Rafael Bengoa | Regional Minister for Health and Consumer Affairs Basque Government. Spain

1. 19th COCHRANE COLLOQUIUMSustainable Evidence-Based Health Care in Times of CrisisMadrid October 19-22 . 2011 Rafael Bengoa | Regional Minister for Health and Consumer Affairs Basque Government. Spain

2. 1992 1997 2002 2007 Evolution of diabetes and cardiovascular disease in the Basque Country% This challenge of this epidemic is going much faster than our reaction to it. 9,1 - 10,5 4,5 - 6,0 6,1 - 7,5 7,5 - 9,0 10,6 - 12,0

3. Massive Demand… Medical consultations/capita. Europe. 2003 9.5 5.9 2.5 European Countries Ecosalud. OCDE 2005.

4. Fragmentation

5. THIS IS THE RESULT ACROSS THE CONTINUUM !

6. Primary Prevention Early Management Acute Management Rehabilitation & secondary prevention

7. “ Having everything under the same roof does not guarantee clinical integration nor a tidy operation across the disease continuum” R. Bengoa Primary Prevention Early Management Acute Management Rehabilitation & secondary prevention

8. Primary Prevention Early Management Acute Management Rehabilitation & secondary prevention Downstream Upstream “ Both downstream and upstream interventions are vital for the final populationoutcome in the control of a disease. It is sterile to continue opposing these two approaches. They are two sides of the same coin. What we need is an integrated approach across the continuum balancing public health interventions and health service interventions and the local organization to operationalise this as a system on the ground “ R. Bengoa

9. MESSAGE IS CLEAR : 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 “system” operating at the local level

10. THAT FRAGMENTATION CANNOT PROVIDE A SUSTAINIBLE HEALTH SYSTEM

11. Tools for Integration Help to move towards a “System” Perspective risk stratification… case nurses… routine clinical reminders… continuum of care… activated patient… regular telemonitoring……

13. ¿WHAT ARE WE TRYING TO DO ? TRYING TO FIT IN SOME OF THOSE MANAGEMENT PROCESSES IN ….

14. Using frameworks/models

15. Some sort of structured patient education: both direct and remote REMOTE PATIENT EDUCATION PATIENT EDUCATION

16. With some sort of case manager Nurses who act a case managers for patients with complex conditions. Their function will be to evaluate their physical and social needs and coordinate their care.

17. Telecare /Telemedicine ++++ Diabetic retinopathy

18. What results are some organizations getting? Is the Evidence Growing?

19. Community Care North Carolina (CCNC) Health programme for: Low-income adults and their children and dishabilities (880.000 habitants) 3000 physicians Objective: Improve the quality, cost, accesibility and utilisation of services for Medicaid recipients Methods to promote integration: • Locally adapted clinical guidelines • Case management services • Financial incentives • Data review and analysis • Feedback on clinical practice Source: http://www.communitycarenc.org/our-results/

20. 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

21. VA Continues to Exceed HEDIS in 2008

22. Why ? Because the Evidence is Increasing Estimated $3.7 million net savings for a ROI of > 2 to 1 Geisinger Proven Health Navigator Model 30% decrease in hospitalizations for asthma and 11% lower ER visits UK Tornbay 29% reduction in ER visits; 11% reduction in ambulatory care sensitive admissions versus control sites Puget Sound 10% relative reduction in hospitalizations and even greater among those with chronic illnesses. Intermountain Health Care SUSTAINIBILITY ?

23. Building some sort of Local Health “System” BETTER CARE FOR INDIVIDUALS ( IOM ) BETTER POPULATION HEALTH LOWER GROWTH IN EXPENDITURE BY ELIMINATING INEFFICIENCIES. TACTICAL APPROACH make the link between clinical behaviour and financial consequences for clinical decisions Incentive if savings made Pathways as a tool to make that link Aim : LINK several lines of work which tend to operate separately

24. DIFFERENT COUNTRIES/SYSTEMS MOVING IN THE SAME DIRECTION FOCUSING ON TRANSFORMATION OF DELIVERY CONTEXT : SOME PROMOTING COMPETITION ; OTHERS NOT. SHIFTING FROM VOLUME AND INPUTS TO VALUE LEANING ON MODELS: KP AND CCM AND OTHERS MANY BUILDING SOME SORT OF LOCAL HEALTH “SYSTEM” Mid-term policy perspective/ trend

25. USA.Section 3022 of the Affordable Care Act (ACA) establishes the Medicare Shared Savings Program for Accountable Care Organizations . England: The White Paper ‘Equity and Excellence: Liberating the NHS’ New Public Health Law . Basque Country . Spain. Wales , New Zealand….. Trend Taking Shape In Normative Policy Interventions

26. How are we moving forward in the Basque Country ?

27. Objective:Simultaneously Managing Crisis & Transformative Change • Short term strategy • Crisis management Drugs: Brand to Generic Human Resources: Salaries Tecnologies: Desinvestment… • Long term strategy • Reforming Delivery Chronic Diseases Agenda Integrated Care SUSTAINIBILITY?

28. Create a narrative/ a common language …. PROVIDE A NARRATIVE THAT GOES BEYOND “COST CONTAINMENT” A NARRATIVE WICH PROVIDE A VISION AND STRUCTURE PROVIDES DIRECTION AND STABILITY IN A CRISIS ENVIROMENT THE HARDER THE EXTERNAL ENVIROMENT IS, THE GREATER THE COHESION CAN THE COMMON VISION PROVIDE IN THE BASQUE COUNTRY = THE MAIN NARRATIVE IS “CHRONIC DISEASES” AND CLINICAL INTEGRATION R. Bengoa

29. Launch interventions in a coherent package: Many levers simultaneously 7 13 12 2 1 3 14 5 6 10 11 8 9 4 Autocuidado Experiencias en las principales enfermedades crónicas, potenciando la adherencia y el uso apropiado de los recursos Prevención y Promoción Prevención de aparición y desarrollo de enfermedades crónicas (De_Plan, prevención tabáquica) Historia Clínica unificada Implantación universal a finales de 2011 Estratificación Estratificación operativa de la población vasca de forma sistematizada y periódica desde 2011 Atención clínica integrada Un tercio de las organizaciones a 2013, con procesos integrados Innovación desde los profesionales Generación de 15-25 proyectos de innovación al año y extensión de los que demuestren resultados (~90%) Centro Investigación Cronicidad Ser un referente internacional en el conocimiento sobre enfermedades crónicas Modelo hospitales subagudos Implantación del modelo en hospitales de media estancia y creación de nuevo hospital de crónicos en Álava Experiencias de telemonitorización Monitorización a distancia del 1% de enfermos crónicos severos (~22.500) Centro Servicios Multicanal Despliegue en Euskadi de todos los servicios para mediados de 2013 Receta electrónica Implantación efectiva del sistema de receta electrónica en todo Euskadi en 2012 – 2013 Competencias Avanzadas Enfermería Formar a 300 enfermeras en los nuevos roles hasta 2013 Colaboración sociosanitaria 4 municipios con funcionamiento integrado, 1 hospital con plan de altas con prevención de dependencia, 1 unidad de ortogeriatría Financiación y Contratación Implantación plena de un sistema de asignación financiera territorial ajustada por riesgo R. Bengoa

30. Examples: bottom up Organizational Innovation Basurto Sta. Marina H H 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

31. This Should Look Better At The Next LSN Meeting!!!!

32. Evidence increasing around a few things… Different diseases , similar needs and similar solutions Much of the evidence sends clear signals in favor of integrated care To pull this off you need patients and staff on board. It is therefore less about structural moves than about staff engagement Evidence growing but scalability still an issue

33. SCALABILITY… 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 THOSE INNOVATIVE IDEAS BY DIFFERENT ORGANIZATIONAL UNITS MUST BE SUBJECTED TO THE EVIDENCE TEST

34. Thank you