1115 aine carroll clinical leaders forum nhc integrated care turning healthcare on its head_ac...
TRANSCRIPT
National Healthcare Conference 2015
Integrated care: turning healthcare on its
headÁine Carroll
Types of integrated care• Integrated care between health services, social services and other care providers (horizontal
integration)• Integrated care across primary, community, hospital and tertiary care services (vertical integration)• Integrated care within one sector (eg, within mental health services through multi-professional
teams or networks)• Integrated care between preventive and curative services• Integrated care between providers and patients to support shared decision-making and self-
management• Integrated care between public health, population-based and patient-centred approaches to health
care – This is integrated care at its most ambitious since it focuses on the multiple needs of whole populations, not just to care groups or diseases
– Source: adapted from International Journal of Integrated Care
Different perspectives
(Shaw et al 2011, p 13)
Burning Platforms Ageing population Chronic disease Money Restructuring Francis and other reports
(Portlaoise) Hospital based model of
care
MoneyGovernment Net Funding for Health
13.7113.33
12.17
12.49
13.78
11.95
10
11
12
13
14
15
2008 2009 2010 2011 2012 2013
Billio
n €
Billion €
Source: HSE monthly performance reports.
Department of Health
Health Commissioning Agency
· Healthcare needs analysis· Models of care· Core service definition · Quality & Standards· Commissioning Intentions· Contract Management
· Performance Management
Regulators· HIQA· MHC· IMB
Health Service Providers
Hospital Groups Community Health Care Organisation
Grant Funded Agencies Primary Care Providers
HIQA · Licensing and compliance monitoring of
residential and specialist ambulatory services for children, older people and people with disabilities.
· Develop standards. · HTAs to evaluate new technologies and · Advise on the collection and sharing of
information across the healthcare services.
National Information and Pricing Office· Separate pricing from
purchasing / commissioning· Hospital Inpatient Enquiry
Scheme (HIPE) (maintained by ESRI)
· National Casemix Programme
Patient Safety Authority· Subsume National Clinical
Effectiveness Committee (NCEC)
· Sets guidelines for eligibility for treatment under UHI
Support Services· Strategy to be developed · Shared Services· PCRS· Electronic claims
management system· Finance Operating Model· MTPF / UHI eClaims · HR· ICT (eHealth)· Audit· Parliamentary Affairs· Informatics
Healthcare Commissioning Agency· Subsume HSE service directors· Convert National Services Framework into
detailed performance targets· Commission services through MFTP and block
allocation contracts· Subsume NTPF and SDU· Divest some responsibilities on move to UHI
Public Hospitals· 6 adult and 1 Paeds hospital groups· Each with a hub that is an academic
medical centre· 48 hospitals (29 statutory and 16
voluntary acute)· Mix of public and private carePrivate Hospitals· Role of private providers under UHI to be
defined· 21 private hospitals (acute and mental)· Approx 3,500 beds· 1 in 6 of all acute beds
Community Health Care Organisations· Successor to ISAs· Review of role of 17 ISAs
(32 Local Health Offices)
Grant Funded Agencies· Status and commissioning
of grant funded agencies to be defined
· Over 2000 separate grant funded agencies
Primary Care Providers – Public and Private · GPs· Dentists · Pharmacists · Opticians
Professional Regulators· Medical Council· An Bord Altranais (Nursing &
Midwifery Board of Ireland)· Dental Council· Pharmaceutical Society of Ireland· Health & Social Care
Professionals Council
Other Regulators· HIQA (see above)· Mental Health Commission· Food Safety Authority of Ireland· Irish Medicines Board· Health Insurance Authority
Professional Bodies· RCSI· HMI· Therapies· IADNM· RCPI· ICGP· Forum of Post Graduate Training
Bodies
Other Agencies· NTPF (move to HCA)· Health Research Board· Irish Blood Transfusion Service· Safefood· Institute of Public Health
Commercial State Company· VHI (UHI provider)
Emerging Future Health System
UHI Providers· Claim settlements
· Payments
Support Services· System wide common services· Shared services & PCRS· MFTP / UHI Claims
National Pricing Office· Price Informatics· Tariff Setting · Pricing
Economic Regulation
Patient Safety
Authority
Health Insurance Authority
Paym
entSLA Cont
ract
&
Perfo
rman
ce M
gt
Perfo
rman
ce
Repo
rting
Paym
ent f
or it
ems
not
cove
red
by U
HI
Ensure quality and safety standards across system
Reco
mm
ends
tarri
ff
Tariffs & Pricing
Polic
y
Perfo
rman
ce R
epor
ting
Cost
Dat
a
Approves payment
Funding
SLA
Regulates the market
Payment
Ensures operational effectiveness and financial stability.Authorises Trust status (tbc)
Clai
ms
Paym
ents
Ambulance
Key to text· Current organisations· Significant changes
Representative Groups· IMPACT· IMO· INO· IHCA· SIPTU· Unite· IDA· PNA· TEEU
Employers · Google, HP, etc
Opportunity costs You can only spend one
healthcare pound or euro once.
Within in a fixed budget if a health care system spends more on one thing, it has to do less of something else
The ‘opportunity cost’ is the value of the best alternative use of resources
Action at all levels of the system
Why change? – Care closer to home!
OUR Enablers and Challenges
Enablers
Thousands of dedicated and able people across the health service
Many major and minor improvements achieved – Cancer, Stroke
Many people have a good experience of the health service
Elements aligned Great desire among people to see
change
Challenges
Poor history of working in a co-ordinated way – fragmented; fractured
High levels of distrust and apprehension
Sense of lack of connection between the top and the bottom
General lack of credibility Have we lost sight of our purpose? ‘We have heard it all before’
National Clinical Programmes:Mission & objectives
1. Improve Quality2. Improve Patient Access3. Value
• For money• For patients• Whilst valuing our staff
Key principles
1. Clinically led – empower clinicians to lead the change
2. Structured programme management approach
3. Nationalise existing best practice4. Engage Patients5. Align stakeholders – Government,
Management, Colleges, Unions, Patients, etc
Why? Partnership between HSE and Clinicians
through the Forum of Postgraduate training colleges
Partnership with Irish Association of the Directors of Nursing and Midwifery and the Therapy Professions Committee
Partnership with patients
Problems Lack of integration Resources Hierarchy Disconnect between strategy and operations HR Finance Procurement Data management
Integrated care programmesShould allow for patient centric treatment that improve outcomes and control costs?
What's the evidence? The evidence base about integration is limited, though a
systematic review was published in 2007 (WHO 15). We have learned 3 important lessons :
Supporting integrated services does not mean that everything has to be integrated into one Package. In reality, there are many possible permutations.
Integration isn’t a cure for inadequate resources. There are more examples of policies in favour of integrated services than
examples of Actual implementation. Managing change may require action at several levels. It requires engagement of health workers and managers, plus a sustained
commitment from senior management and policy-makers.
CAN WE DO INTEGRATED CARE?
Acute Coronary Syndrome:• % STEMI patients that receive PPCI from 67% (2011) 82% (2013) – target 70%National Clinical Programme for Acute Medicine:(comparing 2005-2013)• Introduction of the National Early Warning Score (NEWS) to 100% acute hospitals: received public service excellence award from An Taoiseach• AvLOS 21% • 8% Overnight length of stayNational Clinical Programme for Surgery (comparing 2011-2013):• Surgical volume 16.1%• Bed day usage 8.9%• Day cases 11.2%National Clinical programme for Epilepsy Received an international nursing award for its description of the new national epilepsy service of Ireland (the ‘limelight’ award is part of the
international care challenge series by Sanofi which allows nurses from around the world showcase nursing innovations ) EHR and SOPsNational Clinical programme for Rheumatology/MSK• Physiotherapy led Musculo-skeletal clinics are reducing waiting lists by up to 70%• 10,000 new patients triaged and treated from orthopaedic and rheumatology waiting lists in one yearNational Clinical Programme for COPD• COPD Outreach Model of Care and Pulmonary Rehabilitation Model of Care, Bundles of Care, and patient information materials developed and
issued for adoption. 12 COPD Outreach Clinics now fully operational (2013) providing an “Early Supported Discharge” programme by a COPD Outreach MDT for certain patients with Acute Exacerbations of COPD, that would otherwise require acute in-patient care.
• Average Length of Stay (AvLOS) reduction from 9.1 days in 2009 to 7.6 in December 2012. 5,000 bed days were saved in 2011 compared to 2009 usage
• Access to Pulmonary Rehabilitation in 56% of sites has exceeded the target set (25%). National Clinical Programme for Medicines Management• “Preferred Drug” initiative ( identified for PPIs, Statins, ARBs, ACE Inhibitors, SSRs and SNRs) • Changing prescribers behaviour to prescribe these “preferred drugs” for new prescriptions alone could give up to €19m saving in any year.
National Clinical Programme for Stroke 27 out of 28 hospitals admitting patients with stroke requiring acute care now have a stroke unit. This is an increase from 18
in July 2010. Thrombolysis available in all model 3 and model 4 hospitals either directly or via ambulance access protocols. Thrombolysis rates have increased from 2.4% in 2007 to 9.5% in 2013 exceeding targets and leaving Ireland with one of the
highest rates in the world (UK is 5%, Sweden 6.6% and USA 2.4%) 1.5% increase in patients discharged to home in 2011 (110 patients/yr, 2 patients/week) 2% decrease in case-fatality in 2011 i.e. 70 patients/yr. This was also sustained in 2012. 2.9% decrease in stroke Nursing Home admissions i.e. 150-160 patients/yr
National Clinical Programme for Diabetes Diabetes Retinopathy Screening has commenced in quarter 1 of 2013 and this aims to screen 30% of the diabetic population
in 2013. A national model of care to deliver Continuous Subcutaneous Insulin Infusion (CSII) therapy to children with type 1 diabetes
under 5 years of age has been developed and implemented. 2061 bed days through preventing footcare admissions and reducing length of stay, saved equivalent to €432,810
Retrieval & Transport Medicine• Neonatal retrieval extended to 24/7 nationally in 2013• Paediatric retrieval due to commence a 5 day daytime service in 4 th quarter 2014• National model for adult retrieval designed to support hospital groups. Implementation planned for 2014 in Dublin, Cork and
Galway providing a 7 day daytime service
National Clinical Programme for Audiology • National screening of 99% children within 4 weeks of birth
Our definition An Integrated Care Programme is one which outlines a framework for the
management and delivery of health services which ensure that clients receive a continuum of diagnostic, care and support services, according to their needs over time and across different levels of the health system.
The supporting models of Care will incorporate cross service, multi-disciplinary care and support which will facilitate the maintenance of health and the delivery of appropriate high quality, evidence based care, delivered in a co-ordinated manner which feels seamless to the user.
The ICPs will be underpinned by proactive management of interfaces between stakeholders to reduce barriers to integration and allows for cohesive care provision across a continuum of services
Thank You