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
2. Pr ocy on m anagem ent consult ing ab
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