1. Integrated Care – Incentives and tools for a coordinated pathway for the chronicly ill patient in The Netherlands
Prof. dr. Henk Nies
Vilans, Centre of Expertise for Long-term Care
Utrecht- The Netherlands -
Zonnehuis Chair on Organisation and Policy in Long-term Care, Free University, Amsterdam - The Netherlands
Workshop Forum for Health Policy, Stockholm,
23 May 2012

2. Presentation The Dutch system The quest for integration
Incentives and tools for integration for integration
Organisation
Quality
Funding
Evaluation
Future options

3. The Dutch system Acute care: Health Care Insurance Act
Long term care: Exceptional Medical Expenses Act
Social care: Social Support Act
Public Health: Public Health Act

4. Health Care Insurance Act
Governance:
Part of health care system
Health care insurers (+ 15)
Private providers, partly for-profit, entrepreneurship of doctors
Medical and paramedical care at home (GP’s, dental care, physiotherapy, psychology etc.), in hospital and residential homes
Obligatory health insurance
Additional insurance on voluntary basis
Personal risk (€ 220, SEK 2,006), not for GP expenses
Hospitals: € 22.4 bln, SEK 204 bln; GPs: € 2.5 bln, SEK 22,8 bln), pharmacy: € 6.4 bln, SEK 58.4 bln)

5. Exceptional Medical Expenses Act
Governance:
Part of health care system
Regional insurance offices (27)
Private not-for-profit providers, small part for-profit
Long-term care, rehabilitation: personal care, nursing, personal guidance, residential care, rehabilitation, short stay
Compulsory insurance: care offices
Independent assessment
Co-payments (income-dependent), max € 2,136 (SEK 19,478)
Budget: 23 billion Euros (SEK 210 bln)
In kind/personal budgets (+ 10 %)

6. Social Support Act Governance:
Municipalities
Social support system
Private not-for-profit providers, volunteers, small part for-profit
Personal social services: domestic care/housekeeping, day centres, social participation, informal carers’ support, volunteers, assistive technology/devices, transport
National tax-based, lump sum, partly not earmarked
Co-payments (income-dependent, determined by municipality)

7. Public Health Act Governance:
Municipalities
Public health organisations of municipalities
Public advice and information, population, screening, communicable diseases, epidemiological advice to municipalities, target groups
Mainly tax based (municipalities, national government, health care insurers, patients/citizens, ambulance services
Partly co-payments for some individual treatment (vaccinations) and ambulance services
Budget: € 707 million (SEK 6447) (2007)

8. Conclusion……

9. Find the differences: key figures
Long-term care
Sweden
Netherlands
Population x million (OECD)
9.3
16.5
> 65 x million (OECD)
18.8
15.9
Life expectancy (SCP, 2012) 81
% healthy life years of L.E. 86 75
Expenditure (% of GDP)
10,0
12,0
Private expenditure (% of total) 19 15
Out of pocket payments (% of total) 17 6
Expenditure hospital care (% of total) 44 31
Expenditure LTC (% of GDP)
3.9
3.6
LTC recipients (% of 65+) 23 25

10. Find the differences: system and culture
Many large scale organisations > 100 Mio (SEK 912 Mio) annual budget
Polder culture – corporatistic model - at all levels
Controlled market mechanisms
GP as gatekeeper
Social model in LTC
Informal care: volunteers, carers
Explicit end of life care

11. Challenges
Total expenses: € 5,200 (SEK 47,419) per head of population (health care and long term care): too high i.r.t. outcomes
Relatively young population rapidly ageing
Cost reduction
Dealing with epidemic growth of chronic patients
> 25% suffers from chronic disease
+ 8% more than one disease (under-reported)
Diabetes (668,000), coronary heart disease (648,000), asthma (333,000), COPD (276,000), dementia (245,000), depression (274,000), stroke (191,000)
Labour market for long-term care (now: 800,000 person years, in ,500,000 person years; percentage of labour market: from 12% in 2007 to 24% in 2030)

12. The quest for integration: What happens if….?

13. Incentives and tools for integration: Organisation
Collaborative structures: networks and chains of care
Stroke services (+ 1995) Stepping into stroke care, experiments (around hospitals), evaluation
Geriatric networks (+ 1996) Experiments (regions and geriatric departments), evaluation
National dementia programme (+ 2003) User needs explored, developing (regional) structures, followed by funding mechanisms and care standard
Palliative care (+ 2000) Regional, stepwise built up, consultation and co-ordination, including networks of volunteers

14. Incentives and tools for integration: Organisation
More recent
Dementia care networks well developed (95% coverage)
Palliative care networks well developed
Development of health centres (11% of GPs)
Care groups (GPs and other professionals around specific groups; 80% of GPs)
The neighbourhood as unit of organisation
Small scale organisation of home care (Buurtzorg)
Rediscovery of district nurse

15. Incentives and tools for integration: Quality
Quality models and instruments
Guidelines
Network models
Diseasemanagement
Chronic Care Model
Guided Care Model
Spaghetti Model
Improvement programmes
Collaboratives (stroke, dementia, DM/CCM)

16. Incentives and tools for integration: Quality
Guidelines
Care standards based on CCM (COPD, Diabetes, Vascular risk management, obesities) forthcoming: dementia, asthma, depression, cancer, stroke etc.)
Care programme (standard operationalised)
Individual care plan
Indicators
Case management
Integrated needs assessment
Task delegation to nurse
practitioner, specialised
nurse to GP
Involving informal care

17. Care standard What good care is supposed to be Design
Contents
Organisation
For professionals, insurers and patients
Design
Disease-specific care
Generic care (modules, self-management)
Organisation of care process, incl. quality management
Quality indicators
Strong role for users’ organisation

18. Individual care/health plan
Patiënt’s perspective  self-management plan
Personal perspective
Personal objectives/aims
Self-management capabilities
Shared decision making
Health problems
Professionals perspective  individual treatment plan

19. Incentives and tools for integration: Funding
Integrated funding
One fee for one group of providers for one integrated package of care (organisation costs included)
One contractpartner, many subcontracters
Organisation in care groups
For diabetes (in CZ areas: 35), COPD (18), vascular risk management (15)
Additional fee
For organisation of integrated care
Services separately funded
Specific policy innovation measure plus macro budget
E.g. Dementia care incorporated in contract policies of care offices
Too much success of personal budgets

20. Evaluation
Evidence
Some evidence of improved clinical processes and performance
No sound evidence (yet) of better outcomes for patients
It takes five to ten years to find outcomes
Hard to define performance indicators
Costs have risen, no savings demonstrated (yet): hospitals seem to seek additional income to compensate gains/losses
Structures and quality measures have - to some degree - been implemented
It gets complicated when it is about money
and income

21. Evaluation Experience
Other bottlenecks are self-management, individual care plan (14% of COPD/asthma patients), ICT
Debate on case-management
User involvement is still low
Personal budgets too popular
Contracting across sectors and services is difficult: silos in chronic care
Joint responsibilities  unclear responsibilities
Freedom of choice limited
Tension between protocols and professional
autonomy
New responsibilities for municipalities

22. Concern/chance: the spaghetti model

23. Evaluation What works? Quality as primary driver Collaboratives
Funding: € 10 Mln (SEK 91 Mln)  all care offices include integrated dementia care in their contracts
Integrated funding of primary care
Self steering teams
Informal care, volunteers

24. Paradigm shift
From care and disease,
to health and behaviour

25. Paradigm shift

27. Meaningful activities: care farms

28. Alzheimer café

29. Support for informal carers

30. Evindence based model of Integration

31. Four phases of development
1. Initiative and design phase
Exploring possibilities and chances, project design, agreements
2. Experimental and execution phase
Defining aims and content, coordination care chain, experiments
3. Expansion and monitoring phase
Further development and maturity, monitoring, new questions
4. Consolidation and transformation phase
Continues improvement, new ambitions, integrated structures
Phase 1: The collaboration between health care providers has been intensified or started up. The starting point is a common
problem or chance occurrence, or builds on current cooperation among care professionals. There is a sense of
urgency and there are possibilities for working on these challenges in collaboration. The targeted patient group, the care chain and care process have been defined, as also the needs of patients and stakeholders. The level of ambitions, motivation and leadership determine the progress achieved. A multidisciplinary team designs an experiment or project to execute the present ideas. The collaboration can be signed up in an agreement among care partners.
Phase 2: New initiatives or projects are being executed in the care
chain. The aims, content, roles, and tasks in the care chain
have been clarified and written down in care pathways
and protocols. There is coordination on the level of the
care chain by for instance installing coordinators or setting
up meetings. Information about patient groups,
working procedures or professional knowledge is
exchanged. There are experiments within the collaboration,
results are evaluated to learn from and reflect on.
Preconditions for projects have been considered and
boundary conditions have been solved by collaborative
means or agreements among care providers.
Phase 3: Projects have been expanded or integrated in integrated
care programs. Agreements on the content, tasks and roles
within the care chain are clear and signed up. Collaboration
is no longer on an informal basis. Results are systematically
monitored and improvement areas identified. The
targeted population has been surveyed. More collaborative
initiatives emerge such as mutual education programs.
There is a continuous commitment to the
ambition of the integrated care program. Interorganizational
barriers and fragmented financial structures are on
the agenda of care partners.
Phase 4: The integrated care program is the regular way of working
and providing care. Coordination at care chain level is
operational; information is being shared, transferred and
fed back. A monitoring system periodically shows if
results are sustained, what specific improvement possibilities
have been identified and to what extent patient needs
have been met. The program builds further on successful
results. Organizational structures transform or are newly
designed around the integrated care program. Financial
agreements are arranged with financers by means of integral
contracts covering the care chain as a whole. Partners
in the care chain explore new options for collaboration in
the external environment with other partners. 31

32. Self-evaluation
Contracting
Optimizing processes

33. A European input

37. Thank you
Henk Nies