Integrated Health Care: Challenges and Progress Around the World - - PowerPoint PPT Presentation

Integrated Health Care: Challenges and Progress Around the World

Hernan Montenegro, MD, MPH Health Systems Adviser Health Systems and Innovation Cluster

Outline of presentation

The challenges:

– Population & clinical – Health system: fragmentation of care

Integrated health care: conceptual issues Integrated health care: country experiences and lessons learned (Americas & Europe) Integrated health care: WHO response

Ageing society = greater demand for 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

1000 750 250

1

9

5

9 admitted to District Hospitals 5 referred to other doctor 1 went to tertiary

Ecology of care in a typical month for a population of 1000 (USA & UK)

Kerr White, NEJM, 1961

(PAHO, 2011)

Challenges from the fragmentation of health services

• People’s experience with the system:
• Lack of access to health care
• Loss of continuity of care
• Services that do not conform to users’ needs
• System’s overall performance:
• Lack of coordination among the different health

care levels and settings

• Duplication of services and infrastructure
• Health care provided at the least appropriate

setting, particularly at the hospital level

Causes of fragmentation

• Institutional segmentation of the health system
• Decentralization that fragments the levels of care
• A predominance of vertical programs
• The extreme separation of public health services from

personal health services

• A model of care centered on disease, acute and hospital

care

• Weakness of the health authority’s steering capacity
• Problems with resources
• Multiplicity of paying entities
• Cultural norms and conducts
• Legal and administrative barriers
• Financial practices from some international

cooperating/donor agencies

(PAHO, 2011)

Fragmentation of Health Services

Tertiary Level Secondary Level Primary Level

Social Security

Private- high complexity

MPH

Occupational Hazards

Traditional Medicine Private- low complexity NGOs

Municipalities Universities

HIV/AIDS Malaria-VBD Maternal and Child Health

(PAHO, 2011)

WVL | 14 September 2007

3 |

Model of Care: Continuity of Care

3.1.1 Are patients seen by the same provider (doctor/ health team) whenever they consult? 3.1.2 Is there an appointment and follow-up system, including arranging home visits by the health team? 3.1.3 Is assigning people from a geographical area to lists or registries with a specific PHC provider or provider group encouraged? 3.1.4 Does a good referral and counter-referral system based on case complexity normally function for patients? 3.1.5 Is there a policy that enables ensuring that PHC facilities are regularly covered by physicians or nurses?

10 20 30 40 50 3.1.1 3.1.2 3.1.3 3.1.4 3.1.5

Never Almost never Sometimes Usually Always

% Section I.3: PHC Model of Care: Continuity of Care 3.1 Respondents Responses, in Percent

(PAHO, 2011)

51% 49%

Primary care Non-primary care

% of hospitalized patients according to most appropriate site of care

PAHO, 2004

Division of Health Systems and Public Health

18th June, 2013

Challenge #2 overcoming persisting health system bottlenecks – e.g. information flows

Source: Hofmarcher et al., OECD 2007 92 31 42 46 69 8 65 58 50 31 20 40 60 80 100

There is poor transfer of information between providers leading to, for example, duplication of tests etc. Information on the quality of service delivery is regularly disseminated among providers Providers and payers are equipped with IT so as to encourage communication of patient information amongst themselves A patients file in electronic format exists and contains medical information about the patient Information on medical records and patient needs is routinely transmitted between providers In percent of all countries responding (N=26)

Often Seldom

Hardly debated Debated

Division of Health Systems and Public Health

18th June, 2013

Challenge #2 overcoming persisting health system bottlenecks – e.g. aligning incentives

Source: Hofmarcher et al., OECD 2007 15 12 8 31 15 8 62 69 88 58 73 85

20 40 60 80 100 Contractual arrangements to provide care target the promotion of cooperation among providers as an explicit objective Arrangements to provide and pay for care include stipulations regarding quality goals Payers selectively contract with providers on the basis of the capacity to coordinate care or to provide coordinated care Primary care physicians receive incentive payments Ambulatoy-care specialists or hospitals receive incentive payments Care coordinators receive a budget

In percent of all countries responding (N=26) Often Seldom

Pressure for Change on Health Services Changes in demand Changes in supply Broad social changes

Demographics Epidemiology The public’s expectations

Health Services

Technology and knowledge Workforce Financial pressure Globalization Government reforms

Adapted from Mc Kee, M.; Healy, J. 2002

Sectoral reforms

Levels of Health Service Organization and Management

Level Examples

Individual, family, and community Self-care, home care, etc. Individual provider Physician, nurse, auxiliary, social worker, nutritionist, etc. Health team Multidisciplinary team at first level of care, surgical team, etc. Department/service Obstetrics/gynecology, pathological anatomy, blood laboratory, etc. Individual health facility Hospitals, health centers, etc. Service network Health facilities, medical specialties and subspecialties, etc. System National, regional, subregional

Concepts

Concept Definition Source Integrated Health Services The management and delivery of health services such that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease-management, rehabilitation and palliative care services, through the different levels and sites of care within the health system, and according to their needs throughout the life course. Modified WHO, 2008 Continuity of care The degree to which a series of discrete health care events are experienced by people as coherent and interconnected over time, and are consistent with their health needs and preferences. Modified JL Haggerty et al., 2003 Integrated Health Services Delivery Networks (IHSDNs) “a network of organizations that provides, or makes arrangements to provide, equitable, comprehensive, integrated and continuous health services to a defined population and is willing to be held accountable for its clinical and economic

• utcomes and the health status of the population

served.” Modified SM Shortell et al., 1993

“Integrated Health Services”: Related Concepts

• Horizontal integration
• Vertical integration
• Breadth of integration
• Depth of integration
• Geographic concentration
• Clinical integration
• Health worker– system integration
• Functional integration
• Real integration
• Virtual integration
• Continuity of care

Autonomy, Coordination, and Integration in Health Services

Autonomy Coordination Integration Health information Circulates mainly w ithin a group of the same partners Circulates actively among groups of different partners Orients different partners’ w ork to meet agreed-upon needs Vision of the system Influenced by each partner’s perception and possibly self- interest Based on a shared commitment to improve the overall performance

• f the system

A common reference value, making every partner feel more socially accountable Use of resources Essentially to meet self-determined

• bjectives

Often to ensure complementary and mutual reinforcement Used according to a common framew ork for planning, organization, and assessment activities Decision- making Independent coexistence of decision-making modes Consultative process in decision-making Partners delegate some authority to a unique decision mode Nature of partnership Each group has its rules and may

• ccasionally seek

partnership Cooperative ventures exist for time-limited projects Institutionalized partnership is supported by mission statements and/or legislation

Source: World Health Organization (2000). Towards unity for health: challenges and opportunities for partnership in health development: a working paper. Geneva: WHO.

Main benefits of IHSDNs

• People’s experience with the system:

– Facilitate timely access to services at the first level of care – Improve access to other levels of care when required – Prevent duplication/unnecessary repetition of history-taking diagnostic procedures, and bureaucracy – Improve clinical effectiveness – Improve shared decision-making processes between the provider and the patient – Facilitate the implementation of self-care strategies and chronic disease monitoring

• System’s overall performance:

– Improve the accessibility of the system – Reduce the fragmentation of care – Improve overall system efficiency – Prevent duplication of infrastructure and services – Reduce production costs – Respond more effectively to people’s needs and expectations

(PAHO, 2011)

Some initiatives of integration in LAC

Country Initiative

Argentina Ley de Creación del Sistema Federal Integrado de Salud Law creating the Integrated Federal Health System Bolivia Redes públicas descentralizadas y comunitarias de salud Municipal Intercultural Family and Community Health Network and Network of Services Brasil Más Salud: Derecho de Todos 2008-2011 Better Health: The Right of All 2008-2011 Chile Redes asistenciales basadas en la atención primaria Health care networks based on primary care El Salvador Ley de creación del Sistema Nacional de Salud Law creating the national health system Guatemala Modelo coordinado de atención en salud Coordinated health care model México Integración funcional del sistema de salud Functional integration of the health system Perú Lineamientos para la conformación de redes Guidelines for forming networks República Dominicana Modelo de red de los servicios regionales de salud Model of regional health services network Trinidad and Tobago Experiencia de la Autoridad de Salud de la Región del Este Experience of the Eastern Regional Health Authority Uruguay Sistema Nacional Integrado de Salud Integrated National Health System Venezuela Red de salud del Distrito Metropolitano de Caracas Health network of the Metropolitan District of Caracas

Experiences: Initiatives towards CIHSD across the WHO European Region

Integrated treatment for HIV, tuberculosis and drug dependence

(Ukraine, integrated care programmes introduced mid-2000s)

Using innovative technology towards the integration of care

(Estonia, eHealthFoundation, 2009 launch)

Coordinating the health workforce through integrated care contracts

Germany, Techniker Krankenkasse, 2012)

Aligning financial incentives across services and settings

• f care

(Hungary, Virtual Fund Holding Experiment, 1999-2006)

Prioritizing people-centred services and equitable care

(Israel, Calit Health Services, 2013)

The designations employed and the presentation of this material do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries

HOSPITAL CENTRO SALUD PUESTO SALUD

• CONSUL. COMUNAL

PROYECTO MODERNIZACION ELABORADO POR READECUACION MODELO ATENCION

SIMBOLOGIA

PS Porvenir PS El Amparo PS San Jorge PS Isla Chica CS Los Chiles

• Hosp. Los Chiles

PS Caño Negro

SERVICIOS DE SALUD LOS CHI LES, ANTES DE 1995

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LOS CHILES MEDIO QUESO

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Case of Chile

Efforts T

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Services In The English-Speaking Caribbean

"Shared Services"

27

Division of Health Systems and Public Health

18th June, 2013

Challenge #1 scaling up location/disease specific initiatives

Eastern Lithuanian Cardiology Project Drivers for change in early 2000s

• Uneven distribution of specialists
• Overuse of central facilities
• Lack of coordination across settings
• Poor health outcomes

Outcomes of initiative

• 10-20% reduction in myocardial infarction

mortality at regional hospitals

• Reduced wait times (2-4 weeks to 0-1)

Challenges: Leadership and managerial capacity in other regions; compatibility of national payment scheme following reforms

Lessons Learnt

• Integration processes are difficult, complex and

very long term

• Integration processes require extensive

systemic changes and specific interventions are insufficient

• Integration processes require a commitment by

health care workers, health service managers and policymakers

• Integration of services does not mean that

everything has to be integrated into a single modality; multiple modalities and degrees of integration can coexist within a single system

Barriers & facilitators of HSDNs

(PAHO, 2011)

Barriers Facilitators

1. Institutional segmentation and weakness of the health system, including a weak steering role 2. Sectoral reforms of the eighties and nineties (privatization of health insurance; health service portfolios that are differentiated across different insurers; competition among providers for resources; proliferation of contracting mechanisms; lack of job security for health workers; and regressive cost recovery schemes) 3. High-power groups with competing interests (specialists and ultra specialists; insurers; drug industry, medical supply industry, etc.) 4. External financing modalities that privilege vertical programs 5. Deficiencies in the information, monitoring and evaluation systems 6. Weaknesses in system management 1. High-level political commitment and backing for the development of IHSDN 2. Availability of financial resources 3. Leadership of the health authority and service managers 4. Deconcentration and flexible local management 5. Financial and non-financial incentives aligned with the development of IHSDN 6. Culture of collaboration and teamwork 7. Active participation of all interested parties 8. Results-based management

(PAHO, 2011)

Public Policy Instruments

• Regulatory
• Direct service

delivery

• Capacity-building in
• thers
• Taxes and fees
• Expenditure and

subsidies

• Information and

exhortation

+ Coercive > Government intervention + incentives Voluntary

Key attributes of IHCDNs (PAHO, 2011)

Intervention Attributes Examples

Model of care

• 1. Population & territory

Assigned population

• 2. Wide range of health facilities &

services Comprehensive portfolio of services

• 3. First contact

Gatekeeper and coordinating function

• 4. Appropriate use of specialized

care Hospital reengineering, home care, hospices

• 5. Clinical care coordinating mxs

Clinical practice guidelines

• 6. People-centered care

Gender & cultural sensitive care Governance & strategy

• 7. Single governance system

Shared planning & performance eva.

• 8. Participation

User representatives at boards

• 9. Intersectoral action

Social service assistance Organization & management

• 10. Integrated support systems

Centralized clinical laboratories

• 11. Adequate human resources

Multidisciplinary health teams

• 12. Integrated information system

Single electronic medical record

• 13. Results-based management

Compensation tied to performance Financing

• 14. Adequate financial incentives

Per-capita payment adjusted by risk

Meeting the Challenge at a Systems and Organisational Level

1. Find common cause 2. Develop shared narrative 3. Create persuasive vision 4. Establish shared leadership 5. Understand new ways of working 6. Targeting 7. Bottom‐up & top‐down 8. Pool resources 9. Innovate in finance and contracting

• 10. Recognise ‘no one model’
• 11. Empower users
• 12. Shared information and ICT
• 13. Workforce and skill‐mix changes
• 14. Specific measurable objectives
• 15. Be realistic, especially costs
• 16. Coherent change management strategy

Meeting the Challenge at a Clinical, Service and Personal Level

No ‘best approach’, but several key lessons and marker for success that include all the following:

• Community awareness, participation

and trust

• Population health planning
• Identification of people in need of care

– inclusion criteria

• Health promotion
• Single point of access
• Single, holistic, care assessment

(including carer & family)

• Care planning driven by needs and

choices of service user/carer

• Dedicated care co‐ordinator and/or

case manager

• Supported self‐care
• Responsive provider network available

24/7

• Focus on care transitions, e.g. hospital

to home

• Communication between care

professionals, and between care professionals and users

• Access to shared care records
• Commitment to measuring and

responding to people’s experiences and

• utcomes
• Quality improvement process

Source: Nick Goodwin, 2013

Division of Health Systems and Public Health

18th June, 2013

Background: The new European health policy – Health 2020

People enabled and supported in achieving their full health potential and well-being

Investing in health throughout the life course Tackling health challenge s Strength ening health systems Creating supportive enviro- nment

Better governance for health Reducing inequalities Adding value through partnerships

Division of Health Systems and Public Health

18th June, 2013

Towards people-centred health systems: an operational approach to health systems strengthening

Expec ted Results

Improved health level and equity Maternal and child health

• utcomes

Cardiovascul ar health

• utcomes

Tuberculosis Etc..

Core Services

Continuity of people- centred services

EPHO3 Health protection EPHO4 Health promotion EPHO5 Disease prevention Diagnosis Treatment Rehab & palliative care

Removal of health system bottlenecks

Initiatives towards more CIHSD

Population and individual level service delivery

Governance Health financing Resource generation (human

resources and technology

Etc… Information systems Decision supports Delivery system design

Source: Adapted from WHO Regional Office for Europe, 2013

Division of Health Systems and Public Health

18th June, 2013

Response: support to Member States on health services delivery to date

Division of Health Systems and Public Health

18th June, 2013

A further response: the Framework for Action towards CIHSD in the WHO European Region

A common platform to accelerate the exchange of experiences and how-to policy

• ptions towards the delivery of coordinated/integrated people-centred services

Knowledge Synthesis Field Evidence

Policy Options

Conceptual approach to the coordinate/integrated health services delivery Field evidence on country experiences towards the CIHSD

Consultation process with Member States Framework for Action towards CIHSD

(1) Analytical framework (2) Field evidence (3) Guidelines for change management

Country Support