Steve Shortell: Integrated care: Policy and evidence

HSRN/SDO ConferenceBirmingham, EnglandJune 3 and 4, 2009

INTEGRATED CARE: POLICY AND EVIDENCE

Stephen M. Shortell, Ph.D.Blue Cross of California Distinguished Professor of

Health Policy and ManagementDean, School of Public Health

University of California-Berkeley

“One of the biggest failings of modern healthcare systems is that they so seldom provide integratedmedical care. In emergencies, patients head for the local hospitals; for minor illnesses they consult their family doctor. But for chronic conditions such as diabetes and cardiovascular diseases, which are becoming increasingly prevalent, they require care and advice both in their primary physician and from the hospital. Effective coordination of this care results in better and cheaper treatment, yet too often it does not happen.

– 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

A network of organizations which provides or arranges to provide a coordinated continuum of services to a defined population and is clinically and fiscally accountable for the costs, outcomes and (working with others) the health status of the population served.

Integrated Delivery System(IDS) Definition

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 Services

Source: Adapted from A. Enthoven “Integrated Delivery Systems“, March 25, 2008.

Some Models to Consider

• Chronic Care Model

• Disease Management

• “Medical Home”

Community Resources

and LinkagesOrganizational Leadership and

Practices

Health CareTeamRedesign

Informed PreparedActivated Productive Interactions ProactivePatient TeamAdapted from: E.H. Wagner, B.T. Austin, and M.R. Von Korff, “Organizing Care for Patients with Chronic Illness,” The Milbank Quarterly, 74 (4), 511-544, 1996.

Chronic Care Model

Better OutcomesInfrastructure

The National Health Service and Social Care Long-Term Conditions Model

Community Resources

Decision Support Tools and Clinical

Information System (NPfIT)

Health and SocialCare SystemEnvironment

Sup

porti

ng

Delivery System

Case Management

Supported Self-Care

PromotingBetter Health

Cre

atin

gDisease Management

Empowered and Informed Patients

Prepared andPro-active Health and

Social Care Teams

Source: 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 StudyUse of Care Management Processes by Type of Chronic Condition

Type of CMPs Diabetes (n = 523)+

Asthma(n = 522)

CHF(n = 526)

Depression(n = 497)

Each of 4 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) - - - - 11.1

Source: D. Rittenhouse et al., “Improving Chronic Illness Care: Findings From National Study 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 Groups

Source: 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 services

Adapted from: Malcolm Baldridge National Quality Award, U.S. Department of Commerce, Washington DC

Does Disease Management Really Work

0.350.30.250.20.150.10.050

Disease Control

MorbidityPatient Knowledge

All-cause Mortality

Quality: Outcomes of Care

Source: Scott Weingarten,M.D. “What’s Working and What’s Not in Disease Management: Lessons Learned Nationally and Internationally.” Annual Supplement on Disease Management and Quality Improvement. May 6, 2002.

Does Disease Management Really Work

1.210.80.60.40.20

Quality: Processes of Care

Source: Scott Weingarten,M.D. “What’s Working and What’s Not in Disease Management: Lessons Learned Nationally and Internationally.” Annual Supplement on Disease Management and Quality Improvement. May 6, 2002.

Provider AdherenceTo Guidelines

Medical Home

Four Cornerstones

• Primary CareComprehensive First Contact Care Across the Lifespan

• Patient-Centered CareMeeting the Needs and Preferences of Actively Engaged Patients

• New-Model PracticeEvidence-based: Population-based Registries, Performance Measurement and Improvement, Point of Care Decision Support, Electronic Health Records; Redesigned Work Processes

• Payment ReformPay for Care Coordination; Episode of Care Based Payment

Source: DR Rittenhouse and SM Shortell, “The Patient-Centered Medical Home: Will It Stand 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 England

Whole systems approaches

Shared boundaries and vision between health and social care

Empowering people to take responsibility, including service to users

Providing car based on levels of need (risk stratification)

Not running (competing) services in parallel

Changing professional attitudes and behaviors via organizational culture change

Overcoming resistance to clinical and managerial change

Strong clinical leadership

Training to support staff in new roles, including project management training

Increasing staff competencies

Organizational stability

High-quality information management and technology

Involvement of al key stakeholders, including professional representative bodies

Creating the right incentives

Adequate investment in services

Adequate time frames in which to test services

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 Partnerships

Co-Existence

Assimilation

Transformation(Development of A New Culture)

Rejection(Separate and Hostile Cultures

Old New

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 patient

Adapted from: R. Ruson and C. Ham, “Integrated Care: Lessons from Evidence and Experience”, The Nuffield 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 others

C. Ham, “Only Connect: Policy Options for Integrating Health and Social Care”, The Nuffield Trust, Briefing Paper, April, 2009

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

Supportivepayment andregulatoryenvironment

Organizationsthat facilitatethe work ofpatient-centered teams

Highperformingpatient-centered teams

• Outcomes:• Safe• Effective• Efficient• Personalized• Timely• Equitable

CARE SYSTEMMakingchange possible

Source: Institute of Medicine, Crossing the Quality Chasm, p. 127, 2001.

Key Recommendation

Think Wholistically –Four Interrelated Dimensions

Components Needed to Achieve System-Wide Clinical Integration

Strategic 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 Organization

Bottom 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”