Improving cooperation for better chronic care

1. Improving cooperation for better chronic care Chris Ham HSMC University of Birmingham Bellagio

2. Some history • The journey from infectious diseases (1900-1950) to acute illnesses (1950-2000) to chronic diseases (2000-) • The acute care paradigm based on episodic care, hospital based treatment and increasing specialisation is anachronistic • A new paradigm is needed to respond to the increasing burden of chronic disease (Kane et al, 2005) Bellagio

3. Chronic care model

4. The influence of the Chronic Care Model • The WHO’s Innovative Care for Chronic Conditions Framework • The Expanded Chronic Care Model (BC) • The NHS and Social Care Model in England (and variants in Scotland and Wales) • The Model has also been adapted in other countries e.g. Australia and NZ C Ham and D Singh (2006) Improving care for people with long term conditions: a review of UK and international frameworks, HSMC, University of Birmingham Bellagio

5. The NHS and Social Care Long Term Conditions Model Delivery System Better outcomes Infrastructure Case Management Community Resources Empowered and informed patients Decision support tools and clinical information system (NPfIT) Disease Management Creating Supporting Prepared and proactive health and social care teams Supported Self care Health and social system environment Promoting Better Health Bellagio

6. Some important elements in the Chronic Care Model • Informed and expert patients, taking control of their conditions • Team based care using the skills of doctors, nurses and others • Collaboration and partnership between patients and teams • Integration of care – primary and secondary care; health and social care Bellagio

7. Gaps in chronic care • Commonwealth Fund Survey of six countries, 2005 • Advice on self management was not routine in any country • There were variations in the use of nurses to provide diabetes care • Among patients with diabetes and hypertension, those receiving all tests fell short of recommended care Bellagio

8. Gaps (2) • Sizable majorities of patients reported their medications had not been reviewed • Many patients reported that physicians had not explained side effects • There were shortcomings in physician-patient communication • There were also shortcomings in care coordination (the next big thing?) Bellagio

9. Moving forward • How can these gaps in care be filled? • How can international experience and research evidence be used? • What are the implications for policy and practice? • What are the characteristics of the high performing chronic care system? Bellagio

10. 10 characteristics • Ensuring universal coverage • Care free at the point of use • A focus on prevention e.g. the new contract for family physicians in the NHS • Priority for self management • An emphasis on primary health care (the importance of the medical home) Bellagio

11. 10 characteristics contd. • An emphasis on population management/risk assessment • Care should be integrated (let’s debate what that means) • IT should be used, especially the electronic care record and telehealth • Care should be coordinated (see new OECD report) • These 9 characteristics need to be linked into a coherent whole Bellagio

12. Four supporting strategies • Physician leadership • Measuring outcomes and using the results to drive performance improvement • Aligning incentives e.g. the new contract for family physicians in the NHS • Engaging the community e.g. NZ experience of working with Maori Bellagio

13. Paying GPs for quality • GPs paid using mixture of capitation, salary and fee for service in the past • New payments (April 2004) emphasise quality of care • Payments are based on ‘quality and outcomes framework’ (QOF) • QOF is based on 10 common chronic conditions Bellagio

14. The QOF (1) • GPs earn points if they meet performance targets • Targets cover aspects of care such as blood pressure recording and control • Points convert into extra income for GPs • The incentives are big: up to one third extra income if targets are met Bellagio

15. The QOF (2) • Clinical indicators make up around 50% of the QOF • Organisation of care, patient experience, and providing additional services make up the other 50% • Performance is based on self assessment – a high trust contract • External audit is used to supplement self assessment Bellagio

16. Some US examples of integrated care • Kaiser Permanente • Group Health Cooperative • Veterans Health Administration • Health Partners • Alaskan Medical Service • None is perfect, but all seem to perform better than other forms of care Bellagio

17. Some other examples • Integrated health boards in Scotland • Integrated health boards in New Zealand • Integrated health and social care organisations in Northern Ireland • Care Trusts bringing together health and social care in parts of England • Esther project in Jonkoping, Sweden Bellagio

18. A detour to the UK • The UK has a strong primary care orientation • Patients are registered with a primary care team that serves as a medical home (typically 3-4 physicians, nurses and others) • The best teams provide high quality care based on registration, recall and review • Major weaknesses in the UK are variable standards of primary care and poor integration/coordination with secondary care Bellagio

19. A detour (2) • The NHS suffers from the historical division in British medicine, separating family physicians from hospital specialists • US integrated systems like Kaiser hold lessons for the NHS, especially in multispecialty medical practice • But the NHS has the potential to achieve closer integration of health and social care, and in some places this is happening • New policies like practice based commissioning may support closer integration Bellagio

20. What is integration? • Vertical or virtual? • Organisational, clinical or service integration? • Integrated provision of care or integrated provision and funding? • Integration of all services or focused integration for specific diseases/care groups e.g. frail older people? Bellagio

21. Care coordination • Coordination is particularly important for people with multiple chronic conditions • Primary care (where it works well) can provide coordination • Other approaches have also been used e.g. case managers/community matrons • Patients/families may be care coordinators by default or by design (e.g. by holding budgets) • More than one approach is likely to be needed Bellagio

22. Barriers to integration • Organisational fragmentation • Budgetary fragmentation • Perverse incentives • Professional fragmentation • Conservatism and inertia Bellagio

23. Context is critical • Different systems need to find their own solutions reflecting different contexts • How are the systems represented here rising to these challenges? • Are there other and emerging approaches to care integration we can learn from? • How can approaches be adapted to fit different contexts? Bellagio

24. Language • The language we use may be a barrier to improvement – patients/clients need the right care in the right place at the right time • Is it still helpful to talk about primary care, secondary care and social care? • Or do we need to find a new vocabulary to suit the times? Bellagio