As the prevalence of chronic disease steadily increases in our aging society the awakening of the medical world to the importance of non-medical aspects of health is burgeoning. Best practice guidelines and algorithms, though essential, need to be taken in the context of the individual.  Most chronic conditions do not occur in isolation but co-exist with one another, each taking center stage at any given time or place. 

Take the classic triplet of congestive heart failure, COPD and diabetes.  These conditions intersect in a magical way that has the individual managing multiple medications, dietary restrictions and recommendations, monitoring activities as well as dealing with frightening symptoms such as not being able to breathe, chronic pain from deconditioning or diabetic neuropathy along with the depression and anxiety that inevitably arises.  Throw low income and social isolation or a language barrier into the mix and you can see why it can be so difficult for many to “self-manage”

It has long been recognized that an “interdisciplinary” approach to care better supports patients living with chronic illness than the “doctor knows best” one and team-based care is touted again and again in health care literature and in health system planning. So what does this really look like?

When talking about interprofessional practice, we often rely on referral-based system design. 

When someone has back pain, refer them to physio, when someone has a mental health condition refer them to counselling, smokers to smoking cessation programs, people with chronic disease to dieticians, nurses self-management programs and so on.   On the surface, this seems reasonable and makes us feel holistic, but it is not really integrated care.  It is simply more comprehensive and complicated siloed care.

Firstly, programs we refer to have capacity limitations that lead to long wait times and restrictive eligibility criteria.  Community resource mapping a maze of organizations providing specialized programing that require a “system navigator” to sort through.  Then, once a patient is hopefully connected to the right program, a referral-based system usually indicates a one-way communication pathway usually in the form of a summary of the initial assessment. Ongoing collaboration through bidirectional communication, let alone multi-directional is not supported by our system design and health information infrastructure.  Not only that, our siloed perspectives often prevent us from normalizing integrated care efforts. Reaching out to another provider involved in a mutual patient’s care is the exception, not the rule.  

Referrals are also primarily provider centric- “Ms. A, I am going to refer you Dr. S and Physiotherapist M and diabetes nurse B.  someone will call you with the appointments.  No, I can’t tell them you need evening appointments…”. If the goal is person centered and directed care, referral-based systems miss the mark and cannot be the foundation we use for integrated care.

Ontario Health teams have an opportunity here to redesign and reshape how we set up and support inter-professional team-based care for people living with chronic conditions. Seamless patient driven connections, informational continuity, a platform for provider collaboration and communication and a flexibility of service that rises above “we don’t do that” mentality to “what do you need the most” one. 

This is challenging.  Not only does it deviate from the way we have always done things but also will force organizations and funders to learn to define and measure value and performance differently. 

But then again, that is what transformation is about, right?