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19th COCHRANE COLLOQUIUM Sustainable Evidence-Based Health Care in Times of Crisis Madrid October 19-22. 2011 Rafael Bengoa | Regional Minister for Health.

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Presentación del tema: "19th COCHRANE COLLOQUIUM Sustainable Evidence-Based Health Care in Times of Crisis Madrid October 19-22. 2011 Rafael Bengoa | Regional Minister for Health."— Transcripción de la presentación:

1 19th COCHRANE COLLOQUIUM Sustainable Evidence-Based Health Care in Times of Crisis Madrid October Rafael Bengoa | Regional Minister for Health and Consumer Affairs Basque Government. Spain

2 Evolution of diabetes and cardiovascular disease in the Basque Country% This challenge of this epidemic is going much faster than our reaction to it. 4,5 - 6,06,1 - 7,57,5 - 9,0 9,1 - 10,5 10,6 - 12,0

3 3 Massive Demand… European Countries Ecosalud. OCDE Medical consultations/capita. Europe. 2003

4 4 Fragmentation

5 5 THIS IS THE RESULT ACROSS THE CONTINUUM !

6 6 Primary Prevention Primary Prevention Early Management Early Management Acute Management Acute Management Rehabilitati on & secondary prevention Rehabilitati on & secondary prevention

7 7 Having everything under the same roof does not guarantee clinical integration nor a tidy operation across the disease continuum R. Bengoa Primary Prevention Primary Prevention Early Management Early Management Acute Management Acute Management Rehabilitati on & secondary prevention Rehabilitati on & secondary prevention

8 8 Primary Prevention Primary Prevention Early Management Early Management Acute Management Acute Management Rehabilitati on & secondary prevention Rehabilitati on & secondary prevention Both downstream and upstream interventions are vital for the final population outcome in the control of a disease. It is sterile to continue opposing these two approaches. They are two sides of the same coin. What we need is an integrated approach across the continuum balancing public health interventions and health service interventions and the local organization to operationalise this as a system on the ground R. Bengoa DownstreamUpstream

9 9 MESSAGE IS CLEAR : Most countries are improving in each of the boxes of the continuum but not using the potential of an integrated approach across the continuum. One of the reasons for this is that we do not have a system operating at the local level

10 10 THAT FRAGMENTATION CANNOT PROVIDE A SUSTAINIBLE HEALTH SYSTEM

11 11 Tools for Integration Help to move towards a System Perspective risk stratification… case nurses… routine clinical reminders… continuum of care… activated patient… regular telemonitoring……

12 12

13 13 ¿WHAT ARE WE TRYING TO DO ? TRYING TO FIT IN SOME OF THOSE MANAGEMENT PROCESSES IN ….

14 14 Using frameworks/models

15 15 Some sort of structured patient education: both direct and remote REMOTE PATIENT EDUCATION PATIENT EDUCATION

16 16 With some sort of case manager Nurses who act a case managers for patients with complex conditions. Their function will be to evaluate their physical and social needs and coordinate their care.

17 17 Diabetic retinopathy Telecare /Telemedicine ++++

18 18 What results are some organizations getting? Is the Evidence Growing?

19 19Community Care North Carolina (CCNC) Health programme for: –Low-income adults and their children and dishabilities ( habitants) –3000 physicians Objective: –Improve the quality, cost, accesibility and utilisation of services for Medicaid recipients Source: Methods to promote integration: –Locally adapted clinical guidelines –Case management services –Financial incentives –Data review and analysis –Feedback on clinical practice

20 20 Integrated cardiovascular care…...is leading to reductions in heart attacks and strokes. 17 Stoke-related Hospitalization Rates in No. Cal ST Elevated MIs in No. Cal Age and sex adjusted rate per 1,000 KP Northern California ALL program, PHASE, results.

21 21 VA Continues to Exceed HEDIS in 2008 INDICATOR VA 2008VA 2007 Commercial 2007 Medicare 2007 Medicaid 2007 Breast cancer screening 87%86%69%67%50% Cervical cancer screening 92%91%82%n/a65% Colorectal cancer screening 79%78%56%50%n/a LDL Cholesterol < 100 after AMI, PTCA, CABG 66%62%59%56%38% Diabetes: DM control HbA1c < 9.0% 84% 71% 52% Diabetes: LDL-C<100 68%64%44%47%31% Diabetes: Eye Exam 86%85%55%63%50% Diabetes: Renal Exam 93%91%81%86%74% Diabetes: BP < 140/90 78%77%64%59%56% Hypertension: BP < 140/90 75%76%62%58%53% Smoking Cessation Counseling (3) 89%83%76%n/a70% Smoking : Medications offered (3) 84%n/a51%n/a39% Smoking: Referral/strategies (3) 92%n/a48%n/a39% Immunizations: influenza 84%72%49%72% Immunizations: pneumococcal 94%90%n/a67%

22 22 Why ? Because the Evidence is Increasing Estimated $3.7 million net savings for a ROI of > 2 to 1 Geisinger Proven Health Navigator Model 30% decrease in hospitalizations for asthma and 11% lower ER visits UK Tornbay 29% reduction in ER visits; 11% reduction in ambulatory care sensitive admissions versus control sites Puget Sound 10% relative reduction in hospitalizations and even greater among those with chronic illnesses. Intermountain Health Care SUSTAINIBILITY ?

23 23 Building some sort of Local Health System BETTER CARE FOR INDIVIDUALS ( IOM ) BETTER POPULATION HEALTH LOWER GROWTH IN EXPENDITURE BY ELIMINATING INEFFICIENCIES. TACTICAL APPROACH make the link between clinical behaviour and financial consequences for clinical decisions Incentive if savings made Pathways as a tool to make that link Aim : LINK several lines of work which tend to operate separately

24 24 DIFFERENT COUNTRIES/SYSTEMS MOVING IN THE SAME DIRECTION FOCUSING ON TRANSFORMATION OF DELIVERY CONTEXT : SOME PROMOTING COMPETITION ; OTHERS NOT. SHIFTING FROM VOLUME AND INPUTS TO VALUE LEANING ON MODELS: KP AND CCM AND OTHERS MANY BUILDING SOME SORT OF LOCAL HEALTH SYSTEM Mid-term policy perspective/ trend

25 25 USA. Section 3022 of the Affordable Care Act (ACA) establishes the Medicare Shared Savings Program for Accountable Care Organizations. England: The White Paper Equity and Excellence: Liberating the NHS New Public Health Law. Basque Country. Spain. Wales, New Zealand….. Trend Taking Shape In Normative Policy Interventions

26 26 How are we moving forward in the Basque Country ?

27 27 Objective: Simultaneously Managing Crisis & Transformative Change Short term strategy Crisis management Drugs: Brand to Generic Human Resources: Salaries Tecnologies: Desinvestment… Long term strategy Reforming Delivery Chronic Diseases Agenda Integrated Care SUSTAINIBILITY?

28 28 Create a narrative/ a common language …. PROVIDE A NARRATIVE THAT GOES BEYOND COST CONTAINMENT A NARRATIVE WICH PROVIDE A VISION AND STRUCTURE PROVIDES DIRECTION AND STABILITY IN A CRISIS ENVIROMENT THE HARDER THE EXTERNAL ENVIROMENT IS, THE GREATER THE COHESION CAN THE COMMON VISION PROVIDE R. Bengoa IN THE BASQUE COUNTRY = THE MAIN NARRATIVE IS CHRONIC DISEASES AND CLINICAL INTEGRATION

29 29 Competencias Avanzadas Enfermería Formar a 300 enfermeras en los nuevos roles hasta 2013 Financiación y Contratación Implantación plena de un sistema de asignación financiera territorial ajustada por riesgo Colaboración sociosanitaria 4 municipios con funcionamiento integrado, 1 hospital con plan de altas con prevención de dependencia, 1 unidad de ortogeriatría Innovación desde los profesionales Generación de proyectos de innovación al año y extensión de los que demuestren resultados (~90%) Centro Servicios Multicanal Despliegue en Euskadi de todos los servicios para mediados de 2013 Prevención y Promoción Prevención de aparición y desarrollo de enfermedades crónicas (De_Plan, prevención tabáquica) Estratificación Estratificación operativa de la población vasca de forma sistematizada y periódica desde 2011 Autocuidado Experiencias en las principales enfermedades crónicas, potenciando la adherencia y el uso apropiado de los recursos Historia Clínica unificada Implantación universal a finales de 2011 Atención clínica integrada Un tercio de las organizaciones a 2013, con procesos integrados Receta electrónica Implantación efectiva del sistema de receta electrónica en todo Euskadi en 2012 – 2013 Experiencias de telemonitorización Monitorización a distancia del 1% de enfermos crónicos severos (~22.500) Modelo hospitales subagudos Implantación del modelo en hospitales de media estancia y creación de nuevo hospital de crónicos en Álava Centro Investigación Cronicidad Ser un referente internacional en el conocimiento sobre enfermedades crónicas Launch interventions in a coherent package: Many levers simultaneously R. Bengoa

30 30Examples: bottom up Organizational Innovation Osi Bidasoa Basurto Sta. Marina habitants 24 primary care centers 1 acute hospital 1 medium and long term hospital H. Basurto- C-Bilbao-H. Santa marina habitants First integrated organizational structure (hospital and primary care center) Integrated organizational structure Non Integrated organizational structure DIFFERENT MODELS OF INTEGRATED CARE ORGANISATIONS (systems)

31 31 This Should Look Better At The Next LSN Meeting!!!!

32 32 Evidence increasing around a few things… Different diseases, similar needs and similar solutions Much of the evidence sends clear signals in favor of integrated care To pull this off you need patients and staff on board. It is therefore less about structural moves than about staff engagement Evidence growing but scalability still an issue

33 33 THE PROCESS WILL NOT DEVELOP IN A TIDY SEQUENCE OF LINEAR STEPS. INSTEAD IT WILL PROLIFERATE VIA GROUPS OF INNOVATIVE IDEAS BY DIFFERENT ORGANIZATIONAL UNITS. Van de Ven 1999 THOSE INNOVATIVE IDEAS BY DIFFERENT ORGANIZATIONAL UNITS MUST BE SUBJECTED TO THE EVIDENCE TEST SCALABILITY…

34 34 Thank you


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