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

Ecology of care in a typical month for a population of 1000 (USA & UK) 1000 9 admitted to District Hospitals 5 referred to other doctor 750 1 went to tertiary Kerr White, NEJM, 1961 250 9 5 1

(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 Universities Tertiary Level Private- high Maternal and Child Health complexity Social Security HIV/AIDS MPH Occupational Secondary Level Hazards Malaria-VBD Primary Level Traditional Private- low Medicine complexity Municipalities NGOs (PAHO, 2011)

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Model of Care: Continuity of Care Section I.3: PHC Model of Care: Continuity of Care % 3.1 Respondents Responses, in Percent 50 40 30 20 10 0 3.1.1 3.1.2 3.1.3 3.1.4 3.1.5 Never Almost never Sometimes Usually Always 3.1.1 Are patients seen by the same provider (doctor/ 3.1.4 Does a good referral and counter-referral health team) whenever they consult? system based on case complexity normally function for patients? 3.1.2 Is there an appointment and follow-up system, including arranging home visits by the health team? 3.1.5 Is there a policy that enables ensuring that PHC facilities are regularly covered by physicians or 3.1.3 Is assigning people from a geographical area to nurses? lists or registries with a specific PHC provider or (PAHO, 2011) provider group encouraged?

% of hospitalized patients according to most appropriate site of care 51% 49% Primary care Non-primary care PAHO, 2004

Challenge #2 overcoming persisting health system bottlenecks – e.g. information flows Debated 100 92 Often Seldom In percent of all countries responding (N=26) 80 69 65 58 60 50 46 42 40 31 31 Hardly 20 debated 8 0 There is poor transfer of Information on the quality of Providers and payers are A patients file in electronic Information on medical records information between providers service delivery is regularly equipped with IT so as to format exists and contains and patient needs is routinely leading to, for example, disseminated among providers encourage communication of medical information about the transmitted between providers duplication of tests etc. patient information amongst patient themselves Source: Hofmarcher et al., OECD 2007 Division of Health Systems and Public Health 18th June, 2013

Challenge #2 overcoming persisting health system bottlenecks – e.g. aligning incentives 100 In percent of all countries responding (N=26) 88 85 Often Seldom 80 73 69 62 58 60 40 31 20 15 15 12 8 8 0 Contractual Arrangements to Payers selectively Primary care Ambulatoy-care Care coordinators arrangements to provide and pay for contract with physicians receive specialists or receive a budget provide care target care include providers on the incentive payments hospitals receive the promotion of stipulations regarding basis of the capacity incentive payments cooperation among quality goals to coordinate care or providers as an to provide explicit objective coordinated care Source: Hofmarcher et al., OECD 2007 Division of Health Systems and Public Health 18th June, 2013

Pressure for Change on Health Services Changes in Changes in Broad social supply demand changes Globalization Technology and Demographics knowledge Epidemiology Government reforms Workforce The public’s Financial pressure Sectoral reforms expectations Health Services Adapted from Mc Kee, M.; Healy, J. 2002

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. Hospitals, health centers, etc. Individual health facility Service network Health facilities, medical specialties and subspecialties, etc. System National, regional, subregional

Concepts Concept Definition Source Integrated The management and delivery of health services Modified Health Services such that people receive a continuum of health WHO, 2008 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. Continuity of The degree to which a series of discrete health Modified JL care care events are experienced by people as Haggerty et coherent and interconnected over time, and are al., 2003 consistent with their health needs and preferences. Integrated “a network of organizations that provides, or makes Modified Health Services arrangements to provide, equitable, SM Shortell Delivery comprehensive, integrated and continuous health et al., 1993 Networks services to a defined population and is willing to be (IHSDNs) held accountable for its clinical and economic outcomes and the health status of the population served.”

“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 Circulates mainly Orients different partners’ Health Circulates actively w ithin a group of the w ork to meet agreed-upon information among groups of same partners needs different partners Vision of Influenced by each Based on a shared A common reference partner’s perception commitment to improve the system value, making every and possibly self- the overall performance partner feel more socially interest of the system accountable Use of Essentially to meet Often to ensure Used according to a resources self-determined complementary and common framew ork for objectives mutual reinforcement planning, organization, and assessment activities Decision- Independent Partners delegate some Consultative process in making authority to a unique coexistence of decision-making decision mode decision-making modes Cooperative ventures Institutionalized Nature of Each group has its exist for time-limited partnership is supported partnership rules and may projects occasionally seek by mission statements partnership 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.