Nuria Toro Polanco Senior Researcher, Basque Institute of Healthcare Innovation (O+berri)

1. Conditioning factors for integrated care development in Osakidetza • (Basque Health Service) Nuria Toro Polanco Senior Researcher, Basque Institute of Healthcare Innovation (O+berri) 13th International Conference on Integrated Care, Berlin

2. Conditioning factors for integrated care development in Osakidetza • Key words • Chronic care models • Integrated care • ARCHO • Assessment tools • Leadership • Structural integration vs functional integration • Osakidetza-Basque Health Service • 13th International Conference on Integrated Care

3. Conditioning factors for integrated care development in Osakidetza • Content • ARCHO • Aims • Literature review and hypothesis development • Materials and methods • Results • Managerial implications • Conclusions

4. Conditioning factors for integrated care development in Osakidetza • ARCHO-Background • In Spain, almost 20 million people have chronic conditions • Chronicity involves rethinking on the way in which health services are provided and the role that the patient has to play • There is a great consensus on the need to design new provision models, different from the ones we have now, searching for more proactive, continuous and integrated care • One of the models that has been most widely acknowledged and discussed is the Chronic Care Model (CCM)

5. Conditioning factors for integrated care development in Osakidetza • ARCHO-Background • The CCM identifies the essential elements required by healthcare systems to provide quality care to people with chronic conditions. It is based on productive interactions between informed, empowered chronic patients and a prepared proactive health team. • The essential elements are: • The organisation of the healthcare system • The community • The delivery system design • Self-management support • Decision support • Clinical information systems

6. Conditioning factors for integrated care development in Osakidetza • ARCHO-Background • The CCM is a theoretical and quite abstract model that must be operationalised in healthcare organisations • To do so, several tools have arisen in the USA. • For example, the ACIC (Assessment of Chronic Illness Care) was developed as a practical tool to help teams improve care for chronic illness. • However, these tools have been designed in a very different healthcare system, so contextual adaptation is needed

7. Conditioning factors for integrated care development in Osakidetza • ARCHO • ARCHO (Assessment of Readiness for Chronicity in Healthcare Organisations) • Developed by O+berri, MSD and MH University • Based on Chronic Care Model • A tool that: • provides healthcare organisations a roadmap of interventions to be implemented for the management of chronic conditions (based on integrated care evidence) • enables healthcare organisations to self-assess their degree of readiness to provide integrated care to cope with chronicity. Adapted to NHS context • Consists of 6 dimensions and 80 interventions (items) • Rating scale from 0 to 100 (max. 8000 points)

8. Conditioning factors for integrated care development in Osakidetza • ARCHO • ARCHO (Assessment of Readiness for Chronicity in Healthcare Organisations) • www.iemac.org

9. Conditioning factors for integrated care development in Osakidetza • ARCHO-Results in Osakidetza • ARCHO (Assessment of Readiness for Chronicity in Healthcare Organisations) • PC District 1 (average: 28/100) • IHO 1 (average: 7/100) • PC District 2 (average: 27/100) • IHO 2 (average: 22/100)

10. Conditioning factors for integrated care development in Osakidetza • ARCHO-Results in Osakidetza • ARCHO (Assessment of Readiness for Chronicity in Healthcare Organisations) • PC District 3 (average: 29/100) • IHO 3 (average: 25/100) • PC District 4 (average: 19/100) • IHO 5 (average: 22/100)

11. Conditioning factors for integrated care development in Osakidetza • Aims • Primary aim: • Identify the factors that underlie the observed differences in the score for each organisation; these factors should explain the different degree of readiness to provide integrated care that have shown the evaluated organisations. • These factors can be: • Organisational • Professional • Others

12. Conditioning factors for integrated care development in Osakidetza • Literature review and hypothesis development • Degree of structural and functional integration • Fragmentation in healthcare is one of the main barriers to provide proactive, continuous and integrated care • Structural integration: involves the merger between organisations from different healthcare levels (primary and specialised care) • Functional integration: implies clinical processes coordination between different healthcare levels around the patient H1: “Those organisations that consider providing coordinated care to chronic patients as a priority and therefore show high levels of structural and functional integration, should have higher scores in ARCHO than those that don´t”

13. Conditioning factors for integrated care development in Osakidetza • Literature review and hypothesis development • Organisational culture and Leadership style • Organisational culture may have an influence on the processes oriented to improve performance in healthcare systems • It is the task of managers/leaders to facilitate the necessary changes to achieve the expected results according to the strategies and plans that must be implemented to address chronicity • Four culture types: rational, hierarchical, clan and developmental culture • Two leadership styles:directive vs. facilitative leaders

14. Conditioning factors for integrated care development in Osakidetza • Literature review and hypothesis development • Organisational culture and Leadership style Facilitative style Directive style H2: “The less hierarchical and centralised leadership styles promote the implementation of integrated care models to a greater extent than directive styles. Therefore, in those organisations that are featured by facilitative styles higher scores in ARCHO are expected”

15. Conditioning factors for integrated care development in Osakidetza • Literature review and hypothesis development • Attitude towards integrated care • Based on the “Expectancy Theory”, three concepts are developed • Instrumentality: refers to the perception of the link between integrated care implementation with the achievement of patient, professionals and system outcomes • Valence: it is the value that organisational members assign to the outcomes associated with successful implementation of integrated care • Attitude: combination of two variables H3: “Positive attitudes from professionals towards integrated care is key to carry out the implementation of new models to chronic disease management. The better attitude, the higher score will be expected”

16. Conditioning factors for integrated care development in Osakidetza • Literature review and hypothesis development • Training in integrated care • As well as positive attitude and motivation, skills are needed in order to implement the new management models • “Willingness is not enough but also know-how is needed” H4: “Training in integrated care is relevant in order to carry out the implementation of new models that address chronicity. The higher the level of training, the higher ARCHO score will be expected”

17. Conditioning factors for integrated care development in Osakidetza • Materials and Methods • Quantitative study that aims to investigate the relationship between the dependent variable (ARCHO score) and the independent variables (degree of structural and functional integration, leadership style, attitude and training) • Based on a 61-item questionnaire designed for that purpose

18. Conditioning factors for integrated care development in Osakidetza • Sample profile (n=156) 7 Organisations Professional group Experience on chronic management

19. Conditioning factors for integrated care development in Osakidetza • Results. Descriptive Statistics

20. Conditioning factors for integrated care development in Osakidetza • Results. Correlation matrix

21. Conditioning factors for integrated care development in Osakidetza • Results. Linear regression model

22. Conditioning factors for integrated care development in Osakidetza • Results. Hypothesis testing H1: “Those organisations that consider providing coordinated care to chronic patients as a priority and therefore show high levels of structural and functional integration, should have higher scores in ARCHO than those that don´t” The structural integration level is not statistically related to the variations found in ARCHO scores. For that reason, the first part of the hypothesis is rejected. However, we find statistical significance in relation to the development of the functional integration level and the ARCHO scores. For that reason, we conclude that the more functional integration level we have, the higher scores can be expected in an organisation.

23. Conditioning factors for integrated care development in Osakidetza • Results. Hypothesis testing H2: “The less hierarchical and centralised leadership styles promote the implementation of integrated care models to a greater extent than directive styles. Therefore, in those organisations that are featured by facilitative styles higher scores in ARCHO are expected” The results suggest that there is an statistically significant negative relationship between the hierarchical culture and the ARCHO score. For that reason, we can confirm the second hypothesis: organisations featured by a dominant hierarchical leadership style exhibit a lower degree of readiness to provide integrated care to chronic patients

24. Conditioning factors for integrated care development in Osakidetza • Results. Hypothesis testing H3: “Positive attitudes from professionals towards integrated care is key to carry out the implementation of new models to chronic disease management. The better attitude, the higher score will be expected” A positive attitude towards integrated care is significantly and positively related to the ARCHO score. As predicted, the better the perception of the link between integrated care implementation and the expected outcomes in patients, professionals and system outcomes, the higher the motivation and readiness to implement models that provide integrated care to chronic patients.

25. Conditioning factors for integrated care development in Osakidetza • Results. Hypothesis testing H4: “Training in integrated care is relevant in order to carry out the implementation of new models that address chronicity. The higher the level of training, the higher ARCHO score will be expected” Training has not been found to be significant when it comes to explaining variations in ARCHO scores. For that reason, the hypothesis has been disproved.

26. Conditioning factors for integrated care development in Osakidetza • Managerial implications (I) • It can be stated that Osakidetza-Basque Health Service is on the integrated care pathway, developing projects and initiatives that are yielding promising results; evaluation, however, is not carried out in a systematical way. • Basque health professionals are very familiar with chronic management models and integrated care (93 % of them state to have received information about these concepts). • Integrated care positive outcomes in patients, professionals and the healthcare system are widely recognised.

27. Conditioning factors for integrated care development in Osakidetza • Managerial implications (II) • According to the ARCHO instrument, the degree of readiness to provide integrated care to cope with chronicity differs across different settings. • Not just between organisations but also within them, we have found differences when it comes to scoring the six dimensions and the 80 interventions that derive from them. • In general terms, it can be stated that top managers tend to score higher than doctors and nurses. This trend is even stronger in Primary Care (although not statistically significant).

28. Conditioning factors for integrated care development in Osakidetza • Managerial implications (III) • In relation to leadership culture, it is clear how it has an influence on the integrated care development. • Leaders´ style, values and behaviours may determine the degree in which organisations and professionals participate and are committed to the promotion of integrated care. • Therefore, the great challenge would be the development of leadership models that facilitates the healthcare paradigm transformation through the change in organisational values, shared decision-making and teamworking.

29. Conditioning factors for integrated care development in Osakidetza • Managerial implications (IV) • Last but not least, both structural and functional integration should be carefully analysed. • According to this study, it is functional integration and not structural integration the factor that promotes integrated management of chronicity. • Based on this, the merger of healthcare structures (mainly primary and specialised care) will only make sense if it is to facilitate the integration and coordination of clinical processes; structural integration alone will not assure coordinated care to the chronic patients.

30. Conditioning factors for integrated care development in Osakidetza • Conclusions • The topic addressed is a rather complex issue in which organisational, professional and other type of factors can play a role in the development of integrated care. • We have tried to shed some light on it, testing a limited amount of variables that, according to literature, can have an influence on the degree of readiness to provide integrated care. • However, the amount of variation that is not explained yet is quite high (adjusted R2=0,19). • For that reason, more research is needed in order to extend the knowledge in this interesting and challenging area.

31. Conditioning factors for integrated care development in Osakidetza • Thank you for your attention • toro@bioef.org