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Community based clinical service development - what are our possibilities
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Integrating Care – what are the possibilities?
November 14, 2013
CONFIDENTIAL AND PROPRIETARYAny use of this material without specific permission of McKinsey & Company is strictly prohibited
McKinsey Clinical Leadership Academy | 2
Pace of change in the healthcare industry has been slow to date
Modern medicine is still using fairly primitive technology
Physician’s office – then vs. now
1908 2012
McKinsey Clinical Leadership Academy | 3
1 Assumptions: Healthcare spending increases 1.9 basis points faster than OECD GDP Growth Forecasts (OECD historical rate)
SOURCE: OECD Policy Implications of the New Economy – 2000-50, 2001; Global Insight WMM, 2000-37; Espicom: World Pharma-ceutical Fact Book, 2008; International Monetary Fund; World Economic Outlook Database, October 2009; McKinsey
Rising financial pressure to change…
Share of healthcare costs as part of GDP
Hong Kong
Spain
Italy
U.K.
Australia
5.9
6.0
7.8
8.8
9.3
10.5
Country
Korea
2008
Canada
Germany
France
U.S.
10.8
10.8
11.2
16.1
6.8
8.9
10.0
10.6
10.5
8.17.4
7.5
6.7
8.2
9.7 10.7
11.0
11.6
13.1
12.0
12.7
14.4
2015 2020 2025
8.9
9.0
11.7
13.2
14.0
15.8
2030
12.3
12.3
12.7
18.3
13.5 14.8
13.5
14.0
20.1
14.8
15.3
22.0
16.2
16.2
16.8
24.2
%1 <10 10-15 >15
Ireland 9.4 11.9 13.0 14.4 15.8
McKinsey Clinical Leadership Academy | 4SOURCE: International Diabetes Federation, 2012
Diabetes related deaths Diabetes £ per personDiabetes prevalence
Average = 7.4 %
3.95.65.76.46.67.07.47.57.88.18.28.48.5
9.310.0
Average = 5.4 deaths per 10,000
7.57.2
6.9
4.3
6.56.26.2
4.6
6.05.6
5.0
4.03.9
5.4
2.6
9.2
Average= £ 6.0k
7.77.0
6.66.36.1
9.3
5.95.65.65.4
5.14.2
3.53.3
Diabetes burden across 15 European CountriesEstimated burden of disease
Despite Ireland having low diabetes prevalence and death rates, patient expenditure is still high
McKinsey Clinical Leadership Academy | 5
What patients want – Patient’s Experience of Hospital Services
“Staff nurses, doctors and support workers were efficient, friendly and put my needs first…”
“Being on a waiting list over a year is not acceptable. At 77 years old it is too long to wait.”
“Patients are endlessly asked the same questions and you feel no one consults those notes to avoid asking them again.
“The multi disciplinary team gave me the support and information I required, all administered in a professional and cheerful climate.”
SOURCE: Irish Society for Quality & Safety in Healthcare, 2011
McKinsey Clinical Leadership Academy | 6
The consequences of continuing in a ‘business as usual’ way across the system will be significant
Unless addressed this will lead to an increase in poorly treated and undiagnosed patients who will further reinforce strains across the system
▪ Face reduced access to services,
▪ There is less flexibility in treatment options
Patients
▪ Increased spending on acute services at the expense of social, mental and prevention activities
▪ Disputes with providers may increase,
Payors and health systems
▪ Face major financial challenges
▪ Challenge of delivering more with less
Providers
McKinsey Clinical Leadership Academy | 7
Integrated care can help address these challenges
Goals of integrated care
▪ Provide the best possible quality of care at the minimum necessary costs
▪ Provide better and more pro-active care for a specific group of patients that are most at risk
▪ Empower patients, users and their carers
McKinsey Clinical Leadership Academy | 8
Our research and work across the globe shows that successful integrated care systems require three core building blocks
… by working in a multi-disciplinary system …
… supported by key enablers
Address specific patient needs …Patient cohorts
Clinical protocols and care packages
Care coordination and planning
Performancereview
Case conference
1
2
3
4
Aligned incentives and reimbursement models
Accountability and joint decision-making
Information transparency and decision support
Clinical leadership and team working
Patient engagement
Low risk
Moderate risk
High risk
Very low risk
Very high risk
Success in integrated care
A B
C
McKinsey Clinical Leadership Academy | 9
160x difference in cost!
Total/average
SOURCE: McKinsey team analysis, NHS NWL data; HES 2010/11, FIMS, Q research/NHS Information centre, PSSEX; NHS Reference Costs
4,757
41,675
142,773
322,609
378,020
188
104
186
354
327
39,600
8,700
300
500
2,400
1 Includes elective admissions, outpatient, and A&E 2 Includes community health & primary care
Health spend Social care spend
First, understand the needs of the population you are trying to serve…
Very high
High
Moderate
Low risk
Very low
Very high
High
Moderate
Low risk
Very low
Population
~890,000 1,230 1,168
2010/11 data, 4 London CCGsA
Average cost percapita per annum, £ Total spend, £m
McKinsey Clinical Leadership Academy | 1010
What does a Multi-Disciplinary Team do?
1 Icons are illustrative only: any number of other professionals may be involved in a patient’s care, a case conference or performance review
B
Community pharmacist
Practice nurse
Social care worker
District nurse
GP
Community Mental Health
Patient registry Risk stratification
Care delivery1
Case conference
Performance review
Each MDT holds a register of all patients who are part of the IC programme
The MDT uses an information tool to stratify these patients by risk of emergency admission
Each patient is then given an individual integrated care plan that varies according to risk and need
Patients receive care from a range of providers across settings, with primary care playing the crucial co-ordinating role and everybody using the IC IT tool to coordinate delivery of care
A small number of the most complex patients will be discussed at a multi-disciplinary case conference, which will help plan and coordinate care
The MDT meets regularly to review its performance and decide how it can improve its ways of working to meet its goals
Shared clinical protocolsAll providers in the MDT agree to provide high quality care as laid out in recommended pathways and protocols
Care planning
McKinsey Clinical Leadership Academy | 11
Beyond care delivery, enablers are crucial
SOURCE: McKinsey & Company
▪ CEOs & Boards commitment of resources
▪ Bind in payors, hospitals, primary care and local government
▪ Hold to account for delivery
▪ Support– Patient
records– Clinical
decision making
– Peer pressure
– Payment
▪ Solve Information governance
▪ Role model behaviour
▪ Deliver consistently
▪ Hold peers to account
▪ Work within team
▪ Significant(30%+)
▪ At scale (30%+)
▪ Sustained (3-5 years)
▪ Align risk and reward across system
Governance InformationClinical leadership
Reimbursement& incentives
Patient engagement
▪ Empower patients with informed choice
▪ Make use of behavioural economics
C
… supported by key enablers
McKinsey Clinical Leadership Academy | 12
→ ChenMed: Aims to minimise avoidable hospital admissions through intensive primary care and aligned incentives
SOURCE: Source
Patient experience
▪ ChenMed offers patients regular appointments with their named Primary Care Provider; numbers predetermined by the risk stratification model (min. 1 per month)
▪ ChenMed medical centres are set up to look/feel like a quiet A&E with rapid access for unscheduled appointments available, to reduce patient A&E use
▪ Each centre at capacity – 5 primary care physicians, 10-15 specialists rotating through, 2200+ Medicare patients
▪ Task-shifting is used extensively with trained, but unqualified, health assistants carrying out routine clinical tasks (such as BP monitoring, clinical measurements, administration)
▪ ChenMed aims to offer most services under one roof including primary care, outpatient care, diagnostics, dental care, pharmacy and complementary medicine including acupuncture
How care is organised
Description
CONFIDENTIAL: Not for onward distribution
McKinsey Clinical Leadership Academy | 13
→ Torbay: Integrated health and social care teams are co-located in zones
Note: DN – District Nurse; SW – Social Worker; CCW – Community C.Worker; HSCC – Health and Social Care Co-ordinator; RCO – ReferralCo-ordinators; IC – Intermediate Care Team
SOURCE: Torquay North Health and Social care team
Patients and providers have one number to call
SCLead
Nurse Lead
OT Lead
Front desk
DN team
AdminIC
teamPhysio Lead
GP Triage Desk
HSCC Manager
LeadP.A.
ZoneLead
If a patient comes to A&E and does not require admission to hospital, the acute trust contacts the zone and the Health and Social Care Coordinator contacts various agencies to make sure the patient is able to go home or receive temporary placement if needed
CONFIDENTIAL: Not for onward distribution
McKinsey Clinical Leadership Academy | 1414
Key questions for consideration in the Irish context
▪ What is the appropriate model of primary and community based services in Ireland (Chen Med/Torbay/other)?
▪ Which of the key enablers would be most important in driving change (reimbursement, IT, clinical leadership)?
▪ What will it take to effect this change at scale in this country?