconomicresourcesandlocationofresidence;andperceptionofneedforservices,eitherindividually,sociallyorclinicallyevaluated.

Rogersetal.ImplementationScience2011,6:56Socialnetworks,workandnetwork-basedresourcesforthemanagementoflong-termconditions:aframeworkandstudyprotocolfordevelopingself-caresupport• Thetranslationandimplementationofaself-careagendaincontemporaryhealthandsocial

contextneedstoacknowledgeandincorporatetheresourcesandnetworksoperatinginpatients’domesticandsocialenvironmentsandeverydaylives.

• Thelattercomplimentsthefocusonhealthcaresettingsfordevelopinganddeliveringself-caresupportbyviewingcommunitiesandnetworks,aswellaspeoplesufferingfromlong-termconditions,asakeymeansofsupportformanaginglong-termconditions.

4

• Socialepidemiologytranslationframework,whichnotesthatevidenceonsocialriskfactorsfor

diseasecanbeusedtoguideinterventionstoreducetheincidenceofdisease,toimprovediagnosessothatpatientsreceivetimelytreatment,andtoimprovediseasemanagement.

• Effectiveinterventionsmaytargetthemedicalsystemorindividualsandthecontextsinwhichtheylive.http://circ.ahajournals.org/content/128/25/2725.full

II IntegratedCareModelsIntegratedCareFramework:Despitetherangeanddiversityofapproachesandformatsforhealth-relatedsystem/serviceintegration,thereareten(10)keyingredients—independentofthepopulationserved,contextormodel—foundinallsuccessfulintegratedcareinitiatives(Kodner,2010;Kodner,2009;Suteretal,2009;Williamsetal,2009):• Person-centeredfocusthatincludesawell-definedtargetpopulation,followsaholistic,patient/client-centeredphilosophyandpromotespatient/clientengagementandparticipation

• Populationandgeographiccoveragethatincludesresponsibilityforanidentifiedpopulation/geographicareaaswellasdefinedentrypoint(s)

• Comprehensivebasketofservicesthatcontainsabroadrangeofhealthandcareservices,promotesstronglinksbetweensectors,organizations,servicesandproviders

• Standardizedservicedeliverythatiscomprisedofinter-professionalteams,casemanagement/carecoordination,evidence-basedguidelinesandprotocols,asinglestandardofoutcome-basedcare

• PhysicianintegrationthatpromotestheactiveinvolvementofPCPs/Geriatricians• Organizationaldesignthatreflectsacollaborativestructureatalllevels,astrong,focused,variedgovernance,asharedvisionandleadership,acohesivecultureandeffectivecommunications

• Financialleversandincentivesincludeintegratedbudgets(variousmodels)andalignedincentives• Infrastructuresupportcommonclinicaldecisionsupporttools,anintegratedinformationsystemtocollect,trackandreportactivitiesandacontinuousqualityimprovement(CQI)approach

• Innovationthatimprovesprofessional/institutionalroles,careframeworks,andservices• Timeandresourcesintheamountssufficienttoachieveresultsoverthelong-runandallowforconstantfine-tuningaswellasprovidesufficientfundingforsustainablechange

Ouwensetal,Integratedcareprogrammesforchronicallyillpatients:areviewofsystematicreviewsInternationalJournalforQualityinHealthCarevol.17no.22005• Integratedcareprogrammesseemedtohavepositiveeffectsonthequalityofcare.Coresetof

componentsinintegratedcareprogrammesconsistentwithWagnerCDMtheoryidentifyingsixessentialelementsforgoodchroniccare:communityresourcesandpolicies,healthcareorganization,self-managementsupport,deliverysystemdesign,decisionsupport,andclinicalinformationsystems.Recommendationthatintegratedcareprogrammesshouldconsistofatleastaprofessional-directedintervention,anorganizationalintervention,andapatient-relatedinterventiontosupportself-management.

TheKing’sFundMakingIntegratedCareHappenatScaleandPace,March2013• Thereisno“bestway”ofintegratingcare,henceouremphasisondiscoveryratherthandesign

whendevelopingpolicyandpractice.

5

• 1.Findcommoncausewithpartners.2.Developasharednarrativetoexplainwhychangematters.3.Developpersuasivevisiontodescribewhatchangewillachieve.4.Establishsharedleadership5.Createtimeandspacetodevelopunderstandingandnewwaysofworking.6.Identifybeneficiarieswherethepotentialbenefitsfromchangearegreatest.7.Buildchangefromthebottomupaswellasthetopdown.8.Poolresourcestoenableintegratedteamstouseresourcesflexibly.9.Innovateintheuseofcommissioning,contractingandpaymentmechanismsanduseoftheindependentsector.10.Recognizethatthereisno“bestway”ofintegratingcare.11.Supportandempoweruserstotakemorecontrolovertheirhealthandwell-being.12.Shareinformationaboutusers13.Usetheworkforceeffectively.14.Setspecificobjectivesandmeasureandevaluateprogresstowardstheseobjectives.15.Berealisticaboutthecostsofintegratedcare.16.Actonalltheselessonstogetheraspartofacoherentstrategy.

JennaM.EvansHealthsystemsintegration:competingorsharedmentalmodels?2013InstituteofHealthPolicy,Management&Evaluation,UniversityofToronto,Canada• ACognitivePerspectiveonHealthSystemsIntegration:ConceptualOverview:Sharedmental

model(SMM)theoryisusedextensivelyintheteamperformanceliteraturetohelpexplainteamdynamicsandfunctioning.Whenmultipleindividualsdevelopacommonpsychologicalstructureforunderstandingtheirenvironment,thisallowsindividualstobehaveinwaysthatareconsistentandcoordinatedwitheachotherinthecompletionofinterdependenttasks

CareCoordinationandSystemNavigationModel:MOHLTCPolicyGuidelineforCCACandCSSAgencyCollaborativeHomeandCommunity-BasedCareCoordination,2014• Especiallyforclientswithcomplexcareneeds,carecoordinationfunctionswillsimultaneouslyand

interactivelyoccurthroughclient/familyself-directedactivitiesandfunctions;homeandcommunitycareprovideractivitiesandfunctions;andbroadersystemornetworkactivitiesandfunctions.Eachofthesecomplimentaryprocessesneedstobeunderstoodandalignedtoenhanceclientandfamilyexperience.Thisrequiresahighdegreeofcommunication,informationexchangeandcoordinationtoensureeachprocessaddsvaluetotheclientandisnotduplicative.

• Thefollowingprovidesaconceptualmodelforsimultaneousandcomplementaryindividual(i.e.self-management),sector(i.e.HomeandCommunityCareCoordination)andcommunityornetwork-basedcarecoordinationprocesses(e.g.HealthLinks)1:

1AdaptedfromtheAgencyforHealthcareResearchandQuality(2010)andsupportedbycarestandardsidentifiedby:MeryandWodchis(2013);Wodchis(2012);Kodner(2011,2010,2009);Suteretal.(2009);Williamsetal.(2009);and,MacAdam(2008).

6

III Outcome-BasedCareValue-BasedPerformanceMeasurementPorterRedesigningCare:AStrategicVisionToImproveValueByOrganizingAroundPatients’Needs,March2013Intheabsenceofanoverallstrategyandvisionforprimarycare,weofferaframeworkbasedonvaluetosustainandimproveprimarypractice.• Organizecarearoundsubgroupsofpatientswithsimilarneeds.• Provideteam-basedservicestoeachpatientsubgroupoveritsfullcarecycle.• Measureeachpatient’soutcomesandtruecostsbysubgroupasaroutinepartofcare.• Paymentshouldbemodifiedtobundlereimbursementforeachsubgroupandrewardvalue

improvement.• Patientsubgroupteamsshouldbeintegratedwithotherrelevantproviders.Regularfeedbacktoallstakeholdersofinformationonthecontributionofeachproviderandorganizationtosuccessandcostofcarewilldriveimprovementifitiscomparative,ifitisclearlyorganizedaroundcoherentepisodesofcare,andifitisavailableovertime.Itspurposeistohelpanystakeholderidentifytheircontributiontocareandjudgeitsmeritsincomparisonwithotherprovidersofferingcare,locallyandelsewhere.Thishelpsthemidentifyareasforsecularimprovementintheirorganizations’focus,collaborativenetworksandfunction.PorterandTesibergRedefiningHealthCare:CreatingValue-basedCompetitiononResults(2006)Aperson’sconditionistheunitofvaluecreationinhealthcaredelivery:Improvedvaluecanbeachievedthroughapplyingtheseprinciples:• Reorganizehealthcaredeliveryaroundconditions[keypopulations]overthefullcycleofcare• Integratecareacrossprogramsandsectorsandacrossregions• Increaseproviderexperience,scale,andlearningandusequalityimprovementtodrivevalue

7

• Measureandreportvalueforeveryproviderandforeveryclient• Alignreimbursementwithvalueandrewardinnovation.• UtilizeinformationtechnologytoenablerestructuringofcaredeliveryandmeasuringresultsAnneSnowdonMeasuringWhatMatters:TheCostvs.ValuesofHealthCare,Nov2012,1. AlignhealthsystemvalueswithCanadians’valuestomovefromasystemfocusedonmanaging

providerperformance,toasystemfocusedonstrengtheninghealthandqualityoflife.• Designintegratedservicesacrossthecontinuumofcare,supportedbycooperativemodelsof

healthsystemleadership,wherebyorganizationsandtheirleadersareincentivizedandheldaccountableforachievingqualityoflifeoutcomesforthepopulationstheyserve.

• Givepatientsandfamiliesthetoolstomanagetheirownhealthandwellness,includingcompletetransparencyandaccesstopersonalhealthinformation,tosupporthealthdecisionsthatachievequalityoflife.

• Re-designhealthcaresystemstofocusonhealthyactivelivingthatmitigatesriskofchronicillnessandhastheaddedbenefitofachievingqualityoflife.

2. AlignhealthsystemperformancemetricsandfundingmodelswithCanadianvalues,focusingonhealthandwellnessasacentralmandate.• CreatemetricsthatevaluateandredefinehealthsystemperformancetoreflectCanadians’

values,includingqualityoflife,engagement,andintegratedcaredeliveredbyinter-professionalhealthteams.

• Transformhealthsystemdatastructures,fromtheexistingprovider-centricstructures,whichcapturehealthtransactionsinorganizations,tointerconnectedconsumer-centricdatathatcaptureeachindividual’scaretransactionsacrossthecontinuumofhealthcareservices.

• Attachaccountabilitiestoallstakeholderstoachievemeaningfulconsumerengagementacrossthecontinuumofcare.Thisincludesincentingpatient-provider-institutioncollaboration.

• Re-designperformancemeasurementframeworkstofocusonthepositive,patient-centricoutcomesofhealthandwellness,ratherthanthedominantfocusonnegativeoutcomes,suchasmortality,errors,readmissionrates,andadverseevents.

3. Re-examinehealthworkforcevaluesrelativetotheneedsandvaluesofCanadians,whostriveforpersonalizedandcollaborativerelationshipswithhealthproviderstoachievehealthandwellness.• Re-configurehealthprofessionalpracticemodelsandapproachesfromsingledisciplinetointer-

professionalmodelsofpracticethatfullyengagetheuniquescopeofpracticeandexpertiseeachprofessionalbringstothehealthcareteam.

• Implementaninter-professionalmodeltocoachandmentorCanadianstoachievequalityoflife,acrossthecontinuumofcare.

• AlignreimbursementmodelsforhealthprofessionalswithCanadians’values,suchthatprofessionalsarereimbursedbasedonachievingbest-practicequalityoutcomes,ratherthanreimbursementfocusedonhealthservicetransactions.

MarcBergContractingValue:ShiftingParadigms,Jan2012• Systemsdonotdeliverhighvaluecareefficientlybecausewedesign,implement,andpayfor

disjointedandnon-coordinatedsingleinputs[servicesandprograms]andnotintegratedoutcomes.

8

• ContractingValue:Thebuildingblocksthatmakeitwork1.Definepopulationspecificintegratedcare“services”or“product”bundles.2.Definemeaningfulandmeasurableoutcomesfortheseservices3.Contracttheseoutcomeswithproviders

• Measuringqualityisseenasanalmostunsolvableproblem…yetcomplexityevaporateswhenwelookatcarefromthelensofwhatmatterstothepatient.Valueisproducedwhenpatientgoalsaremet–andthiswillvaryperdomainofcare

IversNetalAuditandfeedback:effectsonprofessionalpracticeandhealthcareoutcomes.CochraneDatabaseofSystematicReviews2012,Issue6.Auditandfeedbackisatestedandeffectiveknowledgetranslationstrategyforimprovingevidencebasedpractice(0.5-15%improvements).Auditandfeedbackisaninformationsysteminwhichtheperformanceofanindividualprofessionalorgroupismeasuredandthenfedbacktothem,withcomparisonstoprofessionalstandards,otherprofessional’sperformanceortargets.Thepurposeistoencouragetheindividualtocontinuallyimprovetheirperformance.AFappearstobemoreeffectiveifthebaselinequalityispoor,ifprovidedbyasupervisororseniorcolleague,ifdeliveredbothverballyandinwrittenformats,ifprovidedmorethanonce,ifitsaimistoincreaseratherthandecreasecurrentbehaviours,ifitincludesbothexplicittargetsandanactionplanandifittimely,non-punitive,andbasedonaccurateandcredibledata.NOTE:Auditandfeedbacksystems,whileknowntobeeffectiveforsingleconditionswithclearindicatorsofevidencebasedcare,becomemorecomplicatedtobuildforcomplexconditionssuchaspalliativecareandforpatientswithmultiplediagnoses,wherethecausesandsymptomatologymaybediverse,patientissuesmaybeidiosyncraticdependingontheircontextandavailablesupportnetworks,andtreatmentapproachesandprocessesmaketradeoffsamongmultipleconflictingclinicalandcomfortneeds,andarethereforeofnecessityindividuallyvariable.Giventhispotentialforindividuallyuniquepathwaysofappropriatecare,wehypothesizethatAFcouldbebasedonfeedbackofachievementofcareprocessesandpatientcentredwellbeingmeasures,withlessemphasisonactionability,withfeedbackofbroaderpopulationoutcomesandprocesses,ratherthanspecific,clinicallydefinedactions,andmoreengagementofbothpatientsandaccountableagencies.WebelievethatthisapproachtoAFwillbemoreeffectiveandequitableforcomplexpopulationsthanprocessfeedbackalone.[AlsoseeMandJSternin,positivedeviation(PD)]

9

K.SutcliffeandK.WeberTheHighCostofAccuracy(HarvardBusinessReview2004)• Thewayseniorexecutivesinterprettheirenvironmentismoreimportantforperformancethan

howaccuratelytheyknowtheirenvironment;interpretativecapacityor“mind-sets”distinguishhighperformancemorethandataqualityandaccuracy

• Spendingscarceresourcestoincreasethemarginalaccuracyofdataavailableislessproductivecomparedtothevalueofenhancingthecapacityofdecision-makerstointerpretwhateverdatatheyhave.Decision-makersaremorelimitedbyalackofcapacitytomakesenseofdatathanbyinadequateorinaccuratedata.

IV. PopulationHealthPromotionandPreventionT.HancockActLocally:Community-basedpopulationhealthpromotion(SenateSub-committeeReportonPopulationHealth,March2009)• Thehealthofindividualscannotbediscussed,understoodoracteduponwithoutrecognizing

thathumanbeingsaresocialanimalsthathaveevolvedtoliveinfamilies,socialgroupsandcommunities.

• Thepromotionofhealthyhumandevelopmentisthekeyunderlyingconceptsothateveryonedevelopsasfullyaspossibleandachievestheirmaximumpotentialasahumanbeing–thisis,orshouldbe,thecentralpurposeofalllevelsofgovernment.

• Fiveformsofcapital–natural,economic,social,built,andhuman–thattogetherform“communitycapital”andneedtobecomethekeymarkersofourprogress.Forthis,newmeasuresarerequiredtointegratethesevariousdimensionsofpersonal,communityandsocietalwellbeing.

• Requiresinvestinginbuildingresilience–theabilitytonotonlycopebutalsotothriveinthefaceoftoughproblemsandcontinualchange(Torjman,2007)–inbothpeopleandcommunities,andintheprocessandstructuresneededforcommunitygovernance.

• Thereisnouniversalmodelthatcanorshouldbeappliedtoallcommunities.Visionforanationalapproachtosupportingasset-basedcommunityactionforpopulationhealthandhumandevelopmentincludes:1. Manyofthedeterminantsofhealthhavetheireffectsatthecommunitylevel,inthesettings–

homes,schools,workplaces,neighbourhoods–wherepeoplelive,learn,workandplay.2. Communities–eventhemostchallengedanddisadvantagedcommunities-havesignificant

andsometimesastonishingstrengths,capacitiesandassetsthatcanbeusedbythecommunitytoaddresstheirproblemsandtoenhancetheirhealth,wellbeingandlevelofhumandevelopment.

3. Provincialandfederalgovernments,philanthropicorganizationsandtheprivatesectorshouldbuildonthestrengthsinherentincommunities,andinvestinasset-baseddevelopment.

4. Recognizeandpartnerwithmunicipalgovernmentsincreatingtheconditionsforhealthandhumandevelopment,adoptholisticwhole-of-governmentapproaches,andsupportcommunitygovernanceprocessesandstructuresthatenablestakeholdersinthecommunity–public,non-profit,privateandcommunitysectors,andcitizens–toidentifyanddefinelocalcommunityissuesandsolutionsandtodeveloplong-term,asset-basedstrategiestoaddressthem.

5. Commitmentbygovernmentsandphilanthropicorganizationstolong-termfundingofcommunitygovernanceinfrastructure.

10

6. Establishorstrengthennationaland/orprovincialorganizationsthatcansupportthecreationofhealthyschools,healthyworkplacesandhealthycommunities.

7. Developnewmeasuresofprogress,sothatourprogresstowardsthesebroadsocietalgoalscanbetracked,applicableatalllevels

8. Asonepartofbuilding(on)communitycapacity,governmentsshoulddevelopmoreintegratedsystemsofhumandevelopmentservices.Particularlyindisadvantagedcommunities,theseservicesshouldbeco-locatedclosetothepeoplewhouseorneedthem;theyshouldbeeasytouseandnavigate(one-stopshopping)andwherepossibletheyshouldbehousedinasinglefacilitythatmaximizestheuseofthesharedspacethroughouttheday.

CMerzelandJD’Afflitti,ReconsideringCommunity-BasedHealthPromotion:Promise,Performance,andPotential(AmericanJournalofPublicHealth,April2003)• Evidencefromhealthpromotionprogramstodateemployingacommunity-basedframework

suggeststhatachievingbehavioralandhealthchangeacrossanentirecommunityisachallenginggoalthatmanyprogramshavefailedtoattain.Challengesincludemethodologicallimitations,interventionsthatweretoonarrowinscope,widecontextualandcommunityvariability,andunrealisticexpectationsregardinglargeimpactsoverrelativelyshorttimeframes,makingitdifficulttodevelopdetailedprogrammodels,derivedfromecologicallybasedtheories,thatspecifythehypothesizedwebofmultiplelevelsofinfluenceandprocessesofcommunitychange.

• ThenotableexceptionisHIVpreventionwhichwerebuiltfromconsiderablecommunityinput,focusedonchangingsocialnormsasameansofalteringindividualbehavior,andtargetedhighrisk,homogenoussocialgroups.

• Themosteffectivestrategyforcommunity-basedhealthpromotionmayinvolvea3-tieredapproach,incorporatingone-on-oneinterventionsforhigh-riskindividuals,community-wideinterventionsandkeymessagesattemptingtochangesocialnorms,andpolicy-leveleffortsthatalsohelpmodifythesocialandpoliticalenvironmentsandgraduallyintegrateprogramcomponents

• Despitechallenges,community-basedprogramscanprovidenumerousstrategicadvantages:canreachpeopleonalargeenoughscaletohaveanimpactonmajorpublichealthproblems;explicitlyaddressthesocialcontextinwhichbehaviorsoccurandhavethepotentialtomodifynorms,values,andpoliciesinfluencinghealth;sustainabilityandimpactmaybeenhancedbecauseprogramsdrawonexistingcommunityresourcesandhelpgeneratelocalownershipandempowerment;canreachinaccessiblepopulationsbyrelyingoninformalcommunitynetworksaugmentingdiffusionofinterventionsandtheireffects;andprogramsareimplementedinrealenvironments,providingpublichealthpolicymakerswithcommunity-testedevidenceofprogramfeasibilityandeffectiveness

• WhatWorksinPrevention:PrinciplesofEffectivePreventionPrograms:9characteristicsthatwereconsistentlyassociatedwitheffectivepreventionprograms:Programswerecomprehensive,includedvariedteachingmethods,providedsufficientdosage,weretheorydriven,providedopportunitiesforpositiverelationships,wereappropriatelytimed,weresocio-culturallyrelevant,includedoutcomeevaluation,andinvolvedwell-trainedstaff.

11

PART2:COMMUNITYMODELSI AccountableCommunitiesforHealthTheAccountableCommunityforHealthmodelisemergingasapromisingvehicletowardreachingthefullpotentialoftheTripleAim-particularlyeffortstoimprovepopulationhealth.AnACHadvancespreviouseffortsincommunityhealthbyengaginghealthcareasacentralpartnerincommunity-widehealthimprovement.Atitscore,anACHisastructureforcollaborationthatrepresentsamajorchangeindirectioninhealthcare.ACHsintegratemedicalcare,mentalandbehavioralhealthcare,andsocialservicesupportswitheffortstoimprovethecommunityconditionsthatshapehealthandwellbeinginageographicalarea.Asemerging,theACHconceptisuniqueinthatit:

• Bringstogethermajorhealthcareprovidersacrossageographicarea,andrequiresthemtooperateaspartnersratherthancompetitors;

• Focusesonthehealthofallresidentsinageographicarearatherthanjustapatientpanel;• Engagesabroadsetofpartnersoutsideofhealthcaretoimproveoverallpopulationhealth;and• IdentifiesmultiplestrandsofresourcesthatcanbeappliedtoACH-definedobjectivesthat

explorethepotentialforredirectingsavingsfromhealthcarecostsinordertosustaincollaborativeefforts.

II HealthyCities(WHO,1986)HealthyCitiesisaglobalmovementthatengageslocalauthoritiesandtheirpartnersinhealthdevelopmentthroughaprocessofpoliticalcommitment,institutionalchange,capacity-building,partnership-basedplanningandinnovativeprojects.HealthyCitiesseektoapplyHealthforAllprinciplessuchasequity,empowerment,intersectoralcollaborationandcommunityparticipationthroughlocalactioninurbansettings.PromotesaPublicHealthapproachtosupportcommunitiestotakeresponsibilityfortheirownhealthandtoencourageeachothertoliveaswellaspossibleCompassionateCities:Publichealthandend-of-lifecare,2005,AllanKellehearCompassionateCommunitiesisaPublicHealthapproachtoendoflifecare.Itencouragescommunitiestosupportpeopleandtheirfamilieswhoaredyingorlivingwithloss.Itaimstoenableallofustolivewellwithinourcommunitiestotheveryendofourlives.• TheCompassionateCitiesvision:PublicHealthshouldembraceendoflifecare,anddeathand

dyingshouldbeseennotjustasamedical,butasocialissueandinvolvethewholecommunity.Death,dyingandbereavementwouldceasetobetaboosubjectsandwouldbecomemorenormalisedwithinsociety.People’sexpectationsofdeathanddyingwouldchange,aswouldhowdeathismanaged.Palliativecarewouldre-orientate,supportinghealthandsocialcarestafftoworkwiththecommunityinprovidingcaretothoseattheendoflife,andtheirlovedones.

DefiningfeaturesofCompassionateCommunities• Haslocalhealthpoliciesthatrecognizecompassionasanethicalimperative.• Meetsthespecialneedsofitsaged,thoselivingwithlifethreateningillnesses,andwithloss.• Hasastrongcommitmenttosocialandculturaldifferences.• Offersaccesstowidervarietyofsupportiveexperiences,interactionsandcommunication.• Promotesandcelebratesreconciliationwithindigenouspeoplesandmemoryofother

importantcommunitylosses.• Provideseasyaccesstogriefandpalliativecareservices

12

• GriefandpalliativecareservicesincludedinlocalgovernmentpolicyandplanningUnderpinnings• WorldHealthOrganization(WHO)’sOttawaCharterforHealthPromotiondemonstratedawayfor

peopletoincreasecontrolovertheirhealth,throughdevelopmentofpersonalskills,creationofsupportiveenvironments,strongcommunitiesandhealthypublicpolicies(WHO1986).

• WHOrecognisesthatcommunitydevelopmentcanhelptoengagecommunitiestoidentifyneedsandassets,andgalvanisecollectiveeffortstoimprovehealth(WHO,1998).Acommunitydevelopmentapproachhelpstobuild‘socialcapital’throughenhancingcommunitynetworksandbuildresilience.Itemphasizesworkingwithcommunitiesratherthanforthem,tofindsolutions,buildonexistingskillsandknowledge,andcreatemeaningfulpartnerships.

• ‘CompassionateCities,’bringsendoflifecarefirmlyintotheconceptof‘HealthyCities’,seenequallyaspartofhealthandrecognisedforitsrelevancewithinthewholelifecourse.HealthyCities(CompassionateCities)arewholecommunitiesthatdecidetopromotethehealthandwell-beingoftheircommunitiesinasystematicandholisticway.

Dementia-friendlycitiesTheconceptofdementia-friendlycommunitiesisanemergingoneandthereisnotyetanextensivebodyofliterature.Adementia-friendlycommunityisoneinwhichpeoplewithdementiaareempoweredtohavehighaspirationsandfeelconfident,knowingtheycancontributeandparticipateinactivitiesthataremeaningfultothem.Toachievethis,communitiesworkingtobecomedementiafriendlyshouldfocusonthefollowing10keyareas:1Involvementofpeoplewithdementia;2Challengestigmaandbuildunderstanding;3Accessiblecommunityactivities;4Acknowledgepotential;5Ensureanearlydiagnosis;6Practicalsupporttoenableengagementincommunitylife;7Community-basedsolutions;8Consistentandreliabletraveloptions;9Easy-to-navigateenvironments;10RespectfulandresponsivebusinessesandservicesAge-friendlycommunities:ThemaindomainsandelementssetoutintheChecklistofEssentialFeaturesofAge-friendly-citiesareequallyimportanttopeoplewithdementia:outdoorspacesandbuildings;transport;housing;socialparticipation;respectandsocialinclusion;civicparticipationandemployment;information;healthandsocialcareservices.(http://www.who.int/ageing/publications/Age_friendly_cities_checklist.pdf)III IntelligentCommunitiesTheTripleHelixiswhentheacademic,privateandlocalgovernmentsectorsworkcloselytogethertowardacommongoalinsideacommunityoraregion.Thisisthenewstrandthatwillenablecitiesandcommunitiestoremain“futureproof”andprofitable.Itwillalsoproducenewinnovationsinrapidandpersistentsuccession.TheIntelligentCommunityIndicatorsprovidecommunitieswithaframeworkforassessment,planninganddevelopment,astheyworktobuildprosperouslocaleconomiesintheBroadbandEconomy.Interactionscreatea"virtuouscycle"ofpositivechange.Broadbandconnectivityfeedsthedevelopmentofaknowledgeworkforceaswellascreatingthefoundationofdigitalinclusionprograms.Bothcontributetoarisinglevelofinnovationinthecommunityaswellasincreasingdemandforconnectivity.AndIntelligentCommunitiesmakethiswaveofchangethecore"valueproposition"ineconomicdevelopmentmarketing.

13

What:Components:Infrastructure(highspeedbroadband;trafficandenvironmentalmonitoring;municipalassetmanagementcapabilities)PLUSqualityoflifematters–education,digitalinclusion,innovation,governanceandthecreationofsustainableandinnovativeecosystems.PART3:POLICYMODELSII IntegratedCommunity-basedHumanDevelopmentandHealthPolicyFourboundarycrossings:1. Acrossdepartments/agencies:wholeofgovernment2. Acrosspublic,private,community:Intersectoralpartnership3. Acrosslevelsofgovernment:multi-levelgovernance4. BringingCitizensIn:empoweredpublicengagementThreechangestrategies:1. Shortterm:Community-drivenpilotprojects(Road-testingnewapproachesinnovations)2. Mediumterm:Embednewwaysofthinking/workinginexistinginstitutions(Bendingthe

Mainstream)3. Longterm:Scaling-uplessonsandinnovations(Leveringprovincial/federalpolicyandprogram

supportforcommunitywork)CriticalSuccessFactors:• Clearlydefined,sharedmission(values-basedandproject-driven)• Citizen-centered,community-driven• Boundarycrossingleadership• Clearlyarticulatedandunderstoodpartnershiptablethatincludes‘targetpopulation’

representation• Professionalsecretariat/management• Willingnesstotakechances• Visiontoguide“doabledemonstrable”projects• Measure,Learn,Adapt,Report

14

II Place-BasedPublicPolicyN.BradfordPlace-basedPublicPolicy(2003,2007)Cityregionsarethenew“strategicspaces”wherepublicpolicyplaysoutontheground.Localgeographiccontexts–theformandnatureofplaces–shapepeople’slifechances.Canada'sfuturecompetitivenessdependsonitsabilitytosetasidetraditional,segmentedandaspatialapproachesanddevelopa"place-basedpublicpolicy"rootedin"collaborative,multilevelgovernance":1. Localgovernancenetworksarerequiredtodeliveronchallengesofeconomicinnovation,social

andculturalinclusion,andecologicalsustainability.Joiningupisnecessarybecause“wickedproblems”–deeplyrooted,interconnected,andunfamiliar–requireholisticinterventionsaddressingmulti-facetedcausality.

2. Theintersectionofpeople,investmentandideasaswellaspolicychallengesvariessignificantlyacrossplaces.

3. Withissuesexpressedincomplex,differentiatedwaysacrossthecountry,nationalgovernmentsneedaspatially-sensitiveperspectivetoinformtheirpolicies.

Traditionalapproaches–typicallycentralizedandtop-down–thatignorelocalvoicesanddevaluecommunityandmunicipalassetswillnotbuildthehighqualityplacesthatarethefoundationfortheprosperityofnationsinaglobalage.Norwilltheybecapableoftherobustpolicylearningnecessarytotacklewickedproblems.A“locallens”isneededtoassessthespatialimpactsofnationalpoliciesandmaximizetheirbenefitsforpeople.Indevelopingacommunities’agenda,akeytaskistoestablishamulti-sectorallocaldecision-makingprocessandacomprehensiveandlong-termplanthataddressesthecommunities’problemsbybuildinguponexistingstrengthsandcapacities(STorjman2007)TransitioningfromGovernmenttoGovernance

15

PART4:CHANGEMODELS(TACKLINGWICKEDCHALLENGES)I CommunityCapacityBuildingMaryLouKelley“ProcessofPalliativeCareDevelopment”:• Communitycapacitydevelopmentapproachtomakecreativeuseofexistinghealthandcommunity

assets-'buildingonwhatalreadyexists'.• Necessaryantecedentconditionswithinthecommunityinclude:sufficientlocalhealthcare

infrastructure;collaborativegeneralistpractice;senseofcommunityempowermentandcontrol;andavisiontoimprovecareofthedying

II. PartneringandInnovationJohnKaniaandMarkKramerCollectiveImpact(StanfordInnovationReview2011)• Largescalesocialchangerequiresbroadcross-sectorcoordinationyetthesocialsectorremains

focusedontheisolatedinterventionofindividualorganizations• Groupsofimportantactorsfromdifferentsectorscanorganizethemselvesaroundacommon

agendaforsolvingaspecificsocialproblemoragreecollectivelytochangetheirbehaviortosolveacomplexissue(orsetofhumanneeds).

• Organizationforcollectiveimpactrequires1.acommonagenda,2.sharedmeasurement,3.mutuallyreinforcingactivities,4.continuouscommunication,and5.abackbonesupportorganization.

16

DonLenihan,RescuingPolicy:TheCaseforPublicEngagement.• Givenanincreaseincomplexity,manyissuescan’tbesolvedbyanyoneindividual,organizationor

governmentworkingalone• Publicinvolvementapproachesarenotaone-size-fitsall4stages:canvassingviewsandopinions;workingtogetheronsynthesisandreframing;choosingprioritiesforactionandevaluationSocialLabs(orSolutionlabsorSocialInnovationorSocialEntrepreneurship):• “Sociallabsbringtogetheradiversegroupofstakeholderstodevelopaportfolioofprototype

solutions,testthosesolutionsintherealworld,usethedatatofurtherrefinethem,andtestthemagain.”(ZaidHassan“TheSocialLabsRevolution:ANewApproachtoSolvingourMostComplexProblems”,social-labs.org)

WEggersandPMacmillanTheSolutionRevolution(HarvardBusinessPress,September2013)

• Developinglightweightsolutionsforseeminglyintractableproblems;tradesolutionsinsteadof

dollarstofillthegapbetweenwhatgovernmentcanprovideandwhatcitizensneed.• Creatingyourownsolutionrevolutioninsixeasysteps.

1. Changethelens.Ifyou’rethinkingaboutsolvingabigproblemsolelyintermsofcurrentprograms,youwillconfinepotentialsolutionstoaflawedstatusquo.Focusingontheoutcometoachieveopensupawholeuniverseofpotentialsolutionsandprospectiveproblemsolvers.

2. Targetthegaps.Developnewmarketsbymeetingneglectedneedsaswellasgapsamongtheecosystemparticipantstryingtoaddressagivenissue.

3. Rethinkconstraints.Don’tletyourresourceconstraintsnarrowyourvision;focusonanendgoalandconsiderhowresourcesoutsidetheorganizationcansupportthatgoal.

17

4. Embracelightweightsolutions.Sometimesthebestsolutionsarealsothecheapest,althoughalongthewaywemayhavetosacrificeoldmodels,traditionaljobs,andevenlong-trustedinstitutions.

5. Buydifferently.Governmentsandlargecompaniespurchasetrillionsofdollarsingoodsandserviceseachyearfrommillionsofdifferentsuppliersandpartners.

6. Measurewhatmatters.Therightmetricsareapowerfulcompassforproblemsolvers,pointingresourcestowheretheywillhavethegreatestimpact.Measurementismosttransformativewheninsightandfeedbackisappliedtohowproblemsgetsolved.

AcceleratebyDr.JohnKotter The100yearoldhierarchicalorganizationalstructureweusetodaywasnotbuilttobefastandagile.Tosucceedbothintoday’sworldandintothefuture,weneedtothink–andact–differently.Kotteradvocatesanewsystem—asecond,moreagile,network-likestructurethatoperatesinconcertwiththehierarchytocreatewhathecallsa“dualoperatingsystem”—onethatallowscompaniestocapitalizeonrapid-firestrategicchallengesandstillmaketheirnumbers.8Accelerators1. CreateasenseofurgencyaroundaBigOpportunity(buildingadualoperatingsystem)2. Buildandevolveaguidingcoalition(drawinginpeoplefromallsilosthatfeeltheurgencydeeply,

readytotakeonstrategicchallenges,dealwithhyper-competitiveness,andachievetheBigOpportunity)

3. Formachangevisionandstrategicinitiatives(i.e.initiativesthecoalitionfeelspassionateabout,makesensetoexecutiveleaders,andhierarchicalsidelackstheabilitytoaddresswellorfastenough)

4. Enlistavolunteerarmy(leadinglargenumbersofpeopletobuyin.Thisacceleratorstartstopull,asifbygravity,theplanetsandmoonsintothenewnetworksystem)

5. Enableactionbyremovingbarriers(peopleactinthespiritofanagileandswiftentrepreneurialstart-uptoremovebarriersthatslowstrategicallyimportantactivity)

6. Generateandcelebrateshort-termwins7. Sustainacceleration(withrelentlessenergyfocusedforwardonmorenewopportunitiesand

challenges)8. Institutechange(winsareinstitutionalized,infusingthechangesintothecultureofthe

organization.Afterafewyears,thisactiondrivesthewholedualoperatingsystemintoanorganization’sDNA)

III LeadershipGovernanceasLeadership:KeyConcepts(RichardChait,BillRyan)• “Threemodes”ofgoverning.Thefirstisthefiduciarymode,inwhichtheboardexercisesitslegal

responsibilitiesofoversightandstewardship.Thesecondisthestrategicmode,inwhichtheboardmakesmajordecisionsaboutresources,programsandservices.Thethirdisthe“generative”mode,inwhichtheboardengagesindeeperinquiry,exploringtheirreasonforbeing,rootcauses,values,optionalcoursesandnewideas.Itgoesbeyondsimpleproblemsolvingandbegins“problemframing.”

18

VisionaryorCreativeLeadershipVisionaryleadershipinvolvesopenness,imagination,persistence,andconviction• Opennesstonewinformationcombinedwithalowdegreeofdeferencetoconvention.Asaresult

oftheirwillingnesstoexperimentandtrythings,visionariesoftenareinthebestpositiontomake“breakthrough”creativediscoveriesorhappyaccidents.

• Vividimagination,highsensitivityandabilitytoseethingswiththeirmind’seye.• Abletobuildanaccurateconceptualmodelofthefuturebasedontheirkeenunderstandingofthe

present.Successfulvisionaryleaderscanbringthatmodelintoreality,creatingthefuture.• Qualityofstrongconviction• Qualityofpersistence.Intheend,thedifferencebetweenasuccessfulandunsuccessfulvisionary

oftencomesdowntodriveandpersistence.5practicalstepstowardsvisionaryleadership:1.PracticeRe-ImaginingHowThingsAre;2.AdoptanOutside-InPerspective.3.Ask"WhyNot?"4.SeekSynergies.5.IntegrateDisparateIdeasIntoYourThinking.JimCollins,MovingfromGoodtoGreat• Level5ExecutiveLeadership:PersonalHumility;ProfessionalWill;Workmanlikediligence;

Ambitiousforthecompany,notthemselves• FirstWho,ThenWhat:Gettingtherightpeopleontheteamcomesbeforevision,strategyand

tactics;Gettherightpeopleonthebus;Getthewrongpeopleoffthebus;Putyourbestpeopleonyourbiggestopportunities,notthebiggestproblems

• ConfronttheBrutalFacts(ButNeverLoseFaithinthePotentialforGreatness):Impossibletomakegooddecisionswithoutanhonestconfrontationofthebrutalfacts;Createaculturewhereinthetruthcanbeheard;Leadwithquestions,engageindialoguenotcoercionandconductautopsieswithoutblame;Don’twastetimetryingto“motivatepeople”-Therightpeopleareself-motivated.

• TheHedgehogConcept:Organizationsshouldonlydowhatthey1)canbegreatat,2)canmakemoneyatand3)haveapassionfordoing.Thisconceptisnotavisionorstrategy,butaniterativeunderstandingthatdrivesgoalsandstrategies(asopposedtobravado).

• ACultureofDiscipline:SustainedgreatresultsdependuponbuildingacultureofdisciplinedpeoplewhoengageindisciplinedthoughtandtakedisciplinedactionwithinthethreecirclesoftheHedgehogConcept.FanaticaladherencetotheHedgehogConceptandthewillingnesstoshunopportunitiesthatfalloutside.“Stopdoing”listsaremoreimportantthan“todo”lists.

• TechnologyAccelerators:Avoidtechnologyfadsbutbecomepioneersinapplyingcarefullyselectedtechnologies.Usetechnologyasanacceleratorofmomentum,notacreatorofit.

• TheFlywheelandtheDoomLoop:Good-to-greattransformationslookdramaticandrevolutionaryontheoutsidebutactuallyareorganic,cumulativeprocessesontheinside.Thereisnosingledefiningaction,nograndprogram,nooneluckybreakormiraclemoment.Sustainabletransformationsfollowapredictablepatternofbuildupandbreakthrough–likepushingonagiant,heavyflywheel.Averageorganizationsfollowthe“doomloop”pattern,jumpimmediatelytobreakthroughwithdisappointingresults,theylurchbackandforth.

19

III SpreadandSustainabilityMurray,ElizabethetalNormalisationProcessTheory:aframeworkfordeveloping,evaluatingandimplementingcomplexinterventions(BMCMedicine2010)• Normalizationoccursatthepointwhereanintervention,approachorphilosophybecomesso

embeddedintoroutinepracticethatbecomesthe“norm”and“disappears”fromview• Theworkthatindividualsandgroupsmustdotoenableaninterventiontobecomenormalized

involvesfourmaincomponents:coherence(orsense-making);cognitiveparticipation(orengagement);collectiveaction(workdonetoenabletheinterventiontohappen);andreflexivemonitoring(formalandinformalappraisalofthebenefitsandcostsoftheintervention)

• Componentsarenotlinear,butareindynamicrelationshipswitheachotherandwiththewidercontextoftheintervention,suchasorganizationalcontext,structures,socialnorms,groupprocessesandconvention

ScalableChange:AFrameworkforPractitioners(RockefellerFoundation,2009)• Changemust:focusonapositivevision;havewidespreadimpact;resultinsystemicchange(with

considerationofallcomponentsregulatory,social,economic,etc)• Successconditions:engageandempowerthetargetpopulationfromthebeginning;designfor

sustainability;buildtrust/credibilityofchangeagents;createandimplementaneffectivedesign;leveragekeypartnerships;effectivelymanagetheproject;learnfromexperience

• Barriers:failuretocreateasenseofurgency;failuretoanticipateandaddressnegativeconsequences;over-emphasisonactionandshort-termgains;underestimatetheimportanceofcommunicationsandpublicrelations

Bestetal,Large-SystemTransformationinHealthCare:ARealisticView(2012)• Largesystemtransformationsinhealthcareareinterventionsaimedatcoordinated,system-wide

changeaffectingmultipleorganizationsandcareproviders,withagoalofsignificantimprovementsintheefficiencyofhealthcaredelivery,thequalityofpatientcare.Mostofthepublishedliteratureonchangeinhealthcaredescribesrelativelysmall-scaleinitiativestypicallycarriedoutbyasinglehealthcareorganizationorservice.

• Arealistreviewofchangeworksontheassumptionthataparticularinterventiontriggersparticularmechanismsofchange.Mechanismsmaybemoreorlesseffectiveinproducingtheirintendedoutcomes,dependingontheirinteractionwithvariouscontextualfactors.Variationsinoutcomescanbeexplainedastheinterplaybetweencontextandmechanisms,nestedinamacroframingofcomplexadaptivesystems.

• Fivesimplerulesoflargesystemtransformationthatwillenhancethesuccessoftargetinitiatives:1.Blenddesignatedwithdistributedleadership;2.Establishfeedbackloops;3.Attendtohistory;4.Engagephysicians;5.Includepatientsandfamilies.

Shakarishvili,ConvergingHealthSystemsFrameworksGlobalHealthGovernance,VolumeIii,No.2(Spring2010)http://www.ghgj.org

• Debatesaroundhealthsystemshavedominatedtheinternationalhealthagendaforseveraldecades.Awealthofcontributionshasbeenmadetoexplainhealthsystemsthroughmultipledefinitions,frameworksandmodels.Mostdebateshavefocusedonconceptualizinghealth

20

systemsobjectives,functionsandperformancemeasurementapproaches,withratherlessfocusonpracticalsolutionsforcollectiveactiontostrengthenhealthsystems

• Thisreviewofavailablehealthsystemsframeworksidentifiesacommongroundandexploresthefeasibilityofconvergingmultiplehealthsystemframeworksasacommontechnicalpointofreferenceforcollectiveactionstostrengthenhealthsystems.Aconcepts-to-actionsroadmapisproposedasthemeansfortranslatingconceptsandtheoriesintopracticalinterventions.

21

PART4:LEADINGPRACTICEADVICEStrengtheningEndofLifeCareinOntario,ResidentialHospiceWorkingGroup2014CommunityContinuumofCarethatisorganizedbasedonessentialdesignprinciples:• Healthpromotingapproachestopreventordelaychronicdiseasewithbroadrecognitionofaging,

deathandlossasinevitableanduniversal• Targetsthewholepopulationnotjustservice-basedcare

o Uniquestrategiesandservicebasketsmayberequiredforpatientswithdifferenttrajectoriesandneed/risklevels

o Isnotlimitedtopatientswhoreceiveformalprofessionalcare• Focusesoncitizenwell-beinginthecontextoftheircommunities

o Empowerspatientsandfamiliesinachievingthecarethatismostrelevantandimportanttothem,inaccordancewiththeirvalues,beliefsandpreferences

o Availabilityofcommunitysystemsthatprovidegenuineandauthenticsupportduringthe95%oftimepatientsandfamiliesarenotwiththeirhealthcareprovider

• Isorganizedaroundtheclientandcaregiverjourney,notjustserviceso Normalizesagingandendoflifecareo Extendsfromdiagnosisthroughtreatmenttodeathandbereavemento Ensuresthat“onceyou’reknown,youneverbecomenotknown”

• Provideseasy,integratedaccesstogoldstandardhealthandsocialcareo Commondesigncharacteristicsacrosslong-termcommunity-basedcomplexchronicdisease

management,geriatric,dementia/behaviouralsupportand/orpalliativecareThatis:ALLcitizenswithlife-limitingillnessshouldexperiencecareasproactive,holistic,patientandfamily-focused,centeringonqualityoflifeandsymptommanagementissues,anddeliveredbyanintegratedinterprofessionalteaminacoordinated,continually-updating,careplan.

o PositionsagingandEOLcarewithinachronicillness/frailtycontinuumo Equitable:Consistenthighquality,highvalueservicesequitablyshouldbedeliveredto

similarpopulationsaccordingtoevidence,leadingpractices,andprofessionalstandards.Allservicesshoulddemonstrateachievevalueformoney;similarservicestargetingpatientswithsimilarlevelsofneedshouldbemoreconsistentlyandequitablyfunded,regardlessofthespecificcaresettingorsectorinwhichtheserviceisdelivered

o Complexity/needvsprognosisasacriteriaforspecialistinterventiono Capacitythatbalancespredictablesupply,demandandpreferenceconsiderationso Providesastandardofcarethatisexemplarywhilebuildingcapacity,sustainabilityand

knowledgethroughcollaborative,sharedcaremodels• Supportseffectivecommunityengagementtomakecreativeuseofhealthandcommunityassets

o Communityasapartner:leadershipandfacilitationisavailableforcommunitydevelopment,healthpromotion,andcapacity-building

o Communityandpopulation-centredsystemthatisorganizedforcollaborativeimpact(withcommonagenda,sharedmeasurement,mutuallyreinforcingactivities,continuouscommunication,andbackbonesupportorganization)

• Thecarepeoplereceiveismoreimportantthantheplace• Thenatureofleadershipsupportismoreimportantthanthetypeoforganization

22

TakingAction• Prospectivelyfindpatientsapproachingend-of-life(the1%)withincommunitiesandtakeaction

basedontheirneeds• Offerpersonalized,patientandfamily-centredcarethatempowerspatientsandfamiliestotake

ownershipoftheirpalliativeandend-of-lifejourney• Enablepatientsapproachingtheirlastyearoflifetoreceiveexemplarycarethroughflexible

“personalized”teamswithinintegratedservicesystems• Workwithincommunitiestonormalizeaging,deathandloss• Strengthenandoptimizeresidentialandhospitalinpatientcapacityforpeoplefacingimminent

death• Ensurestrongprovincialandregionaloversightandaccountability• Usetechnologyasanacceleratorforconnected,integratedsystemsGoldStandardsFramework(Practicesettings)

• TheGoldStandardsFramework(GSF)intheUnitedKingdomisanationalapproachtoprovideendoflife(andothertypesofcareincludingdementiacare)thatfocusesoncapacitybuildingforfrontline,primarycare.GSFfocuseson:

o enhancedqualityofcarewhichimproveshealthserviceproviderskillsandconfidence,leadingtoabettercareexperienceforclients;

o improvedcommunication,coordinationandintegrationacrosssettingsofcare;ando improvedoutcomesforclientswhichallowsthemtoliveanddiewheretheychoose

resultinginreducedhospitalizationsandcost.• GSFisbasedonthe7Csofcare,regardlessofthesettingofcare:communication,

coordination,controlofsymptoms,continuityofcare,continuedlearning,carersupportandcareofthedyingpathway.

• ThegoalofGSFistohelporganizationsimprovethingssuchas:patients’painandsymptommanagement,thelikelihoodofdyinginpatients’placeofchoice,avoidingcrisisandED/hospitalization,improvedhealthserviceprovidersupportandcoordination,andimprovedcoordinationandcommunicationbetweenproviders.

TeamDeliveryandCoordinationRe-ThinkingPalliativeCareintheCommunity:AChangeGuide,Dr.HsienSeow,2014

1. Re-definingQualityCare-Focusingonpatientsultimatelyresultsinimprovedsystem-leveloutcomes.Thereisnooneorbestmodelfordoingthis

2. Re-thinkingIdealModelsofCare-Allteamsexistwithinalargerecosystem–theyworkacrossallphysicianmodelswithnursesalmostalwaysplayinganessentialrole.Theteamisnotdefinedbyitscomposition,size,housingorfundingbutneedstobebuiltonlocalcommunitystrengthsandassets.There’snowinningformula.Acommunity-grownmodelbuiltonyourlocalstrengthsandassetsworksbest;andyoucanachievestandardization,withoutacookie-cutterapproach.Everyregioncanhaveauniqueteam!

3. Re-examiningWhatMakesTeamsEffective-Successfulteamsallhadbehaviours,practicesandcharacteristicsthatcontributetoexcellenceandsuccess.Despiteeachteambeingdifferent,theywereconsistentintheirapproachtopeople,entrepreneurialismandpurpose.Everyoneofthesecomponentswascriticaltosucceeding,sustainingandspreading.

23

4. Re-evaluatingMeasuresofProgress—What’sRealisticandWhat’sNot:Teamsshouldusemeasuresappropriatefortheirstageofdevelopmentintheircommunity.Celebratethesesmallsuccessesateachstage,tostaymotivated,buildmomentumandgrowyourprogram.

5. Re-inventingtheWheelisUnnecessary—LearnFromOthers:Youmaynothavealltheanswersnowbutcollectivelyit’spossible.Teamsusedexistingresourcesdifferentlyandfoundwaystoovercomeexistingsystembarriers.Whatisalsodemonstratedis,thereisnorightanswer,orawrongone,forthatmatter,ifitworksinyourcommunity.Thereisalotofhardworkanddeterminationrequired.Butthechampionsacrosstheprovincecan,andwant,tohelpyou.Youcanlearnfromthem.Youarenotalone.

[Sameresearchisapplicabletopalliativecare,dementiacare,geriatriccare,advancedchronicdiseasemanagement,etc]CollaborativeCareCoordination(NavigationModel)MinistryofHealthPolicyGuideline,2014• Clientsarepartnersinthecarecoordination,careplanningandcaredeliveryprocessin

accordancewiththeirownabilitiesandpreferencesalongacontinuumfromfullyself-orcaregiver-managedanddirected,co-directed/shareddecisionswithanintegratedteam,orfullydirectedbyacarecoordinator.

• WithindifferentApprovedAgencies,thenatureofcarecoordination–frombasictocomprehensive–aswellasthelevelofintensitywillvaryaccordingtothegeneralnatureoftheirprogramsandclientsservedwhilestilltakingintoaccountthespecificneedsandspecificcircumstancesofindividualclients.However,withineachpopulationsubgroup(i.e.lightercare,moderatecareandcomplexcareneeds),carecoordinationpracticesbetweenandacrossApprovedAgenciesshouldbetransparentandconsistentasoutlinedbelow:

LighterCareNeeds ModerateCareNeeds ComplexCareNeeds “Linkage”modelwhich

allowsindividualswithlighttomoderatehealthcareneedstobecaredforinsystemsthatservethewholepopulationwithoutrequiringanyspecialarrangements.

“Coordination”modelthatoperatesthroughexistingstructuresandincludesexplicitprocessestocoordinatecareacrossagenciesaswellaswithprimarycareandotherhealthcaresectors.

“Fullorsystem-wideintegration”modelthroughentitiessuchasHealthLinks,withresourcesfrommultiplesystemsthatarepooled.Careprocesseswillbefullyintegratedwiththeprocessesdeliveredthroughlocalnetworksandprimarycare.Community,informalandvolunteerprovidersshouldfunctionseamlesslyaspartofabroader,integratedinter-professionalteamthatcrossessectors.

OtherExamples:RespondingtoHIV/AIDSThefindingsfromtheHIVtrialsrepresentconsistentevidenceofthecapacityofcom-munity-basedpreventionprograms,implementedinavarietyofsettings,tochangecomplexhealthbehaviorsatthepopulationlevel,instrikingcontrasttomostothercommunityhealthpromotioninterventions.Criticalfactorsinfluencingsuccess:

24

• Mostprogramsusedpeervolunteerstodeliverthehealthmessagesasaprimarymeansofinfluencingsocialnorms

• ‘Partnerships’betweentheaffectedcommunities,government,serviceproviders,non-governmentalorganizationsandresearchersrequiredtoachieveahighlevelofconsultationandcollaborationtoprevent,manageandtreatHIV/AIDS.

• Bottomup(consumerdriven),topdown,andrapidcycleinnovationapproachestoachievetimelyandsafeaccesstoeffectiveandaffordabledrugtherapies

• Wholepopulationapproachesneeded:e.g.inthelate1980s,whenthesequelaeofrisingHIVrateswerebecomingincreasinglyevident,publichealthprogramstacklingHIV/AIDSwerestarted.Dramaticreductionswereachievedincountries(e.g.Uganda)that“wentagainstthecurrent”behaviouralapproachesandchoseadaptablestrategiesthatweredesignedtotargetallsegmentsofthepopulationthroughan“ABC”approachtosexualbehaviourchange

• TheBrazilianexperienceisfrequentlycitedasamodelforotherdevelopingcountriesfacingtheAIDSepidemic,includingtheinternationallycontroversialpoliciesoftheBraziliangovernmentsuchastheuniversalprovisionofantiretroviraldrugs(ARVs),progressivesocialpoliciestowardriskgroups,andcollaborationwithnon-governmentalorganizations.Forexample,incontrasttomanypartsoftheworld,condomswereprioritizedearlyandaggressively,spurredbygovernmentprogramstoincreaseawareness,decreasetheprice,andincreasetheavailabilityofcondoms.Prostitutegroupswereinvolvedinthedistributionofinformationmaterialsandcondoms.Similarly,needleexchangeprogramswereimplemented.

• Communityorganizedhospiceprogramsdevelopedandimplemented