The Policy Context for Developing More Integrated &

Reliable Patient Pathways P a t i e n t P a t h w a y S y m p o s i u m

Cork University Hospital 3rd March 2016

Jim Breslin Secretary General

Department of Health

The Health Outcomes Context

Would you notice 6 years?

You might think so….

Breaking news… • Anglo Irish Bank nationalised • February sees highest increase in unemployment in 40 years;

average of 1,500 people being laid off daily • Fair Deal legislation commences passage through Dáil

But not always…

So here’s an extra 6 years…

• Since 1990 life expectancy in Ireland has increased by:

– 6.3 years in total

– 6.9 for men

– 5.4 for women

• Irish life expectancy is now:

– 79 years for men(1 year above EU average)

– 83 years for women (at EU average)

Age-standardised mortality rates for circulatory system diseases, Ireland

and EU-28, 2002-2012

0

100

200

300

400

500

600

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

European Union (28 countries)

Ireland

Source: Eurostat

Good progress on outcomes but demographics and chronic illness require a major shift in our model of health & social care and are already causing very significant strain on our health services

Projected population growth in the 65 years and older age group, Ireland compared with EU-28 average, 2013 to 2021

Source: Eurostat 0

2.6%

5.7%

8.6%

11.6%

14.8%

17.8%

21.0%

24.1%

0%

5%

10%

15%

20%

25%

2013 2014 2015 2016 2017 2018 2019 2020 2021

EU-28 Ireland

Future Outlook - Demographics

Chronic Illness

• In 2010, 76% of deaths in Ireland were due to 3 major conditions – cardiovascular disease (34%), cancer (30%) and respiratory disease (12%).

• c. 38% of Irish people 50+ have a chronic disease and 11% have more than one.

• As the number of older people increases this burden of chronic disease will grow, HSE estimates by 20% by 2020.

• Estimates project a 70% increase in cancer cases in females & an 83% increase in males between 2015-2040.

Chronic Illness

• In 2011, 40% of all hospitalisations in patients 35 years+ related to 4 chronic diseases; cardiovascular disease, cancer, respiratory disease and diabetes (either as a direct reason for hospitalisation 19%, or a contributory factor 22%)

• 76% of all bed days used, either directly (46%) or as a contributory factor (30%), by patients with these 4 conditions

• 55% (€1.68 billion) of acute hospital budget is attributable to care of patients with these conditions, either directly or indirectly

• Chronic disease accounts for 80% of all GP visits.

Ambulatory Care Sensitive Conditions

• Good quality primary care can help prevent the need for hospital admission

• Well established treatment guidelines for these conditions

• Significant differences between Ireland and other countries & between counties in Ireland

• Will never eliminate need for hospital management but there is potential to significantly improve hospitalisation rates and the standard of care for these conditions.

Ambulatory Care Sensitive Conditions

• Chronic obstructive pulmonary disease (COPD) – 381 hospitalisations per 100,000 population in 2014 – 12,389 hospital stays consuming 107,467 bed-days – Slight increase in age standardised hospitalisation, 2005-2014

• Asthma – 41 hospitalisations per 100,000 population in 2014 – 1,433 hospital stays consuming 6,953 bed-days – 25% reduction between 2005 and 2014

• Diabetes – 129 hospitalisations per 100,000 population in 2014 – 4,406 hospital stays consuming 42,200 bed-days – 25% reduction between 2005 and 2014

Population Health

WHO Principles for Management of Chronic Illness

• National focus on population directed disease prevention & health promotion

• Structured, planned care for patients with long-term chronic conditions

• Information systems and registers to plan and evaluate care

• Support and strengthen self-care

• Shared care that is integrated across organisational boundaries

• Supportive clinical decision systems

• Care that is delivered in the appropriate setting

• Multidisciplinary teams used to provide care

• Monitoring and evaluation framework for chronic disease programmes.

Initiatives Commenced to Date

• National population based preventative strategies under Healthy Ireland (tobacco, alcohol, obesity, physical activity)

• Community Health Organisations • GP contract

– Implementation of diabetes cycle of care under GMS: 63,000 patients registered by end 2015

– Wider contract negotiations

• Development of specialist and community nursing, community intervention teams and other primary care resources

• New Cancer Strategy • HSE Integrated Care Programme for Prevention & Management of Chronic

Diseases – COPD – Asthma – Diabetes – Heart disease

GP ENROLLED POPULATION RISK STRATIFICATION CARE PLANNING CARE DELIVERY AND

CO-ORDINATION

SHARED CARE PATHWAYS AND PROTOCOLS

Primary Care

Acute Care Social Care

Case Manage

Disease Manage

Self -manage

Register • Clinical

• Social

• Risk

GP

Practice Nurse

Community Nurse Specialist

HSCP

Community Pharmacist

HSE Integrated Care Programme for Prevention & Management of Chronic Disease

Source: HSE National Clinical & Integrated Care Programmes

Services for Older People • Demographic: 4% increase in over 85s this year • In common with all other age groups there are inter-relationships between

physical and mental health & between health and social needs & supports • Positive Ageing Strategy required to support a cross-sectoral approach to

healthy ageing • Injection of €140m over the period 2015-2016 in Fair Deal, community beds

and home care packages • Contributed to reduction in delayed discharges from 840 (in Dec 2014) to 553

(on 23/2/2016) • Fair Deal Review to guide future sustainability of scheme • Improved operational processes between hospitals and CHOs • Long Term Care in the Community

– Greater clarity on financing and entitlements needed – Regulation – Greater choice of accommodation options to support independent living

• Integrated Care Programme for Older People: Anticipatory Care and Case Management for Frail Elderly

Healthy Ageing

Source: WHO Report on Ageing and Health, 2015

A RESPONSE TO LONG-TERM COMPLEX CARE

Integration is a fundamental principle of design rather than a system of delivery as a response to long term, complex care.

COMMUNITY DELIVERED It is community delivered but integrated across all agencies and services.

CORE ELEMENTS ARE FUNDAMENTAL TO INTEGRATED CARE

• Population stratification of risk (and case finding) • Anticipatory Care Planning (based on common assessment) • Care co-ordination by a case manager (with agreed care pathways)

LOCAL CONDITIONS Local conditions for Integrated care to flourish needs to be created from bottom up but incentivised from top down.

IMPLEMENTATION IS TYPICALLY BY ‘PIONEERS’

Implementation is typically by ‘pioneers’ leading on change model with dissemination and innovation as the lessons are scaled up

HSE Integrated Care Programme for Older People

Source: HSE National Clinical & Integrated Care Programmes

What does this mean for hospitals?

• Much of a hospital’s effort must be on prioritising activities and resources that will keep people out of hospital through ambulatory care, diagnostics, day hospitals, etc.

• Stronger partnerships with primary care & social care

• Evolution from episodic reactive response to supporting population health models of care which provide greater integration, continuity & coordination of care

Today’s symposium clearly demonstrates that here in Cork you have recognised these issues and are leading the way in tackling them.

Thank you!