Transcript The English Acute Hospital: challenges and opportunities

Improving cooperation for
better chronic care
Chris Ham
HSMC
University of Birmingham
3 April 2008
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Some history
• The journey from infectious diseases (19001950) to acute illnesses (1950-2000) to chronic
diseases (2000-)
• The acute care paradigm based on episodic
care, hospital based treatment and increasing
specialisation is anachronistic
• A new paradigm is needed to respond to the
increasing burden of chronic disease (Kane et
al, 2005)
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Chronic care model
i
i
Wagner EH. Chronic disease management: What will it take to improve care for chronic
illness? Effective Clinical Practice. 1998;1:2-4.
The influence of the Chronic Care
Model
• The WHO’s Innovative Care for Chronic
Conditions Framework
• The Expanded Chronic Care Model (BC)
• The NHS and Social Care Model in England
(and variants in Scotland and Wales)
• The Model has also been adapted in other
countries e.g. Australia and NZ
C Ham and D Singh (2006) Improving care for people with long term conditions:
a review of UK and international frameworks, HSMC, University of Birmingham
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The NHS and Social Care
Long Term Conditions Model
Delivery System
Infrastructure
Community
Resources
Better outcomes
Case Management
Health and social
system environment
Disease
Management
Supported
Self care
Promoting Better
Health
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Creating
Decision support
tools and clinical
information system
(NPfIT)
Supporting
Empowered and
informed patients
Prepared and
proactive health and
social care teams
Some important elements in the
Chronic Care Model
• Informed and expert patients, taking
control of their conditions
• Team based care using the skills of
doctors, nurses and others
• Collaboration and partnership between
patients and teams
• Integration of care – primary and
secondary care; health and social care
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Gaps in chronic care
• Commonwealth Fund Survey of six
countries, 2005
• Advice on self management was not
routine in any country
• There were variations in the use of nurses
to provide diabetes care
• Among patients with diabetes and
hypertension, those receiving all tests fell
short of recommended care
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Gaps (2)
• Sizable majorities of patients reported their
medications had not been reviewed
• Many patients reported that physicians
had not explained side effects
• There were shortcomings in physicianpatient communication
• There were also shortcomings in care
coordination (the next big thing?)
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Moving forward
• How can these gaps in care be filled?
• How can international experience and
research evidence be used?
• What are the implications for policy and
practice?
• What are the characteristics of the high
performing chronic care system?
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10 characteristics
• Ensuring universal coverage
• Care free at the point of use
• A focus on prevention e.g. the new
contract for family physicians in the NHS
• Priority for self management
• An emphasis on primary health care (the
importance of the medical home)
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10 characteristics contd.
• An emphasis on population management/risk
assessment
• Care should be integrated (let’s debate what that
means)
• IT should be used, especially the electronic care
record and telehealth
• Care should be coordinated (see new OECD
report)
• These 9 characteristics need to be linked into a
coherent whole
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Four supporting strategies
• Physician leadership
• Measuring outcomes and using the results
to drive performance improvement
• Aligning incentives e.g. the new contract
for family physicians in the NHS
• Engaging the community e.g. NZ
experience of working with Maori
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Paying GPs for quality
• GPs paid using mixture of capitation,
salary and fee for service in the past
• New payments (April 2004) emphasise
quality of care
• Payments are based on ‘quality and
outcomes framework’ (QOF)
• QOF is based on 10 common chronic
conditions
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The QOF (1)
• GPs earn points if they meet performance
targets
• Targets cover aspects of care such as
blood pressure recording and control
• Points convert into extra income for GPs
• The incentives are big: up to one third
extra income if targets are met
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The QOF (2)
• Clinical indicators make up around 50% of
the QOF
• Organisation of care, patient experience,
and providing additional services make up
the other 50%
• Performance is based on self assessment
– a high trust contract
• External audit is used to supplement self
assessment
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Some US examples of integrated
care
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Kaiser Permanente
Group Health Cooperative
Veterans Health Administration
Health Partners
Alaskan Medical Service
None is perfect, but all seem to perform
better than other forms of care
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Some other examples
• Integrated health boards in Scotland
• Integrated health boards in New Zealand
• Integrated health and social care
organisations in Northern Ireland
• Care Trusts bringing together health and
social care in parts of England
• Esther project in Jonkoping, Sweden
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A detour to the UK
• The UK has a strong primary care orientation
• Patients are registered with a primary care team
that serves as a medical home (typically 3-4
physicians, nurses and others)
• The best teams provide high quality care based
on registration, recall and review
• Major weaknesses in the UK are variable
standards of primary care and poor
integration/coordination with secondary care
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A detour (2)
• The NHS suffers from the historical division in
British medicine, separating family physicians
from hospital specialists
• US integrated systems like Kaiser hold lessons
for the NHS, especially in multispecialty medical
practice
• But the NHS has the potential to achieve closer
integration of health and social care, and in
some places this is happening
• New policies like practice based commissioning
may support closer integration
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What is integration?
• Vertical or virtual?
• Organisational, clinical or service
integration?
• Integrated provision of care or integrated
provision and funding?
• Integration of all services or focused
integration for specific diseases/care
groups e.g. frail older people?
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Care coordination
• Coordination is particularly important for people
with multiple chronic conditions
• Primary care (where it works well) can provide
coordination
• Other approaches have also been used e.g.
case managers/community matrons
• Patients/families may be care coordinators by
default or by design (e.g. by holding budgets)
• More than one approach is likely to be needed
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Barriers to integration
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Organisational fragmentation
Budgetary fragmentation
Perverse incentives
Professional fragmentation
Conservatism and inertia
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Context is critical
• Different systems need to find their own
solutions reflecting different contexts
• How are the systems represented here
rising to these challenges?
• Are there other and emerging approaches
to care integration we can learn from?
• How can approaches be adapted to fit
different contexts?
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Language
• The language we use may be a barrier to
improvement – patients/clients need the
right care in the right place at the right time
• Is it still helpful to talk about primary care,
secondary care and social care?
• Or do we need to find a new vocabulary to
suit the times?
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