Presentation at the conference “Are We in this Together? Innovation Capture and the Role of Public-Private-Partnerships in Providing Health Care Services“ Helsinki, 8 April 2015

1. Bureaucratic or dynamic public sector?
Perspectives from both public and
private sector in health care
Timo Sinervo THL
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2. Background
• Project: Client centered primary care - patient choice
and care integration?
• Freedom of choice and care integration have been topics
internationally and in Finland recent years, both related to
client centeredness
– Now possibility to choose a health center once a year
• Limited knowledge on how these objectives are combined
• Mainly good experiences of patient choice in Sweden
– No experiences on care integration and patient choice
• Patient choice supposed to have positive effect on care
quality and on better access to care
• A risk may be equality, possibilites of the most frail people to
do well-informed choice
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3. • Care integration important among people in need for chronic
care, patient choice may increase fragmentation
• In Finland integration of primary and specialized care as well
as social services developed
• Chronic care model also in Finland as a basis of care models
• Aim to organize and coordinate services from same place
• Private services increasing (outsourcing), municipalities control
the service net
• Aim of the project:
– to compare care models in health centers from the point of
view of purchacer (municipalities), service providers, client
and personnel
– to find out the effects of patient choice on care provision
and planning, clients and employees
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4. Objectives/work packages
• International experiences on care integration and patient
choice
• Care integration and patient choice on clients point of
view
• Care integration and patient choice on point of view of
purchasers and providers
• Care integration and patient choice on workers’ point of
view
• TEKES funding
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5. Clients’ view
• Patient choice
– Who are the patients using patient choice (heavy
users of services, younger/older, educated…)
– Grounds for choosing, differences in patient groups
• Effects of care models on clients
– Experiences of care (quality, access, integration)
– Care process
– Information of patient choice and for choice
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6. Methods
• Questionnaire survey for patients in health centers
– Attitudes on patient choice
– Information on patient choices
– Reasons to change health center
– Experienced quality
• Questionnaire for people who have changed health
center
• ’Vinjetit’, care practices, care processes
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7. Personnel
• The effects of care models on personnel and working
processes
• The effects of patient choice on well-being of workers
and vice versa does well-being or satisfaction of workers
have relation on patient choice (from health center of to)
• Methods
• Personnel survey (30 health centers)
– Stress, well-being, satisfaction, commitment,
autonomy…
• Interviews (35 doctors and nurses, supervisors)
– Experiences of patient choice and care integration
– Experiences of care models, work organization
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8. Backgroung information
• Population on health center
• Waiting time
• Number of personnel
• Number of people changeg from and to the health
center
• Services available
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9. Patient choice and integration
at point of view of purchasers and providers
• Analysis of reported Finnish developments relating to patient
choice and care integration in primary care
• Development in municipalities participating the project
Interviews
1) Managers of primary care (10) and social and health care
services (3)
2) Managers or supervisors of health centers (doctors and
nurses) (20)
3) Managers of private service providers
Care integration and patient choice internationally
• Literature review, grey literature, informants

10. Fokus-health centers
• Espoo
– Population 250000
– 2 private service providers
– Created incentives in contracts with private org., quality bonus
• Tampere
– Population 200000
– 2 private service providers
• Hämeenlinna
– Population 68000
– Segmentation of patients organizationally in one area: two care
paths, one for chronic patients and one for ’episodic’ patients
• Lahti,
– Population 100000
– 2 private health centes
– Segmentation of patients organizationally in whole town, chronic
patients in main health center, other three for episodic patients
• Private service providers Mediverkko, Pihlajalinna, Attendo
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11. Research organizations
THL
- Timo Sinervo, Ilmo Keskimäki, Anna-Mari Aalto, Vesa
Syrjä, Tuulikki Vehko, Marko Elovainio
HES/TaY
- Pekka Rissanen, Juhani Lehto, Liina-Kaisa
Tynkkynen, Miisa Alastalo, Anna Saloranta
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12. Aikataulu
2014 2015
1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12
Tutkimusaineiston keruun
suunnittelu, kyselylomakkeet,
eettinen toimikunta
Haastattelut
Henkilöstökyselyt
Kansainväliset haastattelut
Asiakaskyselyt
Työpajat organisaatioiden
kanssa
Kyselyaineistot yhdistettynä
ja käyttövalmiina
Aineistojen analyysi ja
raportointi
Tiedon levittäminen
Loppuseminaari
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13. Developments in health centers
• Rising role of nurses
– Responsible for the care process (coordination of services
for chronic patients)
• Services for chronic patients developed
– Coordinated, planned care, self management
• Segmentation of clients
– Patients with chronic conditions vs. short episodes
• Several ways to keep the patients out of doctors
appointments
– E-health (own lab results, communication..)
– Group practice, groups for dietary or lifestyle changes
• Many different models of work organization
– Process development
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14. Organisational segmentation
• Mid-size town, main health center area 27000, 5%
chronic care patients
– Chronic care path – episodic path
– Criteria to chronic care path: much use of services, people
who have high risks, or whose illness not in control
– In episodic path mostly people who have some illness
which has start and end, also people with chronic
illnesses if in control
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15. Chronic care path
• Nurses own process, each patient has a coordinator
• Coordinator responsible for a patient, plan care with active
client, can also be psychiatric nurse or physiotherapist from
other organisation in same building
• Contact to coordinator, no personal doctor
• Multiprofessional team
• Also acute things, attempt to solve problems at phone
• Appointments: interview, checking of medications, measures
with nurse
à Doctor may consult or if needed appointment to doctor
• Resource nurse daily, has no scheduled appointments, takes
care of acute things, Ict communication
• On time, flexibility, processes designed for each patient
– If patient need physiotherapist or some other, directly there
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16. Experiences
• All patients rather heavy, multimorbidity
• Team, multiprofessionalism and easy consultations of
doctors help
• ”meaningfull to see change in patients”
• Doctors can concentrate to duties where doctors really
needed, other professionals and specialists available
• Work not always similar
• Change process difficult
• ”Patient in center truly, not organisation and
professions”
• ”We build services around the client he/she needs”
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17. Episodic path
• As light service as possible: resources on phone service,
doctor consult always as back up
– Referrals to laboratory, rtg, groups at phone
• Problem solving at phone (no unnecessary visits)
(prescription of receipts second time)
• Ehealth
• No personal doctors in acute things
• No own rooms
• With chronic patients planned care, care coordinators
responsible, role of doctors small
• No work pairs or teams
• For doctors mornings scheduled appointments, in afternoons
phone work, receipes, consultations (other days in opposite
direction)
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18. Experiences
• Attempt to avoid traditional doctors appointments, doctors
may feel that not enough real work
• Earlier care according to the organisation, now looked
from a point of view of clients
– If client needs, attempt to comnbine nurse and
physiotherapist visits
– Doctor can come and give his/her view if needed, no
scheduled appointment needed
• As a consultant doctor difficult situations as one must have
opinion with few facts, uncertainty
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19. Both paths
• Multiprofessional team available: mental health, services for
alcohol and drug addicts, physiotherapists
• One of psychiatric nurses always named, easy to
communicate (also physiotherapist)
• Social worker, geriatric specialist available at the same
building or floor
– Ortopedic specialist once or twice a month (other specialists
also)
– Some of the team from other organisation
– E-messages
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20. Chronic care model solutions
Organisational
segmentation
• People with chronic care in
need of integration to a certain
care pathway or separate health
center
• Nursers own the process,
doctors as consultants
• Other health centers with basic
services (for short episodes)
• Care integration inside the
health center, social services
specialized care inside org.
• Easy to consultate
• Work methods assimilated
according patients
• Patient choice?
Segmentation inside
health center
• Care processes different for
people with chronic illness and
short episodes
• Doctor-nurse work pair, teams,
personal doctor, personal
nurse
• Nurses’ responsibility of
process
• Nurses have high autonomy
– Doctor consultations easy
• Patients come to nurse visits,
doctors consult if needed
– Doctors appointments also
– Doctor and nurse change
rooms
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21. Outsourcing of health centers
• Motives in outsourcing mainly to increase access to care
and benchmarking of private organisations
– Learning from the private health centers
– Patient choice not a usual motive
– Waiting time shortened (in both private and public)
– New work methods learned and developed
• Differences between public and private
– Decision making quicker in private sector
• Flatter organizations in private sector, no political decision
makers, more autonomy to test and develop
– Private health centers new organizations
• Easier to begin from a ’clean table’
• Recruiting new workers who share the values
• No resistance against change, no learning out from routines
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22. Outsourcing 2
– Experienced workers
– Private sector can choose employees (work environment)
• Private health centers have clearly described work
methods and processes
– On the other hand make changes or pilot new methods
• Outsourcing of mainly basic services, integration?
– Specialized serviced and specialists in public services
– Easier to purchase
• Too tight contracts btw purchaser and provider may
hinder innovativeness
– Number of doctors while work developed to other direction
– No possibilities to increase the role on nurses or to hire
physiotherapists or psychiatric nurses
– Outcomes not doctor visits should be purchased
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23. Integration (?)
• So far inside health centers (not full integration)
• Examples
– In evaluation of patients needs: nurse-doctor collaboration,
doctor as a consultant, patient’s problem solved in phone
(prescription of a recipe at once)
– Nurse-doctor responsibilities and collaboration, nurse
interviews, prepares, less appointments needed, doctor can
shortly see the patient and make evaluation at nurses
appointment
– Health center- specialized care (normally referral to hospital and
health center has no coordination any more or short
consultation of specialist)
– Health center – social services (normally referral consultation in
the next room)
– Organisational – specialists and social services into same
organization and same building (under same budget?)
• No guarantee that care process comes better
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Clinical,makingthe
partsofcareprocess
smoothier
Professional
collaboration
Organisatonal

24. In sum
• Integration inside health centers
– Other professional brought inside health centers
– Major point to get rid of long waiting times
• Doctors and nurses need other professionals to health
centers
• Organisational segmentation interesting solution
– Requires large population
– May mean too homogeneous (simple) patients to episodic
path, and too heavy to chronic care
– Possibility to have different professionals
• Private sector flexible, flat organisations, well-designed
processes, contract may ĺimit
• Also public sector has developed actively, but decision
making more difficult
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