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The Importance of Integrated Care to the Future of Health Systems: National and Regional Developments in Europe and other countries Dr Nick Goodwin & Dr.

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Presentation on theme: "The Importance of Integrated Care to the Future of Health Systems: National and Regional Developments in Europe and other countries Dr Nick Goodwin & Dr."— Presentation transcript:

1 The Importance of Integrated Care to the Future of Health Systems: National and Regional Developments in Europe and other countries Dr Nick Goodwin & Dr Lourdes Ferrer CEO, International Foundation for Integrated Care Paper to: Health Quality and Safety Commission New Zealand Workshop: Towards Integrated Care in New Zealand Wellington, New Zealand, November 14 th 2013

2 The Challenge



5 Ageing Society = Greater Complexity of Care By 2034, >85s will represent c.5% of the population in Western Europe.

6 Care Systems in Europe are Failing to Cope with Complexity Frontier Economics (2012) Enablers and barriers to integrated care and implications for Monitor - The complexity in the way care systems are designed leads to: lack of ‘ownership’ of the person’s problem; lack of involvement of users and carers in their own care; poor communication between partners in care; simultaneous duplication of tasks and gaps in care; treating one condition without recognising others; poor outcomes to person, carer and the system


8 The Challenge: Summary Age-related chronic conditions absorb the largest, and growing, share of health/social care activities Poor co-ordination of care for people with long- term/complex illnesses leads to poor care experiences and adverse outcomes Practical solutions to tackle the socio-determinants of ill- health and pathology of the complex patient Strategies of care co-ordination to create more integrated, cost effective and patient-centred services are growing internationally Lack of knowledge about how best to apply care co- ordination in practice.

9 The European Response There are many different examples of policies and innovation on integrated care around Europe The political agendas, however focus on: – Financial reform – Cost containment – Legislative change – Structural reorganizations – Personalised care – Pilot programmes Not enough on change management and the ‘how to’ of integrated care National Strategies - Examples Denmark & Norway: Coordination Reform Sweden: Joint agencies link funding and delivery (e.g. Jönköping & Nortallje) England: The National Collaborative for Integrated Care and Support (Pioneers) Germany: Versorgungsstrukturgesetz (care structure law) supports interdisciplinary and cross-sector models of care Netherlands: Managed care organizations and bundled payments for certain diseases Health and social care integration in Northern Ireland, Scotland and Wales Spain: vertically and horizontally integrated care organizations to support better chronic care ( e.g. Basque Country, Catalonia, Valencia) Switzerland: physician networks / HMOs

10 Example 1: The Basque System, Spain Developing a favourable policy environment Stimulating systems thinking with new models of care Aligning ‘bottom-up’ and ‘top-down’ integration Providing a distributed leadership approach Care transformation in the midst of a deep economic crisis

11 Bengoa, 2013 -

12 Example 2: Maccabi, Israel Physician group partnership providing co- ordinated care to 1.9m people (25% population) Integrated ICT systems promote communication, continuity of care and supported self-care through ‘patient portal’ and telehealthcare System focus on managing chronic disease and the elderly Investment in leadership and inter- professional working Investment in research Positive impact on care experiences, clinical outcomes and cost containment

13 Maccabi 2011 -

14 Example 3: National Collaborative for Integrated Care, England The ‘Narrative’ Change to NHS Mandate Development of shared care outcomes between government departments, and quality regulator includes new targets Integration encouraged alongside competition by economic regulator Financial reforms supports range of new incentives to providers Commissioning reforms supports new opportunities to pool budgets New resources to support change – and the Integration Transformation Fund (£3.8bn) Pioneers Programme

15 HEALTH IN EUROPE 2020 EUROPE 2020 FLAGSHIPS FOR SMART, SUSTAINABLE AND INCLUSIVE GROWTH Innovation Union New Skills and New Jobs Digital Agenda Youth on the Move New Industrial Policy Platform against Poverty Resource Efficiency innovation for tackling societal challenges, e.g. ageing and health innovation for addressing the weaknesses & removing obstacles in the European innovation system Innovation Union ICTs for tackling societal issues - ageing, health care delivery sustainable healthcare & ICT-based support for dignified & independent living Digital Agenda for Europe E UROPEAN I NNOVATION P ARTNERSHIP ON A CTIVE AND H EALTHY A GEING

16 health & quality of life of European citizens growth & expansion of EU industry Sustainable & efficient care systems +2 Healthy Life Years by 2020 Triple win for Europe Improving prescriptions and adherence to treatment (A1) Better management of health: preventing falls (A2) Preventing functional decline and frailty (A3) Integrated care for chronic conditions, inc. telecare (B3) ICT solutions for independent living & active ageing (C2) Age-friendly cities and environments (D4) Action Groups Reference Sites

17 Action Area  Change Management Action Area  Workforce Development Action Area  Risk Stratification Action Area  Care Pathways Action Area  Patient / User Empowermen t Action Area  Organisational Models Action Area  Finance/Funding Action Area  Dissemination Action Area  ICT Tools EIP AHA B3 Action Plan By 2015 Chronic Conditions’ Programmes available at least 10% of target population in at least 50 regions By 2015 Chronic Conditions’ Programmes available at least 10% of target population in at least 50 regions By 2015 - 2020 Integrated Care Programmes serving older people, supported by innovative tools and services, in at least 20 regions By 2015 - 2020 Integrated Care Programmes serving older people, supported by innovative tools and services, in at least 20 regions SIP TARGETS 2013 Monitoring impact and outcomes 2015 Toolkit Increase the average number of healthy life yrs by 2 in the EU by 2020 Health status and quality of life । Supporting the long term sustainability and efficiency of health and social systems । Enhancing competitiveness of EU industry Chronic ConditionsIntegrated Care Implementation and Scale Up of Chronic Care + Integrated Care Programmes Map of partnership models for implementation of Chronic and Integrated Care Programmes Map of best practice methodologies to support the implementation of Chronic and Integrated Care Map of reusable learning resources Stratification of the population Mapping Best Practices in the EU regions Map of coaching, education and support patient/user empowerment and adherence

18 Developing a Regional Action Framework for Coordinated/Integrated Health Services Delivery (CIHSD) in the WHO European Region Dr. Hans Kluge Director, Health Systems and Public Health European Forum for Primary Health Care Conference Istanbul, Turkey, September 9 th – 10 th 2013

19 Concept note – common approach to CIHSD Field evidence \\ Guide for leading & managing change The Road Map to CIHSD MS Focal Points External Advisory Team Internal Review Team WHO Secretariat PatientsProviders Int’l orgs & NGOs PARTNERS

20 The Integrated Care Response in US and Canada USA Integrated delivery systems for enrolees – E.g. Kaiser Permanente – E.g. Veterans Health HMOs & group practice models – E.g. Mayo, Geisinger, Seattle Managed care or disease management programmes – E.g. PACE Integrated delivery systems for populations: – E.g. Nuka, Alaska – E.g. Massachusetts Canada Health Canada – Health Accord, 2004 – Sets 10 plans to overcome duplications, improve access and promote efficiency – Emphasis on care transitions hospital-home to reduce ‘bed blockers’ Provincial application leads to decentralisation and variation – PRISMA, Quebec – GP group practices, Alberta – Community-oriented primary care centres, Newfoundland and others

21 Example 4: PACE Programme, USA Fully integrated system providing acute and long-term care services to older people (>55) Grew out of On Lok, an innovative senior centre that developed a day hospital approach to care to frail older people Based around an adult care centre that offers: – social and respite services – primary medical care – geriatric outpatients – ongoing care and case management Designed to maintain frail older people in the community for as long as possible, so avoiding institutionalisation Voluntary enrolment, available to those aged >55 eligible for nursing home admissions and covered by both Medicare and Medicaid Important role of informal carers and supportive housing often part of care package

22 Example 4: PACE Programme, USA Between 1987-1997 PACE operated as a federal demonstration programme Since 1997, PACE a permanent provider under Medicare and a state option under Medicaid By January 2005 36 fully operational programmes across 18 states A typical participant: – A woman who is 80 years old with multiple (9.7) medical conditions with limited activities for daily living. 49% have a diagnosis of dementia How PACE achieves integrated care: Pooled financing (Medicare & Medicaid) and authority to control how capitated funding is spent Integrated services by range of staff employed at adult care centre – outside contracts for medical services, acute hospitalisations & nursing home care Case management by multidisciplinary teams including comprehensive assessments, service provision and care co- ordination Prevention and rehabilitation focus

23 Example 4: PACE Programme, USA Evaluations of PACE conclude: Large decreases in hospital use (admissions and lengths of stay) for enrolled patients Increased use of outpatient medical care and therapies, and care in home environment Positive impact on Medicare costs in comparison to non-enrolee groups Client health status and satisfaction with care arrangements good Results in terms of physical functioning inconsistent Conclusions: PACE successful in managing frail older patients and in offsetting costs against more expensive outpatient care Capital and start up costs were substantial, so PACE needed pump-priming from federal and state governments in initial phases Some patients not comfortable with adult day health care settings and/or giving up contact with a personal physician Centres run at a small scale (c.300 enrolees) so issues of economies of scale if more widely adopted

24 Example 5: PRISMA Programme, Quebec, Canada Unlike PACE, PRISMA is a co- ordinated model of care The goal is to integrate service delivery to older people to improve functional autonomy Admission is to persons >65 who have moderate to severe disabilities, but show good potential for staying at home – they need two or more health and social care services from the area in which they live How PRISMA achieves integrated care: Inter- and intra-organisational co- ordination by joint governing board and a service co-ordination committee A single point of entry to care services Case management who work with clients’ family physician and other providers Common assessment process and care plan Joint budget Integrated information system to track patients and support continuity of care

25 The PRISMA Model

26 PRISMA (Canada) Evaluations of PRISMA conclude: Declining trend in institutionalisation Lower client preference to be institutionalised Greater functional autonomy of clients No reduced or significantly changed pattern in the use of health and social care services Positive impact on carer burden No impact on mortality (survival) No reduction in costs Improved system outcomes at no additional cost

27 PRISMA and PACE compared


29 Towards Integrated Health Service Delivery in Latin America

30 Essential attributes of IHSDNs (PAHO, 2011)

31 WHO (Geneva) - Integrated care as a strategy to support universal health coverage

32 WHO (Geneva) Strategy for High Quality and People Centred Integrated Care (HQPCIC) to support Universal Health Coverage

33 Conclusions: Strategies and Progress Integrated care is a global buzzword and strategy for system reform Integrated care takes on multiple forms, and the purpose to which it has been adopted varies Cost-containment / creating sustainable care systems is a central driver, yet evidence suggests that integrated care is primarily a tool for quality improvement Evidence remains varied and limited, especially on costs However, there is enough to suggest what the important components of integrated care must be, and that the approach can support the ‘Triple Aim’ goals of care systems Yet, the failure rate amongst integrated care initiatives is high – more is needed in understanding how to develop, sustain and spread initiatives successfully and for the long-term There are few alternative options …

34 Contact Dr Nick Goodwin CEO, International Foundation for Integrated Care @goodwin_nick @IFICinfo

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