Review of research into comprehensive integrated care systems€¦ · Review of research into comprehensive integrated care systems . John Øvretveit, [email protected] . Director of

Medical Management Centre

21 November 2011

Review of research into comprehensive integrated care systems

John Øvretveit, [email protected] Director of Research, and

Professor of health improvement, implementation and evaluation, The Medical Management Centre,

The Karolinska Institutet, Stockholm.

Mats Brommels Director, and

Professor of medical management, The Medical Management Centre,

The Karolinska Institutet, Stockholm. Reference: Øvretveit, J & Brommels, M 2011 Review of research into comprehensive integrated care systems, Stockholm, The Medical Management Centre, Karolinska Institutet. downloadable from http://public.me.com/johnovr

John Øvretveit,November 21, 2011 1

http://public.me.com/johnovr

Contents EXEC TIVE SUMMARY ...................................................................................................................... 5U

1.2. METHODS .................................................................................................................................... 51.1. INTRODUCTION ............................................................................................................................ 5

1.3. FINDINGS ..................................................................................................................................... 5

Q1: Which research exists about integrated care and integrated care systems?.............................. 5 Q 2: Which integrated care organisations are most similar to the Norrtalje model and how do they perform?............................................................................................................................................ 6 Q 3: What are the lessons from research and evidence about how to improve care for the Norrtaljepopulation and reduce costs?............................................................................................................ 6

PART 1: INTRODUCTION, OBJECTIVES AND METHODS .......................................................... 8 2. INTRODUCTION ............................................................................................................................ 8

2.1. MEANING OF THE TERMS.............................................................................................................. 8Background....................................................................................................................................... 8

Comprehensive integrated care provider organisation (CICPO)..................................................... 9

Purchasing organisation for integrated care (POIC)....................................................................... 9

Comprehensive integrated provider and purchasing system (CIP&PS)........................................... 9

Non-comprehensive or non-integrated organisations..................................................................... 10

Other definitions ............................................................................................................................. 10

2.2. NORRTALJE ACHIEVEMENTS AND LIMITATIONS REPORTED IN THE 2010 STUDY......................... 11

2.3. REVIEW QUESTIONS AND OBJECTIVES ........................................................................................ 12

2.4. METHODS .................................................................................................................................. 12

Searching, grading and presenting the evidence ............................................................................ 12

Search, selection and abstraction ................................................................................................... 12

Grading the evidence ...................................................................................................................... 13

Synthesis and presentation.............................................................................................................. 13

Considering the strength of evidence .............................................................................................. 13

PART 2: FINDINGS .............................................................................................................................. 14 3. WHICH RESEARCH EXISTS ABOUT INTEGRATED CARE AND INTEGRATED CARE SYST MS? ............................................................................................................................................. 14E

3.2. CATEGORIES OF RESEARCH ....................................................................................................... 143.1. INTEGRATED CARE ARRANGEMENTS.......................................................................................... 14

Overview or review studies of integrated care systems................................................................... 14

Overview or review studies of integrated care schemes for specific patient groups....................... 14

Primary studies of specific schemes or integrated care systems..................................................... 14

4. WHICH INTEGRATED CARE ORGANISATIONS ARE MOST SIMILAR TO THE NORRTALJE MODEL AND HOW DO THEY PERFORM? .......................................................... 15

Other less similar are: .................................................................................................................... 16The closest reported comparison systems are:................................................................................ 15

Other reported integrated care organisations or schemes.............................................................. 16

5. TWO CASE EXAMPLES OF SIMILAR INTEGRATED CARE ORGANISATIONS .......... 16

Overview ......................................................................................................................................... 165.1. CASE EXAMPLE 1: FORSSA INTEGRATED CARE ORGANIZATION (FINLAND) ................................ 16

Details:............................................................................................................................................ 17

Macro organisation and financing.................................................................................................. 17

Operational clinical level organisation .......................................................................................... 17

Achievements attributed to the integration ..................................................................................... 18

Future planned developments ......................................................................................................... 19

References ....................................................................................................................................... 19 5.2. CASE EXAMPLE 2: TORBAY AND SOUTH DEVON CARE TRUST (“TORBAY CARE TRUST” OR

“TCT”, UK) ......................................................................................................................................... 19


Overview ......................................................................................................................................... 19

Macro organisation and financing.................................................................................................. 20Details:............................................................................................................................................ 20

Operational clinical level organisation .......................................................................................... 21

Achievements attributed to the integration ..................................................................................... 21

Future planned developments ......................................................................................................... 22

References ....................................................................................................................................... 22

6. WHAT ARE THE LESSONS FROM RESEARCH AND EVIDENCE ABOUT HOW TO IMPR VE CARE FOR THE NORRTALJE POPULATION AND REDUCE COSTS?................ 23O

6.1. CLOSE CLINICAL COORDINATION CAN BE ACHIEVED IN WAYS OTHER THAN THROUGH

STRUCTURAL MERGER AND SHARED FINANCE....................................................................................... 23

6.2. USE INTEGRATION TO REDUCE UNNECESSARY HOSPITAL USE .................................................... 24Summary: Methods for coordination and integration..................................................................... 23

6.3. VALUE IMPROVEMENTS POSSIBLE WITH THE NORRTALJE MODEL .............................................. 24

Strong evidence of cost and quality improvement........................................................................... 24

Less strong evidence of cost and quality improvement ................................................................... 25 6.4. CONTEXT FACTORS AND CONDITIONS CONTRIBUTE TO SUCCESSFUL OR UNSUCCESSFUL

INT GRATIONS...................................................................................................................................... 26

6.5. WHICH ACTIONS ARE IMPORTANT TO ACHIEVING INTEGRATION? .............................................. 27E

6.6. OTHER STUDIES OF RELEVANCE TO THE NORRTALJE INTEGRATION ........................................... 28

PART 3 DISCUSSION AND CONCLUSIONS ................................................................................... 29 7. DISCUSSION.................................................................................................................................. 29

7.1. OBSERVATIONS ON THE FINDINGS.............................................................................................. 29

8. OPTIONS FOR THE FUTURE AND RECOMMENDATIONS .................................................. 30

Advantages...................................................................................................................................... 308.1. 1 RETURN TO 2005 MODEL......................................................................................................... 30

Disadvantages................................................................................................................................. 31

8.2. 2 RETAIN TIOHUNDRA AB, BUT RESTRUCTURE JOINT PURCHASING........................................... 31

Advantages...................................................................................................................................... 31

Disadvantages................................................................................................................................. 31

8.3. 3 OUTSOURCE NON-CORE FUNCTIONS AND SERVICES ................................................................ 31

Advantages...................................................................................................................................... 31

Disadvantages................................................................................................................................. 31

8.4. 4 REINTEGRATE ALL SERVICES TO TIOHUNDRA......................................................................... 31

Advantages...................................................................................................................................... 32

Disadvantages................................................................................................................................. 32

8.5. 5 DEVELOP CLINICAL COORDINATION........................................................................................ 32

Advantages...................................................................................................................................... 32

Disadvantages................................................................................................................................. 32

8.6. RECOMMENDATIONS.................................................................................................................. 32

9. CONCLUSIONS ............................................................................................................................. 33 10. REFERENCES ............................................................................................................................. 34

Appendices (separate document) 1. APPE DIX : DEFINITIONS OF TERMS USED IN THE REVIEW ....................................................................................N

1.1.2. Purchasing organisation for integrated care (POIC) .................................................................................................1.1.1. Comprehensive integrated care provider organisation (CICPO)...............................................................................

1.1.4. Non-comprehensive or non-integrated organisations.................................................................................................

1.1.5. Other definitions...........................................................................................................................................................

1.1.3. Comprehensive integrated provider and purchasing system (CIP&PS) ....................................................................

2. APPE DIX: CLASSIFICATIONS OF TYPES OF INTEGRATION....................................................................................N

2.1.2. Shih et al (2008) ........................................................................................................................................................... 2.1.1. Shortell and Casalino (2007).......................................................................................................................................


2.1.3. Tollen (2008)................................................................................................................................................................ 2.1.4. Berwick et al (2008).....................................................................................................................................................

3. APPE DIX: SUMMARIES OF INTEGRATED SYSTEMS...................................................................................................N

3.1.1. Type 1: INTEGRATED DELIVERY SYSTEM OR LARGE MULTI-SPECIALTY GROUP PRACTICE WITH A HEALTH INSURER.......................................................................................................................................................................

3.1.2. Type 2: INTEGRATED DELIVERY SYSTEM OR MULTI-SPECIALTY GROUP PRACTICE, WITHOUT A HEALTH PLAN .............................................................................................................................................................................

3.1.3. Type 3: PRIVATE NETWORKS OF INDEPENDENT PROVIDERS (eg INDEPENDENT PRACTICE ASSO IATION OR A VIRTUAL NETWORK) ..............................................................................................................................

C

3.1.5. Listing of above............................................................................................................................................................3.1.4. Type 4 : GOVERNMENT-FACILITATED NETWORKS OF INDEPENDENT PROVIDERS

4. APPE DIX: DETAILS ABOUT KAISER INTEGRATED HEALTH SYSTEM.................................................................N

4.1.2. Treating patients at the most cost effective level of care.............................................................................................4.1.1. Integration....................................................................................................................................................................

4.1.4. Information technology................................................................................................................................................4.1.3. Using competition and choice......................................................................................................................................

5. APPE DIX: SPECIFIC METHODS FOR INTEGRATION ..................................................................................................N

5.1.1. Projects for integration established by Amsterdam Academic Medical Centre .........................................................


Executive summary

1.1. Introduction The purpose of this research review is to provide evidence-based recommendations for future options for organising the provision of health and social care in Norrtalje. The report draws on research into integrated care to describe future options and improvements and their advantages and disadvantages. The MMC innovation study found that a unique comprehensive integrated system had been created, termed below “The Norrtalje model”. A high degree of structural and financial integration had been achieved for comprehensive health and social care services for a general population (Øvretveit el al 2010). However, the study found that the integration of professional work and of clinical information systems (clinical care integration) was less than that achieved by the best integrated care schemes for specific patient groups, such as for older people or people with diabetes (Øvretveit 2011). The aim of the review of research reported in this document was to

- find, summarise and compare reports of comprehensive integrated systems to the Norrtalje example, and

- draw on research into clinical level integrated care schemes, in order to - identify future options for Norrtalje and how lower-cost and higher-quality

services could be provided to the Norrtalje and visiting populations.

1.2. Methods A review method previously use for rapid management reviews was used in order to find, assess and synthesise a diverse range of studies and reports from different data bases and sources. It also drew on a review of coordinated care methods made for the MMC Norrtalje study (Øvretveit 2008).

1.3. Findings Q1: Which research exists about integrated care and integrated care systems?

The search revealed a wide range of conceptual studies and commentaries, but few empirical descriptions, and fewer evaluations of comprehensive integrated systems. There was empirical research into specific integration arrangements for certain patient groups. These included financing arrangements which combine fee for service financing arrangements in one “finance bundle” or offer capitation financing. Four types of integrated care arrangements have been described:

Disease based coordinated care systems (eg for diabetes) Patient group integrated care systems (eg for mental health patients) Comprehensive integrated care provider organisation or system (eg the USA

veterans health administration) Comprehensive integrated provider and purchasing organisation or system (eg

Kaiser Permente, Geisinger)


Q 2: Which integrated care organisations are most similar to the Norrtalje model and how do they perform?

The closest reported comparison systems are: Kasier Permenente (California)

Similar to Norrtalje in: combining a purchasing organisation with an integrated provider and with salaried physicians. Different to Norrtalje in: population covered is sixty times lager that of Norrtalje (6.1m vs 0.1m), services provided (eg Norrtalje provides more social care but no very specialized care), in being private not for profit and funded largely by individuals or employers not by taxation, and in resources available for management and support systems (eg information technology). More details are provided in the appendices to this report.

Geisinger health system (Pennsylvania) Similar to Norrtalje in: combining a number of services in an integrated provider and also involves a purchasing organisation. Different to Norrtalje in: population covered is twenty-five times lager that of Norrtalje (2.5m vs 0.1m), with 30% patients enrolled in the Geisinger insurance plan (the other 70% served are enrolled in other insurers plans) and in other respects as for Kaiser above (eg private, little funded by taxation).

Torbay (UK) integrated care systems for older people Torbay community trust manages community health and social care teams and services, and small non-acute hospitals and covers a population of 140k (23% over-65 yrs) The integrated system for older people involves five area-based integrated health and social care teams, aligned with general practices. Each team has one manager, and one referral entry point, and uses one assessment process. Budgets are pooled and can be used by team members to commission whatever care is needed by their patient/client. The teams serve a variety of types of patients, including with long-term conditions, palliative care and people with disabilities. There is a shared information system, assessment and planning system and an easy fast referral process. The teams prioritise the most vulnerable: 83 patients out of 23,000 were classified at the apex of the Kaiser needs model (DoH 2005). Intermediate care services are provided in each of the five areas through the referral entry point, which gives access to district nurses, occupational therapists, physiotherapists, within five working days or if urgent within four hours if urgent (25 %).

Q 3: What are the lessons from research and evidence about how to improve care for the Norrtalje population and reduce costs?

Close clinical coordination can be achieved in ways other than through structural merger and shared finance. However, the integration has reduced some impediments which traditionally hinder clinical coordination. To now achieve the advantages which the structure makes possible for more coordinated clinical and preventative services, the three most important future changes would be to

Create project teams to implement evidence based changes for improving coordination and reducing costs, especially targeted interventions to patients at risk of hospital admission or high primary care utilisation,

Develop clinical information systems to promote and allow efficient clinical coordination and patient support services, possibly by attracting innovation


Develop and test financing incentives and systems for integrated clinical care, again by attracting innovation finance and seeking regulation exemptions.


Part 1: Introduction, objectives and methods

2. Introduction

The purpose of this research review is to provide evidence-based recommendations for future options for organising the provision of health and social care in Norrtalje. The report draws on research into integrated care to describe future options and improvements and their advantages and disadvantages.

Background As regards integrated care for older people, a review found, across Europe, “loosely coupled systems that are facing increasing difficulties”, and reported challenges in providing long-term care for older persons which included increasing marketisation, lack of managerial knowledge (about co-operation and co-ordination), shortage of care workers and a general trend towards down-sizing of social care services which were hindering the “first tentative steps towards integrated care systems” (Leichsenring 2004).

The MMC innovation study of the “Norrtalje model” found a unique comprehensive integrated system had been created. A high degree of structural and financial integration had been achieved of health and social care services for a general population (Øvretveit el al 2010). However, it found that integration of professional work and of clinical information systems (clinical care integration) was less than that achieved by the best integrated care schemes for specific client- or disease - groups, such as for older people or people with diabetes (Øvretveit 2011). The aim of the review of research reported in this document was to,

- find, summarise and compare reports of comprehensive integrated systems to the Norrtalje example, and

- draw on research into clinical level integrated care schemes, in order to, - identify future options for Norrtalje and how lower-cost and higher-quality services could be provided to the Norrtalje and visiting populations.

2.1. Meaning of the terms Integration can be vertical, which joins levels of healthcare (eg primary and secondary care), or horizontal, where different organizations work more closely together or merge (eg health and social care). It can also be “virtual”, using the internet to coordinate and communicate. There is a continuum of degrees of integration from merger to loosely-linked in one respect (eg information exchange).


The following definitions were used to identify and select research describing health systems in some way comparable to the Norrtalje model:

Comprehensive integrated care provider organisation (CICPO) An organized collection of different healthcare provider services and facilities to provide a range of diagnostic, treatment, care and prevention to meet priority needs of the a defined general population.

The system may also include social care provision. The range of services may be owned and managed by one organisation (as is Norrtalje, by Tiohundra AB). Or each may be independently owned, but organized through contracts and other agreements and systems to provide a service, in close collaboration with the other services.

Another definition is of an “integrated delivery system” which is “a network of organisations which provides or arranges a co-ordinated continuum of services and is clinically and fiscally accountable for the health of the population served. Key features of an integrated delivery system include: shared values and goals, alignment of incentives, physician leadership and a culture of teamwork” (Ham & de Silva 2009)

Purchasing organisation for integrated care (POIC) This is an organisation which contracts with an insurer or government funder to ensure a range of services is provided and coordinated for a defined population. As a purchasing organisation it does not itself own or provide any services direct to the population.

Comprehensive integrated provider and purchasing system (CIP&PS) This type of organisation includes a funding or purchasing organisation, which may own some or all provider services. One example is Kaiser Permenente in the USA which is a combined health plan (insurer) and a set of provider services, including salaried physicians which provide coordinated care and prevention for the insured


population. Another example is the combination of the Norrtalje Tiohundra and the Norrtalje political board and its administration, which provides care to the resident and visitin rrtalje model”.

an a general population

, collaborative initiatives for improving care or health promotion alliances).

g population. This is referred to in this report as “the NoNon-comprehensive or non-integrated organisations

The above types of organisations are to be distinguished from: - Arrangements to provide integrated care for disease- or age-specific patient

groups (eg patients with diabetes or children) rather th(eg within a geographic area, or for military veterans).

- Loose arrangements to coordinate independent providers, for different purposes (eg clinical networks

efinitions

wn or contract for a

cutting across multiple services,

Ps and other primary care professionals into a primary

primary health care team with other community-based

the integration of this health and social care team with hospital specialists.

Other dIntegration “the term integration has taken on a wide range of meanings...as it can signify anything from the closer coordination of clinical care for the individuals to the formation of MCOs (managed care organisations) that either owide range of medical and social support services” Leutz (1999) “...a coherent set of methods and models on the funding, administrative, organisational, service delivery and clinical levels designed to create connectivity, alignment and collaboration within and between the cure and care sectors. The goal of these methods and models is to enhance quality of care and quality of life, consumer satisfaction and system efficiency for patients ... providers and settings.(Kodner and Speeruwenberg) Ham et al (2008) describe four types of integration:

the integration of Ghealth care team,

the integration of the health professionals,

the integration of this community-based team with social care,


2.2. Norrtalje achievements and limitations reported in the 2010 study

The overall finding of this study was that the initial integration in 2006-2009 established a new integrated macro-structure. This did not of itself result in better clinical care coordination but removed many barriers to establishing coordination at the patient level. It concluded that both macro- and micro-integration were needed for better care coordination and outcomes and that other actions were needed to modify the specialised systems and cultures which the organisation inherited (Ovretveit et al 2010). The second finding was that macro- and micro-integration was difficult to achieve at the same time, and required investment finance and change-management capacity. Few organisations achieve both, in part because of the complexity of and different types of changes which are needed, and the different skills and sizable change capacity required. The study considered it possible that a limited management capacity could achieve both, if the changes were phased over time, and are part of a long-term plan, and that macro-integration may be the necessary first step. After this, management then has to engage and motivate clinical personnel to take advantage of the removal of the structural and financial impediments, and to support personnel in making clinical level changes. This requires a sustained programme, and also patience on the part of stakeholders who expect results for patients in a short timescale. The study considered it possible that clinical level improvements could have been made by enthusiastic and committed clinical personnel alone in a “bottom-up way”, and without the macro-integration. However, it would be likely that these changes would have been limited and possibly not sustained due to the “pull-back” of unchanged traditional finance and management structures. A third study finding was that better clinical level information systems could have speeded and supported clinical change, and could also have helped provide evidence of the impact of changes from data recorded on patient outcomes. Clinical quality process and outcome data are needed for many different types of improvement. Current systems in Sweden do not support clinical care coordination, do not allow easy transfer between different computer systems at different sites, or allow data to be gathered to track how other changes might be impacting patient care. Finally, the evaluation found that existing County and Municipality higher level financing and reporting rules and systems reinforced the traditional separate facilities and services, and that these would take time to change and were difficult to change. In Norrtalje, after the integrated organisation was established, much administrative work had to be done to show higher authorities how finance was distributed in the new organisation, and that this followed the rules and decisions for each traditional budget which remained in existence outside of Norrtalje. The finance system and reporting had to meet the national and county requirements, as well as those of the new integrated political body. Work on this delayed work to establish micro-structures for better organizing entire episodes of care and care groups, rather than the traditional facility- and service-based organisation.


2.3. Review questions and objectives The above findings, and the assignment for the 2011 evaluation led to the formulation of these questions for the review which is reported below in this document:

- Which research exists about integrated care and integrated care systems? - Which integrated care organisations are most similar to the Norrtalje model and

how do they perform? - What are the lessons from research and evidence about how to improve care for

the Norrtalje population and reduce costs?

2.4. Methods The search and review updated an earlier review (Øvretveit 2008), carried out as part of an evaluation of the Norrtalje model by MMC.

Searching, grading and presenting the evidence Because the research was spread across many different databases, and used many different research designs providing different types of evidence about an ill-defined subject, an iterative management research review method was used. This is described in Øvretveit (2009b, 2005a, 2005b and 2003b), Greenhalgh et al (2004), and Greenhalgh and Peacock (2005). The steps were as follows:

- Definition of users of the research, their decisions to be informed by the research review, and the review questions to be answered,

- Broad scan Define objectives and search terms, find and note the various literature on the subject.

- Narrow the focus on previous reviews Identify and select previous reviews, assess these for answers to the review questions.

- Open out inclusion Bring in high-quality individual studies in order to provide additional evidence to answer the review questions, noting the strength of evidence of the findings and assigning a grade score.

- Open inclusion more widely Add other research (of acceptable evidence strength) to fill in the evidence gaps to the questions, noting that the evidence at this level is weaker, using a snowball approach to identify relevant studies (Greenhalgh and Peacock 2005).

- Review and synthesise Combine the evidence in order to answer the questions, noting the degree of certainty (through the grading system). Identify unanswered questions and priorities for research, and provide any recommendations that are supported by the evidence.

Search, selection and abstraction The search looked for systematic reviews of research that sought to describe or evaluate integration care systems, as well as primary studies that reported evaluations of integrated delivery systems and care-coordination improvements or improvements that included care coordination as a primary element. The identification, exclusion and assessment followed the following method:

- Listing of reviews or primary studies delivered by search - Exclusion of studies, which on further investigation, were not about integrated

care systems or clinical care coordination, empirical evaluations, or relevant conceptual frameworks,

- Exclusion of studies below the threshold of evidence level grade “E4” (see “grading” below), or which were not reviews studies or of evaluations

- Final selection of studies for abstraction and summarizing


This review also followed up references in some studies which referred to other research which had not been identified in the formal search, and looked for unpublished or early findings presented at conferences and in the “grey literature”.

Grading the evidence A grading system was chosen which would give a simple indication to readers of the degree of certainty of statements in this review, based on an assessment of the strength of evidence of the study finding reported according to the design and conduct of the study. This was based on a combination of a modified GRADE evidence scale (Grade working group 2004) and a grading system used in earlier reviews of health management subjects (Øvretveit 2003b, and by Greenhalgh et al 2004). The criteria used to grade evidence as E1, E2, E3, E4 were:

E1: Strong evidence of results: consistent findings of results in two or more randomised controlled trials.

- This corresponds to the GRADE scale “A”: “Several high-quality studies with consistent results. Further research is very unlikely to change our confidence in the estimate of effect”

E2. Moderate evidence: consistent findings of results in two or more scientific studies of acceptable quality (non-randomised control trial and before-after design, no control).

- Corresponds to GRADE scale “B”: “One high-quality study or several studies with some limitations. Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate”.

E3. Limited evidence: only one study giving results, or inconsistent findings of results of several studies. Studies of results showing perceptions are graded E3 if they were collected and analyzed according to accepted scientific methods using an appropriate design.

- Corresponds to GRADE scale “C”: “One high-quality study. Several studies with some limitations. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate”.

E4 Very low strength of evidence. Any estimate of effect is very uncertain. One or more studies with very severe limitations. Expert opinion. No direct research evidence.

Synthesis and presentation

After studies were selected, graded and organised in tables and summarised, the first draft outline was made with headings for the main questions to be answered. A first draft was written, drawing on the study summaries and tables to find evidence to answer the questions, and to identify which papers would need more detailed analysis for possible evidence to answer the questions.

Considering the strength of evidence The phrase ‘strength of evidence’ has a number of different meanings. In order to assess whether the label ‘strong evidence’ indicates that the same results are likely to be achieved in a local setting, and are generalisable from the research, decision-makers need to be clear which meaning is being used Meanings may include: - accuracy - strength of effect in one study - strength of effect in a study where other explanations are excluded - predominant aggregated effect from summation of many studies (for example,

some with no effect, some with large effect) - a consistent pattern of the same findings across many studies.


Part 2: Findings

3. Which research exists about integrated care and integrated care systems?

The search revealed a wide range of conceptual studies and commentaries, but few empirical descriptions, and fewer evaluations of such systems. There is empirical research into specific arrangements for certain patient groups. Many are studies of interventions to improve coordination or coordination schemes such as disease management systems or care management. These also include financing arrangements, which combine fee for service financing arrangements in one “finance bundle”, or offer capitation financing.

3.1. Integrated care arrangements Integrated care arrangements which have been described can be classified as:

- Methods for integration which can be applied to coordinate the care provided to one or to many different patient groups (eg one shared electronic medical record, agreed shared clinical practice procedures, separate payments combined in “one bundle”)

- Disease- or patient group based coordinated care schemes or systems (eg for diabetes, or for mental health patients in an area)

- Comprehensive integrated care provider organisation or system (eg the USA veterans health administration)

- Comprehensive integrated provider and purchasing organisation or system (eg Kaiser Permente, Geisinger)

3.2. Categories of Research The relevant research can be classified as of three types,

Overview or review studies of integrated care systems Eg Shih et al 2008 multiple case study of 16 USA integrated health systems; Gleave, 2009 multiple case study of four USA integrated health systems; and Ham & Smith 2010 multiple case study of 5 local integrated care systems.

Overview or review studies of integrated care schemes for specific patient groups

Eg Disease management programmes (Krause 2005), or for depression in primary care Neumeyer-Gromen 2004).

Primary studies of specific schemes or integrated care systems Eg comparison of Kaiser and UK by Feacham et al 2002, or evaluation of 16 UK integrated care pilots (Rand and Ernst & Young 2010).


4. Which integrated care organisations are most similar to the Norrtalje model and how do they perform?

Norrtalje is unique in establishing an integrated health and social service finance structure, which contracts an integrated health and social service provision organisation for most health and social care services to a local population. All other systems are much larger. Their provider parts of the system cover a different population to the insurer part of their system, although some people are covered by both. Additionally most other systems contract many physicians and providers which are not employed in the system.

The closest reported comparison systems are: Kasier Permenente (California)

Similar to Norrtalje in: combining a purchasing organisation with an integrated provider and with salaried physicians. Different to Norrtalje in: population covered is sixty times lager that of Norrtalje (6.1m vs 0.1m), services provided (eg Norrtalje provides more social care but no very specialized care), in being private not for profit and funded largely by individuals or employers not by taxation, and in resources available for management and support systems (eg information technology). More details are provided in the appendices to this report.

Geisinger health system (Pennsylvania) Similar to Norrtalje in: combining a number of services in an integrated provider and also involves a purchasing organisation. Different to Norrtalje in: population covered is twenty-five times lager that of Norrtalje (2.5m vs 0.1m), with 30% patients enrolled in the Geisinger insurance plan (the other 70% served are enrolled in other insurers plans) and in other respects as for Kaiser above (eg private, little funded by taxation).

Torbay Care Trust (UK) Similar to Norrtalje in: public organisation and financing, combining a purchasing organisation with an integrated social and health care provider, and in population covered (140,000) and in high % of over 65 (23%) Different to Norrtalje in: does not employ GPs or include a hospital in the provider organisation part of the Trust. Has more developed clinical level coordination in its wholistic client assessment systems, care coordination roles and integrated local area clinical teams.

Forsse integrated care organisation (Finland) Similar to Norrtalje in: Different to Norrtalje in:


More details of Torbay and Forsse are give later, and about Kaiser and Geisinger in the Appendix to this review

Other less similar are: Large Provider systems such as: Mayo Health System (regional system of clinics, hospitals and nursing homes, as well as Mayo Clinic, an integrated multi-specialty physician group practice employing 3,400 physicians); Partners HealthCare (which includes 2 academic medical centres seven hospitals, health centres, home health and long term care and a physician network, and contracts with 1,000 PCPs (primary care physicians) and 3,500 specialists); as well as Health Partners (Minnesota (health plan is 640k coverage)) Henry Ford Health System (Michigan (health plan is 600k coverage) Independent practice associations such as: The Hill Physicians Medical Group (California) contracted on a capitation basis by health maintenance organisations to provide defined coordinated care to 350,000 patients, using systems provided by the group to support its PCP and specialist physicians which own the group (as well as the 2,200 other independent providers contracted by the group). The Veterans Health Administration (VHA) This is funded by the federal government out of taxes and provides services to 40m veterans of US armed forces (not their families), through 21 regional integrated systems (VISNs). Each VISN has a large academic medical centre, many polyclinics and other services. Personnel are salaried and their services linked through a nation wide electronic medical record.

Other reported integrated care organisations or schemes Other integrated care schemes or organisations which have been studied empirically are:

UK NHS pooled finance for social services and secondary health: budget experiments for specific care groups such as mental health, children and families and older people (Gulliver et al. 2001)

UK NHS mergers of social services and secondary health care for specific client groups, such as mental health or children and families (Gulliver et al. 2001)

UK MHS mergers of social services and some health care for adults such as Somerset NHS trusts (Peck et al 2001).

Netherlands integrated care schemes (Struijs et al 2010)

5. Two case examples of similar integrated care organisations

5.1. Case example 1: Forssa integrated care organization (Finland) Overview

Name of Organisation: Forssa healthcare municipal federation Population covered: 35,300


Main services provided: primary and community care including dental care, mental health and psychosocial services, substance abuse services and environmental health, specialty in-hospital and out-patient services (“basic level”), plus purchasing specialised secondary and tertiary care. Services and populations not covered: residential care for the elderly, social benefits administration (organised by local municipal authorities). Type of integration: primary, community and “basic” secondary care Financing: “member” municipality tax-funded contributions based on service utilisation Evidence of effects: structural and work processes changes carried out that have resulted in reduced hospital utilisation, and a higher proportion of services provided in ambulatory settings. Successful cost control with moderate growth and cost per capita constantly below national average. Increased hospital productivity.

Details: Macro organisation and financing

The Forssa healthcare municipal federation was established in 2001 by five municipalities in the vicinity of the industrial town Forssa, serving 35 300 people. Municipalities have the legal responsibility to organise and fund health care and social services to their inhabitants. National government provides about 30% of the costs through subsidies to municipalities. Municipalities typically organise primary care and social services as a public service, although some services are purchased from private providers, such as residential care for psychiatric patients or substance abuse services. Secondary care is provided by regional municipal federations. Membership of the federation is mandatory for municipalities; municipalities are, consequently, both co-owners of hospital federations and purchasers of hospital and specialist care. As providers of primary care municipalities thus carry out what is termed in the UK, “primary care purchasing”. In Forssa the five municipalities have transferred purchasing to their “local” federation, thus combining their purchasing power. The “Forssa model” integrates the primary care centres, community care, environmental health and care for the elderly of the five municipalities with services of the local hospital. The hospital has departments of medicine, surgery and gynaecology, and in addition, specialists in anaesthesiology, otorhinolaryngology, paediatrics, neurology and geriatrics. In 2010 the total costs of Forssa healthcare were € 60m. Eighty-percent of services were provided by the organisation, 20 % were purchased from a district general hospital about 100 km away, a university hospital 200 km away, and private local providers.

Operational clinical level organisation Within the integrated care organisation Forssa healthcare combines a strategy of centralising some services to the hospital site to maximise economies of scale, and creating local units in the municipalities to give basic services with good access. Local services include GP services, maternal and child health, mental health and care for the elderly. The hospital has 30 beds in medicine, 34 beds in surgery and gynaecology, 6 beds for haemodialysis, 4 cardiac care unit beds and 6 beds for day surgery. With good cooperation between municipalities, mental health services and psychosocial support for children and families are coordinated with psychiatry, clinical


psychology and social worker services, and provided locally in cooperation with the schools and other municipal authorities. Centralising (to the local hospital) clinical chemistry, radiology, physiotherapy, technical support and services, central supply, pharmacy administration and food supply has enabled Forssa to provide specialty services, and to do so in a cost-efficient manner. GP on call services are provided by the hospital accident and emergency department on a 24/7 basis. Operation theatre on-call during nights and the delivery unit were abolished in the early days of the Forssa federation, as were paediatric beds and specialists’ nightly on-call services. Those services are provided by the district general hospital. Forssa healthcare is based on the desire of the five municipalities to design and deliver an area based healthcare and social services strategy, aiming to promote health and social wellbeing of the population. The federation provides an organisation with unified management, one shared budget with pooled resources and local political control through the governing board of the federation. The understanding is that, because of the integration of services, those most in need can best be provided services. Forssa healthcare has identified a number of “critical success factors” that guide decisions about service structure. Those are services clearly focusing on psychosocial services of children and adolescents, common health problems in the population, especially diabetes and cardiovascular diseases, mental health and substance abuse care. Clinical care processes are the basis of the service organisation, seen as a key to efficient service provision, seamless care, a professional service and a capacity for change. In terms of services, Forssa healthcare gives special attention to organising comprehensive out-patient services, including the basic specialties, elective intervention services provided, above all, in out-patient or day-surgery units. Nurse led units (with support from consulting specialists) provide specialised services to rheumatology, neurology, diabetes, chronic obstructive lung disease, memory loss and cancer patients. Local service units actively cooperate with social services in the municipalities, especially to give care for the elderly, children and families.

Achievements attributed to the integration Forssa healthcare reports the following improvements that were made possible by the integrated care organisation:

Out-patient department visits have increased and in-hospital care has been reduced, especially in psychiatry.

The rate of day-surgery has risen to 60 % of all surgical procedures. A GP can typically be seen for a scheduled appointment within 4-7 days. The mandated maximum waiting time (of six months) for hip and knee

replacements has not exceeded for any patient during a number of years. These measures of access exceed what is usually seen in Finnish healthcare. In addition, school health services have been developed and improved in all municipalities. A model for preventing violence within the family has been adopted. The raised awareness of mental health and substance abuse problems and willingness to pay attention to those in all service provision is a result of highlighting the issues in continuing professional development programmes. Health programmes for persons in long-term unemployment have been designed and implemented in local health centres. Dental care services have been preserved in all five municipalities by developing dental care teams, giving dental hygienists more responsibility. Child health clinics


have focused on families in most need. School health services involve families, not only students. Care for the elderly has been improved in cooperation with the five municipalities. Forssa healthcare provides long-term care, geriatric specialty services and medical and nursing services at home, whereas municipalities organise residential homes and home help services. Eighty nursing home beds have been closed as municipalities have built 60 new residential homes. The hospital facilities have been turned into a geriatric centre with ambulatory services. Nursing staff has been reorganised into specialised teams, examples are home care, crisis, discharge, rehabilitation and end-of-life care teams. Forssa healthcare has succeeded in retaining qualified professionals in primary care, and also in the hospital despite its downsizing and reduction of specialty services. The low staff turnover during times when primary care has been plagued by shortage of especially physician labour suggests that professionals find the integrated care model attractive. Since 2002, the five municipalities have shown consistently lower per capita costs for healthcare and social services than the country and district averages, although costs have grown at the same pace. The Government Institute for Health and Welfare compiles national statistics on needs-standardised healthcare and care for the elderly costs per capita. These data show total costs have in 2004-2009 been below national averages, with one exception (one municipality in 2009). Municipal contributions to the federation grew with 3.5 % 2006-2007, but only 0.6 % in 2009-2010, showing success in cost control. The hospital has reduced its running costs (in real terms) with 5 % between 2005 and 2009, as did two other local hospitals in the country, whereas four other hospitals showed cost increases of 3-17 %. In a countrywide analysis of hospital productivity Forssa ranked 7 out of 17, with productivity being 7 % above the national average.

Future planned developments The Forssa chief executive feels that the structures are in place for an integrated service, that clinical processes have been planned and documented, and that staff has acquired skills in continuous improvement. The next challenge is to systematically monitor health outcomes, to assess the effectiveness of clinical interventions and to test models of care (like Wagner’s “chronic care model”) for cost-effectiveness.

References Forssa healthcare municipal federation annual reports 2006-2010. Presentation by Forssa healthcare municipal federation chief executive to federation member representatives on 14 June 2011. National statistics published by the Institute of Health and Welfare, Finland.

5.2. Case example 2: Torbay and South Devon Care Trust (“Torbay Care Trust” or “TCT”, UK)

Overview

Name of Organisation: Torbay and South Devon Care Trust (“TCT”) Population covered: 140,000 population in a defined area.


Main services provided: public community health and social care, plus purchasing specialist health care and some social care Services and populations not covered: not acute and general practitioner services, not people under 65 years. Type of integration: structural and financial provider and purchaser: one organisation (The Trust) employs people to give the services provided to the population served and to purchase services not provided. Financing and contracting: NHS and local authority finance is allocated to the Torbay Trust to purchase defined services for the population and to provide health and social care. Evidence of effects: changes to ways of providing care and reduced use of hospital beds.

Details: Macro organisation and financing

Established in 2006, the Torbay Care Trust was formed by merging Adult Social Care function of the municipality and the Torbay health purchasing trust (the Torbay Primary Care Trust). Because of the high older population in the area (23% over 65), TCT was formed to remove some of the barriers between health and social care services. In 2011 the Care Trust also assumed responsibility for NHS community services in the Southern Devon area, which included the transfer of staff. The Trust is accountable to NHS South West Strategic Health Authority and performance is monitored by the independent UK Care Quality Commission. It is one of the five UK integrated NHS and social care organisations. Financing and contracting UK Department of health and local authority finance is allocated to the Torbay Trust to purchase defined services for the population and to provide health and social care including learning disabilities services. As regards health purchasing (mostly acute services) the trust spent £290m (2010/11) much of which was spent on local hospitals services (South Devon Healthcare Trust £96m). The trust does not employ general medical, dental or pharmacy services but “purchases” them under their national contract agreements. It does have some funding and other responsibilities as regards these services and is able to influence their practice with regard to coordinating care in certain ways. The budget for service provided directly by the trust is £110 or about 40% of the total budget of £290m. 12% of this was spent on social care services – mostly employed staff but some contracted private services. The municipality delegates its social care function to the TCT through a partnership agreement and provides its finance to the TCT through a “pooled fund arrangement” (allowed through Section 75 of the NHS Act 2006). The pooled fund surplus was £320k in 2010/11. There was an overspend of £115k in healthcare and an underspend of £435k in social care. There is a risk sharing agreement between the Care Trust and the municipality to share 50% of the over or underspends.


Torbay Care Trust Expenditure Analysis 2010/11

£13mOther Costs

4%

£22mGPs7%

£8mDentists

2%

£32mPrescribing/Pharmacy

10%

£34mStaff11%

£22mMental Health Hospitals

7%£5mAmbulance Services

2%

£39mSocial Care

12%

£19mOther Healthcare

6%

£6mManagement

2%

£123mAcute & Community

Hospitals37%

Operational clinical level organisation The macro changes in 2006 were established at the same time as local structural changes to enable clinical level coordination. These included 5 co-located zone teams (integrated health & social care teams) each aligned with the independent GP practices in their zones. Each gives a single point of access for people in the area to the services provided by the team and to other services which the team refers the person to. Each team has one manager, uses one assessment process, and assigns a care coordinator for most service users. Budgets are pooled and can be used by team members to commission whatever care is needed by their patient/client (“micro purchasing”) and experiments are starting with personal care budgets held by service users. The teams serve a variety of types of patients, including with long-term conditions, palliative care and people with disabilities. There is a shared information system, assessment and planning system and an easy fast referral process. The teams prioritise the most vulnerable: 83 patients out of 23,000 were classified at the apex of the Kaiser needs model (DoH 2005). Intermediate care services are provided in each of the five areas through the referral entry point, which gives access to district nurses, occupational therapists, physiotherapists, within five working days or if urgent within four hours if urgent (25 %) (reference Øvretveit 2011 Exeter PHC SDO visit field notes, and Peck et al 2001).

Achievements attributed to the integration The formation of the clinical integration structures and systems described above are one achievement: the single point of contact for intermediate care services allows access to a range of community services within 3.5 hours, and there is a weekend working pilot scheme. Other achievements were documented in an independent evaluation in 2010: a significant reduction in use of bed days, reduced emergency admissions for patients over 65, virtual elimination of delayed transfer and improved access to intermediate care. The evaluation reports,


“A reduction in the average number of daily occupied hospital beds used from 750 in 1998/90 to 528 in 2008/09.

For people aged 85 and over, Torbay uses only 47% of bed days for people experiencing two or more emergency hospital admissions compared with similar areas.

Torbay is one of the best performing areas in England in the use of hospital beds and day surgery according to independent analysis conducted by the NHS Institute for Innovation and Improvement.

The importance of these results is that they provide hard evidence of the benefits of integrated care.” (HSMC 2010).

The following factors might explain these: a receptive context for change, organisational stability, leadership continuity, partnership working as the overriding local strategy and keeping the Kaiser vision about appropriate care at the right level ‘at centre stage’ (HSMC 2010). The Torbay integration, and the organisations experience with and capacity for project management also allowed it to receive finance and support as a pilot project in the UK ‘Making the Shift’ programme to move services from hospital to the community. This project had three results

Substitution of location and skills: initiating insulin in primary care rather than in secondary care.

Substitution of location: developing a decision making tool to assess feasibility of projects to shift diagnostics.

Segmentation and simplification: communication plan aimed at practitioners to improve care for people at the end of life with any diagnosis.

(Ham et al 2008). Future planned developments

Among the improvements to coordination planned, and which are made easier by the integration, include: developing a shared and secure health and social care electronic health record; user held care records; and a community stroke service. For the latter initial funding has been allocated which will be reduce over several years with operational funding coming from the projected savings from reduced lengths of stay in secondary care (acute) and community services (inpatient rehabilitation).

References HSMC 2010 News. http://www.hsmc.bham.ac.uk/news/news/2010/1/Torbay-Project.shtml Ham C Parker H Singh D Wade E 2008 Making the shift from hospital to the community: lessons from an evaluation of a pilot programme Primary Health Care Research & Development 2008 doi:10.1017/S1463423608000856) See also, NII 2010 Joined up care, National Institute for Innovation and Improvement, UK.


http://www.hsmc.bham.ac.uk/news/news/2010/1/Torbay-Project.shtml


6. What are the lessons from research and evidence about how to improve care for the Norrtalje population and reduce costs?

6.1. Close clinical coordination can be achieved in ways other than through structural merger and shared finance.

Perhaps the main lesson for improving patient care and reducing costs is that close clinical coordination can be achieved in ways other than through structural merger and shared finance. Merging and sharing finance in one organisation reduces some impediments to clinical level coordination by making it easier to combine personnel into multidisciplinary teams, to create communication systems within the same organisation, to create common incentives tied to the same coordination-directed objectives, to agree information sharing, and to agree budget transfers. Also, to some extent it is easier in one organisation to agree clinical work procedures, such as single points for referral and protocols and procedures. However, good clinical level coordination can be achieved between independent and separately financed providers and service, as the USA network health systems and clinical level coordination schemes show, and as the UK integrated care pilots are showing. What appears to be critical are effective easy to use shared electronic medical records, an agreed range of clinical working practices which make coordination easy, required and rewarded, and a culture which emphasises that coordination and communication is central to professional work and essential to patient outcomes. Thus structural integration helps but does not ensure clinical coordination. There is an argument that clinical coordination may be more quickly and effectively achieved applying the range of methods and experience now available about the subject rather than by changing large scale structure and financing.

Summary: Methods for coordination and integration Clinical coordinating methods Single access point Wholistic client needs assessment and planning Care coordinator role Clinical information sharing and access Coordination performance feedback Training Operational methods facilitating clinical coordination Referral Single entry Co-location Formal team agreements Information systems Culture


Macro Structural and Financial One organisation for all provider services One budget for all services One purchaser for all services Combined purchaser and provider for all services Contracts and agreements between providers Contracts and agreements between purchaser and providers require coordination actions by providers

6.2. Use integration to reduce unnecessary hospital use Another set of lessons comes from research into changes outside of hospitals for improving hospital outpatient effectiveness and efficiency. Roland et al (2007) found that transferring some services from hospital to primary care and some professional behaviour change strategies are effective in reducing demand on outpatient services. As regards the transfer of outpatient services to primary care, effective strategies that maintain quality are: primary care clinics for chronic diseases; discharging hospital outpatients to no follow-up, patient-initiated follow-up or GP follow-up; and direct access by GPs to hospital-based diagnostic tests, investigations and treatments. Research on relocating specialists into community settings indicated that this does not reduce outpatient demand but may improve access in remote areas. As regards liaison activities between primary care and specialists, this may improve service quality but does not reduce outpatient attendance. Research into strategies to change professional’s behaviour shows evidence that

Specialist educational outreach and structured referral sheets reduce GP referrals.

Ineffective interventions include: passive dissemination of referral guidelines, audit-and-feedback of referral rates; discussion of referral rates with an independent medical advisor.

6.3. Value improvements possible with the Norrtalje model

A third set of findings is that specific changes could be adopted in Norrtalje which could both improve quality and reduce cost. The review by Øvretveit 2011 found that there was strong evidence that the following both improves quality and reduces cost, and that some of these findings could be expected if the same interventions were implemented in Norrtalje:

Strong evidence of cost and quality improvement Interventions and changes which the evidence showed to be very likely to save money and suffering caused by under-coordination were all inter-organisational improvements, or which were carried out within integrated systems. To spread this type of change widely would require changes to financial systems to give incentives and spread costs and savings between different providers. The strongest evidence was for: Some disease management programmes targeted at severely and moderately ill

asthma, diabetes or heart failure patients at risk of preventable hospitalisation.


Multidisciplinary teams for patients with heart failure, giving follow-up with specialist heart failure nurses and patient caregiver education (E2 McAlister 2004).

Some discharge planning programmes with support, for older patients with congestive heart failure (E2 Phillips 2004).

Nurse-led and team-post hospital interventions for congestive heart failure patients (E3, Rich et al 2001, 1995, E3, McAlister et al 2001) but only if started before or soon after discharge, focusing on high-risk patients, and using face-to-face encounters with nurse care managers rather than telephone-only contact (E3, Wagner 2004).

Team coordination for stroke patients giving early coordinated discharge from hospital and providing post-discharge care and rehabilitation at home (E3 Langhorne 2005).

Transitional Care Model (TCM) for older patients with complex needs leaving hospital (E3, Naylor et al 1999, 2004, and for other patients E3, Coleman et al 2006).

Almost certainly cost more than they save: Discharge planning which only gives an assessment of a patients needs to post-

discharge services (E3 Richards 2003)

Less strong evidence of cost and quality improvement These interventions might save money and avoidable suffering caused by under-coordination Some disease management programmes for heart failure patients in the general

population (E2, Whellan 2005) and for older people (E2, Yu et al 2006) and diabetes patients in the general population (E2, Norris et al 2002, E2, Knight et al 2005)

Community mental health teams carefully targeted for patients with severe mental illness (E2 Simmonds 2001).

Some assertive community treatment for mental health patients if effective and well-specified models are followed and patients are carefully selected (E2, Latimer 1999, E1 Marshall & Lockwood 2000)

Some case management approaches for severely mentally ill patients carefully targeted to particular patients (E1 Gorey 1998 E1 Ziguras 2000), but questioned by Marshall 1998 E1).

Some carefully targeted case management approaches for older people with congestive heart failure (E1 Windham 2003)

Disease management with multidisciplinary teams and specialized clinics for patients with coronary heart disease in the general population (E1 McAlister et al 2001) especially those with telephone follow-up or a home-based component (E1 Holland et al. 2005)

Some specialist outreach clinics (E3 Gruen 2003).


Some handover systems if carefully co-developed with users and using a number of methods to implement (E4 Arora et al 2009)

Some approaches to medication reconciliation can reduces error, may reduce adverse drug events and are likely to save extra costs and suffering caused by such events, if carefully co-designed with users. Specially designed computer based systems more effective than EMR “add-ons” (E4 Kramer et al 2009)

Some clinical pathway approaches can reduce in-hospital complications and improve documentation, and give lower length of stay, with likely cost savings (E3 Kwan et al 2005, Renholm et al 2002, Rotter et al 2010).

6.4. Context factors and conditions contribute to successful or unsuccessful integrations

Although the point was made earlier that clinical coordination can be achieved without integrated organizational structure and finance, there is also research which shows separate structures and finance for providers and services do cause barriers to coordination. One overview study of integration examples in Europe included a survey of managers which identified the following hinderances to care coordination (Hofmarcher 2007):

- Obstacles to exchange of client/patient information between providers, typically poor ICT, concerns about privacy, and professional resistance.

- Capacity and resource limitations in non-hospital settings leading to referral to hospital rather than specialist supported care outside of hospital

- Payment schemes not aligned with system-wide objectives & few financial incentives to encourage coordination of care

- Regulatory and administrative barriers to cooperation across sectors

As regards joint purchasing in the UK, either by pooling budgets or by separate but coordinated purchasing, Hudson et al (1999) identified helping factors: wide consultation; securing trust and commitment; articulating desired ends; developing facilitating structures; and identifying clear responsibilities. Similar factors we identified by Rummery (1999). Stewart et al (2003) reported nine case studies into integrated working in health and social care in Scotland. Their analysis of the cases identified a number of “drivers and barriers” in three areas : national policy frameworks, the local planning context, and operational factors.


6.5. Which actions are important to achieving integration?

Few studies were found in this rapid review which gave enough detail about implementation to answer this question. One study in Northern Ireland found that integration in service provision was mainly achieved through a “programme of care approach” to resource procurement and allocation (Heenan 2006). Programmes of care are divisions of health and social care, into which activity and finance data are assigned, so as to provide a management framework (there are nine for most Trusts: acute services; maternity and child health; family and child care; elder care; mental health; learning disability; physical and sensory disability; health promotion, and primary health and adult community. They are used to plan and monitor the services, by allowing performances to be measured and targets set and managed on a comparative basis (because all Trusts use a similar set of programmes). Øvretveit 2006, building on research into coordination, teams and integration in the UK NHS, describes different methods for improving cooperation between separate services,

- Patient care focused integration: Care management; Shared care or discharge planning; Patient pathway for entire illness episodes (cross service); Common health record (or EHR)

- Organisation focused: Teams or networks; Partnership agreements; Joint appointments or mergers

- Regulation or contract focused: Requirements in planning: Purchaser requirements; Accreditation/inspection requirement.

Øvretveit 2006 also describes specific methods to increase integration: 1)Needs-outcome agreements between people or organisations; 2)Incentives or punishment; 3)“Process-based” approaches; 4)Informal and personality-based approaches;


5)Training-based approach; 6) Structural approaches; 7)Create Systems; 8)Contracting/funding requirements for cooperation. Hudson and Henwood (2002) suggest from their study of Northern Ireland integration that “organizational culture might provide potential leverage for change”. They propose that research is needed to “uncover which factors promote and which factors inhibit integrated approaches to care coordination within care management arrangements. In particular, which barriers are best overcome by structural changes and which can be overcome by other mechanisms such as joint training?”.

6.6. Other studies of relevance to the Norrtalje integration

Two other fields of research are relevant to the Norrtalje integration: studies of mergers in general; and studies of contracting-out services which highlight the rationale and evidence for and against some tioHundra AB services being separated and contracted directly by the tioHundra Forvaltningen. Field, J & Peck, E 2003 reviewed the literature on mergers and acquisitions in the private sector and identified concepts and explanatory frameworks relevant to organizational structures in health and social care. They concluded that the evidence shows that that it is difficult to merge two organizations successfully and they describe the explanations given in the research and the implications for health and social care mergers. The research shows that important for implementation are the roles played by individuals, especially senior managers, non-executive directors and elected members; the roles played by professional groups; and the role of organizational cultures. The private merger research shows that the strategic objectives or financial savings are rarely achieved; productivity initially drops; staff morale drops and anxiety and stress is high among personnel before and during the change. The paper concludes that “It is surely important… for managers to be familiar with the broad messages in the merger literature so that they are aware of what they are accepting and rejecting. From a research perspective, however, there is a strong case for more studies of these new organizational forms and the use of a wider range of theories to interpret the data. Generalisation to health and social care integrations should be made with caution: the implementation process is more consensual, community and personnel consultation and support is necessary, the financial incentives and the type of services are different, as are the regulatory frameworks. However, a study of a mental health and social care merger in England came to similar conclusions and identified the important role of culture in slowing integration (Gulliver et al. 2001). A study of a mental health and social care merger in England (Gulliver et al. 2001) considered both the creation of new joint health and social care purchasing arrangements as well as an integrated health and social care trust for provision. The study explains the lack of significant impact on quality in terms of “continuity within the system”, in terms of continuity of decision-making within the commissioning board; of personnel, and of team management. It notes that personnel were slow to identify with the new organization or the new multidisciplinary teams which were created. A sub-study explained the latter in terms of personnel holding to their professional or unit indentities and culture for a sense of security in the changing situation (Peck et al. 2001). It reports ambiguity among managers as to whether to create a one new culture or to maintain and enhance the existing professional cultures by increased mutual understanding and respect.


One synthesis of research into interprofessional collaboration and quality in primary health care reported that many methods have been developed to help planning, implementation and evaluation of interprofessional collaboration ((including definitions, principles, frameworks, barriers and facilitators) (CHSRF 2008). It reports that certain types of interprofessional collaboration has been found to be cost effective in some primary healthcare settings (eg decreased costs for blood pressure control, and lower readmission rates and costs for team-managed, home-based primary care). Although the research shows positive outcomes of interprofessional collaboration, it was not possible to identify how variation among interprofessional collaborative models affect outcomes. MacAdam 2008 undertook a systematic review of frameworks of integrated care for the elderly This study found that research suggests some models of integrated health and social care for the elderly can result in improved outcomes, client satisfaction and/or cost savings or cost effectiveness. The key elements (which also need to organised to support each other) were (Kodner, 2006).

• umbrella organizational structures to guide integration of strategic, managerial and service delivery levels; encourage and support effective joint/collaborative working; ensure efficient operations; and maintain overall accountability for service, quality and cost outcomes • multidisciplinary case management for assessing and planning client needs, providing a single entry point into the health care system, and packaging and coordinating services • organized provider networks joined together by standardized procedures, service agreements, joint training, shared information systems and even common ownership of resources to enhance access to services, provide seamless care and maintain quality • financial incentives for health promotion, prevention, and rehabilitation as well as to enable service integration and efficiency

No single part of any integrated models of care has been shown to be effective in itself. However, all successful models use multidisciplinary care/case management for older people at risk of poor outcomes, supported by access to a range of health and social services. The strongest also include active involvement of physicians. Frequently found necessary infrastructure supports for integrated care are decision tools, common assessment and care planning and integrated data systems.

Part 3 discussion and conclusions

7. Discussion

7.1. Observations on the findings The review of research revealed little empirical research into organisation and performance of comprehensive health and social systems. In this it confirmed the uniqueness of the Norrtalje model. The review found some studies reporting frameworks for conceptualising different approaches for integrating care and for measuring integration. Some of these studies


and some empirical studies described the barriers and hinderances to clinical coordination and organisational integration. Those reported were primarily structural barriers (different organisations and responsibilities), financial barriers (item of service payment, or few incentives for coordination), cultural and professional barriers (eg suspicion of other professions or lack of trust, different values and philosophies of care), and barriers to the free flow of clinical and other information between providers and organisations (eg incompatible EMR or computer systems, privacy regulations). The review also revealed some empirical research into interventions and models of care at the clinical level, some of which were found to be effective for improving coordination and some for saving resources. The main findings of relevance to future planning for Norrtalje are - the structural and part-financial integration has removed a key barrier which has

slowed clinical integration elsewhere, - specific changes could be adopted in Norrtalje which could both improve

quality and reduce cost, - user friendly clinical information systems which allow easy access between

providers and which can be used by patients are essential to cost effective coordination, but require significant investments and careful design,

- individual and organisation accountability for coordination as well as specific care items are important and are made real with monitoring information and reporting,

- changes to attitudes about and payment for coordination are an important background to specific changes (culture and incentives)

- there are proven interventions and models for improving clinical coordination which could form a starting point for improvements in Norrtalje,

- simple project management and rapid cycle testing are effective for implementing changes but require the organisation to invest in developing these change intervention capabilities.

8. Options for the future and recommendations

The following were developed by comparing Norrtalje with other integrated care schemes and were assessed for their advantages and disadvantages using four criteria: maximizing patient choice; maximizing speed and ease of access for those most in need; low cost/efficiency; quality and safety.

8.1. 1 Return to 2005 model Municipality and county re-employs care personnel Dissolve the joint county and municipality political board and management structures But use interventions successful elsewhere to improve clinical coordination

Advantages Possible management savings.


Disadvantages Cost; demoralizing for personnel; politically unpopular.

8.2. 2 Retain Tiohundra AB, but restructure joint purchasing

Dissolve joint political board and local Forvaltningen

Centralise health purchasing and administration returning it to the main Stockholm purchasing organisation. Municipality finance provided to Tiohundra separately, rather than being “pooled” with health financing. Tiohundra competes with others for county- health contracts and municipality- social care contracts.

Advantages Save cost of joint political board and local Forvaltningen.

Disadvantages Cost of recentralizing health purchasing and reforming municipality administration and financing system. Loss of close relationships between TioHundra and Forvaltningen. Introducing primary care patient choice system could reduce coordination and add costs.

8.3. 3 Outsource non-core functions and services Invite competitive bids for administrative and clinical support services and consider outsourcing Significantly reduce Tiohundra to limited hospital and minor injuries emergency and related primary care centre. Contract out all other services (with or without Tiohundra bid) Contract-out specific diseases to disease management services (eg diabetes, heart disease, some mental health) and/or care management for some frail elderly, where focused care management may save costs and increase their quality of life. Build contract management and systems to ensure easy information exchange between Norrtalje public services and the outsourced services.

Advantages Possible lower costs for outsourced services. Disease management might be more effectively run by commercial services with dedicated information and systems.

Disadvantages Removing some Tiohundra services reduces some of the advantages of scale and of integration. Commercial disease management may be more costly than developing existing specialist nurse based approaches. It would be costly and difficult to build a system to enable clinical communication between more independent services.

8.4. 4 Reintegrate all services to TioHundra Re-employ clinical and care services which were contracted out, and reintegrate into TioHundra structure to make more comprehensive services (eg private home care services). Possibly also restructure TioHundra around care group service lines (eg with matrix organisation with care group leaders/pathway leaders and facility leaders)


Advantages Clinical information exchange, coordination and financing may be easier between providers in the same organisation than with providers in separate organisations.

Disadvantages Reduces competition and choice.

8.5. 5 Develop clinical coordination 1 Keep the current macro-structure and finance arrangements to allow managers to focus on supporting clinical coordination improvements 2 For high cost patient groups:

choose proven coordination improvements and implement through supported clinician-led project teams

eg use: post-hospital care management models to reduce readmissions or ER use; case and disease management models; Chad Boult's PACE prorgamme for older patients with co-morbidities (JAMA 2010 304, 17, 1936-43); Coleman care transitions patient coaching model for hospital discharge (see Ovretveit 2011)

develop systems to identify patients most at risk of deterioration and develop proactive early support

develop education and support services for self-care and carers 3 Develop clinical information and communication systems, led by clinicians, to support point of care work and coordination (seek relaxation of regulations to allow innovation, and seek innovation finance) 4 Establish clinician networks for specific diseases or care groups to develop services (eg through referral protocols, guidelines, audit, etc). 5 Plan financing and incentives to encourage the implementation of these changes (eg ensuring costs and savings of the changes are spread fairly between stakeholders).

Advantages Provides stability to management and personnel to focus on the work of improving clinical care coordination. Uses proven effective coordination improvements which will save money and improve quality if the right patients are targeted, and if effective clinician led project management is used to implement changes.

Disadvantages There is no guarantee that improvements which save money and improve quality will be chosen and effectively implemented. Incentives for clinicians and TioHundra to make these changes are weak, and there is little expert support to develop an effective approach to making improvement changes.

8.6. Recommendations There is no evidence, nor reason to believe that any radical change to the Norrtalje model and structure would provide less costly services or higher quality. There is reason to believe that any significant restructuring would disrupt current arrangements, reduce quality and add costs in the short term, and possibly also in the long term. The evidence suggest that, to achieve the advantages which the structure makes possible for more coordinated clinical and preventative services, the most effective changes would be to,


Create project teams to implement evidence based changes for improving coordination and reducing costs, especially targeted interventions to patients at risk of hospital admission or high primary care ultilisation,

Develop clinical information systems to promote and allow efficient clinical coordination and patient support services, possibly by attracting innovation finance to the unique circumstances of the Norrtalje system and seeking regulation exemptions for piloting such changes


Provide incentives and culture change for clinicians to improve coordination.

Reduce costs through substitution: moving services (eg from hospital) to less expensive sites or providers, delegate some physician tasks to specialist nurses, and from nurses to nurse assistants.

9. Conclusions

The Norrtalje model is unique and the only comprehensive local integrated funding and proving system which, as far as we know, exists and which is described in research. The integrated finance and provider structure has removed some key obstacles to providing coordinated clinical care and preventative services and provides the basis for significantly more cost-effective quality care. The closest models against which to compare Norrtalje are large health systems (Kaiser Permanente, Geisinger, Veterans health administration, and others) as well as some smaller integrated systems, but for specific patient groups (e.g. some UK NHS integrated provider trusts). Alternative models to Norrtalje were identified from the review of research together with the advantages and disadvantages of each. There is no evidence nor reason to believe that the alternative models would provide less costly services or higher quality. There is reason to believe that any significant restructuring would disrupt current arrangements, reduce quality and add costs in the short term, and possibly also in the long term. The evidence suggest that, to achieve the advantages which the structure makes possible for more coordinated clinical and preventative services, the three most important future changes would be to

Create project teams to implement evidence based changes for improving coordination and reducing costs, especially targeted interventions to patients at risk of hospital admission or high primary care ultilisation,

Develop clinical information systems to promote and allow efficient clinical coordination and patient support services, possibly by attracting innovation finance to the unique circumstances of the Norrtalje system and seeking regulation exemptions for piloting such changes



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