Integrated Care in china yan Zhang Ph.D Huazhong University of Science and Technology

1. Research on Global Budget on One Certain Disease in Multi-level Institutions: Integrated Service Orientation Integrated Care in chinayan Zhang Ph.DHuazhongUniversity of Science and Technology Email: yanzhang@hust.edu.cn

2. CONTENT • Background • Objective • Intervention • Investigation • Finds

3. Background Disorder flow Lack of coordination Fragmented Healthcare Delivery System • Health Reform Quality Efficiency and Effectiveness Access Utilization of healthcare increasing Efficiency

4. Integrated health care system: International perspective and China practice • Sep 1-3, 2012, Beijing • “Study on the Efficiency and Effectiveness of the Integrated Health Care Services in Rural China” supported by the China Medical Board； • “Research on the vertical Integration management model of Chinese rural medical service based on complex adaptive system theory” supported by the National Natural Science Fund.

5. Objective • Overall goals: • Seamless care • Improved care • Better health • Lower cost • Objective: • To explore the mechanism of Global Budget of Multi-level Institutions on one certain disease (GBMI) to stimulate health personnel to supply integrated care in primary institutions.

6. Intervention Design • Case-control study • Qianjiang District, Chongqing, China • 4 similar township hospitals were divided into intervention group and control group. • All residents with hypertension, 4176 • 1st July 2012 --- 31st December 2013

7. Integrated Service on Hypertension Focus Personalized follow-up and Monitoring Continuous Service Team (CST) Global Budget of Multi-level Instituions Continuous Service Path • Member • Service • Commands • Rewards • CPP • CCP • CMP • Follow-up • Monitoring • Education • … • 3 institutions • Calculation • Adjustment • Allocation • Punishments

8. Continuous Service Team (CST) • Member: • Village health personnel; • General practitioners, public health personnel in township hospital; • Hypertension specialists in county hospital; • Coordinator et al. • Service: • Supplied all managed hypertension patients with all preventive and medical care • Healthcare includes blood pressure monitoring, health education, medical care and doctor visit.

9. Personalized Follow-up and Monitoring Salt group Obese group Routine Follow-up Different service forms Alcohol and tobacco group Personalized Follow-up Anxiety group Risk Factors Assessment Different service contents Motion group Risk Factors Criteria Medical treatment Elderly group Doctor Visit Difficult group Drug group

10. Continuous Service Path, CSP • Continuous Primary-care Pathway，CPP • Continuous Clinical-care Pathway，CCP • Continuous-care Management Pathway，CMP • CST supplied above 10000 personalized health intervention services to 4167 managed patients by December 2012.

11. County Hospital Cardiology Endocrinology Continuous Clinical-care Pathway Township Hospital GPCoordinator Pub. Hea. Per Continuous Primary-care Pathway Village Clinic Village Doc 1 Village Doc 3 Village Doc 2

12. Continuous Clinical-care Pathway，CCP Insurance Payment Continuous Diagnosis Access Standards Enter Form Continuous Treatment CCP Variation Analysis Continuous Medication Out

13. Global Budget of Multi-level Instituions

14. Investigation • 2 investigations on 1st July and 31st December 2012; • Multistage stratified random sampling,593:578; • The status of health self-assessment, experiences of seeing doctors, doctor visits and individual information. • The data of expenditure on all managed patients were exported via Health Insurance Information Management System; • The medical records were collected in medical institutions regularly.

15. Results1 • Management rate of hypertension increased from 58.1% to 93.5% (P<0.01) in intervention group; • Standardized management rate from 37.1% to 42.3% (P<0.01) in intervention group; • Medication adherence rate increased by 8.7% in intervention group; • The ratio of expenditure on township hospitals to global expenditure increased from 21.3% to 25.4% (P=0.023), which were all higher than those of control group.

16. Results2 • Standard control ratio of hypertension is likely to reach 65% by Dec 2013 by means of Markov Prediction Model with continuous intervention; • 38 patients have received continuous clinical services from CST while the average expenditure is 7% lower than that without CST; • Growth rate of hospitalized hypertension patient in county hospital decreased from 15% to 12% while that in township hospital decreased by 6.3% in intervention group.

17. Finds • The expansion of patients with hypertension could be controlled and the behavior could be changed. • The CST under GBMI can supply integrated care under the existing global budget. Although the effect was not significant, a longer intervention period may make it better. • The cooperative mechanism established by CST and GBMI between county and village can play positive role in encouraging the health personnel to change service concepts, strengthening multi-level collaboration and improving effectiveness of service, thus it is in favor of continuity of medical and preventive services.

18. Thank you for your patients Welcome to China!