Hospital Medicine around the World- Taiwan Experience

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This is the presentation by Dr. Hung-Bin Tsai to introduce the hospitalist program in National Taiwan University Hospital at International Hospital Medicine Forum of Hospital Medicine 2014.

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  • It uses private-sector providers, but payment comes from a government-run insurance program that every citizen pays into. Since there's no need for marketing, no financial motive to deny claims and no profit, these universal insurance programs tend to be cheaper and much simpler administratively than American-style for-profit insurance.
    The classic NHI system is found in Canada, but some newly industrialized countries -- Taiwan and South Korea, for example -- have also adopted the NHI model
  • 1.Demand for PDMC may be as high as 29% in home care patients within 30 days after discharge.
    PDMC is needed more by patients with malignancy and lower BI.
    2.More focus should also be given to those with lower BI, higher CCI, and longer length of hospital stay, as they more frequently have red flag signs.
    樹金忠文章: PLoS One 2013
  • Hospital Medicine around the World- Taiwan Experience

    1. 1. 1 Dr. Hung-Bin Tsai Division of Hospital Medicine, Department of Traumatology, National Taiwan University Hospital March 25, 2014 Hospital Medicine Around the World - Taiwan Experience Special Interest Forum 2014
    2. 2. National Health Insurance in Taiwan (TNHI)  Started on March 1, 1995  Spend 6.6% GDP for health in 2011.  Compulsory social health insurance program for all citizens from birth  Health Insurance IC Card  Second Generation National Health Insurance System2
    3. 3. Payment System of TNHI  Healthcare institutions signed contracts with the BNHI: 92.47%  Early years : “fee-for-service” → spiraling growth of medical cost  Pay-for-performance system (first introduced in 2001)  breast cancer therapy, diabetes, asthma and hypertension treatment  Global Budget Payment System  Taiwanese version of the Diagnosis Related Groups (Tw-DRGs)  adopted 111 DRGs into practice for the first year (2010) and would take 5 years to phase in the complete system (more than 500)
    4. 4. The Hospitalist Program in National Taiwan University Hospital (NTUH) Founded in Oct. 2009  Current 8 Hospitalists  Teaching: yes  Services offered:  Medical management of multimorbid patients  Consultative services  Co-management of surgical patients  Palliative care  Medical education to nurse practitioners & nurses  Quality improvement  Information technology  Integrated post-discharge transitional care (PDTC) 4
    5. 5. Current situation of Hospital Medicine in Taiwan  Leading hospitalist program in Taiwan: NTUH, since Oct 2009.  Hospitalist program for 2-year young VS obligation for primary care: Chang-Gang Medical Center, since 2006  ED observation units model: Chi Mei Medical Center in Southern Taiwan, since Aug 2012. 5
    6. 6. Potential implications of Hospital Medicine in the development of best practice models in Taiwan.  Co-management for surgical patients  Reduce weekend effect of adverse outcome for weekend admission patients  Post-discharge transitional care  Palliative care for multimorbid aged patients 6
    7. 7. J Hosp Med 2011;378-382 Higher clinical severities of patients in hospitalist-run vs. Internalist-run ward Hospitalist-run vs. Internalist-run Ward: [After Propensity score matching] Less LOS for 6 days Less admission cost per patient: 3,590 USD Less paid by NHI per patient: 3,202 USD
    8. 8. Risk Factors for 30-day readmission: Intern Med J 2011 Jul 25. - CCI - Cancer - LOS  - Anemia
    9. 9. NTUH Hospitalist program reduce weekend effect of adverse outcome   (Propensity score matching)  Weekday  admission  (n =496) Weekend  admission  (n=496) P value Age (yr) 70.1 ± 15.6 70.0 ± 15.8 0.930 a Male gender 249 (50.2) 251 (50.6) 0.899 b Chronic disease CCI, unadjusted 2.6 ± 2.5 2.5 ± 2.4 0.432 a ED triage level 0.703 b 1-2 256 (51.6) 262 (52.8) 3-5 240 (48.4) 234 (47.2) BI at admssion 53.9 ± 36.9 51.3 ± 36.5 0.276 a Malignancy 103 (20.8) 109 (22.0) 0.699 b Outcomes ICU admission 9 (1.8) 5 (1.0) 0.299 b CPR event 1 (0.2) 3 (0.3) 0.374 b DNR consent 97 (19.6) 94 (19.0) 0.872b   Hospital mortality 42 (8.5) 40 (8.1) 0.818b
    10. 10. BMC Med. 2011 Aug 17;9:96. PLoS One 2013 Post-discharge Transitional Care (PDTC) Can Reduce Readmission Rate and Mortality 10 Pearls of PDTC: 8AM-8PM Call Center + Follow-up clinic in hospitalist-run ward 2 case managers to make phone calls Followed on post-discharge 1,7,14,30 days
    11. 11. Our Challenges  What are the needs to run local programs and chapters of Hospital Medicine? To redesign clinical schedule (need time for academic work) - Pair hospitalists, 2 wards by 4 teams 8a-6p for 7 or 14 days - Each team care 18 patients by 1 doc & 2 NPs To relieve night shift burden - on duty 6 nights per month - we need moonlighters/nocturist! 11
    12. 12. Our Challenges  What is the potential role of SHM in terms of teaching, research and networking? 1.One of the successful hospitalist programs in North- East Asia. 2.We wound design more detailed post-discharge transitional care model to link intermediate care (post-acute care) 3.To compare different interprofessional coordinated care models in USA, EU, Asia. 12
    13. 13. Suggestions to improve the international section and the HMX community  Regional annual experts meeting for consensus of best practice model in hospital medicine.  Encourage short-term (6 month to 1 year) exchange program for fellows to learn different models in healthcare system (such as palliative care).  To compare the burn-out index of hospitalists in different healthcare systems. 13
    14. 14. Acknowledgement: NTUH hospitalists provided holistic, integrated, non-border and trusted (HINT) services in Taiwan 14 Hot-blooded Hospitalists
    15. 15. Thanks for your attention! My Official E-mail: hbtsai@ntuh.gov.tw If you talk to a man in a language he understands, that goes to his head. If you talk to him in his language, that goes to his heart. ~Nelson Rolihlahla Mandela

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