11-12 Abril 2013

1. New funding and commissioning model as a driving force for the transformation of the Basque Health System provision model13th International Conference on Integrated CareBerlin April 2013 11-12 Abril 2013

2. CHRONICITY STRATEGY: RATIONALE AND AIMS CARE INTEGRATION IN 2012 FRAMEWORK CONTRACT: POPULATION INTERVENTION PLANS IMPLEMENTATION: TARGET POPULATIONS ASSESSMENT CONCLUSSIONS

3. Year2009-2010 New demographic challenges 2010 – 1/6 of the population is over 65 years old 2049- 1/3 of the population is over 65 years old In conclusion, more chronic patients New economic challenges Strategy

4. BASQUE COUNTRY POPULATION 2.2M • Public HealthProvider, Osakidetza with: • 320 PrimaryHealth Centers • 12 Acute Hospitals (4,278 beds) and 4 Chronic Care Hospitals (524 beds) • Mental Health: Three regional networks with 4 psychiatric hospitals, (777 beds) and 2 Contracted Long term Mental hospitals

5. Modelbasedonstructures ModelbasedonSystems Fragmented Reactive Paternalist Continuum of care Proactive Patientempowerment

6. A. PRIMARIA A. ESPECIALIZADA SUBAGUDOS SALUD PÚBLICA Health System based on 11 “Microsystems” Local network of health care and social care providers sharing responsibility in health outcomes Working around a common health agenda providing continuity of care= patient - centered. Definition of “Microsystem” Lookingforeficiencies, avoidingduplicities and identifying new ways of delivery of care

7. 2 12 10 14 13 11 5 1 3 4 8 7 6 9 Advances made in Chronicity Strategy Prevention and Promotion Stratification Self-care Single medical record Innovation by professionals Integrated health care Chronicity Research Centre Advanced Nursing Competences Sub-acute Hospital model Tele-monitoring experience Social health collaboration e-prescription Financing and Contracting Multichannel Service Centre In this context, COMMISSIONING and FUNDING become the lever of change and catalyst for the setting up of microsystems

8. 0,25% 97% 0,25% 0,5% Bundled payment: 3% of the budget tagged to interorganizational interventions, innovation and quality at local level Funding and commissioning: Framework contract MICROSYSTEM Sub-acute Hospitals Primary care Hospitals Core Activity Core Activity Core Activity 1.600M€ Population Intervention Plan (PIP) 32M€ 2% Local Projects Quality 8M€ Bottom up 8M€ + 800M€Drugs and external contracts

9. + - - Construction of the Population Intervention Plan Coordination of Resources Identification of target population Definition of intervention strategies Population Intervention Plan Activities and interventions to be carried out depending on the kind of pathology or severity Required health professionals and resources, services, units, equipment, ICT, clinical sessions,… Structured mutiservice interventions: defined population, shared objectives and decision making, coordinated actions, most efficient delivery site, actors, resources indicators and assessment. Patients are stratified according to the clinical profile +    Internal specialist Primary Care Doctor Social worker Coordinating nurse

10. PIP in 2012 Framework Contract Intervention strategies for each segment or strata of the population PIP Multi-morbidity Case management PIP Diabetes PIP COPD PIP CHF Disease management Chronicpopulation • Active patient • Physical activity and diet Self-management support • Cardiovascular risk • Anti-flu vaccine • Tobacco withdrawal Prevention and Promotion • Tobacco withdrawal screening and advice • Anti-flu vaccination General population

11. Highlycomplexmultimorbidity 43.000 • Highriskpatients 173.000 • Chronicpatients 636.000 Populationwithoutchronicconditions 1.400.000 • General population • Implementation • STRATIFICATION: 100% population stratified Case management Disease management Self management support Prevention and Promotion 2/26/2013 ACT Kick Off Meeting Amsterdam 10

12. - - Data collection POPULATION STRATIFICATION ACG Predictive Modelling (ACG-PM) • Age and gender • Patients´global co-morbidity • Patologies-Dx (EDCs) • Patologies-Rx (Rx-MGs) • Special Population • Hospital Dominant Conditions (>50% chances hospitalization • Frailty Markers • Previous Resource Consumption • Cost of Previous health care Resource Consumption Prediction Pharmacy Cost Prediction PI: Risk Prediction Index Prediction Hospitalization Probability 2/26/2013 11

13. Criteria for choosing 2012 target populations Selection criteria PIP: Excluded <13 years of age, neoplasia, transplants and dialysis < 1 admission in last 12 months. Outliers PI Case management PIP 6.930 Inclusion criteria COPD: Aged ≥ 40 years. CHF: Aged ≥70 years DM: Aged ≥30 years Disease management PIP COPD PIP CHF 44.482 PIP DM Chronic population Self-management support 38.250 Prevention and Promotion Healthy population 39.375 *Two or more Ollero categorias and at least two of the followingchronicpathologies: DM, EPOC, IC

14. Target populations for each province

15. Assessment framework targets: General premises. • Small number Indicators at microsystem and not at care level • Prioritization of Effectiveness, Efficiency and health results. • Homogeneous indicators between microsystems • Reflect patient management at different strata of the pyramid • Enable a snapshot of the microsystem and its development • Quarterly Assessment • Horizon of the assessment framework is 2 years

16. ACT Programme Diabetes Assessment framework targets: indicators • % Diabetic patients with analytical study conducted in the last year and HbA1c in the last 6 months •  % Patients in the intervention group with annual screening for microalbuminuria excretion (OP) • No patients in the intervention group that received annually exploration feet x 100 • % Patients in the intervention group with physical activity counselling • Number of non-face consultations between primary and hospital • Mean patient satisfaction with the progress of activation received DM management • % Patients with good control figures HBP • ………………….. Chronic Heart Failure • % HF patients treated with ACE inhibitors or ARBs (ARAII) • % of patients with weight control • No. attended hospital emergency • No. HF patients in the intervention group with systolic function defined * 100 • % Patients with influenza vaccination in intervention group……

17. CONCLUSSION Funding and commissioning: ComplexProcesswithmultipleactors • Scientific Evidence • Experiences from other organizations • Compilation of ideas and best practices • Methodological support TOP-DOWN • Bundled payment • Intervention groups. • Patient selection criteria. • Assessment Framework. • Weights in the financing framework PIPs BOTTOM-UP • Cultural Change • Browse new models of care (most appropriate and most cost-effective): + home + PC and-Hospitals • Governance and coordination elements • Local innovations • Registration and local patient recruitment. • Care pathways • Personalized plans • Effective delivery of care (care coordination). • Monitoring results.

18. THANK YOU Patricia Arratibel Joana Mora Jose Mari Begiristain Alberto García Alcaraz Adela Olascoaga Pepe Quintas Esteban de Manuel