Organizational Models in Community-Based Health Care: A Review of the Literature

Compnent 2 of Building a Stronger Foundation: A Framework for Planning and Evaluating Community-Based Services in Canada

W. John B. Church, Ph.D. ¹, L. Duncan Saunders, MBBCh., Ph.D.¹, Margaret I. Wanke, M.H.S.A.¹ , Raymond W. Pong, Ph.D.²

Prepared for the Federal/Provincial/Territorial Conference of Deputy Ministers of Health through the Advisory Committee on Health Human Resources
1995

¹ Healthcare Quality and Outcomes Research Centre
Department of Public Health Sciences
University of Alberta
Edmonton, Alberta

² Northern Health Human Resources Research Unit
Laurentian University
Sudbury, Ontario

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Executive Summary

Over the past decade Canadian provinces and territories have conducted extensive reviews of their health care systems. Current provincial and territorial health reform initiatives have placed a growing emphasis on community-based health services models.

In the context of this shifting policy emphasis the Federal/Provincial/Territorial Advisory Committee on Health Human Resources fielded a Request For Proposal for a project entitled: A Framework for Evaluation and Policy Decisions for Community-Based Health Care in Canada -Focus on Health Human Resources. The project has three major deliverables. The first component involves a systematic review and critical assessment of the literature on community-based health human resources. The second component involves a systematic review and critical appraisal of the literature on community-based health services models. The third component of the project involves the development of a terminology and a framework for evaluating and establishing policies related to community-based models. This summary highlights the second component of the project.

The objective of the second component of the project was to determine which organizational structures and organizational dimensions (modalities) result in higher quality and more cost-effective community-based health services. To achieve this objective the research team conducted a systematic search and critical assessment of the literature on community-based health services using pre-established criteria.

After a preliminary review of the available literature and the relevant policy questions, the team established an initial definition of community-based health services, and identified organizational characteristics and expected outcomes. Community-based Health Services Delivery Models were broadly defined as encompassing organizations or programs that are delivered closer to home, in non-institutional settings, and providing a spectrum of services. The organizational characteristics included: governance, service delivery approaches, service catchment, funding, and management structures. The outcomes identified included: sense of control (individual and collective), fairness (equity), value for money (cost-effectiveness), quality and outcomes of care, and quality of life.

The body of literature reviewed was established through a systematic search of the following: relevant on-line data bases; relevant unpublished government and academic studies; and relevant hard copy sources. The criteria used for the identification and review of relevant articles were derived from the definition of community-based health service delivery, and the modalities/outcomes matrix. There is a great need for methodologically strong studies comparing the outcomes of different modalities of community-based health care services delivery.

Preliminary findings based on the available literature are summarized below.

Governance

In the area of governance, the majority of the literature either attempted to interpret a phenomenon or provided opinion on a particular policy issue. The literature suggested that effective lay governance in the health sector has been impeded in three major ways: imbalanced resources; failure to empower communities or individuals; and, a lack of accountability to communities. In the past physicians and administrators have dominated health decision making because of their control over specialized knowledge. This has been reinforced by the tendency to frame health care decision making within the boundaries of technical knowledge.

The literature on citizen participation suggested there is no empirical evidence that community governance boards empower citizens in relationship to other stakeholders. The literature on patient choice suggested that, when provided with appropriate information about treatment options, patients are inclined to choose less invasive and less costly interventions.

Service Delivery

The literature on community-based health services models reviewed for this component indicated that, in general, integrated, multi service, multidisciplinary models are less costly, and more cost-effective, than comparable services provided by single-service providers and institutional providers. This is particularly evident when comparing the community health centre organizational model with solo fee-for-service physician practice. The major cost saving appears to occur through a reduction in the use of hospital outpatient and inpatient services by populations receiving services from community health centres. Community health centres also offer patients increased access to care.

Beyond community health centres, community-based services appeared to offer the potential for cost savings in the provision of continuing care for the elderly, mentally ill, children, and terminally ill patients. Studies on care of the elderly, prenatal care, children, the mentally ill, and the te rminally ill, indicated that community-based health services can lead to increased access to care, and better health outcomes at a lower cost than care provided by stand-alone providers or in institutional settings. Specifically, better outcomes have been recorded in the quality of life of the elderly, mentally ill, and terminally ill patients. In addition, better outcomes have been recorded for newborns when their mothers receive coordinated prenatal care. Quality of care improvements have been noted for these populations. However, additional research needs to be conducted in this area to determine the range of quality of life outcomes that are affected by the choice of service delivery modality.

Funding Approach

Either a population-based or needs-based approach or a combination of the two seemed likely to lead to a more equitable distribution of resources, and a focus on health outcomes. Implementing such an approach will require development of a valid proxy for measuring the health status of the population, and reliable mechanisms for gathering the data necessary to accurately track population health at the regional level.

Service Catchment Area

A clear definition of the service catchment area is an essential to decision making based on the health of the population, including assessing needs and allocating health care resources based on these needs. Unanswered important questions concerning CBHS include: the usefulness of geographic catchment areas for improving the population health; and, the optimum size of catchment areas.

Management Systems, Processes and Structures, and Outcomes

The literature on integration at a regional and/or system level was based largely on discussions of the facilitators and barriers to the integration of hospital systems in the United States. The consensus of the literature reviewed was that there are significant barriers to system integration associated with the existing distribution of power and resources. Overcoming these barriers will require strong leadership, a new corporate culture, clear vision, and integrated information systems.

Of particular importance, both in terms of successful implementation and costs, was the inclusion of physicians in decision making related to the process of change and the overall management of an integrated system. Several authors suggested that integration will not work unless physicians have been involved in decision making. The system must incorporate the preferences of the medical profession along with those of administrators and patients.

There was a consensus in the literature examined that, to date, there was no good empirical evidence to support the supposition that integrated systems were less costly than non-syst educational models and management practices, at least until more definitive models and approaches can be identified.