Sorcha Mckenna, Head of Healthcare Practice, McKinsey

Integrating Care – what are the possibilities?

November 14, 2013

CONFIDENTIAL AND PROPRIETARYAny use of this material without specific permission of McKinsey & Company is strictly prohibited

McKinsey Clinical Leadership Academy | 2

Pace of change in the healthcare industry has been slow to date

Modern medicine is still using fairly primitive technology

Physician’s office – then vs. now

1908 2012


1 Assumptions: Healthcare spending increases 1.9 basis points faster than OECD GDP Growth Forecasts (OECD historical rate)

SOURCE: OECD Policy Implications of the New Economy – 2000-50, 2001; Global Insight WMM, 2000-37; Espicom: World Pharma-ceutical Fact Book, 2008; International Monetary Fund; World Economic Outlook Database, October 2009; McKinsey

Rising financial pressure to change…

Share of healthcare costs as part of GDP

Hong Kong

Spain

Italy

U.K.

Australia

5.9

6.0

7.8

8.8

9.3

10.5

Country

Korea

2008

Canada

Germany

France

U.S.

10.8

10.8

11.2

16.1

6.8

8.9

10.0

10.6

10.5

8.17.4

7.5

6.7

8.2

9.7 10.7

11.0

11.6

13.1

12.0

12.7

14.4

2015 2020 2025

8.9

9.0

11.7

13.2

14.0

15.8

2030

12.3

12.3

12.7

18.3

13.5 14.8

13.5

14.0

20.1

14.8

15.3

22.0

16.2

16.2

16.8

24.2

%1 <10 10-15 >15

Ireland 9.4 11.9 13.0 14.4 15.8

McKinsey Clinical Leadership Academy | 4SOURCE: International Diabetes Federation, 2012

Diabetes related deaths Diabetes £ per personDiabetes prevalence

Average = 7.4 %

3.95.65.76.46.67.07.47.57.88.18.28.48.5

9.310.0

Average = 5.4 deaths per 10,000

7.57.2

6.9

4.3

6.56.26.2

4.6

6.05.6

5.0

4.03.9

5.4

2.6

9.2

Average= £ 6.0k

7.77.0

6.66.36.1

9.3

5.95.65.65.4

5.14.2

3.53.3

Diabetes burden across 15 European CountriesEstimated burden of disease

Despite Ireland having low diabetes prevalence and death rates, patient expenditure is still high


What patients want – Patient’s Experience of Hospital Services

“Staff nurses, doctors and support workers were efficient, friendly and put my needs first…”

“Being on a waiting list over a year is not acceptable. At 77 years old it is too long to wait.”

“Patients are endlessly asked the same questions and you feel no one consults those notes to avoid asking them again.

“The multi disciplinary team gave me the support and information I required, all administered in a professional and cheerful climate.”

SOURCE: Irish Society for Quality & Safety in Healthcare, 2011


The consequences of continuing in a ‘business as usual’ way across the system will be significant

Unless addressed this will lead to an increase in poorly treated and undiagnosed patients who will further reinforce strains across the system

▪ Face reduced access to services,

▪ There is less flexibility in treatment options

Patients

▪ Increased spending on acute services at the expense of social, mental and prevention activities

▪ Disputes with providers may increase,

Payors and health systems

▪ Face major financial challenges

▪ Challenge of delivering more with less

Providers


Integrated care can help address these challenges

Goals of integrated care

▪ Provide the best possible quality of care at the minimum necessary costs

▪ Provide better and more pro-active care for a specific group of patients that are most at risk

▪ Empower patients, users and their carers


Our research and work across the globe shows that successful integrated care systems require three core building blocks

… by working in a multi-disciplinary system …

… supported by key enablers

Address specific patient needs …Patient cohorts

Clinical protocols and care packages

Care coordination and planning

Performancereview

Case conference

1

2

3

4

Aligned incentives and reimbursement models

Accountability and joint decision-making

Information transparency and decision support

Clinical leadership and team working

Patient engagement

Low risk

Moderate risk

High risk

Very low risk

Very high risk

Success in integrated care

A B

C


160x difference in cost!

Total/average

SOURCE: McKinsey team analysis, NHS NWL data; HES 2010/11, FIMS, Q research/NHS Information centre, PSSEX; NHS Reference Costs

4,757

41,675

142,773

322,609

378,020

188

104

186

354

327

39,600

8,700

300

500

2,400

1 Includes elective admissions, outpatient, and A&E 2 Includes community health & primary care

Health spend Social care spend

First, understand the needs of the population you are trying to serve…

Very high

High

Moderate

Low risk

Very low

Very high

High

Moderate

Low risk

Very low

Population

~890,000 1,230 1,168

2010/11 data, 4 London CCGsA

Average cost percapita per annum, £ Total spend, £m


What does a Multi-Disciplinary Team do?

1 Icons are illustrative only: any number of other professionals may be involved in a patient’s care, a case conference or performance review

B

Community pharmacist

Practice nurse

Social care worker

District nurse

GP

Community Mental Health

Patient registry Risk stratification

Care delivery1

Case conference

Performance review

Each MDT holds a register of all patients who are part of the IC programme

The MDT uses an information tool to stratify these patients by risk of emergency admission

Each patient is then given an individual integrated care plan that varies according to risk and need

Patients receive care from a range of providers across settings, with primary care playing the crucial co-ordinating role and everybody using the IC IT tool to coordinate delivery of care

A small number of the most complex patients will be discussed at a multi-disciplinary case conference, which will help plan and coordinate care

The MDT meets regularly to review its performance and decide how it can improve its ways of working to meet its goals

Shared clinical protocolsAll providers in the MDT agree to provide high quality care as laid out in recommended pathways and protocols

Care planning


Beyond care delivery, enablers are crucial

SOURCE: McKinsey & Company

▪ CEOs & Boards commitment of resources

▪ Bind in payors, hospitals, primary care and local government

▪ Hold to account for delivery

▪ Support– Patient

records– Clinical

decision making

– Peer pressure

– Payment

▪ Solve Information governance

▪ Role model behaviour

▪ Deliver consistently

▪ Hold peers to account

▪ Work within team

▪ Significant(30%+)

▪ At scale (30%+)

▪ Sustained (3-5 years)

▪ Align risk and reward across system

Governance InformationClinical leadership

Reimbursement& incentives

Patient engagement

▪ Empower patients with informed choice

▪ Make use of behavioural economics

C

… supported by key enablers


→ ChenMed: Aims to minimise avoidable hospital admissions through intensive primary care and aligned incentives

SOURCE: Source

Patient experience

▪ ChenMed offers patients regular appointments with their named Primary Care Provider; numbers predetermined by the risk stratification model (min. 1 per month)

▪ ChenMed medical centres are set up to look/feel like a quiet A&E with rapid access for unscheduled appointments available, to reduce patient A&E use

▪ Each centre at capacity – 5 primary care physicians, 10-15 specialists rotating through, 2200+ Medicare patients

▪ Task-shifting is used extensively with trained, but unqualified, health assistants carrying out routine clinical tasks (such as BP monitoring, clinical measurements, administration)

▪ ChenMed aims to offer most services under one roof including primary care, outpatient care, diagnostics, dental care, pharmacy and complementary medicine including acupuncture

How care is organised

Description

CONFIDENTIAL: Not for onward distribution


→ Torbay: Integrated health and social care teams are co-located in zones

Note: DN – District Nurse; SW – Social Worker; CCW – Community C.Worker; HSCC – Health and Social Care Co-ordinator; RCO – ReferralCo-ordinators; IC – Intermediate Care Team

SOURCE: Torquay North Health and Social care team

Patients and providers have one number to call

SCLead

Nurse Lead

OT Lead

Front desk

DN team

AdminIC

teamPhysio Lead

GP Triage Desk

HSCC Manager

LeadP.A.

ZoneLead

If a patient comes to A&E and does not require admission to hospital, the acute trust contacts the zone and the Health and Social Care Coordinator contacts various agencies to make sure the patient is able to go home or receive temporary placement if needed

CONFIDENTIAL: Not for onward distribution


Key questions for consideration in the Irish context

▪ What is the appropriate model of primary and community based services in Ireland (Chen Med/Torbay/other)?

▪ Which of the key enablers would be most important in driving change (reimbursement, IT, clinical leadership)?

▪ What will it take to effect this change at scale in this country?

Health & Medicine

Sorcha Mckenna, Head of Healthcare Practice, McKinsey