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  1. 1. Procy on management consulting ab Models of integrated health care and social services: A vision about future trends Göran Stenberg, Director Procyon Management Consulting AB. Suècia
  2. 2. Procy on management consulting ab
  3. 3. Procy on management consulting ab This presentation: Use systems thinking and especially complexity science or a complex adaptive systems approach to understand the integration of health care and social services. Some examples from Sweden
  4. 4. Procy on management consulting ab Six rules Six init ial r ules t o guide our sy st em t hink ing 1.Pat ient needs ex ceeds or ganizat ional boundar ies 1.One or sev er al or ganizat ions can be r egar ded as a sy st em
  5. 5. Procy on management consulting ab 1. Under st anding indiv idual unfulf lled needs is necessar y 1. Indiv idual pat ient s also belong t o t ar get / pat ient gr oups. Under st anding t ar get gr oups and t heir needs ar e impor t ant 1. Sy st em design is built on a basic under -st anding of w hole sy st em fr om beginning t o end. Cr ucial is inter sect ion of dif fer ent pr ov ider s 6. Changing focus of w or k fr om inside-out t o out side-in – a shift fr om get t ing t he pat ient s t o f t int o the exist ing sy st em t o let t ing t he sy st em incor por at e pat ient k now ledge and ex per iences int o it s act iv it ies
  6. 6. Procy on management consulting ab Background • People w it h complex needs fr equently r equir e cont inuous car e in mult iple set t ings • Without int egr at ion, all aspect s of healt h car e and social car e ser v ice per for mance, suf fer s • The pr oblems obser v ed – a r esult of t he pr e-v ailing mindset ( Nor man 2001) “When t he map changes t he landscape”. Rat ional t hink ing – v iew ing or ganisat ions as machines
  7. 7. Procy on management consulting ab • A challenger t o t he pr ev ailing mindset, v iew s or ganizat ions as human sy st ems, i.e. t hat is human pur poseful int er action COMPLEX ADAPTIVE SYSTEMS ( CAS) • A sy stem is r efer r ed t o “complex” w hen it has so many v ar iables and int er act ing for ces t hat it cannot be under st ood by t r adit ional t op- dow n t hink ing and appr oaches ( Ant hes 2003)
  8. 8. Procy on management consulting ab Problem statement How can t he CAS appr oach be used by manager s to suppor t t he int egr at ion of healt h car e and social car e t o secur e appr opr iat e car e for t he benef t of t he pat ient ?
  9. 9. Procy on management consulting ab Theory and discussion • The machine model: The t r adit ional w ay of dealing w it h complex it y is r at ional and sy st ematic • Unit s w ould be managed separ at ely accor ding t o t he r ules of t he machine model - if each par t could w or k bet t er, t hen t he w hole should w or k bet t er ( Mor gan 1986) ATHOMISTIC • This det er minedly inw ar d focus w ill r esult in poor or no under st anding of the life sit uation of an elder ly per son w it h mult iple healt h and social pr oblems
  10. 10. Procy on management consulting ab • Inst ead of theor ies assuming cause and ef fect link ages bet w een separ at e par t s, w e need t heor ies t o deal w it h pat ter ns and pr inciples ( Zimmer man et al. 1998) HOLISTIC • CAS is not a t ool box but a model for t hink ing as a pr epar ation for action • A foundat ion of CAS is t he impor t ance and t he abilit y of self or ganizat ion ( Kaufman 1993) - Creating order without help from the outside
  11. 11. Procy on management consulting ab • When complex ity is at hand: Impossible to design an opt imal sy st em in adv ance - t oo many v ar iables t o t ak e int o account ( For sber g et al. 2004) • Reconsider at ion of st andar d manager ial t ask s and sear ch for new r ules
  12. 12. Procy on management consulting ab Innovative managers of integrated care Some guiding principles: 1. Planned appr oaches t o change has been r eplaced by mor e emer gent w ay s of w or k ing. CAS agent s – all t he int egr at ed car e par t ner s – adapt and change const ant ly w hen t hey face new cir cumst ances in or der t o maint ain t he sy st em 1. Agent s in t he local sy st em hav e bot h t he r esponsibilit y and capabilit y t o act 1. Innov at iv e manager s r egar d t he pat ient as an act iv e co-pr oducer - may not only empow er t he pat ient but is also a mean t o ser v ice quality ( Kellogg et al. 1997)
  13. 13. Procy on management consulting ab 1. Sense mak ing is used t o inf uence change in complex sy st ems ( Snow den 2002) 1. Agent s gener ously shar e k now ledge and infor mat ion in or der to str engthen t he ent ir e sy st em ( C.F Tet enbaum 2008) and incr ease it s t ot al v alue 1. Teambuilding ar e act iv ely pr omoted - int er -or ganizat ional as w ell as inter -pr ofessional - of great impor t ance for t he v alue cr eat ion w it h user s ( Edgr en & St enber g 2006)
  14. 14. Procy on management consulting ab 1. Under st anding t he unw r it t en r ules help sy st em designer s t o mov e aw ay fr om t r adit ional r ules Tr ad: Pr ofessionals pr imar ily see t hemselv es as w ork ing independent ly in t heir ow n responsibilit y t o t he patient New : All healt h and social car e pr ofessionals see t hemselv es as par t of a t eam in par t ner ship w it h pat ient s t o impr ov e healt h ( Inst it ut e of Medicine 2007) 1. Manager s cr eate the means for continuous lear ning ( Senge 1990) and feedback r egenerat es t he sy st em
  15. 15. Procy on management consulting ab 1. Wor k ing r elat ionships bet w een agent s ar e collegial and built on t r ust - leading in an integr at ed car e sy st em is about leading peers - may mean t hat ow n or ganizat ional int er est s may need t o be put aside in fav our of t he w hole sy st em 1. Integr at ion is about int egr at ing agent s in a CAS and t heir dif fer ent t ask s w it hout r educing the dif fer ences t hat leads t o an ef fect iv e pr ov ision of t hese t ask s ( Edgr en 2006)
  16. 16. Procy on management consulting ab Conclusion An integrated health care system is built upon the collective intelligence of different professionals who use their knowledge together with the individual to meet Individual patient needs A hierarchal top-down approach, following machine model thinking, does not fit with the inherent logic of integration which requires adapting to local circumstances. A CAS approach views systems as living organisms
  17. 17. Procy on management consulting ab CAS is a powerful concept but more efforts is needed to communicate the potential of the CAS approach to managers of integrated care.
  18. 18. Procy on management consulting ab Some examples of integrated health care organisations in Sweden
  19. 19. Procy on management consulting ab Sweden’s decentralised Health Care system 20 County Councils - Responsible for financing and providing Health Care services for the entire population 290 local authorities - Responsible for social service, housing and Care for elderly and disabled
  20. 20. Procy on management consulting ab Components in the Swedish Health Care System  Public Health Care System based on an overall goal: - “Good health and health care for all on equal conditions”  Social Insurance System partly covering loss of income by illness  Decentralised system with 20 self-governed County Councils lead by politicians elected every fourth year  Financing mainly by County Council direct taxes (70%). The rest is governmental subsides and patient fees  90 % public hospitals. 40 % private primary care units  Freedom of choice of primary care unit (not GP). PCU financed mainly by capitation based on population profile  Local authorities are responsible for elderly care, social care and home service.
  21. 21. Procy on management consulting ab Integrated Health Care Public Health High Specialized Health Care Specialized Elective Health Care Specialized Acute Health Care Patient processes Competence transmission acute elective Region of Skane Vision – integrated health care
  22. 22. Procy on management consulting ab Medical value added. Development and reneval. Distribution of knowledge Adequate time between referral and care Reasonable time between investigation, diagnose and treatment. Investigations and treatments that are plannable in time, content and volume Shortest possible time between alarm and adequate pre-hospital care Acute grave conditions or acute seriouse illness or injuries Adequate treatment Improved prognose Concentrated organization Process efficiency, free of disturbance, quality and concentration. Acute or elective severe not frequent diseases or injuries Elderly, children and youths. Chronical diseases or common health care problems Local health care Specialized acute health care Specialized elective health care Highly specialized health care Accessibility Co-operation Result Effects Needs Nearness Accessability all day around Improved health status. Confident population. Teamwork between competences needed Some charateristics of integrated health care organisation in Skåne Finance Spec.LA PCU Pat
  23. 23. Procy on management consulting ab Integrated teams at the ED in Malmö Support and making it easier to estimate the patients need of care and level by using the right competence of professions • Self care advice • Triage • Collaboration between GP/PC and hospital Advice nurse • Admittance to ward • Contact with physician, ward and relatives before admittance • Coordinating discharges Hospital nurse • Activity and functionel estimate • Estimate the need of disabilty aid • Contact with local community rehab. Occ. therapist • Info about the patient´s social situation • Coordinating community services • Patient info about services available Social worker • Estimate patient´s physical capability • Judge the need of disability aid • Rehabilitation programs before discharge Physiotherapist GP back up Physi- cian back up
  24. 24. Procy on management consulting ab  29 % of all elderly patients with acute needs recieved treatment from the integrated team. The future expectations is 50 %  The patients meet the competence they need in the same locality  Patients as well as professionals are very satisfied with the teamwork  Promote collaboration between different organisations and units and the understanding and trust grows  The flow of information between the units has improved  The locistic has improved, the time spent in the ED is reduced, a growing number of patients can be referred back home and quality in home care has improved. Some results with the integrated team
  25. 25. Procy on management consulting ab  Care for elderly patients in the ED has a clearer focus  Many patients by pass the ED directly to the medicine ward  The physiotherapist in the triage estimate the patients need for treatment or disability aid.  Collaboration around relevant aid e.i wheel chair for the patient. Functional estimates improves the quality in home care.  Advicing nurse sees 20 – 30 acute patients per day (10 %) ledading to shorter waiting times. Some more results with the integrated team
  26. 26. Procy on management consulting ab TioHundra AB i Norrtälje - Stockholm Norrtälje Local community Stockholm County Council Purchaser Private GP-s Primary Care incl. GP Hospital Care incl. ED Social services Elderly Care Home Care Public Company ”TioHundra AB”
  27. 27. Procy on management consulting ab TioHundra AB – Norrtälje - vision  ”It is time to think in new ways. We will create a patient oriented organisation”.  Responsibility for the local population and financiation  Increased focus on health and functional ability  Integrated health care and social care organisation  New possibilities to boarderless collaboration around users/patients to solve their health and care needs.
  28. 28. Procy on management consulting ab TioHundra – some resultats Elderly care  Shorter waiting times to homes for elderly  Half the number of waiting patients/users  Improved quality of care and lower costs  The number of beds needed has been reduced  Home service has improved in collaboration with home care  Quality and users satisfaction are in some areas above avarage in Sweden
  29. 29. Procy on management consulting ab TioHundra – some resultats Phychiatry  Community and County Council phychiatry in the same organization  New developments of care outside hospital – reduced beds needed by 40 %. Rehabilitation and elderly care  All physioterapists, occopational therapists and other rehabilitation competences in the same organisation – increased effeciency and lower costs
  30. 30. Procy on management consulting ab Some identified barriers - structural - organisation culture - profession culture - IT Exemple of bridging dimensions: - hub function - common house - physically close - uniform financing - collected range Findings in studied integrated care organisations in Europe
  31. 31. Procy on management consulting ab Patient perspective as driver force for organising Most care needs to be taken care of outside hospitals Defiended population or patient groups/target groups Management task to bridge barriers Incentives supporting commom actions:  Common task- clear assignment and targets  Collaboration is a natural part in the culture  Knowledge of each others different conditions  Combination of monetary och non monetary incentives
  32. 32. Procy on management consulting ab Innovation in health care system Integrated organisation Patient Processes Target groups (Patient groups) Specialities Competences Health care units Patient results Production results
  33. 33. Procy on management consulting ab Managed and organised from a patient perspective Compensation based on patient results Patient process Units, clinics etc Resultat messured as: Cost, use of resources, production e.i number of patients, visits, bed days, treatments, re-operations, returns, mortality etc Managed and organised from a production perspective Patient need Results in terms of: Medical quality Patient satisfaction Quality of life Cost efficiency From producer perspective to patient perspective
  34. 34. Procy on management consulting ab Corner stones Patient results Patient groups Patient result based compensation Patient processes Professional self control Leadingtobett er….. Basedon….. Compensatedfr om….. Through…..
  35. 35. Procy on management consulting ab Quality Cost Higher OK Lower Lower Bonus Bonus Investing in quality improvement OK Bonus Compensation as agreed Quality development Higher Cost improvement Rationalization Question/ terminate ”To create new relations between cost and quality” Compensation model
  36. 36. Procy on management consulting ab