Pan-Canadian SPOR Network in Primary and Integrated Health Care Innovations: Network Membership Requirements

Member Network Requirements

1. Tripartite Leadership: Each member network within the pan-Canadian SPOR Network in Primary and Integrated Health Care Innovations (referred to hereafter as the pan-Canadian Network) will be co-led by clinical, research and policy leads that collectively cover the continuum of care (prevention, primary, secondary, tertiary, and home care),1 one of which must represent primary health care. The tri-partite leadership will also be responsible for ensuring the network has multi-faceted mechanisms for incorporating patient and citizen perspectives:

  • The clinical lead will be a recognized leader with a demonstrated track record, ideally in primary and integrated healthcare delivery and a vision for innovation and transformation and a commitment to evidence-informed health delivery. He/she will have the capacity to mobilize the creative ideas, tacit knowledge and experience, and collaboration of health professionals across sectors of care and consumers towards a common goal of innovation and improvement in cost-effective care delivery. The clinical lead will be instrumental in forging the collaborations with health professionals in other sectors of care (e.g., primary, secondary, tertiary, prevention and public health, home and long-term care) and sectors outside of health (e.g., housing, social services, education), which are required to facilitate horizontal and vertical integration of care delivery. The clinical lead will also be instrumental in identifying and addressing facilitators and barriers to clinical adoption, inform relevant processes for monitoring and feedback to enable more rapid uptake of new and more effective practices, and in co-designing with the policy lead the implementation and scale-up protocols for incorporating new approaches to care.

  • The policy lead will be a recognized leader within the health system who has a vision for innovation and transformation, is committed to evidence-informed policy-making, and has authority about health policy or the delivery of health services. He/she will be responsible for: assessing the policy and system impacts of proposed innovations in primary and integrated care; identifying the resource, management and policy changes that may be needed for effective transition to a new approach to delivery; engaging with policy and decision makers across ministries/departments within and outside of health; co-designing with the clinical lead the implementation and scale-up protocols for incorporating new approaches to care; identifying the financial, cost and resource indicators that need to be assessed to determine value in the science and feedback and monitoring protocols; and negotiating and coordinating the requirements for evidence-informed change with all relevant stakeholders.

  • The science lead will be a recognized leader and researcher, ideally with expertise in primary and integrated models of care and a vision for innovation and transformation. He/she will be responsible for developing and coordinating the expertise within the research community to work with the clinical and policy leadership to: ensure the views of patients and citizens are included in the work of the pan-Canadian SPOR Network; synthesize relevant scientific knowledge and identify important gaps to inform and guide the proposed approach; develop innovative, cost effective, patient-centered and evidence-informed approaches to care; develop the local and national research protocols for comparative effectiveness assessment, including characterizing and measuring the attributes of different approaches to care and linking with provincial evaluation initiatives in primary healthcare and other sectors of care as appropriate; identify/develop relevant indicators to assess outcomes that are relevant to all stakeholders; and publish and disseminate new knowledge generated through research in traditional and non-traditional venues, as appropriate (e.g, peer-reviewed publications, policy briefs, patient brochures and websites, etc.).

In addition to the science, clinical and policy network leads, the member network team involves relevant stakeholders (e.g., policy makers, healthcare providers, researchers, patients/citizens/informal careproviders) with the required experience and expertise to bridge existing silos in care to achieve primary and integrated health care transformation in the member network’s jurisdiction.

2. Strategic Scope: The member network will focus on new approaches to the delivery of primary and integrated care both horizontally and vertically across the care continuum to address: individuals with complex needs across the life course, showing capacity to evolve the network's scope over time to include age groups from children to older adults; and multi-sector integration of upstream prevention strategies and care delivery models:

  • Individuals with complex needs across the life course including age groups, from children to older adults: This subgroup of the population has high health needs and accounts for a significant amount of health services use and costs. Their heavy use of health care services is attributable to a number of complex and interdependent health and system-level factors, including poor health, inadequate access to primary and preventive care, suboptimal (or entirely absent) social services, and fragmented service delivery as well as individual, social and structural determinants of health that lead to or reinforce conditions of vulnerability (e.g., stigmatization, frailty for the elderly). Individuals with complex care needs are often identified in the literature as a medically and socially vulnerable population sub-group including, but not limited to, older adults with multiple chronic conditions, the frail elderly, those with multiple co-morbidities, those with mental illness, Aboriginal peoples, children with complex care needs, and individuals of low socio-economic status and living in conditions of vulnerability;2,3,4 and

  • Multi-sector integration of upstream prevention strategies and care delivery models:
    Assessing the upstream predictors of high and complex health care needs and developing corresponding prevention strategies that are integrated with community-based primary health care delivery models has the potential to decrease the burden and cost of treatment and improve overall health and well-being across the life course. Moreover, the health of individuals can be threatened if they live in conditions of vulnerability influenced by individual and structural determinants of health (e.g. age, socio-economic status, sex and gender, sexuality, developmental/functional, disability, inability to communicate effectively, racial/ethnic background, geography, racial discrimination, poverty, poor housing and inadequate social assistance programs). For instance, these can include Aboriginal children and their families and others living in vulnerable circumstances. These conditions must be tackled through upstream strategies involving sectors within and outside of health (e.g. education, social services, transportation, housing, etc.).

3. Engagement of Key Stakeholders in Primary and Integrated Care Re-Design: To address the complex care needs of individuals across the life course, and to ensure multi-sector integration of upstream prevention strategies and care delivery models, a comprehensive stakeholder engagement strategy that fosters meaningful and sustainable engagement in the re-design, implementation and evaluation of primary and integrated health care is needed. To foster horizontal and vertical integration and transitions across care, the engagement strategy must effectively bridge silos in social services, community-based primary health care, public health, acute care and long-term care (e.g. home care, ambulatory specialty care, pre-hospital emergency care, rehabilitation, counseling, community pharmacies, long term and palliative care, community support and advocacy groups). It must also involve other key sectors that influence the determinants of health (e.g., housing, education, transportation, employment).

4. Patients/citizens/informal care providers: A key enabler of innovation will be to develop mechanisms of harnessing the rich experiences, perspectives and recommendations from patients/citizens/informal care providers, including family members and friends, who are part of the system and the clientele for its services. Member networks must include meaningful mechanisms for patients/citizens/informal care providers engagement in its core activities (e.g.planning the network and its research, designing and conducting studies, interpretation of results, disseminating results, monitoring change) and governance. It is expected that citizens, patients and informal caregivers will be active participants in the development and implementation of new, potentially more cost-effective and person-centered approaches to care and related research, they will be part of the decision-making process for planning small and large scale implementation and will contribute to the identification and development of indicators that measure patient experiences and outcomes.

5. Capacity for Rapid Evaluation, Monitoring and Feedback: A key requirement for each member network is the demonstrated experience or capacity to conduct rapid turn-around research to inform decision-making with complex multi-faceted interventions, provide timely monitoring and feedback to management and clinical care teams and policy leads in the network about progress and reporting on clinical, system-level and population-level outcomes and related costs. This will require demonstration of a meaningful and formal relationship between the network and its regional SUPPORT Unit (for regions where SUPPORT Units are in operation) or other organizationsand organizations such as SUPPORT Units and(e.g., Research Data Centres). The member network, supported by relevant organizations in their region their regional SPOR SUPPORT unit5 or other organization, will need to demonstrate that they can provide monitoring and feedback through data access within a three month timeframe through at least one of the following approaches:

  • Population-based Administrative and Financial Data: Timely access for researchers to linked administrative data for practice, system, and population level outcome monitoring of target populations of citizens and patients and costs. Demonstrated capacity to create meaningful process, cost and/or outcome indicators from the data that can be used to inform progress and evaluate the comparative cost-effectiveness of different approaches.

  • Electronic Health Record Data: These data include information from multiple point-of-care digital information systems that include electronic medical records, personal health records, laboratory and drug information systems, diagnostic imaging data and reports, home care and rehabilitation electronic records, and in future integrated care systems that manage the longitudinal continuum of care. The most rapid method of acquiring data for use in monitoring and evaluation in the future will be through these point-of-care digital systems. Each network will be expected to have a plan for how these data could be acquired and used in the future.

  • Patient-Reported Outcomes: The challenge in this decade is to develop more efficient methods of regularly collecting individual/patient-reported outcomes data than the traditional cross-sectional surveys that will allow new interventions and approaches to integrated primary health care to be monitored and evaluated on a real-time and temporal basis. The pan-Canadian SPOR Network in Primary and Integrated Health Care Innovations will support efforts for jurisdictional networks to develop and integrate new approaches to data collection in this area, along with the regional SUPPORT units. Each network will need a plan to collect information on patient-recorded outcomes. These include methods of reducing response burden for patient reported outcomes through computer-adaptive testing (e.g. NIH PROMIS project), improving the ease and timeliness of patient report through the use of mobile technologies or patient portals.

6. Implementing and Evaluating eHealth Solutions that could improve the Cost-effectiveness Primary and Integrated of Care Delivery: Each member network will need to demonstrate that it has capacity to embed and evaluate ehealth innovations or Smart Health Applications within primary and integrated care that include: (a) integrated solutions to support the continuum of personal and population-based care; (b) empower patients to manage their health conditions and improve health; (c) patient-centered care through personalized decision support; and/or (d) access to population and health system monitoring for prevention, early detection and intervention.

7. Partnership(s) with Academic Institutions, Health Policy and Delivery Organizations, and Other Partners to Develop Research Capacity in Primary and Integrated Health Care: The member network will provide new opportunities for research training (including embedded research within health policy and delivery organizations) in primary and integrated care. To ensure sustainability, these training opportunities will need to be integrated into graduate level training in clinical, health services, policy, and population health, and aligned with SUPPORT training plans and build on existing capacity that was created through previous programs where relevant (e.g. STIHRs, CADRE, etc.). Each network will be expected to document partnerships and potential partnerships how they have partnered with universities and their health professional and graduate level training programs to increase the number of graduate students trained, and the number of scientific faculty to provide training and mentorship.

8. Geographic Scope: One of the key factors that will determine the potential impact of a member network, and the SPOR Network in Primary and Integrated Health Care Innovations overall, is the extent to which Canadians, community-based practices and their patients/priority populations (specifically, individuals with complex needs across the life course) are directly involved. For example, in the United Kingdom, 80% of practices are members of the primary care research network. So as new findings emerge about the effectiveness of, for example new biomarker screening tests for cancer or case managers for chronic disease, all practices that are engaged in producing new knowledge become invested in applying these findings to practice. If this approach is coupled with policy and clinical leadership, then the implementation strategies needed for systems change can be optimized for more rapid scale-up and uptake of successful interventions as well as broad scale disinvestment in ineffective strategies.

The proposed 5-year goal for the pan-Canadian SPOR Network in Primary and Integrated Health Care Innovations is to have 25% of Canada’s population with complex care needs linked to primary and integrated models of care. Evidence suggests that individuals with complex needs account for approximately 5% of the total Canadian population. To achieve this proposed goal, networks need to demonstrate that the models of care that are linked to their network cover a minimum of 5% of the subpopulations of focus (e.g., individuals with complex needs) in their jurisdiction at the time of application, and have a viable plan to increase the network’s population coverage to specific targets in the first 5 years (Appendix 1).

For example, if a province has a population of 500,000, approximately 25,000 individuals (5%) are expected to be individuals with complex needs. Of this 25,000, it is expected that 1,250 (5%) are linked to the network at entry.

9. Linkage With Community-Based Primary Health Care Innovation Teams: The SPOR Network in Primary and Integrated Health Care Innovations will incorporate and build on existing CBPHC research and capacity assets in the country. The 12 recently funded CBPHC Innovation Teams are a key asset in Canada’s CBPHC landscape and, given their cross-jurisdictional mandate (including international in three cases), most member networks will have representatives of these teams within their jurisdiction. To build on synergies, and to incorporate advances in models of CBPHC and methodologies for cross-jurisdictional and international comparisons that the teams will pioneer, and scale up from successful CBPHC Team innovations, each member network will be expected to develop linkages with the local CBPHC team members within their network jurisdiction.

Moreover, teams will meet annually to develop and monitor CBPHC performance, innovation and impact using a common set of jointly defined indicators, which member networks can expand upon as new priorities are developed through the pan-Canadian Network.

10. Partnership Funding: The pan-Canadian Network embraces a partnership funding model (1:1 matching from CIHR) for all components of its structure, including member networks. Member networks must demonstrate partnership funding for the: (1) network development funds (with 75% required in cash); (2) network management and operations funds; and (3) priority research funding opportunities. A network’s partnership funding can come from a variety of public, private for-profit and/or private not-for-profit sources (e.g., ministries of health, social services, and/or education; provincial health research funding organizations; health charities; private foundations, etc.).

Appendix 1: Impact of Provincial/Territorial Networks Based on Population Size and Extent of Involvement

Province/Territory Population Census: 2012 Maximum Impact Factor (% of Canadians) by Population Scope of Provincial/Territorial Networks
Total Individuals with complex needs* At Full Application (5%) 5 years (10%) 10 years (25%)
British Columbia 4,400,057 220,003 11,000 22,000 55,001
Alberta 3,645,257 182,263 9,113 18,226 45,566
Saskatchewan 1,033,381 51,669 2,583 5,167 12,917
Manitoba 1,208,268 60,413 3,021 6,041 15,103
Ontario 12,851,821 642,591 32,130 64,259 160,648
Quebec 7,903,001 395,150 19,758 39,515 98,788
New Brunswick 751,171 37,559 1,878 3,756 9,390
Nova Scotia 921,727 46,086 2,304 4,609 11,522
PEI 140,204 7,010 351 701 1,753
Newfoundland 514,536 25,727 1,286 2,573 6,432
NWT 41,462 2,073 104 207 518
Nunavut 31,906 1,595 80 160 399
Yukon 33,897 1,695 85 169 424
Canada 37,876,745 1,893,837 94,692 189,384 473,459

*Individuals with complex needs figures are based on an estimate that they represent approximately 5% of the total population.

Footnotes

Footnote 1

This means that each lead cannot come from the same sector of care.

1

Footnote 2

Malone RE. (1995).

2

Footnote 3

LaCalle E. Rabin E. (2010). Frequent Users of Emergency Departments: The Myths, the Data, and the Policy Implications. Annals of Emergency Medicine, 56(1): 42-8

3

Footnote 4

Khan Y. Glazier RH. Rahim M. Schull MJ. (2011). A Population-based Study of the Association between Socioeconomic Status and Emergency Department Utilization in Ontario, Canada. Academic Emergency Medicine, 18(8)

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