Continuing Care. Design (NHS 1.3)

Transcription

1 Continuing Care DRAFT Design (NHS 1.3) Strategy Document October 2015

2 Table of Contents Executive Summary... 3 Chapter 1 Introduction Global Health System Evolution Continuing Care System Design International Responses to Continuing Care Design Definition of Continuing Care Chapter 2 Case for Change Qatar s Shifting Healthcare Landscape Current Continuing Care System The Patient Perspective The Healthcare Provider Perspective Case for Change Chapter 3 The Future Continuing Care System Continuing Care Vision Future Continuing Care System National Integrated Continuing Care Model Chapter 4 Strategic Framework Objectives Objective 1: Establish Leadership and Governance for Continuing Care Objective 2: Develop a National Integrated Continuing Care System Objective 3: Develop a Comprehensive Range of Continuing Care Services Objective 4: Invest in Continuing Care System Enablers Objective 5: Engage Patients, Caregivers and Communities Objective 6: Provide Suitable and Effective Funding for Continuing Care Implementation 49 Chapter 5 Implementation Implementation Approach and Timeline Indicative Costs Appendices... 53

3 Executive Summary The National Continuing Care Design Strategy places patients and families at the center. It promotes the development of interconnected services and processes that support and empower patients to live healthy, active and fulfilling lives. The National Continuing Care Design Strategy presents a roadmap to deliver world-class personalized, coordinated and integrated care closer to home.

4 Qatar s continuing care system aims to meet the needs of a diverse patient population that spans children with disabilities, youth with complex conditions, adults with short, intermittent or chronic health conditions, elderly with complex needs and end-of-life patients requiring palliative care. These diverse patient populations have conditions that manifest in very different ways and these differences are further compounded by the uniqueness of each patient. These seemingly different patient groups share one thing in common; they all experience healthcare as a journey that involves ongoing interactions with multiple healthcare providers they all need continuing care. Qatar s continuing care system aims to ensure that patient journeys through the healthcare system are as straightforward and simple as possible minimizing gaps, gridlocks, detours or blockages. The continuing care system will achieve this through a combination of processes and services that work in tandem. Processes facilitate the proactive identification and assessment of patients with ongoing care needs, patient transitions to appropriate settings and coordination and delivery of services. This ensures that patients receive the right care, at the right time, in the right environment by the right team. Table 1 contrasts elements of the current and future state of Continuing Care delivery in Qatar. Table 1 Current and Future state of Continuing Care Delivery in Qatar Fragmented Care Current Lack of standardized and efficient care transitions Highly-hospital focused Role of care coordination not well defined Limited capacity and range in continuing care related services to meet growing demand Reactive and episodic care Future Integrated care that coordinates primary, secondary, social and community support Efficient system navigation Supporting care closer to home settings Patient and family centered care coordination Broad range of comprehensive services across a range of care settings Proactive and standardized pathways

5 This strategy presents a roadmap for the design and implementation of an integrated continuing care system while expanding and connecting Qatar s healthcare continuum as represented in Figure 1. Qatar Continuing Care Vision World class personalized, coordinated and integrated care closer to home Advancing Continuing Care Areas for Action Develop a Defined Comprehensive Care Continuum Establish a Health System Navigation and Care Coordination Process Deploy System-Wide Predictive Patient Assessment Tools Expand the Range and Capacity of Alternative Care Settings Expand Homecare and Community Services Develop a National Assistive Technology Service Key Enablers Qualified Workforce Health and Information Technology Appropriate Funding Models Innovation and Research Foundational Factors National Continuing Care Governance National Care Integration Board Continuing Care Delivery Standards Patient and Family Engagement Figure 1. Advancing Continuing Care: A Roadmap for Design and Delivery

6 Chapter 1 - Introduction Continuing care systems have to cater to a diverse patient population that spans children with disabilities, youth with complex conditions, adults with short, intermittent or chronic health conditions, elderly with complex needs to end-of-life patients requiring palliative care. As such, continuing care patients are not defined by age, diagnosis or length of time they require services, but by their need for ongoing care. As a consequence, there is no single clinical model, specialty, level of care, care setting or healthcare provider that can address all the needs of patients requiring continuing care. This chapter describes global healthcare system evolution as a driver for the development of continuing care systems and how leading systems have approached continuing care design. A definition of continuing care and the guiding principles is also presented.

7 1.1 Global Health Systems Evolution Demographic trends across the world tell a clear story: over the next 25 years, populations will grow, age and become even more diverse. How and where people live, and what their needs and expectations are will change. Internationally, a growing number of people with more complex needs than ever before will require access to care. People around the world trust and value the care provided in hospital settings. However, while hospitals provide excellent care for patients in need of acute services, they are not ideal settings for patients once their acute care needs are met. Staying in hospitals longer than needed can place patients at risk of acquiring infections and functional decline as a result of long periods of inactivity. In addition, hospital care becomes unnecessarily costly if utilized for non-acute needs. As the number of patients requiring ongoing care increases, healthcare systems have focused on expanding primary care and diversifying community-based care. This expansion has achieved a partial reduction in the demand on hospitals but has also led to healthcare systems that are significantly more complex for healthcare professionals to manage and for patients to access and navigate. Patients and families often experience gaps, gridlocks, detours and blockages through their healthcare journey. Those with complex and chronic conditions, often fail to receive coordinated care and revert back to their trusted source of care - hospitals. Thus, the imbalance across healthcare systems continues. At the root of this dysfunction is the fact that healthcare no longer follows a straight path that has a clear beginning and an end. Rather, the healthcare journey is complex with many potential twists, turns and cross-roads, particularly for those with chronic conditions and long term care needs. In order to address this, new models of care utilize continuing care systems to ensure the ongoing provision of the right care, at the right time, in the right place by the right team.

8 Engaged Patients and Families DRAFT 1.2 Continuing Care System Design Continuing care systems have to cater to a diverse patient population that spans children with disabilities, youth with complex conditions, adults with short, intermittent or chronic health conditions, elderly with complex needs to end-of-life patients requiring palliative care. These diverse patient populations have conditions that manifest in very different ways and these differences are further compounded by the uniqueness of each patient. As a consequence, there is no single clinical model, specialty, level of care, care setting or healthcare provider that can address all the needs of patients requiring continuing care. However, this group of patients experience common challenges in accessing, navigating and coordinating their care needs. While there needs to be a significant expansion of point of care services to support increasing demand, this alone will not resolve the challenges faced by patients requiring continuing care. A continuing care system needs to support the identification, assessment and transition of patients and the coordination and delivery of services. This is best addressed through a strategic framework considering policy development, standards, accountability, workforce and patient engagement as shown in Figure 2. Organizational Services and Processes Person and Family Centered Care Policy Development, Standards and Coordination Healthcare professionals working in partnership Figure 2. Continuing Care Strategic Framework 1 The integration of these diverse strategic, planning and delivery components will most ably resolve the system complexity and drive person and family centered care.

9 1.3 International Responses to Continuing Care Design An international review of leading healthcare systems reveals a consistent set of strategic themes that should be considered when designing effective continuing care systems 2-6. These themes are shown in Figure 3. Compliance with Regulations and Standards Focus on Technological Innovation and Research Supporting and Maintaining Patient Independence Care Closer to Home Effective and Appropriate Funding Models Person and Family Centred Care Healthy Active Aging Investments in Formal and Informal Workforce Innovations in Alternative Care Settings Access, Integration and Coordination of Care Figure 3. Common Strategic Themes Addressed by Leading Continuing Care Systems

10 Definition of Continuing Care The following definition has been developed for the purpose of this strategy and all related continuing care programs in Qatar: A coordinated and integrated system of care that safely and proactively transitions patients to the most appropriate care setting. Continuing care clients are not defined by age, diagnosis or length of time they require services, but by their need for ongoing care. The following guiding principles will be used to adapt international best practice developments to customize a progressive continuing care system for Qatar. This innovation will complement the National Health Strategy in achieving Qatar s ambition to develop a world-class comprehensive health system. Anticipatory and Predictive The use of evidence-based patient assessment tools to proactively identify current and future patient health and social needs. These tools allow risk stratification and personalization of care to meet the unique needs of every patient. Easier Access and Navigation Fewer doors to access with a defined menu of services to support seamless patient transitions across services and providers that work together in partnerships and alliances. Coordinated and Integrated Systematic use of care coordinators and case managers applying a set of standardized care pathways and protocols that bridge organizational boundaries. Defined Care Continuum A comprehensive care continuum with clearly defined levels of care that deliver the right care, at the right time, by the right team in the most appropriate care setting with care closer to home when appropriate.

11 Comprehensive Needs- Based Services A wide range of services to support ongoing care that include, but are not limited to; rehabilitation, reablement, cognitive/behavioral, psychosocial, complex care and specialist nursing and therapy services to meet the needs of pediatric, adult and geriatric patients. Services are delivered across hospital, community and home settings by multidisciplinary teams. Accountability and Governance System-wide accountabilities and responsibilities are clearly defined. A clear mandate for implementation is in place. Person-centered Care Models of care should be designed based on patient need, preference and expectations rather than organizational boundaries and priorities. It is important to fully appreciate that this definition and the guiding principles reflect contemporary practice. Continuing Care can no longer be effective in a health system if limited to the provision of specific medical services to a specific patient cohort at a specific stage of the patient journey.

12 Chapter 2 The Case for Change Qatar s growing, changing and aging population is creating a shift in the healthcare landscape. Patients, families and healthcare providers are impacted by this changing environment. A national continuing care system will facilitate the development of strategic and sustainable solutions to meet current and future challenges. This chapter presents an assessment of the changing healthcare landscape and its impact on the current continuing care system. Patient and provider perspectives are presented making a compelling case for change.

13 2.1 Qatar s Shifting Healthcare Landscape Qatar s healthcare system is designed to deliver primary, secondary and tertiary care. Public healthcare delivers primary care services through a network of primary health centers, while public hospitals deliver over 80% of secondary and tertiary care services. Private sector healthcare provision is expected to increase significantly as opportunities for investment are identified. For the majority of patients, the healthcare journey involves multiple referrals between primary healthcare and the hospital system, where patients receive the care they need and are then discharged. The current healthcare system is arranged around organizational boundaries and assumes that patients follow a linear path from primary care to hospitals and then home. Although heavily burdened, this system design has provided care for those with short term acute conditions. Qatar s population is growing, aging and changing, as outlined in Table 2. This shifting healthcare landscape makes a compelling case for change.

14 Table 2: The Shifting Healthcare Landscape A growing population that has tripled in the last ten years and is expected to exceed an unprecedented 2.5 million by The healthcare system will continue to experience significant increases in the demand for services. Shifting demographics will see a 2.7 fold increase in the number of Qataris that are 65 and older 7. In addition, a greater number of children with complex health conditions and disabilities will be surviving into adulthood. The healthcare system will have to address the growing burden of chronic disease and the demands of age-related health challenges. Local communities that have a unique cultural diversity combining nationals and expats from over 60 countries. This diversity will have implications for patient needs, preferences and choices in healthcare delivery. Empowered and informed patients and families have increasing expectations of quality and flexibility of healthcare provision. Moreover, patients and families are seeking a greater understanding of their healthcare conditions and expecting to participate in the decision making process with their healthcare provider. A governmental drive towards greater efficiency and accountability in the delivery of public health services across Qatar has been mandated. Demographic and economic shifts demand the healthcare system deliver more while continuing to drive effectiveness, quality and transparency in order to ensure its ongoing sustainability. A rapid pace of technological innovation is transforming healthcare delivery models through implementation and standardization of care practices, reduction of duplication and enhancement of quality and patient safety. In addition, new technologies area adding capacity to coordinate the needs of patients both directly and remotely.

15 Qatar s shifting healthcare landscape, outlined in Table 2, will increasingly expose any system inefficiency and capacity and workforce shortages. The healthcare system is tackling these challenges by heavily investing in the expansion of existing services, which in turn have introduced numerous plans to support continuing care as the volume of patients requiring ongoing care increases (see Figure 4). This will bring initial benefits by easing operational pressures on individual organizations, however, these benefits are unsustainable given that they are largely uncoordinated. These developments do not present a cohesive strategic solution to deliver a proactive, effective or contemporary national continuing care system. Primary Care Secondary & Tertiary Care Continuing Care Continuing Care Figure 4. Current Continuing Care System within the Broader Healthcare Context

16 The effectiveness of current continuing care delivery was evaluated by conducting a concurrent, focused review utilizing an evidence-based, clinical utilization review tool: Managing Care Appropriately for Patients 8 (MCAP ). MCAP utilizes individualized patient assessments to determine if patients have been admitted to the most appropriate level of care for their condition, and if not, what level of care should they be transitioned to. Aggregation of review results determines the maturity of current healthcare navigation, coordination and integration functions. Figure 5 presents a high level summary of the key findings. Current Level of Care Emergency Care Intensive & Acute Care Rehab, Skilled Nursing & LTC Outpatient Care Activity Potentially Shifted to Lower Level of Care 20 to 25% 20% 30 to 40% 20 to 30% 58% of days of care could be delivered at a lower level of care 20% of days of care could be delivered at home 31% of patients in current levels of care have co-occurring conditions Figure 5. Key Findings from a Concurrent Clinical Utilization Review across Qatar A demand model was developed to project the need for healthcare services across the entire health system. The model incorporated the MCAP review findings to estimate how the demand for healthcare services can be redistributed if alternative levels of care and settings were made available (see Figure 6).

17 * + Hospital based * Self care currently not reported/ recorded Community based Current activity (admissions/ visits) Real demand (if alternative LoC and settings exist) Figure 6. Potential Shift in Activity if Alternative Levels of Care Existed 4 It can be concluded that a more comprehensive care continuum, with defined levels of care and effective continuing care processes, would result in a redistribution of demand across the healthcare system and drive care closer to patients homes and community. This would ultimately improve service quality, release ED capacity and reduce hospital bed shortages.

18 2.3 The Patient Perspective Patients experience healthcare as a journey; the journey may be short, long or frequently made. Patient journeys are becoming more complex and influenced by increasingly high expectations. Patient and family engagement is important in the future design of health services. Initial engagement of patients in Qatar 9 would support the case for change; the need for a cohesive national solution to deliver a proactive, person centered continuing care system. Patient feedback, see Figure 7, suggests that easier access to services, care closer to home, better coordination and integration of services and greater patient empowerment would be highly desirable. Figure 7. Representative Findings from Patient Engagement Activities

19 Healthcare providers play a fundamental role in the design and implementation of healthcare systems and services. Extensive engagement with public and private healthcare providers, the national insurance provider and the regulatory body supported the need for rebalancing of the healthcare system while paying particular attention to the needs of patients with complex and chronic conditions. There was significant consensus between all public and private stakeholders regarding the following: There is a need to modernize the continuing care system in line with international best practice while preserving the unique cultural sensitivities Care coordination is needed at a national level to bridge provider and organizational boundaries The expansion of care into community settings is urgently needed to meet growing demand The continuing care system must be designed to adapt to unique patient needs as a onesize-fits-all solution will not provide optimum outcomes A population health approach should be utilized in developing new services to ensure local community needs are addressed Funding is a major enabler and appropriate incentives must be developed to allow the private sector to launch continuing care services Healthcare stakeholders ranked the priorities that should be addressed in a redesigned continuing care system, on a scale of 1 to 5, and the results 10 are shown in Figure 8. Person and Family Centered Care 4.8 Access, Integration & Coordination of Care 4.6 Supporting Patient Independence 4.4 Care Closer to Home 4.3 Appropriate Funding Models 4.2 Healthy Active Aging 4.1 Focus on Technological Innovation and Research Compliance with Regulations and Standards Investment in Formal & Informal Workforce Innovations in Alternative Care Settings 3.8 Figure 8. Healthcare provider ranking of priorities to be addressed by continuing care system

20 The current state assessment of continuing care delivery in Qatar indicates that insufficient and inadequate services and systems are in place to tackle the changing healthcare landscape. To provide a coordinated and integrated system of care for patients with continuing care needs, the following challenges will need to be addressed as part of a connected framework of improvement: There is a significant lack in alternative care settings, innovative care models and integrated patient pathways, leading to an unbalanced demand across the care system. A comprehensive care continuum remains absent and undefined across Qatar. Having a defined health care continuum gives clarity to the range and scope of services available to patients as they experience their journey through the health care system. Patient transitions between levels of care and navigation through the healthcare system are constrained and difficult Phased movements across levels of care can increase bed capacity and support clinicians to actively identify continuing care patients and plan for their needs. The delays in transitioning patients may impact on their plan of care or compromise access to appropriate treatment. A significant portion of patients with ongoing care needs, particularly those with multiple and complex conditions, are receiving reactive episodic care Continuing care delivery requires a broad range of service inputs that may be most appropriately delivered through multiple providers. The development of a shared, single, coordinated plan of care both supports professional collaboration and patient and family experience. There is a lack of predictive tool usage and risk stratification to support the identification of patients requiring continuing care A continuing care process needs to start with the proactive identification and assessment of patients with on-going needs and actively support their access to appropriate treatment and services. A system wide application of evidence-based assessment tools supports health professionals in the clinical decisions they need to make. Community and home based services are minimal and unable to meet the current demand or respond to new service development opportunities. A proactive assessment of population health needs driving the design of associated community services could significantly extend the care continuum and add important new levels of care to support both the step up and step down of patients across the health system.

21 The challenges and limitations as outlined currently position continuing care delivery as a limited set of services that are perceived as an end point for patients. Many patients will have already experienced lengthy or complex uncoordinated care before coming into contact with continuing care related services. By this time, significant opportunities to expedite treatment, planning or solutions may have been lost. These system challenges make a strong case for change particularly when reviewed in line with continuing care best practice principles. The case for change becomes even more compelling when the impacts on patients, providers and the regulator, outlined in Table 3, are taken into consideration. Table 3. Current Continuing Care System Features Impact on Patients, Providers and Regulator Continuing Care Principle Current State Assessment Impact on Patients and Families Impact on Providers Impact on Regulator Anticipatory and Predictive There is limited use of evidence-based patient assessment tools to proactively identify ongoing patient needs. Current assessment tools do not systematically bridge clinical and organizational boundaries Patients and families lack a comprehensive health and social care assessment. Patients have limited opportunity to participate in planning for their future care Providers ability to respond to changing patient need or service demands is compromised Limited access to large data sets to allow predictive health system planning for population based health programs Easier Access and Navigation The healthcare system is complex with overlapping service provision. There is no clearly defined menu of services linked to providers. Partnerships across providers are limited Patients experience disjointed healthcare services with no navigation support Patients seek treatment in the Emergency Departments Providers work in silos and lack the benefit of system connectivity Unbalanced care provision with significant unmet population health needs. Increased demands for treatment abroad Coordinated and Integrated System wide care coordination is absent. Case management activities and clinical pathways use is limited within organizational boundaries Patients, particularly those with complex and chronic conditions, receive disjointed and overlapping services from multiple providers Limited connectivity and feedback across primary, secondary and tertiary care providers Poor accountability for care delivery outcomes with no formal coordination oversight Care quality monitoring does not effectively measure health outcomes

22 Continuing Care Principle Current State Assessment Impact on Patients and Families Impact on Providers Impact on Regulator Defined Care Continuum The care continuum in Qatar is undefined with limited levels of care and appropriate care settings. Institutional settings are utilized as the main point of care delivery Patients may not receive the best care, at the best time, in the best setting Increased pressure on primary and ambulatory care settings Acute beds occupied by nonacute patients resulting in increased lengths of stay, discharge delays and capacity problems Unsustainable increases in healthcare costs as long-term care patients receive costly acute care Costly investment in designing, building and running institutional care settings Comprehensive Needs-Based Services A population based approach to service planning and provision is limited Patient do not receive comprehensive and holistic care in their local communities Vulnerable populations suffer from isolation and lack of integration in the society Providers are challenged by patients increasing expectations Unsustainable growth in healthcare budgets to cover duplicated provision and increased reliance on acute care Accountability and Governance Lack of clearly defined system-wide accountabilities and responsibilities particularly as it relates to complex care provision Patients experience difficulty in securing coordinated services from multiple providers Clinicians and administrators are frequently challenged with resolving system barriers Standardization and regulation of referral, transfer, discharge, and transition processes is challenging Person- Centered Care Service design and care planning processes currently lack a strong patient and family voice Limited selfmanagement and engagement programs to support patients as partners The wishes and preferences of vulnerable patients may be overlooked Unengaged patients and families may not comply with care plans Poor patient reported experience measures (PREM) Sub-optimum improvements in health outcomes despite increased expenditures. Mounting pressure on regulator to improve the perceived quality of services.

23 Chapter 3 The Future Continuing Care System DRAFT Qatar aims to develop a continuing care system that consistently delivers world-class personalized and coordinated care closer to home. In order to successfully achieve that, continuing care must be delivered as a system-wide framework driving the identification, assessment, planning and coordination processes for patients with ongoing needs, regardless when and where they interact with the healthcare system. This chapter presents Qatar s continuing care vision, model and underlying system features.

24 3.1 Qatar s Continuing Care Vision World-class personalized, coordinated and integrated care closer to home. World-class continuing care is better, sooner, more convenient care that is delivered in the patient s home or in community settings that are as close to a home environment as their care needs will allow. Care will be personalized and customized to meet the unique needs of every patient and their caregiver, whether it be short, intermediate or long term. Care will be coordinated through a national central point of access, in which health navigators will utilize comprehensive assessment tools to deliver funded packages of care that integrate the services of public and private providers across the care continuum.

25 3.2 The Future Continuing Care System A fundamental transformation in Qatar s healthcare system is needed in order to develop strategic and sustainable solutions to meet current and future challenges. This transformation cannot be achieved unless Qatar s healthcare system shifts from a reactive, provider-centric model to a proactive, patient-centric model that designs and delivers coordinated and integrated services wrapped around individual patient needs. In order to support the sustainable solutions developed by Qatar s national healthcare strategies, continuing care must be approached as a system-wide framework driving the identification, assessment, planning and coordination processes for patients with ongoing needs, regardless of when and where they interact with the healthcare system. The rebalanced and connected healthcare system is presented in Figure 9. Figure 9. The rebalanced and connected healthcare system This rebalanced and connected system embraces and builds upon the innovative strategies of NHS setting the following fundamentals: Primary care is the first point of contact in the healthcare system, and is the ongoing point of contact for any primary care and preventative health needs Secondary and tertiary care institutions are supported to focus on providing care to patients with the most acute needs Continuing care processes bridge the current gap between primary and secondary/tertiary care by coordinating and integrating care, consistently driving care closer to home and packaging community services to handle increasing demands of patients with short and long term needs

26 3.3 The National Integrated Continuing Care Model The national continuing care model, underpinned by international best practice, is shown in Figure 10. The model places the needs of the patient and their family at the center of the healthcare system and stresses the need for comprehensive, coordinated and integrated care. The model focuses strongly on supporting care delivery closer to home and offers solutions for driving step-up and step-down care, which avoid admission to secondary care facilities when appropriate and support timely discharge when an inpatient admission is necessary. In addition, the model has been designed to support and maintain the patient s level of independence, flexibly transitioning between levels of care as their needs change. Secondary Services Integrated Continuing Care System Primary and Community Services ICU & HDU Step down Step Up Bedded Intermediate Care Step down Step Up Home with Primary Follow up Home with Support Services Acute & Subacute Step down Step Up Home with Clinical Services Supported Living Health System Navigation System-Wide Clinical Pathways Technology to Enable Service Delivery Figure 10. Qatar s National Integrated Continuing Care Model

27 The key features of the national continuing care model can be summarized as follows: A Comprehensive Care Continuum with Expanded Levels of Care The National Continuing Care Model proposes a health system built on expanded and defined levels of care that will establish a comprehensive care continuum. Patient acuity, clinical service needs, care environment and healthcare provider competencies and in turn length of stay and costs vary from one level of care to another. The model recommends the significant expansion of intermediate levels of care to support patient transitions and rebalance demand across the healthcare system. The model also recommends the expansion of communitybased levels of care to address a broader range of patient acuity levels. A description of the recommended levels of care is presented in Appendix A. Use of Predictive Risk Stratification and Patient Assessment Tools At patient level, risk assessment and decision support tools, based on comprehensive evidence-based clinical criteria, facilitate identification of patients with ongoing care needs and allocation to the most appropriate level of care while proactively driving care closer to home. This ensures that everyone who would benefit from a care plan gets one, and that the complexity of the care plan is proportionate. Risk stratification also recognizes that people are not static in their level of risk so the model of care flexes as their level of risk changes. At health system level, data from evidence-based tools can be aggregated to understand population health needs, and support the design and expansion of services and care settings to meet the demand for each level of care. Care Coordination Patient and family centered assessments are the focus of care coordinators utilizing a range of validated and reliable tools. Assessment by a care coordinator can occur at any level of care, and in any facility or environment and facilitates the development of a plan for care, transitions to alternate levels of care within an organization and early discharge planning. One of the main tools to support care coordination is the Comprehensive Clinical Assessment InterRAI suite, which includes several instruments designed for application in acute and community care.

28 Health System Navigation The newly developed national integrated continuing care system will have a mandate to establish a health system navigation and coordination function. This national function includes; a central point of access to a comprehensive needs assessment performed by specially trained national health system navigators. These national system navigators utilize predictive tools, cross-organizational pathways, health and social funding options and a system-wide menu of public and private provider services in order to commission personalized packages of ongoing care. National health system navigators work closely with organization-based care coordinators to ensure seamless patient transitions to the most appropriate level of care. Integrated Care Delivery Care integration is a desirable outcome in contemporary health system design. The model supports a systematic approach to achieving integration through the use of standardized system-wide tools, pathways in order to support the development of a single, shared and integrated plan of care. Support of Communitybased Care Activities The model introduces holistic patient and family centered assessment tools to support the identification and planning of health and social care. More expanded levels of care support the targeted development and expansion of community-based services to meet local population needs, rebalance demand across the system and drive care closer to home. Use of Technology to Enable Service Delivery The model recognizes the significant potential offered by health technologies in enabling continuing care service delivery. A sustainable, integrated national continuing care system adopts the development of robust information, telehealth and mobile technology infrastructure across healthcare organizations and at a national level. Such an infrastructure will support shared record systems, evidence-based assessment tools, smart sensors, community workforce management systems and system level analytics.

29 Chapter 4 Strategic Framework Objectives There is a compelling case for change and a need to enhance the provision of comprehensive Continuing Care in Qatar. It is important to recognize that in isolation, even the best continuing care service models will fall short and fail to address the healthcare system challenges in Qatar. This chapter presents an integrated strategic framework to develop an efficient national continuing care system, integrated with primary and secondary services, that delivers coordinated, patient and family centered care.

30 Engaged Patients and Families DRAFT 4. Strategic Framework Objectives A strategic framework of interconnected objectives has been developed. Its implementation will support an integrated continuing care system design unique to Qatar. Central to all outcomes is patient and family centred care. Organizational Services and Processes Person and Family Centered Care Policy Development, Standards and Coordination Healthcare professionals working in partnership Objective 1: Objective 2: Objective 3: Objective 4: Objective 5: Objective 6: Establish Leadership and Governance for Continuing Care Goal 1: Develop a National Continuing Care Body Goal 2: Establish a National Care Integration Board Goal 3: Develop National Continuing Care Service Delivery Standards Develop a National Integrated Continuing Care System Goal 4: Develop a Comprehensive Care Continuum Goal 5: Expand the Range and Capacity of Alternative Care Settings Goal 6: Establish a Health System Navigation Process Goal 7: Deploy System-wide Predictive Patient Assessment Tools Develop a Comprehensive Range of Continuing Care Services Goal 8: Develop Integrated Continuing Care Centers Goal 9: Expand Home and Community Services Goal 10: Expand Supported Living Provision Goal 11: Develop a National Assistive Technology Service Invest in Continuing Care System Enablers Goal 12: Build a Professional Continuing Care Workforce Goal 13: Expand the Use of Mobile and Information Technologies Goal 14: Develop Dedicated National Health Insurance Packages Goal 15: Develop Continuing Care Innovation and Research Infrastructure Engage Patients, Caregivers and Communities Goal 16: Raise Awareness and Understanding of Continuing Care Benefits Goal 17: Co-design Services with Patients, Families and Caregivers Goal 18: Enhance the Role of Carers, NGOs and Volunteer Organizations Provide Suitable and Effective Funding for Continuing Care Implementation Goal 19: Allocate Direct Programmatic Funds for Implementation Goal 20: Encourage Private Sector Investment

31 Objective 1: Establish Leadership and Governance for Continuing Care The large scale system change required to build an effective continuing care system can only be achieved through strong and dynamic leadership operating within an enabling governance structure. The current model of responsibility and accountability for continuing care system design and delivery will be enhanced to include three levels: regulatory, strategic and organizational as shown in Figure 11. Policy & Standards Coordination & Integration Operational Guidelines & Protocols Figure 11. Three-Tiered Continuing Care Governance Structure The Regulatory Level: establishes the national direction for continuing care development through policy, legislation, licensure, standards and allocation of funding and resources to effect change and promote the delivery of quality continuing care services. The Strategic Level: drives continuing care transformation, care coordination and the integration of services from multiple public and private providers. This new level will ensure national alignment of continuing care service development. The Organizational Level: provides continuing care services directly to patients and families. Individual organizations comply with the national policies and standards while developing their own guidelines and processes to direct service provision.

32 SYSTEM POINT OF CARE PARTNERSHIPS DRAFT Goal 1: Establish a National Continuing Care Body Effective continuing care is best implemented through a delivery framework that integrates and coordinates both system and point of care services. This is best driven through a dedicated national continuing care body with a mandate to operate at the strategic level described earlier (Figure 11). The main role of this body is presented in Figure 12. Delivering on the Supreme Council of Health Continuing Care Strategy and Priorities Enabling Point-of-Care Coordination and Integration Across the System Continuing Care System Planning and Partnerships Supporting Quality, Safety and Efficiency of Continuing Care Services Connecting Patients to Care Facilitating Patient Transitions Supporting Patients in Their Homes Working with Public and Private Providers Across the Continuum Primary Care Providers Hospital Providers National Health Insurance Private Healthcare Providers Social Development Funds Non-Governmental Organizations Figure 12. The Role of a National Continuing Care Body

33 Goal 2: Establish a National Care Integration Board Health services, if delivered in isolation, will result in service fragmentation, suboptimal care and higher costs due to overlap and duplication. Patient and family centered care, delivered through the vehicle of integrated continuing care is a means to address fragmentation and improve access, quality and continuity of services in a more efficient way, especially for people with ongoing and complex needs. A National Care Integration Board is proposed as a means to bring together key healthcare and social care providers to endorse system-wide integration initiatives. The Board will oversee the development of system-wide, cross-organizational pathways through a robust clinical engagement mechanism. A formal charter that sets out principals, goals and aims of the Board will be used to guide the interactions of member organizations. This approach builds trust between all organizations and provides a basis for resolving potential disagreements. In this manner, integration will be vertical (continuing care services integrating with primary and secondary care) and horizontal (health services integrating with social care). This ensures that integration occurs at clinical, professional, organizational and system levels to deliver comprehensive services that address the needs of patients, caregivers and their communities.

34 Goal 3: Develop National Continuing Care Service Delivery Standards National continuing care service delivery standards ensure the provision of quality continuing care services and processes that meet the individual needs, preferences and abilities of each patient. These standards will be applicable to both public and private continuing care providers. Standards should address a range of issues that support quality continuing care service delivery, including, but not limited to; Standardized assessment processes and tools Patient and family involvement in care planning Care and service coordination Integrated care plan development Clinical and therapeutic processes Medication management Operational processes Workforce skills and licensure Facilities and settings Patient and family concerns, complaints and feedback Assistive technology provision Quality assurance, improvement, monitoring and reporting The standards and reporting processes will be developed through the formal process of the Supreme Council for Health Quality Management Department. These standards would support the delivery of the national strategic framework for continuing care through establishing clear expectations of both the regulator and providers.

35 Step-Down Care Step-Up Care Care Coordination as a Connector DRAFT Objective 2: Develop a National Integrated Continuing Care System A continuing care system infrastructure must be developed as the foundation on which continuing care services can be efficiently delivered. This system infrastructure will be built through the development of a comprehensive care continuum, expanded care settings and supportive processes to ensure patients with ongoing care needs are identified and supported in navigating the healthcare system. Goal 4: Develop a Comprehensive Care Continuum Review of international best practice reveals that a comprehensive health care continuum comprises fifteen to twenty different levels of care that encompass a range of patient acuities and intensities of care. The care continuum in Qatar will be expanded by introducing additional levels of care to ensure patients receive the right care, at the right time, in the right place by the right team. Of particular importance is the significant expansion of intermediate and communitybased levels of care to support patient transitions and rebalance demand across the healthcare system. The recommended consolidated levels of care for Qatar s healthcare continuum are shown in Figure 13 and detailed in Appendix A. Defining the scope of services across these levels of care will further support the development of system-wide clinically led guidelines, pathways and plans of care. Supported Living Home with Support Services Home with Primary Follow-Up Home with Clinical Services Bedded Intermediate Care Acute & Subacute ICU & HDU Figure 13. The care continuum with expanded levels of care

36 These recommend levels of care will be used as the basis for a formal stakeholder consultation process to reach consensus on a nationally approved list of levels of care definitions. These levels of care will support system planners in the design of future health services and the regulator in issuing continuing care provider licenses. Goal 5: Expand the Range and Capacity of Alternative Care Settings Significant expansion of healthcare services is required to relieve current system pressures and meet the increasing future demand. Planning for expansions in capacity should take into account the expanded care continuum so that demand is rebalanced across all existing and proposed levels of care. A demand model 11 was developed, utilizing the recommended levels of care, to assess the current estimated demand and future potential demand in the State of Qatar for the period 2016 to 2033 utilizing Qatar Health facilities Master Plan (QHFMP) data 12. The demand model projected the rebalanced demand across three main categories; inpatient admissions (Table 4), outpatient visits (Table 5) and emergency department visits (Table 6). Table 4. Rebalanced Volume of Inpatient Admissions across the Expanded Care Continuum Redistributed volum e of adm issions over the consolidated recom m ended LoC ( ) Level of Care ICU and HDU 32,444 44, , ,852 48, , ,448 51,57 3 Acute and subacute 1 28, , , , , , , ,7 97 Bedded intermediate care 4, ,41 2 5,349 5,293 5,1 20 5,059 4,860 4,525 Home with primary follow up 5,1 23 6,564 6,296 6,020 5,51 6 5,203 4,646 3,947 Home with clinical serv ices 1 6,028 20, , , , , , ,348 Home with support serv ices 2,21 8 2,843 2,7 27 2,609 2,390 2,256 2,01 4 1,7 1 1 Supported liv ing 1 5, , , , , , , ,598 Others Total 204, , , , , , , ,856 Table 4 indicates that approximately 20% of all inpatient admissions can potentially be shifted to alternative levels of care such as intermediate care and supported living or discharged to home setting with suitable support (clinical services, support services or primary care follow-up). The projected number of beds for intensive, acute, intermediate and supported living is shown in Appendix B. As with inpatient admissions, a significant potential exists to balance the demand across the continuum by expansion of home and community care options. Table 5 shows the projected volume of ambulatory care visits that can potentially be delivered in hospital outpatient departments, community settings (primary care and private clinics) and those that can be more

37 appropriately delivered in a home setting with appropriate support or through supported self management programs. Table 5. Rebalanced Volumes of Outpatient, Community and Home Visits Hospital OPD Nationals 1,81 6,27 5 1,21 5,07 5 1,282,7 68 1,237,699 1,338,7 86 1,363,37 2 1,466,636 1,465,445 Non Nationals - non SMLs 3,287,858 1,824,693 1,834,960 1,654,778 1,640,688 1,573,120 1,552,571 1,530,163 SMLs 1 06,503 93, , , , ,594 68, ,7 22 Hospital OPD demand 5,210,635 3,133,542 3,207,681 2,969,762 3,054,103 3,007,086 3,087,921 3,063,331 Community care Nationals 2,842,37 0 4,282,904 4,51 4,1 49 6,684,044 7,21 2,296 8,37 3,845 8,991,540 8,984,240 Non Nationals - non SMLs 5,856,716 7,504,063 7,551,418 9,528,612 9,449,248 10,317,534 10,182,398 10,035,436 SMLs 2,1 1 0,490 3,27 8,600 3,1 45,049 4,1 7 7,243 4,033, ,444,807 4,326,438 4,263,995 Community care demand 10,809,576 15,065,566 15,210,617 20,389,899 20,695,257 23,136,186 23,500,376 23,283,671 Homecare and Self-care Nationals 292,207 1,1 01,433 1,21 9,7 88 2,993,1 86 3,321,542 4,328,381 4,7 43,27 1 4,7 51,7 62 Non Nationals - non SMLs 573,580 1,868,868 1,975,083 4,225,581 4,307,723 5,285,626 5,322,356 5,259,199 SMLs 1 39, , , ,607,549 1,595,825 2,007,1 83 1,993,407 1,969,7 52 Homecare and Self-care demand Redistributed Volume of OP visits across hospital OPD, community care and homecare ( ) 1,004,844 3,645,902 3,875,581 8,826,315 9,225,090 11,621,190 12,059,034 11,980,712 A large group of patients, particularly those with stable chronic illness, has the potential to remain healthy if supported with targeted self care programs and access to regular primary care. However, if this population is not proactively managed and supported, it will represent a sizeable increase in demand for continuing care that if not met will result in greater pressures on acute and primary care. As with inpatients and outpatients, the potential exists to rebalance the demand for emergency services by shifting care to urgent community and primary care services. Table 6 shows the projected volume of emergency visits that can be shifted to urgent community care and primary care versus those that should remain in the emergency departments. Table 6. Rebalanced Volumes of Emergency Department Visits Redistributed volume of ED visits across ED and Urgent Community Care/Primary Care ( ) Emergency Departments 1,7 50,01 1 1,1 99,91 7 1,208,563 1,21 7,293 1,231,01 3 1,240,664 1,256,648 1,245,1 44 Urgent Community Care and Primary Care 54,060 34,961 44,446 53,927 68, , ,608 95,1 50