MAKING PEOPLE- CENTERED CARE A REALITY

HOW ?

Dublin Castle. 6 October 2015

Rafael Bengoa rafael.bengoa@deusto.es

5 Octubre 2015

• SAME CHALLENGES ?

• SAME WHATS ?

• SAME HOWS ??

• Types of Hows

- Instrumental Hows

- Change Management Hows

◦ Population : 2.3. million

◦ 320 Primary Health Centers

12 Acute Hospitals (4,278 beds)

4 Chronic Care Hospitals (524 beds)

Mental Health: Three regional networks with 4 psychiatric hospitals, (777 beds)

Staff: 25.816 (2012)

1.500.000

2.500.000

3.500.000

4.500.000

5.500.000

6.500.000

7.500.000

8.500.000

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011(*

)

2012 (

**)

2013

2014

2015

2016

2017

2018

2019

2020

2021

2022

Realistic case Best case Worst case

WHEN NOT TO BECOME MINISTER !

DEMOGRAPHY

SAME CHALLENGES !!

EPIDEMIOLOGY. CHRONIC CLINICAL COMPLEXITY

FRAGMENTATION. SILOS

EXPECTATIONS ECONOMIC

…

1992 1997 2002 2007

13.500 diagnósticos

6.000 medicamentos

4.000 procedimientos quirúrgicos

20.000.000 de actos clínicos

omplejidad

22 profesionales/ paciente

C

Más pacientes crónicos.

Más pluripatología

«No se puede hacer medicina del siglo XXI con el chasis de 1.970» . Bengoa

HEALTH SYSTEM JOURNEY*

REACTIVE ACUTE BIO-MEDICAL MODEL

POPULATION HEALTH. OUTCOME BASED PAYMENT ACCOUNTABLE CARE BROADER

INTERSECTORAL HEALTH AND HEALTH DETERMINANTS

HEALTH IN ALL POLICIES

FINANCING

DELIVERY

PAYING FOR VOLUME

BUNDLED PAYMENT

GLOBAL PAYMENT

PAYMENT FOR VALUE & VOLUME

DBS Health R. Bengoa / P. Arratibel

INDIVIDUAL MEDICAL CARE

FRAGMENTED CARE PASSIVE PATIENT

INTEGRATED+

CONNECTED CARE

ACTIVE PATIENT. ACCOUNTABLE CARE ORGANIZATIONS LOWER COST

TRIPLE AIM PEOPLE-CENTERED CARE COORDINATED

CHRONIC CARE

FINANCING COMMUNITY DEVELOPMENT

BROADER STAKEHOLDER INVOLVEMENT

INFORMAL /FORMAL NETWORK & CIVIL SOCIETY

POLICY

STRATIFIED PREVENTIVE CARE

* We asume the intermediate stage of population health/accountable care is a key step towards broader intersectorial work. However, one can be doing intersectorial work simultaneous to moving along this journey.

MORE AT HOME MORE IN

PRIMARY HEALTH CARE

LESS IN HOSPITALS

MORE IN THE COMMUNITY

DIRECTION OF TRAVEL …

MORE PREVENTION

• ATTACK INEQUALITIES

• BETTER CHRONIC CONDITIONS MANAGEMENT

• GET BEYOND FRAGMENTATION OF CARE • IMPROVE PATIENT-CENTEREDNESS & EMPOWERMENT

• IMPROVE QUALITY AND PREVENTION

• MOVE TOWARDS POPULATION HEALTH MANAGEMENT.

• FISCAL SUSTAINIBILITY

SAME POLICY INTENT

LOCAL INTEGRATED ORGANIZATIONS

SWEDEN “ Local health care- chains of care” U.S.A “Accountable Care Organizations”(ACOS)

SCOTLAND “Health & Social Care Partnerships” ENGLAND “Integrated care pioneers” Vanguard Sites N. IRELAND “Integrated care partnerships” NEW ZEALAND “Locality clinical partnerships» (LCP) SPAIN (BASQUE COUNTRY) “Sistema Local Integrado” ( OSI ) NETHERLANDS “ Care Groups” IRELAND --------------------------------------------

NOT ALONE ON THIS JOURNEY !!

Instrumental “Hows”

Unprecedented Management “Arsenal”!!

• Electronic medical records

• Electronic prescription

• Telemedicine, telecare, telemonitoring

• Risk Stratification

• Outcome based payment schemes

• Integrated care

• Coordination Health & Social Care

• New professional roles (nursing)

• Patient Empowerment & self-management

• Third sector participation

• Transformation of subacute facilities • New Metrics: measure value and

outcomes ; not only activity

STRUCTURES “COMMUNITY”

SYSTEM

• Managing Structures

• Fragmentation

• Reactive episodic care

• Paternalistic

• 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 POPULATION MANAGEMENT !

WE HAVE “SYSTEM” FRAMEWORKS

13

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

14

Año 2009-2010 2011 2012

MORE AT HOME MORE IN PHC LESS IN HOSPITALS

A STRATEGY TO TACKLE CHRONICITY IN THE BASQUE COUNTRY

LEAN ON EARLY WINS 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

16

© 2008 University of Oregon 2020

National Study 2004

Medication Adherence by Level of Activation for Different Conditions

LEAN ON GROWING INTERNATIONAL EVIDENCE…..

•Results seem to support new payment models:

• Improvements in quality

The Alternative Quality Contract (AQC)

. Measures not related to incentives do not improve

The Alternative Quality Contract (AQC)

Expenditure ….

Fuente: http://www.bluecrossma.com/visitor/about-us/affordability-quality/aqc.html

The Alternative Quality Contract (AQC)

• SAME CHALLENGES ?

• SAME WHATS ?

• SAME HOWS ??

• Types of Hows

- Instrumental Hows ( Stratification, EMRs.. )

- Change Management “Hows”

HEALTH SYSTEM JOURNEY*

REACTIVE ACUTE BIO-MEDICAL MODEL

POPULATION HEALTH. OUTCOME BASED PAYMENT ACCOUNTABLE CARE BROADER

INTERSECTORAL HEALTH AND HEALTH DETERMINANTS

HEALTH IN ALL POLICIES

FINANCING

DELIVERY

PAYING FOR VOLUME

BUNDLED PAYMENT

GLOBAL PAYMENT

PAYMENT FOR VALUE & VOLUME

DBS Health R. Bengoa / P. Arratibel

INDIVIDUAL MEDICAL CARE

FRAGMENTED CARE PASSIVE PATIENT

INTEGRATED+

CONNECTED CARE

ACTIVE PATIENT. ACCOUNTABLE CARE ORGANIZATIONS LOWER COST

TRIPLE AIM PEOPLE-CENTERED CARE COORDINATED

CHRONIC CARE

FINANCING COMMUNITY DEVELOPMENT

BROADER STAKEHOLDER INVOLVEMENT

INFORMAL /FORMAL NETWORK & CIVIL SOCIETY

POLICY

STRATIFIED PREVENTIVE CARE

* We asume the intermediate stage of population health/accountable care is a key step towards broader intersectorial work. However, one can be doing intersectorial work simultaneous to moving along this journey.

FOCUS ON CORRECTING “SYSTEM BLINDNESS” AT THREE LEVELS !

FOCUS ON ALIGNMENT OF THREE LEVELS

CORRECTING SYSTEM BLINDNESS &

ENSURING ALIGNMENT FOR

TRANSFORMATION IS

A LEADERSHIP CHALLENGE !

TRANSFORMATIONAL LEADERSHIP = MANAGE TWO AGENDAS SIMULTANEOUSLY

• “RESIST” CULTURE

• TOUGH BUT DOES NOT CHANGE STATUS QUO

• TRANSFORMATIVE CULTURE

• TOUGH BUT DOES CHANGE STATUS QUO

&

LOW HANGING FRUIT HIGH HANGING FRUIT

26

BASQUE COUNTRY : AT THE POLICY LEVEL….

• 2009 . DEVELOPED A VISION. A COHESIVE STRATEGY

• PROVIDED A NARRATIVE THAT GOES BEYOND “COST CONTAINMENT”

• RAISED CHRONICITY & INTEGRATED CARE TO

THE POLICY AND POLITICAL LEVEL

• DEVELOPED SOME REACHABLE GOALS

• FUNDED THE TRANSFORMATION

R. Bengoa

BASQUE COUNTRY

THE VISION WAS CHRONICITY

cronicidad.blog.euskadi.net/.../ChronicityBasqueCountry

TRANFORMATIONAL LEADERSHIP SOME “TOP DOWN” IS NECESSARY. THE KEY QUESTION IS “WHAT TYPE OF TOP DOWN” ?

Some level of “orquestration” from above required but seeking commitment rather than compliance One key element of the “orquestration” are the new payment reforms ( value) rather than from micromanagement of providers.

A LOT OF “BOTTOM UP”

• DEVELOPED A “HIGH INVOLVEMENT CULTURE” WITH HEALTH CARE PROFESSIONALS.

• DEVELOPED AN ENVIRONMENT WHERE LOCAL PROVIDERS COULD INNOVATE ORGANISATIONALY.

• ADDRESS SCALABILITY WITH LOCAL SELF - DISCOVERY

• UNLOCKED THE BENEFITS OF LOCAL HEALTH CARE INNOVATION

• REINFORCE RESEARCH AND POLICY CAPACITY

• Create “lateral capacity”- Some agencies to support that local innovation( O Berri, Kronikgune, Etorbizi.)

Hospitales

Atención Primaria

Mejor Eficiencia Interna

Utilización de tratamiento Menor costo

Reducción de Eventos Adversos

Reduccion de Reingresos

Mejor Prevención + detección temprana

Más eficiencia interna

Reducción de Pruebas+Desviaciones Innecesarias

Reducción visitas a urgencias prevenibles

M Á S S A L U D

M E N O R G A S T O

Mejor Gestión de Pacientes complejos

Utilización de estructuras menos caras

Fuente: The Dartmouth Institute 2013

Not everything requires integration but the most complex problems do!

BUILD ON EARLY WINS • EARLY WINS YES BUT NOT “YOUR” EARLY WINS. • RATHER ENCOURAGE EARLY WINS TO BE LOCAL. • ALLOW MODELS WHICH PERMIT LOCAL ORGANIZATIONS TO RETAIN SOME OF THE EFFICIENCIES FOUND. • THIS WILL GIVE THOSE WINS SUSTAINIBILTY OVER

TIME

NEW METRICS AS A CHANGE AGENT. MEASSURE VALUE AND OUTCOMES; NOT ONLY ACTIVITY

Indicator Baseline

Baseline

improvement

rate

Target

improvement

rate

Target

Potentially avoidable hospitalizations per

100,000 population for chronic conditions

1,037 per 100,000

(2007)

2.2%

(2000–07)

4.4%

(2016)

809 per

100,000

(2016)

Adults with hypertension whose blood

pressure is under control

41.2%

(2005-08)

2.6%

(2001–08)

5.2%

(2016)

53.2%

(2016)

Admissions for uncontrolled diabetes

without complications per 100,000

population

21.1 per 100,000

(2007)

4.0%

(2000–07)

8.0%

(2016)

13.4 per

100,000

(2016)

Hospital patients with heart failure who

received recommended hospital care

95.0%

(2008)

2.7%

(2005–08)

5.4%

(2016)

100%

(2016)

Adults age 50 and older who received

colorectal cancer screening

60.1%

(2008)

2.4%

(2000–08)

4.8%

(2016)

75.9%

(2016)

Adults ages 18–64 at high risk (e.g., those

with respiratory disease) who received an

influenza vaccination in the past 12

months

31.7%

(2008)

1.6%

(2000–08)

3.2%

(2016)

37.0%

(2016)

Hospital patients with pneumonia who

received recommended hospital care

89.8%

(2008)

3.2%

(2007–08)

6.4%

(2016)

100%

(2016)

All-cause 30-day readmission rates for

patients discharged alive to a nonacute

care setting with a principal diagnosis of

heart failure

24.9%

(2010)

-0.7%

(2008–10)

1.7%

(2016)

22.5%

(2016)

Source: Agency for Healthcare Research and Quality; Centers for Medicare and

Medicaid Services/The Joint Commission; authors’ estimates.

WHAT WOULD I DO DIFFERENTLY TODAY ? • CHANGE DOESN ´T JUST HAPPEN. IT MUST BE MANAGED ACTIVELY BY TOP MANAGEMENT

• THERFORE FOCUS MORE ON “HOW”. THAT IS THE DIFFICULT JOB.

• SPEND EVEN MORE POLICY AND STRATEGIC TIME ON HIGH HANGING FRUIT.

• ENSURE BETTER THAT TOP TEAM SHARES SAME STRATEGIC COMMITMENT. SOMETIMES

THEY SAY “YES” WHEN THEY MEAN “NO” .

• FOCUS ON GETTING BUY-IN: STOP CASCADING STUFF DOWN AND REINFORCE “BOTTOM UP

• ALIGN FINANCE TO THE STRATEGY

& LOW HANGING FRUIT HIGH HANGING FRUIT

THANK YOU

Deusto Business School Health

UNIVERSITY OF DEUSTO

Rafael.bengoa@deusto.es

Tel. 944 139 463