EUROPEAN FORUM FOR PRIMARY CARE

3 - 4 Septembre 2012

Rafael Bengoa. Minister of Health and Consumer Affairs Basque Government.Basque Government. Spain

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SYSTEM –WIDE IMPLEMENTATION ?

2. 2 M

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Objective at Policy Level:Simultaneously Managing Crisis & Achieve Transformative Change

Short term strategy

Crisis ManagementD

rugs: Brand to Generic

Human Resources: Salaries

Tecnologies: Desinvestment…

Long term strategy

Transforming DeliveryC

hronic Care Agenda

Integrated Care

Patient empowerment…

SUSTAINIBILITY?

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Fragmentatión…

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WHY ?

WE HAVE AN ORGANIZATION PERFECTLY SET UP FOR

REACTIVE & RESCUE MEDICINE

WE DO NOT HAVE A LOCAL ORGANIZATION

WHICH SEEKS PROACTIVE CARE

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Most countries are improving in each of the boxes of the continuum but not using the potential of an integrated approach across the continuum.

One of the reasons for this is that we do not have a “microsystem” operating at the local level

Transformation of Delivery…

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WHEN YOU TRACK WHAT YOU DO YOU CONFIRM TWO THINGS : FRAGMENTATION AND EXPECTATION OF A PASSIVE PATIENT !

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PROVIDE A MOTIVATING NARRATIVE… and stick to it..

Año 2009-2010 2011 2012

DEVELOMENT OF THE STRATEGY

TRACKING IMPLEMENTATION

FIRST RESULTS

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First Create a Narrative/ a common language ….

PROVIDE A NARRATIVE THAT GOES BEYOND “COST CONTAINMENT”

A NARRATIVE WHICH PROVIDE A VISION AND A “STRUCTURE”

PROVIDES DIRECTION AND STABILITY IN A CRISIS ENVIRONMENT

THE HARDER THE EXTERNAL ENVIRONMENT IS, THE MORE COHESION CAN THE COMMON VISION PROVIDE

THIS PROVIDES A CONTEXT FOR MANAGERS TO GET OFF THE TREADMILL AND TAKE TIME FOR PERSPECTIVE

R. Bengoa

IN THE BASQUE COUNTRY = THE MAIN

STORY IS “CHRONICITY ”

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Using frameworks/models

MEDICINE POPULATION HEALTH

EFFICIENCY

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WE NEED TO BUILD SOME SORT OF LOCAL HEALTH “MICROSYSTEM”

POPULATION HEALTH

MEDICINE

EFFICIENCY

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Primary Prevention

Primary Prevention

Early Management

Early Management

AcuteManagement

AcuteManagement

Rehabilitation& secondary

prevention

Rehabilitation& secondary

prevention

EFFICIENCY

MEDICINE POPULATION

HEALTH

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“ Having everything under the same roof does not guarantee clinical integration nor a tidy operation

across the disease continuum” R. Bengoa

CEO

U1 U2 U3

THE APPARENTLY EASIEST WAY - TOP DOWN ?

What does ?

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Most organization do not have the integrators in place… We were no exception

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R. BENGOA/J. MORA

Develop Management Processes as Integrators

TOP- DOWN

STANDARIZABLE INTERVENTIONS

CALL CENTER

ELECTRONIC

MEDICAL

RECORD

FINANCING AND

JOINT

COMMISSIONING

ELECTRONIC

PRESCRIPTIONSTRATIFICATIÓN

CASE

NURSINGPACIENT

EMPOWERMENT HEALTH AND SOCIAL

CARE

COORDINATION

SUBACUTE

CENTRES

INTEGRATED

CARE

BOTTOM UP

LOCAL INNOVATION

POPULATION

HEALTHMEDICINE

EFFICIENCY

TRIPLE

AIM

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Launch of Bottom up projects.Evolution of bottom up innovation projects –from 2010 until now

Innovation projects have increased year by year specially in 2012 thanks to CP (+50%) and KronikguneInnovation projects have increased year by year specially in 2012 thanks to CP (+50%) and Kronikgune

40

25

55

25

90

25

33

0

20

40

60

80

100

120

140

160

2010 2011 2012

Distribución de proyectos de Innovación según fuentes de financiación

Kronikgune

Becas Dep

CP

* 141 proyectos de innovación de los cuales se han seleccionado 90 en el CP (72 individuales)

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Aligning Incentives :Commissioning (2012). 3% of the budget bound to Local Popullation-based Intervention Plan

ActivityActivity

CalidadCalidad Bottom up

Bottom up

Local Popullation-

based Intervention Plan

Local Popullation-

based Intervention Plan

97%

2%

0,5% 0,5%

Prevention and Promotion

self-management

Disease management

Case management

Intervention strategies for each segment or strata of the population

Intervention strategies for each segment or strata of the population

PI Diabetes PI EPOC PI IC

PI Multi-pathologies

Tobacco withdrawal screening and advice Anti-flu vaccination

Cardiovascular risk Anti-flu vaccine Tobacco withdrawal

Anti- flu vaccines

Anti-flu vaccine Anti-flu vaccine Anti-flu vaccine

Active patient Physical activity

and diet

5%

20%

75%

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Sense of Scale…Manageable

Population without chronic disease 1.394.539

636.000

173.000

43.000

Prevención y Promoción

Soporte a la autogestión

Gestión de enfermedad

Gestión del caso

863.

888

pa

cie

nte

s

cró

nic

os

en E

us

kad

i

Population without chronic disease 476.401

205.827

54.890

13.722

Prevención y Promoción

Soporte a la autogestión

Gestión de enfermedad

Gestión del caso

274.

439

pac

ien

tes

cró

nic

os

en

Eu

ska

di

Micro

Meso

Population without chronic disease 187.656

81.214

21.567

5.414

Prevención y Promoción

Soporte a la autogestión

Gestión de enfermedad

Gestión del caso

108.

285

pac

ien

tes

cró

nic

os

en

Eu

ska

di

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1 Comarca Bilbao + H. Basurto + H. Santa Marina

Comarca Uribe + H. Cruces + H. Gorliz

Comarca Ezkerrealdea + H. San Eloy + H.Gorliz + H. Cruces

Comarca Interior + H. Galdakao-Usansolo + Santa Marina

Comarca Araba + HUA + H. Leza

Comarca Ekialde + H. Donostia

OSI Bidasoa ( H. Bidasoa + 3 centros de AP)

Osi Goierri (Goierri + H. Zumarraga)

Osi Bajo Deba (Subcomarca Bajo Deba + H. Mendaro)

Osi Alto Deba (Subcomarca Alto Deba + H. Alto Deba)

Subcomarca Tolosaldea + Clinica La Asunción

2

3

4

5

6

7

8

9

10

11

FUENTE: Equipo de trabajo

11 microsystems in Basque Country

OSI Goierri-

Alto UrolaOSI Alto

Deba

Araba

Treviño

Bilbao

Ezkerraldea

OSI Bajo Deba

Interior

UribeOSI

Bidasoa

La Asunción

Donostia

a

Cruces

Galdakao-Usansolo

Basurto

Gorliz

Sta. Marina

HUA

Donostia

Gipuzkoa

Zamudio

• Leza

San Eloy

1

2

3 4

5

6

7

8

9

10

11

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SPEED ?? BOTTOM UP ORGANIZATIONAL INNOVATION

Osi Bidasoa

BasurtoSta. Marina

•384.000 habitants •24 primary care centers•1 acute hospital•1 medium and long term hospital

H. Basurto- C-Bilbao-H. Santa marina

•85.000 habitants •First integrated organizational structure (hospital and primary care center)

Integrated organizational

structure

Non Integrated organizational

structure

DIFFERENT MODELS OF INTEGRATED CARE ORGANISATIONS (systems)

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Osi Bidasoa – Eficiency

-4.40%

Referral rate of medical consultation

+1.9%successive visits

-7.18%First visits

+0.17Index of successive/firts

-3.04%Hospital admissions

YEAR 2010 YEAR 2011 APRIL 2012

GP Expenditure 12.414.000 11.870.000 3.788.900

HP expendieture

38.912.000 38.337.000 12.415.900

OSI Expenditure

51.325.000 50.208.000 16.204.800

% VARIATION -2.1% -1.91%

Results in terms of activity

Economical results of OSI BIDASOA

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Promic – Case management Cardiac Failure (PP o GE)

Coordinated process between acute hospital and primary care, case nurses and patient self-care

RESULTS Patients (Nª) Age % hospitalization or death

GI 66 78 +/-12 19.7%

GC 47 79 +/-12 40.4%

•113 patients (55 in Araba and 58 Bizkaia) (66 patients in the intervenvention group (PROMIC))

• Incidence rate: 10-day events/6827 patients PROMIC group vs 15/1490 patient-days in the control.

• The survival time was higher in PROMIC group than in the control

• 40% of reduction in risk of death or readmission in the PROMIC group

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TELBIL at 6 month of telemonitoring Pluripathological

patients in Primary Care

RESULTS:

•MORTALITY IG 1 (3,85%) CG 2 (6,67%) total 5,36%

•HOSPITAL ADMISSIONS: -27%

•DURATION OF HOSPITAL STAY (9,6 IG versus 12,2 días CG)

•Baseline Functional Status (BFS) : Better in Telbil Intervention Group than in control grupo

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Integrated cardiovascular care…

...is leading to reductions in heart attacks and strokes.

17

1,0

1,1

1,2

1,3

1,4

1,5

1,6

1,7

1,8

1,9

2,0

Stoke-related Hospitalization Rates in No. Cal.

1998-2007ST Elevated MIs in No. Cal.

1998-2007

0,4

0,6

0,8

1,0

1,2

1,4

1,6

1,8

2,0

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

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KP Northern California ALL program, PHASE, results.

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Speed ??

Risk stratification…

100% of the population stratified

Electronic Medical record

is being implemented in the whole health

care organizations

More than 30 coordination projects to improve

continuum of health of our

chronic patients

More than 500 active patients on

diabetes and 1500 in 2012

Telehealth and

telemedicine with good

results

3 New cases nursing is

being implemented (71 ECGA)

Osarean

Case nursing Self-management

Integration

Electronic Medical record

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Different Countries/Systems Moving In The Same Direction

Focusing on delivery reform

Context : some promoting competition ; others not.

Shifting from volume and inputs to value

Leaning on same Models: KP and CCM , Triple Aim and others

All Building some sort of Local Health “Microsystem”. Europe and ObamaCare

A lot of learning potential if brought together

Mid-term policy perspective/ trend

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PRETTY FAST WITH NEW NARRATIVE

PRETTY FAST WITH THE TOOLS /INTEGRATORS

LOGIC OF CAPACITY BUILDING THROUGHOUT POSITIVE

SLOWER GOING TO SCALE

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THE PROCESS WILL NOT DEVELOP IN A TIDY SEQUENCE OF LINEAR STEPS.

INSTEAD IT WILL PROLIFERATE VIA GROUPS OF INNOVATIVE IDEAS BY DIFFERENT

ORGANIZATIONAL UNITS. Van de Ven 1999

! CONFIRMED !