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Introduction: In Canada, Ontario Health Teams(OHTs) have been formed to drive integrated healthcare for a group of providers who will be clinically and fiscally responsible for delivering a continuum of care to a designated population. How clinical populations are defined, and their care is addressed, is a challenge in communities where seasonal visitors outnumber year-round residents. Of the 50 teams approved to date, Muskoka and Area OHT is responsible for one of the smallest patient populations yet largest geographies in the province. Collaborative community leadership required bespoke data analyses tailored to ensure care integration efforts were relevant to local healthcare realities.Aims/ObjectivesTheory or Methods:A case study showcasing the efforts of one geographically challenged OHT will be presented, in which the value and challenges of using linked administrative health data for retrospective analysis will be discussed in the context of:1.Patient engagement and integrated care planning;2.Local clinical leadership and health system transformation; 3.Embedded research capacity and the OHT Impact Fellowship Program; 4.Utilizing Ontario’s health data repositories for systems planning; 5.Standardized measures of attributable populations and provincial metrics; 6.Northern and rural healthcare realities in Ontario, Canada; and 7.Local healthcare needs and care integration activities. Highlights or Results or Key Findings: Health Intelligence efforts to define and drive care is influenced by the scale of analyses (i.e. province-wide, or at the level of an OHT’s attributed population, or specific clinical populations). Unintentional generalizations relevant to one geography, can cause misalignment of models with others, particular in contexts where determinants of health are distributed in a non-random fashion. Leveraging the province’s extensive health data repositories was proven essential for local analysts to paint a true picture of how care is delivered within the Muskoka and Area OHT, and how strategic planning, population segmentation, and care pathway development must be constructed to be applicable to the local Barnett: Decisions and datamining in a rural Ontario Health Team (Canada): How looking into our past drives innovation and care integration. context. Forward thinking clinical leadership, political acumen, and project management expertise was essential in acquiring and applying required datamining expertise. Conclusions: Relying on health has proven essential to local understanding of existing metrics and patient flow intelligence to inform strategic directions and population management plans. Ontario benefits from strong health data infrastructures and expertise, however smaller OHTs rarely have such capacity locally. Standardized measures require local refinement for successful care transformation.Implications for applicability/transferability, sustainability, and limitations: This study speaks to a single experience and has all of the strengths and limitations of observational research. The principles and practices discussed, however, are applicable across teams seeking to define their local care contexts to drive transformation. Disadvantaged northern and rural communities may benefit disproportionately. |
