Community based clinical service development - what are our possibilities

1. Integrating Care – what are the
possibilities?
November 14, 2013
CONFIDENTIAL AND PROPRIETARY
Any use of this material without specific permission of McKinsey & Company is strictly prohibited

2. Pace of change in the healthcare industry has been slow to date
Physician’s office – then vs. now
1908
2012
Modern medicine is still using fairly primitive technology
McKinsey Clinical Leadership Academy
| 1

3. Rising financial pressure to change…
Share of healthcare costs as part of GDP
%1
Country
<10
2008
2015
2020
2025
10-15
>15
2030
Korea
5.9
6.7
7.4
8.1
8.9
Hong Kong
6.0
6.8
7.5
8.2
9.0
Spain
7.8
8.9
9.7
10.7
11.7
Italy
8.8
10.0
11.0
12.0
13.2
U.K.
9.3
10.6
11.6
12.7
14.0
Ireland
9.4
11.9
13.0
14.4
15.8
Australia
10.5
10.5
13.1
14.4
15.8
Canada
10.8
12.3
13.5
14.8
16.2
Germany
10.8
12.3
13.5
14.8
16.2
France
11.2
12.7
14.0
15.3
16.8
U.S.
16.1
18.3
20.1
22.0
24.2
1 Assumptions: Healthcare spending increases 1.9 basis points faster than OECD GDP Growth Forecasts (OECD historical rate)
SOURCE: OECD Policy Implications of the New Economy – 2000-50, 2001; Global Insight WMM, 2000-37; Espicom: World PharmaMcKinsey Clinical Leadership Academy
ceutical Fact Book, 2008; International Monetary Fund; World Economic Outlook Database, October 2009; McKinsey
| 2

4. Despite Ireland having low diabetes prevalence and death rates, patient
expenditure is still high
Diabetes burden across 15 European Countries
Estimated burden of disease
Diabetes prevalence
Diabetes related deaths
7.5
7.2
6.9
6.5
6.2
6.2
6.0
5.6
5.4
5.0
4.6
4.3
4.0
3.9
10.0
9.3
8.5
8.4
8.2
8.1
7.8
7.5
7.4
7.0
6.6
6.4
5.7
5.6
3.9
Average = 7.4 %
2.6
Average = 5.4 deaths per 10,000
SOURCE: International Diabetes Federation, 2012
Diabetes £ per person
9.3
9.2
7.7
7.0
6.6
6.3
6.1
5.9
5.6
5.6
5.4
5.1
4.2
3.5
3.3
Average= £ 6.0k
McKinsey Clinical Leadership Academy
| 3

5. What patients want – Patient’s Experience of Hospital Services
“Staff nurses, doctors and support workers
were efficient, friendly and put my
needs first…”
“Being on a waiting list over a year is not
acceptable. At 77 years old it is too long
to wait.”
“Patients are endlessly asked the same
questions and you feel no one consults
those notes to avoid asking them again.
“The multi disciplinary team gave me the
support and information I required, all
administered in a professional and cheerful
climate.”
SOURCE: Irish Society for Quality & Safety in Healthcare, 2011
McKinsey Clinical Leadership Academy
| 4

6. The consequences of continuing in a ‘business as usual’ way across the
system will be significant
Patients
▪
▪
Face reduced access to services,
There is less flexibility in treatment options
Payors and health systems
▪
Increased spending on acute services at the expense
of social, mental and prevention activities
▪
Disputes with providers may increase,
▪
▪
Unless
addressed this
will lead to an
increase in
poorly treated
and
undiagnosed
patients who
will further
reinforce
strains across
the system
Face major financial challenges
Providers
Challenge of delivering more with less
McKinsey Clinical Leadership Academy
| 5

7. Integrated care can help address these challenges
Goals of integrated care
▪
Empower patients, users and their carers
▪
Provide better and more pro-active care for a
specific group of patients that are most at risk
▪
Provide the best possible quality of care at the
minimum necessary costs
McKinsey Clinical Leadership Academy
| 6

8. Our research and work across the globe shows that successful integrated
care systems require three core building blocks
Success in integrated care
A Address specific patient needs …
Patient cohorts
Very high risk
B … by working in a multi-disciplinary
system …
1 Clinical
protocols and
care packages
2 Care
coordination
and planning
High risk
Moderate risk
Low risk
Very low risk
3 Case
conference
4 Performance
review
C … supported by key enablers
Aligned incentives
and reimbursement
models
Accountability
and joint
decision-making
Information
transparency and
decision support
Clinical leadership
and team working
Patient engagement
McKinsey Clinical Leadership Academy
| 7

9. A First, understand the needs of the population you are trying to serve…
2010/11 data, 4 London CCGs
Health spend
Average cost per
capita per annum, £
Population
Very
high
4,757
High
Moderate
Low risk
322,609
378,020
Total/average
~890,000
188
8,700
142,773
Very low
1 Includes elective admissions, outpatient, and A&E
Total spend, £m
39,600
41,675
Social care spend
327
2,400
354
160x difference in cost!
500
300
186
104
1,230
1,168
2 Includes community health & primary care
SOURCE: McKinsey team analysis, NHS NWL data; HES 2010/11, FIMS, Q research/NHS
Information centre, PSSEX; NHS Reference Costs
McKinsey Clinical Leadership Academy
| 8

10. B What does a Multi-Disciplinary Team do?
The MDT uses an
information tool to
stratify these patients
by risk of emergency
admission
Patient registry
Each patient is then given
an individual integrated
care plan that varies
according to risk and need
Performance review



Care planning
Care delivery1
Risk stratification
GP
The MDT meets regularly
to review its performance
and decide how it can
improve its ways of
working to meet its goals
A small number of the
most complex patients
will be discussed at a
multi-disciplinary case
conference, which will
help plan and
coordinate care
Practice nurse
Case conference
District nurseSocial care
worker
Community Community
pharmacistMental Health
Each MDT holds a register of
all patients who are part of the
IC programme
All providers in the MDT agree
to provide high quality care as
laid out in recommended
pathways and protocols
Shared clinical protocols
Patients receive care from a range of
providers across settings, with primary
care playing the crucial co-ordinating role
and everybody using the IC IT tool to
coordinate delivery of care
1 Icons are illustrative only: any number of other professionals may be involved in a patient’s care,
a case conference or performance review
McKinsey Clinical Leadership Academy
| 9

11. C Beyond care delivery, enablers are crucial
… supported by key enablers
Reimbursement
& incentives
▪ Significant
▪
▪
▪
(30%+)
At scale (30%+)
Sustained (3-5
years)
Align risk and
reward across
system
SOURCE: McKinsey & Company
Governance
▪ CEOs & Boards
▪
▪
commitment of
resources
Bind in payors,
hospitals,
primary care and
local
government
Hold to account
for delivery
Information
▪ Support
– Patient
▪
records
– Clinical
decision
making
– Peer
pressure
– Payment
Solve
Information
governance
Clinical
leadership
▪ Role model
▪
▪
▪
behaviour
Deliver
consistently
Hold peers to
account
Work within
team
Patient
engagement
▪ Empower
▪
patients with
informed choice
Make use of
behavioural
economics
McKinsey Clinical Leadership Academy
| 10

12. CONFIDENTIAL: Not for onward distribution
→ ChenMed: Aims to minimise avoidable hospital admissions through
intensive primary care and aligned incentives
Description
▪
▪
ChenMed medical centres are set up to look/feel like a quiet A&E
with rapid access for unscheduled appointments available, to
reduce patient A&E use
▪
Each centre at capacity – 5 primary care physicians, 10-15
specialists rotating through, 2200+ Medicare patients
▪
Task-shifting is used extensively with trained, but unqualified, health
assistants carrying out routine clinical tasks (such as BP monitoring,
clinical measurements, administration)
▪
Patient
experience
ChenMed offers patients regular appointments with their named
Primary Care Provider; numbers predetermined by the risk
stratification model (min. 1 per month)
ChenMed aims to offer most services under one roof including
primary care, outpatient care, diagnostics, dental care, pharmacy
and complementary medicine including acupuncture
How care is
organised
SOURCE: Source
McKinsey Clinical Leadership Academy
| 11

13. CONFIDENTIAL: Not for onward distribution
→ Torbay: Integrated health and social care teams are co-located in zones
Patients and providers have one number to call
SC
Lead
If a patient comes
to A&E and does not
require admission to
hospital, the acute trust
contacts the zone and
the Health and Social
Care Coordinator
contacts various
agencies to make sure
the patient is able to go
home or receive
temporary placement
if needed
OT
Lead
Front desk
Nurse
Lead
HSCC Manager
Admin
DN
team
IC
team
Physio
Lead
GP Triage
Desk
Lead
P.A.
Zone
Lead
Note: DN – District Nurse; SW – Social Worker; CCW – Community C.Worker; HSCC – Health and Social Care Co-ordinator; RCO – Referral
Co-ordinators; IC – Intermediate Care Team
SOURCE: Torquay North Health and Social care team
McKinsey Clinical Leadership Academy
| 12

14. Key questions for consideration in the Irish context
▪
What is the appropriate model of primary
and community based services in Ireland
(Chen Med/Torbay/other)?
▪
Which of the key enablers would be most
important in driving change
(reimbursement, IT, clinical leadership)?
▪
What will it take to effect this change at
scale in this country?
McKinsey Clinical Leadership Academy
| 13