What does the concept‘Integrated Care’ mean for hospitals?

Moscow, 28th of May 2004Professor Cor Spreeuwenberg

Past Dean Faculty of Health SciencesMaastricht University

Structure of this presentation

background of health care innovations integrated care and its related concepts disease management and the role of hospitals case: diabetes care new public health and the role of hospitals case: lifestyle related diseases lessons learnt towards an agenda for health promoting

hospitals

Phenomena of all health care systems have to face

fragmentation of care between and within providing institutions lacking co-ordination, continuity, seamless care rising number of chronically ill and elderly hospitals dealing with acute care and neglecting chronic care need for effectiveness and efficiency under-use of management tools and information technology insufficient appreciation of the skills of nurses and paramedics empowerment of patients in decision-taking and management monkeys who look over the shoulder of the providers - > governments, insurers, employers, purchasers, third parties,

interest groups

Health care systems in Europe- fragmentation

since 2nd half 20th century sharp division between - hospital-care and community-care +nursing homes - primary and secondary care - responsibility for individuals and for collectives - general health care and mental health care - prevention and cure/care - medical care and social care (well-fare)

in Western Europe focus lies on - individuals > collectives - cure and care > (collective) prevention

Ageing in selected countries and its impact upon HCE, 2000(R.Blank & V. Burau, 2004)

% 65 + % of total HCE

Exp % 65+ 2020

France 15.9 30.0 19.5

Germany 16.8 34.1 21.7

Italy 17.6 34.3 19.4

Netherlands

13.6 41.2 18.9

Sweden 17.8 54.2 20.8

UK 15.7 43.0 16.3

Contrast between acute and chronic

care (D. Kodner, 1994)

Acute care disease - oriented ‘high tech’ episodic cure one-dimensional professional hospital

Chronic care function - oriented ‘high touch’ continuous and/or

cyclic care multi-dimensional family and volunteers home

Strengths and weaknesses of hospitals

strengths- professionalism- competence- equipped for acute care- self-consciousness- overview regional health

care- organizational skills- natural leadership- financial position, power

weaknesses- mono-dimensional

interest- preference for

interventions- poorly equipped for care- arrogance- internal orientation- few interest in other

health care providers- feel no intrinsic need to

co-operate

Health care innovation- some recent concepts

integrated care shared care transmural Care substitution of care organizational networks disease management self-management

Integrated care- definition

WHO, 2001:

Integrated care is the bringing together of - inputs, delivery, management and

organization of services - related to diagnosis, treatment, care,

rehabilitation and health promotion.

Integration is a means to improve services in relation to access, user satisfaction and efficiency

Integrated care- related concepts shared care and transmural care

functional collaboration of all providers who are relevant or solving a certain problem

common philosophy and strategy based on formal agreements specified tasks for all providers needs to be organized and managed (networks) sharing of information (exchange, storage) protocols as a means for co-operation incentives for quality improvement involvement of patients and family

Integrated care - examples

shared care for patients with prevalent chronic illness

palliative support teams stroke services antenatal, perinatal and postnatal care &

surveillance ambulant cystic fibrosis treatment and dialysis after-hospital-care at home day services for patients with cancer,

dementia, depression and Parkinson’s disease

Substitution of care

horizontal substitution - provision of care by a generalist in stead of a specialist: c.g. hospitial care -> community care vertical substitution - provision of care by the ‘lowest’ provider who is

qualified to assure the standard of care: c.g. physician -> nurse diagonal substitution - combination of horizontal and vertical substitution

substitution may be partial or complete

Disease management- background

originally an American concept: - related with managed care - focus on efficiency more than on quality - programmatic care - usually organized by a third party between insurers/PH agencies/employers and providers challenge for Europe: - primary responsibility for providers - disease management as a form of integrated

care

Disease Management - an organizational principle for integrated care -

aim: efficient care as well as high quality of care designed for specific diseases or health problems care for collectives; less on individuals strong client orientation focus on the whole process of care (protocols) use of management instruments (+ICT) for

feedback separation of treatment and management/control can be organized by third parties or by providers (!)

Disease Management- use of management instruments:

benchmarks and feedback -

focus on measurable outcome parameters benchmarks that represent the aims of care benchmarks that aim to improve the

outcomes/results individualized contracts/agreements with

providers steering based on objective outcome-

parameters feedback: concrete, clear, personal and oral

Disease management - patients’ perspective -

positive more focus on

patient orientation towards content, process, attitude

ideally: more orientation towards human values

more involvement in feedback systems

negative standardization of

care less personal

involvement of professionals

if freedom of choices (opting out) -> higher premiums

Disease management

- professional perspective -

negative loss of traditional

autonomy bureaucracy rules

easily the care process

doubts about the interests of patients

resistance to change

Positive patient orientation:

content, process, attitude

ideally more orientation on human values

patient profits from quality improvement

patients involved in feedback-systems

Examples of integrated carewith involvement of hospitals

between hospital and primary care - case: diabetes mellitus

between public health, primary care and hospital

- case: new public health

Case: diabetes care- The state of the art: St.Vincent’s declaration -

content: according to ‘evidence based’ and internationally accepted protocols and guidelines

considered as a risk factor for cardiovascular disease

efficient and effective organization physical and psychological access emphasis on lifestyle and behavior attitude: acknowledging the specific needs,

demands and features of the patient

Diabetes care- typical traditional organization -

diabetic control: internist or family physician (GP) acute care and complications: family physician

(GP) information and counselling: specialized nurse (if

so) insulin-injections at home: district nurse periodic checks of the eyes: ophthalmologist periodic checks of the CV-system: cardiologist emergency cases: GP/ambulance services

Diabetes care- Quality of care in Europe: the CODE-2 study -

HbA1c: 23% well, 35% moderately, 42% badly regulated systolic blood pressure: 69% well regulated (Europe 85%!) cholesterol blood level < 5,2 mmol/l 35% according the standard annual check of the eye: 28% annual check of the feet: < 15 %

The Maastricht Region- some features -

capital of the province of Limburg surrounded by Belgium (Flandres, Wallonia)

and Germany; rather isolated from rest Netherlands

140.000 inhabitants in the region 90 GPs and one (academic) hospital longstanding relations between specialists and

GPs Diagnostic & Transmural Centre in the hospital ownership of GPs and involved specialists

Diabetes care in the Maastricht Region - its main characteristics -

structural co-operation between all providers, local insurer, patient organization and Health Inspectorate

combination of shared care and disease management

adaptation to needs and wishes of the caregiver inclusion of all diabetes patients whole trajectory: from prevention to palliation vertical and horizontal substitution use of a common protocol integrated quality assurance system

Diabetes care in Maastricht

- Role of physicians and specialized nurses-

physicians diagnosis initial treatment instable patients assessment of complications planning

defining protocols supervision of nurses (MS) education

specialized nurses early detection education and

counseling periodical checks adaptation of treatment prevention of

complications defining of protocols link to family physicians education

Diabetes care in Maastricht (140.000inh)- model for patients with diabetes mellitus -

nuclear team of - medical specialist - general practitioner - advanced clinical nurse specialist (ACNS) 1 = patients of MS 2 = patients of ACNS 3 = patients of GP MS>ACNS>GP ! ACNS supervises GP!

2

3

1

Diabetes care in Maastricht- management instruments -

organization hosted in regional (Academic) hospital

managers and nurses appointed by the hospital easy understandable and actual protocols management-information (ICT, focus groups) students screen of patients of participating GPs benchmarks discussed yearly with projectleader structure for supervision and advice permanent education newsletter

Diabetes Care in Maastricht

- Scientific evaluation -

permanent qualitative and quantitative evaluation quantitative evaluation: - performance and clinical outcomes of care by

nurses equal or even better than that of physicians - self-management: no improvement qualitative: - > 90 % patients more satisfied than in usual care - costs are equal to usual care health technology assessment is in process

Diabetes care in Maastricht- Keys for success

enthusiast and competent management goal-oriented, systematic, programmatic approach creation of a sense of urgency longstanding relationship between hospital and GPs common interests of participating providers (creating) national interest temporary extra funding for development scientific evaluation -> (inter-)national publications positive clinical results satisfied patients and participants

Co-operation between PH-agency, primary care and hospital

Case: New public health

Public Health- definition and tasks -

the science and promoting of health trough the organized efforts of society

part of primary care if it functions as first contact important fields: - health protection - health promotion and prevention - care for specific groups - health administration ruled by governments and public administrators in Europe lack of collaboration with other

primary care providers, secondary care and mental health

New Public Health - I - definition and stakeholders -

Integration of public health policy, public health practices and curative care

Stakeholders: - PH policy: national, regional and local politicians - PH practices: regional PH-institutes: managers,

nurses, physicians, health educators - curative care: hospital management, GPs, medical specialists, home care organizations Fits WHO ‘Toward Unity for Health’ (TUFH)-project

New Public Health - II - European examples and tasks of partners -

examples in Europe - Primary Health Trusts in the United Kingdom - New PH-programme for CVD in Maastricht meaning: joint approach for primary, secondary

and tertiary prevention of diseases - PH agencies . promoting healthy behaviour - PH agencies and GPs . screening to detect patients at risk - curative sector . diagnosis, treatment & improving life style of patients at risk

Areas for New Public Health

Areas that covers the tasks of generalists and public health agencies

addiction and addictive diseases contagious diseases (HIV/Aids and

tuberculosis) diseases influences by life-style and behaviour child care (surveillance during childhood) maternal care

Organization New Public Health for cardiovascular diseases (Maastricht Region)

N ew P u b lic H ea lth M aas trich t

A cad em ic H osp ita l R eg ion a l P H In s titu te(b oard : reg ion a l m u n ic ip a lit ies

R eg ion a l G P s

H ea lth p rom ote rs in th e p u b lic a reain p u b lic a reas (c .g . sh op s , lib ra ries )

S c reen in g an d h ea lth ed u ca tionp a tien ts a t risk (G P -o ffices )

m ed ica l sp ec ia lis ts : h ig h risk(acad em ic h osp ita l)

P rog ram m a M an ag em en t

New public health- complicating factors

dependency of PH-agency of a political context fragmentation of the political context bridging the gap between a

political/administrative structure and a health care embedded structure

long term between PH-interventions and clinical results

need to focus on intermediate results like changes in behaviour

Lessons learnt from experienceswith shared approaches (I) -enabling factors (Kodner & Spreeuwenberg, IJIC, 2003)

Funding pooling of funds prepaid capitationOrganizational co-location of services discharge and transfer agreements inter-agency planning and/or budgeting service affiliation or contracting jointly managed programs or services strategic alliances or care networks consolidation, common ownership or merger

Lessons learnt from experienceswith shared approaches (II) -enabling factors (Kodner & Spreeuwenberg, IJIC, 2003)

Administrative inter-sectoral planning needs assessment/ allocation chain joint purchasing or commissioningService delivery joint training centralized information, referral and tasks care/care management multidisciplinary/interdisciplinary teamwork around the clock (on call) coverage integrated information systems

Lessons learnt from experienceswith shared approaches (III) -enabling factors (Kodner & Spreeuwenberg, IJIC, 2003)

Clinical standard diagnostic criteria (e.g. DSM IV) uniform, comprehensive assessment procedures joint care planning shared clinical records continuous patient monitoring shared, evidence-based decision support tools (guidelines, protocols) regular involvement of patients and family

Challenges to Integrated Care(Thanks to D. Light)

to move from turf battles and defence of professionalism to a sense of working together

to align payment structures and incentives so that they promote integrated care and not work against it

to keep politicians from making new rules and programs that inadvertently obstruct than facilitate integrated care

to examine carefully any proposal by investor-owned corporations to deliver services to those with chronic conditions at risk

Towards an agenda for health promoting hospitals

behave as a leader of the regional health care system look for opportunities for integrated care in the region develop a strategy with other providers and the staff integrate services at an appropriate level focus on the needs of chronic patients: treatment,

prevention, screening, care and self-management reconsider the appropriate role of physicians, nurses

and paramedics encourage shared training of doctors, nurses and

paramedics be open and transparent