Integrated Care Key Lessons from International Evidence

Dr Nick Goodwin, PhDCEO, International Foundation for Integrated Care

Making People Centred Care a Reality6th October 2015, Printworks, Dublin Castle, Ireland

www.integratedcarefoundation.org

The Narrative

Overcoming Fragmentation

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

Designing Better Care for People

Goodwin N, Alonso A (2014) Understanding integrated care: the role of information and communication technology in Muller S, Meyer I, Kubitschke L (Eds) Beyond Silos: The way and how of eCare, IGI Global

The real-life experience of Malcolm and Barbara in the UK context is not unique but illustrates a number of key problems that fragmented health and care systems create, including:

• a lack of ownership from the range of care providers to support ‘holistic’ care needs, driven by silo-based working and separate professional and organisational systems for governance and accountability;

• a lack of involvement of the patient/carer in supporting them to make effective choices about their care and treatment options or enabling them to live better with their conditions through supported self-care and empowerment strategies;

• poor communication between professionals and providers, exacerbated by the inability to share and transfer data, silo-based working, and embedded cultural behaviours;

• care and treatment by different care providers for only a part of their needs, rather than seeing the person as a whole and managing all of the needs;

• the resultant simultaneous duplication of care (e.g. repeated tests or re-telling of a person’s medical history) and gaps in care (e.g. as appointments are missed or information and follow-up is not applied);

• a poor and disabling experience for the service users as information is hard to get hold of, differing advice and views are presented, confusion is created in the next steps of a course of illness;

• reduced ability for people to live and manage their needs effectively; and ultimately• poor system outcomes in terms of the inability to prevent unnecessary hospitalisations or long-term

residential home placements

Achieving the ‘Triple Aim’

The hypothesis for integrated care is that it can contribute to meeting the “Triple Aim” goal in health systems

• Improving the user’s care experience (e.g. satisfaction, confidence, trust)

• Improving the health of people and populations (e.g. morbidity, mortality, quality of life, reduced hospitalisations)

• Improving the cost-effectiveness of care systems (e.g. functional and technical efficiency)

The Building Blocks

Integration Strategies Needed at Every Level

Source: adapted from Valentijn et al (2013) Understanding integrated care: a comprehensive conceptual framework based on the Integrative functions of primary care, IJIC, vol13. Jan-Mar

WHO Europe’s Framework for Action Towards Coordinated/Integrated Health Service Delivery

Technical, Behavioural and Cultural Competence

Necessary System Reform

Care Systems Need to ChangeThink of the hospital as a cost centre, not a revenue centre

Hospitals can sustain revenue as aspects of care are shifted to communities

Imison et al (2012) Older people and emergency bed use. The King’s Fund, London

Priorities for Action and Investment

1. Active support for self-management

2. Primary prevention3. Secondary prevention4. Managing ACS conditions5. Integrating care for people with

mental and physical health needs

6. Care co-ordination - integrated health and social care teams

7. Primary care management of end-of-life care

8. Effective medicines management9. Managing elective admissions –

referral quality10. Managing emergency admissions –

urgent care

Focusing on Quality of Life

• More effective approaches:– Population management– Holistic, not disease-based– Organisational interventions targeted

at the management of specific risk factors

– Interventions focused on people with functional disabilities

– Management of medicines

• Less effective approaches:– Poorly targeted or broader

programmes of community based care, for example case management

– Patient education and support programmes not focused on managing risk factors

The importance of engaging people and communities

Engaging people can work through:• shared decision-making; care plans; • on-line courses; written

information and access to care records;

• self-monitoring; group education; • goal setting, coaching and

motivational interviewing

Engaging communities can work through• community participation: planning

and goal setting; patient and user groups

• community awareness: health education; building social networks

• community-delivered care: people as partners in care

The Imperative to Invest in Health Promotion

“Those who suffer most from under-coordination are the poor,

vulnerable, old and those from ethnic minorities. The avoidable

deterioration of their health results In high costs for public systems“

“The Future Health of Millions of Children, the Sustainability of the

NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public

health”NHS 5 Year Forward View

Finding the right payment mix – towards theCappucino Model

Integrated health & social care systems with capitation-type joint funding appear to provide the better platform for integration of care

Examples: NHS Highland, Scotland; Torbay, England; Norrtalje, Sweden; Kinzigtal, Germany; South Karelia, Finland

Type of funding:• Capitation according to population

health need• Pooled Budgets• Bundled Payments• Pay for performance• Pay for innovationType of contracting:• Joint commissioning• Outcome vs. activity• Prime contractor / risk-sharing

model

Source: Guus Schrijvers (2014) Health Care Innovation following the Cappuccino Model

Putting The Building Blocks Together

WHO HQs 5 Interdependent Strategies for its Global Strategy on Integrated Health Services Delivery

1. Empowering and engaging people;

2. Strengthening governance and accountability;

3. Reorienting the model of care;

4. Coordinating services; and

5. Creating and enabling environment The interdependency of the five strategic directions to support people-centred

and integrated health services with key actions (WHO/HQ, 2015)

The Rainbow Model for Integrated Care

Final taxonomy contained 21 key features that support integrated care across 8 domains

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4446832/table/Tab5/

Valentijn P et al (2015) Towards an international taxonomy of integrated primary care: a Delphi consensus approach. BMC Fam Pract, 16(1):64-015-0278-x

The Rainbow Model: Final Taxonomy Summary

Clinical integration: case management, continuity of care, multi-disciplinary care plans, supportive relationship with client

Professional integration: inter-professional education, inter-disciplinary teams

Organisational integration: shared governance and accountability; shared strategy; trust

System integration: aligned regulatory frameworks to support care coordination and team work;

Functional integration: shared information systems; collective learning and joint research; regular feedback on performance measures

Normative integration: shared vision; reciprocity of behaviour; mutual gain; visionary leadership; distributed leadership; shared norms and values

Valentijn P et al (2015) Towards an international taxonomy of integrated primary care: a Delphi consensus approach. BMC Fam Pract, 16(1):64-015-0278-x

Creating An Enabling Environment

Developing a Guiding Coalition

• Guiding team a key change management strategy

• Development of co-operation and agreements at level of policy-making,

• Team at a senior decision-making level with credibility and ability to take change agenda forward

• Both within health but also with other sectors, including the community

Examples and tools:• MoH in Basque country supporting regional

research institute and convening high-level meetings to take agenda forward;

• Creation of National Collaborative for Integrated Care in England leading to a £5.3bn funding stream to drive integration agenda

Building support for change

• Integrated care will mean different things to different people – different motivations, priorities and understanding

• Attitudes to change at a local level need careful handling as it’s a high relational task

• Invest in the development of ‘social capital’ required – awareness and adaptation of strategies in the face of key norms, values and cultures

• Being inclusive at all stages of design and delivery, avoiding top-down’ mandates for partnership working

Examples and tools:• Engaging partners at all levels of the health

system in Slovakia;• Stakeholder analysis to understand the views

of different stakeholders and so assess and create plans to overcome ‘resistant forces’ to change

• Effective communication strategies• Network management through skilled brokers

or ‘boundary spanners’• Community councils and democratic

representation at local level (e.g. Eksote, Finland)

Collaborative Capacity

• Building relationships and strengthening ties between partners in care to establish trust and a willingness to take shared accountability for outcomes;

• Developing effective and reliable multi-disciplinary teams requires the legitimacy, ability and skills to work together including the authority to act;

• Addressing language barriers through shared communication channels and common understanding of terms and definitions;

Examples and tools:• Diagnostics tools (ITMA, POET)• Inter-professional education and learning;• Team-building courses and training

programmes (e.g. TeamSTEPPS©);• Relationship management and inter- personal

communication skills;• Promotion of MDTs and team working skills

and competencies; • Methods and forums for reconciling

differences

Leadership

Long Term Commitment

Communication

New Skills to Lead and Manage Networks

Be Disruptive

Take the Agendato a Policy Level

Promote Shared & Distributed Leadership

Transparent Entrepreneurship

Be Brave

“Strong and respected clinical leadership is essential for

achieving clinical integration.”Ken Kizer, former CEO, VHA

“You also need thick skin-ness, bloody mindedness and tenacity because

every man and their dog who describes themselves as an ‘expert’ would probably have told you never

to have started the journey”David Meates, CEO, Canterbury DHB

Lessons from the Experience

Conclusions

We’ve been here before many times in the past

• Integrated care programmes are fragile

• They require constant effort to nurture

• Building social capital is a necessity, not an option

• Achieving better care, first and foremost, is about changing culture

• Values are important – they inspire action through emotion

People want to be a part of something when they feel that what they are doing aligns with

their attitudes, values and beliefs and improves peoples healthcare

Seven Key Lessons for Service Delivery (Goodwin, 2015)

Theme Characteristics

1 Population-health management

The ability to have an in-depth understanding of the health needs of communities supported through data that can provide intelligence on the priorities that should be addressed

2 Primary and secondary care prevention

The ability to support people to live better with their conditions, for example through educational programmes or self-care support

3 Personalised care co-ordination

The ability to plan and co-ordinate services effectively around people’s needs helps to overcome fragmentations and improve care experiences ad outcomes

4 Effective ICT systems Care professionals must be able to communicate well with each other and people must be able to interact effectively with care providers in a way that supports shared decision-making.

5 An integrated delivery system

Care systems need to be responsive to people’s needs, especially during times of crisis. The inability of provider networks to respond in real-time means that care co-ordination efforts are undermined.

6 Building social capital and collaborative capacity

Promoting shared values and understanding can help provide the necessary commitment to take integrated care forward.

7 Research and evaluation

Measuring, monitoring and responding to evidence to judge or benchmark care quality and outcomes is essential to improving quality of care through integration

Final Remarks

Building systems of integrated care is a complex task involving simultaneous attention at the macro-, meso- and micro-level

Key factors for success are dependent on technical skills and capacities, but also on cultural norms and values, management and leadership, and sensitivity to the context in which they are grown

There are no ‘short cuts’ – the journey to integrated care is part of the essential learning process

Dr Nick GoodwinCEO, International Foundation for Integrated Care

nickgoodwin@integratedcarefoundation.orgwww.integratedcarefoundation.org@goodwin_nick @IFICinfo