Goodwin, Nick - From lean thinking to complex adaptative system
Innovative Healthcare DesignFrom lean thinking to complex adaptive system Developing new service models to integrate care around patients with complex care needs Dr Nick Goodwin, Senior Fellow, The King’s Fund, UK Paper to MIHealth Forum, Fira Barcelona, 24 May 2012
The Need to Focus on Complexity• People with long- term and chronic illnesses are the main challenge facing health care systems worldwide• Numbers are predicted to increase as populations age and lifestyle choices lead to earlier onset of chronic conditions• Yet, health systems are largely configured for individual diseases
INTEGRATED CARE• Integrated care is an approach for any individuals where gapsin care, or poor care co-ordination, leads to an adverse impacton care experiences and care outcomes.• Integrated care is best suited to frail older people, to thoseliving with long-term chronic and mental health illnesses, and tothose with medically complex needs or requiring urgent care.• Integrated care is most effective when it is population-basedand takes into account the holistic needs of patients. Disease-based approaches ultimately lead to new silos of care.
The Mrs Smith test... Many people with mental, physical and/or medical conditions are at risk of long hospital stays and/or commitment to long-term care in a nursing home. Mrs. Smith is a fictitious women in her 80s with a range of long-term health and social care problems for which she needs care and support. Mrs. Smith encounters daily difficulties and frustrations in navigating the health and social care system. Problems include her many separate assessments, having to repeat her story to many people, delays in care due to the poor transmission of information, and bewilderment at the sheer complexity of the system.
From a fragmented set of health Social Worker and social care services … G.P. Practice Nurse Domiciliary Care District Nurse O.T. O.T. DiabetologistFamily & Friends Home Cardiologist
… to a co-ordinated service that meets her needs Integrated Team SAP Home Family and Specialist Services Friends
Integrated care for frail older people in Torbay, UKTorbay Care TrustIntegrated health and social care teams,using pooled budgets and servinglocalities of c.30,000 people, workalongside GPs to provide a range ofintermediate care services. By supportinghospital discharge, older people havebeen helped to live independently in thecommunity. Health and social care co-ordinators help to harness the jointcontributions of team members.The results include reduced use ofhospital beds, low rates of emergencyadmissions for those over 65, andminimal delayed transfers of care.(Thistlethwaite, 2011)
The ESTHER Project, SwedenJönköping County CouncilTeam of physicians, nurses, and otherproviders who joined together toimprove patient flow and coordination ofcare for elderly patients within a six-municipality region in Sweden.The Esther Project team consisted ofphysicians, nurses, social workers, andother providers representing theHöglandet Hospital and physicianpractices in each of the six municipalities.Closer cooperation among specialists andother providers meant that PCPs andhomecare nurses were able to do forpatients some of the things specialistshad been doing. Additionally, patienteducation was recognized as critical.
The PACE Programme, USAPromoting All-Inclusive Carefor the ElderlyFully integrated system providing acuteand long-term care services to olderpeople (>55) based around an adult carecentre that offers: social and respiteservices, primary medical care, geriatricoutpatients, ongoing care and casemanagement, informal carers.Since 1997, PACE a permanent providerunder Medicare - 36 fully operational "Without PACE, I would not be ableprogrammes across 18 states. A typical to keep working and care for myparticipant: woman who is 80 years old mother. Without the day program, Iwith multiple (9.7) medical conditionswith limited activities for daily living. 49% dont think I would have a life. Itshave a diagnosis of dementia. wonderful.”Successful in managing care out ofhospital cost-effectively. High clientsatisfaction.
Systemic Characteristics• Universal coverage, care free at point of use – Use of prepaid capitation-based budgets• Primary/community care driven – Developing new services that wrap around primary care practices to support people in local communities has a record of success• Emphasis on chronic and long-term physical and mental health care• Emphasis on population health management and public health• Alignment of regulatory frameworks with goals of integrated care• Funding/payment flexibilities to promote integrated care – Seeing the hospital as a cost-centre, not a revenue centre• Workforce educated and skilled in chronic care, teamwork (joint working) and care co-ordination
Organisational Characteristics• Strong administrative and clinical leadership• Shared mission, values and culture• Common organizational and governance structure• Shared organizational/financial accountabilities• Aligned financial incentives and use of funding flexibilities (e.g. pooled/capitated budgets)• Organized provider network embedded in system• Integrated IT & single electronic health record• Responsibility for defined population and/or service area (e.g. registered list)• Continuous quality measurement and improvement
Delivery Characteristics There are many different ways in which professionals and providers can work directly with communities, patients/clients to support integrated care. These ‘tools’ focus on the ‘how’ of clinical and service integrationExamples of tools for clinical or professional Examples of tools for service integration:integration: • Assisted living/care support in home• Case finding and use of risk-stratification • Single point of entry• Standardised diagnostic and eligibility criteria • Care co-ordination• Comprehensive joint assessments • Case management• Joint care planning • Disease management• Single or shared clinical records • Centralised information, referral and intake• Decision support tools such as care • Multi-disciplinary teamwork guidelines and protocols • Inter-professional networks• Technologies that support continuous and • Shared accountability for care remote patient monitoring • Co-location of services• Peer review • Discharge/transfer agreements • Personal health budgets
From ‘Lean Thinking’ … to Complex Adaptive Systems Address workplace organisation, Because complex adaptivestandardisation, elimination of non- systems self-organize, value added steps to improve flow, no one can impose an eliminate waste organizational design.