2º world congress on integrated care … · sydney . 23-25 november 2014 ... bilbao . spain rafael...
TRANSCRIPT
Sydney . 23-25 November 2014
ACHIEVING TRANSFORMATIONAL CHANGE SOME “INSIGHTS” FROM THE POLITICAL LEADERSHIP OF HEALTH
SYSTEMS
RAFAEL BENGOA DBS HEALTH . University of Deusto. BILBAO . SPAIN
2º WORLD CONGRESS ON INTEGRATED CARE
• GETTING BEYOND FRAGMENTATION • TARGETTING BETTER CHRONIC CONDITIONS MANAGEMENT • IMPROVE PATIENT-CENTEREDNESS & EMPOWERMENT
• ENSURING A BROADER POPULATION PERSPECTIVE.
• BETTER BALANCE BETWEEN ILLNESS & HEALTH CULTURES
• CHANGING PAYMENT SCHEMMES TO ENCOURAGE VALUE VERSUS ACTIVITY…
Have a common problem ; Some common aims Have precision medicine Got “precision management” - Frameworks - Tools Patient is saying provide me with continuity of care Have some positive results why is it so difficult to pull this off ? Is there enough policy push and pull on this agenda ?
Precision Medicine
WE HAVE “SYSTEM” FRAMEWORKS
WE HAVE THE TOOLS …..
Basque OSABIDE GLOBAL:
ELECTRONIC MEDICAL RECORD . EMR
STRUCTURES COMMUNITY SYSTEM
• Mental map Structures
• Fragmentation
• Reactive episodic care
• Paternalistis
• vertical leadership
• Financing structures
• PATIENT CENTERED.
• Continuity of care
• Proactive system
• Patient empowerment
• Decentralized leadership
• Paying for value
• Health & social care coordination
Vs. PATIENT
T MOVING TO “SYSTEM” MANAGEMENT
Some Positive RESULTS Community based service changes provide benefits in : - Improved outcomes - Patient satisfaction - Patient safety - Increased use of care plans - New roles for staff - Ambiguous results at reducing costs
11
Bedday rate for patients aged 75+,
emergency admissions
4000
4500
5000
5500
6000
6500
Mar-06
Mar-07
Mar-08
Mar-09
Mar-10
Mar-11
Year ending
Bed
day
rat
e p
er 1
000
aged
75+
Borders
Lothian
Board
averageHighland
Ayrshire &
ArranTayside
Sept-11
Re-shaping Care
Prog/LTC Prog
Evidence of Impact – Bed day rate for patients aged 75+ (emergency admissions)
550 Beds
SCOTLAND D. Feeley
BILBAO INTEGRATED AREA (TELBIL PROJECT)
Telemonitoring of home-based chronic patients with COPD and HF
• Reduction in admisssions : 27%
• 2,5 days shorter stay in every admission (9,6 versus 12,2 days)
• Punctuation in funcional scale: better in intervention group
• Satisfaccion rate : 81% patients very satisfied
• 77% of patients refers better control of their illness
13
USA : Integrated cardiovascular care…
...is leading to reductions in heart attacks and strokes.
17
1,0
1,1
1,2
1,3
1,4
1,5
1,6
1,7
1,8
1,9
2,0
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
Stoke-related Hospitalization
Rates in No. Cal. 1998-2007
ST Elevated MIs in No. Cal. 1998-2007
0,4
0,6
0,8
1,0
1,2
1,4
1,6
1,8
2,0
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
Age
an
d s
ex a
dju
ste
d r
ate
pe
r 1
,00
0
Age
an
d s
ex a
dju
ste
d r
ate
pe
r 1
,00
0
KP Northern California ALL program, PHASE, results.
SUFFICIENT POLICY PUSH AND PULL?
DIFFERENT SYSTEMS BUT SAME ACKNOWLEDGEMENTS
• Present health care ¨systems¨ are not systems
• Business as usual will not create the required organisation of the future
• Complex change therefore need to take the issue up to the policy
level
• Complex change therefore need to have an implementation plan
SENIOR LEADERSHIP MANAGED 2 AGENDAS SIMULTANEOUSLY
• “RESIST” CULTURE
• TOUGH BUT DOES NOT CHANGE STATUS QUO
• TRANSFORMATIVE CULTURE
• TOUGH BUT DOES CHANGE STATUS QUO
18
“ONLY DISRUPTIVE INNOVATIONS HAVE THE POTENTIAL TO MAKE
HEALTH CARE MORE AFFORDABLE AND ACCESSIBLE ”
C. CHRISTENSEN
SENIOR LEADERSHIP WAS “DISRUPTIVE”. POSITIVE DISRUPTION. “The home is the hub“ “ New payment mechanisms: Paying for value” DON T USE YOUR CAPITAL FOR NEGATIVE DISRUPTION
Senior leadership packaged and communicated extensively the Reasons for Change.
Much broader consultation processes… Support of Unions…
20
SENIOR LEADERSHIP PROVIDED A “ VISION”
AT THE POLICY LEVEL….
• IN MANY ORGANIZATIONS THE LIMBS ARE MOVING BUT THERE IS NO HEAD; NO VISION. NO COHESIVE STRATEGY • COORDINATED/INETEGRATED CARE PROVIDES THAT VISION
• PROVIDES A NARRATIVE THAT GOES BEYOND “COST CONTAINMENT” • NEED TO ELEVATE THE ISSUE TO THE POLICY LEVEL
R. Bengoa
Senior leadership sought a better balance of push & pull strategies…..
- Some level of “orquestration” from above but seeking to identify
commitment rather than compliance - Key element of the “orquestration” is from the payment reforms ( value) rather than from micromanagement of providers. - Distributed leadership is more frequent
22
R.BENGOA/J. MORA
Senior leadership used many levers ….
TOP- DOWN STANDARIZABLE INTERVENTIONS
CALL CENTER
ELECTRONIC
MEDICAL
RECORD
FINANCING AND
JOINT COMMISSIONING
ELECTRONIC
PRESCRIPTION
STRATIFICATIÓN
CASE
NURSING PACIENT
EMPOWERMENT HEALTH AND SOCIAL CARE
COORDINATION
SUBACUTE
CENTRES
INTEGRATED
CARE
BOTTOM UP LOCAL INNOVATION
SCALABILITY
Senior leadership developed a “high involvement culture” with health care professionals.
• More bottom-up participatory process helps to enforce continuity of projects and get beyond political cycles
• These “high involvement cultures” require an environment where local providers can innovate organisationally.
24 NHS Staff Management and Health Service Quality West and Dawson
Staff Engagement
Senior leadership sought early wins in order to sustain progress.
EARLY WINS YES BUT NOT “YOUR” EARLY WINS.
RATHER ENCOURAGE THEM TO BE LOCAL. ALLOW MODELS WHICH PERMIT LOCAL ORGANIZATIONS TO RETAIN SOME OF THE EFFICIENCIES FOUND. THIS WILL GIVE THOSE WINS SUSTAINIBILTY OVER TIME
SCOTLAND
27
R. BENGOA/J. MORA
BASQUE COUNTRY …
TOP- DOWN
STANDARIZABLE INTERVENTIONS CALL
CENTER
ELECTRONIC
MEDICAL
RECORD
FINANCING AND
JOINT
COMMISSIONING
ELECTRONIC
PRESCRIPTION STRATIFICATIÓN
CASE
NURSING PACIENT
EMPOWERMENT
HEALTH AND
SOCIAL CARE
COORDINATION
SUBACUTE
CENTRES
INTEGRATED
CARE
BOTTOM UP
LOCAL INNOVATION
POPULATION
HEALTH MEDICINE
EFFICIENCY
TRIPLE
AIM
Institute of Health Improvement Framework for Implementation
29
ADDRESS SCALABILITY
• MAKE IT POLICY
• MOVE MANY LEVERS
• NEW PAYMENT SCHEMES WIL GALVANIZE CHANGE
• EFFICIENCY DRIVE: SHARED SAVINGS
ARRANGEMENTS WILL BRING MORE PROFESSIONALS
OIN BOARD
• PILOTS YES & GENERALIZE
• BUT ALSO SEEK SCALABITY FROM SELF DISCOVERY :
UNLOCK THE BENEFITS OF LOCAL HEALTH CARE
INNOVATION
“Make no little plans .
They have no magic to stir men´s blood and probably will not themselves be realized ”
Daniel H.Burnham, architect and town planner of cities, “Closing in 1911-1912”.
