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EUROPEAN FORUM FOR PRIMARY CARE 3 - 4 Septembre 2012

EUROPEAN FORUM FOR PRIMARY CARE 3 - 4 Septembre 2012. Rafael Bengoa. Minister of Health and Consumer Affairs Basque Government. Basque Government. Spain. SYSTEM –WIDE IMPLEMENTATION ? 2. 2 M.

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EUROPEAN FORUM FOR PRIMARY CARE 3 - 4 Septembre 2012

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  1. EUROPEAN FORUM FOR PRIMARY CARE 3 - 4 Septembre 2012 Rafael Bengoa. Minister of Health and Consumer Affairs Basque Government. Basque Government. Spain

  2. SYSTEM –WIDE IMPLEMENTATION ? • 2. 2 M

  3. Objective at Policy Level:Simultaneously Managing Crisis & Achieve Transformative Change • Short term strategy • Crisis Management Drugs: Brand to Generic Human Resources: Salaries Tecnologies: Desinvestment… • Long term strategy • Transforming Delivery Chronic Care Agenda Integrated Care Patient empowerment… SUSTAINIBILITY?

  4. Fragmentatión…

  5. WHY ? • WE HAVE AN ORGANIZATION PERFECTLY SET UP FOR • REACTIVE & RESCUE MEDICINE • WE DO NOT HAVE A LOCAL ORGANIZATION • WHICH SEEKS PROACTIVE CARE

  6. Transformation of Delivery… Most countries are improving in each of the boxes of the continuum but not using the potential of an integrated approach across the continuum. One of the reasons for this is that we do not have a “microsystem” operating at the local level

  7. WHEN YOU TRACK WHAT YOU DO YOU CONFIRM TWO THINGS : FRAGMENTATION AND EXPECTATION OF A PASSIVE PATIENT !

  8. PROVIDE A MOTIVATING NARRATIVE… and stick to it.. Año2009-2010 2011 2012 DEVELOMENT OF THE STRATEGY TRACKING IMPLEMENTATION FIRST RESULTS

  9. First Create a Narrative/ a common language …. PROVIDE A NARRATIVE THAT GOES BEYOND “COST CONTAINMENT” A NARRATIVE WHICH PROVIDE A VISION AND A “STRUCTURE” PROVIDES DIRECTION AND STABILITY IN A CRISIS ENVIRONMENT THE HARDER THE EXTERNAL ENVIRONMENT IS, THE MORE COHESION CAN THE COMMON VISION PROVIDE THIS PROVIDES A CONTEXT FOR MANAGERS TO GET OFF THE TREADMILL AND TAKE TIME FOR PERSPECTIVE IN THE BASQUE COUNTRY = THE MAIN STORY IS “CHRONICITY ” R. Bengoa

  10. Using frameworks/models MEDICINE POPULATION HEALTH EFFICIENCY

  11. MEDICINE POPULATION HEALTH EFFICIENCY WE NEED TO BUILD SOME SORT OF LOCAL HEALTH “MICROSYSTEM”

  12. POPULATION HEALTH MEDICINE EFFICIENCY Primary Prevention Early Management Acute Management Rehabilitation & secondary prevention

  13. THE APPARENTLY EASIEST WAY - TOP DOWN ? • “ Having everything under the same roof does not guarantee clinical integration nor a tidy operation • across the disease continuum” R. Bengoa What does ?

  14. Most organization do not have the integrators in place… We were no exception

  15. POPULATION HEALTH MEDICINE EFFICIENCY Develop Management Processes as Integrators TOP- DOWN STANDARIZABLE INTERVENTIONS ELECTRONIC MEDICAL RECORD FINANCINGAND JOINT COMMISSIONING ELECTRONIC PRESCRIPTION CALL CENTER STRATIFICATIÓN TRIPLE AIM CASE NURSING INTEGRATED CARE PACIENT EMPOWERMENT SUBACUTE CENTRES BOTTOM UP LOCAL INNOVATION HEALTH AND SOCIAL CARE COORDINATION R.BENGOA/J. MORA

  16. Launch of Bottom up projects.Evolution of bottom up innovation projects –from 2010 until now Innovation projects have increased year by year specially in 2012 thanks to CP (+50%) and Kronikgune * 141 proyectos de innovación de los cuales se han seleccionado 90 en el CP (72 individuales)

  17. Intervention strategies for each segment or strata of the population PI Multi-pathologies Case management 5% • Anti- flu vaccines 97% 2% 0,5% 0,5% PI Diabetes PI EPOC PI IC Disease management 20% • Anti-fluvaccine • Anti-flu vaccine • Anti-fluvaccine • Active patient • Physical activity and diet self-management • Cardiovascular risk • Anti-flu vaccine • Tobacco withdrawal 75% Prevention and Promotion • Tobacco withdrawal screening and advice • Anti-flu vaccination Calidad Bottom up Aligning Incentives :Commissioning (2012). 3% of the budget bound to Local Popullation-based Intervention Plan Activity Local Popullation-based Intervention Plan

  18. 108.285 pacientes crónicos en Euskadi 274.439 pacientes crónicos en Euskadi 863.888 pacientes crónicos en Euskadi • Gestión del caso • Gestión del caso • Gestión del caso 43.000 13.722 5.414 • Gestión de enfermedad • Gestión de enfermedad • Gestión de enfermedad 173.000 54.890 21.567 • Soporte a la autogestión • Soporte a la autogestión • Soporte a la autogestión 636.000 81.214 205.827 Population without chronic disease476.401 Population without chronic disease1.394.539 Population without chronic disease 187.656 • Prevención y Promoción • Prevención y Promoción • Prevención y Promoción Sense of Scale…Manageable Meso Micro

  19. Uribe OSI Bidasoa a H Cruces Bilbao OSI Bajo Deba Donostia Gorliz Galdakao-Usansolo Donostia Sta. Marina Ezkerraldea Interior 8 2 5 9 10 11 6 4 11 1 5 9 8 7 10 6 3 4 3 1 2 7 Zamudio San Eloy Basurto OSI Goierri-Alto Urola La Asunción Gipuzkoa OSI Alto Deba Araba H H H H H H H H H H H H H H Treviño HUA • Leza H 11 microsystems in Basque Country • Comarca Bilbao + H. Basurto + H. Santa Marina • Comarca Uribe + H. Cruces + H. Gorliz • Comarca Ezkerrealdea + H. San Eloy + H.Gorliz + H. Cruces • Comarca Interior + H. Galdakao-Usansolo + Santa Marina • Comarca Araba + HUA + H. Leza • Comarca Ekialde + H. Donostia • OSI Bidasoa ( H. Bidasoa + 3 centros de AP) • Osi Goierri (Goierri + H. Zumarraga) • Osi Bajo Deba (Subcomarca Bajo Deba + H. Mendaro) • Osi Alto Deba (Subcomarca Alto Deba + H. Alto Deba) • Subcomarca Tolosaldea + Clinica La Asunción FUENTE: Equipo de trabajo

  20. Basurto Sta. Marina H H SPEED ?? BOTTOM UP ORGANIZATIONAL INNOVATION DIFFERENT MODELS OF INTEGRATED CARE ORGANISATIONS (systems) Non Integrated organizational structure Integrated organizational structure Osi Bidasoa • H. Basurto- C-Bilbao-H. Santa marina • 85.000 habitants • First integrated organizational structure (hospital and primary care center) • 384.000 habitants • 24 primary care centers • 1 acute hospital • 1 medium and long term hospital

  21. -4.40% +1.9% -7.18% +0.17 -3.04% Osi Bidasoa – Eficiency Results in terms of activity Referral rate of medical consultation Index of successive/firts successive visits Hospital admissions First visits Economicalresults of OSI BIDASOA

  22. Promic – Case management Cardiac Failure(PP o GE) Coordinated process between acute hospital and primary care, case nurses and patient self-care • 113 patients (55 in Araba and 58 Bizkaia) (66 patients in the intervenvention group (PROMIC)) • Incidence rate: 10-day events/6827 patients PROMIC group vs 15/1490 patient-days in the control. • The survival time was higher in PROMIC group than in the control • 40% of reduction in risk of death or readmission in the PROMIC group

  23. TELBIL at 6 month of telemonitoring Pluripathological patients in Primary Care RESULTS:

  24. Integrated cardiovascular care… ...is leading to reductions in heart attacks and strokes. Stoke-related Hospitalization Rates in No. Cal.1998-2007 ST Elevated MIs in No. Cal. 1998-2007 Age and sex adjusted rate per 1,000 Age and sex adjusted rate per 1,000 KP Northern California ALL program, PHASE, results. 17

  25. 100% of the population stratified Electronic Medical record is being implemented in the whole health care organizations More than 30 coordination projects to improve continuum of health of our chronic patients More than 500 active patients on diabetes and 1500 in 2012 Telehealth and telemedicine with good results 3 New cases nursing is being implemented (71 ECGA) Speed ?? Electronic Medical record Risk stratification… Integration Osarean Self-management Case nursing

  26. Different Countries/Systems Moving In The Same Direction Mid-term policy perspective/ trend • Focusing on delivery reform • Context : some promoting competition ; others not. • Shifting from volume and inputs to value • Leaning on same Models: KP and CCM , Triple Aim and others • All Building some sort of Local Health “Microsystem”. Europe and ObamaCare • A lot of learning potential if brought together

  27. PRETTY FAST WITH NEW NARRATIVE • PRETTY FAST WITH THE TOOLS /INTEGRATORS • LOGIC OF CAPACITY BUILDING THROUGHOUT POSITIVE • SLOWER GOING TO SCALE

  28. THE PROCESS WILL NOT DEVELOP IN A TIDY SEQUENCE OF LINEAR STEPS. INSTEAD IT WILL PROLIFERATE VIA GROUPS OF INNOVATIVE IDEAS BY DIFFERENT ORGANIZATIONAL UNITS. Van de Ven 1999 ! CONFIRMED !

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