The Search for Integration and Quality Meg A. Kellogg | University of California, Berkeley Nuria Mas | IESE, Barcelona Miguel Figallo | IESE, Barcelona Terhilda Garrido | Kaiser Permanente Jed Friedman | World Bank, Washington DC

Workshop Agenda PART I

Impact of Integration in La Ribera

Lessons from Kaiser Permanente

Nuria Mas & Miguel Figallo

Terhilda Garrido

Introduction to integration and to La Ribera’s integration progress

Meg Kellogg

Econometric modeling of integrative impact

PART II

Jed Friedman, Nuria Mas & Miguel Figallo

Attendee Discussion

Attendee Discussion

Introduction to Integration and Progress in La Ribera Meg A. Kellogg | University of California, Berkeley * 17 years as integrated care executive * Review of international literature * Site visits and interviews in La Ribera

INTEGRATION Coordinated Care | Continuity of Care | Comprehensive Coverage

Integrated Care

Primary care through hospitalization and beyond: all levels coordinated

Integration Methods, processes and models used to achieve this coordinated care

Why Integrate? To improve the experience and outcomes of

patients and to enhance overall efficiency of health systems

Accountable for a population

Standardized Delivery

Comprehensive range of services and coordinated care transitions

Shared culture and objectives; incentives

encouraging integration

Payment and financial flows

Integrated Information

Systems

Integrated Providers: 1. Interdisciplinary

teams 2. Enhanced and

flexible roles 3. Special care

coordinator roles

QUALITY OUTCOMES

monitoring and achieving

Eight Characteristics of Integration

Accountability for the Health of an Assigned Population

Potential Enhancements:

* More patient engagement and

activation for shared decision-making and self care

* Better disease information on

population, eg identifying total # with chronic diseases in the area and the

individual patients with diabetes, COPD, asthma, CHF in the community

• Risk analysis and targeted management of complicated and

chronically ill patients

Currently:

* Ribera Salud UTE is accountable for total population (250,000) in the

geographic area of La Ribera Departmento de Salud (Health Dept). Excellent opportunity for population

health management

* Patients allowed to go outside area

* Engage in prevention and health promotion efforts for the community

Comprehensive Coverage and Coordinated Care Transitions

Currently:

* Accountable for full range of services

Primary care through hospital and rehabilitation since 2003 when primary

care was added to agreement (exceptions: quaternary, transport, social services and long term care)

*Physical integration achieved in 5

integrated centers with range of services including urgent care,

radiology, lab. (46 other small doctors offices)

Potential Enhancements:

* Additional efforts for seamless transitions across levels/providers of

care

* Increase efforts in follow up across transitions including home care.

Shared Culture and Objectives; Integrative Employee Incentives

Currently:

* Strong and energized leadership and incentive-based culture

* Subset of objectives are requested by Valencia Health Ministry who measures

across areas.

* Detailed incentive program for individual providers (To be described tomorrow by

Dr. Scheffler)

Potential Enhancements:

* Include incentives rewarding integrated care impact (eg lower readmits)

Payment and Financial Flows

Potential

Enhancements:

* Valencia government should consider risk adjusting the capitation at least by age for payments per department in

PPPs and for comparisons of cost results.

* Mgmt may want to consider alternative organizational structures; for example—create and capitate a

multispecialty medical group to be accountable for care. Or more practically, consider additional interdisciplinary

care structures and incentives.

* Payments to surgeons and radiologists are heavily based on volume. Reconsider impact, especially for

surgeons.

* Due to payment structure and amount, there are also incentives which encourage attracting patients from

outside Ribera to enhance income. This is a financial fact of life but bears reflection.

Currently:

* Ribera Salud UTE receives a capitation payment based on population numbers to take

care of the range of health needs in the geographic department of La Ribera.

* Traditional organizational structure with money to top and paid out in salaries and

incentive bonuses to individuals.

* Payments to designated specialists and link agents to encourage “backward integration.”

Emphasis: Pre-hospitalization consults.

Integrated Information Systems

Currently:

* Integrated hospital electronic medical history system and administrative data

*Separate primary care system, “Abucasis” owned and required by Valencian government

* Portals to see hospital record from primary care

and some portal access for attending hospital staff to see primary care diagnosis, test results, and

prescription history.

* Since 2003, La Ribera has been working on “networking” the inpatient and outpatient systems

* SMS messaging used to notify primary care

physicians that their patient is in the hospital and for some patient communications.

Integrated Information Systems

Potential Enhancements:

* Weaknesses point to many potential

opportunities for maximizing the use of IT in La Ribera and other Valencia departments

* Perhaps Valencian government and at least the 5 PPP areas can agree to study barriers

(eg a separate ambulatory system required by Valencia) and create a way forward. Objective:

a patient-oriented record system which is integrated across sites of care and can be

used for analysis and comparisons.

Missing Capabilities

* Re: clinical data, only transactional clinical operations are served. No true integration of the patient records across sites of care, precluding

analytical studies.

* No embedded care alerts

* Care protocols are not automated but in separate paper binders. Adherence not measurable, especially care paths across sites of care.

* No electronic Patient connections, precluding IT

use for: patient engagement and reminders, feedback of test results, appointments or health

education.

Integrated Providers

Enhanced and flexible roles

* Enhanced flexibility for assigning roles and tasks due to ability to hire “private” providers

* Enhanced roles for nursing including care

coordination and increased use of primary care visits to nurses. Nurse manager responsible for each “Area

Basica” within La Ribera. Central nurse roles in mental health patient communications and midwifery

for pregnancy and delivery

Special care coordinator roles

* Effective creation and use of unique care coordination roles:

• Link agents, since 2003—certain internists and specialists from hospital go to integrated health centers

and help evaluate cases, especially need for hospitalization.

• Referente, since 2005—primary care doctor becomes disease “expert” to improve early detection of complications (eg urology, pain management)

• Nurse managers play key roles in care coordination such as coordination of tests and stages of care, and

communications with patients and families.

Interdisciplinary teams

* There are some care teams for specific patient problems, but low emphasis on multispecialty

structures and interprofessional teams.

Standardized Delivery

Currently:

*There are 7-8 complete care pathways to date, often integrative in their inclusion of protocols related to primary, specialty

care, rehabilitation and chronic care. 35 initially contemplated

* Nursing practice is also standardized

through scorecards and technical manuals.

Potential Enhancements:

* Besides lung diseases and readmission for

diabetes, there have not been analytical studies done to monitor adherence or impact/outcomes of

these pathways.

* As previously noted, the lack of an integrated patient data repository is a major barrier to

monitoring care across sites of care. Also noted was the fact that the pathways are in hardcopy

binders.

Potential Enhancements:

* Transparency problems preclude the benefits of comparisons and related identification of identifying

best practices and improving outcomes for La Ribera and all the areas in Valencia.

* Note that neither Valencia nor Ribera gave this study

team their quality results and trends, only the parameters they monitor. The team relied on La

Ribera’s hospital data and on the limited available public data for any comparisons demonstrating

integrative impact, efficiency and quality

Quality

Currently:

*Patient satisfaction trends good and generally rising. Also appears to be low rate of patients choosing to

go outside the geographic area (Data NA)

*Valencia measures all geographic departments on certain quality measures. Ribera Salud can see their results vs unidentified others. One published article included a 2012 comparison chart of the areas in Valencia, the only of these comparisons this study

team has seen. The 5 PPPs were all in the top quartile with La Ribera in the middle of the 5.

*Ribera Salud has an extensive performance

monitoring process for management and incentive bonuses. The use of quality measures was increased in the last few years and Valencia also added more

quality measures to the comparisons.

Summary

Capitation per population for primary to tertiary care

Flexible staffing

Strong management and incentive-based culture

Care Coordinator Roles

KEY INTEGRATIVE STRENGTHS IN LA RIBERA

Summary

Capitation per population for primary to tertiary care

Flexible staffing

Strong management and incentive-based culture

Care Coordinator Roles

KEY INTEGRATIVE STRENGTHS IN LA RIBERA

Enhanced information technology-integrated patient records and data repository for analytics

Identification and tracking the health of the assigned population, including risk analysis and targeted actions for certain chronic diseases and high risk populations.

Sharing utilization, quality outcomes and best practices within and across geographic health departments of Valencia

PROMISING PATH FORWARD