Pursuing care integration in Finland. King s Fund, March 21, 2017, Martti Kekomäki ii

Transcription

1 Pursuing care integration in Finland King s Fund, March 21, 2017, Martti Kekomäki martti.kekomaki@fimnet.fi ii

2 outline features of Finnish healthcare, critical for integration definitions problems to be solved goals set integration in practice: results - but why social care? conclusions

3 critical features of Finnish health care, relevant for integration 1: primary care delivered by health centres, owned, financed, and managed by 311 communes, either alone or jointly; working patterns resemble increasingly that of group practices a part of primary care is financed by employers through Social Insurance Institute (SII, Finnish acronyme KELA )

4 critical features of Finnish health care, relevant for integration 1: primary care delivered by health centres, owned, financed, and managed by 311 communes, either alone or jointly; working patterns resemble increasingly that of group practices a part of primary care is financed by employers through Social Insurance Institute (SII, Finnish acronyme KELA ) secondary care delivered by 20 central hospitals, owned and financed by counties counties are formed by municipalities; hospitals are geographical monopolies (Finland is the most sparsely populated member of EU)

5 critical features of Finnish health care, relevant for integration 1: primary care delivered by health centres, owned, financed, and managed by 311 communes, either alone or jointly; working patterns resemble increasingly that of group practices a part of primary care is financed by employers through Social Insurance Institute (SII, Finnish acronyme KELA ) secondary care delivered by 20 central hospitals, owned and financed by counties counties are formed by municipalities; hospitals are geographical monopolies (Finland is the most sparsely populated member of EU) tertiary care delivered by five university hospitals

6 critical features of Finnish health care, relevant for integration 2: every Finn has a unique personal identification code, used in all encounters from birth to autopsy, also in taxation enables long-term follow-up, bundling of costs over time, stratification of patients, risk analysis etc.

7 critical features of Finnish health care, relevant for integration 2: every Finn has a unique personal identification code, used in all encounters from birth to autopsy, also in taxation enables long-term follow-up, bundling of costs over time, stratification of patients, risk analysis etc. Health Portal, created by Finnish Medical Society Duodecim, provides regularly updated information on care guidelines/best practices forms the knowledge basis for local care paths, which are built jointly by hospitals and health centres

8 critical features of Finnish health care, relevant for integration 2: every Finn has a unique personal identification code, used in all encounters from birth to autopsy, also in taxation enables long-term follow-up, bundling of costs over time, stratification of patients, risk analysis etc. Health Portal, created by Finnish Medical Society Duodecim, provides regularly updated information on care guidelines/best practices forms the knowledge basis for local care paths, which are built jointly by hospitals and health centres Health Library, available through internet, provides the same information to all Finns aiming at reducing information asymmetry between the patient and her physician

9 chitical features of Finnish health care, relevant for integration 3: health centres use digitalized life-long medical records as do most hospitals; increasingly, hospitals and health centres share the information system special applications, such as wide-area PACS and lab robots gain share

10 chitical features of Finnish health care, relevant for integration 3: health centres use digitalized life-long medical records as do most hospitals; increasingly, hospitals and health centres share the information system special applications, such as wide-area PACS and lab robots gain share practically all social care (nursing homes, elderly homes, home services, housing, income support, support of families with dependents, illicit drug dependencies etc.) is administered, financed, and often also delivered by municipalities) ICT links between social and health care still are being built

11 chitical features of Finnish health care, relevant for integration 3: health centres use digitalized life-long medical records as do most hospitals; increasingly, hospitals and health centres share the information system special applications, such as wide-area PACS and lab robots gain share practically all social care (nursing homes, elderly homes, home services, housing, income support, support of families with dependents, illicit drug dependencies etc.) is administered, financed, and often also delivered by municipalities) ICT links between social and health care still at their nascent state all manforce is salaried, no self-paying patients in public hospitals

12 definitions, coordination of activities vertical integration: coordination between health centres and hospitals

13 definitions, coordination of activities vertical integration: coordination between health centres and hospitals horizontal integration: coordination between health centres and social work

14 problems to be solved inequity of service distribution, both regional and socio-economical especially in access to health centres cost escalation, due to greying population and technology development overlapping services and other forms of waste, such as separate tellers, silos, repeated encounters, doubled examinations fragmented services, delivered by both health and social workers waiting times especially to health centres between health centres and hospital admissions

15 the basic idea is not competition, making profit, or gaining marked share, but rather working as a well-trained team aiming at citizens ---ability to adapt --- and self-manage --- working under one budget, set according to the estimated needs of target population balancing the marginal cost-effectiveness across all active care

16 examples follow: The Finnish Asthma Program: > two decades of vertical care integration but why horizontal integration? cost analysis: Oulu region - and improved cost containment of heavy users : four years of South Carelian experience conclusions

17 Overall annual costs of asthma care at society level in Finland from 1987 to Haahtela T, et al. JACI 2017

18 Overall annual costs of asthma care at patient level in Finland from 1987 to Haahtela T, et al. JACI 2017

19 lessons from vertical integration: Finnish Asthma Program target on prevention: ban smoking, take antigen environment into account recognize early symptoms, approach definite diagnosis promptly start effective medical therapy: hit early, hit hard educate, shift responsibilities smoothly between professional groups deploy virtual health examination : nobody forgotten adapt care processes to local factors (distances, manpower, ICT, equipment) mobilize lay interest groups for your support keep track over time, prevent sliding back be proud, be loud!

20 but why integrate social care and health care? the product of social and health care is identical the ability to adapt and self-manage thus they are mutual substitutes, at least to some degree

21 but why integrate social care and health care? the product of social and health care is identical the ability to adapt and self-manage thus they are mutual substitutes, at least to some degree they have overlapping activities like home care, care of the handicapped and elderly

22 but why integrate social care and health care? the product of social and health care is identical the ability to adapt and self-manage thus they are mutual substitutes, at least to some degree they have overlapping activities like home care, care of the handicapped and elderly clients problems overlap and intermingle necessitating multi-professional solutions to create tailorized care plan

23 10 % of citizens account for 81 % of total health-soc costs (data from Oulu City, 2011) Percentage of total costs 100% 90% 80% 10 % of the citizens, 81 % of costs 70% 5 % of the citizens, 68 % of costs 60% 50% 40% 30% 20% 10% 0% 1% 3% 5% 7% 9% 11% 13% 15% 17% 19% 21% 23% 25% 27% 29% 31% 33% 35% 37% 39% 41% 43% 45% 47% 49% 51% 53% 55% 57% 59% 61% 63% 65% 67% 69% 71% 73% 75% 77% 79% 81% 83% 85% 87% 89% 91% 93% 95% 97% 99% Percentage of citizens Riikka-Leena Leskelä, Nordic Healthcare Group

24 disaggregation of heavy users of services (10 % of population accounting for 81 % of total costs) health services only (a 32 % cost share in this group) consisting of: unclassified (neoplasms, Tx s, traumas) 14 DMII + cardiovasc patients 9 other chronic somatic diseases 9 health + social services (a 68 % cost share in this group) consisting of: elderly care services 40 services for the disabled 14 psychiatric care 9 patients w/ substance abuse 7 child protection 7

25 care integration benefits from defining client segments worsening control of one s own life increasing health problems

26 care integration benefits from defining client segments: percentual distribution worsening control of one s own life 10 % 5 % 75 % 10 % increasing health problems

27 citizens majority needs occasional contacts with care system and uses ICT to seek for help/advice: little need for integration worsening control of one s own life social support ICT e-health increasing health problems

28 clients with chronic conditions benefit from guided scheduling and permanent patient-doctor relationships worsening control of one s own life social support ICT guide increasing health problems

29 citizens with poor personal life control benefit from peer group support worsening control of one s own life social support group ICT increasing health problems

30 the 68%/5% group needs personal care manager worsening control of one s own life social support care manager ICT increasing health problems

31 when problems mount. mental problems child neglect somatic disease poverty unemployment crime substance dependence

32 it makes horizontal integration imperative somatic disease child neglect crime mental problems poverty unemployment substance dependence

33 it makes horizontal integration imperative somatic therapy child welfare police, court psych specialists housing agency basic salary withdraval therapy

34 health-soc integration matters but only under goal-oriented leadership average health-soc cost escalation in Finland cost development of somatic diseases in EKSOTE plateauing costs of mental/substance patients in EKSOTE after horizontal health-soc integration Timo Salmisaari, South Carelian Health and Social Care District EKSOTE

35 stop talking latin, start listening to the client (compare with John Seddon of U.K.: The Whitehall Effect ) psychiatry mental health services mental health and dependencies adult psycho-social services services supporting social participation according to Timo Salmisaari, M.D., EKSOTE, South Carelia

36 yet horizontal integration is not easy; problems linked to several areas, such as professions and leadership: whose turf? do we have to listen to these people? who is in charge here? culture: do you rock the boat? financing: do we have to share our scarce money? forms of service: does all this belong to us? links to constitutional rights: how to integrate legal authorities into group? scientific basis: where looms the hard evidence? metrics: how to measure the ability to adapt and self-manage? information technology: where are the data, where the information? political machine: how to guarantee sustainability over election periods?

37 Finland: best value for money

38 concluding words integration means commitment to work together over years and decades integration is the main stream, managed competition (quasi-markets) provides marginal aid in selected situations we will see care integration gaining ground in all postindustrial countries, simply because we are running out of money care integration is not just another strategy; it is a deep and permanent cultural change