Sorcha Mckenna, Head of Healthcare Practice, McKinsey

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Community based clinical service development - what are our possibilities

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  • Finally we need to hear what patients are telling us – they are tired of waiting for care and they would like to be able to have continuity of care with people they feel have their best interests at heart
  • Share a couple of examples on novel ways of providing integrated care focusing in the community that really start to get address these issuesChenmed – family owned practices (33 in North america) all identical in their infrastructure set up designed to provide better care for medicare patients – elderly/LTCs v defined population.30% fewer emergency admissions, consistently 98% patient satisfaction
  • Sorcha Mckenna, Head of Healthcare Practice, McKinsey

    1. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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

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