Year 1 Populations for Ontario Health Teams
By Alexandra Piatkowski
Recently, the Ministry of Health announced the first 24 Ontario Health Teams (OHTs) that are being established across the province. The goal of OHTs is “better integrated health care, with a seamless experience when moving between different health care services, providers and settings.” OHTs will eventually be responsible for providing a full spectrum of health care services for their entire attributed populations, but they have also been asked to specify which population(s) they will focus on in Year 1 of OHT implementation.
We have been hearing and learning lots from OHTs, and have been gathering this information here. We did a scan of OHT Year 1 populations and found that many are selecting the same ones, with the top three being seniors, mental health and addictions, and palliative populations. Our scan included information on 27 OHTs who have been approved or are at the full application stage and have made their priority population(s) publicly available. Information sources included full applications, self-assessments, websites, news releases, and social media. Note that information was not publicly available for six OHTs as of January 6, 2020. Please contact us to provide clarification, updates, or ask questions about any of the information we have compiled.
Highlights
More than two-thirds (70%) of OHTs selected seniors as a Year 1 population
Over half (59%) selected mental health and addictions
More than one-third (41%) OHTs selected palliative populations
Four OHTs selected other populations:
Two chose rural
One chose acute gastrointestinal/genitourinary
One chose high health system users
Two-thirds (18) of the 27 OHTs we looked at have selected more than one Year 1 population. Here’s a breakdown of the combinations of priority populations that OHTs selected:
A Closer Look at Priority Populations
Seniors
Seniors may face a range of health and social challenges as they age, such as chronic conditions and social isolation, and hospital use tends to become more frequent. Ontario is aging faster than ever before with older people in Ontario now outnumbering younger ones; there are now more than two million seniors aged 65+ in Ontario. Seniors are a diverse group, and some may require more support than others; we know that some OHTs who have selected seniors as a priority population have stratified within this group according to differing levels of medical and social complexity (i.e. dementia and other chronic conditions, living alone, access to primary care). As the health care needs of seniors increase, so too will their number of interactions with health care providers and different parts of the health system. This necessitates better care planning for transitions across sectors to promote higher quality of care. Residential care is typically the most intensive and most expensive service, providing care to people with complex needs, which also makes a case for supporting seniors to live in the community wherever possible.
Mental Health and Addictions
We know that about two million Ontarians experience mental health and addictions challenges each year, while one-third of those who say that they need mental health and addictions services do not have the support that they need, or only have their needs partially met. Barriers identified include accessibility, timeliness, affordability, and acceptability/stigma. Access to treatment, services and supports are also not equitable. For example, younger people, new Canadians, and people who live in rural and remote communities are less likely to receive timely and high-quality care. Some OHTs have taken a particular focus on sub-populations, such as youth and people who use substances, who have unique needs related to their mental health and wellbeing. Pathways of care across the system are often fragmented and transitions between health care providers and sectors can be challenging. For example, in Ontario, less than one-third of patients with an inpatient mental health or addiction visit have a follow-up visit with a physician within seven days. There is evidence that interventions designed to smooth transitions can prevent issues such as readmissions and promote more integrated care.
Palliative Care
According to patient and caregiver surveys, most Ontarians would prefer to die at home. In reality, most patients end up dying in hospital, which not only affects the experience of patients and families but is also more resource intensive. Palliative care often also begins too late, with nearly half of Ontarians who received palliative care services receiving them within the last month of life. There are many end of life services available in Ontario, but there is a lack of coordination in place to help navigate the system, which may lead patients to receive fragmented care, especially as they move from one setting to another. There is the opportunity to improve the integration of palliative care services in order to improve the experience of individuals at the end of life and promote better resource utilization.
Get Started with Population Health Management
Selecting priority populations is just one of the first steps towards a population health management approach. Our learning journey for OHTs outlines questions they will need to consider at each stage of the development process. Some of the next questions to answer around priority populations include:
How do we take a population-wide perspective on high need/high risk patients?
What tools exist to think about variation, cost, and quality?
What methods exist to stratify levels of need/complexity?
How can we have the biggest impact on population health outcomes for these populations?
What resources, services, and programs currently exist in the community?
How can we collaborate for better outcomes for these populations?
Tackling these questions can help OHTs progress towards becoming a population health management system. To answer these questions and progress your approach to delivering care, check out these resources:
Case studies of people who use substances - These case studies can bring the client/patient perspective into strategic planning meetings, helping you understand their experience.
Youth mental health ecosystem map - This community-led map uncovers the traditional and non-traditional places, spaces, and supports that youth are already using to manage their mental health and well-being.
Muskoka OHT population health assessment - The Muskoka OHT selected seniors as a priority population and we helped them integrate multiple data sources to create a more comprehensive story of their community.
North Toronto seniors profile - This profile of seniors was put together to inform some early OHT thinking at the North Toronto Sub-Region Table. Having all the data in one page that is highly accessible and visual makes evidence-based decision making easier.
Learn more about selecting and addressing population health priorities in your work. Work with us or subscribe to our newsletter to get insights, tools, and resources right in your inbox.
The views and material presented here are not endorsed by any funders or collaborators of Health Commons Solutions Lab. Our work does not reflect the views or the policy development of the Ontario Ministry of Health. The Health Commons Solutions Lab is funded in part by the Ontario Ministry of Health and based at Bridgepoint Health (part of Sinai Health), with collaborators across Ontario.
References
Ministry of Health (9 December 2019). Ontario Introduces 24 Ontario Health Teams Across the Province to Provide Better Connected Care.
Health Quality Ontario (2015). Taking Stock: A report on the quality of mental health and addictions services in Ontario.
Government of Ontario. (2017). Aging with Confidence: Ontario’s Action Plan for Seniors.
Health Quality Ontario. (2016). Palliative Care at the End of Life.