The Importance of Integrated Care to the Future of Health Systems:

National and Regional Developments in Europe and other countries

Dr Nick Goodwin & Dr Lourdes FerrerCEO, International Foundation for Integrated Care

www.integratedcarefoundation.org

Paper to: Health Quality and Safety Commission New Zealand Workshop: Towards Integrated Care in New Zealand

Wellington, New Zealand, November 14th 2013

The Challenge

Ageing Society = Greater Complexity of Care

By 2034, >85s will represent c.5% of the population in Western Europe.

Care Systems in Europe are Failing to Cope with Complexity

Frontier Economics (2012) Enablers and barriers to integrated care and implications for Monitor -

The complexity in the way care systems are designed leads to:

• lack of ‘ownership’ of the person’s problem;

• lack of involvement of users and carers in their own care;

• poor communication between partners in care;

• simultaneous duplication of tasks and gaps in care;

• treating one condition without recognising others;

• poor outcomes to person, carer and the system

The Challenge: Summary

• Age-related chronic conditions absorb the largest, and growing, share of health/social care activities

• Poor co-ordination of care for people with long-term/complex illnesses leads to poor care experiences and adverse outcomes

• Practical solutions to tackle the socio-determinants of ill-health and pathology of the complex patient

• Strategies of care co-ordination to create more integrated, cost effective and patient-centred services are growing internationally

• Lack of knowledge about how best to apply care co-ordination in practice.

The European Response

• There are many different examples of policies and innovation on integrated care around Europe

• The political agendas, however focus on:– Financial reform – Cost containment– Legislative change– Structural reorganizations– Personalised care– Pilot programmes

• Not enough on change management and the ‘how to’ of integrated care

National Strategies - Examples • Denmark & Norway: Coordination Reform• Sweden: Joint agencies link funding and

delivery (e.g. Jönköping & Nortallje)• England: The National Collaborative for

Integrated Care and Support (Pioneers)• Germany: Versorgungsstrukturgesetz (care

structure law) supports interdisciplinary and cross-sector models of care

• Netherlands: Managed care organizations and bundled payments for certain diseases

• Health and social care integration in Northern Ireland, Scotland and Wales

• Spain: vertically and horizontally integrated care organizations to support better chronic care ( e.g. Basque Country, Catalonia, Valencia)

• Switzerland: physician networks / HMOs

Example 1: The Basque System, Spain

• Developing a favourable policy environment

• Stimulating systems thinking with new models of care

• Aligning ‘bottom-up’ and ‘top-down’ integration

• Providing a distributed leadership approach

Care transformation in the midst of a deep economic crisis

Bengoa, 2013 - http://www.ijic.org/index.php/ijic/article/view/URN%3ANBN%3ANL%3AUI%3A10-1-114747/2042

Example 2: Maccabi, Israel

• Physician group partnership providing co-ordinated care to 1.9m people (25% population)

• Integrated ICT systems promote communication , continuity of care and supported self-care through ‘patient portal’ and telehealthcare

• System focus on managing chronic disease and the elderly

• Investment in leadership and inter-professional working

• Investment in research• Positive impact on care experiences,

clinical outcomes and cost containment

Maccabi 2011 - http://www.intel.co.uk/content/dam/www/public/us/en/documents/white-papers/coordinated-healthcare-from-maccabi-and-intel-paper.pdf

Example 3: National Collaborative for Integrated Care, England

• The ‘Narrative’• Change to NHS Mandate• Development of shared care outcomes

between government departments, and quality regulator includes new targets

• Integration encouraged alongside competition by economic regulator

• Financial reforms supports range of new incentives to providers

• Commissioning reforms supports new opportunities to pool budgets

• New resources to support change – and the Integration Transformation Fund (£3.8bn)

• Pioneers Programme

HEALTH IN EUROPE 2020 EUROPE 2020 FLAGSHIPS FOR SMART, SUSTAINABLE AND INCLUSIVE GROWTH

Innovation Union

New Skills and New Jobs

Digital Agenda

Youth on the Move

New Industrial Policy

Platform against Poverty

ResourceEfficiency

• innovation for tackling societal challenges, e.g. ageing and health• innovation for addressing the weaknesses & removing obstacles in the European

innovation system

Innovation Union

• ICTs for tackling societal issues - ageing, health care delivery• sustainable healthcare & ICT-based support for dignified & independent living

Digital Agenda for Europe

EUROPEAN INNOVATION PARTNERSHIP ON ACTIVE AND HEALTHY AGEING

health & quality of life of European

citizens

growth & expansion of EU industry

Sustainable & efficient care

systems

+2 Healthy Life Years by 2020Triple win for Europe

Improving prescriptions and adherence to treatment (A1)

Better management of health: preventing falls (A2)

Preventing functional decline and frailty (A3)

Integrated care for chronic conditions, inc. telecare (B3)

ICT solutions for independent living & active ageing (C2)

Age-friendly cities and environments (D4)

Action Groups

Reference Sites

Action Area

Change

Management

Action Area

Workforce

Development

Action Area

Risk Stratification

Action Area

Care Pathways

Action Area

Patient / User Empowerment

Action Area

Organisational

Models

Act

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nanc

e/Fu

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g

Actio

n Ar

ea

Di

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on

Act

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EIP AHA B3 Action Plan

By 2015Chronic Conditions’ Programmes available at least 10% of target population in at least 50

regions

By 2015 - 2020Integrated Care Programmes serving older people,

supported by innovative tools and services, in at least 20 regions

SIP TARGETS

2013 Monitoring impact and outcomes 2015

Toolkit Toolkit Toolkit

Tool

kit

Tool

kit

Toolkit Toolkit Toolkit

Increase the average number of healthy life yrs by 2 in the EU by 2020Health status and quality of life । Supporting the long term sustainability and efficiency of health and social systems । Enhancing competitiveness of EU industry

Chronic Conditions Integrated Care

Implementation and Scale Up of Chronic Care + Integrated Care Programmes

Map of partnership models for

implementation of Chronic and

Integrated Care Programmes

Map of best practice

methodologies to support the

implementation of Chronic and

Integrated Care

Map of reusable learning

resources

Stratification of the population

Mapping Best Practices in the EU

regions

Map of coaching, education and

support patient/user

empowerment and adherence

Developing a Regional Action Framework for Coordinated/Integrated Health Services Delivery (CIHSD) in the

WHO European Region

Dr. Hans Kluge Director, Health Systems and Public Health

European Forum for Primary Health Care ConferenceIstanbul, Turkey, September 9th – 10th 2013

Concept note – common approach

to CIHSD

Field evidence

\\

Guide for leading & managing change

The Road Map to CIHSD

MS Focal Points

External Advisory

Team

Internal Review Team

WHO Secretariat Patients Providers Int’l orgs &

NGOs

PARTNERS

The Integrated Care Response in US and Canada

USA• Integrated delivery systems for

enrolees– E.g. Kaiser Permanente– E.g. Veterans Health

• HMOs & group practice models– E.g. Mayo, Geisinger, Seattle

• Managed care or disease management programmes– E.g. PACE

• Integrated delivery systems for populations:– E.g. Nuka, Alaska– E.g. Massachusetts

Canada• Health Canada – Health Accord,

2004– Sets 10 plans to overcome

duplications, improve access and promote efficiency

– Emphasis on care transitions hospital-home to reduce ‘bed blockers’

• Provincial application leads to decentralisation and variation– PRISMA, Quebec– GP group practices, Alberta– Community-oriented primary care

centres, Newfoundland and others

Example 4: PACE Programme, USA

• Fully integrated system providing acute and long-term care services to older people (>55)

• Grew out of On Lok, an innovative senior centre that developed a day hospital approach to care to frail older people

• Based around an adult care centre that offers:– social and respite services– primary medical care– geriatric outpatients– ongoing care and case

management

• Designed to maintain frail older people in the community for as long as possible, so avoiding institutionalisation

• Voluntary enrolment, available to those aged >55 eligible for nursing home admissions and covered by both Medicare and Medicaid

• Important role of informal carers and supportive housing often part of care package

Example 4: PACE Programme, USA

• Between 1987-1997 PACE operated as a federal demonstration programme

• Since 1997, PACE a permanent provider under Medicare and a state option under Medicaid

• By January 2005 36 fully operational programmes across 18 states

• A typical participant:– A woman who is 80 years old with

multiple (9.7) medical conditions with limited activities for daily living. 49% have a diagnosis of dementia

How PACE achieves integrated care:• Pooled financing (Medicare &

Medicaid) and authority to control how capitated funding is spent

• Integrated services by range of staff employed at adult care centre – outside contracts for medical services, acute hospitalisations & nursing home care

• Case management by multidisciplinary teams including comprehensive assessments, service provision and care co-ordination

• Prevention and rehabilitation focus

Example 4: PACE Programme, USA

Evaluations of PACE conclude:• Large decreases in hospital use

(admissions and lengths of stay) for enrolled patients

• Increased use of outpatient medical care and therapies, and care in home environment

• Positive impact on Medicare costs in comparison to non-enrolee groups

• Client health status and satisfaction with care arrangements good

• Results in terms of physical functioning inconsistent

Conclusions:• PACE successful in managing frail

older patients and in offsetting costs against more expensive outpatient care

• Capital and start up costs were substantial, so PACE needed pump-priming from federal and state governments in initial phases

• Some patients not comfortable with adult day health care settings and/or giving up contact with a personal physician

• Centres run at a small scale (c.300 enrolees) so issues of economies of scale if more widely adopted

Example 5: PRISMA Programme, Quebec, Canada

• Unlike PACE, PRISMA is a co-ordinated model of care

• The goal is to integrate service delivery to older people to improve functional autonomy

• Admission is to persons >65 who have moderate to severe disabilities, but show good potential for staying at home – they need two or more health and social care services from the area in which they live

How PRISMA achieves integrated care:• Inter- and intra-organisational co-

ordination by joint governing board and a service co-ordination committee

• A single point of entry to care services

• Case management who work with clients’ family physician and other providers

• Common assessment process and care plan

• Joint budget• Integrated information system to

track patients and support continuity of care

The PRISMA Model

PRISMA (Canada)

Evaluations of PRISMA conclude:• Declining trend in institutionalisation• Lower client preference to be institutionalised• Greater functional autonomy of clients• No reduced or significantly changed pattern in the use of

health and social care services• Positive impact on carer burden• No impact on mortality (survival)• No reduction in costs

Improved system outcomes at no additional cost

PRISMA and PACE compared

Towards Integrated Health Service Delivery in Latin America

Essential attributes of IHSDNs (PAHO, 2011)

WHO (Geneva) - Integrated care as a strategy to support universal health coverage

WHO (Geneva)Strategy for High Quality and People Centred Integrated Care

(HQPCIC) to support Universal Health Coverage

Conclusions: Strategies and Progress

• Integrated care is a global buzzword and strategy for system reform• Integrated care takes on multiple forms, and the purpose to which it

has been adopted varies• Cost-containment / creating sustainable care systems is a central

driver, yet evidence suggests that integrated care is primarily a tool for quality improvement

• Evidence remains varied and limited, especially on costs• However, there is enough to suggest what the important components

of integrated care must be, and that the approach can support the ‘Triple Aim’ goals of care systems

• Yet, the failure rate amongst integrated care initiatives is high – more is needed in understanding how to develop, sustain and spread initiatives successfully and for the long-term

• There are few alternative options …

Contact

Dr Nick GoodwinCEO, International Foundation for Integrated Care

nickgoodwin@integratedcarefoundation.orgwww.integratedcarefoundation.org@goodwin_nick @IFICinfo