1. Models of integrated health care and social services: A vision about future trends Gran Stenberg, Director Procyon Management Consulting AB. Sucia Pr ocy on m anagem ent consult ing ab

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3. This presentation: Use systems thinking and especially complexity science or a complex adaptive systems approach to understand the integration of health care and social services. Some examples from Sweden Pr ocy on m anagem ent consult ing ab

4. Six rules Six init ia l r u les t o gu ide ou r sy st em t hink in g 1 .Pa t ient needs ex ceeds or ga niz a t iona l bou nda r ies 1 .One or sev er a l or ga niz a t ions ca n be r ega r ded a s a sy st em Pr ocy on m anagem ent consult ing ab

5. 1 . U nder st a nding w h ole sy st em f r om indiv idu a l beginning t o end. u nf u lf lled needs is Cr u cia l is int er sect ion necessa r y of dif f er ent p r ov ider s 1 . Indiv idu a l p a t ient s 6 . Cha nging f ocu s of a lso belong t o w or k f r om inside-ou t t o t a r get / p a t ient ou t side-in a sh if t f r om gr ou p s. get t ing t h e p a t ient s t o U nder st a nding f t int o t h e ex ist ing t a r get gr ou p s a nd sy st em t o let t ing t h e t h eir needs a r e sy st em incor p or a t e im p or t a nt p a t ient k now ledge a nd ex p er iences int o it s 1 . Sy st em design is a ct iv it ies bu ilt on a ba sic Pr ocy on m anagem ent consult ing ab u nder -st a nding of

6. Background Peop le w it h The p r oblem s com p lex needs obser v ed a r esu lt f r equ ent ly r equ ir e of t he p r e-v a iling cont inu ou s ca r e in m indset ( N or m a n 2 00 1) m u lt ip le set t ings Wh en t h e m a p ch a nges t he Wit h ou t la ndsca p e. int egr a t ion, a ll a sp ect s of h ea lt h Ra t iona l t hink ing ca r e a nd socia l v iew ing ca r e ser v ice or ga nisa t ions a s p er f or m a nce, m a ch ines su f f er s Pr ocy on m anagem ent consult ing ab

7. A ch a llenger t o A sy st em is r ef er r ed t h e p r ev a iling t o com p lex w h en m indset , v iew s it ha s so m a ny or ga niz a t ions a s v a r ia bles a n d h u m a n sy st em s, int er a ct ing f or ces i.e. t h a t is hu m a n t h a t it ca nnot be p u r p osef u l u nder st ood by int er a ct ion t r a dit iona l t op - dow n t h ink ing a nd COMPLEX a p p r oa ch es ( A nt h es 2 0 0 3 ) A DA PTIV E SY STEMS ( CA S) Pr ocy on m anagem ent consult ing ab

8. Problem statement How ca n t h e CA S a p p r oa ch be u sed by m a na ger s t o su p p or t t h e int egr a t ion of h ea lt h ca r e a nd socia l ca r e t o secu r e a p p r op r ia t e ca r e f or t h e benef t of t he p a t ient ? Pr ocy on m anagem ent consult ing ab

9. Theory and discussion Th e m a ch ine m odel: Th e t r a dit iona l w a y of dea ling w it h com p lex it y is r a t iona l a nd sy st em a t ic Unit s w ou ld be m a na ged sep a r a t ely a ccor ding t o t he r u les of t h e m a ch ine m odel - if ea ch p a r t cou ld w or k bet t er, t h en t h e w h ole sh ou ld w or k bet t er ( Mor ga n 1 9 8 6 ) ATHOMISTIC Th is det er m inedly inw a r d f ocu s w ill r esu lt in p oor or no u nder st a nding of t h e lif e sit u a t ion of a n elder ly p er son w it h m u lt ip le h ea lt h a nd socia l p r oblem s Pr ocy on m anagem ent consult ing ab

10. Inst ea d of t h eor ies a ssu m ing ca u se a nd ef f ect link a ges bet w een sep a r a t e p a r t s, w e need t heor ies t o dea l w it h p a t t er ns a nd p r incip les ( Zim m er m a n et a l. 1 9 9 8 ) HOLISTIC CA S is not a t ool box bu t a m odel f or t h ink ing a s a p r ep a r a t ion f or a ct ion A f ou nda t ion of CA S is t h e im p or t a nce a nd t h e a bilit y of self or ga niz a t ion ( K a u f m a n 1 9 93 ) - Creating order without help from the outside Pr ocy on m anagem ent consult ing ab

11. Wh en com p lex it y is a t ha nd: Im p ossible t o design a n op t im a l sy st em in a dv a nce - t oo m a ny v a r ia bles t o t a k e int o a ccou nt ( For sber g et a l. 2004) Reconsider a t ion of st a nda r d m a na ger ia l t a sk s a nd sea r ch f or new r u les Pr ocy on m anagem ent consult ing ab

12. Innovative managers of integrated care Some guiding principles: 1 . Pla nned a p p r oa ch es t o ch a nge h a s been r ep la ced by m or e em er gent w a y s of w or k ing. CA S a gent s a ll t he int egr a t ed ca r e p a r t ner s a da p t a nd ch a nge const a nt ly w h en t h ey f a ce new cir cu m st a nces in or der t o m a int a in t h e sy st em 1 . A gent s in t he loca l sy st em h a v e bot h t h e r esp onsibilit y a nd ca p a bilit y t o a ct 1 . Innov a t iv e m a na ger s r ega r d t h e p a t ient a s a n a ct iv e co-p r odu cer - n t o ocy on Pr m a y not only em p ow er t h e p a t ient bu t is a lso a m eam anagem ent consult ing ab ser v ice qu a lit y ( K ellogg et a l. 1 9 9 7 )

13. 1 . Sense m a k ing is u sed t o inf u ence ch a nge in com p lex sy st em s ( Snow den 2 0 0 2 ) 1 . A gent s gener ou sly sh a r e k now ledge a nd inf or m a t ion in or der t o st r engt h en t h e ent ir e sy st em ( C.F Tet enba u m 2 0 0 8) a nd incr ea se it s t ot a l v a lu e 1 . Tea m bu ilding a r e a ct iv ely p r om ot ed - int er -or ga niz a t iona l a s w ell a s int er -p r of essiona l - of gr ea t im p or t a nce f or t h e v a lu e cr ea t ion w it h u ser s ( Edgr en & St enber g 2 0 0 6 ) Pr ocy on m anagem ent consult ing ab

14. 1 . Under st a nding t he u nw r it t en r u les h elp sy st em designer s t o m ov e a w a y f r om t r a dit iona l r u les Tr a d: Pr of essiona ls p r im a r ily see t h em selv es a s w or k ing indep endent ly in t h eir ow n r esp onsibilit y t o t h e p a t ient N ew : A ll h ea lt h a nd socia l ca r e p r of essiona ls see t h em selv es a s p a r t of a t ea m in p a r t ner sh ip w it h p a t ient s t o im p r ov e h ea lt h ( Inst it u t e of Medicine 2 0 0 7 ) 1 . Ma na ger s cr ea t e t h e m ea ns f or cont inu ou s lea r ning ( Senge 1 9 9 0) a nd f eedba ck r egener a t es t h e sy st em Pr ocy on m anagem ent consult ing ab

15. 1 . Wor k ing r ela t ionsh ip s bet w een a gent s a r e collegia l a nd bu ilt on t r u st - lea ding in a n int egr a t ed ca r e sy st em is a bou t lea ding p eer s - m a y m ea n t h a t ow n or ga niz a t iona l int er est s m a y need t o be p u t a side in f a v ou r of t h e w h ole sy st em 1 . Int egr a t ion is a bou t int egr a t ing a gent s in a CA S a nd t heir dif f er ent t a sk s w it hou t r edu cing t h e dif f er ences t h a t lea ds t o a n ef f ect iv e p r ov ision of t h ese t a sk s ( Edgr en 2006) Pr ocy on m anagem ent consult ing ab

16. Conclusion A hierarchal top-down An integrated health care approach, following system is built upon the machine model thinking, collective intelligence of does not fit with the different professionals inherent logic of who use their knowledge integration which requires together with the adapting to local individual to meet circumstances. Individual patient needs A CAS approach views systems as living organisms Pr ocy on m anagem ent consult ing ab

17. CAS is a powerful concept but more efforts is needed to communicate the potential of the CAS approach to managers of integrated care. Pr ocy on m anagem ent consult ing ab

18. Some examples of integrated health care organisations in Sweden Pr ocy on m anagem ent consult ing ab

19. Swedens decentralised 20 County Councils Health Care system - Responsible for financing and providing Health Care services for the entire population 290 local authorities - Responsible for social service, housing and Care for elderly and disabled Pr ocy on m anagem ent consult ing ab

20. Components in the Swedish Health Care System Public Health Care System based on an overall goal: - Good health and health care for all on equal conditions Social Insurance System partly covering loss of income by illness Decentralised system with 20 self-governed County Councils lead by politicians elected every fourth year Financing mainly by County Council direct taxes (70%). The rest is governmental subsides and patient fees 90 % public hospitals. 40 % private primary care units Freedom of choice of primary care unit (not GP). PCU financed mainly by capitation based on population profile Local authorities are responsible for elderly care, social care and home service. Pr ocy on m anagem ent consult ing ab

21. Region of Skane Vision integrated health care High Specialized Health Care Specialized Specialized Competence Patient processes Acute Health Elective Health transmission Care Care Integrated Health Care Public Health acute elective Pr ocy on m anagem ent consult ing ab

22. Some charateristics of integrated health care organisation in Skne Local Specialized Specialized Highly specialized health care acute health care elective health care health care Needs Elderly, children and Acute grave conditions Investigations and Acute or elective youths. Chronical diseases or acute seriouse illness treatments that are severe not frequent or common health care or injuries plannable in time, diseases or injuries problems content and volume Shortest possible time Reasonable time between Adequate time Accessibility Nearness between alarm and investigation, diagnose Accessability all day between referral and adequate pre-hospital and treatment. care around care Finance Co-operation LA Pat Spec. PCU Improved health status. Result Confident population. Adequate treatment Process efficiency, free Medical value added. Improved prognose of disturbance, quality Development and Effects Teamwork between Concentrated organization and concentration. reneval. Distribution competences needed of knowledge Pr ocy on m anagem ent consult ing ab

23. Integrated teams at the ED in Malm Support and making it easier to estimate the patients need of care and level by using the right competence of professions Advice nurse Hospital nurse Admittance to ward Self care advice Physi- GP Triage Contact with physician, ward and cian back Collaboration between GP/PC and back up relatives before hospital up admittance Coordinating discharges Physiotherapist Social worker Occ. therapist Estimate patients Info about the Activity and physical capability patients social functionel estimate Judge the need of situation Estimate the need disability aid Coordinating of disabilty aid Rehabilitation community services Contact with local programs before Patient info about community rehab. discharge services available Pr ocy on m anagem ent consult ing ab

24. Some results with the integrated team 29 % of all elderly patients with acute needs recieved treatment from the integrated team. The future expectations is 50 % The patients meet the competence they need in the same locality Patients as well as professionals are very satisfied with the teamwork Promote collaboration between different organisations and units and the understanding and trust grows The flow of information between the units has improved The locistic has improved, the time spent in the ED is reduced, a growing number of patients can be referred back home and quality in home care has improved. Pr ocy on m anagem ent consult ing ab

25. Some more results with the integrated team Care for elderly patients in the ED has a clearer focus Many patients by pass the ED directly to the medicine ward The physiotherapist in the triage estimate the patients need for treatment or disability aid. Collaboration around relevant aid e.i wheel chair for the patient. Functional estimates improves the quality in home care. Advicing nurse sees 20 30 acute patients per day (10 %) ledading to shorter waiting times. Pr ocy on m anagem ent consult ing ab

26. TioHundra AB i Norrtlje - Stockholm Stockholm Norrtlje County Council Local community Purchaser Public Company TioHundra AB Private GP-s Primary Care incl. GP Hospital Care incl. ED Social services Elderly Care Home Care Pr ocy on m anagem ent consult ing ab

27. TioHundra AB Norrtlje - vision It is time to think in new ways. We will create a patient oriented organisation. Responsibility for the local population and financiation Increased focus on health and functional ability Integrated health care and social care organisation New possibilities to boarderless collaboration around users/patients to solve their health and care needs. Pr ocy on m anagem ent consult ing ab

28. TioHundra some resultats Elderly care Shorter waiting times to homes for elderly Half the number of waiting patients/users Improved quality of care and lower costs The number of beds needed has been reduced Home service has improved in collaboration with home care Quality and users satisfaction are in some areas above avarage in Sweden Pr ocy on m anagem ent consult ing ab

29. TioHundra some resultats Phychiatry Community and County Council phychiatry in the same organization New developments of care outside hospital reduced beds needed by 40 %. Rehabilitation and elderly care All physioterapists, occopational therapists and other rehabilitation competences in the same organisation increased effeciency and lower costs Pr ocy on m anagem ent consult ing ab

30. Findings in studied integrated care organisations in Europe Some identified barriers - structural - organisation culture - profession culture - IT Exemple of bridging dimensions: - hub function - common house - physically close - uniform financing - collected range Pr ocy on m anagem ent consult ing ab

31. Patient perspective as driver force for organising Most care needs to be taken care of outside hospitals Defiended population or patient groups/target groups Management task to bridge barriers Incentives supporting commom actions: Common task- clear assignment and targets Collaboration is a natural part in the culture Knowledge of each others different conditions Combination of monetary och non monetary incentives Pr ocy on m anagem ent consult ing ab

32. Innovation in health care system Integrated organisation Patient Processes Patient results Specialities Competences Target groups (Patient groups) Production results Health care units Pr ocy on m anagem ent consult ing ab

33. From producer perspective to patient perspective Units, clinics etc Results in Patient terms of: Patient Medical quality process need Patient satisfaction Quality of life Cost efficiency Resultat messured as: Cost, use of resources, production e.i Managed and organised from a patient number of patients, visits, bed days, perspective treatments, re-operations, returns, mortality etc Managed and organised from Compensation based on patient results a production perspective Pr ocy on m anagem ent consult ing ab

34. Corner stones Patient results Thr ou gh.. Leadingto bet e t r.. Professional Patient Patient self control groups processes Basedon.. Compensate f om.. dr Patient result based compensation Pr ocy on m anagem ent consult ing ab

35. Compensation model Quality Higher OK Lower Cost Lower Bonus Bonus Investing in quality improvement OK Bonus Compensation as Quality agreed development Higher Cost Rationalization Question/ improvement terminate To create new relations between cost and quality Pr ocy on m anagem ent consult ing ab

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