Thinking outside the health care box: innovative ... · to share and transfer data, silo-based working, and embedded cultural behaviours; • care and treatment by different care

A movement for changewww.integratedcarefoundation.org @IFICinfo

Thinking outside the health care box:

innovative partnerships in integrated

care around the world

Dr Viktoria Stein

Head of the Integrated Care Academy©

International Foundation for Integrated Care

A movement for change

A little reminder of who we are working

for…

A movement for change Courtesy of Prof. Richard Antonelli, Boston Children’s Hospital, Harvard Medical School


www.childrenshospital.org/care-

coordination-curriculum/care-mapping

Gabe’s map of care


Designing Better Care for

Malcolm and Barbara

Frontier Economics (2012) Enablers and barriers to integrated care and implications for Monitor


A typical family

Zac, 8• ADHS

• Problems at

school

• Problems

making friends

• No regular GP

visits

Dorothy, 65• Minimum

pension

• DM II

• Hypertension

• Hip replacement

• COPD

Sandra, 46• Irregular

employment

• Mental health

issues, self harm

• Smoker

• DM Type II

Stella, 10• No regular

GP visits

• Healthy?

Courtesy of Dr Dan Ewald, North Coast PHN, NSW, Australia


And then there’s me and YOU


Problem statement


Key problems of

fragmented systems

• a lack of ownership from the range of care providers to support ‘holistic’ care needs,

driven by silo-based working and separate professional and organisational systems for

governance and accountability;

• a lack of involvement of the patient/carer in supporting them to make effective choices

about their care and treatment options or enabling them to live better with their conditions

through supported self-care and empowerment strategies;

• poor communication between professionals and providers, exacerbated by the inability

to share and transfer data, silo-based working, and embedded cultural behaviours;

• care and treatment by different care providers for only a part of their needs, rather

than seeing the person as a whole and managing all of the needs;

• the resultant simultaneous duplication of care (e.g. repeated tests or re-telling of a

person’s medical history) and gaps in care (e.g. as appointments are missed or

information and follow-up is not applied);

• a poor and disabling experience for the service users as information is hard to get

hold of, differing advice and views are presented, confusion is created in the next steps of

a course of illness;

• reduced ability for people to live and manage their needs effectively; and ultimately

• poor system outcomes in terms of the inability to prevent unnecessary hospitalisations

or long-term residential home placements

Goodwin N, Alonso A (2014) Understanding integrated care: the role of information and communication technology

in Muller S, Meyer I, Kubitschke L (Eds) Beyond Silos: The way and how of eCare, IGI Global


Views of older people and carers

It’s the same kind of problems for everyone– a lack of somebody picking the ball up and running with it for you… There’s all sorts of things there, but how do you find out about them? I think there’s a lot of assumptions that you know as much as they do about it and you don’t. (Ken)

It seems like one person after another coming in to do different assessments on something else...It’s not like one person comes in and assesses for everything, it was a never ending stream of people coming. (Carole)

What they put in the discharge letter, nothing was explained to me, what she should take at home and help we would have from social care. We brought her home and I was wondering how was I going to manage her? (Nilesh)


• Across Europe, unpaid family carers and friends are the largest providers of health and social care support

• As demographic change increases demand, the ‘balance of care’ increasingly shifts to informal care

• Women are disproportionately affected and are more likely to give up employment to care

• Estimates on the economic value of unpaid informal care in EU Member States range from 50 to 90 percent of the overall costs of “formal” long-term care provision

• Estimated value of contribution made by carers in the UK: 140 billion € per year

• Estimated value of contribution made by carers in Ireland: 5,3 billion € per year (27% of Dept. of social protection’s budget)

The Situation of carers in Europe:

The personal is political

Source: Eurocarers, Stecy Yghemonos, Alpbach 2016


The reality of care settings

Adapted from Goodwin 2008 and 2014

Informal care Self care

Health system

Primary care Family physician

Community nurse Dentist

Pharmacist Therapist

Mental health worker

Walk-in centre

Palliative care

Secondary care Hospital

Inpatient ward Outpatient clinic

Day surgery Treatment center

Tertiary care Specialist unit

Inpatient ward Outpatient clinic Rehabilitation

service Palliative care

service Longterm care

service

Hours with

professional / NHS

= 3 in a year

Hours of self care =

8757 in a year

Need for people

engagement

Need for patient

empowerment


Integrated care is a concept centred

around the needs of service users

‘The patient’s perspective is at the heart of any discussion

about integrated care. Achieving integrated care requires

those involved with planning and providing services to

‘impose the patient’s perspective as the organising

principle of service delivery’

(Shaw et al, 2011, after Lloyd and Wait, 2005)


What is integrated care?


GIRFEC: a whole of system approach

for children, youth and families

http://www.gov.scot/Topics/People/Young-People/gettingitright/publications

Milestones

2004 - 2008 Development and implementation of regional initiative Getting

it right for every child in the Scottish Highlands

2009 Evaluation report for the Scotish government(Scottish Government 2009, http://www.gov.scot/Publications/2009/11/20094457/2)

From 2009 Role-out in other regions of Scotland

2014 GIRFEC becomes the core element of the Children and Young

People Act (Scotland)

From August

2016

Every child in Scotland has a named person

“GIRFEC is the national approach in Scotland to improving outcomes and

supporting the wellbeing of our children and young people by offering the right

help at the right time from the right people. It supports them and their parent(s)

to work in partnership with the services that can help them.”


Wellbeing wheel

http://www.gov.scot/Topics/People/Young-People/gettingitright/wellbeing

8 Indicators of

wellbeing - SHANARRI• Safe

• Healthy

• Achieving

• Nurtured

• Active

• Respected

• Responsible

• Included


GIRFEC: key elements and partners

Key Element Description

Named

person

Trusted person to talk to for children,

youth and parents; contact point for

other services; only acts upon request,

services offered are voluntary

Child’s plan If a child needs more continued support,

the Child’s plan will be developed

together with the child, parents and

professionals

Lead

professional

The coordinator for the Child’s plan

http://www.gov.scot/Topics/People/Young-People/gettingitright/wellbeing


South Karelia, Finland: providing

holistic care in rural and remote areas

Services include: outpatient care, oral healthcare, mental healthcare and

substance abuse services, laboratory and imaging examination services,

medicinal care, rehabilitation services, hospital services, family services, social

services for adults, special services for the disabled, and flexible services for the

elderly that are adaptable to the needs and age structure of the population.

Eksote was founded in 2010 to

provide necessary holistic care

to the133,000 citizens of 9 rural,

remote and resource-poor

districts in Southern Finland.

Eksote has a contract of

services with each district

according to the specific need of

the local population.

http://www.eksote.fi/sites/eng/Sivut/default.aspx


South Karelia, Finland: supporting

people to support themselves

• Established integrated organisation in 2010 combining primary/secondary care with elderly/social care

• Goal was equal access across a rural municipality

• Focus on prevention and citizen responsibility in own care

• Remote monitoring and health coaching

• Mobile health units – use of webcams, broadband and video phones

• Pilot phase had 185 patients

• Care team was a GP, 2 FTE nurses, part-time home care workers, IT engineers and data analysts

• Patients felt less isolated and more secure

• Medication use reduced

• Remote consultations reduced costs by 50% compared to usual care

• Reduced travelling to appointments

Health coaches and an electronic

database support the planning of care

and monitoring of the health status

View the project at:

https://www.youtube.com/watch?v=9VAiEeODspI


Mallu – Mobile Health Clinic

• Established in November 2011

• Acts as a nurse-led mobile clinic to

rural villages throughout Eksote

• Works in cooperation with village

associations

• Electronic patient record

• Includes:

o Nurse consultation

o Health counselling

o Regular health checks

o Treating wounds

o Capillary blood work analysis (e.g.

glucose)

o Vaccinations and medicines

o Dental care (since 2013)

o Physiotherapy


Eksote: key elements and continuous

innovation

• Village associations have a key part to play to promote health and wellbeing and prevent social and medical problems – e.g. themed events for the hard of hearing and with various sports federations.

• Conventional healthcare centres were renamed and reorganised into wellbeing centres, which cater to the specific needs of the local population.

• Education, advise and training are another key element of Eksote, both face to face and remotely.

• Addressing mental health issues are a priority with the mental health clinic for adults being open 24/7. The special unit for children and young people provides psychosocial services during normal office hours.

• Urgent care at home – a new kind of operating model where stand-by urgent care, prehospital care, and home care services are provided at home as needed.

• Newest project: collaboration with Posti provides home assistance while delivering your mail. (https://www.posti.com/english/current/2016/20160210_eksote.html)

http://www.eksote.fi/sites/eng/Sivut/default.aspx


The House of Generations, Austria

In 2007, the House of Generations concept was jointly developed by Caritas

and the local municipality of Schwaz.

In 2010 the House was opened and the first tennants and services moved in.

The governing body now consists of the regional government of Tyrol, the

city council of Schwaz, Caritas, and a private foundation called “Frieden”

(peace in German).

“A meeting point for everyone in Schwaz”


Services and organisations on siteWellbeing bath

Grannies to lend

• Living

• Assisted living

• Shared apartment for people with disabilities

• Apartments for young families

• Life

• Social services

• Respite care

• After school care and child daycare centre

• Meeting room

• Restaurant

• Village shop

• Support for families

• Computeria


The House of Generations grows: key

elements and success factors

• The vision is to provide integrated living for people young and old,

disabled or healthy. The House has an open doors policy and has

become a vital part and meeting point for the town. It is used by local

clubs, for family celebrations and as a vocational training centre.

• One key success factor is the co-location of so many different health,

social services and community services under one roof and a close

collaboration among all service providers in the municipality.

• The house manager is very actively engaging the people and inviting

new ideas and services to add to the spirit of the big family.

• It is managed independently and needs to be financially viable, which

enabled simple and creative solutions, but also supports the sense of

self-sufficiency rather than dependence.

• A key element in all activities is the belief that every person has

valuable skills and talents, from which the community can profit.

WHO Regional Office for Europe. Lessons from transforming health services delivery:

Compendium of initiatives in the WHO European Region. WHO, Copenhagen 2016


Engaging Communities as Partners in

Care in the English NHS

Community engagement, incorporating the voluntary

sector, proved central to achieving better care

experience and outcomes at less cost in all the case

sites.

• Voluntary sector brought into the core multi-

disciplinary team.

• Volunteer co-ordinators discuss cases and develop

care plans

• Community groups engaged as partners in care

and take on specific support role

• All sites placed a premium on building community

awareness and trust with local populations as a

strategy to ensure people knew their services were

available and would recommend and signpost

friends and family to the programmes more often

and before they fell into crisis.


Project CHAIN, Wales

Warner M, Gould N. Integrated care networks and quality of life: linking research

and practice. IJIC 2003


Commonalities and lessons learned


Whole-of systems and health in all

policies approach for integrated care

Source: Adapted from WHO-HQ Global Strategy on people-centred and integrated health services 2015

HEALTH

SYSTEMGovernance,

financing and

workforce

OTHER

SECTORSEducation,

sanitation, social

assistance, labor,

housing,

environment,

others

PERSON

SERVICES

DELIVERY

CONTEXTEpidemiology, cultural, socio-demographic and economic


The ‚Rainbow Model‘:

Interventions on all levels

Valentijn P et al (2015) Towards an international taxonomy of integrated primary care: a Delphi consensus approach. BMC Fam Pract, 16(1):64-015-0278-x


Focus on holistic approach to health

and wellbeing


Integrated care does NOT mean

loss of individualised care


Culture of a Learning Healthcare System

Builds Value

• Common Vision

• Clinical Work Processes

• Data and Evaluation

Transparency


Changing cultures and values

‘Much of the achievement of integrated care and support is dependent

on successful culture change. Both professions and organisations are

likely to have developed particular cultures which help to shape their

identity and foster allegiance.’ (Petch 2014)

‘By its very nature, joint working brings together professionals with

different philosophies and values as well as divergent professional

cultures. Not surprisingly, these differences can act as barriers to

effective joint working’ (Cameron et al 2012)

‘The realisation of a given pilot’s intended changes relied on its ability to

modify existing systems and practices and to make new ones possible.

This ability was especially dependent on organisational culture…. pilots

often found integration activities were hampered by a lack of openness

that several staff perceived to inhibit discussion, and which was part of a

wider ‘blame culture’’ (Rand Europe 2012)


Developing the competencies necessary

on all levels

System

Organisation

Professionals

People

• Education and training systems

• Regulatory bodies

• Management

• Leadership

• Interdisciplinary, cross-sectoral work

• Implementation of integrated care tools

• Shared-decision making

• Patient and community engagement

• Self management and support

Stein 2016


It needs transformational change

Change Management Steps Relationship Building Activities

Tim

e

Developing

Collaborative capacity

Establishing a guiding coalition

Building support for change

Needs Assessment

Establishing mutual gain

Strategic plan

Situational Analysis

Value Case Development

Vison and mission statement

Communication

Implementation and institutionalisation

Monitoring and evaluation

Source: Goodwin N (2015) Managing Change Towards Co-ordinated/Integrated Health Services Delivery

WHO Regional Office for Europe, November 2015

Fe

ed

ba

ck L

oo

p

Cycle

of L

ea

rnin

g


The International Foundation for

Integrated Care

IFIC is a non-profit members’ network that crosses

organisational and professional boundaries to bring people

together to advance the science, knowledge and adoption of

integrated care policy and practice.

The Foundation seeks to achieve this through the development

and exchange of ideas among academics, researchers,

managers, clinicians, policy makers and users and carers of

services throughout the World.

IFIC’s portfolio includes the International Journal for Integrated

Care (IJIC), the ICIC and WCIC conferences, the Integrated

Care Academy© and a strong members platform.


• Webinar series

• Essential skills courses

• Short courses and professional programmes

• International Summer School on Integrated Care

• Postgraduate programmes

• Study tours and exchange programmes

• Special Interest Groups

• Fellowships

• Executive Masterclasses

http://integratedcarefoundation.org/ific

-integrated-care-academy

Portfolio


To conclude

“I can plan my care with people who work together

to understand me and my carer(s), allow me

control, and bring together services to achieve

the outcomes important to me.” National Voices 2013

K. Viktoria Stein, PhD

Head of the Integrated Care Academy©

International Foundation for Integrated Care

[email protected]

www.integratedcarefoundation.org

mailto:[email protected]

http://www.integratedcarefoundation.org/


Documents

Thinking outside the health care box: innovative ... · to share and transfer data, silo-based working, and embedded cultural behaviours; • care and treatment by different care