What does the concept ‘Integrated Care’ mean for hospitals?

1. 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

2. Structure of this presentation • 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

3. Phenomena of all health care systems have to face • 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

4. Health care systems in Europe- fragmentation • 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

5. Ageing in selected countries and its impact upon HCE, 2000(R.Blank & V. Burau, 2004)

6. Acute care disease - oriented ‘high tech’ episodic cure one-dimensional professional hospital Chronic care function - oriented ‘high touch’ continuous and/or cyclic care multi-dimensional family and volunteers home Contrast between acute and chronic care(D. Kodner, 1994)

7. 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 co-operate Strengths and weaknesses of hospitals

8. Health care innovation- some recent concepts • integrated care • shared care • transmural Care • substitution of care • organizational networks • disease management • self-management

9. 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

10. Integrated care- related concepts shared care and transmural care • 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

11. Integrated care- examples • 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

12. Substitution of care • horizontal substitution - provision of care by a generalist in stead of a specialist: c.g. hospitial care -> community care • vertical substitution - provision of care by the ‘lowest’ provider who is qualified to assure the standard of care: c.g. physician -> nurse • diagonal substitution - combination of horizontal and vertical substitution • substitution may be partial or complete

13. Disease management- background • 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

14. Disease Management- an organizational principle for integrated care - • aim: efficient care as well ashigh 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 (!)

15. Disease Management- use of management instruments: benchmarks and feedback - • 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

16. positive more focus on patient orientation towards content, process, attitude ideally: more orientation towards human values more involvement in feedback systems negative standardization of care less personal involvement of professionals if freedom of choices (opting out) -> higher premiums Disease management - patients’ perspective -

17. negative loss of traditional autonomy bureaucracy rules easily the care process doubts about the interests of patients resistance to change Positive patient orientation: content, process, attitude ideally more orientation on human values patient profits from quality improvement patients involved in feedback-systems Disease management-professional perspective -

18. Examples of integrated carewith involvement of hospitals • between hospital and primary care - case: diabetes mellitus • between public health, primary care and hospital - case: new public health

19. Case: diabetes care- The state of the art: St.Vincent’s declaration - • 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

20. Diabetes care- typical traditional organization - • 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

21. Diabetes care- Quality of care in Europe: the CODE-2 study - • HbA1c: 23% well, 35% moderately, 42% badly regulated • systolic blood pressure: 69% well regulated (Europe 85%!) • cholesterol blood level < 5,2 mmol/l 35% according the standard • annual check of the eye: 28% • annual check of the feet: < 15 %

22. The Maastricht Region- some features - • 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

23. Diabetes care in the Maastricht Region- its main characteristics - • 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

24. specialized nurses early detection educationand counseling periodical checks adaptation of treatment prevention of complications defining of protocols link to family physicians education Diabetes care in Maastricht- Role of physicians and specialized nurses- physicians • diagnosis • initial treatment • instable patients • assessment of complications • planning • defining protocols • supervisionof nurses (MS) • education

25. 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! Diabetes care in Maastricht (140.000inh)- model for patients with diabetes mellitus - 2 1 3

26. Diabetes care in Maastricht- management instruments - • 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

27. Diabetes Care in Maastricht- Scientific evaluation - • 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

28. Diabetes care in Maastricht- Keys for success • 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

29. Co-operation between PH-agency, primary care and hospital • Case: New public health

30. Public Health- definition and tasks - • 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 • ruled by governments and public administrators • in Europe lack of collaboration with other primary care providers, secondary care and mental health

31. New Public Health - I- definition and stakeholders - • 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

32. 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 • 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

33. 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

34. Organization New Public Health for cardiovascular diseases (Maastricht Region)

35. New public health- complicating factors • 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

36. Lessons learnt from experienceswith shared approaches (I) -enabling factors (Kodner & Spreeuwenberg, IJIC, 2003) Funding • pooling of funds • prepaid capitation Organizational • co-location of services • discharge and transfer agreements • inter-agency planning and/or budgeting • service affiliation or contracting • jointly managed programs or services • strategic alliances or care networks • consolidation, common ownership or merger

37. Lessons learnt from experienceswith shared approaches (II) -enabling factors (Kodner & Spreeuwenberg, IJIC, 2003) Administrative • inter-sectoral planning • needs assessment/ allocation chain • joint purchasing or commissioning Service delivery • joint training • centralized information, referral and tasks • care/care management • multidisciplinary/interdisciplinary teamwork • around the clock (on call) coverage • integrated information systems

38. Lessons learnt from experienceswith shared approaches (III) -enabling factors(Kodner & Spreeuwenberg, IJIC, 2003) Clinical • standard diagnostic criteria (e.g. DSM IV) • uniform, comprehensive assessment procedures • joint care planning • shared clinical records • continuous patient monitoring • shared, evidence-based decision support tools (guidelines, protocols) • regular involvement of patients and family

39. Challenges to Integrated Care(Thanks to D. Light) • 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

40. Towards an agenda for health promoting hospitals • 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