Transcript PBL: Theory and Practice - HPH

What does the concept
‘Integrated Care’ mean for hospitals?
Moscow, 28th of May 2004
Professor Cor Spreeuwenberg
Past Dean Faculty of Health Sciences
Maastricht University
Structure of this presentation
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background of health care innovations
integrated care and its related concepts
disease management and the role of hospitals
case: diabetes care
new public health and the role of hospitals
case: lifestyle related diseases
lessons learnt
towards an agenda for health promoting hospitals
Phenomena of all health care
systems have to face
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fragmentation of care between and within providing institutions
lacking co-ordination, continuity, seamless care
rising number of chronically ill and elderly
hospitals dealing with acute care and neglecting chronic care
need for effectiveness and efficiency
under-use of management tools and information technology
insufficient appreciation of the skills of nurses and paramedics
empowerment of patients in decision-taking and management
monkeys who look over the shoulder of the providers
- > governments, insurers, employers, purchasers, third parties,
interest groups
Health care systems in Europe
- fragmentation
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since 2nd half 20th century sharp division between
- hospital-care and community-care +nursing homes
- primary and secondary care
- responsibility for individuals and for collectives
- general health care and mental health care
- prevention and cure/care
- medical care and social care (well-fare)
in Western Europe focus lies on
- individuals
> collectives
- cure and care > (collective) prevention
Ageing in selected countries and its
impact upon HCE, 2000
(R.Blank & V. Burau, 2004)
% 65 +
% of total
HCE
30.0
Exp %
65+ 2020
19.5
France
15.9
Germany
16.8
34.1
21.7
Italy
17.6
34.3
19.4
Netherlands
13.6
41.2
18.9
Sweden
17.8
54.2
20.8
UK
15.7
43.0
16.3
Contrast between acute and chronic
care (D. Kodner, 1994)
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Acute care
disease - oriented
‘high tech’
episodic
cure
one-dimensional
professional
hospital
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Chronic care
function - oriented
‘high touch’
continuous and/or cyclic
care
multi-dimensional
family and volunteers
home
Strengths and weaknesses
of hospitals
strengths
professionalism
competence
equipped for acute care
self-consciousness
overview regional health
care
organizational skills
natural leadership
financial position, power
weaknesses
mono-dimensional interest
preference for interventions
poorly equipped for care
arrogance
internal orientation
few interest in other health
care providers
feel no intrinsic need to cooperate
Health care innovation
- some recent concepts
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integrated care
shared care
transmural Care
substitution of care
organizational networks
disease management
self-management
Integrated care
- definition
WHO, 2001:
Integrated care is the bringing together of
- inputs, delivery, management and organization of
services
- related to diagnosis, treatment, care,
rehabilitation and health promotion.
Integration is a means to improve services in relation to
access, user satisfaction and efficiency
Integrated care
- related concepts shared care and transmural care
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functional collaboration of all providers who are
relevant or solving a certain problem
common philosophy and strategy
based on formal agreements
specified tasks for all providers
needs to be organized and managed (networks)
sharing of information (exchange, storage)
protocols as a means for co-operation
incentives for quality improvement
involvement of patients and family
Integrated care
- examples
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shared care for patients with prevalent chronic illness
palliative support teams
stroke services
antenatal, perinatal and postnatal care & surveillance
ambulant cystic fibrosis treatment and dialysis
after-hospital-care at home
day services for patients with cancer, dementia,
depression and Parkinson’s disease
Substitution of care
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horizontal substitution
- provision of care by a generalist in stead of a specialist:
c.g. hospitial care -> community care
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vertical substitution
- provision of care by the ‘lowest’ provider who is qualified to
assure the standard of care: c.g. physician -> nurse
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diagonal substitution
- combination of horizontal and vertical substitution
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substitution may be partial or complete
Disease management
- background
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originally an American concept:
- related with managed care
- focus on efficiency more than on quality
- programmatic care
- usually organized by a third party between
insurers/PH agencies/employers and providers
challenge for Europe:
- primary responsibility for providers
- disease management as a form of integrated care
Disease Management
- an organizational principle for integrated care -
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aim: efficient care as well as high quality of care
designed for specific diseases or health problems
care for collectives; less on individuals
strong client orientation
focus on the whole process of care (protocols)
use of management instruments (+ICT) for feedback
separation of treatment and management/control
can be organized by third parties or by providers (!)
Disease Management
- use of management instruments:
benchmarks and feedback -
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focus on measurable outcome parameters
benchmarks that represent the aims of care
benchmarks that aim to improve the
outcomes/results
individualized contracts/agreements with providers
steering based on objective outcome-parameters
feedback: concrete, clear, personal and oral
Disease management
- patients’ perspective 
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positive
more focus on patient
orientation towards
content, process,
attitude
ideally: more orientation
towards human values
more involvement in
feedback systems
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negative
standardization of care
less personal
involvement of
professionals
if freedom of choices
(opting out) -> higher
premiums
Disease management
- professional perspective Positive
 patient orientation:
content, process,
attitude
 ideally more orientation
on human values
 patient profits from
quality improvement
 patients involved in
feedback-systems
negative
 loss of traditional
autonomy
 bureaucracy rules easily
the care process
 doubts about the
interests of patients
 resistance to change
Examples of integrated care
with involvement of hospitals
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between hospital and primary care
- case: diabetes mellitus
between public health, primary care and hospital
- case: new public health
Case: diabetes care
- The state of the art: St.Vincent’s declaration 
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content: according to ‘evidence based’ and
internationally accepted protocols and guidelines
considered as a risk factor for cardiovascular disease
efficient and effective organization
physical and psychological access
emphasis on lifestyle and behavior
attitude: acknowledging the specific needs, demands
and features of the patient
Diabetes care
- typical traditional organization -
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diabetic control: internist or family physician (GP)
acute care and complications: family physician (GP)
information and counselling: specialized nurse (if so)
insulin-injections at home: district nurse
periodic checks of the eyes: ophthalmologist
periodic checks of the CV-system: cardiologist
emergency cases: GP/ambulance services
Diabetes care
- Quality of care in Europe: the CODE-2 study 
HbA1c:
23% well, 35% moderately, 42% badly regulated
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systolic blood pressure:
69% well regulated (Europe 85%!)
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cholesterol blood level < 5,2 mmol/l
35% according the standard
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annual check of the eye:
28%
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annual check of the feet:
< 15 %
The Maastricht Region
- some features -
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capital of the province of Limburg
surrounded by Belgium (Flandres, Wallonia) and
Germany; rather isolated from rest Netherlands
140.000 inhabitants in the region
90 GPs and one (academic) hospital
longstanding relations between specialists and GPs
Diagnostic & Transmural Centre in the hospital
ownership of GPs and involved specialists
Diabetes care in the Maastricht Region
- its main characteristics 
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structural co-operation between all providers, local
insurer, patient organization and Health Inspectorate
combination of shared care and disease management
adaptation to needs and wishes of the caregiver
inclusion of all diabetes patients
whole trajectory: from prevention to palliation
vertical and horizontal substitution
use of a common protocol
integrated quality assurance system
Diabetes care in Maastricht
- Role of physicians and specialized nurses
physicians
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 diagnosis
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 initial treatment
 instable patients
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 assessment of complications
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 planning
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defining protocols
supervision of nurses (MS)
education
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specialized nurses
early detection
education and
counseling
periodical checks
adaptation of treatment
prevention of
complications
defining of protocols
link to family physicians
education
Diabetes care in Maastricht (140.000inh)
- model for patients with diabetes mellitus -
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nuclear team of
- medical specialist
- general practitioner
- advanced clinical
nurse specialist (ACNS)
1 = patients of MS
2 = patients of ACNS
3 = patients of GP
MS>ACNS>GP !
ACNS supervises GP!
1
2
3
Diabetes care in Maastricht
- management instruments 
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organization hosted in regional (Academic) hospital
managers and nurses appointed by the hospital
easy understandable and actual protocols
management-information (ICT, focus groups)
students screen of patients of participating GPs
benchmarks discussed yearly with projectleader
structure for supervision and advice
permanent education
newsletter
Diabetes Care in Maastricht
- Scientific evaluation 
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permanent qualitative and quantitative evaluation
quantitative evaluation:
- performance and clinical outcomes of care by
nurses equal or even better than that of physicians
- self-management: no improvement
qualitative:
- > 90 % patients more satisfied than in usual care
- costs are equal to usual care
health technology assessment is in process
Diabetes care in Maastricht
- Keys for success
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enthusiast and competent management
goal-oriented, systematic, programmatic approach
creation of a sense of urgency
longstanding relationship between hospital and GPs
common interests of participating providers
(creating) national interest
temporary extra funding for development
scientific evaluation -> (inter-)national publications
positive clinical results
satisfied patients and participants
Co-operation between PH-agency,
primary care and hospital
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Case: New public health
Public Health
- definition and tasks 
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the science and promoting of health trough the
organized efforts of society
part of primary care if it functions as first contact
important fields:
- health protection
- health promotion and prevention
- care for specific groups
- health administration
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ruled by governments and public administrators
in Europe lack of collaboration with other primary
care providers, secondary care and mental health
New Public Health - I
- definition and stakeholders 
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Integration of public health policy, public health
practices and curative care
Stakeholders:
- PH policy: national, regional and local politicians
- PH practices: regional PH-institutes: managers,
nurses, physicians, health educators
- curative care: hospital management, GPs, medical
specialists, home care organizations
Fits WHO ‘Toward Unity for Health’ (TUFH)-project
New Public Health - II
- European examples and tasks of partners 
examples in Europe
- Primary Health Trusts in the United Kingdom
- New PH-programme for CVD in Maastricht
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meaning: joint approach for primary, secondary and
tertiary prevention of diseases
- PH agencies
. promoting healthy behaviour
- PH agencies and GPs
. screening to detect patients at risk
- curative sector
. diagnosis, treatment & improving life style of
patients at risk
Areas for New Public Health
Areas that covers the tasks of generalists and public
health agencies
 addiction and addictive diseases
 contagious diseases (HIV/Aids and tuberculosis)
 diseases influences by life-style and behaviour
 child care (surveillance during childhood)
 maternal care
Organization New Public Health for
cardiovascular diseases (Maastricht Region)
New Public Health Maastricht
Academic Hospital
Regional PH Institute
(board: regional municipalities
Regional GPs
Programma Management
Health promoters in the public area
in public areas (c.g. shops, libraries)
Screening and health education
patients at risk (GP-offices)
medical specialists: high risk
(academic hospital)
New public health
- complicating factors
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dependency of PH-agency of a political context
fragmentation of the political context
bridging the gap between a political/administrative
structure and a health care embedded structure
long term between PH-interventions and clinical
results
need to focus on intermediate results like changes in
behaviour
Lessons learnt from experiences
with shared approaches (I)
-enabling factors (Kodner & Spreeuwenberg, IJIC, 2003)
Funding
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pooling of funds
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prepaid capitation
Organizational
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co-location of services
 discharge and transfer agreements
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inter-agency planning and/or budgeting
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service affiliation or contracting
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jointly managed programs or services
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strategic alliances or care networks
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consolidation, common ownership or merger
Lessons learnt from experiences
with shared approaches (II)
-enabling factors (Kodner & Spreeuwenberg, IJIC, 2003)
Administrative
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inter-sectoral planning
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needs assessment/ allocation chain
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joint purchasing or commissioning
Service delivery
 joint training
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centralized information, referral and tasks
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care/care management
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multidisciplinary/interdisciplinary teamwork
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around the clock (on call) coverage
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integrated information systems
Lessons learnt from experiences
with shared approaches (III)
-enabling factors (Kodner & Spreeuwenberg, IJIC, 2003)
Clinical
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standard diagnostic criteria (e.g. DSM IV)
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uniform, comprehensive assessment procedures
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joint care planning
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shared clinical records
 continuous patient monitoring
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shared, evidence-based decision support tools
(guidelines, protocols)
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regular involvement of patients and family
Challenges to Integrated Care
(Thanks to D. Light)
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to move from turf battles and defence of
professionalism to a sense of working together
to align payment structures and incentives so that
they promote integrated care and not work against it
to keep politicians from making new rules and
programs that inadvertently obstruct than facilitate
integrated care
to examine carefully any proposal by investor-owned
corporations to deliver services to those with chronic
conditions at risk
Towards an agenda for health
promoting hospitals
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behave as a leader of the regional health care system
look for opportunities for integrated care in the
region
develop a strategy with other providers and the staff
integrate services at an appropriate level
focus on the needs of chronic patients: treatment,
prevention, screening, care and self-management
reconsider the appropriate role of physicians, nurses
and paramedics
encourage shared training of doctors, nurses and
paramedics
be open and transparent