outline

1. The Belgian strategic plan for implementing health care innovations for chronic diseases: an overview of the key proposals for reform Dr. Ri De Ridder, MD and Director-General, NIHDI 2014/04/02

2. outline belgian chronic care system ‘as is’ chronic care policy development part 1 chronic care innovation programs chronic care policy development part 2

3. 1. belgian chronic care system ‘as is’ health care delivery and insurance system: fee for service for most ambulatory and medical services (‘nomenclature’) copayments and coinsurance including in primary care freedom of choice in access to services and no formal gate keeping with both high gp service utilization and direct access to specialists and emergency services relative lack of differentiation between service providers within and between primary and secondary care governed by negotiated sectoral agreements

4. primary care dominance of single handed, self-employed practices for general practice (70%), physiotherapy, speech therapists,… home nursing: both larger ‘salaried nurses’ organizations and smaller ‘self-employed’ groups vertical segmentation except for a limited number of integrated primary care centers (covering 3% of population)

5. degree of multidisciplinarity within gp practices

6. (primary care continued) relatively low investment in and low impact of multiple coordinating services except for palliative care at home no full coverage of medical record keeping and sharing of clinical information no systematic clinical data collection not yet integrated ‘clinical leadership’ strategy (e.g. integrated clinical protocols, quality assessment, ..) no integrated financial arrangements horizontal/vertical

7. still: a multitude of interventions targeting chronic ill ranging from very specific measures like a lump sum for Sjögren disease patients up to long term secondary care programs for type 1 diabetes in all hospitals resulting from over time defined specific responses to specific needs within specific regulations without an overall governing plan

8. low uptake of financial incentives for interdisciplinary case discussions esp. by gp’s (mental care, frail older persons, cancer patients,..) difficulties for hospital based liaison to connect with primary care and risk of lack of seamless care

9. a lot of difficulties for integrated care…

10. but also opportunities: local structuring both along professional lines (e.g. on duty services) as on territorial interprofessional basis in primary care longstanding experience with integrated rehabilitation care programs reused when determining ‘reference centers’ for certain chronic conditions and rare diseases “global medical record”: 50% overall coverage/ 77% of 74 + (88% in Flanders)

11. 2. chroniccare policydevelopment part 1 capitation and lump sum elements added to fee for service payments diabetes referencing nurse clinical guidelines and decision support development E-health roadmap hospital care programs

12. governance scientific committee on chronic diseases ministerial plans: hiv, hepatitis c, rare diseases, cancer, …and chronic diseases (2008) nbgovernmental commitment to invest 380 million euros over 2 years into cancer and chronic disease legal instruments for investing hospital and insurance budget in innovative approaches (article 107, B4, article 56)

13. 2008 ministerial plan priority for chronic ill focus on: improving information and tackling administrative hurdles lowering financial burdens specific patient groups socio-professional reintegration patient participation through the observatory for chronic diseases

14. 3. chroniccare innovation programs long term care: care innovation projects ‘protocol 3’ chronic diseases: ‘care trajectories’ mental health care: ‘article 107’ projects

15. long term care: care innovationprojects ‘protocol 3’ originated from and governed by explicit political decisions: started with a 2002 policy note on active ageing, exploratory research on loss on autonomy and instruments and a 2005 interministerial protocol (‘nr. 3’) explicitly setting aside 20% of new investment (40 million euros) in institutional LTC to be used for ‘alternatives for institutional care’ operationalized by NIHDI ‘article 56’ scheme in two phases half of the earmarked budget finally returned to institutional investment under stakeholder pressure

16. Characteristics of P3 program agreement between regions, communities and federal government to finance alternative forms of care national call for present bottom up innovation projects for care for frail older persons, both primary care or institutional care based 63 projects started in first wave for a 4 years period; 52 still active 62 projects applied for second wave a scientific multicenter scientific evaluation to assist decision makers in deciding to finance structurally (or not) alternative forms (‘interventions’) of care

17. Interventions at home

18. Interventions out of the home

19. Implementationanalysis Psy care Night care Occupationaltherapy Case management Day care Others

20. Beneficiaries

21. Type of beneficiaries in the population • Low impaired (with ADL<3 and CPS<3): (n=3018) • Depression (DRS ≥3): 24.2% [22.7 ; 25.8] (n = 2941) • Burden for the informal caregiver (ZBI-12≥10): 50.5% [48.3 ; 52.8] (n = 1886) • Important difficulties with IADL (≥24): 56.9% [55 ; 58.7] (n = 2705) • High impaired (with ADL≥3 or CPS≥3): (n=3829) • Important functional decline ADL≥3: 79.5% [78.3 ; 80.8] (n = 3829) • Important cognitive decline CPS≥3: 54.5% [52.9 ; 56.1] (n = 3767) • Depression (DRS ≥3): 32.8% [31.3 ; 34.3] (n = 3695) • Burden for the informal caregiver (ZBI-12≥10): 50.5% [48.3 ; 52.8] (n = 1886) • Highly impaired (ADL≥3 ) and recent hospitalization (n=733)

22. Definitiveinstitutionalization over total cost

23. Synthesis of projects’ characteristics

24. Concerning case management Long term case management may be useful for highly impaired frail older persons. However: Lack of fulfillment of requirement on workforce, use of clinical and managerial information and system requirements (embeddedness) may impede proper effectiveness (see projects of CM psy and CM with occupational therapy); Short term case management for FOPs coming out of the hospital appears to be an efficient intervention to delay institutionalization. It is not really sensitive to requirements.

25. second wave concentrates on projects using at least case management next step: translating findings into ‘insurance package’ interventions with a insuree linked price/reimbursement (or into regional/community specific regulations)

26. chronic diseases: ‘care trajectories’ originated from a long-lasting negotiation process within the national commission medical doctors/sickness funds in order to transform the conflictual GP/specialists relationship around respective roles in care for chronic ill into a collaborative model inspired by ‘article 56’ field projects on GP led diabetes care was completed by additional agreements in other ‘commissions’ in order to set in place educational support, auto control material provision and other services

27. basic features: intended for diabetes type 2 and for renal failure patients at a certain stage of their disease (inclusion and exclusion criteria) contract between patient, GP and specialist including identifying personal patient goals yearly lump sum incentive for GP and specialist full reimbursement for GP and specialist consultations easier access to medicines administrative criteria justifying yearly prolongation transmission of minimal clinical data sent by GP to central registry

28. additional supporting services: national website by NIHDI collaboration with patient organisations for elaborating patient handouts (‘step for step plan’) creation of GP led local multidisciplinary networks (a low cost/high ROI investment) set up of a multiple aspect assessment procedure (clinical data, patient satisfaction, professionals experience)

29. Total number CT CRF CNI tot 25.259DM2 tot 37.934

30. proportion of patients with recommended tests

31. evolution of Hba1c values included diabetes patients Centrale pijler

32. main findings many of the eligible patients were included follow-up parameters were more frequently controlled improvement of quality of care process was significant outcome improvement: too early to be sure if it is steady GP’s transmitted clinical data for 79% of included patients

33. problems: lack of adherence in some regions/with some professionals too little impact within GP practice concern about procedural use of administrative data

34. next steps continuation of actual care trajectories continuation and more comprehensive scientific assessment with special attention for equity new GP led scheme starting at diabetes diagnosis and with educational support to be developped and rolled out start experimental approaches for multimorbidity

35. mental health care: ‘article 107’ projects hospital law, article 107 sets out the principle of converting parts of hospital budget into other (non hospitalised) forms of care while keeping the budget intact, giving opportunity to hospital personnel to give care in more community based context a program has been rolled out in mental health care aiming to tackle with long term hospitalisation of stable chronic mental ill and by doing that promoting community based mental health care for psychiatric conditions needing secondary care core objective: recovery and reintegration

36. grounded on a common political statement on mental health policy and intense intergovernmental collaboration rolled out through 19 loco regional projects, involving all mental health services on the territory diversification of services (intensive in hospital care, intensive and chronic outreach services at home, preventive services, non hospital residential care and rehabilitation and professional reintegration support services) additional funding for some of these services and for coordination

37. ministry based central coordination with direct contacts with all projects and with central guidance (including a reform guide) interuniversity scientific follow-up and assessment (indicators fixed) 1.118 psychiatric beds closed (90% chronic beds) actual yearly caseload for the first wave of projects (750 beds closed) : 6.293

38. 4. chroniccare policydevelopment part 2 quote from Nick Goodwin (Brussels 28.11.2013): “integrated care is best suited to frail old people, to those living with long term chronic health and mental health illnesses, and to those with medically complex needs or requiring urgent care” you might say that we have been walking the right way…

39. but, Nick Goodwin also said: “integrated care is most effective when it is population based and takes into account the holistic needs of patients. Disease-based approaches ultimately lead to new silos of care”. the need for a more comprehensive global approach beyond the stage of innovation projects gradually became clear

41. Council conclusions “Innovative approaches for chronic diseases in public health and healthcare systems” EMPLOYMENT, SOCIAL POLICY HEALTH and CONSUMER AFFAIRS Council meeting Brussels, 7 December 2010

42. Joint Action addressing chronic diseases and promoting healthy ageing across the life cycle Duration: 39 months, starting date 01/01/2014. Maximum EC cofounding: EUR 4.606.576,00 and 50% EU summit on chronic diseases 3-4 april

43. nationalaction 2011 proposition to launch a national conference on chronic care was accepted by Minister of health and approved by interministerial conference of health KCE (belgian health care knowledge centre) commissioned to elaborate a ‘position paper on the organisation of chronic care for chronic patients in Belgium’

44. based on: analysis of international policy papers review of the (effectiveness of) policies for chronic care in four selected countries/regions (recommended by Ed Wagner and by Ellen Nolte): Denmark, Netherlands, Quebec, Pennsylvania relevant previous KCE recommendations literature review on patient empowerment literature review on new profiles and functions in primary care relevant Belgian initiatives a stakeholder consultation process

46. a root definition the chronic care system offers a coordinated array of needs-based, personalized, goal-oriented, planned, professionally supported services for and with persons with chronic conditions requiring assistance over years or decades with the routine management of their condition as well as the management of acute care episodes. These services are provided in a high quality, efficient, sustainable, accessible, culturally competent and patient empowering manner in the least complex environment that is clinically appropriate. The objective is to improve the beneficiaries’ quality of life and to help them to function better at home, at school/work, in the community

49. Specific analyses for case management projects: Use of chronic care model as frame and particularlythe followingrequirements • Workforce: • Turnover of providers (or not) • Ratio of FOP per CM (≤ 40) • Training of professionals • Presence of intervision • Clinical and managerial information use: • Use of BelRAI for care plan design • Use of register for follow-up of FOP • Presence of agreed, evidence-based interdisciplinary protocols • Appropriate system design • Provision of feedback of the FOP to the GP • Partnership with coordination service (SISD/SEL/GDT or CCSSD)

50. fromrecommendations to politicalaction interministerial agreement (december 2012) to continue a consultative process based on the 20 kce recommendations in order to identify priority actions, feasible timelines and necessary means through five focus group discussions (criticised for not being in the classic stakeholder consultation and negociation format) leading to a global document (‘guidance note’) to be presented at a national conference and confirmed by a ‘protocol agreement’