Integrated Health Service Delivery Networks(IHSDNs)

Dr Malhi ChoAdvisor HSS

Venezuela, Aruba, Curazao, Sint Maarten and Netherland Caribbean

Islands

June 3rd 2015

Overview• Two visions of Health Systems

• The crisis of the current Health Care System

• IHSDNs (The response) o Integrated People Centered Care o Building an IHSDNs

• Systems Thinking for Health Systems Strengthening

Health System Bio-Medical Model PHC – Based System

VALUESHealth as a privilege, a commodity or act of compassion

Health as a Human RightEquitySolidarity

FOCUS Patients/sick individuals People, Families, Communities

GOVERNANCE Doctor - PatientMultiple involvementNHA/MoH leadership

FINANCINGPayment to providers (fee-for-service)Profit oriented

Affordable Universal Access to health and Universal Health CoverageSocial Protection in Health

PROVISION OF SERVICES

Acute, Episodic, Curative careComprehensive integrated and continues Health care and Social Services

DEVELOPMENT OF RESOURCES

Physicians, Nurses and other professions akin to curative careTechnology as a business tool

Wide range of professions and competenciesRational use of technology

SYSTEMS’ APPROACH

Linear Adaptive System

Fragmentation of Healthcare Delivery Services

PRIMER NIVEL

SEGUNDO NIVEL

TERCERNIVEL

Social Security

Private Practice(High Technology)

Other

Providers

Private Non-profit(NGOs)

Local Govs

Universities

HIV

-AID

S

Mala

ria &

Oth

ers

Mate

rnal-

Ch

ild

Healt

h

Ministryof Health

Traditional Medicine

Fragmentation of Healthcare Delivery Services

The Current Health System• Centered on acute, episodic care

• Supply driven and organized by levels that fragment care

• Hospital-based and dependent on costly technologies and specialist care

• Provision of curative services through fragmented process of care

• Lack of continuity, poor quality and safety

• Inefficient referral systems

• Generator of exclusion and dissatisfaction

The patient “vanishes”

The patient “shows up”

The patient is “treated”

The patient is discharged

The current health system and the radar phenomenon

Are we prepared for give responses to the need

of people?

“People with chronic conditions attempt to

obtain continuous care in a systems where

healthcare services and financial mechanisms are oriented to the delivery of

episodic care”.Jesús María FernándezDep. de Sanidad y ConsumoBasque Country, Spain.

Gerard Anderson, Analysis of the Medical Expenditure Panel Survey, 2004.

The lack of or poor coordination in healthcare delivery increases the number of unnecessary hospital

admissions

Source:Medicare Standard Analytic File,2004

Integrated Health Service Delivery Networks (IHSDNs)

Integrated Health Services Delivery NetworksMandates, Context and Justification

Resolution CD49.R22 (September, 2009)

• “Recognizing that integrated health services delivery networks are one of the principal operational expressions of the PHC approach in health service delivery, helping to make several of its essential elements a reality, namely universal coverage and access; the first contact; comprehensive care; appropriate health care; optimal organization and management; and intersectoral action… “

• “…integrated health services delivery networks increase access to the system, reduce inappropriate care and the fragmentation of care, prevent the duplication of infrastructure and services, lower production costs, and better meet the needs and expectations of individuals, families, and communities…”

Systems Benefits of IHSDNs• Improved accessibility; reduced fragmented care;

improved overall efficiency; less duplication of services and infrastructure; more effective response to people’s needs and expectations; reduced production cost and increased cost-effectiveness; decrease in unnecessary hospital admissions; reductions in excessive utilization of diagnostic test; improvement in economy of scales; improved balance between specialist and generalist; better performance of total operating margins, cash flows and net income.

• Dowling, W.L. (1999). Hospitals and health systems. In: Introduction to health services. Williams, S.J.; Torrens, P.R., Editors. 5th ed. Delmar Publishers, An International Thomson Publishing Company.

• 43  Wan, T.T.H.; Lin, B.Y.; Ma, A. (2002). Integration mechanisms and hospital efficiency in integrated health care delivery systems. Journal of Medical Systems, 26: 127-143.

• 44  Lee, S.D.; Alexander, J.A.; Bazzoli, J. (2003). Whom do they serve? Community responsiveness among hospitals affiliated with systems and networks. Medical Care, 41: 165-174.

• 45  Aletras, V.; Jones, A.; Sheldon, T.A. (1997). Economies of scale and scope. In: Ferguson, B.; Sheldon, T.A; Posnett, J. Concentration and choice in health care. London: Financial Times Healthcare.

• 46  Soler, J.L.P (2003). Estrategia de gestion y organizacion de una red de laboratorios de diferentes hospitales publicos. Bogota, Primer Forum Internacional de Redes de Servicios y Ordenamiento Territorial en Salud. Secretaria de Salud de Bogota/Organizacion Panamericana de la Salud.

• 47  Dowling, W.L. (1999). Hospitals and health systems. In: Introduction to health services. Williams, S.J.; Torrens, P.R., Editors. 5th ed. Delmar Publishers, An International Thomson Publishing Company.

• 48  Shortell, S.M.; Gillies, R.R.; Anderson, D.A. (1994). The new world of managed care: creating organized delivery systems. Health Affairs, Vol. 13, Issue 5: 46-64.

Clinical Benefits of IHSDNs• Continuity of care is associated with improvements in

clinical effectiveness, responsiveness, acceptability and efficiency; increased perception of effectiveness (healthcare managers and providers); improve timely access to First Level of Care and other levels when required; less unnecessary repetition of history-taking, diagnostic procedures, and bureaucracy; improved shared decision-making processes between provider and patient and facilitate the implementation of self-care strategies and chronic disease monitoring.

• Christakis, D.A.; Mell, L.; Koepsell, T.D.; Zummerman, F.J.; Connel, F.A. (2001). Association of lower continuity of care with greater risk of emergency department use and hospitalization in children. Pediatrics 2001;107(3):524-29.

• 50  Hjordahl, P.; Laerum, E. (1992). Continuity of care in general practice: effect on patient satisfaction. BMJ 1992;304(6837):1287-90. • 51  Parchman, M.L.; Pugh, J.A.; Noel, P.H.; Larme, A.C. (1992). Continuity of care, self-management behaviors, and glucose control in patients with

type 2 diabetes. Med Care 2002;40(2):137-44. • 52  Ham, Ch (2007). Clinically Integrated Systems: The next step in English health reform? Briefing Paper. The Nuffield Trust. • 53  WHO European Office for Integrated Health Care Services (2001). Workshop on Integrated Care. Barcelona, WHO Integrated Care Meeting. • Lloyd, J.; Wait, S. Integrated Care: A guide for policy makers. London: Alliance for Health and the Future. • 55  Gillies, R.R.; Shortell, S.M.; Anderson, D.A.; Mitchell, J.B.; Morgan, K.L. (1993). Conceptualizing and measuring integration: findings from the health

systems integration study. Hospital & Health Services Administration 1993; 38(4):467-89. • 56  Hartz, Z.M.A.; Contandriopoulos, A.P. Integralidade da atencao e integracao de servicos de saude: desafios para avaliar a implantacao de um

“sistema sem muros”. Cadernos de Saude Publica 2004;20 Sup 2:S331-S336. • 57  Gillies, R.R.; Shortell, S.M.; Anderson, D.A.; Mitchell, J.B.; Morgan, K.L. (1993). Conceptualizing and measuring integration: findings from the health

systems integration study. Hospital & Health Services Administration 1993;38(4):467-89.

Integrated Health Service Delivery Networks (IHSDNs)

Integrated Health Service Delivery Networks (IHSDNs)

Progress in Country Implementation• Countries with on-going reforms based on PAHO’s IHSDNs

framework:o Brazil

• Ordinance 4.279 (2010) on organization of IHSDNs in the SUS• Ordinance 7.508 (2011) on integration and coordination of care between states

(Federal Regulation)• National consultation on a new policy for Hospital Care (2012)• The experience of Minas Gerais

o Chile• The experiences in Ñuble and the Western Metropolitan Regions

o Colombia• New legislation (Act 1438 of January 19, 2011)

o El Salvador• National Health Policy (“Building Hope”)

o New Model of Care (People Centred integrated care)o Strengthening of the First Level of Care (ECOS)

• Intersectorial Health Commissiono Others:

• Panamá, Perú, Paraguay, Uruguay, Trinidad and Tobagoo Regional Level:

• PHC Collaborative Network• Guidelines for implementation of IHSDNs• Development of a Regional Agenda for Hospitals in IHSDNs

Global Trends in Health Systems

and Healthcare Delivery

Título de la presentación

ORGANIZATION

• Strong resurgence of Primary Health Care (PHC) values and principles

• The demand for health services to provide integrated, coordinated and continuous care

• The First Level of Care (Primary Care) “in the drivers seat”

FINANCING• To provide more with the same or less resources• Financial allocation linked to performance• Increased accountability• New ways of paying providers• Push toward Universal Access of Health and

Universal Coverage of Health and Social Protection

QUALITY• People at the center of care• Evidence based medicine• Patient and Provider Safety

MANAGEMENT• Professionalization• More accountability• Assignment /contracting based on competencies• Results Based Management

INNOVATIONS• New modalities of delivery• The technological revolution and the impact on

healthcare cost• New approaches to old problems…and new

problems require creative approaches

Integrated People Centered Care

“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 systems, and according to

their needs throughout the life course” PAHO, 2010

Right to the highestattainable level of

health

Equity

Solidarity

Responsiveness topeoples’ health

needs

Quality-oriented

Go

vernm

ent

accou

ntab

ility

Social justic

eSustainability

Particip

ation

Inte

rsec

toria

lity

First Contact Comprehensive,

integrated and

continuing care Family and

comm

unity

based

Em

ph

asis on

p

rom

otio

n an

dp

reventio

nA

ppropriatecare

Active

participation

mechanismsSound policy,

legal & institutionalframework

Pro-equitypolicies

& programs

Optim

al

organization

& m

anagement

Ap

pro

priate

hu

man

reso

urces

Ade

quat

e an

dS

usta

inab

lere

sour

ces

Inte

rsec

toria

l

actio

ns

Universal

coverage

and access

Systems Thinking in BuildingPHC-Based Systems

HEALTH SYSTEM

Governance

Fina

ncin

g

Development

of Resources

Provisio

n

of Serv

ice

Thank you.