Prof. dr. Henk Nies Vilans, Centre of Expertise for Long-term Care Utrecht- The Netherlands -

1. Integrated Care – Incentives and tools for a coordinated pathway for the chronicly ill patient in The Netherlands Prof. dr. Henk Nies Vilans, Centre of Expertise for Long-term Care Utrecht- The Netherlands - Zonnehuis Chair on Organisation and Policy in Long-term Care, Free University, Amsterdam - The Netherlands Workshop Forum for Health Policy, Stockholm, 23 May 2012

2. Presentation • The Dutch system • The quest for integration • Incentives and tools for integration for integration • Organisation • Quality • Funding • Evaluation • Future options

3. The Dutch system Acute care: Health Care Insurance Act Long term care: Exceptional Medical Expenses Act Social care: Social Support Act Public Health: Public Health Act

4. Health Care Insurance Act Governance: Part of health care system Health care insurers (+ 15) Private providers, partly for-profit, entrepreneurship of doctors Medical and paramedical care at home (GP’s, dental care, physiotherapy, psychology etc.), in hospital and residential homes Obligatory health insurance Additional insurance on voluntary basis Personal risk (€ 220, SEK 2,006), not for GP expenses Hospitals: € 22.4 bln, SEK 204 bln; GPs: € 2.5 bln, SEK 22,8 bln), pharmacy: € 6.4 bln, SEK 58.4 bln)

5. Exceptional Medical Expenses Act Governance: Part of health care system Regional insurance offices (27) Private not-for-profit providers, small part for-profit Long-term care, rehabilitation: personal care, nursing, personal guidance, residential care, rehabilitation, short stay Compulsory insurance: care offices Independent assessment Co-payments (income-dependent), max € 2,136 (SEK 19,478) Budget: 23 billion Euros (SEK 210 bln) In kind/personal budgets (+ 10 %)

6. Social Support Act Governance: Municipalities Social support system Private not-for-profit providers, volunteers, small part for-profit Personal social services: domestic care/housekeeping, day centres, social participation, informal carers’ support, volunteers, assistive technology/devices, transport National tax-based, lump sum, partly not earmarked Co-payments (income-dependent, determined by municipality)

7. Public Health Act • Governance: • Municipalities • Public health organisations of municipalities • Public advice and information, population, screening, communicable diseases, epidemiological advice to municipalities, target groups • Mainly tax based (municipalities, national government, health care insurers, patients/citizens, ambulance services • Partly co-payments for some individual treatment (vaccinations) and ambulance services • Budget: € 707 million (SEK 6447) (2007)

8. Conclusion……

9. Find the differences: key figures

10. Find the differences: system and culture Many large scale organisations > 100 Mio (SEK 912 Mio) annual budget Polder culture – corporatistic model - at all levels Controlled market mechanisms GP as gatekeeper Social model in LTC Informal care: volunteers, carers Explicit end of life care

11. Challenges • Total expenses: € 5,200 (SEK 47,419) per head of population (health care and long term care): too high i.r.t. outcomes • Relatively young population rapidly ageing • Cost reduction • Dealing with epidemic growth of chronic patients • > 25% suffers from chronic disease • + 8% more than one disease (under-reported) • Diabetes (668,000), coronary heart disease (648,000), asthma (333,000), COPD (276,000), dementia (245,000), depression (274,000), stroke (191,000) • Labour market for long-term care (now: 800,000 person years, in 2030 1,500,000 person years; percentage of labour market: from 12% in 2007 to 24% in 2030)

12. The quest for integration: What happens if….?

13. Incentives and tools for integration:Organisation Collaborative structures: networks and chains of care • Stroke services (+ 1995) Stepping into stroke care, experiments (around hospitals), evaluation • Geriatric networks (+ 1996) Experiments (regions and geriatric departments), evaluation • National dementia programme (+ 2003) User needs explored, developing (regional) structures, followed by funding mechanisms and care standard • Palliative care (+ 2000) Regional, stepwise built up, consultation and co-ordination, including networks of volunteers

14. Incentives and tools for integration:Organisation More recent • Dementia care networks well developed (95% coverage) • Palliative care networks well developed • Development of health centres (11% of GPs) • Care groups (GPs and other professionals around specific groups; 80% of GPs) • The neighbourhood as unit of organisation • Small scale organisation of home care (Buurtzorg) • Rediscovery of district nurse

15. Incentives and tools for integration:Quality • Quality models and instruments • Guidelines • Network models • Diseasemanagement • Chronic Care Model • Guided Care Model • Spaghetti Model • Improvement programmes • Collaboratives (stroke, dementia, DM/CCM)

16. Incentives and tools for integration:Quality • Guidelines • Care standards based on CCM (COPD, Diabetes, Vascular risk management, obesities) forthcoming: dementia, asthma, depression, cancer, stroke etc.) • Care programme (standard operationalised) • Individual care plan • Indicators • Case management • Integrated needs assessment • Task delegation to nurse practitioner, specialised nurse to GP • Involving informal care

17. Care standard • What good care is supposed to be • Contents • Organisation • For professionals, insurers and patients • Design • Disease-specific care • Generic care (modules, self-management) • Organisation of care process, incl. quality management • Quality indicators • Strong role for users’ organisation

18. Individual care/health plan Patiënt’s perspective  self-management plan • Personal perspective • Personal objectives/aims • Self-management capabilities • Shared decision making • Health problems Professionals perspective individual treatment plan

19. Incentives and tools for integration:Funding • Integrated funding • One fee for one group of providers for one integrated package of care (organisation costs included) • One contractpartner, many subcontracters • Organisation in care groups • For diabetes (in CZ areas: 35), COPD (18), vascular risk management (15) • Additional fee • For organisation of integrated care • Services separately funded • Specific policy innovation measure plus macro budget • E.g. Dementia care incorporated in contract policies of care offices • Too much success of personal budgets

20. Evaluation Evidence • Some evidence of improved clinical processes and performance • No sound evidence (yet) of better outcomes for patients • It takes five to ten years to find outcomes • Hard to define performance indicators • Costs have risen, no savings demonstrated (yet): hospitals seem to seek additional income to compensate gains/losses • Structures and quality measures have - to some degree - been implemented • It gets complicated when it is about money and income

21. Evaluation Experience • Other bottlenecks are self-management, individual care plan (14% of COPD/asthma patients), ICT • Debate on case-management • User involvement is still low • Personal budgets too popular • Contracting across sectors and services is difficult: silos in chronic care • Joint responsibilities  unclear responsibilities • Freedom of choice limited • Tension between protocols and professional autonomy • New responsibilities for municipalities

22. Concern/chance: the spaghetti model

23. Evaluation What works? • Quality as primary driver • Collaboratives • Funding: € 10 Mln (SEK 91 Mln)  all care offices include integrated dementia care in their contracts • Integrated funding of primary care • Self steering teams • Informal care, volunteers

24. Paradigm shift From care and disease, to health and behaviour

25. Paradigm shift

27. Meaningful activities: care farms

28. Alzheimer café

29. Support for informal carers

30. Evindence based model of Integration

31. Four phases of development 1. Initiative and design phase Exploring possibilities and chances, project design, agreements 2. Experimental and execution phase Defining aims and content, coordination care chain, experiments 3. Expansion and monitoring phase Further development and maturity, monitoring, new questions 4. Consolidation and transformation phase Continues improvement, new ambitions, integrated structures

32. Self-evaluation • Contracting • Optimizing processes

33. A European input

37. Thank you Henk Nies h.nies@vilans.nl