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MAKING PEOPLE- CENTERED CARE A REALITY
HOW ?
Dublin Castle. 6 October 2015
Rafael Bengoa
[email protected] October 2015
• SAME CHALLENGES ?
• SAME WHATS ?
• SAME HOWS ??
• Types of Hows - Instrumental Hows
- Change Management Hows
◦ Population : 2.3. million
◦ 320 Primary Health Centers
12 Acute Hospitals (4,278 beds)
4 Chronic Care Hospitals (524 beds)
Mental Health: Three regional networks with 4 psychiatric hospitals, (777 beds)
Staff: 25.816 (2012)
Beveridge type of NHS Basque Health Service
1.500.000
2.500.000
3.500.000
4.500.000
5.500.000
6.500.000
7.500.000
8.500.000
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
(*)
2012
(**
)
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
Realistic case Best case Worst case
WHEN NOT TO BECOME MINISTER !
DEMOGRAPHY
SAME CHALLENGES !! EPIDEMIOLOGY. CHRONIC CLINICAL COMPLEXITY
FRAGMENTATION. SILOS
EXPECTATIONS ECONOMIC
…
1992 1997 2002 2007
13.500 diagnósticos
6.000 medicamentos
4.000 procedimientos quirúrgicos
20.000.000 de actos clínicos
omplejidad
22 profesionales/ paciente
C
Más pacientes crónicos.
Más pluripatología
«No se puede hacer medicina del siglo XXI con el chasis de 1.970» . Bengoa
HEALTH SYSTEM JOURNEY*
REACTIVE ACUTE BIO-MEDICAL MODEL
POPULATION HEALTH. OUTCOME BASED PAYMENTACCOUNTABLE CARE BROADER
INTERSECTORAL HEALTH AND HEALTH DETERMINANTS
HEALTH IN ALL POLICIES
FINANCING
DELIVERY
PAYING FOR VOLUME
BUNDLED PAYMENT
GLOBAL PAYMENT
PAYMENT FOR VALUE & VOLUME
DBS HealthR. Bengoa / P. Arratibel
INDIVIDUALMEDICAL CARE
FRAGMENTED CARE PASSIVE PATIENT
INTEGRATED+ CONNECTED CARE
ACTIVE PATIENT. ACCOUNTABLE CARE ORGANIZATIONS
LOWER COST
TRIPLE AIM
PEOPLE-CENTERED CARECOORDINATED CHRONIC CARE
FINANCING COMMUNITY DEVELOPMENT
BROADERSTAKEHOLDER INVOLVEMENT
INFORMAL/FORMAL NETWORK & CIVIL SOCIETY
POLICY
STRATIFIED PREVENTIVE CARE
* We asume the intermediate stage of population health/accountable care is a key step towards broader intersectorial work. However, one can be doing intersectorial work simultaneous to moving along this journey.
MORE AT HOME MORE IN
PRIMARY HEALTH CARE
LESS IN HOSPITALS
MORE IN THE COMMUNITY
DIRECTION OF TRAVEL …
MORE PREVENTION
• ATTACK INEQUALITIES
• BETTER CHRONIC CONDITIONS MANAGEMENT
• GET BEYOND FRAGMENTATION OF CARE
• IMPROVE PATIENT-CENTEREDNESS & EMPOWERMENT
• IMPROVE QUALITY AND PREVENTION
• MOVE TOWARDS POPULATION HEALTH MANAGEMENT.
• FISCAL SUSTAINIBILITY
SAME POLICY INTENT
LOCAL INTEGRATED ORGANIZATIONS
SWEDEN “ Local health care- chains of care”U.S.A “Accountable Care Organizations”(ACOS)
SCOTLAND “Health & Social Care Partnerships”ENGLAND “Integrated care pioneers” Vanguard Sites N. IRELAND “Integrated care partnerships”NEW ZEALAND “Locality clinical partnerships» (LCP)SPAIN (BASQUE COUNTRY) “Sistema Local Integrado” ( OSI )NETHERLANDS “ Care Groups”IRELAND --------------------------------------------
NOT ALONE ON THIS JOURNEY !!
Instrumental “Hows”
Unprecedented Management “Arsenal”!!
• Electronic medical records
• Electronic prescription
• Telemedicine, telecare, telemonitoring
• Risk Stratification
• Outcome based payment schemes
• Integrated care
• Coordination Health & Social Care
• New professional roles (nursing)
• Patient Empowerment & self-management
• Third sector participation
• Transformation of subacute facilities
• New Metrics: meassure value and outcomes ; not only activity
STRUCTURES“COMMUNITY”
SYSTEM
• Managing Structures
• Fragmentation
• Reactive episodic care
• Paternalistic
• Vertical leadership
• Financing structures
• PATIENT CENTERED.
• Continuity of care
• Proactive system
• Patient empowerment
• Decentralized leadership
• Paying for value
• Health & social care coordination
Vs. PATIENT
T MOVING TO POPULATION MANAGEMENT !
WE HAVE “SYSTEM” FRAMEWORKS
13
R. BENGOA/J. MORA
BASQUE COUNTRY …
TOP- DOWN
STANDARIZABLE INTERVENTIONS
CALL CENTER
ELECTRONIC
MEDICAL
RECORD
FINANCING AND
JOINT
COMMISSIONING
ELECTRONIC
PRESCRIPTIONSTRATIFICATIÓN
CASE
NURSING PACIENT
EMPOWERMENT HEALTH AND SOCIAL
CARE COORDINATION
SUBACUTE
CENTRES
INTEGRATED
CARE
BOTTOM UP
LOCAL INNOVATION
POPULATION
HEALTH
MEDICINE
EFFICIENCY
TRIPLE
AIM
14
Año 2009-2010 2011 2012
MORE AT HOME MORE IN PHC LESS IN HOSPITALS
A STRATEGY TO TACKLE CHRONICITY IN THE BASQUE COUNTRY
LEAN ON EARLY WINS BILBAO INTEGRATED AREA (TELBIL PROJECT)
Telemonitoring of home-based chronic patients with COPD and HF
• Reduction in admisssions : 27%
• 2,5 days shorter stay in every admission (9,6 versus 12,2 days)
• Punctuation in funcional scale: better in intervention group
• Satisfaccion rate : 81% patients very satisfied
• 77% of patients refers better control of their illness
16
LEAN ON GROWING INTERNATIONAL EVIDENCE…..
•Results seem to support new payment models:
• Improvements in quality
The Alternative Quality Contract (AQC)
.Measures not related to incentives do not improve
The Alternative Quality Contract (AQC)
Expenditure ….
Fuente: http://www.bluecrossma.com/visitor/about-us/affordability-quality/aqc.html
The Alternative Quality Contract (AQC)
• SAME CHALLENGES ?
• SAME WHATS ?
• SAME HOWS ??
• Types of Hows - Instrumental Hows
- Change Management “Hows”
HEALTH SYSTEM JOURNEY*
REACTIVE ACUTE BIO-MEDICAL MODEL
POPULATION HEALTH. OUTCOME BASED PAYMENTACCOUNTABLE CARE BROADER
INTERSECTORAL HEALTH AND HEALTH DETERMINANTS
HEALTH IN ALL POLICIES
FINANCING
DELIVERY
PAYING FOR VOLUME
BUNDLED PAYMENT
GLOBAL PAYMENT
PAYMENT FOR VALUE & VOLUME
DBS HealthR. Bengoa / P. Arratibel
INDIVIDUALMEDICAL CARE
FRAGMENTED CARE PASSIVE PATIENT
INTEGRATED+ CONNECTED CARE
ACTIVE PATIENT. ACCOUNTABLE CARE ORGANIZATIONS
LOWER COST
TRIPLE AIM
PEOPLE-CENTERED CARECOORDINATED CHRONIC CARE
FINANCING COMMUNITY DEVELOPMENT
BROADERSTAKEHOLDER INVOLVEMENT
INFORMAL/FORMAL NETWORK & CIVIL SOCIETY
POLICY
STRATIFIED PREVENTIVE CARE
* We asume the intermediate stage of population health/accountable care is a key step towards broader intersectorial work. However, one can be doing intersectorial work simultaneous to moving along this journey.
FOCUS ON “SYSTEM BLINDNESS” AT THREE LEVELS !
FOCUS ON ALIGNMENT OF THREE LEVELS
24
AT THE POLICY LEVEL….
• VISION. A COHESIVE STRATEGY • PROVIDE A NARRATIVE THAT GOES BEYOND “COST CONTAINMENT”
• RAISE THE ISSUE TO THE POLICY AND POLITICAL LEVEL
• REACHABLE
• FUND TRANSFORMATION
R. Bengoa
BASQUE COUNTRY
THE VISION WAS CHRONICITY
cronicidad.blog.euskadi.net/.../ChronicityBasqueCountry
SOME TOP DOWN IS NECESSARY ….
- Some level of “orquestration” from above but seeking to identify commitment rather than compliance
- Key element of the “orquestration” is from the payment reforms ( value) rather than from micromanagement of providers.
A LOT OF “BOTTOM UP”
• DEVELOPED A “HIGH INVOLVEMENT CULTURE” WITH HEALTH CARE PROFESSIONALS.
• DEVELOPED AN ENVIRONMENT WHERE LOCAL PROVIDERS COULD INNOVATE ORGANISATIONALY.
• ADDRESS SCALABILITY WITH LOCAL SELF - DISCOVERY : UNLOCKED THE BENEFITS OF LOCAL HEALTH CARE INNOVATION
• REINFORCE RESEARCH AND POLICY CAPACITY
Hospitales
Atención Primaria
Mejor Eficiencia Interna
Utilización de tratamiento Menor costo
Reducción de Eventos Adversos
Reduccion de Reingresos
Mejor Prevención + detección temprana
Más eficiencia interna
Reducción de Pruebas+Desviaciones Innecesarias
Reducción visitas a urgencias prevenibles
MÁS
SALUD
MENOR
GASTO
Mejor Gestión de Pacientes complejos
Utilización de estructuras menos caras
Fuente: The Dartmouth Institute 2013
EARLY WINS
• EARLY WINS YES BUT NOT “YOUR” EARLY WINS. • RATHER ENCOURAGE EARLY WINS TO BE LOCAL.
• ALLOW MODELS WHICH PERMIT LOCAL ORGANIZATIONS TO RETAIN SOME OF
THE EFFICIENCIES FOUND.
• THIS WILL GIVE THOSE WINS SUSTAINIBILTY OVER TIME
MANAGE TWO AGENDAS
• “RESIST” CULTURE
• TOUGH BUT DOES NOT CHANGE STATUS QUO
• TRANSFORMATIVE CULTURE
• TOUGH BUT DOES CHANGE STATUS QUO
&
LOW HANGING FRUITHIGH HANGING FRUIT
WHAT WOULD I DO DIFFERENTLY ?
• CHANGE DOESN ´T JUST HAPPEN. IT MUST BE MANAGED ACTIVELY BY TOP MANAGEMENT
• FOCUS MORE ON HOW. THAT IS THE DIFFICULT JOB
• SPEND EVEN MORE TIME ON HIGH HANGING FRUIT
• ENSURE TOP TEAM SHARES SAME STRATEGIC COMMITMENT
• FOCUS ON GETTING BUY-IN: STOP CASCADING STUFF DOWN AND REINFORCE “BOTTOM UP
• ALIGN FINANCE TO THE STRATEGY
&LOW HANGING FRUIT HIGH HANGING FRUIT
