Involving patients and Involving patients and professionals:professionals:

Integrated care as a new way of Integrated care as a new way of managing health servicesmanaging health services

Dr. K. Viktoria SteinInstitute of Social Medicine

Center for Public HealthMedical University Vienna

“Apprehension, uncertainty, waiting, expectation, fear of

surprise, do a patient more harm than any exertion.”

(Florence Nightingale,

1820-1910)

Summarising some factsSummarising some facts

We all know, we are getting We all know, we are getting older, fatter , older, fatter , chronic and/or addictedchronic and/or addicted - until we start to - until we start to forget it all again!forget it all again!

We are constantly reminded of We are constantly reminded of finite finite resources and infinite demandsresources and infinite demands!!

Health care reforms Health care reforms have become a never have become a never ending story in many countries.ending story in many countries.

Nobody is self-sufficient Nobody is self-sufficient - we need to work - we need to work with different professions, specialities and with different professions, specialities and organisations.organisations.

The The patient does have her own opinion patient does have her own opinion and and ultimately makes her own choices about her ultimately makes her own choices about her health, whether we like it or not. So, health, whether we like it or not. So, we need we need to work with them, not only for them.to work with them, not only for them.

In other words...In other words...

Demographic Development – Ageing Demographic Development – Ageing Society/Decreasing PopulationSociety/Decreasing Population

Unsatisfied health and social services professionalsUnsatisfied health and social services professionals Gap between health and social systemsGap between health and social systems Diverging interests of policy makers, professionals and Diverging interests of policy makers, professionals and

health care institutionshealth care institutions Cost containmentCost containment Patient compliance and patient demandsPatient compliance and patient demands Quality assurance and improvementQuality assurance and improvement ICT and medical technology developmentsICT and medical technology developments

Asking the right questions…Asking the right questions…

What do we want from our health and social care What do we want from our health and social care systems?systems?

How do we manage and organise health and social care How do we manage and organise health and social care systems?systems?

o AnalyseAnalyseo Plan and prioritisePlan and prioritiseo CommunicateCommunicateo CooperateCooperateo EvaluateEvaluate

Policy goalsPolicy goals

Adapted from Güntert 2008

Access/Equity

Quality

Patient satisfaction

Effectiveness

Efficiency

Society (Solidarity) Attractiveness

Health Systems EnvironmentHealth Systems Environment

Patient

Insurance

Government Provider

Economic system

Legal system

Culture and Traditions

History

International institutions

Political environment

Adapted from Güntert 2008

Priorities of decision makersPriorities of decision makers

2 levels of priority setting have been identified as highly important for integrated care initiation:

on the policy level, prioritisation of integrated care along with specific promotion measures influence decision making

on the organisational level, the need for clear structures and better management tools both in the organisation itself and in the management of the targeted patient population, reflect the highest priorities for the decision making process.

Stein 2010

……helps finding a solutionhelps finding a solution

„„Integrated care Integrated care is a broader term referring not only to the is a broader term referring not only to the patients‘ perspective patients‘ perspective but also to but also to the technological, the technological, managerial and economic implications of service managerial and economic implications of service

integrationintegration. It is (...) not an end in itself. It should rather . It is (...) not an end in itself. It should rather be understood as a means to improve quality (...) with be understood as a means to improve quality (...) with

the overall aim to the overall aim to improving equitably distributed improving equitably distributed population healthpopulation health.“.“

Gröne/Garcia-Barbero: Trends in Integrated Care. WHO 2002

Country Example: GermanyCountry Example: Germany

Integrated care introduced by law in 2000Integrated care introduced by law in 2000 Health insurers must offer integrated care models to their Health insurers must offer integrated care models to their

clients, primarily Disease Management Programmes (DMPs)clients, primarily Disease Management Programmes (DMPs) Until 12/08 more than 8000 IC contracts, now approx. 5000Until 12/08 more than 8000 IC contracts, now approx. 5000 Models cover all aspects of integrated care, such as DMPs, Models cover all aspects of integrated care, such as DMPs,

health regions, health networks and medical service centershealth regions, health networks and medical service centers Hardly any social services included yet, but a variety of medical-Hardly any social services included yet, but a variety of medical-

technical and medical assistive servicestechnical and medical assistive services http://www.deutsche-gsb.de/herznetz/

Aims and Objectives of ICAims and Objectives of IC

To generate synergies To generate synergies through integrated through integrated processes and standardsprocesses and standards

To improve communication To improve communication and cooperation through and cooperation through multi-disciplinary and cross-multi-disciplinary and cross-sectoral teamssectoral teams

To raise accessibility, quality To raise accessibility, quality and effectiveness through and effectiveness through better coordination within better coordination within and between health and and between health and social care systemssocial care systems

To use ressources effectivelyTo use ressources effectivelyCostsCosts QualityQuality

AccessAccess

Illustration Prof. Rieder, based on Amelung 2006

Forms of Integrated CareForms of Integrated Care

Indication-based Integrated CareIndication-based Integrated Care– Organisation around a diseaseOrganisation around a disease– From prevention to palliative care, or parts of itFrom prevention to palliative care, or parts of it

Population-based Integrated CarePopulation-based Integrated Care– Organisation for a defined community, area or target groupOrganisation for a defined community, area or target group– Comprehensive health and social care servicesComprehensive health and social care services

Medical Services CentresMedical Services Centres– Medical One-Stop-ShopMedical One-Stop-Shop– Often based near or in a hospitalOften based near or in a hospital

...and countless mixed forms...and countless mixed formsWeatherly et.al. BMC 2006

Levels of integrated careLevels of integrated care

Continuum of Integration -Extended model by Ahgren/Axelson:

Full segregation

LinkageCo-

ordination in Networks

Co-operation

Full integration

Ahgren/Axelson 2005, based on Leutz 1999

Different levels of intensity of integration Integration within and between organisations Vertical and horizontal integration The optimal degree of integration depends on the aims

and the evironment of the organisation

Project PRISMAProject PRISMA

Hébert R, Durand PJ, Dubuc N, et.al. PRISMA: a new model of integrated service delivery for the frail older people in Canada. IJIC 2003

Country example: CanadaCountry example: Canada

Partners and Organisations in ICPartners and Organisations in IC

Possible Partners:Possible Partners: Patient organisations, self Patient organisations, self

help groupshelp groups Sickness Funds and health Sickness Funds and health

insurance organisationsinsurance organisations Primary care doctors and Primary care doctors and

group practicesgroup practices HospitalsHospitals Social care service providersSocial care service providers Rehabilitation and LTC Rehabilitation and LTC

facilitiesfacilities PharmaciesPharmacies Community servicesCommunity services TherapistsTherapists

Legal Forms:Legal Forms: ProjectProject AssociationAssociation CooperativeCooperative NetworkNetwork Company LimitedCompany Limited Public ServicePublic Service

Basis should always be a Basis should always be a contractcontract

Health insurance as partner Health insurance as partner advantageousadvantageous

Tools of Integrated CareTools of Integrated Care

Health care networksHealth care networks Case ManagementCase Management Disease ManagementDisease Management GatekeeperGatekeeper Standardised processes, Integrated Care Pathways (e.g. patient Standardised processes, Integrated Care Pathways (e.g. patient

pathways, care pathways, EbM-Guidelines)pathways, care pathways, EbM-Guidelines) Institutionalised communication platforms (e.g. network Institutionalised communication platforms (e.g. network

conferences, patient conferences, case studies)conferences, patient conferences, case studies) Regular patient and actors surveysRegular patient and actors surveys Quality management and controllingQuality management and controlling Compatible ICT structuresCompatible ICT structures

Country example: CroatiaCountry example: Croatia

Croatian Primary PCI Network: Initiated by the Croatian Cardiac Society in 2006 Integrated indication-based care for myocardial infarction (MI) Financed by health insurance and local funds National initiative with management based on county level Partners:

primary care doctors, cardiologists, specialised nurses, health insurance, mobile care services, local authorities

What are patient preferences?What are patient preferences?

For a long time, the patient was considered a passive object who had neither the skills nor the knowledge to participate in the decision making process about her health.

This viewpoint ignored the many facets and aspects, which influence our health and have nothing to do with medical care.

Decisions about education, hygiene, nutrition and life style choices such as smoking or sports activities all are made by the individual - at least to a great extent - and all influence the health status significantly.

What are patient preferences?What are patient preferences?

Still lacks a consistent definition. Statements made by individuals regarding their needs, values

and expectations and the relative importance of treatment properties.

Refer to the individual evaluation of dimensions of health outcomes.

Collecting patient preferences enables the definition of patient-centred outcomes.

These provide objective information about the impact on patient involvement, the experiences, and the needs and wants of patients.

Mühlbacher/Bethge, IJIC 2009

Say/Thomson, BMJ 2003

The core strategies (1)The core strategies (1)

Health literacyensures that patients are provided with information through adequate channels, from brochures to public campaigns, in a comprehensible language.

Coulter et al. 2008

Treatment decision makingreflects the notion of shared decision making concerning therapies and treatment alternatives; not every patient wants to be actively involved but many see a lack of information and respect for their opinion as the most frustrating aspect of health care.

Coulter et al. 2008

The core strategies (2)The core strategies (2)

Self-management of chronic diseasesassists patients in leading a fulfilled and quality life by enabling them to handle their chronic condition as independently as possible – saving lives and resources.

Coulter et al. 2008

The core strategies (3)The core strategies (3)

Design of instrumentsDesign of instruments

All of these measures have to be designed culturally and target group sensitive as a prerequisite for successful implementation and acceptance by the patients.

Sufficient evidence to support the fact that improved patient involvement and empowerment lead to better health outcomes and a reduction of health inequalities.

Coulter et al. 2008

RestrictionsRestrictions

Education Language Access to care Access to information Lack of “enabled professionals”

Coulter et al. 2008

Say/Thompson BMJ 2003

How to measure patient preferences?How to measure patient preferences?

1. Conjoint analysis derived from market research multivariate statistical method patients evaluate set products which are composed of

subcategories of independent characteristics comparing the values enables reseachers to determine the

patient preferences

Mühlbacher/Bethge, IJIC 2009

How to measure patient preferences?How to measure patient preferences?

2. Discrete Choice Experiment (DCE) tool to elicit qualitative preferences and to quantify the value of

preferences A good or service can be described by its attributes The attributes are combined to produce hypothetical scenarios Respondents are presented with paired hypothetical scenarios

and asked to select a preferred option Logistic regression techniques used to analyse responses e.g.

Stata 10; shows the relative importance of influencing attribute

Mühlbacher/Bethge, IJIC 2009

Mühlbacher 2009

Example: ADHD therapyExample: ADHD therapy

Centering on the patient...Centering on the patient...

is the key concept of every integrated care model extensive patient information with trainings, brochures, regular

updates and target agreement encouragement of patient self management involvement and active participation of patients in the

organisation of their therapies and programmes Patient incentives (e.g. bonuses, free additional services) still

discussed controversely Does compliance and adherence really increase?

Key Factors for SuccessKey Factors for Success

Consistent COMMUNICATION Marketing measures, comprehensive information Adherance to pre-defined guidelines and standards Clear structure and responsibilities Formulation of aims and objectives On-going Evaluation ICT solutions Scientific monitoring Regular surveys Quality management

Core elements of ICCore elements of IC

Effectiveness of care is influenced by three interacting elements:

Ahgren IJIC (4) 2003

Evaluating Integrated CareEvaluating Integrated Care

based on Vondeling, IJIC 2003

There are still few scientifically sound evaluation studies on the effects of IC

The problem often being the comprehensiveness of Integrated Care and lack of data

Significant cost effectiveness results in successful projects Doctor‘s are still reluctant in many countries Some concepts used:

Cost-effectivenss and cost-utility analysesSystems theoryTheories of innovation, information and change

based on Vondeling, IJIC 2003

Type of studyType of study Valuation of costs Valuation of costs in both in both alternativesalternatives

Identification of Identification of consequencesconsequences

Measurement/Measurement/valuation of valuation of consequencesconsequences

Cost analysisCost analysis Monetary unitsMonetary units NoneNone NoneNone

Cost Cost effectiveness effectiveness analysisanalysis

Monetary unitsMonetary units Single effect of Single effect of interest, common to interest, common to both alternatives, but both alternatives, but achieved to different achieved to different degreesdegrees

Natural units (e.g. Natural units (e.g. DALYs, life-years DALYs, life-years gained, points of gained, points of blood pressure blood pressure reduction, etc.)reduction, etc.)

Cost utility Cost utility analysisanalysis

Monetary unitsMonetary units Single or multiple Single or multiple effects, not effects, not necessarily common necessarily common to both alternativesto both alternatives

Healthy years Healthy years (typically measured (typically measured as QALYs or HYEs)as QALYs or HYEs)

Cost benefit Cost benefit analysisanalysis

Monetary unitsMonetary units Single or multiple Single or multiple effects, not effects, not necessarily common necessarily common to both alternativesto both alternatives

Monetary unitsMonetary units

Evaluating Integrated CareEvaluating Integrated Care

Country Example: UK - NICECountry Example: UK - NICE

National Institute for Health and Clinical Excellence independent organisation commissioned to develop guidelines (clinical, health care,

patient), collect evidence, evaluate health outcomes and set priorities

one of the leading evaluation bodies worldwide uses QALYs to determine threshold for funding of health

services

Expert Questionnaire - ResultsExpert Questionnaire - Results5 most and least important items for the initiation of integrated care.5 most and least important items for the initiation of integrated care.

ItemItem MeanMean SDSD

1. Priority setting/Policy goals of decision makers supported integrated care1. Priority setting/Policy goals of decision makers supported integrated care 8,218,21 1,7191,719

2. Support of stakeholders (e.g. government, insurance, care providers) for 2. Support of stakeholders (e.g. government, insurance, care providers) for integrated careintegrated care 7,867,86 2,1712,171

3. Dysfunctional system boundaries cause fragmentation3. Dysfunctional system boundaries cause fragmentation 7,797,79 2,3492,349

4. A clear and accepted project/programme structure4. A clear and accepted project/programme structure 7,787,78 2,5642,564

5. Complexity of management of disease/targeted population5. Complexity of management of disease/targeted population 7,737,73 2,0712,071

30. Incentives for patients to join the integrated care project/programme30. Incentives for patients to join the integrated care project/programme 4,984,98 3,0733,073

31. Lack of job satisfaction of the health professionals involved in standard care31. Lack of job satisfaction of the health professionals involved in standard care 4,814,81 2,7482,748

32. Heterogeneity of patients/targeted population (e.g. age range, level of disability)32. Heterogeneity of patients/targeted population (e.g. age range, level of disability) 4,624,62 2,6832,683

33. Unresolved legal aspects for patients care (i.e. shared responsibilities of care 33. Unresolved legal aspects for patients care (i.e. shared responsibilities of care providers)providers) 4,394,39 2,5862,586

34. Focal points/Programmes of international institutions (e.g. EU, WHO) exist for 34. Focal points/Programmes of international institutions (e.g. EU, WHO) exist for integrated careintegrated care

3,673,67 2,5502,550

Stein 2010

ChallengesChallenges

How to initiate integrated care in practice?

Find promoters of integrated care! The focal point should be the autonomy of the patient and how

care can be organised according to her needs. Identification of „missing care“ and needs of actors is key –

status quo analysis. Formulation of aims, objectives and strategy. Training of professionals in team work and management. Allocation of adequate time and resources to the project. There is no one best model!

In SummaryIn Summary

„„An integrated and multidisciplinary approach is An integrated and multidisciplinary approach is necessary to achieve a health care supply chain necessary to achieve a health care supply chain connecting with the needs and demands of the connecting with the needs and demands of the

patient. [...] In the futurepatient. [...] In the future, primary care and care at , primary care and care at home will be the standard home will be the standard and and multidisciplinary multidisciplinary

cooperation will be the key cooperation will be the key to a more patient to a more patient oriented approach.“oriented approach.“

Van Oosterbos, IJIC (2) 2006

www.integratedcare.euwww.integratedcare.eu

www.ijic.orgwww.ijic.org

www.nice.org.ukwww.nice.org.uk

Some useful linksSome useful links

katharina.v.stein@meduniwien.ac.atkatharina.v.stein@meduniwien.ac.at

Thank you and have fun integrating!Thank you and have fun integrating!