The Importance of Integrated Care to the Future of Health Systems: National and Regional Developments in Europe and oth

1. The Importance of Integrated Care to the Future of Health Systems: National and Regional Developments in Europe and other countries Dr Nick Goodwin & Dr Lourdes Ferrer CEO, International Foundation for Integrated Care www.integratedcarefoundation.org Paper to: Health Quality and Safety Commission New Zealand Workshop: Towards Integrated Care in New Zealand Wellington, New Zealand, November 14th 2013

2. The Challenge

5. Ageing Society = Greater Complexity of Care By 2034, >85s will represent c.5% of the population in Western Europe.

6. Care Systems in Europe are Failing to Cope with Complexity The complexity in the way care systems are designed leads to: • lack of ‘ownership’ of the person’s problem; • lack of involvement of users and carers in their own care; • poor communication between partners in care; • simultaneous duplication of tasks and gaps in care; • treating one condition without recognising others; • poor outcomes to person, carer and the system Frontier Economics (2012) Enablers and barriers to integrated care and implications for Monitor -

8. The Challenge: Summary • Age-related chronic conditions absorb the largest, and growing, share of health/social care activities • Poor co-ordination of care for people with long-term/complex illnesses leads to poor care experiences and adverse outcomes • Practical solutions to tackle the socio-determinants of ill-health and pathology of the complex patient • Strategies of care co-ordination to create more integrated, cost effective and patient-centred services are growing internationally • Lack of knowledge about how best to apply care co-ordination in practice.

9. The European Response • There are many different examples of policies and innovation on integrated care around Europe • The political agendas, however focus on: • Financial reform • Cost containment • Legislative change • Structural reorganizations • Personalised care • Pilot programmes • Not enough on change management and the ‘how to’ of integrated care National Strategies - Examples • Denmark & Norway: Coordination Reform • Sweden: Joint agencies link funding and delivery (e.g. Jönköping & Nortallje) • England: The National Collaborative for Integrated Care and Support (Pioneers) • Germany: Versorgungsstrukturgesetz(care structure law) supports interdisciplinary and cross-sector models of care • Netherlands: Managed care organizations and bundled payments for certain diseases • Health and social care integration in Northern Ireland, Scotland and Wales • Spain: vertically and horizontally integrated care organizations to support better chronic care ( e.g. Basque Country, Catalonia, Valencia) • Switzerland: physician networks / HMOs

10. Example 1: The Basque System, Spain • Developing a favourable policy environment • Stimulating systems thinking with new models of care • Aligning ‘bottom-up’ and ‘top-down’ integration • Providing a distributed leadership approach Care transformation in the midst of a deep economic crisis

11. Bengoa, 2013 - http://www.ijic.org/index.php/ijic/article/view/URN%3ANBN%3ANL%3AUI%3A10-1-114747/2042

12. Example 2: Maccabi, Israel • Physician group partnership providing co-ordinated care to 1.9m people (25% population) • Integrated ICT systems promote communication , continuity of care and supported self-care through ‘patient portal’ and telehealthcare • System focus on managing chronic disease and the elderly • Investment in leadership and inter-professional working • Investment in research • Positive impact on care experiences, clinical outcomes and cost containment

13. Maccabi 2011 - http://www.intel.co.uk/content/dam/www/public/us/en/documents/white-papers/coordinated-healthcare-from-maccabi-and-intel-paper.pdf

14. Example 3: National Collaborative for Integrated Care, England • The ‘Narrative’ • Change to NHS Mandate • Development of shared care outcomes between government departments, and quality regulator includes new targets • Integration encouraged alongside competition by economic regulator • Financial reforms supports range of new incentives to providers • Commissioning reforms supports new opportunities to pool budgets • New resources to support change – and the Integration Transformation Fund (£3.8bn) • Pioneers Programme

15. EUROPE 2020 FLAGSHIPS FOR SMART, SUSTAINABLE AND INCLUSIVE GROWTH Digital Agenda Youth on the Move Innovation Union New Industrial Policy New Skills and New Jobs Platform against Poverty Resource Efficiency HEALTH IN EUROPE 2020 EUROPEAN INNOVATION PARTNERSHIP ON ACTIVE ANDHEALTHY AGEING

16. +2 Healthy Life Years by 2020 Triple win for Europe Action Groups Reference Sites

17. EIP AHA B3 Action Plan • Increase the average number of healthy life yrs by 2 in the EU by 2020 • Health status and quality of life ।Supporting the long term sustainability and efficiency of health and social systems । Enhancing competitiveness of EU industry Chronic Conditions Integrated Care SIP TARGETS By 2015 Chronic Conditions’ Programmes available at least 10% of target population in at least 50 regions By 2015 - 2020 Integrated Care Programmes serving older people, supported by innovative tools and services, in at least20 regions Implementation and Scale Up of Chronic Care + Integrated Care Programmes Action Area  Organisational Models Action Area  Change Management Action Area  Workforce Development Action Area  Risk Stratification Action Area  Care Pathways Action Area  Patient / User Empowerment Action Area  ICT Tools Toolkit Map of partnership models for implementation of Chronic and Integrated Care Programmes Map of best practice methodologies to support the implementation of Chronic and Integrated Care Map of reusable learning resources Stratification of the population Mapping Best Practices in the EU regions Map of coaching, education and support patient/user empowerment and adherence Action Area  Finance/Funding Toolkit Action Area  Dissemination Toolkit Toolkit Toolkit Toolkit Toolkit Toolkit 2013 Monitoring impact and outcomes 2015

18. Developing a Regional Action Framework for Coordinated/Integrated Health Services Delivery (CIHSD) in the WHO European Region • Dr. Hans Kluge • Director, Health Systems and Public Health European Forum for Primary Health Care Conference Istanbul, Turkey, September 9th – 10th2013

19. The Road Map to CIHSD

20. The Integrated Care Response in US and Canada USA Canada Health Canada – Health Accord, 2004 Sets 10 plans to overcome duplications, improve access and promote efficiency Emphasis on care transitions hospital-home to reduce ‘bed blockers’ Provincial application leads to decentralisation and variation PRISMA, Quebec GP group practices, Alberta Community-oriented primary care centres, Newfoundland and others • Integrated delivery systems for enrolees • E.g. Kaiser Permanente • E.g. Veterans Health • HMOs & group practice models • E.g. Mayo, Geisinger, Seattle • Managed care or disease management programmes • E.g. PACE • Integrated delivery systems for populations: • E.g. Nuka, Alaska • E.g. Massachusetts

21. Example 4: PACE Programme, USA • Fully integrated system providing acute and long-term care services to older people (>55) • Grew out of On Lok, an innovative senior centre that developed a day hospital approach to care to frail older people • Based around an adult care centre that offers: • social and respite services • primary medical care • geriatric outpatients • ongoing care and case management • Designed to maintain frail older people in the community for as long as possible, so avoiding institutionalisation • Voluntary enrolment, available to those aged >55 eligible for nursing home admissions and covered by both Medicare and Medicaid • Important role of informal carers and supportive housing often part of care package

22. Example 4: PACE Programme, USA • Between 1987-1997 PACE operated as a federal demonstration programme • Since 1997, PACE a permanent provider under Medicare and a state option under Medicaid • By January 2005 36 fully operational programmes across 18 states • A typical participant: • A woman who is 80 years old with multiple (9.7) medical conditions with limited activities for daily living. 49% have a diagnosis of dementia How PACE achieves integrated care: • Pooled financing (Medicare & Medicaid) and authority to control how capitated funding is spent • Integrated services by range of staff employed at adult care centre – outside contracts for medical services, acute hospitalisations & nursing home care • Case management by multidisciplinary teams including comprehensive assessments, service provision and care co-ordination • Prevention and rehabilitation focus

23. Example 4: PACE Programme, USA Evaluations of PACE conclude: • Large decreases in hospital use (admissions and lengths of stay) for enrolled patients • Increased use of outpatient medical care and therapies, and care in home environment • Positive impact on Medicare costs in comparison to non-enrolee groups • Client health status and satisfaction with care arrangements good • Results in terms of physical functioning inconsistent Conclusions: • PACE successful in managing frail older patients and in offsetting costs against more expensive outpatient care • Capital and start up costs were substantial, so PACE needed pump-priming from federal and state governments in initial phases • Some patients not comfortable with adult day health care settings and/or giving up contact with a personal physician • Centres run at a small scale (c.300 enrolees) so issues of economies of scale if more widely adopted

24. Example 5: PRISMA Programme, Quebec, Canada • Unlike PACE, PRISMA is a co-ordinated model of care • The goal is to integrate service delivery to older people to improve functional autonomy • Admission is to persons >65 who have moderate to severe disabilities, but show good potential for staying at home – they need two or more health and social care services from the area in which they live How PRISMA achieves integrated care: • Inter- and intra-organisational co-ordination by joint governing board and a service co-ordination committee • A single point of entry to care services • Case management who work with clients’ family physician and other providers • Common assessment process and care plan • Joint budget • Integrated information system to track patients and support continuity of care

25. The PRISMA Model

26. PRISMA (Canada) Evaluations of PRISMA conclude: • Declining trend in institutionalisation • Lower client preference to be institutionalised • Greater functional autonomy of clients • No reduced or significantly changed pattern in the use of health and social care services • Positive impact on carer burden • No impact on mortality (survival) • No reduction in costs Improved system outcomes at no additional cost

27. PRISMA and PACE compared

29. Towards Integrated Health Service Delivery in Latin America

30. Essential attributes of IHSDNs (PAHO, 2011)

31. WHO (Geneva) - Integrated care as a strategy to support universal health coverage

32. WHO (Geneva)Strategy for High Quality and People Centred Integrated Care (HQPCIC) to support Universal Health Coverage

33. Conclusions: Strategies and Progress • Integrated care is a global buzzword and strategy for system reform • Integrated care takes on multiple forms, and the purpose to which it has been adopted varies • Cost-containment / creating sustainable care systems is a central driver, yet evidence suggests that integrated care is primarily a tool for quality improvement • Evidence remains varied and limited, especially on costs • However, there is enough to suggest what the important components of integrated care must be, and that the approach can support the ‘Triple Aim’ goals of care systems • Yet, the failure rate amongst integrated care initiatives is high – more is needed in understanding how to develop, sustain and spread initiatives successfully and for the long-term • There are few alternative options …

34. Contact Dr Nick Goodwin CEO, International Foundation for Integrated Care nickgoodwin@integratedcarefoundation.org www.integratedcarefoundation.org @goodwin_nick @IFICinfo