EU Models of Care EU Models of Care webinar – introducing the Esther model from Jonkoping 19 October 2015.

EU Models of Care EU Models of Care webinar – introducing the Esther model from Jonkoping 19 October 2015

NHS European Office Who are we? What do we do? Established 2007
Part of the NHS Confederation Funded by national NHS bodies What do we do? Represent NHS organisations in EU policy-making and legislation Assist the NHS with the implementation of EU law Offer strategic advice on EU funding opportunities Promote partnerships between NHS organisations and bodies from other sectors/countries

EU Models of Care Working with NHS England to support Pioneers and Vanguards to develop links and share learning with organisations at leading edge of integrated care in Europe An in-depth look at four different EU Models of Care throughout : Spain (Alzira) Netherlands (Buurtzorg) Sweden (Jonkoping) Germany (Gesundes Kinzigtal) Webinar, followed by study visit – look out for the registration links EU Models of Care conference in spring 2016 Other events and activities throughout the year

Integrated Care Model Pillars

Understanding the Esther model
Nicoline Vackerberg, Quality manager, Esther Coordinator Anna Carlbom, Medical Officer Nurse, Esther Coordinator

Network for health and care collaboration
Sweden has one of the world’s highest percentages of seniors, and in the late 1990s Höglandet’s local hospital began overflowing with patients. Officials from the Jönköping region and healthcare employees collaborated on a better system to care for the elderly, who frequently ended up in the hospital. They dreamed up their fictional character Esther, a reasonably self-sufficient 88-year-old pensioner with some chronic health issues. Then they asked, ”What is best for Esther?” Network for health and care collaboration 2014 "It's about radical customization and trying to design processes based on the needs of the patients and not the needs of the system," said Göran Henriks, an official who helped launch the "Esther Project.“ The system brings together doctors, nurses, pharmacists, social workers and occupational therapists. In many cases, the best possible care is at home, which is far more cost effective. And when a hospital stay is required, municipal social care staff go to "Esther's" home to ensure she has food and a clean bed when she returns. Nicoline Vackerberg, who manages day-to-day operations at the Esther Network, said everyone is encouraged to participate. (While everyone working in senior healthcare is involved in some way, there are 180 "coaches" who have been trained to always ask, "What is best for Esther.") "We do a lot of reflecting. Everyone has the possibility to say 'This is not the best for Esther'," Vackerberg said. Patients also meet in groups with care providers to discuss their care and suggest improvements. The Esther Project has been very successful in reducing hospital admissions (there was a 30% decline from 1998 to 2013) and in cutting costs (roughly $1 million a year from 2002 to 2013). Similar programs are being rolled out to other groups that need complex care in Höglandet, including psychiatric patients. It's also being copied in places as far away as Singapore and San Francisco. --A.P. Network for health and care collaboration 18/09/2018

The Swedish Healthcare system
All public Healthcare is subsidized. A patient pays a maximum of 1100 SEK (87 £) per year. The equivalent for prescription pharmaceuticals is 2200 SEK (175 £) per year. Hospital care is 100 SEK (8£) per day. All maternal care is free of charge. Children have free health- and dental care until the age of 20.

Municipal Healthcare Healthcare in residential homes have been a municipal responsibility since 1992 Responsibility for Healthcare in ordinary homes has changed from county councils to municipality in the last 5 years Includes care up to specialist nurse level Doctors are still employed by the county councils Doctors still responsible for prescribing treatment, medication and so on

Social versus Healthcare in the Municipality
In need of social care an application has to be made to social workers who assess the needs Esther is charged a maximum fee of 1776 SEK/month ( 141 £) In need of Healthcare, contact with Hospital, Primary- or Homecare where Doctor, Nurse and Patient make a care plan Free of charge in most municipalities

It started with six communities/ municipalities in Region Jönköping…
Network for health and care collaboration It started with six communities/ municipalities in Region Jönköping… Network for health and care collaboration

The Höglandet district
inhabitants 6 municipalities 1300 persons in elderly homes 2000 persons healthcare at home 8 public and 8 private primary care units* Eksjö Hospital 263 beds Senior citizens’ organizations Approx. totally 7000 employees Värnamo Mullsjö Habo Vaggeryd Gnosjö Gislaved Network for health and care collaboration *31 public and 17 private primary care units in the whole region

Höglandet’s hospital - Average days
Days in hospital - average 2009 2010 2011 2012 2013 2014 Surgery 3,6 3,4 3,3 3,0 Gynecology 2,1 2,0 1,9 Internal medicine (3,9 – 4,4 period 2001 – 2009) 4,1 4,3 4,2 4,5 Orthopedics 4,4 4,8 Rehabilitation 19,2 19,4 17,8 12,6 9,9 9,2 Total 4,7 4,6 Network for health and care collaboration

The Challenge Person centred care Complexity Delivering a service that is truly patient centred is an enormous challenge which……can only be overcome by actively engaging patients as valuable resource. GREENHALGH, T., HUMPHREY, C. & WOODARD, F User involvement in health care, Chichester, John Wiley & Sons, Ltd. Healthcare systems are complex, and repairing them is complex. GLOUBERMAN, S. & ZIMMERMAN, B Complicated and complex systems: what would successful reform of Medicare look like? Changing Health Care in Canada: The Romanow Papers, 2, Network for health and care collaboration

The Patient Today ACUTE PATIENT CHRONIC or Complex PATIENT
PRIMARY CARE HOSPITAL HOME OLD PEOPLE’S ACUTE PATIENT PRIMARY CARE HOSPITAL HOME OLD PEOPLE’S HOME CHRONIC or Complex PATIENT

Esther’s journey Client integration and co-operation - a must to built trust Primary care Hospital Intensive care Home care Sheltered home Medical unit Psychiatry Network for health and care collaboration Rehabilitation

Individual values What does Esther need/ want? What is important for Esther when she gets sick? Partners Who has to cooperate to fulfil Esther’s needs? Changes in the environment Changes in the system of health care? New methods? New technology? Changes in population? Network for health and care collaboration

Vision Esther Esther will experience safety and independence and she will live an independent life that is supported by an energetic network. Esther: Gets care in or close to her home Sees us as the same provider of care Has equal chance of receiving care over the whole region Knows where and who to turn to Has an individual care plan Höglandet’s care: All personnel are concerned and committed Support each other in achieving the best of Esther Increase competence in the whole care chain Continuous improvement of quality Network for health and care collaboration

The Basic idea What is best for Esther ? Esther… no matter where,
we will be there! Network for health and care collaboration

Results Type of care 2000 2014 Hospital beds 375 263 People living in Care homes 1740 1290 Amount of people getting Healthcare at home 1000 Network for health and care collaboration

Esther start and 2014 Waiting times for referral appointments with gastroenterologists fell from 48 days in 2000 14 days in 2003 14 days in 2014 80 % of all patients at the internal medical clinic are getting an appointment within 2 months 2014.

Unnecessary days at Höglandshospital
patient = discharge ready for >5 days Nässjö Tranås Eksjö Number of days Patients Network for health and care collaboration

Your confidence in the health care system in your county / region?
A lot A Little Ref. Salar. NPE 2015

Coordinator Contact between the General Practitioner and the Dept. of Internal Medicine before the patient arrives to hospital. Discussion about the patient – what is the optimum care level for the patient: - Direct to the acute clinic? Via X-ray? - Direct to the nursing ward? - To an office hour visit? - Give advice? - Is it necessary to admit the patient? Network for health and care collaboration

Discharge – Safety receipt
Network for health and care collaboration

Welcome Back Home package
Staff from municipal social care is already there when Esther returns from the hospital Make sure that… - the home is in order - Esther has got food and a clean bed - Esther got the right equipment and correct medication If needed, attach and test a personal alarm around the wrist Check again the care and social plan together with Esther, make changes when needed Most important! Make sure Esther feels listened to, safe and confident Photo: Johnny Törnkvist Network for health and care collaboration

Readmissions within 30 days in Tranås Nice to know that Mum is not coming home to an empty house. Esther’s daughter It feels satisfying, to not have to leave before Esther says everything is fine. Staff member 2012: 17,4 2013: 15,7 2014: 12,1 Network for health and care collaboration

Esther café Network for health and care collaboration

Esther coach training To work with change/improvement OR ? Network for health and care collaboration

The use of transparant data to create overall understanding and possibility to learn and react.

What has been helpful in creating seamless care ?
Person centredness Communicating systems Mutual responsibility for the person Multi professionalism Improvement together with partners Mutual meetings and education Openness and learning Less hierarchy Your problem is my problem

What could we do better ? Esthers Participation on all levels, all the time. Use of attractive and understandable measurements Spread of good examples Appreciation to partners See Esthers next of kin

How are we doing? Results on the web Studies done about leading and sustaining Esther network Person driven care National studies Network for health and care collaboration

Esther Network’s website
Follow us Network for health and care collaboration

Understanding the Esther model
Any questions?

Next Steps We will: Next EU Models of Care examples:
Share the recording Organise a study visit to Sweden on 25 – 27 January 2016 Follow up with colleagues interested in developing direct links with Jonkoping – please talk to your account management team to incorporate into your support planning Share webinar evaluation survey – please do complete! Next EU Models of Care examples: Gesundes Kinzigtal webinar – 26 November at UK time Register now! For more information, please contact: or

Esther Coach Course Learning by doing; 8 days Making their own personal improvement project (PIP) Making an improvement at their own working place Coaching skills – solution focus approach Site visits in other organisations, in and outside healthcare Network for health and care collaboration

Who are the Esther coaches 2015?
Nurse assistants Nurses Social workers Physiotherapists Occupational therapists Administrators Network for health and care collaboration

Networks that are alive contain… Total openness (take everything people bring) Focus on value Constantly seeking and tapping energy Creating a shared sense of system (shared map and shared narrative) Letting go of need to control – an ecosystem, not a hierarchy (trust) The group asks versus share Network for health and care collaboration

Networks that are alive contain… Crisp aims and priorities Celebration Shared optimism Creativity and opportunism Simplicity Profound respect for logistics ( ”Amateurs discuss strategy…..”) J.McCannon &R Perla 2009 Learning networks for sustainable, large scale improvement Joint commission on quality and patient safety Network for health and care collaboration

No matter where ……….we will be there
Esther international David and Sarah, Sheffield, UK Joe, Sheffield, UK Esther, Calderdale, UK Mrs Smith, Cornwall, UK Dorothy, London, UK Doris, Leeds, UK Margareta, Scotland, UK Henriette, Scotland, UK Alice, San Francisco, USA Suzanne, Gouda, The Netherlands Ester, Singapore Probably more No matter where ……….we will be there Network for health and care collaboration

Local government in Sweden has a long tradition The local authorities and the county councils/regions… are responsible for providing a major part of all public services. have considerable degree of autonomy have independent powers of taxation. have a great deal of freedom to organize their activities as they see fit. The scope for local and regional self- government is also affected by decisions taken in the EU. Independent powers of taxation Local authorities and county councils/regions are entitled to levy taxes in order to finance their activities. A percentage of the inhabitants' income. They decide on the tax rate themselves, the average, overall local tax rate is 30 % % to the local authorities % to the county councils/regions Tax revenues are the largest source of income for the local authorities = 2/3 of their total income Fees The local authorities and county councils/regions may charge for their services. Cost-price principle: Fees may not be higher than the costs relating to the service concerned. If the local authorities and county councils/regions are obliged to provide a service, they may only charge for the service if specifically permitted to do so by law. Network for health and care collaboration

EU Models of Care EU Models of Care webinar – introducing the Esther model from Jonkoping 19 October 2015.

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EU Models of Care EU Models of Care webinar – introducing the Esther model from Jonkoping 19 October 2015.

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