A framework for designing integrated health services delivery: areas for action Juan Tello, Head of Office WHO European Centre on Primary Health Care Division of Health Systems and Public Health Moving towards integrated care in Kosovo 15 February 2017, Hotel Emerald, Prishtina, Kosovo
What can we achieve? Disease burden of largely preventable NCDs in the Region 1 80% Average % of preventable hospitalizations for hypertension in countries studied 2 Relative risk reduction in readmissions 3 Studies finding improved patient satisfaction 3 Some evidence on costeffectiveness 73% 35% 50% $$ 1. WHO Regional Office for Europe (2011); 2. WHO Regional Office for Europe (2016); 3. Nolte & Pitchforth (2014)
INTEGRATED CARE: KEY ELEMENTS
Familiar integrated care frameworks
Familiar integrated care frameworks Bellagio model
Common features in models for integrated care PEOPLE SERVICES SYSTEM CHANGE
Typologies of integration Levels of integration Types of integration Sources: Valentijn et al 2013: 6-8 Sources: Lewis et al 2010
What does integrated care look like in practice?
How do IHSD frameworks look from a person s perspective? Tertiary Tertiary Secondary & tertiary Practice nurse GP Pharmacist Out-of-hours doctor Lab technician Secondary Primary Primary and secondary Primary Home nurse PATIENT Cardiologist CVD MCH TB Smoking cessation Rehabilitation Social worker
Other entry points along the stages of developing services Stages Properties Continuum Model of care Conventional care Selective primary health care Disease-oriented care Coordinated services Integrated services Disease management Care management Whole-person Organization of providers Vertical Linkages Horizontal Collaborative Management of services Management of production Management of resources Management for performance Management for outcomes Continuous improvement Quality of inputs Quality of outputs Quality of processes Quality of outcomes
Mapping stages along continuum of services delivery Continuous performance improvement Quality outcomes 4 Conventional care ( 4) Disease-oriented ( 5 8) Coordinated services ( 9 12) Integrated services delivery ( 13) Quality processes 3 Quality outputs 2 Quality inputs 1 Managing services 4 3 2 1 1 2 3 4 Model of care 1 Vertical 2 Linkages 3 Horizontal 4 Collaborative = 12 6 Coordinated Disease-oriented services Organization of providers
Applying stages to identify priority policy options Stages Conventional care Disease-oriented care Coordinated services Integrated services Value 4 5 8 9 12 13 Priority actions Redesign the model of care Optimize core processes of services delivery Align other health system enabling functions Strengthen integration with other sectors Change management Focus on strategizing changes with people at the centre, convening a wide range of actors from the outset Focus on implementing changes that disrupt the status quo via pilot projects and a high involvement culture Focus on working across many levers and building coalitions Focus on rolling out and scaling-up changes, from projects to business-asusual
What it looks like in practice PHC & PUBLIC HEALTH Entry point: NCDs, TB, palliative care, HIV, EPHOs 4-6 Focus across levels of care, pathways, transitions PHC & HOSPITALS HSD & SOCIAL CARE Entry point: accountability, financing Focus on population health including SDH, environment Entry point: chronicity, multimorbidity, ageing, mental health Focus on LTC, home care, telecare; community care
CALL FOR ACTION WHO European Framework for Action on Integrated Health Services Delivery
The EFFA IHSD: key areas for action POPULATIONS AND INDIVIDUALS Identifying needs Tackling determinants Empowering populations Engaging patients SERVICES DELIVERY PROCESSES!! Designing care Organizing providers & settings Managing services delivery Improving performance SYSTEM ENABLERS Rearranging accountability Aligning incentives Preparing a competent workforce Promoting responsible use of medicines Innovating health technologies Rolling out e-health Strategizing with people at the centre CHANGE MANAGEMENT Implementing transformations Enabling sustainable change
Factors for a new model of care Choice E.g. preferences Multiple settings E.g. rehabilitation People-centred E.g. life course; work De-institutionalized E.g. mental health Closer to home E.g. long term care New technologies E.g. telecare; med science
Population health management Equity promoting services Guaranteed access Cost-effective prevention Efficient allocation of resources Care close to home 24 hour care Access to health record Regular provider Health literacy MODEL OF PHC Outcomes-orientation Coordination of a network of stakeholders Continuous performance improvement Flexible working hours Team work Available specialist advice Clinical autonomy
What is the model of PHC? Innovative responses to patients ESTONIA Online patient portal with access to personal health information including treatments, test results and prescriptions. Access to personal records? Care close to home? IRELAND Early hospital discharge for care delivered by community intervention teams according to personalized care plans helping patients remain at home.
What is the model of PHC? Innovative responses to practitioners SWITZERLAND Rehabilitation team providing services for recovery from brain injury including occupational therapy, physical therapy and speech therapy with focus on patients return to work. Teamwork? Opportunities for improvement? Flexible working hours? TURKEY FRANCE Shared patient rosters in multidisciplinary group practices to better manage workload through flexibility in scheduling while also extending working hours. Peer review groups auditing adherence to clinical guidelines with improvement oriented advice.
What is the model of PHC? Innovative responses to managers BELGIUM Regional mental health pilot projects reconfiguring local institutions for mobile and at home services tailored to local needs Organizational networks? Improving performance? ISRAEL District-led disparity reduction strategies promoting cooperation across local clinics with performance incentives linked to preset composite measures for disparity.
What is the model of PHC? Innovative responses to policy-makers SCOTLAND Lead agency model for the institutional redesign of health and social care services coordinated for adults and children. Intersectoral action? Cost-effective prevention? Populationorientation? NORWAY ITALY Population stratification in Veneto region to target risk factors and manage population chronic care needs. Curbing lifestyle risk factors and work-place absentees with national roll-out of municipality run Healthy Living Centres.
IMPLEMENTING TRANSFORMATIONS
Framework for Action Implementation package: examples of available resources POLICIES BACKGROUND DOCUMENTS EVIDENCE TOOLS The European Framework for Action on Integrated Health Services Delivery takes forward the priority of transforming health services in the WHO European Region. It is closely aligned with the values, principles and strategies of other global and regional commitments. Background documents include a review of health services delivery concepts (Health services delivery: a concept note) and topic specific reports developed through targeted reviews of available literature to explore the evidence and experiences on topics such as the health workforce, patient engagement and population empowerment. Field evidence has been developed through a series of descriptive case studies on initiatives to transform health services delivery, exploring efforts from all 53 Member States. Through a horizontal analysis across cases, lessons learned have been identified and published in a compendium of initiatives in the WHO European Region to transform health services. Tools are developed to support users to adapt and apply the Framework for Action and include to-date a step-by-step guide for developing descriptive case studies on initiatives to transform services as well as a English and Russian glossary of key terms.
Framework for Action Implementation package: examples of available resources TECHNICAL ASSISTANCE TRAININGS ADVOCACY MEASUREMENT Direct country technical assistance aims to support Member States to adapt the Framework for Action in their strategic planning and efforts to transform health services delivery across levels of the health system. Trainings and workshops aim to support Member States, partners and WHO staff to explore the Framework for Action in the context of their work, applying available material and exchanging firsthand experiences. Consultations, technical meetings and reviews are some of the ways in which partners are brought together to discuss pertinent topics, share experiences and debate new research. Participants often include national technical focal points, invited experts, partner organizations, patient representatives, health and social care providers, civil society, special interest groups and WHO staff. Resources for measurement to-date include a methodology and tool for assessing health services delivery performance with hospitalizations from ambulatory care sensitive conditions, identifying entrypoints for strengthening health services delivery.
WHO Regional Office for Europe Division of WHO Regional Office for Europe Health Division Systems of and Health Public Systems Health and Public Health Division of Health Systems and Public Health CONTACT INFORMATION WHO European Centre for Primary Health Care Almaty, Kazakhstan Email: EUCIHSD@who.int For more information on health services delivery at the WHO European Regional Office for Europe, visit: http://www.euro.who.int/en/health-topics/health-systems/health-service-delivery Moving towards integrated care in Kosovo 15 February 2017, Hotel Emerald, Prishtina, Kosovo