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CRITICAL PATHWAY AND HEALTH CARE REFORMS
SANGEETHA ANTOE M.Sc (N)
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INTRODUCTION
• Successful case management relies on critical pathway to guide care
• Critical pathway refers to the expected outcomes and care strategies developed by collaborative practice team
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HOW TO DEFINE..
• Critical paths are guides that outline the critical or key events expected to happen each day of patient’s hospitalization
-Cohen & Cesta,2001
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HOW TO DEFINE..(2)
• Critical pathways are one method of planning, assessing, implementing and evaluating the cost- effectiveness of patient care
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HOW TO DEFINE..(3)
• A series of methods and instruments to allign member of the interdisciplinary and interprofessionally team for the care of the pre defined patient population in order to realize an efficient, patient centered, co-ordinated program of care
-Sermeus & Vanhaecht,2002
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SYNONYMOUS
• Integrated Care Pathways• Multidisciplinary pathways of care • Care Maps • Collaborative Care Pathways• Clinical pathway• Critical pathway• Care track• Care pathway• Anticipated recovery path• Managed care plans
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WHAT ARE ITS FEATURES..
• Predetermined course of progress
• Variance analysis
• Fiscal planning
• Directing
• Orientation
• Identifies outcome
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WHAT DOES IT CONTAINS..
• Specific medical diagnosis• The expected length of stay• Patient identification data• Appropriate time frames (in days, hours,
minutes or visits) for intervention• Patient outcomes• Interventions presented in modality
groups ( medications, nursing activity & so on)• Nursing diagnosis
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What it is actually….
• Clinical tools that organize, sequence and time the major interventions of the nursing staff, physicians, for a particular case type, condition, diagnostic category or nursing diagnosis
• Describe an institutions collective standard of practice, clinical budget
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What it is actually….
• Provides direction and predictability to patient care and to caregivers interacting in that case
• Shows something that must occur in the sequence before one may proceed.
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COMPONENTS
• Clinical Pathways have four main components (Hill, 1994, Hill 1998):
1. a timeline
2. the categories of care or activities and their interventions
3. intermediate and long term outcome criteria
4. and the variance record
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How to develop critical pathway
Professional involved….• Physician• Nurse manager• Staff nurse• Social worker• Dietician• Occupational therapist• pharmacist
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How to develop critical pathway
• Retrospective chart review or concurrent chart review
• identify costs associated with the treatment
• Pathway development teams are organized to develop the tool
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How to develop critical pathway
• Patient care expectations and critical events are identified for incorporation into the path
• Small groups within the development to refine the elements of the path
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How to develop critical pathway
• Newly developed tools can be tested on previously admitted patient
• Implementation with collaboration with other professionals
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Critical pathway analysis
• Analyze the effectiveness
• Variance analysisPositive varianceNegative variance
• Consult with other professionals
• Make change accordingly
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What is your role as Nurse manager
• Assess quality improvement• Effective planning• Evaluate quality• Interdepartmental Communication • Educating the staff of other departments about
the pathway role and responsibilities.
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What is your role as staff Nurse
• Provides patient care
• Follow critical pathway
• Inform any deviance
• Collaborate with other professionals
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Its advantages are……• Provides standardizing medical care for
patients with similar diagnosis• Use resources appropriate to the care needed• Reduce cost• Reduce length of stay• Improve the quality of care• Change practice pattern to increase efficiency
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Its advantages are…• Improves care outcomes
• Use multiple disciplines and services efficiently
• Sense of satisfaction
• Can support continuity and co-ordination of care across different clinical disciplines and sectors
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Its advantages are…
• Support the introduction of evidence-based medicine and use of clinical guidelines
• Support clinical effectiveness, risk management and clinical audit
• Improve multidisciplinary communication, teamwork and care planning
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Its disadvantages are…
• Differences between unique patients
• One more paper work
• Overburdened with administrative cost
• Problems of introduction of new technology
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Its disadvantages are…
• Require commitment from staff and establishment of an adequate organizational structure
• May take time to be accepted in the workplace
• Need to ensure variance and outcomes are properly recorded, audited and acted upon.
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HEALTH CARE REFORMS
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INTRODUTION
• Health care reform is a general rubric used for discussing major health policy creation or changes for the most part, governmental policy that affects health care delivery in a given place
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Introduction
• Despite various development plans, lack of or inadequate basic infrastructure, both social and physical, continues to remain a major constraint to progress in many parts of our country
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Definition
• Health care Reform is defined as a sustained, purposeful change to improve the efficiency, equity and effectiveness of the health sector’
-(Berman 1995).
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AIMS
• Broader the population that receives health care coverage
• Improve the access to health care specialists
• Improve the quality of health care
• Decrease the cost of health care
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Reform strategies
• alternative financing (user-fees, health insurance, community financing, private sector investment)
• institutional management (autonomy to hospitals, monitoring and management by local government agencies, contracting)
• public sector reforms (civil service reforms, capacity building, productivity improvement); and
• collaboration with the private sector (public/private partnerships, joint ventures)
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A.N.A PROPOSA L FOR HEALTH CARE REFORM
• Health care delivery system restructuring• Universally available standard health care
package• Phase in of services, initial emphasis on
pregnancy and children• Changes to reflect changing national
demographics
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A.N.A PROPOSA L FOR HEALTH CARE REFORM
• Long term care coverage• Insurance reform• System review and evaluation• Case managed health care• Decreased health care costs.
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Health care reforms in various countries
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THE NETHERLANDS
• Health care insurance based on risk equalization • compulsory insurance package is available to all
citizens at affordable cost without the need for the issued to be accessed for risk
• Health insurers are now willing to take on high risk individuals because they receive compensation for the higher risks
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RUSSIA
• Compulsory medical insurance with privately owned providers in addition to state run institutions
• Health care reforms in 2011 allocate more than 300 billion rubles to improve health care in country
• Medical insurance tax paid by companies for compulsory medical insurance will increase from current 3.1% to 5.1% from 2011
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TAIWAN
• Taiwan changed the health care system in1995 to National Health Insurance model
• As a result 40% who had been previously uninsured are now covered
• 72.5% are happy about it, but they are unhappy about the cost of premium ($20/ month)
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UNITED KINGDOM
• Private sector health care is quiet small (15%)• Focus is on prevention of ill health• Baby formula milk fortified with vitamins and
minerals to improve the health of the children• Measles, mumps & chicken pox were mostly
eradicated with national programs of vaccination
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UNITED STATES
• 17% of GDP is spent on health care, but 77% of Americans have at least one chronic disease
• U.S ranks 31st in life expectancy and 40th in child mortality
• Health care system ranks 37th among nations• Therefore the reforms are concentrating on
reducing the cost of health care rather than on improving outcomes
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UNITED STATES• The mixed public private health care system in
U.S is the most expensive in the world• Greater portion of GDP is spent on it• According to 2008 common wealth fund report,
U.S ranks last in the quality of health care among developed countries
• WHO,2000 ranked U.S health care system 37th in overall performance & 72th by overall level of health
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UNITED STATES…
• U.S Government provides health care to just over 25% of its citizens through various agencies but otherwise does not employ a system
• Health care is generally centered around regulated private insurance methods
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GERMANY
• Sickness fund- but able to opt out if they have a very high salary
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SWISS
• Use more of privately based health insurance system where citizen are risk rated by age and sex, among other factors
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HEALTH IN INDIA
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INDIAN SCENERIO
• 37% of Indian population is undernourished• 55% have a diet which is calorie sufficient but
nutrient deficient• 8% is over nourished• Total imbalance of nutrition leads to anemia, TB
and many disease which increases the disease burden
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INDIAN SCENERIO…
• Arthritis. HT, DM, CVD, cancer and elderly increases the disease burden
• 65% of Indian population lives in rural areas while only 2% qualified medical doctors are available
• Government spending on Health care continues to be one of the lowest in the world
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INDIAN SCENERIO…
• Penetration of Med claim is currently done by state-owned insurance companies, covering only about 2.5 million people i.e. less than 0.50% of the country’s population
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INDIAN SCENERIO…
• Report on National Commission on Macroeconomic and Health, 2005Households undertook nearly three- fourths of all
health spendingPublic spending was only 22%Public private health spending ratio : In India-1:4 In China- 2:3 In Pakistan- 1:3
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Indian health care is expected to double between 2009 and 2012.
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Health ExpenditureCentral Government :05.2%
State Government :15.2%
Municipal Corp. & Private Donors:01.3%
Insurance & Third party: 03.3 %
Out of Pocket: 75%
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Public private share of care
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Outpatient Care
Hospitalization
Institutional Deliveries
Antenatal Care
Immunizations
Public-Private Sector Shares
Private Public
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Private Health Service Providers
• World Bank (2004) estimated that at independence the private sector in India had 8% of health care facilities. Today 93% of all hospitals, 64 %of beds, 80-85% of doctors, 90% of out patients and 60% of inpatient are in private sector.
• Private health sector has over 71,000 crore market in India
• The CII McKinsey report of 2004 expects it to grow to 156,000 crore by 2012
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Reasons for lack of access to Govt facilities
• Better availability
• Convenience
• Perceived quality of private care
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Health expenditure in India is dominated by private spending and inadequate public spending has become a common feature
%
Brazil 3.2
Korea 1.8
Thailand 1.2
China 0.7
India 0.9
Inter- country comparison of public expenditure onHealth as a % GDP
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1.5 3.33.3
Nurses Per ’000 pop
2001*
Per ’000 pop
2001* Per ’000 pop
2001*
Physicians Beds
1.5
1.5
4.3
7.4
1.2
1.0
1.8
1.8
0.9
1.6
7.5
India
Other low income countries (e.g., sub-Saharan Africa)
Middle income countries
(China, Brazil Thailand, South
Africa, Korea)
High income countries (e.g., US, Western Europe, Japan)
World average
1.9
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HEALTH CARE REFORMS IN INDIA
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GOI is adopting alternative means of financing such as seeking loans from the World Bank and other international financing institutions to upgrade and manage the labour welfare and health programs (such as National Family Welfare Program and Employee State Health Insurance Scheme) in the country
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ESTABLISHMENT OF CORPORATE HOSPITALS
• GOI has encouraged the establishment of corporate hospitals in order to improve the quality of healthcare.
• These corporate hospitals have tie-ups with most
insurance companies and large business organizations to provide superior healthcare for the employees.
• Eg: Apollo Hospital chain, Escorts Hospital, Tata Memorial Hospital, Max Healthcare, and Fortis Hospital chain from Ranbaxy
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Employee health care reform in India
• Economic reforms was launched in India in 1991
• In addition to the involvement of the public and private sector corporations, various government, international and multi-lateral health agencies, and other private stakeholders such as private health insurers got involved in the reform process.
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Social Insurance Scheme
• Covers only 3% of population
• Employees State Insurance Scheme (ESIS)
• Central Government Health Scheme (CGHS)
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The Employee State Insurance
• ESI provides six social security
benefits to employees:
1. Medical benefit
2. sickness benefit
3. maternity benefit
4. disablement benefit
5.dependant’s benefit
6. funeral expenses
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ESIC
• Insurance system which provides both cash and medical benefits
• Spread over 677 centers in 25 states & union territories across India, covering 7.8 million employees and more than 25 million beneficiaries
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Public Private Partnership
• means to bring together a set of actors for the common goal of improving the health of a population based on the mutually agreed roles and principles
-WHO 1999
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Public Private Partnership
• Entrusting Health Centers to NGOEntrusting Health Centers to NGO
Special features: PHC and CHCs handed over to
NGOs Finances managed by Govt. Operations managed by NGO
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It is employed in
• disease surveillance
• purchase and distribution of drugs in bulk
• contracting specialists for high risk pregnancies
• national disease control programs
• adoption and management of primary health centers
• contracting out medical education and training
• engaging private sector consultants
• Telemedicine
• Contracting out of Information, Education & Communication (IEC) services
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Community based Participatory research
• Medical officers to use community based participatory research to partner with community and develop, test and disseminate programs that they can sustain and improve health.
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NRHM
• National Rural Health Mission was launched 12 th April, 2005 with an objective to provide effective health care to the rural population
• improving access• enabling community ownership• strengthening public health systems for efficient
service delivery• Enhancing equity and accountability • Promoting decentralization
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Janani Suraksha Yojana and ASHA
NRHM JSY
Antenatal Check up
Institutional Care during delivery
Immediate post-partum
(coordinated care)
↑↑Institutional Deliveries
in BPL families
↓↓ all MMR & IMR
Cash assistance
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DECENTRALIZATION
• Transfer of political ad economic power to local levels of government.
• Delegation of powers to Medical officersDelegation of powers to Medical officers
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Decentralized Planning
• “District Health Mission” at the District level and the “State Health Mission” at the state level
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Strengthening Public Health Delivery in India
• New concept of Indian Public Health Standards introduced
• Indian Public Health Standards (IPHS) are set of standards envisaged to improve the quality of health care delivery in the country under the National Rural Health Mission.
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Strengthening Sub-centres
• Each sub-centre will have an Untied Fund for local action @ Rs. 10,000 per annum.
• Maintaining Logistics: Supply of essential drugs, both allopathic and AYUSH, to the Sub-centres.
• Postings of Additional ANMs wherever needed
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Strengthening PHCs
• Infrastructure Strengthening as per IPHS guidelines
• Adequate and regular supply of essential quality drugs and equipment (including Supply of Auto Disabled Syringes for immunization) to PHCs
• Provision of 24 hour service in 50% PHCs
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Strengthen CHCs
• Infrastructure strengthening by implementation of IPHS standards
• Developing standards of services and costs in hospital care
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Sanitation and Hygiene
• Total Sanitation Campaign (TSC) implemented through guidance of District Health Mission
• Components of TSC include IEC activities, rural sanitary marts, individual household toilets, women sanitary complex, and School Sanitation Programme
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Strengthening Disease ControlMechanisms
• National Disease Control Programmes have been redefined and updated
• New Initiatives launched for control of Non Communicable Diseases.
• Disease surveillance system have been decentralized with the launch of IDSP
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Human Resources
• Appointment of Contractual staffAppointment of Contractual staff
• Interest free loan for two wheelers to Interest free loan for two wheelers to ANM ANM
• Reorganization of the entire cadre of Reorganization of the entire cadre of PMOPMO
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• Ur ba n Heal t h c a r eUr ba n Heal t h c a r e Lack of health infrastructure in urban areas. Project proposed for primary health care in
urban slums. Towns with less than one lakh population to be
covered.1 FHW per 25,000 population and 1 FHV per
1,000 population in urban slums.
Reorganization & Restructuring
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Improving MIS through computer applications.
• GIS applicationsGIS applications Village-wise Data of prevalence of disease Utilized for micro-planning of disease control
activities
• Web based reporting of RCHWeb based reporting of RCH At state level computer generated reports are
received
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School Health check-up Programme
• Check up• Referrals• Preventive measures• Treatment• Submission of report• Remedial measures
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MEDICAL TOURISM
• India is a popular destination for medical tourist who receive effective medical treatment at lower costs than in developed countries
• As the Indian healthcare delivery system strives to match international standards the Indian healthcare industry will be able to tap into a substantial portion of the medical tourism market
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MEDICAL TOURISM
• Reduced costs, access to the latest medical technology, growing compliance to international quality standards and ease of communication all work towards India’s advantage
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MEDICAL TOURISM
• A recent CII-McKinsey study on healthcare says Medical Tourism alone can contribute Rs. 5,000-10,000 crores additional revenue for tertiary hospitals by 2012, and will account for 3-5 per cent of the total healthcare delivery market.
• What India needs to do is to strengthen basic infrastructure like Airports, Power, Roads etc. to support these initiatives.
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PROBLEMS
• lack of sufficient evidence based information about, and the impact-assessment of various initiatives
• Providing employee health insurance cover is not a mandatory requirement in the private sector in India till now
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PROBLEMS
• Local authorities have been given authorities to implement national programmes but there is no financial authority
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FICCI Healthcare Excellence Awards 2009
State Government with Excellence in Reforms
• Government of Tamil Nadu
• Government of Gujarat
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As a NURSE
• Nursing personnel must understand the magnitude of this health challenge and take coordinated action to promote healthy lifestyles, prevent disease and provide health care to those in need.
• taking preventive, promotive and rehabilitative primary healthcare services to the doorsteps of our citizens
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