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Global Trends Long Term Conditions London. 7 June 2007 King´s Fund and Health Services Management Centre of the University of Birmingham Dr. Rafael Bengoa •ESADE Business School •Kroniker Observatory. Bilbao.Spain The Burden ! Frank´s Cat. Very different systems=Similar Problems Adults' experiences in five countries 8,672 people > 18 across 5 countries Shortfalls in delivering safe, effective, patient- centered, timely, efficient & equitable care - Widespread failure to give patients plans to manage chronic conditions at home & gaps in receipt of preventive tests Widespread failure in involving patients in treatment decisions Australia UK Canada USA New Zealand Schoen et al, Health Affairs 2004, web exclusive:487-503 Patient Reports on Reminders for Preventive Care, 2004 75 50 Percent of adults receiving preventive care reminders 37 38 AUS CAN 44 49 50 UK US 25 0 NZ 2004 Commonwealth Fund International Health Policy Survey Sicker Adults with Chronic Conditions: Receipt of Self-Management Plan in Six Countries, Percent of sicker adults with chronic conditions* whose doctor gave plan to manage care at home 100 65 58 56 50 45 50 37 0 CAN US NZ AUS UK GER * Adult reported at least one of six conditions: hypertension, heart disease, diabetes, arthritis, lung problems (asthma, emphysema, etc.), or depression. .Data: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults (Schoen et al. 2005a). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 5 Sicker Adults with Hypertension or Diabetes Who Received Recommended Care by Self-Management Plan or Nurse Involvement, 2005 Neither self-management plan or nurse Self-management plan and/or nurse Percent 100 74 61 78 77 67 86 81 68 91 79 64 50 50 0 NZ AUS UK CAN Includes blood pressure and cholesterol for hypertension; Hemoglobin A1c and cholesterol checked, and feet and eyes examined for diabetes 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults US GER Percent of Doctors Reporting Practice Is Well Prepared to Care for Chronic Diseases, 2006 Percent of physicians reporting “well prepared”: Patients with multiple chronic diseases Patients with mental health problems AUS CAN GER NET NZ UK US 69 55 93 75 67 76 68 50 40 70 65 48 55 37 Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians Doctor’s Office Has a Nurse Regularly Involved in Care Management, Sicker Adults, 2005 Base: Adults with chronic disease Percent who have a nurse involved in case management 75 50 25 36 16 41 47 52 19 0 AUS CAN NZ US 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults GER UK Capacity to Generate Patient Information, 2006 Percent of primary care practices reporting very or somewhat easy to generate List of patients by diagnosis List of patients' medications, including Rx by other doctors 92 100 81 80 75 55 50 25 63 72 59 68 88 74 37 37 26 25 0 CAN US GER NET NZ AUS Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians UK Physicians Reporting Routinely Sending Patients Reminder Notice for Preventive or Follow-Up Care. Percent of physicians Yes, using a manual system Yes, using a computerized system 100 75 5 18 16 50 25 24 65 20 8 0 AUS 14 CAN 93 83 61 28 GER 32 18 NET NZ UK Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians US Patients Did Not Receive Counseling About Exercise and Diet in Past Year, Sicker Adults, 2005 Base: Adults with chronic health condition 75 45 50 29 31 US CAN 36 36 NZ AUS 50 25 0 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults UK GER Primary Care Doctors’ Reports of Any Financial Incentives for Quality of Care Improvement, 2006 Percent of physicians reporting any financial incentive* 100 95 79 75 72 58 43 50 41 30 25 0 UK NZ AUS NET GER CAN *Receive of have potential to receive payment for: clinical care targets, high patient ratings, managing chronic disease/complex needs, preventive care, or QI activities Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians US Barriers to Change • Political: Systems increasingly “politicised” and acute brings more votes ! • Financial: Incentives aligned to acute care ! • Economic: Markets on acute technology ! • Societal & clients: Acute preference ! • Workforce: Acute = spectacular medicine ! • Health system model: Fragmented R. Bengoa / Kroniker Observatory Need to Pull on several levers: R. Bengoa / R. Kawar TYPICAL CARE •Patient appears • Patient is treated •“find it and fix it” • Patient is discharged … then disappears from radar screen Improved integrated CARE and follow up… At risk Population identified Patient appears Patient is treated Patient is empowered Patient is discharged with a care plan … never disappears from radar screen R. Bengoa. Kroniker Observatory. WE HAVE BETTER MODELS OF CARE ! Models that keep people on the radar screen ? Sistema de Salud Comunidad Recursos y Politicas Stratification Organizacion de atencion sanitaria Auto gestión Paciente Informado Activado Diseño Apoyo a sistema la prestación decision Interacciones Productivas Sistemas de información clinica Equipo de salud Proactivo Resultados Clínicos y Funcionales Health Care Models: Multiples Adaptations Worldwide By Elements By Countries By Programs CCM Gallery: MacColl Institute Disease Continuum Primary Prevention Early Detection Secondary Prevention Disease Management POPULATION BASED INDIVIDUALS HEALTH CARE Comunidad Recursos y Politicas Sistema de Salud Organizacion de atencion sanitaria Auto gestión Paciente Informado Activado Diseño Apoyo a sistema la prestación decision Interacciones Productivas Sistemas de información clinica Equipo de salud Proactivo Resultados Clínicos y FuncionalesKroniker. 2006 • who adds more to population health ? : Public health or Health services ? Sterile Debate ! • Growing evidence today that improvement will come from operating across the continuum. • Key question is where to start the transformation : - A broad public health perspective ? - A more reduced clinical level reorganization first ? More and More Tools • Predictive Tools: Risk Stratification – PARR 1 & PARR 2 ( Patients at Risk for Rehospitalization ) – Combined Predictive Model • Primary Health Care service frameworks ( UK, New Zealand. ) • Disease Specific Service Frameworks • Adapted Balanced Scorecard. “A single system scorecard” • Rand: Measuring and Reporting the Performance of Disease Management Programs • IHI: Breakthrough Series Formal Policy. • Denmark National Board of Health: “CHRONIC CONDITIONS - PATIENT, HEALTHCARE AND COMMUNITY” 2006 • UK - The NHS Improvement Plan (2004) - Our Health, Our Care, Our Say(2006) - Expert patient • Australia The National Chronic Disease Strategy (NCDS) 2006 • New Zealand Care Plus . Danish National Board of Health Health Policy Studies on Chronic Conditions…. Growing Awareness: “System Problem Needing “Systems” Solution” • USA : IOM Redesign Imperatives: – – – – – Reengineered care process Effective use of information technologies Knowledge and skills management Development of effective teams Coordination of care over patient conditions, services, sites of care. • France: Inspection Generale des Affaires Sociales .2006 “Lessons from other countries on Disease Management”. (Bras, Duhamel, Grass) • Germany : The Lauterbach Report • Canada, Spain, Australia ….. Policy… Do national policies match local priorities ? GETTING TO THE POLICY LEVEL ! Policy Interest seems to Grow when… • When the use of models exposes fragmentation within our systems. Gestión de casos complejos • Use of the models helps to identify incoherent policies. Sistema de Salud Comunidad Recursos y Politicas Organizacion de atencion sanitaria Auto gestión Gestión de la Atención Apoyo a la auto gestión Paciente Informado Activado Diseño Apoyo a sistema la prestación decision Interacciones Productivas Sistemas de información clinica Equipo de salud Proactivo Estratificación del riesgo Resultados Clínicos y Funcionales • When perceived as a form to abandon cottage industry set up ( solo or single handed GP) • When seen as a way to shift to non physician caregivers • Some countries (Spain ) which have not moved into purchaser-provider split now organizing local single systems where those functions are integrated. • When evidence on Organizational models/solutions are presented • When Results of models elsewhere are presented! R. Bengoa. Society… Changes from 'outside' health care system • Rising # of CC associations • Third sector from 'invisible' to very 'visible' • 'Inpatient' patient associations • Rising politicization of certain groups • Growing NGO activities in CC • Allies from other sectors • Citizen 'rights' support (EU and national) Some key allies outside health sector!!!! Asset Planners Strategic Asset Planning Strategic Asset Planning (SAP) maximizes the performance of fixed, physical or capital assets that have a direct and significant impact on achieving corporate objectives. Companies and organizations depend on vital assets to drive they often see them as individual, stand-alone objects operating in the background. In reality, companies are a their business; however, collection of strategic assets that exist single system. as a Harvard Business School SAP symposium, 2003 Can we align the work outside and inside the health care sector more effectively ? Changes from 'within' health care system Changes from 'outside' health care system • Massive amount of burden • Rising # of CC associations • Third sector from 'invisible' information • Existence of better models of care for chronic conditions • Growing number of microprojects • Slow move from micro demonstration projects to macro policy support • Continuity in building business case (health outcomes, economic, management results) to very 'visible' • 'Inpatient' patient associations • Rising politicization of certain groups • Growing NGO activities in CC • Allies in other sectors (e.g. Asset managers ) • Citizen 'rights' support (EU and national) Low Income Countries: How do Global Priorities match Country Priorities ? Global Level Regional Level FUNCTIONS National Level Local Village Level Intersection Local Level Village health worker/ District medical officer Chronic Care models : Low Income Countries ? • 75% of deaths due to Chronic Conditions are in LICs. • Need to build organised horizontal systems in order to cope with massive shower of vertical programmes from the north • Chronic disease models required as frameworks for planners so they don´t copy our fragmented “systems” • Solo practitioners is the norm so need models which integrate. • Lack of human resources : will need to shift to non – physician caregivers • Will need to rely on self - management to handles their chronic disease epidemics R. Bengoa .Kroniker. 2007 • WE HAVE HEAVY EPIDEMIC BURDEN ! • WE HAVE CONCERNED PATIENTS • WE HAVE BETTER MODELS OF CARE ! • THOSE MODELS FAVOUR INCREASED PATIENT ENGAGEMENT • WE HAVE ENCOURAGING RESULTS.. • WE ARE TRACKING THEM ACROSS COUNTRIES Observatory on the Quality and Management of Chronic Conditions www.kroniker.com E-mail: [email protected]