Key principles of integrating care: evidence, lessons and examples from around the world

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Key principles of integrating care: evidence, lessons and examples from around the world Dr Viktoria Stein Head of the Integrated Care Academy International Foundation for Integrated Care
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Key principles of integrating care: evidence, lessons and examples from around the world Dr Viktoria Stein Head of the Integrated Care Academy International Foundation for Integrated Care Problem statement Designing Better Care for Malcolm and Barbara Frontier Economics (2012) Enablers and barriers to integrated care and implications for Monitor The traditional health system structure Healt h syst em Prim ary 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 Tert iary care Specialist unit Inpatient ward Outpatient clinic Rehabilitation service Palliative care service Longterm care service I nform al care Self care Adapted from Goodwin 2008 and 2014 The social services DEFINING SOCIAL SERVICES Social services, social welfare, social protection, social assistance, social care, social work, personal social services Emphasis on personal services designed to meet an individual user s needs (foster care placement) VS. social services for categories of citizens (unemployment benefit) Why integration? Definitions Emerging long-term care systems Social care system Services Residential care Providers Professions Methods Legal Framework Policies The formal informal care divide Volunteers The health-social care divide Long-term care linked-in, co-ordinated, integrated? Identity - Policies - Structures - Functions - Processes - Resources/Funding Users Inform al carers: family, friends Health care system Hospitals - Services Providers Professions GPs - Methods Legal Framework Policies Leichsenring et al., 2013; Sources: Leichsenring et al., 2013; The reality of care: patients manage themselves already Hours with professional / NHS = 3 in a year Healt h syst em Need for people engagement Need for patient empowerment Prim ary 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 Tert iary care Specialist unit Inpatient ward Outpatient clinic Rehabilitation service Palliative care service Longterm care service I nform al care Self care Hours of self care = 8757 in a year Adapted from Goodwin 2008 and 2014 The Situation of carers in Europe: The personal is political 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) Source: Eurocarers, Stecy Yghemonos, Alpbach 2016 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 What is integrated care? Many definitions for Integrated Care A Systems Definition...the search to connect the healthcare system (acute, primary medical, and skilled) with other human service systems (e.g., long term care, education, and vocational and housing services) to improve clinical outcomes (clinical, satisfaction, and efficiency). Leutz 1999 Whole-of systems and health in all policies approach for integrated care CONTEXT Epidemiology, cultural, socio-demographic and economic SERVICES DELIVERY HEALTH SYSTEM Governance, financing and workforce PERSON OTHER SECTORS Education, sanitation, social assistance, labor, housing, environment, others Source: Adapted from WHO-HQ Global Strategy on people-centred and integrated health services 2015 Focus on holistic approach to health Project CHAIN, Wales Warner M, Gould N. Integrated care networks and quality of life: linking research and practice. IJIC 2003 Many definitions for Integrated Care A Process definition:...a coherent set of methods and models on the funding, administrative, organizational, service delivery and clinical levels designed to create connectivity, alignment and collaboration within and between the cure and care sectors...[to]...enhance quality of care and quality of life, consumer satisfaction and system efficiency for patients with complex problems cutting across multiple services, providers and settings. Kodner & Spreeuwenberg, IJIC 2002 The complexity of modern long-term care delivery Primary care Public health Diagnosis Hospitals Treatment Palliative Rehab Pharmacies Rehabilitation Centre Primary care Home care Community and social care Source: Pathways for long-term care provision in Austria, Interlinks, European Centre 2009 The Kaiser Triangle Evercare & Pfizer models Case management Highly complex patients Kaiser model Disease management High-risk patients Supported self care 70-80% of people with chronic conditions Population-wide prevention Source: Goodwin, based on Singh and Ham, 2006 Many definitions for Integrated Care A patient s definition: 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 Apprehension, uncertainty, waiting, expectation, fear of surprise, do a patient more harm than any exertion. (On Nursing, Florence Nightingale, ) By Lourdes Ferrer Engaging patients, carers and communities for the provision of coordinated/integrated health services: strategies and tools WORKI NG DOCUMENT Key ingredients for integrated care: lessons learned and evidence Many Frameworks Have Been Developed to Understand The Key Elements for Successful Integrated Care! The WHO European Framework for Action on Integrated Health Services Delivery The European Framework for Action on Integrated Health Services Delivery The European Framework for Action on Integrated Health Services Delivery: an overview Health Services Delivery Programme Division of Health Systems and Public Health PEOPLE SERVICES SYSTEM Identifying health needs Tackling determinants Empowering populations Engaging patients Reorienting the model of care Organizing providers & settings Managing services delivery Improving performance Rearranging accountability Aligning incentives Preparing a competent workforce Promoting rational use of medicines Innovating health technologies Rolling out e-health CHANGE Strategizing with people at the centre Implementing transformations Enabling sustainable change The European Framework for Action on Integrated Health Services Delivery: an overview. WHO Regional Office for Europe, Copenhagen 2016 The WHO European Region: 53 Member States 900 Mio inhabitants 10 Lessons learned from 85 cases across the Region The European Framework for Action on Integrated Health Services Delivery: an overview 1. Put people and their needs first 2. Reorient the model of care 3. Reorganize the delivery of services 4. Engage patients, their families and carers 5. Rearrange accountability mechanisms 6. Align incentives 7. Develop human resources for health 8. Uptake innovations 9. Partner with other sectors and civil society 10. Manage change strategically Health Services Delivery Programme Division of Health Systems and Public Health WHO Regional Office for Europe. Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region. WHO, Copenhagen 2016 Focusing on Quality of Life More effective approaches: Population management Holistic, not disease-based Organisational interventions targeted at the management of specific risk factors Interventions focused on people with functional disabilities Management of medicines Less effective approaches: o Poorly targeted or broader programmes of community based care, for example case management o Patient education and support programmes not focused on managing risk factors The Need for More Evidence Systematic review looked at impact on utilisation, cost effectiveness and expenditure across 19 studies: Range of population groups (but not multiple morbidity) Not explicit on nature of integrated care Different focus of type of approach e.g. horizontal and vertical Most focused on hospital utilisation through (re)admissions, lengths of stay and ED visits Cost reduction is reported, but scale of results difficult to determine as not always quantified and mostly without controls Evidence on cost-effectiveness poor Heterogeneous nature of complex service innovations mean that few conclusions can be drawn Some lessons learned Structural integration by itself does not foster integrated care the approach needs to focus on strategies for co-ordination at a clinical and service level The needs of people and populations must come first the people s perspective should be the organising principle through which strategies are framed No one size fits all there is no single model for integrated care and the approach needs to work around the specifics of local contexts Cultural norms and attitudes matter greatly building social capital through engagement and empowerment takes time and energy, but is ultimately a catalyst for sustainable change Effective leadership and management for integrated care across care systems is key professionals and managers working together with communities to develop shared objectives, social contracts and fostering distributed leadership and commitment The King s Fund 2014 The Promise of Integrated Care The hypothesis for integrated care is that it can contribute to meeting the Triple Aim goal in health systems Improving the user s care experience (e.g. satisfaction, confidence, trust) Improving the health of people and populations (e.g. morbidity, mortality, quality of life, reduced hospitalisations) Improving the cost-effectiveness of care systems (e.g. functional and technical efficiency) So what does it need to create sustainable integrated care? 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) Community Engagement Nuka Health System, Alaska Mission: Working together with the Native Community to achieve wellness through integration if health and other services Vision: A Native Community that enjoys physical, mental, emotional and spiritual wellbeing Key approach: Shared responsibility, commitment to quality, family wellness Consumer-owners Some results since present: 95% enrolled in primary care, up from 35% Same day access for routine appointment, down from 4 weeks Waiting list for behavioural health consultation eliminated 36% reduction in hospital days 42% reduction in ER 58% reduction in specialist clinics High patient satisfaction with respect to culture and traditions Staff turnover reduced by 75% Alaskan Native leadership has ownership and management of care system since people south of Anchorage and spread across 1800km of land and islands Range of services including: inter-disciplinary primary care, dentistry and optometry, behavioural health, patient education and peer2peer health promotion home care case management telehealth with self-management of chronic illness Focus on rights and responsibilities approach 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): x It needs senior leadership and a top-down/bottom-up approach TOP- DOWN STANDARIZABLE INTERVENTIONS STRATIFICATION CALL CENTER ELECTRONIC MEDICAL RECORD FINANCING AND JOINT COMMISSIONING ELECTRONIC PRESCRIPTION BOTTOM UP LOCAL INNOVATION CASE NURSING PATIENT SUBACUTE HEALTH AND EMPOWERMENT SOCIAL CARE CENTRES COORDINATION INTEGRATED CARE Bengoa, Mota 2013 Different cultures, organisations and work ethics Community Control Formal board Professional chimneys Administrative hierarchy Operating workflow Cure Care Adapted from Glouberman/Mintzberg 2001 Changing cultures and strengthening competencies in Canterbury, NZ Common goals Consistent leadership Engagement of professionals and communities Quality improvement, not cost containment Developing skills and capacity Robust primary care Pegasus Health Focus on care transitions Focus on care at home Information systems to support communication and used to drive quality improvement Effective learning strategies Long-term view Professional cultures that support team work One System, One Budget Timmins & Ham, Setting the level of integration against user need to optimise care Source: adapted from Leutz 1999 in Nolte & McKee (2008) Adjusted clinical Pilot groups, project started Veneto in 2012 with Region, 2 local Italy health units, roll-out continued until 2015 Construction of database, retrospective analysis of population, identification of risk groups and gaps analysis lead to: Almost 5 mio inhabitants Based on Corti MC. USING A POPULATION RISK-ADJUSTEMENT TOOL TO INTEGRATE HEALTH SERVICE DELIVERY IN REGIONE VENETO. Presentation during Second CIHSD Technical Meeting of the WHO Regional Office for Europe. Istanbul 2015 Key Lessons: population health management does not work without data analysis Align all available data sets Invest in data quality Use predictive modelling Concentrate on quality improvement of service delivery NOT cost reduction Based on Corti MC. USING A POPULATION RISK-ADJUSTEMENT TOOL TO INTEGRATE HEALTH SERVICE DELIVERY IN REGIONE VENETO. Presentation during Second CIHSD Technical Meeting of the WHO Regional Office for Europe. Istanbul 2015 relationship between health and social care professionals? Breaking down the walls in heads and systems The common reality Changing roles and responsibilities In need of additional competencies to deliver integrated care Hébert R, Durand PJ, Dubuc N, et.al. PRISMA: a new model of integrated service delivery for the frail older people in Canada. IJIC 2003 Focusing on the competencies necessary on different levels System Education and training systems Regulatory bodies Organisation Management Leadership Professionals Interdisciplinary, cross-sectoral work Implementation of integrated care tools Shared-decision making People Patient and community engagement Self management and support Feedback Loop Cycle of Learning Integrated care needs transformational change Change Management Steps Needs Assessment Relationship Building Activities Establishing a guiding coalition Situational Analysis Value Case Development Vison and mission statement Strategic plan Establishing mutual gain Building support for change Developing Collaborative capacity Time 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 Culture of a Learning Healthcare System Builds Value Common Vision Clinical Work Processes Data and Evaluation Transparency 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. ICA Portfolio 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 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
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