Steve Shortell: Integrated care: Policy and evidence
INTEGRATED CARE: POLICY AND EVIDENCE Stephen M. Shortell, Ph.D. Blue Cross of California Distinguished Professor of Health Policy and Management Dean, School of Public Health University of California-Berkeley HSRN/SDO Conference Birmingham, England June 3 and 4, 2009
“One of the biggest failings of modern healthcaresystems is that they so seldom provide integratedmedical care. In emergencies, patients head forthe local hospitals; for minor illnesses theyconsult their family doctor. But for chronicconditions such as diabetes and cardiovasculardiseases, which are becoming increasinglyprevalent, they require care and advice both intheir primary physician and from the hospital.Effective coordination of this care results in betterand cheaper treatment, yet too often it does nothappen. – The Health of Nations, Economist, July 17, 2004:13
Global Challenge of Chronic Disease• 60 Percent of All Deaths Worldwide• 80 Percent Occur in Low and Middle Income Countries• Double the Number of Deaths Occurring from Infectious Diseases• Huge Negative Economic Impact – 10 years • China – $558 Billion • India – $237 Billion • UK – $33 Billion
Integrated Delivery System (IDS) DefinitionA network of organizations which provides orarranges to provide a coordinated continuumof services to a defined population and isclinically and fiscally accountable for thecosts, outcomes and (working with others) thehealth status of the population served.
Key Features of An Integrated Delivery System (IDS)• Shared Values and Goals• Alignment of Incentives• Physician Leadership• A Culture of Teamwork
Key Features of An Integrated Delivery System (IDS) (cont’d) • Comprehensive Longitudinal Electronic Medical / Health Records • Shared Practice Guidelines • Patient-Centered • Integration Across Settings • Matching Resources and Services to Population Needs • Linkages to Public Health and Social ServicesSource: Adapted from A. Enthoven “Integrated Delivery Systems“, March 25, 2008.
Some Models to Consider• Chronic Care Model• Disease Management• “Medical Home”
Chronic Care Model Community Resources Organizational and Linkages Leadership and Practices Health Care Team RedesignInformed PreparedActivated Productive Interactions ProactivePatient TeamAdapted from: E.H. Wagner, B.T. Austin, and M.R. Von Korff, “Organizing Care forPatients with Chronic Illness,” The Milbank Quarterly, 74 (4), 511-544, 1996.
The National Health Service and Social Care Long-Term Conditions Model Infrastructure Delivery System Better Outcomes Community Case Management Resources Supporting Empowered and Informed Patients Creating Disease Decision Support Management Tools and Clinical Information System Prepared and (NPfIT) Pro-active Health and Supported Self-Care Social Care Teams Health and Social Care System Environment Promoting Better HealthSource: Department of Health 2005a.
Summary of Evidence• Use More Evidence-Based Care Management Processes, Preventive Services and Health Promotion Programs (Casalino et al., 2003, Mehrota et al., 2006; Gillies et al., 2006)• Use More Elements of the Chronic Care Model (Shortell et al., 2005, 2009)• More Likely to Use Electronic Medical Records (EMRs) (Robinson et al., 2009)
Summary of Evidence (Cont’d)• The U.S. Veterans Administration (VA) Provides Higher Quality of Care to Its Patients than a Matched Group of Non-VA Medicare Patients (Asch et al., 2004; Peterson et al, 2004; Kerr, 2004)• The U.S. Kaiser Permanente System Demonstrated Higher Quality than NHS with Similar Cost Per Beneficiary (Feachem et al., 2002; Han et al., 2003)• Mixed or Limited Evidence on Costs (Fulop, 2009)• Internationally Little Evidence of Impact on Outcomes of Care (Fulop, 2009)
Kaiser-Permanente Reduces Cardiac Deaths by 73 Percent• Linkage of Teams with Electronic Health Record and Advanced Clinical Care Registry• Integrated Nursing and Pharmacy Teams Worked Collaboratively with Patients and Their Doctors• Involved Proactive Patient Outreach, Education, Lifestyle Adjustments, and Effective Medication Management• “Technology itself cannot solve the health care crisis. Our Colorado region achieved results by aligning people and technology in the most efficient care delivery system...an integrated approach to deliver the right care at the right time” – George Halvorson, President and CEO
UC Berkeley Study Use of Care Management Processes by Type of Chronic Condition Type of CMPs Diabetes Asthma CHF Depression Each of 4 (n = 523)+ (n = 522) (n = 526) (n = 497) Chronic Illness It Treats (n = 491) Patient list or registry 70.2% 62.4% 58.5% 40.8% 39.1% Provide patient educators 73.9% 53.8% 53.6% 35.4% 30.5% Physician feedback on quality 66.1% 56.1% 50.8% 32.8% 30.9% Nurse care managers 54.7% 42.7% 47.5% 25.1% 23.8% Patient reminders 51.4% 35.2% 35.0% 19.7% 19.1% Point-of-care reminders 51.2% 36.4% 33.1% 22.9% 19.5% No. (%) using all 6 CMPs 21.6% 10.5% 10.1% 4.4% - No. (%) using all 24 CMPs - - - - 3.7% Mean CMP Use (out of 6) 3.7 2.9 2.8 1.8 - Mean CMP Use (out of 24) - - - - 11.1Source: D. Rittenhouse et al., “Improving Chronic Illness Care: Findings From NationalStudy of Care Management Processes in Large Physician Practices,” 2009, Under Review.
National Study of Large Physician Organization and Management of Chronic Illness – Key Findings • Only ½ of Recommended Care Management Processes Are Used • Disease Registries • Patient Educators • Performance Feedback to Physicians • Highest for Diabetes; Lowest for Depression • Factors Associated with Greater Use • Patient-Centered Management Behaviors • Participation in Quality Improvement Programs • Hospital / Health System Ownership • External Evaluation on Quality • Very Large GroupsSource: National Study of Physician Organizations II, UC-Berkeley, 2009
Patient Centered Management Behaviors 1) Organization does a good job of assessing patient needs and expectations 2) Staff promptly resolve patient complaints 3) Complaints are studied to identify patterns and prevent problems from recurring 4) Organization uses data from patients to improve care 5) Organization uses data on patient expectation or satisfaction when developing new servicesAdapted from: Malcolm Baldridge National Quality Award, U.S. Department of Commerce,Washington DC
Does Disease Management Really Work 0.35 0.3 0.25 0.2 Disease Control 0.15 0.1 Morbidity 0.05 Patient Knowledge 0 All-cause Mortality Quality: Outcomes of CareSource: Scott Weingarten,M.D. “What’s Working and What’s Not in DiseaseManagement: Lessons Learned Nationally and Internationally.” AnnualSupplement on Disease Management and Quality Improvement. May 6, 2002.
Does Disease Management Really Work 1.2 Provider 1 Adherence 0.8 To Guidelines 0.6 0.4 0.2 0 Quality: Processes of CareSource: Scott Weingarten,M.D. “What’s Working and What’s Not in DiseaseManagement: Lessons Learned Nationally and Internationally.” AnnualSupplement on Disease Management and Quality Improvement. May 6, 2002.
Medical Home Four Cornerstones • Primary Care Comprehensive First Contact Care Across the Lifespan • Patient-Centered Care Meeting the Needs and Preferences of Actively Engaged Patients • New-Model Practice Evidence-based: Population-based Registries, Performance Measurement and Improvement, Point of Care Decision Support, Electronic Health Records; Redesigned Work Processes • Payment Reform Pay for Care Coordination; Episode of Care Based PaymentSource: DR Rittenhouse and SM Shortell, “The Patient-Centered Medical Home: Will ItStand the Test of Health Reform?”, JAMA, May 20, 2009, 301(19);2038-2040.
Chronic Care Management in the UK• Use of Community Matrons• A Lot of Different Initiatives• Risk Stratification• Peer Support and Patient Self-Management are Not Routine Part of Care• No Financial Incentives for Participation in Chronic Care Initiatives• Relatively Little Evaluation to Date• New Integrated Care Pilots
Critical Success Factors for Chronic Disease Programs in EnglandWhole systems approaches Training to support staff in new roles, including project management trainingShared boundaries and vision betweenhealth and social care Increasing staff competenciesEmpowering people to take responsibility, Organizational stabilityincluding service to users High-quality information management andProviding car based on levels of need (risk technologystratification) Involvement of al key stakeholders, includingNot running (competing) services in parallel professional representative bodiesChanging professional attitudes and Creating the right incentivesbehaviors via organizational culture change Adequate investment in servicesOvercoming resistance to clinical andmanagerial change Adequate time frames in which to test servicesStrong clinical leadership Focusing on realistic targets Not assuming that initiatives will reduce costs
Barriers to the Creation of a Strong Culture• Diverse services or products that must be provided• Complex external environment• Outcomes difficult to measure• High degree of diverse professionals who work in health care organizations. Professional identities and concerns are often more important than organizational goals and objectives• A high degree of specialization – opportunity for a lot of subcultures to develop• Rapid growth. Move so quickly that the organization doesn’t have a chance to reflect on what’s been created.
Culture Outcome Options in Forming PartnershipsCo-ExistenceAssimilation
Transformation(Development of A New Culture) Old NewRejection(Separate and Hostile Cultures
Some Practical Lessons • Be clear about what you are trying to achieve • Start with the work that directly impacts the patient and work “backward” to design the organizational forms that will best promote this • “Cultivate the soil” • Trust among partners • Local leadership • Culture of quality improvement • Effective communication • Information technology • Work on the cultural differences between partners • Align the incentives – including front line staff • Don’t assume economies of slope or scale – may take time • Be patientAdapted from: R. Ruson and C. Ham, “Integrated Care: Lessons from Evidence and Experience”, TheNuffield Trust, Summary Report, November, 2008
Policy Options for Integrating Health and Social Care • Partnerships between primary care trusts (PCTs) and local authorities • Important to recognize variations in context and relationships among stakeholders from one area to another • User focused. What are we trying to achieve? • Leadership of PCT board members and senior managers is key • Integrated governance plus health and social care teams aligned with GP practices • Need to involve acute care hospitals • Clearly articulate the ends to be achieved but be flexible on the means • The Care Quality Commission can spread positive examples and best practices to othersC. Ham, “Only Connect: Policy Options for Integrating Health and Social Care”, The Nuffield Trust, BriefingPaper, April, 2009
Makingchange possible CARE SYSTEM • Outcomes:Supportive Organizations High • Safepayment and that facilitate performing • Effectiveregulatory the work of patient- • Efficientenvironment patient- centered teams • Personalized centered teams • Timely • Equitable REDESIGN IMPERATIVES: SIX CHALLENGES • Redesigned care processes • Effective use of information technologies • Knowledge and skills management • Development of effective teams • Coordination of care across patient conditions, services, and settings over time. • Use of performance and outcome measurement for continuous quality improvement and accountability Source: Institute of Medicine, Crossing the Quality Chasm, p. 127, 2001.
Components Needed to Achieve System-Wide Clinical IntegrationStrategic x Cultural x Technical x Structural = Results 0 1 1 1 = No Significant Impact on Anything Really Important 1 0 1 1 = Small, Temporary Effects; No Lasting Impact 1 1 0 1 = Frustration and False Starts 1 1 1 0 = Inability to Capture the Learning and Spread it Throughout the OrganizationBottom Line Need all four components integrated and aligned with each other for lasting system-wide impact
Thank You! What we all strive for“Healthier Lives In A Safe World”